Managing Pain in the Long Term Care Setting

1. Managing Pain in the Long Term Care Setting Mary P. Evans MD CMD FACOG FAAHPM Blue Ridge Long Term Care Associates President, Virginia Medical Directors Association

2. Objectives • Discuss the most common pain syndromes in the LTC population • Describe several classes of pain medications and their indications • Understand non-pharmacologic approaches to pain management and their use in LTC • Describe appropriate pain regimen options for the LTC population

3. Prevalence of pain in LTC • 45-80% of residents in nursing facilities have chronic pain • 51% of residents who report intermittent pain have pain every day • Of these patients, 84% had order for prn pain meds, but only 15% of patients received prn med • Nationally, LTC facilities are doing poorly on pain quality measures Ferrell et al, Pain in the Nursing Home, JAGS 1990;38:409-414

4. Common causes of pain in LTC • Back pain 40% • Arthritis 29% • Previous fx 14% • Neuropathy 11% • Leg cramps 9% • Foot pain 8% • Claudication 8% • Headache 6% • Generalized 3% • Cancer 3% Stein et al, Pain in the Nursing Home. Clin Geriatr Med 1996;12:601-613

5. Pain in Long Term Care • Incident pain • Acute pain • Chronic pain

6. Pain types • Musculoskeletal pain • Bone pain • Visceral pain • Neuropathic pain • Malignancy pain • Psychosocial pain/existential pain

7. Concept of “Total Pain” • Physical pain: medical conditions • Emotional pain: anger, depression, anxiety • Social pain: loneliness, family issues, financial issues • Spiritual pain: life’s meaning, leaving a legacy, hopelessness, abandonment • *Think of these concepts with patients who have pain that is difficult to control

8. Barriers to pain relief: • Unrecognized pain • Difficulty communicating needs • Lack of assessing for pain • Unavailability of pain med order • Pain med not available • Narcotic script issues • Cultural barriers and beliefs • Personal opinions and beliefs • Family interactions • Physician attitudes, beliefs, biases, skills

9. Fears of addiction: terminology • Use of pain medication: • Physical dependence on pain medication – normal state of adaptation to ongoing pain med use • Addiction to pain medication – psychological dependency • Pseudoaddiction to pain medication – apparent drug-seeking or asking for increased dosage when pain is undertreated • Tolerance to pain medication – may need increased dose due to lessened effect or disease progression

10. Pain assessment • Chronicity: Acute, chronic, constant, intermittent • Onset timing: Incidental, procedural, breakthrough, disturbance • Quality, intensity • Alleviating factors • Exacerbating factors • Associated symptoms, radiation of pain • How it affects the patient: what is the patient no longer able to do as a result of the pain? What does this pain mean to the patient?

11. Pain assessment • What has been tried before to help the pain? • Which pain medications have been tried? • Were they helpful? • Which medication, dose, timing seems to work best? • Any difficulties taking oral meds?

12. Patients with cognitive impairment • Pain is likely under-recognized, under-treated • Communication difficulty • Assessment difficulty • Non-verbal pain assessment scales: • FACES pain scale • FLACC scale (face, legs, arms, consolability, cry) • Discomfort scale • PAINAD scale

13. Nonverbal pain signs • Facial expression- grimacing, frown, grinding teeth • Posture – guarding, bracing, defensive posture • Movement – rocking, rubbing, fidgeting, restlessness • Behaviors – agitation, physical aggression, resisting cares, yelling out • Vocalization - crying, groaning, whining, sighing • Activities – ADL function, participation, gait

14. Incident pain • Occurs with particular activities • Getting out of bed • Taking a shower • Transferring to chair

15. Pain treatment – incident pain • Anticipate the pain • Oral pain med 30-60 min prior to procedure • Premedicate before procedures: • Dressing changes for wounds • Moving patient for shower • Transfer to hospital for procedure

16. WHO Analgesic Ladder By mouth – oral or sublingual, avoid injections By the clock – schedule routinely, appropriate interval By the ladder – Step 1 – Acetaminophen (limit dosage), NSAID Step 2 – Opioid or combination Acetaminophen/Opioid Step 3 – Pure opioid, addition of adjuvant By the individual – can add adjuvants at any step; can start at higher step to relieve pain initially; quality of life; comorbidities, family support

17. Equianalgesic table (OME) • Morphine PO 30 mg • Morphine SC or IV 10 mg (1/3 dose) • Oxycodone PO 20-30 mg • Hydrocodone PO 30 mg • Hydromorphone PO 7.5 mg (1/4 dose) • Hydromorphone SC or IV 1.5 mg • TransdermalFentanyl patch 12 mcg-25 mcg

18. Musculoskeletal Pain Causes • Muscles, ligaments, tendons, bones, nerves, joints • Sprains, strains, overuse syndromes • Bruises, bumps • Inflammation, infection • Loss of blood flow to muscle • Low back pain in the most common chronic musculoskeletal pain

19. Musculoskeletal Pain • Aching, stiffness • “pulled muscle” feeling • Fatigue, disrupts sleep

20. Rx for musculoskeletal pain • Acetaminophen • Acetaminophen/narcotic combo • Pure opioid • Corticosteroid

21. Rx for musculoskeletal pain • Muscle spasms: • Cyclobenzaprine • Orphenadrine • Metaxalone • Methocarbamol • Carisoprodol • Tizanidine • Baclofen • Benzodiazepines

22. Non-pharmacologic treatment of musculoskeletal pain • PT/OT • Splint for immobilization, rest • Mobilization • Heat, cold • Relaxation, biofeedback • Stretching exercises • Therapeutic massage

23. Bone Pain • Described as aching, dull, deep, boring, constant, may be weather-dependent • Difficult to localize • Present at rest and with movement • Somatic pain

24. Bone pain causes: • Fractures • Healed fracture • DJD • Metastasis to bone (breast, lung, prostate) • Sickle cell disease • Myeloma • Paget’s disease

25. Rx for bone pain • Corticosteroids • Calcitonin • Bisphosphonates (*GI symptoms, keep upright) • Palliative radiotherapy • Nonsteroidal anti-inflammatory drugs • Narcotic pain meds

26. Visceral Pain • Distension of hollow organ • Stretching of smooth muscle • Stomach • Small and large intestines • Gall bladder • Kidney/ureter

27. Visceral Pain • Crampy, intermittent pain • May be difficult to localize • Can be mild to severe • History is important – especially timing of pain

28. Treatment of Visceral Pain • Evacuation of the distended hollow viscus • Relief of constipation, disimpaction • Surgical treatment • Prevent future episodes

29. Treatment of visceral pain • Bowel obstruction: • Octreotide ($$$$) • Anticholinergics: hyoscine, scopolamine, glycopyrrolate ($) • Corticosteroids ($) • especially end of life care

30. Example: Visceral pain • Appendicitis • Early inflammation – crampy abdominal pain, nausea and vomiting • Patient is uncomfortable, writhing on table • Visceral pain, difficult to localize • Later in course – localization of pain to right lower quadrant, fever, malaise, leukocytosis • Patient lies still, + rebound

31. Neuropathic Pain Causes: • Compression of nerve • Post-entrapment nerve injury • Regional pain syndromes • Skeletal muscle spasms • Post-herpetic neuralgia

32. Neuropathic pain treatment • Acetaminophen • Acetaminophen/narcotic combo • Pure opioid • Add adjuvant meds, therapies early on

33. TENS • Administered by therapist • Transcutaneous electrical nerve stimulation • Battery-operated, portable units • Electrical current disrupts pain signal • Questionable validity (Cochrane Collaboration, 2008)

34. Physical Modalities: • Heat, cold application • Muscle massage, stretching, ROM • Ultrasound, TENS • Acupuncture, acupressure • Physical and occupational therapy • Positioning, devices, pillows, chairs

35. CAM modalities • Meditation, relaxation • Spiritual counseling and prayer • Hypnosis, biofeedback • Aromatherapy, herbal therapy • Music and sound therapy • Art therapy

36. Adjuvant Modalities E-stim Diathermy Laser therapy Heat/cold application Topical treatments – menthol, capsaicin

37. Electrical stimulation history • First documented use in ancient Rome, AD 63 • ScriboniusLargus described pain relief by standing on an electrical fish at the seashore • 16th-18th century – electrostatic devices for headaches and pain • Benjamin Franklin was a proponent of electrical stimulation treatment of pain

38. E-stim • Administered by therapist • Electrical current causes contraction of muscle or muscle group • Helps strengthen affected muscle • Promotes blood supply to area – promotes healing

39. Topical Capsaicin • Active component of chili peppers • Ointment, spray, cream forms • Minor aches, pains, DJD, strains and sprains • Post-herpetic neuralgia • Neurons are depleted of neurotransmitter (substance P), fatigues nerves

40. Pain Rx in the Elderly • “Start low, go slow” • Don’t forget the bowel regimen

41. Anticipate side effects • Constipation – add stool softener, stimulant right away • Nausea, vomiting – often transient for 3-4 days • Sedation – no driving, methylphenidate, caffeine • Delerium – lorazepam • Pruritis – usually dissipates; antihistamine • Urinary retention – monitor output, comfort • Myoclonic jerks – metabolite buildup; lower dose or consider rotating to a different opioid • Respiratory depression – uncommon except when starting fentanyl patch in opioid-naïve patient

42. Pain management – special circumstances • Hospice, end of life care • Multiple drug allergies • Route of administration alternatives: • Transdermal fentanyl • Oral meds administered rectally • Avoid injectable meds if possible

43. Adjuvant pain regimens • Addition of antidepressants • TCA’s: Amitriptyline, nortriptyline* • SSRI‘s: paroxetine, citalopram • NSRI: venlafaxine* • Other: bupropion • * watch for anticholinergic symptoms

44. Adjuvant pain regimens • Addition of neuroleptics: • Gabapentin • Topiramate • Lamotrigine • Carbamazepine • Levetiracetam • Pregabalin • Phenytoin • Valproic Acid

45. Adjuvant pain regimens • NMDA antagonists: • Ketamine • Dextromethorphan • Memantine • Amantadine • Local Anesthetics: • Lidocaine – gel, patch • Mexiletine

46. Adjuvant pain regimens • Other: • Baclofen • Cannabinoids • Methylphenidate • Capsaicin

47. Adjuvant pain regimens • Alpha-adrenergic agonists: clonidine, tizanidine • Corticosteroids: • Dexamethasone (intracranial pressure) • Prednisone (DJD, bone pain)

48. Difficult to control pain • Pain despite escalating doses • Consider possibility of drug diversion • Consider existential/psychosocial pain

49. Opioid rotation • Chronic pain – may try rotating to another opioid • “Opioid fatigue”, tolerance • Remember to reduce calculated conversion dose by 50% for cross-tolerance

50. Here’s what I do • Post-op patients: • Schedule pain meds x 7 days • prn pain meds available • Treat pain aggressively until comfortable • Remember the bowel regimen!