Basic concerns in managing the resident with pain.

Though more and more residents are requiring significant pain control efforts (see accompanying article by Dr. Terry Kinzel, pg. 27), there are still many less demanding but still important situations challenging the nursing and medical staff in dealing with pain. Identifying pain and controlling it judiciously in the nursing home require special knowledge and skills.

For example, even though persistent pain increases threefold between the teen years and the 9th decade of life, there is an interesting paradox: chronic pain in all anatomic areas, EXCEPT the joints, tends to decrease with age, due in part to an aging-related increase in pain threshold. Nevertheless, the predominance of mild-to-moderately severe chronic pain in the nursing facility is persistent, and may be worsened by the co-morbidity of chronic anxiety and/or depression.

It is also of interest to note that some of the causes of acute pain, such as myocardial infarction and peptic ulcer formation, may be "silent," asymptomatic or misperceived as something else in one-third or more of elderly nursing facility patients. When pain does manifest itself, then, or there is a change in intensity or severity, it is essential for clinicians and aides to attempt to identify the cause. For example, acute back pain in an elderly patient who was sitting up in bed at the onset of pain may be due to a crushed vertebrae in advanced osteoporosis, a condition prevalent in over 60% of residents.

The absence of pain when other signs or symptoms are present of a condition that usually produces pain is also very common. Asymptomatic gastritis occurs in one-third to 40% of patients taking NSAIDs, with the only signs or symptoms being black stools and dropping hemoglobin. If the NSAID is continued for 3 to 6 months, over one-half of all nursing facility patients will develop significant anemia, and 20% of those may be admitted to the hospital with an acute GI bleed.[1]

It is therefore imperative to do monthly hemoglobins in nursing facility patients who must take NSAIDs. A decrease of as little as one gram in hemoglobin in a month or to levels below 12 g/dL in either sex is a warning sign of NSAID gastritis, and an indication that the NSAID should be discontinued.[1]

The most common causes of chronic pain in the nursing facility are osteoarthritis and/or "burned-out" prior rheumatoid arthritis. These arthritic conditions are essentially noninflammatory pain states that do not require the usage of steroidal (e.g. prednisone) or non-steroidal antiinflammatory drugs (NSAIDs such as ibuprofen). A recent study found that 4000 mg of acetaminophen (APAP) daily gave favorable results when compared with both the analgesic (1200 mg) and antiinflammatory (2400 mg) daily doses of ibuprofen in osteoarthritic knee pain.[2]

As mentioned, APAP is certainly safer and less costly than the NSAIDs in most pain states in the nursing home patient. An exception may be the patient with acute inflammation from gouty arthritis or metastatic cancer bone pain, where the NSAIDs are clearly superior.

Step Care Approach to Pain Management

Mild to Moderate Pain - Step 1 is Peripheral Analgesia

It is important to assure that in chronic pain peripherally-acting analgesics are regularly scheduled. APAP is the safest and least expensive peripheral analgesic. It is worth noting that regular APAP 650 mg qid eliminated the need for prn narcotic/peripheral combinations in mild to moderate pain in NF patients with osteoarthritis.[3]

If a patient needs a narcotic combination product such as Darvocet-N-100, Tylenol with Codeine or Percocet as often as twice or more a week, the simple substitution of APA 650 mg qid on a regular schedule may practically eliminate the need for the combination.[3] Higher doses of APAP, 4000 mg per day, have been shown to be equal in efficacy to 1200 to 2400 mg ibuprofen.[2]

Non-acetyl salicylates such as Trilisate, Arthralgan, Arthropan, Mobidin/Magan, Disalcid and Dolobid are safer, in terms of GI toxicity, than other NSAIDs, but are clearly more expensive. Enteric-coated aspirin (ECASA) is another very safe and much cheaper alternative to acetaminophen and much less expensive than the NSAIDs or the non-acetyl salicylates.

NSAIDs, such as Motrin/Rufen, Ansaid, Naprosyn/Anaprox, Rimadyl, Voltaren, Clinoril, Feldene, and Tolectin, should be avoided for the arthritic pain of nursing facility patients as much as possible due to their adverse GI effects in chronic usage. The concurrent use of H-2 blockers such as Tagamet, Zantac, Pepcid or Axid, may help to prevent the gastritis seen with NSAIDs, but they do not prevent NSAID-induced peptic ulcer disease. Carafate, Prilosec or Cytotec may prevent gastritis and peptic ulceration, but share with the H-2 blockers the disadvantage of being very expensive ($100 to $150 or more per month).

An additional safe method of local treatment of arthritic pain is with the topical creams and gels such as Mobisyl, Aspercreme, Banalg, etc. These topical preparations contain some form of salicylate, and as long as they are not put on extensive areas of the skin do not produce systemic toxicity. An exception would be the patient who is on warfarin or heparin; anticoagulated patients may experience some light bleeding around moles and hair follicles when extensive amounts of topical salicylate are applied.

Moderate to Severe Pain - Step 2 is Narcotic Analgesics - and Perhaps Patient-Controlled Analgesia (PCA) or Antidepressant

If pain is moderate to severe and NOT terminal, and especially if the patient has rehabilitation potential, care must be taken to avoid addiction. Though Dr. Kinzel discusses the problem of undermedication of pain, needless narcotic addiction in older patients does occur, and typically begins with the inappropriate daily long-term usage (greater than 2 to 4 weeks) of narcotic combinations such as Darvocet-N-100/Wygesic, Percodan or Percocet, Talwin Compound, or narcotics such as oxycodone, morphine, meperidine, Dilaudid, etc. to treat arthritic pain.

If a narcotic must be used, it should be the second step in step-care treatment after APAP, ECASA, non-acetyl salicylate or NSAID is given on a regular basis. CODEINE 8 mg up to 60-120 mg qid may be added to the peripheral analgesic (preferably APAP) as the safest oral narcotic. Initial nausea and vomiting may occur with any narcotic, and constipation may be avoided by the use of regular schedule of sugar-free psyllium (e.g. Metamucil), one tablespoonful in 12 oz. daily to twice a day, and/or Surfak 240 mg bid. If constipation persists, then sorbitol 70% syrup 15-60 ml once to twice daily may be added or substituted.

In severe terminal pain, as Dr. Kinzel points out, morphine orally is the preferred agent. The use of the sustained-release tablet (e.g., MS Contin) at 8 to 12 hour intervals is the most rational way to allow a sound night's sleep. There is usually no need to use narcotic injections, as the oral or rectal route (if patient is NPO) are just as reliable.

The shorter-acting narcotics propoxyphene and pentazocine are no more effective than placebo, and meperidine (Demerol) has an active metabolite that causes excitation, insomnia and seizures on chronic usage.

Third Step in Moderate to Severe Pain - Antidepressant To Decrease Afferent Perception of Pain, Anxiety, Depression, and Possibly Prevent Stress-Associated Peptic Ulcer Disease (PUD)

Doxepin or Desipramine in doses as low as 10 mg per day, with monthly increases from 10 to 25, 25 to 50, 50 to 75 and possibly up to 75 to 100 mg per day, may provide excellent second or third step analgesia. However, constipation and urinary retention may be seen at higher doses of antidepressant.

Summary

1. Pain relief should be prophylactic and geared to the

multiple pathological states frequently found in older

patients.

2. Terminal pain relief should be step-care structured and keep

the patient consistently comfortable without oversedation or

depressed respirations (less than 12 or more per minute).

3. Anxiety with pain should be conservatively managed to

prevent adding further CNS or orthopedic insults (drug-induced

fall and fractures) to the patient's problem list. The

new OBRA guidelines for longer-acting benzodiazepines 

(LABZ) for anxiety and sleep are important to follow,

especially the avoidance, as much as possible, of all LABZ

such as Valium, Dalmane, Centrax, Doral, ProSom, Librium,

Paxipam, Tranxene and Azene, and careful usage of shorter-acting

BZs such as Serax, Halcion, Xanax, Ativan and

Restoril.

4. Depression should be assumed to be a component of

chronic pain syndromes and should be managed.

5. Chronic, non-terminal pain relief should not shorten the

patient's lifespan by its effects on the GI tract or by

creating addiction through careless use without indications.

Stepped Care: Illustrative Case

A.D. was a 77-year old white female with bone metastases of large bowel carcinoma. After her initial APAP 650 mg QID, was changed to ibuprofen 600 mg QID, she went through codeine 8, 15, 30 and up to 60 mg q 4 h, which was changed to morphine sustained-release tablets 30, then 60, 90, 120, 180 and finally 240 mg q h, and doxepin 25, 50 and finally 75 mg q HS was added with monthly increments after persistent depressive-pain-anxiety-upper GI dyspepsia-pain syndrome was noted. Intermittent nausea was controlled with haloperidol 0.5-1.0 mg po q 6 h prn and obstipation required sorbitol 70% 60 ml q HS and Surfak 240 mg TID. She slept 6-8 hours a night, enjoyed her family and friends with little discomfort, and died peacefully in her sleep six months after the start of step-care pain management. She never needed an injection of narcotics.

References

[1] Cooper JW, Mallet L, Wade WE. J Pharmacoepidem 1990; 1(1):61-70, [2] Bradley JD, et al. New Engl J Med 1991; 325:87-91. [3] Cooper JW, Wilcher DW. J Am Ger Soc 1981; 29:429.

James W. Cooper, Pharm., PhD., FASCP, is Professor and Head of the Department of Pharmacy Practice at the University of Georgia.