When the standard of care is bad medicine

When the standard of care is bad medicine – KevinMD.com – Myles Gart, MD | Physician | July 2019

This article explains that when you are in the hospital with acute pain, there’s a simple formula for prescribing pain medication (opioids) according to your stated pain level. No wonder so many patients inflate their numbers!

However, even though this article was published in July 2019, it assumes pain will be treated according to a patient’s report of their pain. That’s not what I’m hearing from pain patients who are sent home with aspirin or Tylenol even after major surgeries.

For the last three decades, the numeric pain score has been the go-to assessment for acute pain in the hospital setting. Since this methodology was developed for research purposes to see if drug “A” had an effect on patient “A,” its clinical utility is not just worthless but dangerous.

Let’s look at a simple example of a pain order set that is commonly used across the country.

  • If a patient says their pain is between 0 to 3 give X.
  • If a patient says their pain is between 4 to 7 give 2x and
  • If a patient says their pain is between 8 to 10 give 3x.

Wow, 3x can be a whopping dose of an opioid. You won’t believe this, but there are even order sets giving instructions to increase the dose to 4x for a score of 9 and 5x for a score of 10.

I had never heard of this before. This is what happens when very specific aspects of medicine are standardized.

Can someone tell me how these type of pain orders are patient-specific?

Can someone tell me why a 75 year old who says their pain is a 9 gets the same dose as a 27-year-old Navy Seal who says their pain is a 9 as well?

When you say “everyone” who says their pain is a 10 out of 10 gets 25 mg of Oxycodone IR every 6 hours PRN, you end up with many respiratory “events.”

Unfortunately, this is the standard of care in our nation’s hospitals: Bad medicine!

I’ve long been disgusted with this utter lack of consideration for the actual patient in all their complexity, not just their chart. And this is a danger that will increase exponentially with artificial intelligence, which only looks at database records to determine treatment.

Should I complicate the issue even more? How do you treat the patient who says their pain is a 9 and has COPD, obstructive sleep apnea, a BMI of 45, and who is opioid naïve or opioid-tolerant? That is a conundrum. Isn’t the nurse just supposed to take the word of the patient and treat according to the number?

According to the World Health Organization, untreated pain can be considered torture!

It’s too bad America is no longer listening to the World Health Organization.

the CDC says go low and slow when treating pain unless of course your 95-year-old grandmother who weighs all of 102 pounds soaking wet says her hip fracture pain is a 10 out of 10, then give the maximum opioid dose on the order set – who cares about starting low and going slow and following a logical opioid progression, right?

For us dinosaurs who were around before the ubiquitous use of the numeric pain score in the hospital setting, there is something called objective signs of pain.

I know it’s hard to believe, but when your body is in severe pain, it tells us with such crazy things as heart rate, respiratory rate, blood pressure, and pupil size.

It’s amazing how you can observe an individual in pain and use these objective signs to guide your analgesic therapy and even incorporate them into your pain order sets.

These objective measures would be present mainly in acute pain. Those of us who have pain all the time have to some degree adapted to it and don’t show so much distress.

My body no longer responds with adrenalin surges and intense muscle gripping to painful areas. Pain that would have alarmed me decades ago is just the daily grind now:

  • Headaches that would have sent me to the ER are just incredibly painful until I can take my prescribed opioid medication to bring the pain down to tolerable levels.
  • Crippling muscle spasms that would have persisted for days/weeks I now medicate with prescribed muscle-relaxants and resolve in the comfort of my own home.
  • Intense joint pain that would have led to a doctor’s appointment with an Xray (that would show nothing wrong) I partially relieve with opioid medication just enough so I can move the joint, exercise it, and eventually get it back into alignment.
  • Being achy and tired every hour of every day would have alarmed me, but now I know it’s just my body struggling to keep functioning even when pain signals are telling me to stay lying down all the time.

Is anyone currently practicing this method? Yes, every day with patients in the ICU on ventilators as well as hundreds of thousands of individuals having surgery under general anesthesia every year.

So please tear up your numeric scoring method for analgesic treatment and help join the movement to start a new standard of care that is safe and based on objective measures.

Myles Gart is an anesthesiologist

There has to be a distinction made between “standards of care” and “standard doses of medication”.

Standardized doses of medication may provide a starting point for reference, but then the “standard of care” should require them to be adjusted according to the individual patient’s need.

2 thoughts on “When the standard of care is bad medicine

  1. Judith

    THIS: ” when your body is in severe pain, it tells us with such crazy things as heart rate, respiratory rate, blood pressure, and pupil size.” So many doctors do not pay attention to this, or chalk it up to anxiety. But yes, these are definitely impacted by pain!

    Liked by 1 person

    1. Zyp Czyk Post author

      I wonder if my unusually fast pulse might be related to living with pain all the time… I know that everything is interconnected so I think pain will eventually affect the homeostasis of mind and body as a coping mechanism.



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