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Fast Fact and Concept #89: Pain Management In Nursing Homes: Analgesic Prescribing Tips

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Title: Fast Fact and Concept #89: Pain Management In Nursing Homes: Analgesic Prescribing Tips

Author(s): Liao, Soloman; Weissman, David E

Approximately 25% of deaths in the United States occur in long-term care facilities, a care setting in which pain is common, and often poorly treated. Reasons include inadequate pain education for nursing home staff, perceived regulatory barriers in the use of opioid analgesics, societal barriers regarding the nature of pain in the elderly (e.g. pain is normal and thus need not be treated), and high prevalence of resident cognitive impairment leading to inadequate pain assessment. Physicians can help improve pain management of their nursing home residents by the way in which they prescribe analgesics. This Fast Fact will review simple strategies for improving pain management outcomes.

How are medications distributed in nursing homes?

There is a critical shortage of registered nurses in nursing homes; it is common for there to be only one RN for 15-30 residents. In most facilities, scheduled medications are distributed twice per 8 hour shift by one of several individuals, with more or less pain education (a Registered Nurse or Certified Nursing Assistant or Certified Medication Assistant). This system limits the opportunity for a skilled nurse to do frequent assessments of pain and monitoring the response to analgesics. The large patient-nurse staffing ratio limits the utility of PRN medication orders, especially orders more frequent than every 4 hours, and also limits the ability of nurses to monitor pain in cognitively impaired residents, since these residents are typically unable to initiate a request for PRN medication. Thus, specific instructions from the prescriber for how a medication is to be used is vital.

Tips for improving pain management

  1. Communicate your concerns regarding pain with a nursing supervisor; discuss how to maximize opportunities for a) pain assessment and b) provision of timely feedback to you for medication changes. Review with the nursing supervisor the facility method of pain assessment documentation and standards for pain assessment and treatment.
  2. Write an order for a registered nurse to do a complete pain assessment on a regular basis.
  3. Whenever pain is constant, write an order for a scheduled medication, preferably a long-acting medication.
  4. Write orders for PRN medication at intervals of every four hours (MSIR 15 mg q4h prn pain). If you know that the patient is likely to need frequent PRN medication, write the order as a scheduled order with, hold if no pain, or patient may refuse.
  5. Do not write simultaneous PRN orders for multiple analgesics, only one opioid-non-opioid combination product should be prescribed at any one time.
  6. Plan ahead, it is common for nursing home residents to have increasing pain related to physical therapy, dressing changes, etc. Write an analgesic order that anticipates painful activity: (e.g. morphine elixir 10 mg PO 30 min prior to bath).
  7. Do not forget to order a prophylactic bowel regimen for patients on opioids.
  8. Include options for non-pharmacological pain therapies (e.g. heat, massage, PT).

References:

Buchanan RJ, Choi M, Wang S, Huang C. Analyses of nursing home residents in hospice care using the minimum data set. Palliat Med 2002 Nov;16(6):465-80.

Miller SC, Mor V, Wu N, Gozalo P, Lapane K. Does receipt of hospice care in nursing homes improve the management of pain at the end of life? J Am Geriatr Soc 2002 Mar;50(3):507-15

Kovach CR, Weissman DE, Griffie J, Matson S and Muchka S. Assessment and treatment of discomfort for people with late-stage dementia. J Pain Symptom Manage 1999; 18: 412-419.

Weissman DE, Griffie, J, Muchka S and Matson S. Building an institutional commitment to pain management in long-term care facilities. J Pain Symptom Manage 2000; 20:35-43.

Improving Pain Management in Long-Term Care Settings: a resource guide for institutional change. Weissman DE, Griffie J, Muchka S and Matson, S. Medical College of Wisconsin, 1998.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Liao, S and Weissman DE. Fast Facts and Concepts #89 . Pain management in nursing homes: prescribing tips. April 2003. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 5/2003

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)
Training: Fellows, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Patients/Families, Nurses, Social Workers

ACGME Competencies: Medical Knowledge, Patient Care, System-based Practice

Keyword(s): Addiction, Chronic non-malignant pain, Controlled substance regulations, Pain, Pain assessment, Pain treatment


The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).