08/09/11

Dear Dr. Jeff:

It seems I keep hearing about increased survey emphasis on pain management in residents, yet I’m not sure what more I can do than prescribe the proper analgesics and check back that my patients’ pain is being taken seriously by nursing and facility staff. Are skilled nursing facilities and attending physicians really doing such a poor job after all the training and reminders we’ve received over the past few years?

Dr. Jeff responds: Yes, unfortunately, I think we are still doing a poor job of controlling pain in our frail, elderly residents. This failure is not a consequence of indifference or cruelty, but it is real and it is largely correctable.

I believe that the ineffective pain control in skilled nursing facilities results from a combination of multiple factors including misconceptions about the appropriate use of pain medications, failure to use nonpharmacologic methods, limited education regarding the epidemiology of pain in the elderly, and the persistence of misguided priorities in long-term care.

Pain control was once one of the cornerstones of medicine. Although lacking cures for most ills, doctors had abundant treatments to relieve suffering. Plant extracts containing salicylates from willow bark and meadowsweet (spiraea) were used by Hippocrates and other ancient physicians. Indeed, when chemists at Bayer AG learned to synthesize acetyl salicylic acid in the late 19th century, they gave it the brand name aspirin after the Greek name for meadowsweet.

Paracelsus pioneered the use of a tincture of opium called laudanum in the 1500s (possibly based on treatments known to the Byzantines).

Today, physicians routinely write orders for analgesics with known half-lives of 4-6 hours to be administered twice a day "as needed." What are patients supposed to do about their pain between doses?

Although only one pain medication (meperidine, or Demerol) appears on the Beers Criteria for usually inappropriate medications in the elderly, there is a prevailing myth that elderly patients are unable to tolerate effective doses of needed medications. Indeed, although I am still waiting to see my first case of acetaminophen-induced liver failure in the elderly, we have been cowed into reluctance to prescribe effective doses of even this basic pain reliever for fear of liver damage.

Nobody Needs ‘As Needed’

Unfortunately, this underprescribing feeds into incorrect expectations of many patients that old age is inherently painful. Other factors include societal fears of drug abuse and religious notions of suffering as a spiritual exercise.

Underprescribed and inadequately dosed medications are only the tip of the iceberg of unaddressed pain in long-term care. The majority of pain-medication orders are p.r.n. ("as needed") orders, to be given after the patient is experiencing pain and usually after the patient’s request. Although it might be reasonable to have such an order to treat pains that are infrequent and unpredictable (a stubbed toe, an achy morning), this is not a reasonable approach to treating chronic or predictable pain.

Pain medications are much more effective when used before the pain becomes established and severe. Even in the best of circumstances, an as-needed analgesic given after the patient requests it will not be administered until the nurse finds time to return to the medication cart; locates, pours, and signs for the medicine; and brings it to the resident and administers it. This process requires much more time if the medication is kept in a double-locked narcotics cabinet to prevent diversion. With time for the drug to be absorbed, it may well be an hour or more from when a resident asks for analgesia and pain relief occurs.

Most pain in long-term care is predictable. Dressing changes for wounds, especially when the wounds are large or deep and when a technique such as wet-to-dry dressings is producing mechanical debridement, are typically painful. Pain medication should be administered a suitable time before the dressing change.

Physical activity, and particularly physical therapy or range of motion exercises, can be expected to be painful for patients with known active arthritis, prior fractures, or other musculoskeletal conditions. Again, medication should be routinely administered well before these scheduled activities.

Patients with recent surgical incisions, painful neuropathies, or other sources of chronic pain can be expected to have pain throughout the day and should have pain medications routinely administered.

Let Reason Prevail

Those physicians who make home visits know that all our patients keep pain medications in their medicine cabinets. Life, we all know, is not without its occasional pains. (I’m not referring to state surveys here.) Yet several national studies suggest that fewer than 30% of nursing home residents, who are more vulnerable than community-dwelling seniors, have even a p.r.n. order for pain medicine.

This means that when the occasional headache or sore shoulder does occur, the resident must report it to a nurse who will track down the physician or nurse practitioner to get an order, then perhaps wait for delivery from the pharmacy or obtain medication from the floor stock or emergency kit before the patient can get a couple of aspirins.

Ironically, pain relief may be delayed longer if the pain is severe, since the Drug Enforcement Administration has placed absurd barriers in the way of effective prescribing and administering of controlled substances.

Many nonpharmacologic alternatives for pain relief are ignored by most nursing homes despite their common places in the community. Modalities such as ice and heat act much more rapidly than oral therapies and are usually within the scope of practice of nurses and/or physical therapists.

Massage therapy may relieve chronic muscle pain. Although everyone knows that the treatment of choice for a scraped knee is a mother’s kiss, many of the elements involved (therapeutic touch combined with reassurance and distraction) are as effective and have a much quicker onset than a drug designed to block prostaglandins (that probably will require paging an off-site clinician).

The majority of nursing home residents have significant cognitive impairment. Many of these people are unable to express that the unpleasant sensation they have is pain. Crying, loss of appetite, agitation, withdrawal, poor sleep, calling out, and resisting care may all be expressions of pain.

In far too many cases, these signs are assumed to be behavioral complications of dementia for referral to a psychiatrist. Imagine an elderly, demented man in your facility who punches an aide who is trying to help him put on his shirt. Are you more likely to order a major tranquilizer or an x-ray of the man’s shoulder?

In one of my favorite research trials, a dementia unit attempted a controlled comparison of various commonly used sleep preparations to determine which was most effective. The researchers selected acetaminophen as the control since it is inexpensive, safe, and not associated with somnolence. To their chagrin, the acetaminophen was the most effective hypnotic. The reason, of course, is that the pain of osteoarthritis, extremely common in demented elderly people, is most severe at night. Most of the residents were having difficulty falling asleep because they were in pain.

This Won’t Hurt

Facilities that undertake major pain-control programs usually find that their pain statistics degrade at first. This paradoxical result occurs because the first step is usually to identify the giant reservoir of undiagnosed or unaddressed pain before beginning to treat it. In the end, the numbers dramatically improve.

Many clinicians have noted the phenomenon of the "hospice honeymoon." This is the remarkable clinical improvement that many hospice patients experience after referral to the program. The combination of unrestricted diets, elimination of medications presumably administered to prolong life or treat asymptomatic conditions, accompanied by proactive pain control frequently leads to increased alertness, improved appetite with weight gain, and improved mood.

Indeed, there are now several studies demonstrating that patients with certain advanced cancers will live longer on hospice than with standard "life-prolonging" oncology treatments. I suspect that most of our nursing home residents with advanced disease, even if their life expectancies are longer than 6 months, would benefit from these palliative care approaches as well.

Facilities must examine their pain-management policies and strategies. Improvements might include required orders for analgesics before activities likely to induce pain. Consulting pharmacists should question all orders for medications not consistent with their known pharmacology.

Nurses should question any p.r.n. pain medication order for a patient who cannot effectively request medications and should generally encourage around-the-clock analgesia for anyone who frequently requires medication. Written procedures might encourage nurses to relieve pain with readily available ice packs and hot water bottles. Behavioral-management teams should routinely consider pain management.

The aphorism, attributed to Hippocrates, that the role of medicine is "to cure sometimes, to relieve often, and to comfort always" is certainly true in long-term care. We still have a long way to go in the provision of relief and comfort.CfA

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