Chronic pain: we're undertreating the elderly: having read many accounts of undertreatment, this consultant pharmacist mounted his own study. Here's what he found. (Feature Article).

As a consultant pharmacist who regularly visits more than 10 nursing homes in Texas throughout the year, I observe residents every day who experience pain. I am concerned that for many of these residents, chronic pain is being undertreated.

Undertreatment of chronic pain can be devastating, both mentally and physically. Quite often, residents not assessed and treated for chronic pain will develop a host of other problems, including depression, anxiety, impaired memory, decreased socialization, sleep disturbances and impaired ambulation, not to mention increased healthcare utilization and higher overall costs.

Frequently offered at skilled or assisted living facilities are medication orders used to treat the chronic pain that results from such medical conditions as rheumatoid arthritis, osteoarthritis, degenerative joint disease, osteoporosis with recurrent fractures, and neuropathic pain--all disorders often associated with aging.

One study reported chronic pain to be twice as prevalent in those who are more than 60 years of age as in younger individuals. (1) Another national study reported in Clinics in Geriatric Medicine estimated that between 45 and 80% of residents in skilled nursing facilities suffer from chronic pain. (2)

Recently I decided to mount my own study of this situation. Joined by three colleagues--Helle Borgen Tucker, PharmD; Brian Stacks, PharmD; and Lori Loth, PharmD--I sought to answer the question: Are we, as healthcare providers working with the elderly, doing enough to recognize and treat chronic pain?

We devised a study of nine nursing homes in the Greater Houston area, involving a pool of 889 residents. We gathered data on residents from this group who had routine medication orders for chronic pain vs residents who had orders for pain medication as needed (PRN), and which medications each of the two types of orders commonly involved.

The results were clear and supported our suspicions: Residents are being undertreated for chronic pain. Of the 889 resident charts we reviewed, only 34% (300 of 889 residents) had routine medication orders to manage chronic pain--well below the estimated range of 45 to 80% of residents suspected of suffering from the condition. Almost 80% of our sample population (704 of 889) had PRN medication orders for pain, and this clearly did not meet their needs.

Nine months later we returned to seven of the nine facilities to take another sample. Our results mirrored the first round of data collection: Once again, we found that pain was being underassessed and undertreated.

Various factors contribute to the undertreatment of chronic pain in the elderly, including:

* misconceptions that the elderly are less sensitive to pain, tolerate it well and do not tolerate opioid analgesics;

* communication issues--elderly adults might be confused or have difficulty communicating pain-related issues;

* difficulty defining the source of the problem--many elderly have more than one source of chronic pain; and

* increased risk of drug-drug and drug-disease interactions.

Every resident should be assessed for pain upon admission, at each quarterly review and anytime pain is suspected. Should pain be suspected, one of several methods can then be used to assess the degree of pain, depending on the resident's communication level. For example, a complete description of the pain can be obtained either verbally or, if needed, in writing. An alternative method uses a visual scale of 0 through 10, with 0 representing "no pain at all" and 10 signifying "the worst pain that they have ever experienced." A third approach is a visual scale with different facial expressions. The faces are arranged in order from smiling and happy, representing "pain free," to an extreme grimace, representing "severe pain."

Once the degree of pain has been determined, the pain must then be treated. Traditionally, chronic pain has been treated using nonpharmacologic methods, such as relaxation, massage therapy, distraction, heat and cold. Pharmacologic methods are also available, such as the World Health Organization Pain Treatment Ladder with nonopioid and opioid analgesics.

The WHO method consists of a three-step analgesic ladder in which more aggressive therapy can be added as the resident experiences increasing pain, (with [+ or -] meaning "with or without"):

(1.) Nonopioid [+ or -] adjuvant 

(2.) Opioid for mild to moderate pain [+ or -] nonopioid [+ or -] adjuvant

3. Opioid for moderate to severe pain [+ or -] nonopioid [+ or -] adjuvant

Nonopioid analgesics include acetaminophen, tramadol, aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). The first choice of analgesic for residents without liver disease is acetaminophen. Cyclooxygenase-2 (Cox-2) inhibitors, such as rofecoxib (Vioxx) and celecoxib (Celebrex), are newer agents that may prove to be safer alternatives to NSAIDs in the treatment of chronic pain. Codeine, oxycodone, hydrocodone, propoxyphene, morphine and fentanyl are commonly used opioids. Although concerns exist about administering opioids to elderly adults, clinical experience has shown that long-term use of opioids for pain relief does not cause loss of control, tolerance or addictive behavior--as reflected, for example, in the chronic pain management guidelines published in 1999 by the American Medical Directors Association.

After treatment has begun, it is important to monitor the resident's response. Because the severity of pain can vary over time, it is important to use appropriate pain assessment tools. Re-evaluation should occur whenever it is believed that inadequate pain management is affecting a resident's sleep pattern, mood, cognition, behavior, participation in usual activities or ability to perform activities of daily living.

Several key principles should be considered when prescribing medication for chronic pain in the long-term care setting. A fundamental principle is to use routine, not PRN, administration. Treatment goals should aim to decrease the resident's pain and improve functioning, mood and sleep. The dosage should be adjusted to meet these goals and should be limited only by possible side effects or potential toxicity. The least invasive route of administration should be used first. When dosing the analgesic, begin with a low dose and titrate upward as needed until a satisfactory level of comfort is achieved. For episodic pain, fast-onset, short-acting analgesics should be used. Finally, it is important to reassess and adjust the dose to optimize pain relief while appropriately managing side effects.

An American Geriatrics Society panel advised the following when reassessing pain:

* Reassess regularly for improvement, deterioration or complications.

* Evaluate significant issues identified in the initial evaluation.

* Repeat the same quantitative assessment scales in follow-up.

* Evaluate analgesic use, side effects and compliance.

* Assess effects of any nonpharmacologic intervention.

In the future, I would like to conduct another study similar to our first one, but this time with educational programs presented between the initial and follow-up phases. I'm fairly confident that after staff have been exposed to regular in-services on pain management, residents will enjoy an improved quality of life, experience fewer pain-related physical and mental disorders, and probably require fewer psychotropic drug orders.

For now, the answer to the question we sought to research in our study--Are we, as healthcare providers working with the elderly, doing enough to recognize and treat chronic pain?--is no. But through continued discussion, education and ongoing evaluation of residents' needs, we can improve. The benefits will flow widely--from residents enjoying more activities and having fewer pain-related disorders, to better-utilized staff, to reduced healthcare costs. It would be a clear "win-win-win" for residents, staff and families.

References

(1.) Crook J, Rideout E, Browne G. The prevalence of pain complaints in a general population. Pain 1984;l8:299-314.

(2.) Stein WM, Ferrell BA. Pain in the nursing home. Clinics in Geriatr Med 1996;12:601-13.

Larry McClaugherty, RPh, MPH, FASCP, is a consultant pharmacist for PharMerica. He is past chairman of the Academy of Consultants for the Texas Pharmacy Association. For further information, phone [phone] or write PharMerica at 1289 N. Post Oak, Suite 130, Houston, TX 77055.