Pain points

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The Centers for Disease Control and Prevention found only a third of nursing home residents had a documented weekly assessment of their pain. The nursing home population underreports pain levels, posi
The Centers for Disease Control and Prevention found only a third of nursing home residents had a documented weekly assessment of their pain. The nursing home population underreports pain levels, posi

Few things more commonly afflict the elderly than pain. The American Geriatrics Society estimates up to 80% of the nearly 2 million residents in long-term care facilities suffer with varying degrees of it daily. 

It is exacting a heavy toll on the healthcare system. Just a handful of years ago, pain treatments nationwide soared to $635 billion, according to the American Physical Therapy Association — more than twice what was spent on heart disease and three times what was spent on cancer.

In a June 2016 report by the Office of Inspector General for Health and Human Services, Medicare spending for Part D drugs has continued to rise by more than $10 billion a year.

The drive has been fueled heavily by “commonly abused opioids” — Medicare doled out $4 billion in 2015 alone for them.

To make matters worse, seniors in long-term care settings also are paying a high price for the ongoing nationwide epidemic of painkiller addiction. Recent regulatory changes reversed long-standing policies that encouraged powerful painkillers to ease suffering and now heavily restrict opioid prescribing. It has had a chilling effect on doctors and bedside caregivers.

“Ten years ago, there was an increased emphasis on using routine scheduled analgesics to ‘get ahead of the pain,' as opposed to just relying on PRN analgesics, which had been the practice in the past,” observes Albert Barber, PharmD, CGP, clinical pharmacist for AlixaRx.

Many say the changes leave too many nursing home residents under-dosed. Yet many of those same elderly now suffer from addiction issues once confined to the young.

In short, the long-term care industry may now be facing its most challenging medication management problem ever.

Addiction levels ‘astounding'

Nearly 18% of everyone over age 65 suffering from chronic pain either abuse or are addicted to opioids, according to Jerome Wilborn, M.D., national medical director for post-acute service at IPC Healthcare, a TeamHealth company. Many of them are being forced into a cruel withdrawal.

“Pain control in the nursing home setting, in general, is poor,” he says. “There are more patients in pain in the nursing home setting than there should be. Our ability to better treat those patients with pain has a lot to do with either good outcomes or in the case of addiction and abuse, bad outcomes.” 

Adds Jayne Warwick, RN, HBScN, director, industry insight and marketing for PointClickCare: “The older a [nursing home] resident gets, the less likely they are to receive any analgesia, and with these new restrictions, getting the right analgesia will be even harder.”

Wilborn is hardly alone in raising a ruckus about painkiller addiction in the elderly.

As Kaiser Health News reported in July, a JAMA Internal Medicine study revealed that nearly 15% of hospitalized Medicare beneficiaries had filled a prescription for an opioid within a week after being discharged in 2011. Of those who filled the first prescription, 42.5% had another pharmacy claim for an opioid painkiller at least 90 days later, “opening the door to long-term use and dependence.”

But the most damning news of elderly painkiller addiction came in the June 2016 OIG report, which called the number of opioids being prescribed to seniors “astounding.” As noted by the news site, the OIG report concluded that nearly one-third of Medicare beneficiaries received at least one prescription for opioids such as OxyContin, Percocet, Vicodin and fentanyl, with an average of five refills, over the past year. A Health and Human Services spokesman told reporters that since 2013, the agency has been monitoring so-called “high-risk beneficiaries” suspected of overusing commonly abused drugs and last year, flagged nearly 16,000 beneficiaries as potential problem drug users. Most notably for long-term care providers, beginning in 2017, the federal government will pay only for prescriptions written by Medicare-enrolled doctors.

Officials clamp down

In March, the Centers for Disease Control and Prevention released sweeping standards for prescription painkillers. For physicians with elderly patients in nursing homes, the new rules were game changers. Many clinicians today continue to castigate (and in many cases, ignore) the rules, saying their burdensome restrictions leave too many seniors addled with pain. 

Among other things, the rules urge doctors to try over-the-counter analgesics before resorting to scheduled narcotics. With the exception of post-surgical, cancer and terminal patients, physicians now can write opioid prescriptions for only three days or less. Concurrently, the Food and Drug Administration swiftly instituted so-called “black box” death and addiction warnings on the labels of nearly 90 brand-name and 141 generic painkillers.

Hamstrung from the start

Nursing homes and other senior living providers are fighting the issue on multiple fronts. They're handicapped before they even start for one compelling reason: Pain is not easy to diagnose. 

“When you are dealing with people in a cognitively alert, verbal population, as is more likely in acute care, they will complain if they feel the pain medication isn't working. This is not as likely to occur within the long-term care population,” explains Warwick. In addition, opioids can complicate proper assessment because they cause confusion and constipation, she adds.

As much as Wilborn places the onus of diagnosing pain on his and his peers' shoulders, he is the first to acknowledge the difficulty. 

“You can't necessarily walk in and say, ‘Mrs. Smith, are you having pain?' because what if she can't articulate that to you?” he observes. “Now you start to look at things like grimacing. You have to really spend more time.”

Spotting addiction in the elderly is equally challenging. 

“It's underreported because the elderly don't fit the typical drug addiction stereotype,” Wilborn says. “You don't think of the gray-haired guy having a problem taking oxycodone.”

No one in the provider community could have guessed how powerfully addictive this new generation of synthetic opiates would be. But those in the pharmacy community differ on the extent of addiction, as well as diversion, inside the walls of skilled nursing facilities.

Frank Grosso, R.Ph., executive director and CEO of the American Society of Consultant Pharmacists, flatly rejects any notion that painkiller addiction is a serious issue in nursing homes. While SNFs have a slightly higher opioid prescription rate than other long-term care settings, Grosso asserts that over prescribing and misuse of opioids is minimal because “regulations require ongoing monitoring of medication orders by the physician, patient pain assessment and documentation of administration and effectiveness of the pain medication.”

Both Warwick and Barber say addiction tends to rise in settings other than nursing homes. 

“There is more concern with short-term rehabilitation residents who have major surgeries to ensure they are properly assessed and making sure opioid use is reduced as much as possible prior to discharge home,” says Warwick. Barber agrees. 

“It's pretty difficult for [nursing home] residents to abuse painkillers while inside the facility because, with few exceptions, the vast majority of them don't self-administer,” he says. “They get the drugs from a nurse. They can beg for more PRN meds, but the nurses are pretty limited by whatever the drug orders say. That's pretty closely monitored.” And with the advent of electronic medical records, opioid administration and tracking typically stanches overuse, he adds.

Joe Kramer, vice president of sales and marketing for Geri-Care Pharmaceuticals Corp., believes prescribers have a “blind spot” when prescribing opioids because “the benefits of use of opioids in persons with chronic pain lasting longer than three months have not been well documented.” 

Closer look needed

Both Wilborn and Kramer believe some soul-searching is in order. Still, Kramer asserts, “The present state of opioid misuse and addiction hasn't forced the long-term care industry to reevaluate its prescribing and care practices.”

Most observers cannot confidently say how much of a “problem” opioid use really is. That's likely because until recently, few were paying close attention. Several years ago, the CDC found that only 32% of nursing home residents had a documented weekly assessment of their pain. That doesn't surprise Wilborn. 

“For institutionalized patients, underreporting is the rule of the day,” he says. “Whether it's the hospital, where they presumably have better surveillance systems, versus an assisted living facility, a lockdown unit or skilled nursing facility, many of those instances are just not reported.”

The whole issue of painkiller dosing remains a double-edged sword. Hypersensitivity abounds around it, but even today, many facilities keep plenty of opioid stock on hand. 

“What a facility doesn't want to have happen is for the state or a survey team to come in and question a resident and have them say, ‘I needed my pain meds and they didn't give it to me,'” notes Bob Smith, COO for Ron's Pharmacy Services, a member of the Guardian Pharmacy family. “So to protect themselves, they have it there. Some of the regulations actually are forcing the hand of the prescriber and the facility is under pressure to ensure those drugs are always available.” 

Providers also are somewhat hogtied by what they see as onerous prescribing rules. Warwick asserts, for example, that “Drug Enforcement Administration rules complicate the prescribing of opioids in long-term care since the nurse is not always viewed as the agent in [that] setting.”

Wilborn agrees: “One problem is the feds decoupled the nurses' prescriptive authority away from us. So when patients go into a nursing home, or if they need an opioid or controlled substance, we actually have to call the pharmacist.

“It is very cumbersome, difficult [and] frustrating to call a long-term care pharmacy to order a scheduled substance for a patient who is in pain. In fact, many of the doctors just say, ‘I'm not doing this. There has to be a better way.' That's not the right answer. Now you have a patient who is in potentially worse pain who is not being treated.”

Smith said last year, CMS hinted in its proposed “mega rule” to disallow PRN orders for opiates without a documented “need” after 48 hours of nursing home admission.

“That would be huge,” Smith says. “And I think you'd see people running away from writing PRN orders, especially with the hydrocodone products, if this legislation is passed.”

Grosso believes the problem lies in poor, lagging communication during care transitions.

“This is due primarily to the current requirements for direct communication of verbal prescriptions from the prescriber to the dispensing pharmacist,” he says. “The DEA only recognizes the center's nurse as an agent of the physician in rare cases where specific written contractual arrangements are already in place.” 

Grosso said ASCP and other stakeholders are working with the agency “to allow an appropriately licensed nurse in a skilled nursing center to assist in the communication process to assure patient needs are met with fewer technical delays.”

All of these challenges will become less of a problem only when clinicians start paying closer attention to managing pain in particular, and medications in general.

“What complicates this is inadequate physician clinical attention to patients' overall conditions,” Wilborn adds. “This is a medical management issue that rests at physicians' feet. But that's not to say that it wouldn't be nice to have some help.” 

But the help for some may not benefit physicians, as funding remains focused around fighting addiction. The Obama administration said at the end of August that it would distribute $53 million to 44 states in an effort to curb opioid abuse. The money will be focused on overprescribing of pain killers, increased access to treatment and making sure the antidote naloxone is widely available. It's anyone's guess how the next administration will handle the sticky wicket of opioids.