Sourcebook : Improving Care for the End of Life : 3.16 Review Prescribing Practices for Opioid Drugs

One striking opportunity for improvement is in opioid drug prescribing practices. The most glaring issue for many Breakthrough Series teams was the use of meperidine. One hospital calculated the morphine equivalent dosages for all of its repeated dose prescriptions. Half were for meperidine, the only opioid that is routinely contraindicated because of its short duration of action and because one of its metabolites is a central nervous system stimulant (often causing delirium and agitation). Although physicians' commitments to historical prescribing patterns are strongly held, a pharmaceutical committee embarked on a program of changes to prevent this misuse. Similar pharmacy-based and often automated approaches could nearly halt incorrect conversions from one delivery system or drug to the next (e.g., when changing from an IV to oral morphine).

Key Recommendations for Managing Chronic Pain in Older People
Pain should be an important part of each assessment of older patients; along with efforts to alleviate the underlying cause, pain itself should be aggressively treated. Pain and its response to treatment should be objectively measured, preferably using a validated pain scale. Non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution. In older patients, NSAIDs have significant side effects and are the most common cause of adverse drug reactions. (The new Cox-2 agents may have a better side effect profile) Acetaminophen is the drug of choice for relieving mild to moderate musculoskeletal pain. Opioid analgesic drugs are effective for relieving moderate to severe pain. Non-opioid analgesic medications may be appropriate for some patients with neuropathic pain and other chronic pain syndromes. Nonpharmacologic approaches (e.g., patient and caregiver education, cognitive-behavioral therapy, exercise, etc.), used alone or in combination with appropriate pharmacologic strategies, should be an integral part of care plans for most chronic pain patients. Referral to a multidisciplinary pain management center should be considered when pain management efforts do not meet the patient’s or the health care provider’s goals. Regulatory agencies should review existing policies to enhance access to effective opioid analgesic drugs for older patients in pain. Pain management education should be improved at all levels for all healthcare professionals. Source: The American Geriatrics Society, 1998.

Key Recommendations for Managing Chronic Pain in Older People

Pain should be an important part of each assessment of older patients; along with efforts to alleviate the underlying cause, pain itself should be aggressively treated.
Pain and its response to treatment should be objectively measured, preferably using a validated pain scale.
Non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution. In older patients, NSAIDs have significant side effects and are the most common cause of adverse drug reactions. (The new Cox-2 agents may have a better side effect profile)
Acetaminophen is the drug of choice for relieving mild to moderate musculoskeletal pain.
Opioid analgesic drugs are effective for relieving moderate to severe pain.
Non-opioid analgesic medications may be appropriate for some patients with neuropathic pain and other chronic pain syndromes.
Nonpharmacologic approaches (e.g., patient and caregiver education, cognitive-behavioral therapy, exercise, etc.), used alone or in combination with appropriate pharmacologic strategies, should be an integral part of care plans for most chronic pain patients.
Referral to a multidisciplinary pain management center should be considered when pain management efforts do not meet the patient’s or the health care provider’s goals.
Regulatory agencies should review existing policies to enhance access to effective opioid analgesic drugs for older patients in pain.
Pain management education should be improved at all levels for all healthcare professionals.

Source: The American Geriatrics Society, 1998.

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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.

For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].