No pain = all gain
No pain = all gain
Statistics underscore the need for greater scrutiny. Collectively, up to 50% of pain in the elderly goes untreated, the American Medical Association reports. The number of nursing home residents who are under-treated for pain can reach as high as 80%, adds the National Institutes of Health.
The mandate, if not necessarily the progress, is there.
The barriers to effective pain management are plentiful. For starters, many seniors falsely assume that pain is a normal part of aging. It's also not uncommon for seniors and their family members to shun pain medications for fear of addiction and other side effects. Further, Alzheimer's disease and other forms of dementia may make it difficult for a resident to communicate pain or discomfort, while some caregivers may lack the knowledge and support needed to provide prompt, appropriate pain relief.
Timely access to controlled medications also continues to be a challenge in the long-term care setting due to drug shortages and what some consider excessively strict federal regulations.
“The Drug Enforcement Agency's interpretation of the Controlled Substances Act is one barrier that's impeding timely access to appropriate controlled medications for nursing facility residents and those enrolled in hospice programs,” notes Jennifer Hardesty, PharmD, FASCP, clinical services manager for Remedi SeniorCare.
There is no question that pain's effects on quality of life are far-reaching. Not only does pain diminish pleasure and interfere with social relationships and one's ability to stay active, it is also linked to other debilitating conditions, such as depression and anxiety.
And operators who aren't doing enough to manage residents' pain ultimately will deal with some painful outcomes of their own. These include citations from surveyors who, under new pain management regulations, are paying close attention to a facility's recognition, evaluation and management of pain in residents.
“If a pain management concern is identified, surveyors are encouraged to evaluate other related F-Tags, including F-Tag 425, to determine if the medications required to manage a resident's pain were available and administered as indicated — and ordered at admission and throughout the stay,” explains Hardesty.
Greater education and awareness surrounding effective pain management has surfaced in recent years, including a better understanding by caregivers to look for non-verbal cues and other conditions that might indicate pain, such as sleep cycle shifts, mood changes, functional decline, or weight loss — factors directly addressed in various sections of MDS 3.0.
“I've really seen a better understanding of the need for getting patients out of pain. Medical schools are doing a better job with this and there's greater training and education taking place to promote timely and appropriate treatment of pain [in the long-term care environment],” says Rob Taymans, president and owner, Guardian Pharmacy of Tampa.
Better access to advanced pain management solutions is another positive development that's leading to more timely treatment. Solutions that allow caregivers to administer a steady, consistent and reliable dose to residents are essential for alleviating pain and preventing it from recurring — or worsening — between doses.
“Pain management typically requires time-dependent administration. An additional dose must be administered as the last dose is wearing off or the patient is likely to suffer a recurrence of pain,” stresses Ron Kutrieb, president and CEO, AccuPax.
His company's SafeDose medication management system produces a strip of packets with the day, date and time of administration printed on each, so the caregiver knows precisely when the next dose is due.
Effective from afar
Remote dispensing, which makes medication available around the clock, is another solution that's gaining traction. Many residents experience severe pain and need Schedule II narcotics immediately, and remote dispensing helps ensure that the right medications are always available for those residents, says Carla Corkern, CEO of Talyst. The company's Remote Dispensing System dispenses pharmacist-approved, patient-specific, multi-dose packets at the facility to accommodate new residents, STAT orders, first doses and PRNs.
“Once the pharmacist has signed and approved the Schedule II narcotic prescription, the medication will always be available for the nurse to administer to the resident,” she says.
The downfall: Remote dispensing is currently available in only 14 states. Even where allowed, quantity and formulary restrictions may exist to limit access to these prescribed, clinically needed medications, according to Lena Sturgeon, RN, executive vice president, Millennium Pharmacy Systems.
“The reality is that the ordering and dispensing of pain medications is treated by legislation like it is the same in long-term care as the acute care setting. It is not,” Sturgeon explains. She noted that the physician, pharmacy and resident are not all under one roof and it's not uncommon for a long-term care pharmacy to be two hours away from the nursing community.
If onsite dispensing isn't available, contracting with pharmacies that offer 24-hour delivery service can ensure prompt, anytime delivery and administration.
It's an approach that's worked well for Crossroads Hospice. Crossroads also provides an emergency symptom kit with a few doses of pain medication for use in home hospice patients and some facility patients (depending on facility policy) who experience a pain crisis after hours.
The kit offers an “emergent dose of narcotics and other commonly needed medications to use almost immediately,” says DeAnna Looper, RN, CHPN, CHPCA, corporate clinical consultant, legal nurse consultant and educator for Carrefour Associates LLC, the management company for Crossroads Hospice. Crossroads also relies on compounding pharmacies to combine medications not manufactured by drug companies, such as hydrocodone without acetaminophen, in a wide variety of dosages.
Senior housing operators also may want to tap pharmacy-provided medication management programs aimed at improving clinical outcomes and reducing care costs. Education is the foundation for these programs' success.
“We've dedicated significant resources to develop training and provide support and in-servicing to help our customers manage pain and medications most effectively,” notes Taymans. Aside from onsite in-services, Guardian also offers online education. More facilities are embracing the educational resources, typically offered as part of Guardian's customer service offering, Taymans says.
“Pain management has become a hot topic and surveyors are actively looking at it,” he added.
Experts agree that the best intervention comes from better medication management — as opposed to relying on pain medications alone. Educating on appropriate pain medication use is the heart of Millennium Pharmacy's medication therapy management programs.
“Medication therapy changes can often change or reduce the need for pain medications,” Sturgeon explains.
New routes to relief
Today, drug delivery options are as varied as the residents being treated. Beyond traditional oral dosing, facilities can now manage pain through subcutaneous and intravenous methods, as well as topically and rectally, to accommodate resident limitations and impairments. Some providers, including Crossroads Hospice, even offer buccal options, such as narcotic-infused lollipops, that allow pain medication to be absorbed through the cheeks.
Patient-controlled analgesia is another option that may be well suited to hospice patients and others who experience severe or chronic pain.
“We are learning that giving patients more control over the timing of their medications through the use of push-button intravenous medication delivery can improve pain control and diminish side effects,” explains Scott Miller, M.D., a palliative care certified physician who serves as medical director for The Center for Compassionate Care in Pittsburgh. “These systems have the ability to deliver doses of medication instantly, while also being able to control for frequency of use and maximum dosages over specific time periods.”
The smaller these devices get, the more mobile they are. However, experts warn that PCA and other forms of intravenous pain management are not good options for the cognitively impaired.
Additionally, faster-acting, extended release formulations are now available, allowing providers to manage pain more effectively, while making the most of clinicians' time. One new drug that's capturing providers' attention is the Butrans patch, which is available in several dosages and applied just once a week.
“[Residents] need long-term pain management options and this is one option that addresses that,” says Moshe Lewis, M.D., a pain management specialist who operates several clinics in California. Because many long-term care residents can't take pills, topical medications, like Diclofenac gel, also are helpful, he says.
One former staple that's falling out of favor with some care providers is the Fentanyl patch.
“We have learned that if the patient is underweight, perspires profusely, is febrile or [has] a low baseline body temperature, these patches are not as effective,” Carrefour Associates' Looper says.
Non-steroidal anti-inflammatory (NSAID) drugs are becoming more sophisticated, too, thanks to combination formulas that blend pain and inflammation relief with other benefits. “Vimovo and Duexis are new combinations of NSAIDs with stomach protectants that limit the number of medications dispensed,” says rheumatologist Robin Dore, M.D., clinical professor of medicine at UCLA's division of rheumatology. “One of the most common side effects of NSAID therapy is GI upset, so it's convenient to have NSAIDs combined with medications that decrease the risk of GI-adverse events.”
While today's medications do a better job of managing pain, side effects are still a concern. “This is an ongoing challenge and requires regular medication rotation, regardless of whether the medication is an opioid,” Lewis stresses.
Increasingly, senior housing operators are thinking beyond traditional medication therapy when managing pain, opting instead for more holistic, comprehensive solutions.
“There's been a tremendous increase in non-pharmacologic pain treatments, such as acupuncture, biofeedback and massage,” confirms Taymans.
Meditation, guided imagery, music and aromatherapy also are showing promise in the non-pharmacological intervention category.
Lewis says he's seen more insurance plans covering acupuncturists and osteopaths, and more physician assistants and nurse practitioners are also becoming more involved in treatment — many of whom, he says, have a greater sensitivity to one's pain.
The key message, experts stress, is that pain management is anything but one-size-fits-all. “Everyone is unique and so is their pain. What works for one person may not work as well for another,” Taymans notes. “The more options we have to manage pain, the better the outcomes will be.”