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

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

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

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

Pain in Long Term Care Incident pain Acute pain Chronic pain

Pain types Musculoskeletal pain Bone pain Visceral pain Neuropathic pain Malignancy pain Psychosocial pain/existential pain

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

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

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

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?

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?

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

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

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

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

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

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 Transdermal Fentanyl patch 12 mcg-25 mcg

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

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

Rx for musculoskeletal pain Acetaminophen Acetaminophen/narcotic combo Pure opioid Corticosteroid

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Electrical stimulation history First documented use in ancient Rome, AD 63 Scribonius Largus 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

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

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

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

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

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

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

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

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

Adjuvant pain regimens Other: Baclofen Cannabinoids Methylphenidate Capsaicin

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

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

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

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!

Here’s what I do: Patients with dementia, behaviors: Difficulty asking for meds, communicating Schedule acetaminophen tid-qid Have opioid available for pain not relieved by acetaminophen Consider lidocaine patch Consider scheduled opioid for daily moderate to severe pain (bowel regimen!)

Here’s what I do: Hospice, end of life care: Have liquid morphine, liquid lorazepam available Rectal acetaminophen Can also administer oral meds via rectal route Transdermal fentanyl patch (appropriate dose) if unable to swallow (not in opioid naïve patients) Long-acting opioids once optimal 24h dose achieved

Questions?

Use of methadone -advantages Acyclic analog of morphine, heroin NMDA receptors – neuropathic pain Used in hospice, end of life care Long half-life, long-acting Strong analgesic Cheap ($) Chronic pain use – anti-addictive Less sedative than other opioids

Use of Methadone - drawbacks Many metabolites Liability risk (?) Variable metabolism/half-life in the elderly Use cautiously in select patients

Use of Methadone Approved in the US for detoxification treatment of opioid addiction Must follow strict federal regulations in detox programs Programs must be certified by Federal Substance Abuse and Mental Health Services Administration Programs must be registered with the Drug Enforcement Agency (DEA)