Christine Kilgore is a freelance writer in Virginia.Progress on pain management in skilled nursing facilities and other long-term care settings lies largely in the realization of the headline above. Pain has deleterious effects on physical function and the quality of life, said several caregivers who are leading pain management efforts within their facilities or communities.“Pain is not a normal part of life,” emphasized William D. Smucker, MD, CMD, a family physician and medical director of the Altenheim Nursing Home in Strongsville, Ohio.With that understanding in place, systems and processes established to systematically evaluate patients for pain can be successful, the experts said. So can processes for successfully managing pain.Indeed, it's not easy: Nursing homes are challenged by the “opioid paradox,” the growing recognition that, on one hand, opioids are often the most effective option for pain management but that, on the other hand, as class II-IV drugs they're subject to regulatory burdens that might hamper their use.Still, physicians and other caregivers can rest reassured that the basics still apply. “Excellent pain relief can be achieved without a lot of fancy stuff,” said Jonathan Evans, MD, CMD, medical director of two skilled nursing facilities in Charlottesville, Va.That's good, he added, since “Pain management is the ultimate measure of both caring and the quality of care. … You can achieve any quality measure you want, but if the patient is in pain, you've failed.”Interdisciplinary AssessmentAs pain management has come under scrutiny in recent years, physicians, pain researchers, and other caregivers have begun to appreciate that they can't rely on patients to tell them they're in pain. “We have to assume that patients have pain until proven otherwise,” said Dr. Evans.The facilities that Dr. Evans has advised and those he serves as medical director encourage nursing assistants, therapists, and other caregivers to monitor residents for pain while assisting them in their activities of daily living and providing other care. These personnel are empowered to report any statements, behaviors, or other signs and symptoms that suggest that a resident may be in pain.In addition to such facility-wide vigilance, the routine and consistent use of pain scales leads to quality in pain assessment – as long as those scales have been selected that best suit individual residents. Some people will easily describe pain using a 0-10 verbal scale, while others may prefer scales that use general descriptors (“mild” to “severe”).The great majority of patients with cognitive deficits, on the other hand, will require some form of nonverbal, observational pain evaluation. According to AMDA's recently updated clinical practice guideline on pain management in the long-term care setting, such evaluation of patients with and without cognitive deficits takes into account factors such as facial expression, body language, negative vocalization, and consolability.The guideline lists these nonspecific signs and symptoms that may suggest the presence of pain:▸ Change in behavior, striking out, increasing or recurring agitation.▸ Change in gait.▸ Loss of function, decreased activity levels.▸ Resisting certain movements during care.▸ Bracing, guarding, rubbing.▸ Fidgeting, increasing or recurring restlessness.▸ Frowning, grimacing, fearful facial expressions, grinding of teeth.▸ Eating or sleeping poorly.▸ Sighing, groaning, crying, breathing heavily.“You have to figure out what [tool] applies to or works best for each individual, and then agree on what you'll use in each case,” said Dr. Smucker, who chaired the committee that updated AMDA's pain management guideline last year. “I have some patients who cannot calibrate the 0-10. They'll always tell you that their pain is never better than a 7, yet when you ask them if it's absent, mild, moderate, or severe they'll say ‘mild.’”On the other hand, “I've seen many patients who rate their pain as mild and then I find out that they're about to be discharged from physical therapy due to lack of progress – the physical therapist will tell me that they can't bear any weight because of their pain,” he said.With patients who have dementia, Dr. Smucker tries to pass his hands over their shoulders, elbows, wrists, knees, and ankles as he sits down to talk with them. Otherwise, “they may not remember to tell me about aches and pains,” he said. “I think there's some kind of physical memory reminder that can go on.”One problem, he and others emphasize, is that misconceptions and biases against pain are “as common among patients as they are among caregivers,” Dr. Smucker said. Some patients believe that acknowledging pain is a sign of weakness, for instance, while others believe that using an opioid for chronic pain means a disease is severe or death is near.Mary Evans, MD, CMD, who practices long-term care in Charlottesville along with her husband Jonathan, emphasized that “it's the experience of the patient that counts.” Caregivers must try to discern and address any psychological or spiritual components to a resident's pain, and they should never dismiss it or make presumptions, she says.In terms of formal evaluation, at a minimum, residents should be assessed for pain upon admission, during periodic scheduled assessments, and whenever a change occurs in a person's condition or routines, AMDA's guideline says.Treatment TrendsAMDA's guideline and recently updated recommendations from an American Geriatrics Society's Panel on Pharmacological Management of Persistent Pain in Older Persons convey a similar set of key messages for long-term care.For one, both guidelines emphasize that acetaminophen is a “first choice” for patients with mild to moderate pain who do not have liver disease. Secondly, the guidelines discourage use of nonsteroidal anti-inflammatory drugs (NSAIDs) because of increasing evidence of multisystem toxicity, and describe opioids as the often best choice for moderate to severe pain and diminished quality of life because of pain. Adjuvant drugs for neuropathic pain should probably be used more often than they have been, the documents suggest (see box, page 26).For Dr. Smucker, the most significant impact of the guidelines frequently has been the use of short trials of acetaminophen in patients who have negative behaviors or trouble with activities of daily living, therapy, or ambulation. “There are multiple causes for patients being agitated, angry, or resisting care, for instance, but chief among them is the possibility that they're having pain,” he explained. “So frequently, a 2- to 3-day trial of Tylenol will cause these negative behaviors to abate. … It will often enable nurses to move their patients, to help them bathe. It's such a simple thing – it's worth trying.”Caregivers in a 150-bed skilled nursing facility in Henderson, N.C., can similarly attest to the role of acetaminophen in pain management. Their experience, however, stems from an interdisciplinary effort to reduce the use of psychotropic medication.While reviewing charts of patients receiving psychotropic drugs or having certain problems such as falls or disruptive behaviors, “We began talking about more global interventions and asking, ‘are some of these patients in pain? Are they depressed?’” explained Mark D. Coggins, PharmD, the director of pharmacy services for the Golden Living Centers in Inman, S.C., who led the effort.Dr. Coggins' group subsequently identified patients who they thought had the highest potential for pain and, for most of them, prescribed short courses of acetaminophen while reducing their intakes of antipsychotic drugs. The team is still analyzing outcomes data for possible publication, but it is clear that the “the ability of patients to participate in physical therapy and to maximize their therapy, increased dramatically,” Dr. Coggins said.The trial also taught the team that pain might often be unrecognized in people with Alzheimer's disease or other dementias. Dr. Coggins said he'll never forget the reaction of a nurse who was at first adamantly opposed to reducing psychotropic drugs in unruly residents. He recalled, “Three days after we started the Tylenol therapy, she came to me, crying” and described the changes she'd seen in one of her patients with dementia.“She said this patient's behaviors were nothing like they had been before,” Dr. Coggins said. “She was really afraid that [her patient] had long been in pain,” said Dr. Coggins, adding that a short course of up to 3 g/day of acetaminophen for several days is safe in patients without underlying liver disease.Several medical directors told Caring for the Ages that standing orders or protocols for acetaminophen to be given as needed are important for many patients – but with the proper parameters set. “I don't want to see someone starting Tylenol on Thursday and then still receiving it come Monday,” said Keith A. Guest, MD, CMD, of the long-term care practice Senior Health Associates, based in Okatie, S.C. “I want to have received a call [once it's past 72 hours].”A fundamental principle of pain management for moderate to severe pain or for recurrent, chronic pain is that at least one scheduled analgesic medication should be prescribed. The use of fewer “as-necessary” prescriptions is indicative of pain-management progress in long-term care, said Dr. Mary Evans. “With pain management on an as-needed basis, you need to ensure that patients will be able to tell you they're having pain. If pain occurs multiple times a day, you'll need to schedule a pain medicine. And if they have significant pain, you'll need to schedule ongoing medications with breakthrough doses as needed.”With the toxicity of NSAIDs in the elderly gaining appreciation (the AGS takes a stronger stance against their use in its new recommendations than in the previous version), the acceptance and use of opioids in nursing home patient will likely increase, said Dr. Smucker, who is also associate director of the Summa Health System family medicine residency in Akron, Ohio. “It's impressive to see how relatively small doses of opioids can be very beneficial for the elderly and not cause adverse effects.”Bruce Ferrell, MD, professor of medicine in geriatrics at the University of California, Los Angeles, and chairman of the AGS's panel on pharmacological management of pain, said that no organ damage has been associated with long-term use of opioids for pain relief.“Opioids may be safer in the long run for patients who are at high risk for side effects from NSAIDs or acetaminophen, especially [when these are given] at high doses or for long periods,” he said. “The side effects of NSAIDs, for example, are really dose and time related.”Implementation by the Food and Drug Administration of Risk Evaluation and Mitigation Strategies (REMs) for certain opioid pain medications might require prescribers to have certain experience or training, and to formally assess patients for risk of abuse, but in long-term care, addiction is highly unlikely with appropriate prescribing, sources for this story said. Several added that this should be emphasized to patients and families.Similarly, respiratory depression, which many nursing home residents fear, is an uncommon adverse effect from opioids. Concern about it does not warrant withholding opioid treatment from patients with moderate to severe pain who are unresponsive to or unable to safely take other medications, AMDA's guideline says. Its risk can be minimized by starting with a low oral dose of opioid and titrating slowly upward.In general, this principle of initiating pain medications with low doses followed by careful upward titration is an important one for most older patients, as is the use of frequent assessment for optimum pain relief and adverse effects, the sources said.AMDA and other LTC organizations have been advocating that nurses be able to act as physicians' agents in dispensing controlled substances, so as not to delay treatment for pain, but for now at least under Drug Enforcement Agency rules, physicians must sign each order for class II-V drugs (see page 20).The establishment of processes for rapid access to pain medication – strengthening “on-call” expectations for physicians, for instance, or setting up systems by which hospitalists send orders directly to LTC pharmacists instead of only writing them into discharge orders – is therefore an important element of pain management, according to AMDA.Medication use is but one element of treating pain. As AMDA's clinical practice guideline on pain management says, other interventions and comfort measures may bring substantial relief and can reduce the need for high doses of pain-relieving medications.Such measures include simple exercise, passive or active joint movement, repositioning, relaxation techniques such as massage therapy or aromatherapy, comforting music, reassuring words and touch, the opportunity to talk to others about pain, and the services of a chaplain or other pastoral counselor.Caregivers might also try back rubs, hot or cold compresses, whirlpool baths, and showers to see if these measures are helpful, the AMDA guidelines say. Efforts to maintain comfortable room temperatures and to minimize background noise are also important.“We should always ask, Is there anything we can do that's nonpharmacologic?” said Dr. Guest. Christine Kilgore is a freelance writer in Virginia. Progress on pain management in skilled nursing facilities and other long-term care settings lies largely in the realization of the headline above. Pain has deleterious effects on physical function and the quality of life, said several caregivers who are leading pain management efforts within their facilities or communities. “Pain is not a normal part of life,” emphasized William D. Smucker, MD, CMD, a family physician and medical director of the Altenheim Nursing Home in Strongsville, Ohio. With that understanding in place, systems and processes established to systematically evaluate patients for pain can be successful, the experts said. So can processes for successfully managing pain. Indeed, it's not easy: Nursing homes are challenged by the “opioid paradox,” the growing recognition that, on one hand, opioids are often the most effective option for pain management but that, on the other hand, as class II-IV drugs they're subject to regulatory burdens that might hamper their use. Still, physicians and other caregivers can rest reassured that the basics still apply. “Excellent pain relief can be achieved without a lot of fancy stuff,” said Jonathan Evans, MD, CMD, medical director of two skilled nursing facilities in Charlottesville, Va. That's good, he added, since “Pain management is the ultimate measure of both caring and the quality of care. … You can achieve any quality measure you want, but if the patient is in pain, you've failed.” Interdisciplinary AssessmentAs pain management has come under scrutiny in recent years, physicians, pain researchers, and other caregivers have begun to appreciate that they can't rely on patients to tell them they're in pain. “We have to assume that patients have pain until proven otherwise,” said Dr. Evans.The facilities that Dr. Evans has advised and those he serves as medical director encourage nursing assistants, therapists, and other caregivers to monitor residents for pain while assisting them in their activities of daily living and providing other care. These personnel are empowered to report any statements, behaviors, or other signs and symptoms that suggest that a resident may be in pain.In addition to such facility-wide vigilance, the routine and consistent use of pain scales leads to quality in pain assessment – as long as those scales have been selected that best suit individual residents. Some people will easily describe pain using a 0-10 verbal scale, while others may prefer scales that use general descriptors (“mild” to “severe”).The great majority of patients with cognitive deficits, on the other hand, will require some form of nonverbal, observational pain evaluation. According to AMDA's recently updated clinical practice guideline on pain management in the long-term care setting, such evaluation of patients with and without cognitive deficits takes into account factors such as facial expression, body language, negative vocalization, and consolability.The guideline lists these nonspecific signs and symptoms that may suggest the presence of pain:▸ Change in behavior, striking out, increasing or recurring agitation.▸ Change in gait.▸ Loss of function, decreased activity levels.▸ Resisting certain movements during care.▸ Bracing, guarding, rubbing.▸ Fidgeting, increasing or recurring restlessness.▸ Frowning, grimacing, fearful facial expressions, grinding of teeth.▸ Eating or sleeping poorly.▸ Sighing, groaning, crying, breathing heavily.“You have to figure out what [tool] applies to or works best for each individual, and then agree on what you'll use in each case,” said Dr. Smucker, who chaired the committee that updated AMDA's pain management guideline last year. “I have some patients who cannot calibrate the 0-10. They'll always tell you that their pain is never better than a 7, yet when you ask them if it's absent, mild, moderate, or severe they'll say ‘mild.’”On the other hand, “I've seen many patients who rate their pain as mild and then I find out that they're about to be discharged from physical therapy due to lack of progress – the physical therapist will tell me that they can't bear any weight because of their pain,” he said.With patients who have dementia, Dr. Smucker tries to pass his hands over their shoulders, elbows, wrists, knees, and ankles as he sits down to talk with them. Otherwise, “they may not remember to tell me about aches and pains,” he said. “I think there's some kind of physical memory reminder that can go on.”One problem, he and others emphasize, is that misconceptions and biases against pain are “as common among patients as they are among caregivers,” Dr. Smucker said. Some patients believe that acknowledging pain is a sign of weakness, for instance, while others believe that using an opioid for chronic pain means a disease is severe or death is near.Mary Evans, MD, CMD, who practices long-term care in Charlottesville along with her husband Jonathan, emphasized that “it's the experience of the patient that counts.” Caregivers must try to discern and address any psychological or spiritual components to a resident's pain, and they should never dismiss it or make presumptions, she says.In terms of formal evaluation, at a minimum, residents should be assessed for pain upon admission, during periodic scheduled assessments, and whenever a change occurs in a person's condition or routines, AMDA's guideline says. As pain management has come under scrutiny in recent years, physicians, pain researchers, and other caregivers have begun to appreciate that they can't rely on patients to tell them they're in pain. “We have to assume that patients have pain until proven otherwise,” said Dr. Evans. The facilities that Dr. Evans has advised and those he serves as medical director encourage nursing assistants, therapists, and other caregivers to monitor residents for pain while assisting them in their activities of daily living and providing other care. These personnel are empowered to report any statements, behaviors, or other signs and symptoms that suggest that a resident may be in pain. In addition to such facility-wide vigilance, the routine and consistent use of pain scales leads to quality in pain assessment – as long as those scales have been selected that best suit individual residents. Some people will easily describe pain using a 0-10 verbal scale, while others may prefer scales that use general descriptors (“mild” to “severe”). The great majority of patients with cognitive deficits, on the other hand, will require some form of nonverbal, observational pain evaluation. According to AMDA's recently updated clinical practice guideline on pain management in the long-term care setting, such evaluation of patients with and without cognitive deficits takes into account factors such as facial expression, body language, negative vocalization, and consolability. The guideline lists these nonspecific signs and symptoms that may suggest the presence of pain: ▸ Change in behavior, striking out, increasing or recurring agitation. ▸ Change in gait. ▸ Loss of function, decreased activity levels. ▸ Resisting certain movements during care. ▸ Bracing, guarding, rubbing. ▸ Fidgeting, increasing or recurring restlessness. ▸ Frowning, grimacing, fearful facial expressions, grinding of teeth. ▸ Eating or sleeping poorly. ▸ Sighing, groaning, crying, breathing heavily. “You have to figure out what [tool] applies to or works best for each individual, and then agree on what you'll use in each case,” said Dr. Smucker, who chaired the committee that updated AMDA's pain management guideline last year. “I have some patients who cannot calibrate the 0-10. They'll always tell you that their pain is never better than a 7, yet when you ask them if it's absent, mild, moderate, or severe they'll say ‘mild.’” On the other hand, “I've seen many patients who rate their pain as mild and then I find out that they're about to be discharged from physical therapy due to lack of progress – the physical therapist will tell me that they can't bear any weight because of their pain,” he said. With patients who have dementia, Dr. Smucker tries to pass his hands over their shoulders, elbows, wrists, knees, and ankles as he sits down to talk with them. Otherwise, “they may not remember to tell me about aches and pains,” he said. “I think there's some kind of physical memory reminder that can go on.” One problem, he and others emphasize, is that misconceptions and biases against pain are “as common among patients as they are among caregivers,” Dr. Smucker said. Some patients believe that acknowledging pain is a sign of weakness, for instance, while others believe that using an opioid for chronic pain means a disease is severe or death is near. Mary Evans, MD, CMD, who practices long-term care in Charlottesville along with her husband Jonathan, emphasized that “it's the experience of the patient that counts.” Caregivers must try to discern and address any psychological or spiritual components to a resident's pain, and they should never dismiss it or make presumptions, she says. In terms of formal evaluation, at a minimum, residents should be assessed for pain upon admission, during periodic scheduled assessments, and whenever a change occurs in a person's condition or routines, AMDA's guideline says. Treatment TrendsAMDA's guideline and recently updated recommendations from an American Geriatrics Society's Panel on Pharmacological Management of Persistent Pain in Older Persons convey a similar set of key messages for long-term care.For one, both guidelines emphasize that acetaminophen is a “first choice” for patients with mild to moderate pain who do not have liver disease. Secondly, the guidelines discourage use of nonsteroidal anti-inflammatory drugs (NSAIDs) because of increasing evidence of multisystem toxicity, and describe opioids as the often best choice for moderate to severe pain and diminished quality of life because of pain. Adjuvant drugs for neuropathic pain should probably be used more often than they have been, the documents suggest (see box, page 26).For Dr. Smucker, the most significant impact of the guidelines frequently has been the use of short trials of acetaminophen in patients who have negative behaviors or trouble with activities of daily living, therapy, or ambulation. “There are multiple causes for patients being agitated, angry, or resisting care, for instance, but chief among them is the possibility that they're having pain,” he explained. “So frequently, a 2- to 3-day trial of Tylenol will cause these negative behaviors to abate. … It will often enable nurses to move their patients, to help them bathe. It's such a simple thing – it's worth trying.”Caregivers in a 150-bed skilled nursing facility in Henderson, N.C., can similarly attest to the role of acetaminophen in pain management. Their experience, however, stems from an interdisciplinary effort to reduce the use of psychotropic medication.While reviewing charts of patients receiving psychotropic drugs or having certain problems such as falls or disruptive behaviors, “We began talking about more global interventions and asking, ‘are some of these patients in pain? Are they depressed?’” explained Mark D. Coggins, PharmD, the director of pharmacy services for the Golden Living Centers in Inman, S.C., who led the effort.Dr. Coggins' group subsequently identified patients who they thought had the highest potential for pain and, for most of them, prescribed short courses of acetaminophen while reducing their intakes of antipsychotic drugs. The team is still analyzing outcomes data for possible publication, but it is clear that the “the ability of patients to participate in physical therapy and to maximize their therapy, increased dramatically,” Dr. Coggins said.The trial also taught the team that pain might often be unrecognized in people with Alzheimer's disease or other dementias. Dr. Coggins said he'll never forget the reaction of a nurse who was at first adamantly opposed to reducing psychotropic drugs in unruly residents. He recalled, “Three days after we started the Tylenol therapy, she came to me, crying” and described the changes she'd seen in one of her patients with dementia.“She said this patient's behaviors were nothing like they had been before,” Dr. Coggins said. “She was really afraid that [her patient] had long been in pain,” said Dr. Coggins, adding that a short course of up to 3 g/day of acetaminophen for several days is safe in patients without underlying liver disease.Several medical directors told Caring for the Ages that standing orders or protocols for acetaminophen to be given as needed are important for many patients – but with the proper parameters set. “I don't want to see someone starting Tylenol on Thursday and then still receiving it come Monday,” said Keith A. Guest, MD, CMD, of the long-term care practice Senior Health Associates, based in Okatie, S.C. “I want to have received a call [once it's past 72 hours].”A fundamental principle of pain management for moderate to severe pain or for recurrent, chronic pain is that at least one scheduled analgesic medication should be prescribed. The use of fewer “as-necessary” prescriptions is indicative of pain-management progress in long-term care, said Dr. Mary Evans. “With pain management on an as-needed basis, you need to ensure that patients will be able to tell you they're having pain. If pain occurs multiple times a day, you'll need to schedule a pain medicine. And if they have significant pain, you'll need to schedule ongoing medications with breakthrough doses as needed.”With the toxicity of NSAIDs in the elderly gaining appreciation (the AGS takes a stronger stance against their use in its new recommendations than in the previous version), the acceptance and use of opioids in nursing home patient will likely increase, said Dr. Smucker, who is also associate director of the Summa Health System family medicine residency in Akron, Ohio. “It's impressive to see how relatively small doses of opioids can be very beneficial for the elderly and not cause adverse effects.”Bruce Ferrell, MD, professor of medicine in geriatrics at the University of California, Los Angeles, and chairman of the AGS's panel on pharmacological management of pain, said that no organ damage has been associated with long-term use of opioids for pain relief.“Opioids may be safer in the long run for patients who are at high risk for side effects from NSAIDs or acetaminophen, especially [when these are given] at high doses or for long periods,” he said. “The side effects of NSAIDs, for example, are really dose and time related.”Implementation by the Food and Drug Administration of Risk Evaluation and Mitigation Strategies (REMs) for certain opioid pain medications might require prescribers to have certain experience or training, and to formally assess patients for risk of abuse, but in long-term care, addiction is highly unlikely with appropriate prescribing, sources for this story said. Several added that this should be emphasized to patients and families.Similarly, respiratory depression, which many nursing home residents fear, is an uncommon adverse effect from opioids. Concern about it does not warrant withholding opioid treatment from patients with moderate to severe pain who are unresponsive to or unable to safely take other medications, AMDA's guideline says. Its risk can be minimized by starting with a low oral dose of opioid and titrating slowly upward.In general, this principle of initiating pain medications with low doses followed by careful upward titration is an important one for most older patients, as is the use of frequent assessment for optimum pain relief and adverse effects, the sources said.AMDA and other LTC organizations have been advocating that nurses be able to act as physicians' agents in dispensing controlled substances, so as not to delay treatment for pain, but for now at least under Drug Enforcement Agency rules, physicians must sign each order for class II-V drugs (see page 20).The establishment of processes for rapid access to pain medication – strengthening “on-call” expectations for physicians, for instance, or setting up systems by which hospitalists send orders directly to LTC pharmacists instead of only writing them into discharge orders – is therefore an important element of pain management, according to AMDA.Medication use is but one element of treating pain. As AMDA's clinical practice guideline on pain management says, other interventions and comfort measures may bring substantial relief and can reduce the need for high doses of pain-relieving medications.Such measures include simple exercise, passive or active joint movement, repositioning, relaxation techniques such as massage therapy or aromatherapy, comforting music, reassuring words and touch, the opportunity to talk to others about pain, and the services of a chaplain or other pastoral counselor.Caregivers might also try back rubs, hot or cold compresses, whirlpool baths, and showers to see if these measures are helpful, the AMDA guidelines say. Efforts to maintain comfortable room temperatures and to minimize background noise are also important.“We should always ask, Is there anything we can do that's nonpharmacologic?” said Dr. Guest. AMDA's guideline and recently updated recommendations from an American Geriatrics Society's Panel on Pharmacological Management of Persistent Pain in Older Persons convey a similar set of key messages for long-term care. For one, both guidelines emphasize that acetaminophen is a “first choice” for patients with mild to moderate pain who do not have liver disease. Secondly, the guidelines discourage use of nonsteroidal anti-inflammatory drugs (NSAIDs) because of increasing evidence of multisystem toxicity, and describe opioids as the often best choice for moderate to severe pain and diminished quality of life because of pain. Adjuvant drugs for neuropathic pain should probably be used more often than they have been, the documents suggest (see box, page 26). For Dr. Smucker, the most significant impact of the guidelines frequently has been the use of short trials of acetaminophen in patients who have negative behaviors or trouble with activities of daily living, therapy, or ambulation. “There are multiple causes for patients being agitated, angry, or resisting care, for instance, but chief among them is the possibility that they're having pain,” he explained. “So frequently, a 2- to 3-day trial of Tylenol will cause these negative behaviors to abate. … It will often enable nurses to move their patients, to help them bathe. It's such a simple thing – it's worth trying.” Caregivers in a 150-bed skilled nursing facility in Henderson, N.C., can similarly attest to the role of acetaminophen in pain management. Their experience, however, stems from an interdisciplinary effort to reduce the use of psychotropic medication. While reviewing charts of patients receiving psychotropic drugs or having certain problems such as falls or disruptive behaviors, “We began talking about more global interventions and asking, ‘are some of these patients in pain? Are they depressed?’” explained Mark D. Coggins, PharmD, the director of pharmacy services for the Golden Living Centers in Inman, S.C., who led the effort. Dr. Coggins' group subsequently identified patients who they thought had the highest potential for pain and, for most of them, prescribed short courses of acetaminophen while reducing their intakes of antipsychotic drugs. The team is still analyzing outcomes data for possible publication, but it is clear that the “the ability of patients to participate in physical therapy and to maximize their therapy, increased dramatically,” Dr. Coggins said. The trial also taught the team that pain might often be unrecognized in people with Alzheimer's disease or other dementias. Dr. Coggins said he'll never forget the reaction of a nurse who was at first adamantly opposed to reducing psychotropic drugs in unruly residents. He recalled, “Three days after we started the Tylenol therapy, she came to me, crying” and described the changes she'd seen in one of her patients with dementia. “She said this patient's behaviors were nothing like they had been before,” Dr. Coggins said. “She was really afraid that [her patient] had long been in pain,” said Dr. Coggins, adding that a short course of up to 3 g/day of acetaminophen for several days is safe in patients without underlying liver disease. Several medical directors told Caring for the Ages that standing orders or protocols for acetaminophen to be given as needed are important for many patients – but with the proper parameters set. “I don't want to see someone starting Tylenol on Thursday and then still receiving it come Monday,” said Keith A. Guest, MD, CMD, of the long-term care practice Senior Health Associates, based in Okatie, S.C. “I want to have received a call [once it's past 72 hours].” A fundamental principle of pain management for moderate to severe pain or for recurrent, chronic pain is that at least one scheduled analgesic medication should be prescribed. The use of fewer “as-necessary” prescriptions is indicative of pain-management progress in long-term care, said Dr. Mary Evans. “With pain management on an as-needed basis, you need to ensure that patients will be able to tell you they're having pain. If pain occurs multiple times a day, you'll need to schedule a pain medicine. And if they have significant pain, you'll need to schedule ongoing medications with breakthrough doses as needed.” With the toxicity of NSAIDs in the elderly gaining appreciation (the AGS takes a stronger stance against their use in its new recommendations than in the previous version), the acceptance and use of opioids in nursing home patient will likely increase, said Dr. Smucker, who is also associate director of the Summa Health System family medicine residency in Akron, Ohio. “It's impressive to see how relatively small doses of opioids can be very beneficial for the elderly and not cause adverse effects.” Bruce Ferrell, MD, professor of medicine in geriatrics at the University of California, Los Angeles, and chairman of the AGS's panel on pharmacological management of pain, said that no organ damage has been associated with long-term use of opioids for pain relief. “Opioids may be safer in the long run for patients who are at high risk for side effects from NSAIDs or acetaminophen, especially [when these are given] at high doses or for long periods,” he said. “The side effects of NSAIDs, for example, are really dose and time related.” Implementation by the Food and Drug Administration of Risk Evaluation and Mitigation Strategies (REMs) for certain opioid pain medications might require prescribers to have certain experience or training, and to formally assess patients for risk of abuse, but in long-term care, addiction is highly unlikely with appropriate prescribing, sources for this story said. Several added that this should be emphasized to patients and families. Similarly, respiratory depression, which many nursing home residents fear, is an uncommon adverse effect from opioids. Concern about it does not warrant withholding opioid treatment from patients with moderate to severe pain who are unresponsive to or unable to safely take other medications, AMDA's guideline says. Its risk can be minimized by starting with a low oral dose of opioid and titrating slowly upward. In general, this principle of initiating pain medications with low doses followed by careful upward titration is an important one for most older patients, as is the use of frequent assessment for optimum pain relief and adverse effects, the sources said. AMDA and other LTC organizations have been advocating that nurses be able to act as physicians' agents in dispensing controlled substances, so as not to delay treatment for pain, but for now at least under Drug Enforcement Agency rules, physicians must sign each order for class II-V drugs (see page 20). The establishment of processes for rapid access to pain medication – strengthening “on-call” expectations for physicians, for instance, or setting up systems by which hospitalists send orders directly to LTC pharmacists instead of only writing them into discharge orders – is therefore an important element of pain management, according to AMDA. Medication use is but one element of treating pain. As AMDA's clinical practice guideline on pain management says, other interventions and comfort measures may bring substantial relief and can reduce the need for high doses of pain-relieving medications. Such measures include simple exercise, passive or active joint movement, repositioning, relaxation techniques such as massage therapy or aromatherapy, comforting music, reassuring words and touch, the opportunity to talk to others about pain, and the services of a chaplain or other pastoral counselor. Caregivers might also try back rubs, hot or cold compresses, whirlpool baths, and showers to see if these measures are helpful, the AMDA guidelines say. Efforts to maintain comfortable room temperatures and to minimize background noise are also important. “We should always ask, Is there anything we can do that's nonpharmacologic?” said Dr. Guest. Helpful Resources▸ AMDA's clinical practice guideline “Pain Management in the Long Term Care Setting,” updated in 2009 (www.amda.com).▸ American Geriatrics Society's guideline “Pharmacological Management of Persistent Pain in Older Persons” (J. Am. Ger. Soc. 2009;57:1331-46).▸ “Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain,” by the American Pain Society and the American Academy of Pain Medicine (J. Pain 2009;10:113-30).▸ www.geriatricpain.org, a Web resource of free tools and resources, whose content was developed by representatives of five John A. Hartford Centers of Geriatric Nursing Excellence. ▸ AMDA's clinical practice guideline “Pain Management in the Long Term Care Setting,” updated in 2009 (www.amda.com). ▸ American Geriatrics Society's guideline “Pharmacological Management of Persistent Pain in Older Persons” (J. Am. Ger. Soc. 2009;57:1331-46). ▸ “Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain,” by the American Pain Society and the American Academy of Pain Medicine (J. Pain 2009;10:113-30). ▸ www.geriatricpain.org, a Web resource of free tools and resources, whose content was developed by representatives of five John A. Hartford Centers of Geriatric Nursing Excellence.