Intensity of Pain: Are we Focused on the Wrong Metric?
Chronic Pain Treatment should focus on improving function and quality of life
Summary of a commentary in the New England Journal of Medicine
Authors: Jane Ballantyne, MD, FRCA, Professor of Anesthesiology and Pain Medicine, University of Washington School of Medicine Mark Sullivan, MD, PhD, Executive Director of COPE for Chronic Pain CME; Professor of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, and Clinician, UW Center for Pain Relief
It would seem intuitive that reducing pain intensity should be the primary goal of treatment for chronic pain. But such a strategy can be counterproductive. Leading pain specialists at the University of Washington (UW) argue that focus on the pain score has led to overprescribing of opioids, escalating dosing levels, and increased risks for patients. Jane Ballantyne, MD, FRCA, and Mark Sullivan, MD, PhD, both of the UW School of Medicine-Seattle, argue a new approach to pain treatment is needed in their commentary in the New England Journal of Medicine.
In the commentary, Ballantyne and Sullivan discuss the growing influence of the basic pain scale (patients’ self-reported rating of their pain on a scale of 0-10). For many patients with chronic pain, “especially those who have developed opioid dependence, maintaining low pain scores requires taking continuous or escalating doses of opioids at the expense of worsening function and quality of life.” Instead, according to Ballantyne and Sullivan, treatment should focus on helping patients improve their ability to function at work and at home, shifting the focus from pain to moving on with their lives. This shift will require embracing multimodal therapies that encompass behavioral, physical, and integrated medical approaches.
Ballantyne and Sullivan clarify that use of the pain scale for measuring acute or post-surgery pain, as well as for end-of-life pain, is distinct from its use for chronic pain. “When pain is chronic, its intensity isn’t a simple measure of something that can be easily fixed,” they write. Instead, multiple measures of the complex causes and consequences of pain, including associated depression and anxiety, are needed for effective treatment. “For this purpose, nothing is more revealing than a conversation between a patient and a clinician, which allows the patient to be heard and the clinician to appreciate the patient’s experiences and offer empathy, encouragement, mentorship, and hope.”
Read the commentary:
Intensity of Chronic Pain — The Wrong Metric? Jane C. Ballantyne, M.D., and Mark D. Sullivan, M.D., Ph.D. N Engl J Med 2015; 373:2098-2099, November 26, 2015. DOI: 10.1056/NEJMp1507136
Related Journal Article:
Must we reduce pain intensity to treat chronic pain? Sullivan, Mark D. MD, PhD; Ballantyne, Jane MD, FRCA. Pain 2016; 157(1):65-69. DOI: 10.1097/j.pain.0000000000000336
Treating chronic pain: When ‘How much does it hurt?’ isn’t enough, November 30, 2015, stat.com