It is now well known that pain is both highly prevalent and undertreated in the elderly. Pain management is a particular problem in nursing-home patients, a vulnerable population that poses significant and unique challenges to caregivers in terms of their ability to provide adequate treatment. Some of these challenges include the misconceptions and unfounded fears about patients becoming addicted to prescription opioids.
The magnitude of this public health problem has been well documented over the last decade. In 2001, researchers from Brown University published the first nationwide study of pain management in nursing homes, which revealed persistent and severe pain among patients. Using data gathered through the federally required Minimum Data Set (MDS) and examining the pain experience of more than two million people residing in nursing homes in the U.S., researchers found that more than 40% of elderly residents who were in pain at the start of the study were still experiencing moderate pain daily or excruciating pain 60 to 180 days later. suhagra
In the year following this dramatic report, the Centers for Medicare and Medicaid Services (CMS) launched the Nursing Home Quality Initiative, an effort that included strengthening CMS’s regulatory and enforcement activities to better track and address complaints and deficiencies. A two-year progress report, released by the CMS in 2004, indicated that nursing homes in general had improved their performance on many of the publicly reported quality measures. For example, the average nursing home reduced the number of long-stay residents with pain by 38%.
Although important ground might have been gained since Brown University’s study, conducted almost 10 years ago, it is clear that more work is yet to be done. The American Geriatrics Society Panel on Persistent Pain in Older Persons estimates that 45% to 80% of nursing-home residents have substantial pain. The panel lists the consequences of poor pain management as sleep deprivation, poor nutrition, depression, anxiety, agitation, decreased activity, delayed healing, and lower overall quality of life.
Further, a study by Hutt and colleagues, published in 2006, found that many nursing-home residents had poorly managed pain because of inadequate medication treatment. Using an experimental Pain Medication Appropriateness Scale (PMAS), researchers assessed the suitability of pain management practices in 12 nursing homes. Criteria in the PMAS include type of pain (e.g., neuropathic, persistent or breakthrough pain); pain severity; degree of relief obtained from medication; a constipation regimen for patients taking opioids; and exclusion of geriatric high-risk drugs, such as codeine-containing drugs, anticholinergic muscle relaxants, or long-acting benzodiazepines.
Data from about 1,200 patients revealed a mean total PMAS that was 64% of optimal, an indication of generally poor manage ment of pain. Fewer than half of these residents with recurrent pain received prescriptions for scheduled pain medications, and 23% received at least one high-risk medication. In addition, even though 70% of the patients in the study had long-lasting pain, most of them were prescribed medications designed for shorter-term pain. The scores overall were better for residents in homes where the nurses had received training for pain relief.
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As mentioned earlier, there are many barriers to effective pain assessment and management in nursing homes. For example, many of these nursing-home residents have cognitive or functional impairments, such as delirium, dementia, or speech disorders, that may limit their ability to articulate their pain. In addition, elderly patients in particular can be stoic and might be reluctant to express their pain for a variety of reasons. They might think that their pain cannot be relieved, or they might fear that their pain is an indicator of serious illness. Many elderly patients do not want to appear “weak” or to be a bother to their physician, whereas many others believe the pervasive myth that pain is a natural part of the aging process.
Insufficient knowledge and training in pain management by health care professionals, an absence of standardized pain assessment tools, and the lack of a standardized approach to treating pain have also been identified as obstacles to pain management in nursing homes. Staffing shortages and the high rate of staff turnover in nursing homes only compound these challenges by creating problems in communication and coordination among specialists, primary care providers, and other members of a patient’s health care team. Moreover, despite evidence of the safety and efficacy of opioids for the treatment of pain in the elderly, the fear of dependence and addiction among both patients and physicians remains a significant bar-rier.
Another major concern shared by nursing-home patients and their health care providers is the possibility of analgesia-related side effects, according to David Rabin, RPh, CCP, a pharmacist consultant to nursing homes in Pennsylvania, New Jersey, Delaware, and Maryland.
“From a pharmacist’s perspective, there is a fine line between getting the results you want from the medicine and keeping the side effects to a minimum.”
Although providers make every attempt to ensure that the therapeutic benefits outweigh the adverse events, in pain treatment, he says, “there are at least some side effects that are going to be excessive with whatever dose of medication you are using, and then sometimes you have to try to treat the side effect almost as if it is another condition.”
The biggest problem for patients, he says, is constipation, a common side effect resulting from opioid use. In the past, physicians waited to see whether a patient became constipated while using the medication; now an appropriate bowel regimen is recommended for all patients receiving opioid analgesics.
Dizziness and drowsiness, two more common side effects of opioids, are of particular concern to physicians, notes Mr. Rabin, as falls are a major problem in the elderly and especially in nursing-home patients. Patients in nursing homes are generally more frail than elderly adults living in the community. They also tend to be older, to have more chronic illnesses, and to have difficulty walking, factors that increase the risk of falling.
Respiratory depression is perhaps the most feared opioid side effect, says Mr. Rabin, and it is often the reason for the reluctance to use opioids appropriately, especially in patients nearing the end of life. However, tolerance to respiratory depression develops rapidly, over a period of days to weeks; therefore, it occurs rarely in patients receiving chronic opioid therapy.
In a consensus statement, the American Pain Society and the American Academy of Pain Management concluded:
… respiratory depression induced by opioids tends to be a short-lived phenomenon, generally occurs only in the opioid-naive patient, and is antagonized by pain. Therefore, withholding the appropriate use of opioids from a patient who is experiencing pain on the basis of respiratory concerns is unwarranted.
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The task of dispelling myths and misconceptions about pain medications often falls to pharmacists, who have become the front line of health care for the elderly population. Heavily monitored and regulated, staffed by primarily unlicensed personnel, and lacking a regular physician presence, the nursing-home environment is unlike other health care settings and presents a unique opportunity for pharmacists to educate patients, caregivers, and other health care providers about adverse effects and the appropriate use of pain medications. However, it is clear that more research is needed into how to better assess and manage pain in this population of patients, who are often unable or reluctant to communicate their pain experience. Education is also important so that both nursing-home residents and physicians have complete knowledge about the risks and benefits of pain medications.