Fast Fact and Concept #089: Pain Management in Nursing Homes: Analgesic Prescribing Tips

2nd Edition

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

Background

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 part of normal aging and thus need not be treated), and high prevalence of resident cognitive impairment leading to inadequate pain assessment (see Fast Fact #126). 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 licensed nurses in nursing homes; it is common for there to be only one nurse for 15-30 residents. In most facilities, scheduled medications are distributed twice per 8 hour shift by a licensed vocational or practical nurse (LVN or LPN), who often have minimal pain education. 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

• 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’s method of pain assessment documentation and standards for pain assessment and treatment.
  
• Write an order for a nurse to do a complete pain assessment on a regular basis.
  
• Whenever pain is constant, write an order for a scheduled medication, preferably a long-acting medication.
  
• Write orders for PRN medication at intervals of every four hours (e.g. morphine sulfate immediate release 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.”
  
• Do not write simultaneous PRN orders for multiple analgesics—only one opioid/non-opioid combination product (such as oxycodone+acetaminophen) should be prescribed at any one time.
  
• 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).
  
• Don’t forget to order a prophylactic bowel regimen for patients on opioids.
  
• Include options for non-pharmacological pain therapies (e.g. heat, massage, PT).

References:

1. Jones KR, Fink R, Pepper G, Hutt E, Vojir CP, Scott J, Clark L, Mellis K. Improving nursing home staff knowledge and attitudes about pain. Gerontologist. 2004;44(4):469-78.
2. Winn PA, Dentino AN. Effective pain management in the long-term care setting. J Am Med Dir Assoc. 2004; 5(5):342-52.
3. Tarzian AJ, Hoffmann DE. Barriers to managing pain in the nursing home: findings from a statewide survey. J Am Med Dir Assoc. 2005; 6(3 Suppl):S13-9.
4. 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.
5. Stevenson KM, Dahl JL, Berry PH, Beck SL, Griffie J. Institutionalizing effective pain management practices: practice change programs to improve the quality of pain management in small health care organizations. J Pain Symptom Manage. 2006;31(3):248-61.

Fast Facts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For comments/questions write to: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu.  

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Liao S, Weissman DE. Fast Fact and Concept #89. Pain Management in Nursing Homes: Analgesic Prescribing Tips. 2nd Edition. October 2007. End-of-Life/Palliative 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

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

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

Keyword(s): Pain>opioids