"It encourages them to complain”: potential unintended consequences of routine pain screening

Ahluwalia SC, Giannitrapani K, Cromer R, Pisciotta M, Schreibeis-Baum H, Dobscha S, Krebs E, Lorenz KA. "It encourages them to complain”: potential unintended consequences of routine pain screening. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.

Objectives: The Veterans Health Administration (VHA) implemented the "Pain as the 5th Vital Sign" (P5VS) initiative in 1999, requiring a pain intensity rating on a 0-10 scale at all clinical encounters. We sought to better understand the perceived impact of implementing a routine pain screening program on primary care clinicians and clinical processes in order to identify opportunities for improving pain screening and management. Methods: We conducted multidisciplinary focus groups in California and Oregon VHA hospital and community-based urban and suburban sites. Participants discussed screening practices; usefulness and preferred approaches to pain screening; multidisciplinary roles in screening and management; and critical information needs for pain assessment and management . We qualitatively analyzed the focus groups and characterized themes using constant comparison. Results: (1) Screening encourages an affirmative response regardless of actual pain, "Now all of a sudden, I got extra work to do even though it doesn't really bother the patient that much" and that problem is heightened because a) it prompts recall of old and chronic pain; and b) patients perceive "0" on the scale as non-response. (2) Screening focuses the patient on the pain problem, rather than on a solution, which challenges provider efforts to effectively manage chronic pain. (3) Screening sets the expectation that any affirmative answer will be addressed, and thereby (4) perversely worsens reliance on drug treatment because visit brevity and limited access to non-drug treatments . (5) Screening can unnecessarily change the focus of the clinic encounter, because addressing pain consumes extra time and re-directs the patient from other complaints. As one provider noted, ""I have a lot of things to do on this short visit-five, six different problems-and then there's this pain. Oh, gosh, I didn't address that. Well, what am I going to do? " Implications: Providers perceive pain screening as heightening expectations and interfering with other primary care priorities. Clinicians seek better balance of pain focus with other patient and evidence-based visit needs. Impacts: The risks of routine pain screening need more consideration and should be balanced with the potential benefit.