Older adults are increasingly prescribed opioids for the treatment of pain (Chou et al., 2015), with one third of Medicare Part D beneficiaries having at least one opioid prescription in 2016 (Tilly, Skowronski, & Ruiz, 2017). Opioid use by long-term care (LTC) residents with chronic pain is twice that of community-dwelling older adults (Hunnicutt et al., 2018). In LTC settings, 35% to 93% of residents experience pain extensive enough to impair function (Fain et al., 2017; Griffioen et al., 2019; Schofield & Abdulla, 2018) and up to 80% of residents with chronic pain are prescribed opioids (Fain et al., 2017).
Although pain is prevalent in LTC residents and management of pain is a Centers for Medicare & Medicaid Services (CMS; 2019) quality measure, chronic pain is often under-treated in LTC residents (Barry, Parsons, Passmore, & Hughes, 2015; Hunnicutt et al., 2018; Knopp-Sihota, Patel, & Estabrooks, 2016). Untreated chronic pain, defined as pain lasting longer than 3 months, can result in increased care needs and costs due to disruptive behavioral responses, such as agitation and aggression, decreased socialization and poorer quality of life, and further cognitive decline in individuals with dementia (Griffioen et al., 2019; Knopp-Sihota et al., 2016). LTC residents often do not report pain because they believe pain is a natural part of aging and that pain medications can result in adverse events and lead to addiction. Further, residents with dementia are at particular risk for underrecognized pain due to difficulties in reporting pain (Barry et al., 2015) and the assumptions of staff that they cannot reliably report pain (Barry et al., 2015; Monroe et al., 2014). Lack of staff education and knowledge about chronic pain can result in overlooking residents' pain symptoms. The lack of standardized pain protocols makes it difficult for staff to implement and maintain individualized treatment plans for chronic pain in LTC (Dirk, Rachor, & Knopp-Sihota, 2019; Farless & Ritchie, 2012). High staff turnover, inadequate staffing, and lack of resources further contribute to optimal pain management in LTC.
Because of the risks associated with nonsteroidal anti-inflammatory drugs in older adults, opioids are often considered a safe and effective pain management strategy in LTC where residents can be monitored frequently (Abdulla et al., 2013; Pitkala et al., 2015). A study of more than 600,000 long-stay Medicare beneficiaries found that 32% of residents were prescribed opioids over a 120-day period, often in association with adjuvant therapies and other pain medications (Hunnicutt et al., 2018). Approximately one half of residents prescribed opioids were long-term (>90 days) opioid users. Another study of long-stay Medicare beneficiaries found that short-term opioids, such as hydrocodone, are most commonly prescribed, and only 2.2% of residents prescribed opioids received long-acting opioids such as transdermal fentanyl (Hunnicutt, Hume, Ulbricht, Tjia, & Lapane, 2019).
There is considerable variability in the tolerability and safety of opioids prescribed to LTC residents (Pitkala et al., 2015). Older adults are at increased risk of opioid-related adverse events due to body composition and metabolism changes, comorbidities such as renal failure, and polypharmacy including medications that can interact with opioid pharmacokinetics. Adverse events range from minor to major and include constipation, nausea, urinary retention, sedation, respiratory distress, increased falls and fractures, cognitive decline, and delirium (American Geriatrics Society [AGS] Panel on Pharmacological Management of Persistent Pain in Older Persons, 2009; Pitkala et al., 2015).
Guidelines and Policies for Opioid Use for Chronic Pain Management
A guest editorial by Arnstein and Herr in the June 2019 issue of the Journal of Gerontological Nursing provided an overview of opioid prescribing practice as well as policy changes that have an impact on treatment of chronic pain among older adults. Arnstein and Herr (2019) argue that pain management for older adults should improve comfort and functioning while avoiding harm from under- or over-prescribing opioids. For example, many older adults are stable on low doses of opioids that allow them to remain independent (Gold, 2017). Arnstein and Herr (2019) call for nurses to advocate for vulnerable older adults through education, advocacy, and research, and provision of person-centered care.
There are many clinical practice guidelines regarding chronic pain management for older adults to help guide the use of opioids in LTC. Guidelines most relevant to opioid use in LTC are discussed in greater detail below and synthesized in Table 1.
Synthesis of Pain Management Guidelines for Older Adults
Due to the variability in tolerance and risk of adverse events, experts recommend that opioid prescriptions “start low and go slow” and are gradually titrated upward based on tolerability and pain alleviation (Guerriero, 2017; Schofield & Abdulla, 2018). The World Health Organization (WHO) Pain Relief Ladder was first published in 1986 and proposes a stepwise approach to pain management (Ginsburg, Silver, & Berman, 2009). Step 1 of the ladder is to treat pain with non-narcotics. If pain persists or increases, Step 2 includes the addition of a weak opioid and Step 3 moves toward prescribing a stronger opioid. Adjuvant treatments, such as antidepressant, anticonvulsant, and other agents used for neuropathic pain, should be considered for any step of the ladder. The Pain Relief Ladder includes five recommendations: (a) administer analgesics orally; (b) give analgesics at regular intervals and adjust dosage until pain is controlled; (c) guide prescribing by the patient's reported level of pain, as measured by a pain intensity scale; (d) adapt analgesic dosage to the individual; and (e) prescribe analgesics carefully and with a constant concern for details about dose and scheduling that is personalized and shared with each patient (Vargas-Schaffer, 2010).
Although the WHO Pain Relief Ladder is useful, there are more recent guidelines specific for pain management in older adults that address the role of opioids in managing pain. These include the AGS Pharmacological Management of Persistent Pain in Older Persons guideline last updated in 2009 and the 2013 British Geriatric Society and British Pain Society guideline for managing chronic pain in older adults (Abdulla et al., 2013). The Society for Post-Acute and Long-Term Care Medicine Pain Management in the Long-Term Care Setting Clinical Practice Guideline includes recognition of pain; assessment of pain, including cause and impact on function and quality of life; treatment using an organized stepwise approach, such as the WHO Pain Relief Ladder; and monitoring of the effectiveness of the pain management plan (American Medical Directors Association [AMDA], 2012). These guidelines provide specific recommendations for assessing pain, treatment, and monitoring for effectiveness and risk. Most importantly, they balance pain control with the risks of opioid and nonopioid medications for older adults.
The CDC Guideline for Prescribing Opioids for Chronic Pain–United States, 2016 is intended to guide opioid prescribing for chronic non-cancer pain, exclusive of palliative and end-of-life care (Dowell, Haegerich, & Chou, 2016). Written at the height of the opioid crisis in the United States, the guideline aims to provide clinicians with resources that aid in assessing, prescribing, and communicating to patients of all ages about opioid treatment for chronic pain. Although the guideline concurs with many of the recommendations in Table 1, it identifies several high-risk prescribing practices that have relevance to older adults with chronic pain, particularly those living in LTC settings. First, there is insufficient evidence supporting the long-term (>1 year) use of opioids for chronic pain based on the findings of a systemic review of the literature by Chou et al. (2015). Consequently, the guideline recommends clinicians evaluate benefits and adverse events 1 to 4 weeks after starting opioid therapy and then at least every 3 months. To meet this recommendation, LTC facilities must have standardized pain management protocols that include scheduled assessments and reassessments. Second, patients who have not experienced significant pain relief within 1 month are unlikely to do so with continued use. Regardless of opioid effectiveness, clinicians should use other therapies and taper opioids to lower dosages or discontinue use. Using other therapies may be problematic in LTC residents because of risks associated with nonopioid medications and intolerance to nonpharmacological therapies due to physical limitations. Finally, the guideline also discourages clinicians from prescribing opioids and benzodiazepines concurrently, a particular challenge in LTC where more than 13% of residents receive benzodiazepines (Stevenson et al., 2010).
Although the CDC guideline advocates for an interprofessional patient-focused approach to managing chronic pain, there is also the risk that these guidelines may influence when clinicians prescribe opioids and encourage them to taper or discontinue use in older adults who have used opioids long-term to manage their pain without adverse events. Arnstein and Herr (2019) voice the concern about adoption of the guidelines as policy mandates by governmental and health care organizations. These concerns raise the risk that clinicians then prioritize policy over clinical judgement without regard to the individual patient and the potential harms of non-opioid therapy in older adults.
The December 2018 AMDA policy statement addresses the challenges of managing chronic pain of LTC residents who often are not suited for non-opioid and alternative therapies advocated by the CDC guidelines (The Society for Post-Acute and Long-Term Care Medicine, 2018). The purpose of the statement, according to AMDA Executive Director, Chris Laxton, was “One of the federal responses to the opioid epidemic has been to restrict them. That has resulted in some of our residents who have been well managed to not get access to pain meds when they have needed them” (Newman, 2018, para. 6). The AMDA policy statement considers the consequences of chronic pain on quality of life for LTC residents and the goal of prescribing opioids responsibly. The policy statement identifies four opioid stewardship principles (Table 2). Together these principles highlight the paradox LTC clinicians face when treating LTC residents' chronic pain. Their challenge is to be empathetic to residents with pain, seek pharmacological treatment that is effective and safe while exploring alternative pain therapies that do not pose undue risk. The new policy statement is a reminder of another important pain management principle—listen to the patient—which should be combined with objective evidence to guide pain management decisions. In LTC, that means that clinicians and staff must be proficient at assessing pain and using results to develop a person-centered treatment plan. The policy also states that medical directors and nursing home leadership develop an interprofessional team approach to ensure development and use of policies and processes to guide appropriate opioid prescribing and monitoring.
Using the Society for Post-Acute and Long-Term Care Medicine's Opioid Stewardship in Long-Term Care (LTC) Strategies to Guide Practice
Implications for Nursing Practice
LTC nurses, including RNs and nurse practitioners, as members of interprofessional teams, should be knowledgeable of chronic pain assessment and management, especially the appropriate prescribing of opioids. Current guidelines have several nursing implications.
First, LTC settings lack comprehensive and person-centered pain assessment protocols (Dirk et al., 2019; Farless & Ritchie, 2012). Formal assessments are difficult because of resident, provider, and system level factors (Griffioen, Willems, Kouwenhoven, Caljouw, & Achterberg, 2017). Resident factors include recognition and self-reporting pain due to comorbidities and misconceptions about the experience of pain as one ages as well as limited ability to communicate symptoms among residents with cognitive impairment. Provider level factors include lack of knowledge in assessing pain, insufficient time to perform frequent comprehensive assessments, beliefs and attitudes about pain among older adults, and concerns for adverse events and dependence or addiction. System level factors include lack of policies and procedures, lack of resources, and inadequate staffing. Further, the MDS 3.0 pain evaluation is only required quarterly or when a resident's status changes, resulting in a complete lack of, or only informal, pain assessments (Farless & Ritchie, 2012). Therefore, it is imperative that nurses advocate for, and participate in, the development and adoption of pain assessment protocols that comprehensively assess and reassess residents' chronic pain in a systematic way on a defined schedule.
Second, staff education regarding pain management is important for quality care. LTC nurses must have a strong knowledge of pain management guidelines, including the prescribing of opioids, to guide their own practice and educate other staff. Staff education is difficult in LTC settings due to turnover and lack of time for professional development. Education efforts are often most effective coupled with other activities such as quality improvement initiatives (Farless & Ritchie, 2012). One way to educate LTC nurses about pain management is through nurse residency programs. Nurse residency programs are common in acute care settings but only a few have been implemented for LTC settings (Cadmus, Salmond, Hassler, Black, & Bohnarczyk, 2016; Edelman, Neller, McLeskey, Garrett, & Davis, 2018). Although these programs have demonstrated success, LTC organizations must be willing to support nurses to enroll in such programs for them to achieve the successes of acute care programs.
There is a need for greater emphasis on chronic pain management in pre-licensure nursing programs (Fishman & Young, 2016; Fishman et al., 2013). An interprofessional consensus summit of clinicians and educators published a set of core competencies for health professions students that focus on four pain management domains: (a) the multidimensional nature of pain; (b) pain assessment and measurement; (c) management of pain; and (d) clinical conditions influence on pain management (Fishman et al., 2013). These competencies should be incorporated into nursing programs (Herr et al., 2015). Further, continuing education programs, such as nurse residency programs, and staff education should include these competencies when teaching about chronic pain management in nursing home residents.
Third, a LTC resident's verbal report of pain should always be considered in conjunction with other symptoms and observations, especially with older adults with dementia. It is imperative that LTC nurses not only assess chronic pain, but also listen to the resident and family to advocate for the best individualized pain management plan. LTC nurses should advocate that all nursing home staff, residents, and family members report changes in a resident's pain status or behavioral symptoms to trigger a formal nursing pain assessment and plan to address the pain. To do this well, nurses must be prepared to use their communication skills to share their pain assessment findings with the interprofessional team and to advocate for relieving suffering and improving the quality of life for LTC residents.
Finally, further nursing research into chronic pain management for LTC residents and the role of opioids in that management could advance knowledge to drive practice and policy. There is a lack of evidence on optimal pain management in LTC including the effectiveness and risk of long-term opioid therapy for the treatment of chronic pain (Chou, 2015; Monroe et al., 2014). Research could identify pharmacological and nonpharmacological pain management strategies that demonstrate opioid stewardship, relieve suffering, and improve quality of life. The lack of research evidence on optimal pain management is in part because clinical trials often exclude older adults, especially those with cognitive impairment or living in LTC (Farless & Ritchie, 2012).
LTC residents experience more chronic pain than community-dwelling older adults. Management of their pain is complicated by comorbidities, especially cognitive impairment, that hamper the ability of residents to report pain. LTC staff often lack training in pain assessment and management. Pain management policies exist to guide LTC clinicians and staff in prescribing opioids to residents but should never supersede a person-centered approach that uses clinical judgement and input from residents themselves. LTC nurses are in an ideal position to contribute as part of the interprofessional team to develop pain assessment and management tools for LTC residents and to participate in research to develop more evidence-based guidelines for pain management for vulnerable older adults in LTC.
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Synthesis of Pain Management Guidelines for Older Adults
|Patients should be carefully evaluated for pain, likely causes at scheduled times or when a change occurs. Evaluation should include screening for risk of adverse events, tolerance, diversion, or substance use.|
|A formalized interprofessional treatment plan should be developed and adhered to for each resident. The plan should “start low and go slow,” beginning with the least invasive route of administration.|
|The first line of treatment should be nonopioids, preferably acetaminophen.|
|Nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 selective inhibitors should be used with extreme caution.|
|Opioids and benzodiazepines should not be prescribed concurrently.|
|Opioids are recommended for all residents with moderate to severe pain, pain-related physical impairment, or diminished quality of life when no other alternative therapy is likely to have an equivalent effect.|
|Residents with continuous pain should be treated with scheduled around-the-clock dosing.|
|When long-acting opioids are prescribed, breakthrough pain should be treated using short-acting opioids.|
|Adjuvant analgesic and other drugs, psychological interventions, physical and occupational therapies, and other complementary therapies should be considered based on resident history and comorbidities.|
|Psychological interventions, such as cognitive-behavioral therapy; the use of physical therapy and assistive devices to increase physical activity; and complementary therapy, such as acupuncture, massage, and transcutaneous electrical nerve stimulation.|
Using the Society for Post-Acute and Long-Term Care Medicine's Opioid Stewardship in Long-Term Care (LTC) Strategies to Guide Practice
|Opioid prescribing should be based on:|
|• A clear indication for use|
|• Inadequate response to nonpharmacological or appropriate pharmacological treatments|
|• Appropriate response to opioids that outweighs risks|
|Risks of adverse events, dependency, and diversion are minimized by:|
|• Not prescribing long-acting opioids for opioid naïve patients|
|• Tapering opioids to lowest dose required to maximize functional ability|
|• Tapering or stopping opioids when risks outweighs benefits|
|• Prescribing minimal quantities of opioids at discharge|
|Nursing home and medical directors' responsibilities as interprofessional team leaders include:|
|• Overseeing policy and procedures|
|• Participating in opioid diversion activities|
|• Providing ongoing education about opioid prescribing, safety, and monitoring|
|Legislation, regulations, and other policies:|
|• That prevent needed access to opioids for symptom relief are unacceptable|
|• Should be consistent across states for LTC residents|
|• Must promote access to substance use treatment|
|• Must reduce barriers to obtaining medication for treatment of opioid dependence|