Opioids have a place, but staff need to encourage nonpharmacological solutions.
Pain is universal, but its prevalence increases with advancing age, disability and morbidity. Anywhere from 45% to 80% of residents of long-term-care facilities are estimated to have pain associated with injuries, postoperative status, arthritis, cancer and other chronic conditions.
Helping residents manage pain is challenging, especially today, given the demands of the pandemic and slimmed down work forces. But by incorporating guidelines for assessment, treatment and monitoring of pain into routine care, long-term-care staff can alleviate or at least ameliorate much unnecessary pain among residents.
In November 2021, AMDA—The Society for Post-Acute and Long-Term Care Medicine published an updated set of pain management guidelines, as it has several times since publishing its first guidelines on the subject in 1999. Post-acute and long-term-care facilities should have written policies and procedures in place for pain assessment and management, according to the organization. Although staff and practitioners may change over time and treatment options may vary, the process should be universal and enduring.
AMDA represents more than 50,000 medical directors, physicians, nurse practitioners, physician assistants and other practitioners working in post-acute and long-term-care settings.
“Our biggest push with the clinical practice guidelines is to improve the assessment of pain and identification of the underlying cause and type of pain we are treating,” says Barbara Resnick, Ph.D, CRNP, a professor in the Department of Organizational Systems and Adult Health at the University of Maryland School of Nursing and part of the core group that revised the AMDA pain management guidelines. With its revised guidelines, AMDA is challenging staff and residents to search for and treat the underlying cause of pain, and to try nonpharmacological treatments, such as physical activity for those with musculoskeletal pain, rather than relying on kneejerk prescriptions for pharmaceuticals, she says.
The challenge
Identifying and describing pain and accurately diagnosing its causes present ongoing challenges, says AMDA in the guidelines. Residents’ perceptions of, responses to, and descriptions of pain vary widely. They differ in how they perceive and respond to pain and how much pain they tolerate. What’s more, many residents in post-acute or long-term-care settings have limited ability to report and describe pain.
Meanwhile, staff can bring with them their own biases, such as “excessive reliance on pre-existing information and failure to reconsider previous conclusions or interventions when evidence suggests that current working assumptions might be wrong,” the guidelines state. Staff can also be swayed by the conclusions of others, even if those conclusions are against their better judgment.
Both undertreatment of pain and overtreatment with and excessive dosing and duration of opioids can affect mental status and behavior, according to AMDA. “In addition, the clinical, legal, and political landscape has shifted between pressure to treat pain aggressively and stricter prescribing guidelines related to heightened concern about the adverse impacts of pain medications. Ultimately, treatment is a balancing act that requires careful assessment of the patient and the clinical knowledge to find the path that provides enough of the right interventions and limits marginal, problematic, or ineffective treatment.”
Team effort
Effective pain management in long-term care calls for coordination and communication among medical directors, attending physicians, nursing staff, consultant pharmacists, social workers, pharmacists and others – as well as residents and their families and friends.
“A variety of health care professionals working in the [post-acute and long-term-care] setting … make and document observations (e.g., that a patient does not sleep at night, has become more withdrawn, or has a change in usual eating patterns),” according to the guidelines. “However, only some may be qualified to determine the significance of those observations (e.g., the cause of sleeplessness or of a change in eating patterns). In contrast, practitioners may not be present to observe patients in detail or deliver treatments but are responsible for analyzing the significance and causes of symptoms.” What’s needed among the entire interprofessional team is an understanding of the specific functions and tasks of each.
The guideline provides information to help all levels of staff provide appropriate pain-related information to practitioners for the final diagnosis and to provide input – along with other members of the healthcare team – for the pain management plan, says Resnick.
Assessing pain
Among many residents in long-term-care facilities, pain is one symptom among many, e.g., anorexia, confusion, dysphagia, falls, impaired behavior, indigestion, nausea, weight loss, according to AMDA. “Pain should be considered and managed in the context of the whole patient, not in isolation (a ‘silo’)”.
While periodic screening for pain is important, it is no longer recommended to consider pain as the “fifth vital sign” or to record pain level when other vital signs are measured. Even so, residents without diagnoses of chronic pain or active pain problems should be screened for pain on admission, on a change of condition, quarterly, and annually, according to the guidelines.
Assessment may be both direct and indirect. Direct assessment involves gathering information directly from the patient, either through conversation, observation (e.g., pain while dressing) or physical exam. Indirect assessment involves reviewing other sources of information, such as current and previous medical records, diagnostic tests and the observations of those in direct contact with the patient.
“Verbal description is only one of several ways to express pain,” as noted in the guidelines. Further, “limited ability to communicate does not preclude the existence of pain.”
Analgesics and opioids
Several stepwise approaches to analgesic prescribing have been developed. The World Health Organization Pain Ladder for managing cancer-related pain, for example, identifies the following approach:
- Step 1: Non-opioid analgesics for mild pain.
- Step 2: Low-potency opioids (e.g., hydrocodone, morphine) for moderate pain.
- Step 3: High-potency opioids (e.g., hydromorphone, oxycodone) for severe pain.
- Adjunctive medications as indicated at any step
Any discussion of opioids for pain management is bound to be a lively one, given the medical and media attention to the topic. As noted in the guidelines, opioids have an important place in pain management, particularly for cancer-related pain, end-of-life pain and cases of severe chronic pain in residents with co-existing illnesses. However, even when opioids are indicated, nonpharmacological interventions and non-opioid medications should be tried or used concurrently.
Opioid dependence is just one potential hazard of opioids. According to the guidelines:
- Opioids have pharmacological effects throughout the GI tract.
- Constipation is a universal, predictable opioid side effect.
- Major psychiatric and behavioral side effects are common, including agitation, anxiety, dementia, depression, dysphoria, euphoria, hallucinations, nightmares, paranoia and psychosis.
- Respiratory depression is often listed as a major complication of opioids and can be particularly hazardous for patients with respiratory impairment. Fentanyl carries a strong warning that it can cause serious, life-threatening, or fatal respiratory depression.
Other adverse effects of opioid use may include abdominal pain, anorexia/weight loss, apathy, confusion, delirium, dizziness, falls, impaired function, lethargy, pruritus (itchy skin), sedation, urinary retention, and death.
Nonpharmacological interventions
The guidelines stress that nonpharmacological interventions have a role both independently and in conjunction with pharmacotherapy in chronic pain management. Cognitive behavioral therapy and exercise/movement have demonstrated the strongest evidence of effectiveness.
Based on prior research and reviewed in the guidelines, cognitive behavioral therapy involves efforts to change thinking patterns or unhelpful attitudes, beliefs and thoughts, such as “My pain will never get better” or “It will never go away,” or fear that movement or activity will worsen pain. But the guidelines recognize that such therapy requires patients to have insight into triggers for their pain and stress as well as their emotional, behavioral, and physical reactions to pain and stress. This requirement may limit its applicability among post-acute and long-term-care residents.
Movement and exercise have been proven to improve pain severity, physical function and quality of life. Structured exercise can include walking, yoga, tai chi, motor-control exercise, and progressive relaxation. Stretching can improve function and reduce symptoms due to chronic low-back pain. Strengthening exercises may be helpful for painful joints, extremities, and trunk muscles. Physical therapy demonstrates small to moderate effects on pain and disability, and some benefit for anxiety, depression, and quality of life.
“Most people don’t move,” says Dr. Resnick. “Many older adults think, ‘I’m achy, so I’ll sit still and feel better.’” Staff and long-term-care residents themselves must believe in the benefits of exercise and movement. For the resident, it’s believing, “If I get up every couple of hours, or get up and walk to the bathroom, my back won’t hurt so much.” Staff need to verbally encourage residents to move to the extent they can, and if necessary, point out others in the facility who are doing so. (“Your roommate gets up frequently.”)
Encouraging exercise and movement takes time and effort, but dealing with residents’ pain-related behavior takes even more time, she says. Just going to the medicine cart, bringing medication to the resident, and making sure they take it is time-consuming.
“I believe we will continue to develop more nonpharmacological approaches to pain and hopefully continue to develop and use motivational interventions to get individuals to do them. There will be fewer kneejerk responses to give a pill for pain, and more time spent thinking about other options.”