Pain measures and cut‐offs – ‘no worse than mild pain’ as a simple, universal outcome

Now admittedly the patient in question had undergone a life-saving operation in a brand new hospital staffed by some wonderful and talented people. However, a pain score of 6/10 is not mild, but borderline between moderate and severe, and the patient did need something for that. Was the nurse ignorant of what pain scores meant, or was it just that caring professionals typically underestimate patients’ pain [1]? Both these questions are deserving of research, but for this patient, the only point is that the system failed him, and for him the reasons behind the failure were of little interest. He had pain that was borderline severe, and it was not treated. This is not uncommon. A fairly recent survey of Italian hospital wards came to the hardly original conclusion that those wards in which less analgesic was prescribed had higher rates of patients experiencing severe pain than those where more analgesics were prescribed [2]; Fig. 1 shows the clear inverse relationship between the presence of severe pain and the percentage of patients treated for their pain. There is a wealth of evidence that pain is poorly treated, and that significant proportions of patients suffer from moderate or severe pain, whether it is acute pain in hospital [3] or chronic pain in the community [4, 5]. Barriers to progress are many and varied, but one particular and important barrier is a degree of confusion about pain scoring systems and what they mean. How does a simple categorical verbal rating system (no pain, mild, moderate, severe) relate to a 100-mm visual analogue scale (VAS) or an 11-point numerical rating scale (NRS)? Does it matter what the anchors are at each end? Where are the boundaries for moderate or severe pain? What is the minimal clinically significant difference? Does it matter whether the scale has been ‘validated’ in Welsh, or Farsi, or Urdu? All of which makes for terrific grist for