Feeling Your Pain
Hospitals have to treat agony. But now they must find the best measure of it
In a small valley between the rushing Clark Fork River and the towering Rocky Mountains lies Missoula, Mont. Long famous for its natural serenity, today it is becoming known for a different kind of peace, as a trailblazer in the ability to quell pain.
Three quarters of surgical patients in the United States say they get poor relief from acute pain. And among nearly 600 hospitalized cancer patients in a national study, nearly half weren't given enough painkillers. One of the chief reasons was that doctors tended to view pain as less severe than did the patients themselves. But this may be changing, thanks to techniques pioneered in Missoula and elsewhere that are now becoming a part of national hospital practice. The country's 18,000 hospitals, nursing homes, and other care facilities can no longer be accredited unless they measure pain as "the fifth vital sign"--monitoring and treating it as carefully as they do temperature, blood pressure, breathing, and pulse. "Our surveyors are out in the field now," says Russ Massaro, an executive vice president of the Joint Commission on Accreditation of Healthcare Organizations. "We intend that any patient in an accredited institution will receive scientific pain care."
To accomplish this, patients are being taught to rate their pain's origin, location, and intensity on a variety of scales, and staff members then chart the changes in intensity ratings every few hours, offering medication as needed. The latest compliance numbers just came in. In 2001, just 7 percent of facilities weren't up to snuff.
For patients, it's not just a matter of not hurting. Research has shown that when pain is controlled, people recover from illnesses more quickly and leave the hospital sooner. "Patients get better care with these assessments," says Charles Cleeland, director of the pain research group at M. D. Anderson Cancer Center in Houston. "For example, if you've had chest surgery and are in a lot of pain, you're not going to want to cough. So you're more likely to develop pneumonia" because gunk builds up in the lungs. That's life threatening. Pain ratings make it more likely that such agony will be noticed and treated with analgesics, and the chances of pneumonia go down with the pain.
Comfort index. When Linda Lewis checked into the University of Maryland Medical Center in Baltimore two weeks ago, she didn't know her pain was at an 8. That's on a scale where 0 at one end means no pain and 10 at the other end is the worst pain she could imagine. Lewis, a 54-year-old pharmacy technician in Cumberland, Md., "just knew it was excruciating, because I had a lung tumor that was pressing against my vocal cords and esophagus," she says. But hospital nurses explained the reason for the scale and told her they'd be asking her for numbers throughout her stay. If the pain got higher than a 4, they said, they'd ask other questions about its location and onset and whether it was sharp or dull, just to get a better handle on what was happening.
Lewis had her left lung removed, and right after surgery she thought her pain rated 8. She had a pump attached to her that streamed in nerve-blocking drugs when she pushed a button. "And the pain went down steadily," Lewis says. "On the third day it was a 6, and then a 4 or 5. It just felt like someone was pulling on me. Then they took the pump out, and I told them it jumped again, but they gave me Percocet." And the pain diminished to a 3. "People were coming around every three or four hours, asking about pain. I think they managed it really well." Nurses at George Washington University Hospital in Washington, D.C., track such ratings on bedside charts.
But the responsibility isn't all with the doctors and nurses. Teaching people how to use a scale, and picking the right one, are crucial, says Ira Byock, a palliative care physician and cofounder of the pain project in Missoula: "After trying several sample tools, we adopted 0-to-10 scales at both our hospitals, St. Patrick and Community Medical Center. Before that, some places were using 0-to-5 scales, and it just got confusing. If you got a call from the intensive care unit saying the patient had a 6, you didn't know if it was off the chart or just midrange. The same scale gave everyone a common language."
Other scales just seem harder for people to grasp. A "faces" scale, for instance, has a smiling face at the low end and a crying face at the high end. The trouble is that not everyone cries in pain or smiles in its absence. (These scales are still useful for children; it's important to match the scale to the abilities of the person using it.) Other scales just use words, like "very severe pain" and "pain as bad as it can be." But different words can mean different things to different people.
So patient education is a premium, but for hospitals it's also a potential pitfall. "A mandate without money" is what the doctor in charge of one major medical center's pain service calls the new standards. "We have only one pain nurse for the whole hospital," the doctor says, "and she's got to do all the patient and staff training on how to use the scales, as well as talk to patients about pain treatments." One stumbling block is that patients don't want to report pain because they don't want to be put on opiates; recent publicity about deaths on drugs like OxyContin have just made this worse. Fears of addiction or of just "being a bad patient" require discussion, says nurse Linda Torma, who teaches at the Missoula campus of Montana State University's College of Nursing. Some patients are in denial about their pain because they fear it means their disease has spread, and they have to learn how important pain is for diagnosis. That's a lot for a pain nurse to handle.
Missoula's solution, says Byock, was to get grant money to go out to the community. "We went to senior centers, churches, malls, you name it," he says. "The goal was to get people to understand how to report pain before they actually needed to. When people started walking into the ER saying, `I have pain between 8 and 10,' we knew that we'd succeeded."
Suffering's Faces
0 No hurt
2 Hurts little bit
4 Hurts little more
6 Hurts even more
8 Hurts whole lot
10 Hurts worst
This story appears in the February 18, 2002 print edition of U.S. News & World Report.