Q: How Does the Pain Scale Work?

You’re in a lot of pain and you’ve decided to come to the ER. We get you back to a bed, and inevitably part of our assessment is asking you to rate your pain from 0-10. If you’re like many other people, this either confuses you or gives you anxiety. Here are some actual questions I’ve received about the pain scale…

What if I give a number that’s wrong?

(A: There is no right or wrong number. Unless you give a number outside the scale.)

What if I rate it too high and you give me heavy drugs I don’t want?

(A: We can’t give you pain meds you don’t want.)

If I rate it too low will you refuse to give me pain meds?

(A: Your treatment doesn’t rely on the pain scale number, and the doctor will prescribe what he or she thinks is appropriate, regardless of the number you throw out.)

Obviously, the pain scale question creates some anxiety for many. But when you’re asked this question, you need to relax…well, as much as you can. You are in pain, after all.

Stepping on a Lego is definitely a 10, just so we’re clear.

I’ll admit, the fact that the pain scale trips everyone up is mostly on us. It’s one of those things that healthcare professionals think is easy to manage, but it isn’t. Here’s the simple answer to the “problem” of the pain scale: It’s just a reference. If your chief complaint coming in is pain, then we want to know your starting point so we know how well our interventions have worked. If you rated your pain a 5 and we gave you Tylenol, we want to know if that Tylenol worked. If you rate your pain a 2 an hour later, then we feel confident about our intervention. If you rate it an 8 all of a sudden, we know we need to re-evaluate.

We don’t have some reference sheet with numbers on the pain scale next to the appropriate drugs. The pain scale does NOT dictate what drugs you get. At all.

A ridiculous scenario:

RN: “Hey doc, the patient in room ten says their pain is a 7/10, and I really think they need something to help ease things up. They appear to be in agony.”

Doc: “Well, offer them a warm blanket. That’s all we can do for a 7. Too bad they didn’t say 8—we have all this morphine sitting around…”

See? It’s silly. The doctor will prescribe what they think is appropriate based upon your presentation and assessment, not some arbitrary number. If the number you gave dictated your drugs, then people would only rate their pain either a 2 or a 10, depending on whether or not they wanted narcotics.

Many patients seem to think saying 10 (or more—”It’s a 19!” guarantees eye rolls) guarantees them narcotics, like we’re a fast food joint and they’re ordering a combo meal. Drug seekers are real, and we despise them for taking up time and resources, but don’t worry about being pegged a drug seeker if you aren’t one. Every state has a system to track narcotic prescriptions (in Ohio, we have the OARRS), and the drug seekers’ reports light up like a Christmas tree in Times Square. It’s always fun to walk into a room with a doctor and watch the patient’s face as the doctor says, “You were prescribed ten Percocet yesterday. Where did all of those go?” Usually, the answer is that they lost the prescription or that the drugs “accidentally got flushed down the toilet.” These people are only in the ER to waste everyone’s time, and they are usually easy to pick out.

Of course, it’s okay to say your pain is a 10, if that’s what you’re feeling. For some people, a 10 is labor and delivery. For others, it’s a kidney stone. For someone else, it’s a hangnail.

If you are in pain, just give a number you think is appropriate. More importantly, describe it. We care more about where your pain is on your body, whether or not it’s radiating (traveling) to another place in your body, and the quality of the pain (pressure, stabbing, burning, cramping, etc…). I’ve seen people having massive heart attacks rate their chest pain only a 2. I’ve had patients with broken bones, dislocated joints, acute appendicitis, and all sorts of other situations requiring attention and/or hospitalization rate their pain less than five. I’ve also had patients rate sore throats and minor cuts and scrapes a 10. It’s all relative, and none of it dictates the drugs given. The physician’s assessment dictates the drugs given—as it should be.

So feel free to let loose whatever number you feel is right for you. And you really don’t have to downplay it. Just say what you think it is. We really aren’t going to judge you as long as you aren’t trying to lie. Please don’t lie. And please don’t demand narcotics. We’re in a tough spot with the opioid epidemic in this country, and we’re doing our best, but we’re also being watched closely. (I’ll do a post about pain itself and addressing the opioid crisis in the near future.)

But, if you truly need an accurate pain scale to judge which number to assign your pain, I’ve always liked this one:

So who am I to give advice? Your answer is here.

Have a question? Ask here.

And, of course, feel free to leave a comment. I’m okay with being corrected or engaging in conversation.

Related links:

Johns Hopkins Magazine: “The Trouble With Treating Pain”: https://hub.jhu.edu/magazine/2014/fall/treating-pain-problems/

“Reinventing the Pain Scale in the Emergency Department”: https://www.kevinmd.com/blog/2013/10/reinventing-pain-scale-emergency-department.html

A fair perspective on the pain scale from someone with chronic pain: https://themighty.com/2019/01/1-10-faces-pain-scale-problem-bad-chronic-pain/

One of my favorite comedy bits about the pain scale:

2 thoughts on “Q: How Does the Pain Scale Work?

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