Post-acute and long-term care providers employ many strategies to address the challenge of managing pain, including by treating pain according to current clinical practice guidelines, encouraging safety, and aiming for the best possible outcome for our patients and residents. In addition, providers must remain vigilant by following the regulations in the Requirements of Participation, State Operations Manual (SOM), Appendix PP, and the F tags such as F697 associated with pain management. And, to complicate matters, they must accomplish all this while considering the nuances related to insurance, step therapy, drug formularies, and the multiple Drug Enforcement Administration (DEA) prescribing requirements for providers practicing in facilities. They must also be aware of the Centers for Medicare & Medicaid Services quality measures for pain, crunch the data, and analyze their facility’s standing compared with local and national rankings.
While providers have had to do all these things for many years, the last decade — fraught with opioid overdoses and death — has further increased the complicated nature of pain management.
The Continued Opioid Crisis
Sadly, the rate of opioid-related drug overdose deaths has continued to climb. The Centers for Disease Control and Prevention has reported that drug overdoses have increased remarkably since 1999, with a staggering 30% increase from 2019 to 2020; 75% of the deaths in 2020 involved an opioid (“Understanding the Opioid Overdose Epidemic,” June 1, 2022, http://bit.ly/3izz9Nx). Provisional 2021 data from the CDC show an additional 15% increase in opioid-related deaths (“U.S. Overdose Deaths In 2021 Increased Half as Much as in 2020 — But Are Still Up 15%,” May 11, 2022, http://bit.ly/3QEqHcl). However, deaths caused by prescription opioids alone have steadily declined since 2011 (National Institute on Drug Abuse, “Overdose Death Rates,” Jan. 20, 2022, http://bit.ly/3QBbXeq).
Although it is common knowledge that younger adults are most affected by the opioid crisis, opioid-related deaths among those aged 55 and up have hovered around 19% since 2012 (KFF, “Opioid Overdose Deaths by Age Group,” http://bit.ly/3IQ5f2i).
New Approach for Pain Based on Expert Consensus
Due to the opioid crisis, guidance about pain management continues to change. The updated “2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain” (MMWR Recomm Rep. 2022;71:1–95, http://bit.ly/3Wbn4Ml) offers 12 recommendations grouped into four areas of concern. These include steps that are familiar to prescribers of any drug:
- 1.Determine initially whether opioids are appropriate.
- 2.Select specific medications and dosages.
- 3.Decide the duration and follow-up.
- 4.Conduct risk assessment.
The new guidelines also acknowledge the importance of informed, patient-centered decisions and the collaborative nature of pain management. To this end, they recommend several strategies that include improved communication around risks and benefits, and improved safety and effectiveness of pain medication while also concentrating on quality of life for patients (CDC, “What’s New, What’s Changed,” Nov. 3, 2022, http://bit.ly/3iEV1qT).
Note that the guidelines are not applicable for the treatment or management of pain related to sickle cell disease, cancer, palliative care, or end-of-life care.
The recommendations are intended to advise on strategies for pain management for all age groups; we in PALTC would naturally focus on their application for residents arriving for short-stay rehabilitation services as well as long-term residents. In addition, facilities and providers are being re-educated about resources and pathways to treat residents who have a substance use disorders, including opioid use disorder. The latest revised SOM, Appendix PP (effective on October 24, 2022) emphasizes having assessment and treatment options available for pain management for residents with these conditions, with consequences such as survey citations for not addressing them (CMS, “Nursing Homes,” Nov. 11, 2022, http://bit.ly/3k8VDW5).
The CDC guidelines are also prompting clinicians to think twice before selecting an opioid as the first choice for pain management. As in previous and current guidelines as well as surveyor guidance in Appendix PP, providers will face increased scrutiny over whether nonpharmacological and nonopioid therapies are being considered and initiated as treatment options before opioid use. Once again, the patient or resident’s specific needs as well as the risks associated with any therapy that includes opioids should be thoroughly weighed in all cases.
Useful Therapies for Treating Pain
- •Nonopioid medications such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and selected antidepressants and anticonvulsants.
- •Physical treatments (e.g., heat therapy, acupressure, spinal manipulation, remote electrical neuromodulation, massage, exercise therapy, or weight loss).
- •Behavioral treatment (e.g., cognitive behavior therapy or mindfulness-based stress reduction).
From CDC, “Guideline at a Glance,” Nov. 3, 2022, http://bit.ly/3IU6I7Z.
Types of Pain: Selecting the Duration of Treatment, Re-evaluating Success
The CDC guidelines have a new emphasis on assessment of the type of pain, which addresses the expected duration of pain:
- •Acute pain (duration < 1 month)
- •Subacute pain (duration of 1–3 months)
- •Chronic pain (duration > 3 months)
A new recommendation in the guidelines states that “when opioids are needed for acute pain, clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.” This is a challenge when our facilities accept short-stay residents on opioid regimens and during care transitions when a resident is discharged home. In addition, abrupt discontinuation of opioids may predispose the resident to withdrawal and adverse events.
Simply stated, opioid prescribing requires careful discussion and assessment between the provider and the resident about the benefits and risks of opioids.
Additional Risk Factors and Planning for Overdose
Combination therapy of opioids with benzodiazepines is a known risk factor for adverse outcomes and should be avoided or mitigated as much as possible.
Naloxone, a rescue medication used to reverse opioid overdose, has now been highlighted in the SOM as a necessary emergency medication to have on hand at facilities. Any successfully designed treatment plan will incorporate mitigation around potential adverse drug events, overuse, overdose, and availability of naloxone.
Tapering and deprescribing must be carefully assessed before implementation, and, if appropriate, must be carried out slowly with the acknowledgment of the patient or resident to reduce the risks associated with opioid dependence. Written opioid overdose policies should be available in facilities that include education of facility staff on how to identify a potential overdose occurrence. Many organizations have created resources that contain their policies and procedures, which can be tailored to the individual needs of the facility or organization.
Legislation Changes the Game in the Efforts for Access to Treatment Medications
Of recent importance is the Consolidated Appropriations Act of 2023, signed into law at the end of 2022, which includes a provision to relax the requirements for obtaining the “X-waiver” to prescribe buprenorphine, one of the US Food and Drug Administration’s approved medications to treat opioid use disorder (H.R.2617, https://bit.ly/3XEyskP). For more information, see
- •Substance Abuse and Mental Health Services Administration (SAMHSA), “Removal of Data Waiver (X-Waiver) Requirement,” Jan. 12, 2023, http://bit.ly/3koOJvU.
- •American Society of Addiction Medicine (ASAM), “ASAM Praises Congress for Passing Vital Provisions in End-of-Year Legislation that Will Increase Access to Addiction Care and Save Lives,” Dec. 23, 2022, http://bit.ly/3ZGEu6s.
Mr. Accetta is the president/owner of Rivercare Consulting, LLC, a care strategy and consulting business for PALTC organizations. A board-certified geriatric pharmacist, he serves as a consultant and educator in a variety of roles. Rob currently serves on the Board of Directors of the American Society of Consultant Pharmacists (ASCP). He is a graduate of St. John’s University College of Pharmacy and Health Sciences in New York.