Pain Tolerability Question Could Lead to Better Treatment

John Markman, MD

If a patient described their pain as tolerable, it could decrease a clinician’s inclination to initiate higher-risk treatments, new study findings showed.

Because the focus of the numeric rating scale on pain intensity reduces the chronic pain experience, there can be negative trade-offs involved in analgesic decision-making.

John Markman, MD, and colleagues hypothesized that adding a standardized pain tolerability question—“is your pain tolerable?”—could help align a patient’s expectations with realistic treatment goals.

Markman, from the Translation Pain Research Program in the Department of Neurosurgery at the University of Rochester, and the investigators recruited participants electronically after an encounter at 1 of 157 participating primary care facilities from December 2016-March 2017. Patients were included if they had an active prescription for an analgesic medication or an ICD-10 visit diagnosis for chronic pain in their electronic health record (EHR).

Each participant was asked the pain tolerability question if their pain was tolerable. The patient answered either “yes,” “no,” or “not in pain” and then rated their average pain intensity during the last 24 hours (0=no pain; 10=the worst pain imaginable).

The responses to the question were compared to responses on the numeric rating scale using logistic regression.

Overall, 1384 patients were invited to take part in the survey of the numeric rating scale and pain tolerability question and 663 (47.9%) responded. Some patients (124) were excluded because they responded with “not in pain” to the pain tolerability question or 0 on the numeric rating scale. Others (2) were excluded because they didn’t complete the numeric rating scale.

Among the final sample of 537 patients, the median age was 62.2 years old and 206 (38.4%) were men.

Less than 40% (202 patients) had >1 chronic pain diagnosis. The most common pain diagnosis was musculoskeletal pain like osteoarthritis or soft-tissue disorder (54.9%; 295 patients).

For pain ratings of intolerable, patients had higher numeric rating scores (OR per 1-point increase on numeric rating scale, 1.1; 95% CI, 1.02-1.2; P=.01). Among the moderate pain range of 4-6, 40 of 211 patients (19%) said their was pain intolerable. In the severe range of the numeric rating scale (7-10), 72 of 137 patients (52.6%) considered their pain to be intolerable.

Because the goal of treatment for chronic pain was to make the pain more tolerable for the patient as opposed to attaining a targeted numeric rating, Markman and the investigative team said their findings confirmed the “intuitive assumption that most patients with low pain intensity (numeric rating scale score, 1-3) find their pain tolerable.”

The middle range scores led to different results from the lower numeric rating scale scores. Some patients who rated their pain score in the middle range of 4-6 said their pain was tolerable, which could decrease the chance a clinician would start a higher-risk treatment. Even some patients with severe pain reported symptoms as tolerable.

Clinicians could ask their patients about pain tolerability to directly address the limitations of the numeric rating scale, which can be subjective.

Additional research could be conducted to further understand the value of asking the pain tolerability question.

The study, “Comparison of a Pain Tolerability Question With the Numeric Rating Scale for Assessment of Self-reported Chronic Pain,” was published online in JAMA Network Open.