Correspondence

Assessment of Patients' Pain

N Engl J Med 1996; 334:59January 4, 1996

Article

To the Editor:

Attitudes toward analgesic therapy were strongly influenced by efforts in the 1930s to “solve the problem of drug addiction.” An influential paper published in 1941 stated, “The use of narcotics in terminal cancer is to be condemned if it can possibly be avoided.”1 Undertreatment of pain has been repeatedly documented.2

One hypothesis is that members of the medical staff do not know the intensity of pain the patient is experiencing and would more adequately treat it if they knew.3,4 To test this hypothesis, we interviewed 48 patients admitted in pain (from cancer in 18 patients, from sickle cell crises in 7, from AIDS in 7, and from other causes in 16) to a medical floor the previous day. Medical and nursing staff members primarily responsible for their care were also interviewed. Each was asked to rate the severity of the patients' pain on a scale of 0 to 10. Staff members were also asked how they thought the patients would rate the pain.

The physicians rated the patients' pain intensities an average (±SD) of 2.1±2.4 units lower than the patients did, and the nurses rated the patients' pain 1.8±2.4 units lower. However, the physicians and nurses accurately judged what the patients' ratings of their pain intensity would be. Only 17 physicians (35 percent) rated their patients' pain within 1 scale division of the patients' ratings, whereas 33 (69 percent) stated within 1 scale unit what the patients would say the pain was (P = 0.002 by the chi-square test). Nurses' ratings were similar. Thirty-two (67 percent) of the doctors and 33 (69 percent) of the nurses thought the pain was really less than the patients said it was. We conclude that many physicians and nurses may be aware of patients' perceptions of pain intensity but think that they overstate the intensity of their pain. Our findings were similar for patients with cancer and for those with other diseases.

Possible explanations of this discounting of patients' expressed severity of pain include rejection of the idea that the emotional component of pain is a major contributor to “real” pain, despite research identifying it as such dating back to World War II5; denial of severe pain to justify a decision that opiates are not appropriate therapy for a specific patient; and the absence of “pain behavior” by the patient. The reasons that pain intensity as expressed by the patient is discounted must be understood if this attitudinal barrier to better pain control is to be overcome.

Suzanne Krivo
Marcus M. Reidenberg, M.D.
Cornell University Medical College, New York, NY 10021

5 References

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   Lee LE Jr. Medication in the control of pain in terminal cancer. JAMA 1941;116:216-219
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   Marks RM, Sachar EJ. Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med 1973;78:173-181
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   Angell M. The quality of mercy. N Engl J Med 1982;306:98-99
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   McGivney WT, Crooks GM. The care of patients with severe chronic pain in terminal illness. JAMA 1984;251:1182-1188
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   Beecher HK. Relationship of significance of wound to pain experienced. JAMA 1956;161:1609-1613
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Citing Articles (7)

Citing Articles

1. 1

   Phil Harper, Steven Ersser, Mary Gobbi. (2007) How military nurses rationalize their postoperative pain assessment decisions. Journal of Advanced Nursing 59:6, 601-611
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2. 2

   Marcus M. Reidenberg, Beth F. Jung. (2006) Comment About the Three Commentaries. Pain Medicine 7:4, 365-366
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3. 3

   Monique van Dijk, Hans M. Koot, Huda Huijer Abu Saad, Dick Tibboel, Jan Passchier. (2002) Observational Visual Analog Scale in Pediatric Pain Assessment: Useful Tool or Good Riddance?. The Clinical Journal of Pain 18:5, 310-316
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4. 4

   Rebecca A Drayer, Jessica Henderson, Marcus Reidenberg. (1999) Barriers to Better Pain Control in Hospitalized Patients. Journal of Pain and Symptom Management 17:6, 434-440
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5. 5

   Elizabeth H. Winslow. (1998) Effective Pain Management. American Journal of Nursing 98:7, 16HH-16II
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6. 6

   Michele S Hirsch, Robert M Liebert. (1998) The physical and psychological experience of pain: the effects of labeling and cold pressor temperature on three pain measures in college women. Pain 77:1, 41-48
   CrossRef

7. 7

   Allen H. Lebovits, Isaiah Florence, Ramesh Bathina, Veronica Hunko, Mary T. Fox, Celia Y. Bramble. (1997) Pain Knowledge and Attitudes of Healthcare Providers: Practice Characteristic Differences. The Clinical Journal of Pain 13:3, 237-243
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