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Painful Truths About Pain Screening

Recognizing the importance of pain, VA has, for over a decade, routinely required staff to assess and document the intensity of pain using the 5th Vital Sign, a 0 to 10 numeric rating scale (NRS). The patient's report is central to efforts to relieve pain, but pain of equal intensity can accompany a range of human experiences—from the torture of metastatic cancer to the joy of childbirth. Can a simple measure of pain intensity inform efforts to manage pain effectively?

The HELP-Vets Study found that the NRS measure of current pain intensity was only moderately accurate for chronic disabling pain measured with the Brief Pain Inventory (BPI). HELP-Vets evaluated the variability and clinical usefulness of pain screening at random outpatient encounters in the VA Los Angeles and Long Beach Healthcare Systems (March 2006 - June 2007) at 19 oncology, cardiology, and primary care clinics in three large urban Southern California counties. HELP-Vets targeted the screening experience with baseline surveys of clinic-based physician and nursing staff followed by post-encounter patient and physician surveys to characterize each encounter combined with chart reviews.1

Reasons for suboptimal performance of the NRS included the chronicity of pain in primary care and the lack of fidelity in scale administration. Substituting a rating of average pain over the past week significantly improved sensitivity for clinically important pain. HELP-Vets also found that staff used informal queries (e.g., "Is your knee good today?") rather than the NRS in about 50 percent of cases; this practice was associated with pain underestimation. Although direct patient reports could avoid errors related to fidelity in scale use, clinicians tended to document more severe, and possibly more actionable pain, suggesting the importance of comparing clinician-documented and patient-reported approaches.

HELP-Vets informs why the linkage between pain assessment and improved care is missing. Busy providers noted pain score information in two-thirds of encounters but acted on moderate to severe pain with augmented management in only 15 percent of cases.2 Knowledge, as well as attitudes and skills, proved important—including physicians' perception of the accuracy of nurses' pain reports. The most commonly cited reasons not to act on the NRS value included that the patient preferred not to change his/her approach (56 percent); everything has been done (35 percent); and the patient is not experiencing pain (26 percent).

A VA CDA-funded qualitative study of primary care opioid management identified additional concerns about pain assessment. Patient interviews identified a strong theme that physicians did not want to listen to patients' pain experiences and did not understand the effect of pain on patients' lives. Patients felt the NRS lacked meaning and did not accurately reflect their experience of chronic pain; for example, "this business about what kind of pain are you feeling from 1 to 10, I don't do real well with that because I don't know how do you rate what's a 1 and what's a 10, you know." Several participants indicated that the NRS detracted from individualized treatment of patients, by reducing their experience to a number. As one stated, "I mean, just a question like, 'tell me something in your daily life, how your pain affects it.' That would be the most beautiful question in the world." Our research suggests that assessment of pain intensity alone will not likely change practice. Pain assessment that incorporates more patient-centered information (such as pain-related impairment), and that allows clinicians to assess response to therapies might facilitate individualized care. Furthermore, screening needs to be meaningfully linked to management, and needs to include a focus on high value clinical conditions and expanded options, especially non-pharmacologic approaches, for management.

HELP-Vets identified approaches to routine pain assessment that may be more informative than the NRS, including a three-item measure that includes assessment of emotional and physical pain interference, the PEG.3 We plan to evaluate the PEG versus the NRS, as well as compare clinician-documented versus patient-reported approaches directly in a multi-site randomized controlled pain assessment trial, the Effective Screening for Pain (ESP) Study. ESP will query clinicians about how to improve the pain assessment process—including linkage of pain assessment to management—and explore prototype approaches and tools to facilitate the assessment-management link.

In summary, measurement is a necessary but not sufficient step to improving patients' pain. Pain measurement can be improved, especially by incorporating information about pain-related functional interference to inform individualized goals. Additionally, the assessment-management link must be strengthened, which will require better access to non-pharmacologic treatment. Pain is one of various patient-centered symptom concerns, so learning how to systematically improve care for Veterans living with pain should inform a more humanistic, quality of life-centered VA health care system.

  1. Lorenz, K.A. et al. "How Reliable is Pain as the Fifth Vital Sign?" The Journal of the American Board of Family Medicine 2009; 22:291-8.
  2. Zubkoff, L. et al. "Does Screening for Pain Correspond to High Quality Care for Veterans?" Journal of General Internal Medicine 2010; 25:900-5.
  3. Lorenz, K. A. et al. "Exploring Alternative Approaches to Routine Outpatient Pain Screening," Pain Medicine 2009; 10: 1291-9.

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