Chronic pain is not acute pain: forget the numerical pain scale

November 27, 2015, 11:11 am



Intensity of Chronic Pain — The Wrong Metric? Ballantyne JC, Sullivan MD. N Engl J Med 2015 Nov 26;373:2098-9.

Full Text

This short but very important “Perspective” article argues that numerical pain scales are absolutely the wrong way to evaluate and monitor  chronic pain. The authors point out that:

Opioids . . . have good short-term efficacy, but there is little evidence supporting their long-term benefit.

They note that the “titrate to effect” method that can be successful in treating acute or end-of-life (e.g., cancer) pain may not be appropriate or effective in cases of chronic pain:

For many patients, especially those who have become dependent on opioids, maintaining low pain scores requires continuous or escalating doses of opioids at the expense of worsening function and quality or life. And for many other people, especially adolescents and young adults, increased access to opioids has led to abuse, addiction, and death.

Evidence demonstrates that, brain-wise, chronic pain is a different beast than acute pain, reflecting not so much nocioception as emotional and psychosocial overlays. In those cases “[s]uffering maybe related as much to the meaning of pain as to its intensity.” With chronic pain the goal should be to reduce, not pain intensity, but the related suffering. Opioids and pain scales are counterproductive for efforts to reach that goal. Rather, chronic pain programs must address psychological and physical consequences.

An excellent recent Wall Street Journal article demonstrated who such an approach might work for chronic back pain.

To read my Emergency Medicine News column on opioids and pain as the “fifth vital sign,” click here.

Note carefully that the argument advanced in this piece that pain scales are not helpful applies specifically to cases of chronic non-cancer pain. While it leaves open the possibility that they may  still apply to cases of acute pain, we’ve all seen examples where patients try to game the system, as illustrated in this very funny bit from comedian Brian Regan:


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