Pain management in long-term care requires a systematic, step-wise approach that includes thorough assessment and that avoids jumping straight from reports of pain to treatment, say two authors of the new clinical practice guideline (CPG) “Pain Management in the Post-Acute and Long-Term Care Setting.”
“You need a solid foundation for getting to treatment in the first place,” said Steven Levenson, MD, CMD, who chaired the work group that developed AMDA – The Society for Post-Acute and Long-Term Care Medicine’s newly revised CPG.
And when patients report ongoing pain despite treatment, “we need to ask, were adequate details and background obtained?” Dr. Levenson told Caring. “We don’t want to guess and add to what’s not working, but go back and [reevaluate] the whole situation. We should question, challenge, and if necessary, be skeptical if something isn’t working as anticipated.”
A section on recognition and assessment addresses how to screen for pain and how to obtain and document details. It discusses how to define and characterize an individual’s pain, for instance, and presents key assessment components related to pain and key elements of physical examination.
The CPG also addresses the roles of interprofessional team (IPT) members and the responsibilities of medical practitioners. It stipulates, for instance, that IPT members should provide “essential accurate and detailed information to help medical practitioners precisely define the problem, identify causes, clarify the impact of pain on the patient, and individualize and adjust treatments.”
A section on diagnosis and interpretation compares acute and chronic (persistent) pain, addresses the importance of distinguishing nociceptive and neuropathic pain, and includes tables of medications that can cause or exacerbate pain and of medications that may cause headache.
“The CPG reminds us of the importance of the diagnosis of the pain, of matching diagnosis to treatment, and of assessing the underlying problem as much as possible,” said Barbara Resnick, PhD, CRNP, a member of the pain management CPG work group.
Physical, psychosocial, and functional aspects of pain need to be considered simultaneously, she and Dr. Levenson said in interviews about the CPG.
Correcting Old Thinking, Reviewing All Treatment Options
Rich with practical tables, hyperlinks, and the incorporation of Q&As that enable access to information by questions as well as by steps, the CPG offers a comprehensive review of treatment options, both pharmaceutical and nonpharmaceutical, and includes tables with dosing information for commonly used nonopioid and opioid analgesics and for adjuvant medications. One section addresses the use of standing versus as needed (PRN) doses in different pain categories.
“One of the challenges with pain management in a nutshell is that there are so many variables for a given patient that it’s very hard to say that in certain situations you should always use [particular treatments],” said Dr. Levenson, who worked as a PALTC medical director for over 40 years and has authored a number of articles in Caring and JAMDA on medical direction in long-term care.
However, “as a general rule of thumb,” he said, “there is a lot more evidence today that opioids are not good for chronic musculoskeletal pain (and chronic noncancer pain) and that it’s better to try every combination of nonpharmacological interventions and nonopioid medications you can come up with [before prescribing opioids].”
The “old thinking about using Tylenol or ibuprofen for mild pain and opioids for moderate-severe pain does not apply to chronic noncancer pain,” he emphasized, noting that opioids have side effects and are a major source of behavioral and psychiatric symptoms in long-term care. “It’s not just about severity [of pain]. It’s about the whole picture.”
Even when opioids are indicated, nonpharmacological interventions and nonopioid medications should be tried first or used concurrently, the CPG says.
The guideline also calls it “essential” for practitioners to know and follow warnings and government- and manufacturer-issued guidance for the appropriate use of fentanyl. Fentanyl patches are too often misused in long-term care, Dr. Levenson said.
Dr. Resnick, of the University of Maryland School of Nursing, emphasized that heat and local treatments are often “very effective” for musculoskeletal pain and that physical activity/movement is a useful — but significantly underused — behavioral intervention for many residents who have pain.
The CPG addresses these issues, Dr. Resnick noted, and also answers these questions: “When is a pain consultation indicated?” and “What should be monitored regarding pain, and how should it be done?”
The question of how decisions should be made about changing, adding, or stopping analgesics is another important one addressed in the CPG, Dr. Levenson said.
Monitoring pain and adjusting treatments involves the same steps and principles of initial cause identification and assessment, with comparisons made of “frequency, intensity, duration, and other characteristics of the pain,” he said.
The “Magic Process” for Pain
The CPG calls on IPT members to try to minimize the impact of cognitive biases on decision-making related to pain — to not over-rely on previous information, for instance, and to avoid making assumptions or jumping to conclusions too quickly.
It outlines the systems and processes that a facility needs to support effective pain management and offers examples of policies and procedures. “We don’t have the magic pill for pain, but I think the CPG is the magic process for pain,” Dr. Resnick said during a webinar held in November 2021 on the guidelines.
“And it’s a team process,” she emphasized in the interview. Frontline caregivers can initiate an evaluation and “pass it on to the [nurse practitioner] or whomever can get there first” to flesh out the assessment and develop a plan, said Dr. Resnick, who has codeveloped a CPG tool kit that is expected to be available soon for use in implementing the guideline.
Dr. Levenson told Caring that pain in long-term care is too often “a reflection of an inadequate care process” and noted that surveyor feedback “can’t be relied upon to know that we’re doing pain management properly.”
“A little bit more time taken up front [and a more systematic and thorough approach] could head off many of the things that go wrong in long-term care,” he said, “and pain is particularly noteworthy in this regard.”
The CPG is available through the AMDA website in both paper and electronic versions for $49 and $39, respectively, for members and $65 and $52 for nonmembers. A free copy is available to anyone who joins the Society or renews their membership in 2022.
Christine Kilgore is a freelance writer based in Falls Church, VA.