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AMDA Clinical Practice Guideline (CPG) for Pain Management

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1 AMDA Clinical Practice Guideline (CPG) for Pain Management
For Medical Directors and Attending Physicians

2 Introduction to Pain Pain is common in the long-term care setting.
Unrelieved chronic pain is not an inevitable consequence of aging Aging does not increase pain tolerance or decrease sensitivity to pain Most chronic pain in the long-term care setting is related to arthritis and musculoskeletal problems Pain may be associated with mood disturbances (for example, depression, anxiety, and sleep disorders) An estimated 45 to 80 percent of nursing home patients have some chronic pain [1]. For various reasons, pain may not be adequately recognized or treated. The treatments that are given may be inconsistent or hazardous. Having more than occasional, minimal pain is always undesirable, and is not normal. Also, it is not true that pain is a normal part of aging. Approximately one in four long-term care patients have some form of arthritis. Many elderly also have pain related to damage or diseases of the nervous system; for example, diabetic neuropathy, postherpetic neuralgia and post-stroke [2]. Patients in long-term care settings experiencing pain may also have symptoms of sleep disturbances, depression and anxiety. [1]. Stein WM, Ferrell BA. Pain in the nursing home. Clin Geriatr Med 1996; 12(3)(Aug): [2]. AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc 2002; 50(6): 1-20.

3 Introduction to Pain The use of pain scales Acute vs. chronic pain
Long-term care interventions Believe it or not, the cognitively impaired (senile or demented) patient can feel, and often can report pain. Pain management principles are similar for both acute and chronic pain. Some important distinctions exist in recognition, assessment, treatment, and monitoring of acute pain versus chronic pain. For example, the causes and characteristics of chronic pain are more likely to have already been identified. But, when a patient is in acute pain, both causes and characteristics of the pain may have to be identified rapidly. Individuals with chronic pain usually need treatment over the long term, because the causes of pain don’t go away. Causes of acute pain often –but not always– can be corrected.

4 Pain in the Elderly Definition of Pain—An individual’s unpleasant sensory or emotional experience Acute pain is abrupt usually abrupt in onset and may escalate Chronic pain is pain that is persistent or recurrent One nationwide study [3] on persistent severe pain found that 14.7 percent of the 2.2 million nursing home patients in the United States were in persistent pain. Also, 41.2 percent who reported some pain at a first assessment were in severe pain 60 to 180 days later. This study analyzed Minimum Data Set data representing all nursing home patients in all 50 states, and found that the rate of pain persistence varied considerably by state from 37.7 percent in Mississippi to 49.5 percent in Utah. Media reports, government and public reaction, and occasional lawsuits regarding pain management have begun to put pressure on long-term care facilities and practitioners regarding pain management. The Centers for Medicare and Medicaid kicked off a national state initiative to improve the quality of care in nursing facilities in 2002 – and pain is a key part of that effort! The program is called “The Nursing Home Quality Initiative” and the prevalence of pain in nursing facility patients is one of several quality measures chosen for study in both chronic and post-acute patient populations. [3] Teno JM, Weitzen S, Wetle T, Mor V. Persistent Pain in Nursing Home Residents, JAMA 2001; 285(16):2081. Partners Against Pain web site at (Pain Management Center, Pain in the Elderly).

5 Pain in the Elderly The most common reason for unrelieved pain in the U.S. is failure of staff to routinely assess for pain Therefore, JCAHO has incorporated assessment of pain into its practice standards “The fifth vital sign” The American Pain Society states that the most common reason for unrelieved pain is failure of staff to routinely assess for it. There remains a great need for improved training in pain management at all levels of medical education. Also, allied health professionals and in particular, direct care staff (nurses and nursing assistants) need on-going education in pain assessment and management. We also need to educate patients and families. Some patients don’t report pain because they think pain is expected, they don’t want to bother anyone, they don’t think treatment will help, or they fear the side effects of pain medication. Sometimes, families disapprove of giving pain medications for similar reasons.

6 Pain in the Elderly Condition causing pain Frequency (%) Low back pain
Sources of pain in the nursing home Source: Stein et al, Clinics in Geriatric Medicine: 1996 Condition causing pain Frequency (%) Low back pain 40 Arthritis 37 Previous fractures 14 Neuropathies 11 Leg cramps 9 Claudication 8 Headache 6 Generalized pain 3 Neoplasm: Non-cancer pain accounts for 97% of pain complaints in nursing facilities. But, pain is a serious problem for patients with cancer. Among advanced cancer patients, 40% to 50% have moderate to severe pain and 25-30% have very severe or excruciating pain. In rating their pain, the majority of patients (69%) say that they are most affected by pain that impairs their functioning. Cancer-related physical pain includes bone pain, soft tissue pain, neuropathic pain, intracranial pain and visceral pain. Mechanisms of cancer pain include direct tumor extension, tissue compression and infiltration leading to inflammation and swelling. Cancer can cause many acute and chronic pain syndromes, as can diagnostic and therapeutic interventions.

7 Conditions Associated with the Development of
Pain in the Elderly Conditions Associated with the Development of Pain in the Elderly Degenerative joint disease Gastrointestinal causes Fibromyalgia Peripheral vascular disease Rheumatoid arthritis Post-stroke syndromes Low back disorders Improper positioning

8 Conditions Associated with the Development of
Pain in the Elderly Conditions Associated with the Development of Pain in the Elderly Crystal-induced arthropathies Renal conditions Gastrointestinal disorders Osteoporosis Immobility, contracture Neuropathies Pressure ulcers Headaches Amputations Oral or dental Pathology Although we can only estimate the exact number of patients in long-term care facilities who develop pain, most long-term care patients have predisposing factors for developing pain. There are very diverse presentations of pain in the elderly. [4] Rational selection of pain treatment strategies requires a comprehensive assessment by the practitioner .[5] A high suspicion for the presence of pain is warranted for all patients. Every patient should be regularly evaluated for pain upon admission, at each quarterly review, at a change of condition prompting evaluation by the practitioner and completion of the MDS, and of course, when pain is suspected. Elderly patients may have multiple causes of pain. Remember this as you approach patients and document reported pain sites in the medical record. [4] Guay DR. Adjunctive agents in the management of chronic pain. Pharmacotherapy ; 21: [5] Joint Commission on Accreditation of Healthcare Organizations. Pain management today. In: Pain Assessment and Management: An Organizational Approach. Joint Commission in Accreditation of Healthcare Organizations. Oakbrook Terrace, IL; 2000:1-6.

9 Barriers to the Recognition of Pain in the LTC setting:
Pain in the Elderly Barriers to the Recognition of Pain in the LTC setting: Different response to pain Staff training Cognitive or sensory impairments Practitioner limitations Social or Cultural barriers System barriers Co-existing illness and multiple medications Elderly patients may not show the same signs and symptoms as younger patients. Patients may not be able to report feeling pain or respond to questions about pain because of cognitive or sensory impairments or difficulties with language or speech. Racial, ethnic, and gender biases may hinder patients from reporting pain and may reduce a caregiver’s sensitivity to the signs and symptoms of pain. Use of multiple medications may also modify reactions to pain. Caregiving staff may not be adept at assessing pain or use appropriate assessment instruments. Practitioners may have biases about pain or be unfamiliar with contemporary approaches to pain management. Other factors such as high staff turnover, poorly functioning care teams and inadequate communication among interdisciplinary team members may inhibit adequate pain management programs.

10 Pain in the Elderly: Myths
To acknowledge pain is a sign of personal weakness Chronic pain is an inevitable part of aging Pain is a punishment for past actions Chronic pain means death is near Chronic pain always indicates the presence of a serious disease Acknowledging pain will mean undergoing intrusive and possible painful tests.

11 Pain in the Elderly: Myths
Acknowledging pain will lead to loss of independence The elderly – especially cognitively impaired – have a higher pain tolerance The elderly and cognitively impaired cannot be accurately assessed for pain Patients in LTC say they are in pain to get attention Elderly patients are likely to become addicted to pain medications Under-recognition of pain is rooted in the nature of pain and societal attitudes toward it. Pain is subjective and lacks consistent objective biological markers. Therefore, numerous myths about pain have emerged in society and continue to persist. Policies, procedures and guidelines need to be developed and implemented in each facility to ensure communication among providers throughout the care process. Facilities should consider the following: (1) using a common pain vocabulary (2) seeking the input of all individuals who interact with the patient (3) designating a staff member who will be the champion of pain management the facility – meaning that all patients are properly assessed and treated (4) documenting pain assessment and treatment consistently in the medical record (5) integrating quality indicators into the QA plan that addresses all aspects of pain management.

12 Pain in the Elderly Consequences of untreated pain: Depression
Suffering Sleep disturbance Behavioral disturbance Anorexia, weight loss Deconditioning, increased falls Elder patients with pain may experience the consequences of pain that are listed above. We need to ensure that nurses, nursing assistants and other staff are alert to these consequences and not automatically attribute them to natural disease processes. Pain is often associated with mood disturbance in the older patient. Conversely, patients may be diagnosed with a mood or thought disorder and treated with a psychotropic medication when their real problem is unrecognized, untreated pain. Some evidence suggests that the use of a mild analgesic can reduce the usage of psychotropic drugs.

13 Pain in the Elderly Inferred Pain Pathophysiology 6]
Nociceptive pain – Explained by ongoing tissue injury Neuropathic pain – Believed to be sustained by abnormal processing in the peripheral or central nervous system Psychogenic pain – Believed to be sustained by psychological factors Idiopathic pain – Unclear mechanisms In the long-term care setting, the comfort and well being of the individual patient should always come first – regardless of the reason for the pain. This principle is the foundation for effective management of pain. Adequate pain management should be sought in each case. Individualized care planning tailors pain management to each patient’s needs, circumstances and risk factors. Consider the idea of Total pain. The four components of total pain – physical pain, emotional pain, social pain and spiritual pain interact with each other. Accordingly, effective comfort care addresses all four components. We should look for depression, anxiety and agitation and emotional pain caused by anger, fear, loneliness, strained family relationships, and financial problems. [6] Ad Hoc Committee on Cancer Pain of the American Society of Clinical Oncology. Cancer pain assessment and treatment curriculum guidelines. J Clin Oncol. 1992; 10: Available at: Accessed February 5, 2002.

14 AMDA Pain Management CPG—Steps
Recognition Assessment Treatment Monitoring AMDA’s guideline for pain management consists of four major areas: Recognition of a person who is having pain Assessment of the person with pain to identify details and seek underlying causes Treatment selection Monitoring of patient status We’ll discuss steps related to each of these four areas in further detail.

15 Pain in the Elderly-Recognition
Possible Indicators of Pain in MDS – Version 2.0 Restlessness, repetitive movements (B5) Sleep cycle (E1) Sad, apathetic, anxious appearance (E1) Change in mood (E3) Resisting care (E4) Change in behavior (E5) Functional limitation in range of motion (G4) Change in ADL function (G9) The primary way to identify pain is to examine and question the patient. But in addition, the Minimum Data Set (MDS) contains some “clues” that a resident might be having pain. You should ask the nursing staff to review the most recent MDS for some of these indicators that could indicate the presence of pain and should prompt further investigation. A tool for this is included in the pain CPG implementation tool kit.

16 Pain in the Elderly-Recognition
Possible Indicators of Pain in MDS – Version 2.0 Pain site (J3) Pain symptoms (J2) Restlessness, repetitive movements (B5) Sleep cycle (E1) Sad, apathetic, anxious appearance (E1) Change in mood (E3) Resisting care (E4)

17 Pain in the Elderly-Recognition
Possible Indicators of Pain in MDS – Version 2.0 Loss of sense of initiative or involvement (F1) Any disease associated with pain (I1) Pain symptoms (J2) Pain site (J3) Mouth pain (K1) Weight loss (K3)

18 Pain in the Elderly-Recognition
Possible Indicators of Pain in MDS – Version 2.0 Oral status (L1) Skin Lesions (M1) Other skin problems (M4) Foot Problems (M6) ROM restorative care (P3) The MDS may be used as a tool to aid in pain assessment. However, it does not help to confirm whether a symptom or finding means that the patient actually has the problem. Also, The evaluation of pain generally cannot wait for a formal MDS review to be performed. The MDS does not substitute for a comprehensive bedside patient evaluation and discussion with the interdisciplinary team.

19 Pain in the Elderly– Recognition
Non-specific signs and symptoms suggestive of pain: Frowning, grimacing, fearful facial expressions, grinding of teeth Bracing, guarding, rubbing Fidgeting, increasing or recurring restlessness Striking out, increasing or recurring agitation Eating or sleeping poorly All members of the care team can be trained in looking for these non-specific pain “clues” in facility patients. A “Be a Pain Detective” clue sheet has been included in the pain CPG implementation tool kit. However, all of these symptoms are nonspecific and could represent other conditions such as delirium. Therefore, a physician should help distinguish the meaning of such symptoms when it is not readily apparent.

20 Pain in the Elderly– Recognition
Non-specific signs and symptoms suggestive of pain: Sighing, groaning, crying, breathing heavily Decreasing activity levels Resisting certain movements during care Change in gait or behavior Loss of function Older patients often describe discomfort, hurting or aching – rather than use of the specific word – pain. A patient’s self-report should not routinely be the sole basis in evaluating pain – additional direct examination is important in helping to identify pain characteristics and possible causes. Practitioners and licensed nurses should encourage all members of the interdisciplinary care team to use a common vocabulary to describe pain and a standard array of pain assessment that are understood by everyone who uses them. Licensed Nurses need to promote an aggressive, coordinated approach to pain management throughout your facility. This includes formal education about pain assessment and treatment in training and orientation programs for all employees – including nursing assistants.

21 Pain Management CPG— Recognition Steps
Is pain present? Have characteristics and causes of pain been adequately defined? Provide appropriate interim treatment for pain. Because some individuals may be reluctant to acknowledge feeling pain, phrase the question such as: “Are you having pain now”? “Does it hurt anywhere”? or “How is your pain today compared to yesterday/your worst day”? It may help to ask a family member how the individual historically has expressed discomfort. It is important to ask about key characteristics of pain – (1) onset (2) frequency (3) location and (4) radiation. Also, ask patient to describe pain – e.g., burning, aching. Consider how pain is affecting the patient’s mood and activities of daily living (ADLs) and note factors that make pain better or worse.

22 Pain Management CPG— Recognition
Pain Intensity Scales for Use with Older Patients – Visual Analogue Scale No pain Terrible pain l______l_____l_____l______l_____l______l_____l______l______l Ask the patient:“Please point to the number that best describes your pain” No one scale is the “gold standard.” A scale should be appropriate and reliable for the individual. For cognitively impaired and uncommunicative patients, verbal scales are generally not useful. Instead, use scales that rate and score behaviors suggestive of pain. If a patient has some cognitive impairment but can respond to simple yes-no questions reliably, ask: “Do you have pain now?” or “Do you have pain everyday?” or “Does pain keep you from sleeping at night?” Regardless of drawbacks, use a standardized scale to quantify the intensity of the patient’s pain at its best and worst. Important: Sometimes it is appropriate to modify pain scales to the patient environment and population. For example, you may ask a patient – “Tell me how intensely you are feeling your pain – none, some or severe”? Even with this simple scale – you often get the clinical information you need. Scale has worst possible pain at a # 10

23 Pain Management CPG— Recognition Documenting an Initial Pain Assessment
Pattern: Constant_________ Intermittent__________ Duration: __________ Location: __________ Character: Lancinating____ Burning______ Stinging_____ Radiating______ Shooting_____ Tingling______ Other Descriptors:________________________________ Exacerbating Factors:______________________________ Relieving Factors:_________________________________ This is an example of a tool for the initial assessment of pain. (It continues on the next slide…)

24 Pain Intensity – (None, Moderate, Severe) 1 2 3 4 5 6 7 8 9 10
Worst Pain in Last 24 Hours (None, Moderate, Severe) Mood: ________________________________________ Depression Screening Score: ______________________ Impaired Activities: ______________________________ Sleep Quality: __________________________________ Bowel Habits: __________________________________ Other Assessments or Comments:__________________ ______________________________________________ Most Likely Causes Of Pain: _______________________ Plans: ________________________________________ Use this or a similar tool for documenting pain (location, intensity, nature, etc.) initially and periodically in enough detail to permit differentiation of the causes of pain and to facilitate evaluation of the progress of pain management. Pay particular attention to body regions and systems that appear to be contributing to the pain. Incorporate information from the patient’s family and members of the multidisciplinary team, especially when the patient suffers from moderate to severe dementia or has impaired communication.

25 Pain Management– Assessment Steps
Perform a pertinent history and physical examination Identify the causes of pain as far as possible Perform further diagnostic testing as indicated Identify causes of pain Obtain assistance/consultations as necessary Summarize characteristics and causes of the patient’s pain and assess impact on function and quality of life Physicians and other staff must regularly ask patients about their pain and assess it systematically. Critical point: Pain Management may be most successful when the underlying cause of the pain is identified and treated (if possible). Do all you can to help with the assessment and help the team find the underlying cause!! The physician’s summary progress note should describe important diagnoses or conditions that are contributing to the patient’s pain. Also give reasons for recommending why significant potential treatment options were not employed, taking into account: (1) patient’s overall state of health (2) preferences of the patient, family or advocate and (3) the patient’s advance directives. The scope of the work-up depends on patient prognosis, goals, and identified causes. An extensive work-up may not be necessary if the causes are already known, the patient has an end-stage condition, or if identifying the pain would not change the care plan. In light of this, you may want to consider the following laboratory testing options for individuals with pain: Hemoglobin and hematocrit (if anemia is suspected) Fasting glucose (to screen for diabetes or to assess glucose control) Blood urea nitrogen and creatinine (to assess renal function – especially if analgesics are prescribed) Liver profile (if liver disease is suspected – especially if analgesics are prescribed) Urinalysis (if infection, urolithiasis, or other genitourinary disease is suspected) Uric acid (if crystal-induced arthropathy is suspected) Alkaline phosphatase (if Paget’s disease or other bone involvement is suspected) Spine x-rays (if recurrent compression fractures are suspected) CT Scan or MRI (if spinal stenosis is suspected)

26 Pain Management– Assessment Steps
Pain History [7] – Important Elements to Include: Known etiology and treatments – previous evaluation, pain diagnoses and treatments Prior prescribed and non-prescribed treatments Current therapies Physicians – Should seek additional information from the patient’s family or advocates since they may provide information of causes and conditions contributing to the pain, as well as results of any previous investigations. Consulting Pharmacists – They can help review medications (current and past) and their efficacy. Nursing Staff - Can perform a direct evaluation of pain during routine care such as checking for redness or warmth in a painful joint, and palpating the suprapubic area for evidence of pain or distention. [7] Portenoy RK. Opioid prescribing to patients with and without chemical dependency. Presented at: The International Conference on Pain and Chemical Dependency; June 6-8, 2002: New York, NY.

27 Pain Management– Assessment Steps Chronic Pain History
“PQRST” Provocative/palliative factors (e.g., position, activity, etc.) Quality (e.g., aching, throbbing, stabbing, burning) Region (e.g., focal, multifocal, generalized, deep, superficial) Severity (e.g., average, least, worst, and current) Temporal features (e.g., onset, duration, course, daily pattern)  Medical History Existing comorbidities Current medications Source: Valley, MA. Pain measurement. In: Raj PP. Pain Medicine. St. Louis MO. Mosby, Inc. 1996:36-46. This mnemonic is a good reminder of what should be covered in a comprehensive chronic pain history.

28 Pain Management– Treatment Steps
Adopt an interdisciplinary care plan Set goals for pain relief Implement the care plan Tailor the treatment plan to the individual patient’s causes, needs, and preferences. Also, do not regard an advance directive that limits diagnostic procedures as limiting treatment of pain. Factors that influence the choice of treatments are: (a) the underlying diagnoses or conditions that are causing or contributing to pain (b) the severity, location and causes of the pain (c) patient prognosis (d) patient risk factors and co-morbidities (e) current medication regimen (f) cost-effectiveness of the interventions (g) evidence of effectiveness of certain interventions and (h) availability of providers. Also, there are a number of therapeutic approaches for chronic pain that should be considered in the short or long-term such as: (a) pharmacotherapy (b) rehabilitative approaches (c) psychological approaches (d) anesthesiologic approaches (e) surgical approaches (f) neurostimulatory approaches (g) complementary/alternative approaches and (h) lifestyle changes. [8] Be sure to offer a realistic outlook to guide patient, family and staff expectations – reviewing treatment goals and possible medication side effects. [8] Joint Commission on Accreditation of Healthcare Organizations. Pain management today. In: Pain Assessment and Management: An Organizational Approach. Joint Commission in Accreditation of Healthcare Organizations. Oakbrook Terrace, IL; 2000: 1-6.

29 Pain Management– Treatment Steps
Provide a Comforting and Supportive Environment – Reassuring words/touch Topical or low-risk analgesic Talk with patient/caregivers about pain Back rub, hot or cold compresses Whirlpool, shower Comforting music Chaplain services Nursing assistants and other staff play a key role in providing patient comfort measures. Don’t just order analgesics. Simple measures often provide substantial relief.

30 Pain Management– Treatment Steps Ethics and Pain
The old ethic of under-prescribing  “just say no”  “it hurts so good” The new ethic  trust: believing what patients say  commitment: formalized mutual agreement  standardized care: guidelines on assessment and treatment  collaboration: working together Source: Marino A. J Law, Med Ethics, 2001 For patients with acute pain, the primary goals are: (1) establish causes of pain (2) find appropriate regimen as quickly as possible, and (3) adjust pain management regimen while minimizing side effects and continue to find underlying causes. For patients with chronic pain, the primary goals are: (1) improving quality of life and (2) relieving pain by identifying reasons for fluctuations in the severity of chronic symptoms.

31 Pain Management– Treatment
General Principles for Prescribing Analgesics in the Long-Term Care Setting Evaluate patient’s overall medical condition and current medication regimen Consider whether the medical literature contains evidence-based recommendations for specific regimens to treat identified causes For example, acetaminophen for musculoskeletal pain; narcotics may not help fibromyalgia In most cases, administer at least one medication regularly (not PRN)

32 Pain Management– Treatment
General Principles for Prescribing Analgesics in the Long-Term Care Setting Use the least invasive route of administration first For chronic pain – begin with a low dose and titrate until comfort is achieved For acute pain – begin with a low or moderate dose as needed and titrate more rapidly Reassess/adjust the dose to optimize pain relief while monitoring side effects At this point, prescribe appropriate interventions – medications and complimentary (non-pharmacologic) interventions -- as indicated. Document pain relief measures in the patient record, including refusal of relief measures by the patient and reasons, if possible.

33 Pain Management– Treatment
Appropriateness of regular or PRN dosing: Intermittent/less severe pain –  Start with PRN then switch to regular if patient uses more than occasionally.  Start with a lower regular dose and supplement with PRN for breakthrough pain.  Adjust regular dose depending on frequency/severity of breakthrough pain. When prescribing opioids with only partial relief, increase the scheduled dose if more than 2 to 4 rescue doses are being used. If little or no relief despite increasing doses, reconsider whether opioids are the appropriate treatment at all.

34 Pain Management– Treatment
Appropriateness of regular or PRN dosing More severe pain  Standing order for more potent, longer-acting analgesic and supplement with a shorter acting analgesic PRN Severe/recurrent acute or chronic pain  Regular, not PRN dosage of at least one medication – Start with low to moderate dose, then titrate upwards Medication may be more effective if it is given before the patient engages in activities known to exacerbate pain; for example, receiving wound care or being bathed. Such a flexible regimen may result in more effective pain management. All analgesics have benefits and risks that vary according to the patient’s age, diagnoses, conditions, use of other medications and previous experience with a drug or class of drugs. In general, older people may be more likely to experience adverse reactions to medications.

35 Pain Management– Treatment
Goal of treatment is to decrease pain, improve functioning, mood and sleep Strength of dosage should be limited only by side effects or potential toxicity Reassess medication’s effectiveness frequently and adjust dosage to meet these goals. Remember: It is important to consider medication as just one component of an overall treatment approach that may include other non-pharmacological approaches. Also: Depending on underlying causes, consider other alternatives to systemic pain medications; for example, nerve blocks, intra-articular or spinal injections, radiation therapy or hormonal treatments.

36 The World Health Organization (WHO) has recommended a three-step ladder approach to pain management. In Step 1, non-opioid analgesics with or without an adjuvant are recommended. Steps 2 and 3 recommend an opioid if pain persists or increases, plus a non-opioid and possibly an adjuvant. Depending on the cause, degree and frequency of pain, it may be appropriate to try different non-opioid medications or combinations of smaller doses before advancing up the ladder.

37 Pain Management CPG– Treatment Non-Opioid Analgesics Used in the Long-Term Care Setting
Acetaminophen – The analgesic of first choice in patients (who do not have liver disease and do not consume excess amounts of alcohol) with mild to moderate pain. NSAIDS – Use if acetaminophen fails to provide relief, or if the patient has an acute inflammatory condition. Considerable risk of GI bleeding, sodium retention and renal impairment occur in the elderly. COX –2 inhibitors – Recommended when NSAIDS are recommended for long-term treatment of individuals who have chronic pain caused by inflammatory or other underlying conditions such as osteoarthritis. These agents reduce but do not eliminate risk of GI bleeding. Risk of renal impairment is the same as NSAIDs. Tramadol – As a centrally acting analgesic it may be the next agent added to acetaminophen or NSAIDS, either alone or in combination, to manage moderate to severe pain.

38 Pain Management CPG– Treatment
Opioid Therapy: Prescribing Principles and Professional Obligations [9] Drug Selection Dosing to optimize effects Treating side effects Managing the poorly responsive patient It is important to learn: (1) how to assess patients with pain and make appropriate decisions about a trial of opioid therapy and (2) basic principles of monitoring for signs of drug dependency. Administering opioids to frail elderly patients may be associated with an increased risk of symptoms such as anorexia, hypotension, falls, altered mental status and bowel ileus. These risks may be exacerbated by other medications with CNS side effects or those with anticholinergic or hypotensive properties. Also, starting with a lower dose and titrating slowly upwards may minimize complications such as respiratory depression. [9] Portenoy RK. Opioid prescribing to patients with and without chemical dependency. Presented at: The International Conference on Pain and Chemical Dependency, June 6-8, 2002: New York, NY.

39 Pain Management CPG– Treatment Opioid Analgesics Used in the Long-Term Care Setting (Oral and Transdermal) Codeine, oxycodone, hydrocodone, hydromorphone and fentanyl are commonly used opioids. Codeine, oxycodone, hydrocodone have been available as immediate-release (short-acting) preparations or in combination with aspirin or acetaminophen. Many or these are now available both in immediate and sustained or extended-release (long-acting) forms. Opioid analgesics are appropriate for moderate to severe acute pain that is not relieved by, or is unlikely to respond to other categories of analgesics. The judicious use of opioid analgesics for more severe chronic pain is a component of comfort care for patients in the long-term care setting. Although legitimate concerns about drug abuse may influence medication choices, they do not justify failure to treat severe pain. Long-term use of opioids for pain relief does not appear to cause organ damage and does not cause loss of control, tolerance or addictive behavior in most individuals. Patients starting opioid treatment should be place on bowel regimes to avoid constipation. Also, tapering is required to avoid significant withdrawal symptoms – do not stop abruptly.

40 Pain Management CPG– Treatment
When starting a patient on opioids, begin with an immediate-release preparation. After establishing the amount needed daily to control pain, convert to regular daily dose with a sustained release preparation given every 8–24 hours. Like non-opioids, opioids may be best administered at regular intervals rather than PRN. Regular dosing provides continuous pain relief and reduces adverse events. Some patients may refuse transition to long-acting agents. Reasons for this may be that the patient could be manifesting: (a) addiction/chemical coping (b) fear (c) lack of additional coping strategies (d) loss of perceived control (e) true physiologic effect of the drug on their pain.[10] [10] Passik SD, Whitcomb L, Kirsch K, et al. Pain outcomes as assessed with a pain assessment and monitoring tool in chronic non-malignant pain patients treated with opioids: results of final analyses. Paper presented at: The International Conference on Pain and Chemical Dependency, June 6-8, 2002; New York, NY. * Duration of effect increases with repeated use due to cumulative effect of drug

41 Pain Management CPG– Treatment Oral Morphine to Transdermal Fentanyl
Pain Management CPG– Treatment Oral Morphine to Transdermal Fentanyl * NOTE : This table is designed to convert from morphine to transdermal fentanyl and is based on a conservative equianalgesic dose. Using this table to convert from transdermal fentanyl to morphine could lead to overestimation of dose. The fentanyl transdermal patch is another option for patients who require around-the-clock pain control. It is inadvisable to use them as the initial approach without establishing that the patient requires continuous opioid use – i.e., 10 mg q 4-6 hours. Transdermal opioids require hours to reach a “steady state” and may be administered every 48 – 72 hours. It may therefore be necessary to ensure that the patient is also being treated with immediate release opioids on a scheduled or PRN basis for the first hours when transdermal opioid use is begun.

42 Treatment Topical Analgesics
Counterirritants (menthol, methyl salicylate) Supplied as liniments, creams, ointments, sprays, gels or lotions May be effective for arthritic pain (not multiple joint pain) Capsaicin cream (0.025%) and (0.075%) Derived from red peppers Depletes substance P, desensitizes nerve fibers associated with pain Main limitations are skin irritation and need for frequent application Need to use routinely for optimal effectiveness Topical agents, either used alone or in combination with other analgesics, may provide relief for patients with both musculoskeletal and neuropathic pain. Capsaicin cream should be started at a dose of 0.025% and advanced to higher concentration if necessary. It may be raised to the 0.075% strength for six weeks before declaring treatment failure. The recommended hierarchy for treatment of neuropathic pain is as follows: (1) Control of blood glucose levels for diabetes-related pain (2) Topical analgesics (3) Acetaminophen (4) Anti-convulsants (5) Physical and occupational therapy (6) Conventional NSAIDs or COX-2 inhibitors (7) Tramadol or tramadol/acetaminophen (8) Opioids and, (9) Appropriate complementary treatment.

43 Treatment Analgesics of Particular Concern in the Long-Term Care Setting
Chronic use of the following drugs are not recommended: Indomethacin Piroxicam Tolmetin Meclofenamate Propoxyphene Meperidine Pentazocine, butorphanol and other agonist-antagonist combinations Indomethacin, Piroxicam, Tolmetin and Meclofenamate cause serious side effects such as peptic ulceration and/or gastrointestinal hemorrhage, confusion, agitation and hallucinations. Propoxyphene – efficacy no better than acetaminophen and has undesirable CNS side effects. It may be acceptable to keep a patient on this drug if they have been taking it a long time and have difficulty obtaining pain relief with other medications. Meperidine – higher doses and more frequent administration have little effect on pain relief and are associated with increased confusion. Pentazocine, butorphanol and other agonist-antagonist combinations have little analgesic ceiling effects, are associated with dysphoria and hallucinations, and they may precipitate withdrawal in opioid-dependent patients.

44 Treatment Non-Analgesic Drugs Sometimes Used for Analgesia
Neuropathic pain Antidepressants Anticonvulsants Antiarrhythmics Baclofen Inflammatory diseases Corticosteroids Osteoporotic fractures Calcitonin Both tricyclic antidepressants and anticonvulsants have been shown to be helpful in some pain conditions. The anticonvulsant gabapentin has been shown to be an effective treatment for the pain of diabetic neuropathy and postherpetic neuralgia (but it does have significant side effects, and should be started at a low dose). Calcitonin may help relieve pain from osteoporotic fractures, reducing the need for high doses of analgesic medications. They are often most effective when used for baseline pain management, supplemented by analgesics for breakthrough pain. Drugs from these two classes are sometimes used simultaneously. These drugs do have a high side effect profile in the elderly – particularly significant anticholinergic side effects.

45 Treatment Factors to evaluate when considering complementary therapies
Patient’s underlying diagnosis and co-existing conditions Effectiveness of current treatment Preferences of the patient and family or advocate Past patient experience with the therapy Availability of skilled experienced providers There is evidence of effectiveness for: (1) patient education (2) cognitive/behavioral therapy and (3) exercise. While there is no evidence to support the effectiveness of these therapies in elderly patients in long-term care, they may be beneficial to some individuals: (1) physical and occupational therapy (2) positioning with braces, splints and wedges (3) cutaneous stimulation such as heat/cold, massage therapy, pressure and vibration (4) neuro stimulation such as acupuncture, transcutaneous electrical nerve stimulation (5) chiropractic and (6) magnet therapy. Other non-physical therapies that may provide pain relief are: (1) psychological counseling (2) spiritual counseling (3) peer support groups (4) alternative medicine such as herbal therapy, naturopathic and homeopathic remedies (5) aromatherapy (6) music, art, drama therapy (7) biofeedback (8) meditation and (9) hypnosis.

46 Pain Management CPG– Monitoring Steps
Re-evaluate the patient’s pain Adjust treatment as necessary Repeat previous steps until pain is controlled It is important to use an appropriate pain assessment tool to re-evaluate the patient’s pain any time that caregivers believe inadequate pain control is affecting the patient’s ADL, sleep pattern, activity level, mood, cognition, behavior and other personal or therapeutic goals. Also – review the characteristics of the pain and impact on quality of life. Re-evaluate the treatment plan and effectiveness of medications and complementary therapies. Note any side effects of drugs. Re-evaluate conditions or diagnoses associated with the pain. **Nursing Assistants and other direct caregivers who spend the most time with patients from day to day – are well placed to monitor and report patient’s pain.

47 Pain Management CPG– Monitoring Opioid Therapy: Monitoring Outcomes
Critical outcomes: The “Four A’s” Analgesia – Is pain relief meaningful? Adverse events – Are side effects tolerable? Activities - Has functioning improved? Aberrant drug-related behavior Monitor the “Four A’s” over time, with frequency of visits appropriate to situation. Document assessment of the “Four A’s” and interventions to address concerns: unrelieved pain, side effects, aberrant drug-related behavior.[11] Also – constipation must be managed with continued use of opioids as follows: (a) Encourage the patient to drink ample fluids including fruit juice. (b) Use regular doses of stimulant laxative (senna) and stool softener in combination with lactulose or sorbitol as indicated. (c) Increase daily fiber with adequate hydration. (d) Help patient stay as mobile as possible. (e) Assist patient to sit for a bowel movement. (f) Provide for patient comfort and privacy. (g) If no bowel movement in 2-3 days, prescribe Milk of Magnesia, a bisacodyl suppository or enema. (h) Reduce analgesic if feasible or reduce other drugs that affect bowel motility. [11] Passik SD, Whitcomb L, Kirsch K, et al. Pain outcomes as assessed with a pain assessment and monitoring tool in chronic non-malignant pain patients treated with opioids: results of final analyses. Paper presented at: The International Conference on Pain and Chemical Dependency, June 6-8, 2002; New York, NY.

48 Pain Management CPG– Monitoring
When patient is unresponsive to clinical management consider referral to: Geriatrician Neurologist Physiatrist Pain clinic Physician certified in palliative medicine Psychiatrist (if patient has co-existing mood disorder) As noted previously – there are many approaches to pain management. Tapping into the expertise of other medical specialties may help find an otherwise elusive solution.

49 Dilemmas in Pain Management
While addressing pain management, have strategies in mind for common problems Patient refusal of potentially beneficial medication Patient and family pressure to prescribe certain drugs Patient and family misconceptions about illness Unrecognized or denied psychiatric disturbances When patients and families or advocates resist the use of treatments that may be beneficial, members of the interdisciplinary care team should discuss the situation among each other, and then advise the patient, family or advocate about potentially useful alternatives offered by the physician – even if these may not be quite as good as the rejected approach. When no identifiable causes or significant relief can be identified, it may be necessary to collaborate with the physician to explain to the patient and family that all reasonable efforts have been tried and that it is not medically appropriate to continue to add more drugs or change to medications with more side effects or higher risks for the patient.

50 Reviewing the Physician’s Role
Prevention strategies Communication with patients/families Documentation Participate in Quality Improvement Follow policies and procedures Physicians have a key role in addressing pain. By contributing to a culture in which pain management is a priority, you can help ensure that a facility and its staff address pain effectively. By communicating information, documenting appropriately, and following pertinent policies/procedures, you help to create an environment in which patients receive adequate pain management.

51 Summary Views about management of pain in the elderly have changed in recent years It is an expectation that pain be managed Pain can be effectively treated in the long-term care setting A culture of patient comfort should permeate all aspects of facility operations Long-term care facilities should review and revise their operating procedures to incorporate pertinent information about the recognition, assessment, treatment and monitoring of pain.

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