Isn't it time for a 21st Century Pain assessment?

The evaluation of pain is extremely difficult due to its subjective nature. We need to move to an evaluation of acute pain that not only takes the patient’s perception into account, but also, for the first time, incorporates objective measures of pain into a global assessment matrix.

When a patient is in pain, either from an injury or surgical procedure, the pertinent question should be, “is the pain tolerable?” Each of us has a threshold at which point the addition of an analgesic should be considered to prevent the consequences of untreated acute pain.

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This threshold should not be based on an arbitrary numerical value, but whether the pain is tolerable for that individual. Once the patient states that their pain is intolerable, we then attempt to correlate this subjective feeling with the following objective measures prior to the initiation, maintenance and escalation or de-escalation of analgesic treatment.

Here is a mnemonic to aid in remembering the objective measures of acute pain:

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·      Observation-Is the patient grimacing, screaming, diaphoretic, combative, crying, sleeping, drowsy, etc.? This observation must be made after confirming that the physical/verbal symptoms are not due to delirium, hypoxemia, hypercarbia, acidosis or other metabolic issues that may be confused with the outward appearance of discomfort. Once it is established that the physical signs are due to pain, you can proceed with analgesic treatment. If, however, you have not established that your observation is from pain, or if the patient appears drowsy, somnolent or obtunded, do not give analgesics.

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·      Respiratory Rate-In my opinion, respiratory rate in the presence of a patient stating that their pain is intolerable is the most important indicator and guide for analgesic therapy. A normal respiratory range is between 12-20 breaths per minute. These are actual breaths associated with ventilation of a normal tidal volume. They are not attempted, shallow or obstructed respirations. Once it is confirmed that there are no abnormal neurologic, metabolic or psychological issues involved, the respiratory rate may now be assessed. A true respiratory rate greater than 20 with a patient stating intolerable pain is a good indication for analgesic treatment. If, however, the respiratory rate is less than 12, I would not initiate or escalate opioid analgesic therapy.

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·      Heart Rate-Heart rate is usually elevated when a patient has intolerable pain, but just like any other objective measure, other factors may also come into play. If a patient is on a beta blocker, the heart rate response to pain may be masked. In addition, if a patient is hypovolemic, hyperthyroid, hypercarbic or has a hyper-dynamic neuroendocrine disorder, the heart rate may be misleading.

·      Blood Pressure-Blood pressure is usually elevated when a patient has intolerable pain. However, as with heart rate, other factors must be taken into consideration prior to attributing the elevated blood pressure to pain. In addition, all objective measurements should be compared to the patient’s pre-pain baseline. For example, if a patient had a baseline blood pressure of 160/90, then 160/90 would not be considered as an indication of acute pain with this individual.

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·      Pupil Size-It is an often-missed indicator of pain, however, pupil size may not only indicate severe pain, but also help guide narcotic de-escalation. For example, if a patient is in pain, there are increased circulating catecholamines from sympathetic stimulation. This leads to pupillary dilation. On the other hand, pinpoint pupils can indicate the central nervous system’s response to a therapeutic narcotic level. Can narcotics be titrated to pupil size? No, but pupil size can definitely be used as a guide in the treatment of acute pain.

Putting it all together

Our first approach in the assessment of acute pain is to observe with critical attention the objective indicators of pain: heart rate, blood pressure, respiratory rate and pupil size. If your evaluation shows a patient who is resting quietly in bed with a heart rate of 60, blood pressure of 120/80, respiratory rate of 12, what then is your initial impression prior to asking for the patient’s “feeling?”

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Based on the objective measures, I would maintain current analgesic levels. When asked, however, the patient does not respond how you would expect and rates their pain as intolerable. This is the dilemma facing healthcare providers on a daily basis and their resolution is to escalate analgesic therapy with opioids over 90% of the time.

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This mistake stems from recommendations, such as those from the Agency for Healthcare Research and Quality, whose position is that “patients’ self-reports are the most reliable indicator of their experiences of pain.”

This line of reasoning is devoid of any objective measures and places the patients’ “self-reports” as the cornerstone in an acute pain management protocol. In addition, the reliance solely on the subjective measure of a patients’ self-report exposes providers to unnecessary legal consequences of under-treatment as well as opioid over-treatment resulting in possible respiratory morbidity, mortality or long-term addiction if this model is continued into the outpatient setting.

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While the legal implications of the way practitioners assess and treat acute pain in the hospital and post discharge are beyond the scope of this article, it is important to note that hospitals, pharmaceutical companies and practitioners are being sued for mortalities related to the inappropriate prescriptive use of opioids.

As for big pharma, their culpability lies in the inaccurate education and detailing of opioids as either not as addictive or not as dangerous as they truly are.

The objective measures of pain and critical thinking of where a patient is relative to where they were or where they should be, is requisite prior to the patient’s self-report of whether they view their pain as tolerable or intolerable. When married together into a global pain matrix, these measures will guide the practitioner with the initiation, maintenance, escalation or de-escalation of analgesic therapy. In my experience, nurses feel that they will be reprimanded if they withhold analgesics from a patient who has rated their pain a nine out of 10 on the universal pain scale. This fear routinely leads to unintended consequences.

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