Dear Dr. Diane| Volume 24, ISSUE 2, P4-5, March 2023

3 AM: How to Prevent After-Hours Calls for Pain Management

      Dear Dr. Diane: I am a new medical director of a PALTC facility, and I am often called to write other physicians’ pain scripts at all times of the night. My facility wants me to write the pain management policy and address this with the staff and clinicians. Do you have any advice on how I should approach this problem, and avoid getting called all times of the night?
      Dr. Diane responds:
      Three in the morning is probably the worst time to think about the pain management policies of a post-acute and long-term care facility, yet I — like you — have found myself doing just that. A post-acute resident who was in recovery from hip surgery had presented to our facility with no prescriptions for pain medication. The admitting physician’s team refused to write or fax any prescriptions and gave orders for the nurses to call back to the hospital, which they did.
      After many hours of calling the hospital, the hospitalist group, and the surgeon, our director of nursing called me to say the resident’s family was upset and filing a complaint. This resident had had no pain medication since his discharge from the hospital — by the time I was contacted, he had gone over 10 hours without pain management. So at 3:00 a.m. I wrote emergency prescriptions, faxed them to the pharmacy, and vowed I would fix this problem once the sun rose.
      In the morning when I arrived at the facility to do a consultation with this patient, I declared we would fix this problem. As I called the provider team’s leadership and communicated our plans to the clinical providers, I declared we would fix this problem. And three months later, when the facility was sold to another chain and all the processes we had created were abandoned, I declared we would fix this problem.
      As PALTC providers and clinical leaders we juggle regulations, policies, care delivery, and corporate edicts daily. With every admission, readmission, and transition of care, we must evaluate and reevaluate medications, wading through a sea of as-needed (pro re nata, PRN) drugs, to create a treatment plan. As we consider our clinical approach to pain management, it is essential that we address some of the leading challenges facing our industry.

      Getting Back to the Basics

      The first thing to consider is the basics of pain management, particularly in the era of opioids. As the health care industry strives to meet the challenges of opioid use and abuse, many policy makers fail to understand the complexity of pain management in our PALTC facilities.
      Because the PALTC continuum spans the breadth of palliation and pain management — from providing care to individuals who require rehabilitative services to those at the end of their life — opioids continue to be an important component of our pain management strategies. The U.S. Department of Health and Human Services recently issued its final report on opioid use in PALTC facilities, acknowledging that it is common in PALTC and is linked to the rehabilitative needs of our residents (D. Stevenson et al., “Opioid Use in Long-Term Care Settings: Final Report,” Office of Behavioral Health, Disability, and Aging Policy, Aug. 9, 2022,
      In our approach to opioids, it is important that we lean into the blueprint provided by AMDA – The Society for Post-Acute and Long-Term Care Medicine in its recently updated Pain Management Clinical Practice Guideline ( and observe a few basics that will serve as reassurance to your residents and leadership.
      The first important step is documentation. In their documentation, providers should:
      • 1.
        Start by defining what you are treating.
      • 2.
        In the treatment plan, explain the clinical rationale and justification for the medication choice.
      • 3.
        Record the anticipated outcome and contingency planning.
      This may seem like Pain 101, but I’ve reviewed hundreds to thousands of progress notes from coast to coast, and I’ve found their lack of documentation alarming. Let’s look at these steps in more detail.
      • 1.
        What are you treating? Consider the difference between the following diagnoses:
      • Back pain
      • Chronic back pain secondary to spinal stenosis
      • Chronic back pain secondary to spinal stenosis; lumbar radiculopathy
      These descriptions have resounding differences. Even in the age of the electronic medical record, we can still capture the quality, duration, and type of pain.
      • 2.
        What is the treatment plan and clinical rationale? The logic behind a prescription is too often missing in documentation. Whether we are choosing an opioid or not, clearly stating our rationale is necessary to demonstrate justification for the chosen clinical approach.
      • 3.
        What is the outcome you anticipate, and what is your contingency plan? This is the simplest of steps. In the emergent or urgent care setting, scripts are written for three days or occasionally seven days with justification. This is done in anticipation of an outcome: either the pain is resolved or follow-up must occur.
      Similar logic needs to be documented in our admission and progress notes in our communities:
      • What is the length of treatment that we anticipate when we write our scripts?
      • Even for a 30-day supply for a short-acting PRN opioid, have you documented your follow-up? Will the patient be visited in a week, two weeks, or one month to review this PRN pain medication utilization?
      • What happens if the patient is requesting medication around the clock? Do you anticipate changing to a long-acting agent?

      Deprescribing Pain Medications When Appropriate

      Another key element clinicians ask is, Should we be deprescribing pain medication? I have listened to both sides of this argument, even if some think there isn’t a side. In my opinion, every medication should be considered and reconsidered when it comes to deprescribing.
      Every month we are asked to review the medication administration record (MAR), and every month we sign or click yes to continuing each medication. With this action, we are saying that we have evaluated that this medication needs to be given. Here are a few things to consider:
      • Review the MAR for evidence of pain medications being withheld. For example, an order for morphine was provided with the statement to hold for lethargy and/or sedation. So, if that medication is being held, should this individual continue with the medication? (This question brings back bad memories for me: the surveyor asked it in a facility where I had just become the medical director – good times!)
      • Consider opportunities for deprescribing PRN opioids. For instance, if a resident hasn’t been using this medication, should it be deprescribed? First, reassess the resident to determine whether she is experiencing pain (more on that soon). If the resident is functional and not complaining of pain, then do we keep opioids on her MAR? I have stood on both sides of the “keep the acetaminophen order” debate, and I have settled it with this: if a resident who doesn’t typically have pain suddenly starts to experience it, I want to be alerted. This is a significant change in the resident’s condition, so the nursing staff should call, even if they wake me up at night.
      • Consider opportunities for deprescribing antiepileptics, antidepressants, and other medications we utilize for pain. We aren’t just talking about opioids; the same considerations need to be applied to all such drugs. Do we remain on this same dose? Is this medication having any benefit? Does the benefit outweigh the risk? For example, a resident with diabetic neuropathy and worsening renal function had been taking gabapentin for years. After he was started on dialysis, his gabapentin dose remained unchanged. He was sent back to the hospital with altered mental status — where he was found to have gabapentin toxicity. He would have benefited from a dose reduction in accordance with renal dosing guidance and then further dose reductions once dialysis was started.

      Understanding Racial Disparities and Pain Management

      The final key element to consider is how racial disparities in health care can impact pain management. Once upon a time, we were taught that different races respond to pain differently. That time was 2020 and all the years that preceded it. The textbooks, journal articles, and guidances that describe the differences in nociceptive receptors and pain tolerance remain grounded in the falsehood that race is a biological factor.
      As the medical field begins to integrate the long-standing evidence that race is a social, not a biological, construct, the question becomes how we reconsider our approach to pain management. In the past three years, with increased awareness focused on race bias in health care, many medical practitioners have been desperately trying to unlearn what they’ve been taught. Unfortunately, a deep-seated implicit bias around pain management remains. So where do we begin?
      We have all seen testimonials and reports of people describing how their clinical providers failed to treat their pain and ignored their symptoms. The question is how we move forward with our newfound knowledge. To eliminate both conscious and unconscious bias in pain management, we must:
      • 1.
        Accept that this bias exists.
      • 2.
        Persistently seek to individualize care and treatment plans.
      • 3.
        Restore trust in the patient–clinician relationship.
      Consider the following example. Review of a resident’s MAR reveals that she has not been provided any of the short-acting opioids that were ordered to be given every six hours PRN for pain. The first step is to reassess this resident to determine whether she is having pain. If the answer is no, then reconsider whether her PRN medication is necessary. But if the answer is yes, follow the steps provided in the figure below.
      Overall, our approach to the challenges of pain management revolves around us leaning into our foundational strengths and resources, driving quality, and approaching care with intention and compassion.
      Dr. Diane Sanders-Cepeda is a geriatrician and Certified Medical Director who has focused her career on geriatric care across the post-acute and long-term care continuum.