Created with AI narration by News Over Audio (NOA) and ElevenLabs. Most of my interactions with medical professionals over the last two years have been preceded with the same straightforward but perplexing request: “Rate your pain on a scale of zero to 10.”
I’ve asked patients this exact same question thousands of times during my medical training, so I try to figure out how to put a number on the combination of my prickly thighs, painful hips, and tingly, itchy pain that’s right next to my left shoulder blade. I pause, and pick a number—mostly at random. “Is it three or four?” I hazard a guess, aware that the true solution is nuanced, multifaceted, and not quantifiable in this narrow sense.
One of those squarely things is pain. Sometimes it burns, sometimes it drills, and sometimes a deep-in-the-muscles clenching discomfort results. Mine depends on my mood or how much attention I give it; if I’m totally absorbed in a movie or a project, mine will almost totally vanish. Pain can also be so severe that it causes people to develop opiate addiction or cancel trips. When experienced for good reason like delivering a child even 10+ pain can be tolerable. But given the residual effects of a head injury, what use do the pains I currently experience?
Reducing various levels of suffering to a single number originated in the 1970s. However, the “pain revolution” of the 1990s, when there was a marked rise in focus on pain management mostly with opioids was credited with the widespread usage of the zero-to-10 scale. Modern doctors are more aware of their ability to (and should) consider treating pain as well as the horrible results of so freely prescribing narcotics. Only now are they learning how to more precisely assess suffering and handle its numerous manifestations.
A little over 30 years ago, doctors who supported the use of opioids gave pain management, which had hitherto been a specialized field, a strong new lease on life. They started advocating for pain assessment as the “fifth vital sign” at every visit. The phrase was even protected by copyright by the American Pain Society. However, there was no objective scale for pain, in contrast to the other vital signs of blood pressure, temperature, heart rate, and breathing rate.
How is the immeasurable measured? Physicians and nurses were urged by society to employ the zero-to-10 grading system. At about the same time, Purdue Pharma’s OxyContin, a slow-release opioid painkiller, received FDA approval. The pharmaceutical company itself actively promoted opioids as the obvious remedy and urged physicians to regularly document and manage pain.
To be fair, the zero-to-10 rating system may be considered a step forward in an era where pain was much too frequently overlooked or inadequately handled. Even those cancer patients in excruciating pain from cancer in their bones did not have access to morphine pumps when I saw them in the 1980s; doctors recognized pain as a natural byproduct of illness.
Prescriptions for even a few opioid pills were difficult to write in the emergency room where I worked in the early 1990s. You had to ask the chief nurse to unlock a special prescription pad and make a copy for the state agency that monitored prescribing patterns. Regulators were (rightfully) concerned that dispensing drugs would result in addiction. That means that some patients who were in need of relief probably didn’t get it.
Prescription writing for all kinds of pain, including knee arthritis or back issues, became significantly simpler and was encouraged after pain specialists and opioid manufacturers lobbied for more general use of opioids claiming that newer formulations were not addictive, or far less so than prior iterations. As a young doctor embracing the “pain revolution,” I most likely asked patients thousands of times to rate their pain on a zero to 10 scale and wrote numerous scripts each week for painkillers since monitoring “the fifth vital sign” soon became standard in the medical system.
A zero-to- ten pain rating evolved over time into a required box to complete electronic medical records. Regular pain assessment became a requirement for medical centres accepting federal health-care funds according to the Joint Commission on the Accreditation of Healthcare Organisations. Medical groups included pain management among their list of patient rights, and post-visit patient surveys now included satisfaction with pain treatment. (A poor showing could indicate less reimbursement from some insurance companies.)
But there were some obvious problems with this method of treating pain. A growing body of research indicates that greater pain management was not achieved by quantifying patients’ discomfort. Physicians were either uninterested in or unsure of how to react to the recorded response. Additionally, receiving appropriate therapy did not always follow from patients’ satisfaction with their doctor’s explanation of pain. The medications were also contributing to the escalating opioid crisis. According to research, between 3 and 19% of patients who receive a prescription for painkillers from a doctor go on to become addicted.
Still, doctors who sought to alleviate suffering had limited choices. According to Linda Porter, who leads the Office of Pain Policy and Planning at the National Institutes of Health, “we had a good sense that these drugs weren’t the only way to manage pain.” But our knowledge of the complexity or alternatives was poor. Many types of pain underexplored and untreated for years were left untreated by the fervent love for drugs.
Congress began funding a program the Early Phase Pain Investigation Clinical Network, or EPPIC-Net designed to investigate several kinds of pain and identify better answers only in 2018, a year when almost 50,000 Americans died of an overdose. The network links experts from twelve academic specialised clinical centres and is designed to initiate fresh field research and identify customised remedies for various types of pain.
In some cases, as when a nurse uses it to change a medication dosage for a patient hospitalised following surgery or an accident, a zero-to- 10 scale makes sense. And researchers and pain experts have tried to develop better rating tools dozens, in fact, none of which was sufficient to reflect the complexity of pain a European panel of experts decided. One that the Veterans Health Administration developed included visual cues and extra questions.
A five linked with a frown and a pain level that “interferes some activities.” The survey produced findings no better than the zero-to- 10 approach and required far more time to complete. Many medical groups, including the American Medical Association and the American Academy of Family Physicians, were rejecting not just the zero-to- 10 scale but the whole idea that pain could be properly self-reported quantitatively by a patient by the 2010s.
A few medications had become available during the years that opioids had dominated pain management: gabapentin and pregabalin for neuropathy, and lidocaine patches and creams for musculoskeletal aches. “According to Rebecca Hommer, interim director of EPICC-Net, “there was a growing awareness of the incredible complexity of pain—that you would have to find the right drugs for the right patients.”
Researchers are now searching for biomarkers associated with various pain types so that drug studies can use more objective measures to assess the effectiveness of the medications. A deeper comprehension of the neural pathways and neurotransmitters that generate different types of pain could also aid in the development of medications that interrupt and tame various pain sensations.
It is improbable that any medications developed from this research would become opioid blockbusters; by their very nature, they will benefit fewer patients. Additionally, drug corporations find them to be less desirable candidates. In order to evaluate the safety and effectiveness of promising pain-taming compounds, EPICC-Net is assisting small pharmaceutical companies, academic institutions, and even individual physicians with the design and execution of early-stage trials. With the intention of accelerating the FDA’s approval of new medications, drug manufacturers will receive this information for use in late-stage trials.
Just getting started are the first EPICC-Net studies. It will be difficult to find improved medicines since the nervous system is a vastly uncharted world of molecules, cells, and electrical connections that interact in a variety of ways. The researchers that figured out how humans perceive the two most fundamental sensations cold and hot were awarded the 2021 Nobel Prize in Physiology or Medicine. By contrast, pain is like a hydra. A mere figure could seem conclusive. However, nobody’s pain is being eased by it.