1. Managing Pain in the Long Term Care Setting
Mary P. Evans MD CMD FACOG FAAHPM
Blue Ridge Long Term Care Associates
President, Virginia Medical Directors Association

2. Objectives
Discuss the most common pain syndromes in the LTC population
Describe several classes of pain medications and their indications
Understand non-pharmacologic approaches to pain management and their use in LTC
Describe appropriate pain regimen options for the LTC population

3. Prevalence of pain in LTC
45-80% of residents in nursing facilities have chronic pain
51% of residents who report intermittent pain have pain every day
Of these patients, 84% had order for prn pain meds, but only 15% of patients received prn med
Nationally, LTC facilities are doing poorly on pain quality measures
Ferrell et al, Pain in the Nursing Home, JAGS 1990;38:

4. Common causes of pain in LTC
Back pain 40%
Arthritis 29%
Previous fx 14%
Neuropathy 11%
Leg cramps 9%
Foot pain 8%
Claudication 8%
Headache 6%
Generalized 3%
Cancer 3%
Stein et al, Pain in the Nursing Home. Clin Geriatr Med 1996;12:

5. Pain in Long Term Care
Incident pain
Acute pain
Chronic pain

6. Pain types Musculoskeletal pain Bone pain Visceral pain
Neuropathic pain
Malignancy pain
Psychosocial pain/existential pain

7. Concept of “Total Pain”
Physical pain: medical conditions
Emotional pain: anger, depression, anxiety
Social pain: loneliness, family issues, financial issues
Spiritual pain: life’s meaning, leaving a legacy, hopelessness, abandonment
*Think of these concepts with patients who have pain that is difficult to control

8. Barriers to pain relief:
Unrecognized pain
Difficulty communicating needs
Lack of assessing for pain
Unavailability of pain med order
Pain med not available
Narcotic script issues
Cultural barriers and beliefs
Personal opinions and beliefs
Family interactions
Physician attitudes, beliefs, biases, skills

9. Fears of addiction: terminology
Use of pain medication:
Physical dependence on pain medication – normal state of adaptation to ongoing pain med use
Addiction to pain medication – psychological dependency
Pseudoaddiction to pain medication – apparent drug- seeking or asking for increased dosage when pain is undertreated
Tolerance to pain medication – may need increased dose due to lessened effect or disease progression

10. Pain assessment Chronicity: Acute, chronic, constant, intermittent
Onset timing: Incidental, procedural, breakthrough, disturbance
Quality, intensity
Alleviating factors
Exacerbating factors
Associated symptoms, radiation of pain
How it affects the patient: what is the patient no longer able to do as a result of the pain? What does this pain mean to the patient?

11. Pain assessment What has been tried before to help the pain?
Which pain medications have been tried?
Were they helpful?
Which medication, dose, timing seems to work best?
Any difficulties taking oral meds?

12. Patients with cognitive impairment
Pain is likely under-recognized, under-treated
Communication difficulty
Assessment difficulty
Non-verbal pain assessment scales:
FACES pain scale
FLACC scale (face, legs, arms, consolability, cry)
Discomfort scale
PAINAD scale

13. Nonverbal pain signs
Facial expression- grimacing, frown, grinding teeth
Posture – guarding, bracing, defensive posture
Movement – rocking, rubbing, fidgeting, restlessness
Behaviors – agitation, physical aggression, resisting cares, yelling out
Vocalization - crying, groaning, whining, sighing
Activities – ADL function, participation, gait

14. Incident pain Occurs with particular activities Getting out of bed
Taking a shower
Transferring to chair

15. Pain treatment – incident pain
Anticipate the pain
Oral pain med min prior to procedure
Premedicate before procedures:
Dressing changes for wounds
Moving patient for shower
Transfer to hospital for procedure

16. WHO Analgesic Ladder
By mouth – oral or sublingual, avoid injections By the clock – schedule routinely, appropriate interval By the ladder – Step 1 – Acetaminophen (limit dosage), NSAID Step 2 – Opioid or combination Acetaminophen/Opioid Step 3 – Pure opioid, addition of adjuvant By the individual – can add adjuvants at any step; can start at higher step to relieve pain initially; quality of life; comorbidities, family support

17. Equianalgesic table (OME)
Morphine PO 30 mg
Morphine SC or IV 10 mg (1/3 dose)
Oxycodone PO mg
Hydrocodone PO 30 mg
Hydromorphone PO 7.5 mg (1/4 dose)
Hydromorphone SC or IV 1.5 mg
Transdermal Fentanyl patch 12 mcg-25 mcg

18. Musculoskeletal Pain Causes
Muscles, ligaments, tendons, bones, nerves, joints
Sprains, strains, overuse syndromes
Bruises, bumps
Inflammation, infection
Loss of blood flow to muscle
Low back pain in the most common chronic musculoskeletal pain

19. Musculoskeletal Pain Aching, stiffness “pulled muscle” feeling
Fatigue, disrupts sleep

20. Rx for musculoskeletal pain
Acetaminophen
Acetaminophen/narcotic combo
Pure opioid
Corticosteroid

21. Rx for musculoskeletal pain
Muscle spasms:
Cyclobenzaprine
Orphenadrine
Metaxalone
Methocarbamol
Carisoprodol
Tizanidine
Baclofen
Benzodiazepines

22. Non-pharmacologic treatment of musculoskeletal pain
PT/OT
Splint for immobilization, rest
Mobilization
Heat, cold
Relaxation, biofeedback
Stretching exercises
Therapeutic massage

23. Bone Pain
Described as aching, dull, deep, boring, constant, may be weather-dependent
Difficult to localize
Present at rest and with movement
Somatic pain

24. Bone pain causes: Fractures Healed fracture DJD
Metastasis to bone (breast, lung, prostate)
Sickle cell disease
Myeloma
Paget’s disease

25. Rx for bone pain Corticosteroids Calcitonin
Bisphosphonates (*GI symptoms, keep upright)
Palliative radiotherapy
Nonsteroidal anti-inflammatory drugs
Narcotic pain meds

26. Visceral Pain Distension of hollow organ Stretching of smooth muscle
Stomach
Small and large intestines
Gall bladder
Kidney/ureter

27. Visceral Pain Crampy, intermittent pain May be difficult to localize
Can be mild to severe
History is important – especially timing of pain

28. Treatment of Visceral Pain
Evacuation of the distended hollow viscus
Relief of constipation, disimpaction
Surgical treatment
Prevent future episodes

29. Treatment of visceral pain
Bowel obstruction:
Octreotide ($$$$)
Anticholinergics: hyoscine, scopolamine, glycopyrrolate ($)
Corticosteroids ($)
especially end of life care

30. Example: Visceral pain
Appendicitis
Early inflammation – crampy abdominal pain, nausea and vomiting
Patient is uncomfortable, writhing on table
Visceral pain, difficult to localize
Later in course – localization of pain to right lower quadrant, fever, malaise, leukocytosis
Patient lies still, + rebound

31. Neuropathic Pain Causes:
Compression of nerve
Post-entrapment nerve injury
Regional pain syndromes
Skeletal muscle spasms
Post-herpetic neuralgia

32. Neuropathic pain treatment
Acetaminophen
Acetaminophen/narcotic combo
Pure opioid
Add adjuvant meds, therapies early on

33. TENS Administered by therapist
Transcutaneous electrical nerve stimulation
Battery-operated, portable units
Electrical current disrupts pain signal
Questionable validity (Cochrane Collaboration, 2008)

34. Physical Modalities: Heat, cold application
Muscle massage, stretching, ROM
Ultrasound, TENS
Acupuncture, acupressure
Physical and occupational therapy
Positioning, devices, pillows, chairs

35. CAM modalities Meditation, relaxation Spiritual counseling and prayer
Hypnosis, biofeedback
Aromatherapy, herbal therapy
Music and sound therapy
Art therapy

36. Adjuvant Modalities
E-stim Diathermy Laser therapy Heat/cold application Topical treatments – menthol, capsaicin

37. Electrical stimulation history
First documented use in ancient Rome, AD 63
Scribonius Largus described pain relief by standing on an electrical fish at the seashore
16th-18th century – electrostatic devices for headaches and pain
Benjamin Franklin was a proponent of electrical stimulation treatment of pain

38. E-stim Administered by therapist
Electrical current causes contraction of muscle or muscle group
Helps strengthen affected muscle
Promotes blood supply to area – promotes healing

39. Topical Capsaicin Active component of chili peppers
Ointment, spray, cream forms
Minor aches, pains, DJD, strains and sprains
Post-herpetic neuralgia
Neurons are depleted of neurotransmitter (substance P), fatigues nerves

40. Pain Rx in the Elderly “Start low, go slow”
Don’t forget the bowel regimen

41. Anticipate side effects
Constipation – add stool softener, stimulant right away
Nausea, vomiting – often transient for 3-4 days
Sedation – no driving, methylphenidate, caffeine
Delerium – lorazepam
Pruritis – usually dissipates; antihistamine
Urinary retention – monitor output, comfort
Myoclonic jerks – metabolite buildup; lower dose or consider rotating to a different opioid
Respiratory depression – uncommon except when starting fentanyl patch in opioid-naïve patient

42. Pain management – special circumstances
Hospice, end of life care
Multiple drug allergies
Route of administration alternatives:
Transdermal fentanyl
Oral meds administered rectally
Avoid injectable meds if possible

43. Adjuvant pain regimens
Addition of antidepressants
TCA’s: Amitriptyline, nortriptyline*
SSRI‘s: paroxetine, citalopram
NSRI: venlafaxine*
Other: bupropion
* watch for anticholinergic symptoms

44. Adjuvant pain regimens
Addition of neuroleptics:
Gabapentin
Topiramate
Lamotrigine
Carbamazepine
Levetiracetam
Pregabalin
Phenytoin
Valproic Acid

45. Adjuvant pain regimens
NMDA antagonists:
Ketamine
Dextromethorphan
Memantine
Amantadine
Local Anesthetics:
Lidocaine – gel, patch
Mexiletine

46. Adjuvant pain regimens
Other:
Baclofen
Cannabinoids
Methylphenidate
Capsaicin

47. Adjuvant pain regimens
Alpha-adrenergic agonists: clonidine, tizanidine
Corticosteroids:
Dexamethasone (intracranial pressure)
Prednisone (DJD, bone pain)

48. Difficult to control pain
Pain despite escalating doses
Consider possibility of drug diversion
Consider existential/psychosocial pain

49. Opioid rotation Chronic pain – may try rotating to another opioid
“Opioid fatigue”, tolerance
Remember to reduce calculated conversion dose by 50% for cross-tolerance

50. Here’s what I do Post-op patients: Schedule pain meds x 7 days
prn pain meds available
Treat pain aggressively until comfortable
Remember the bowel regimen!

51. Here’s what I do: Patients with dementia, behaviors:
Difficulty asking for meds, communicating
Schedule acetaminophen tid-qid
Have opioid available for pain not relieved by acetaminophen
Consider lidocaine patch
Consider scheduled opioid for daily moderate to severe pain (bowel regimen!)

52. Here’s what I do: Hospice, end of life care:
Have liquid morphine, liquid lorazepam available
Rectal acetaminophen
Can also administer oral meds via rectal route
Transdermal fentanyl patch (appropriate dose) if unable to swallow (not in opioid naïve patients)
Long-acting opioids once optimal 24h dose achieved

53. Questions?

54. Use of methadone -advantages
Acyclic analog of morphine, heroin
NMDA receptors – neuropathic pain
Used in hospice, end of life care
Long half-life, long-acting
Strong analgesic
Cheap ($)
Chronic pain use – anti-addictive
Less sedative than other opioids

55. Use of Methadone - drawbacks
Many metabolites
Liability risk (?)
Variable metabolism/half-life in the elderly
Use cautiously in select patients

56. Use of Methadone
Approved in the US for detoxification treatment of opioid addiction
Must follow strict federal regulations in detox programs
Programs must be certified by Federal Substance Abuse and Mental Health Services Administration
Programs must be registered with the Drug Enforcement Agency (DEA)