Treat pain aggressively to improve resident comfort.

Unwarranted fears of causing drug dependence are leading to undertreatment and needless suffering of residents in pain, says Dr. Kinzel, a specialist in palliative therapy. He offered guidelines for safe and effective relief for these patients in this interview with NURSING HOMES Editor Richard L. Peck.

Peck: Isn't it difficult for nursing home staff sometimes to monitor for and identify pain in these patients?

Dr. Kinzel: Yes, it can be. Sometimes these patients aren't articulate, or are experiencing some form of dementia or aphasia, or perhaps they just don't want to complain. Pain should always be suspected when encountering, say, a refusal to eat, problems with sleeplessness or agitation. Sudden onset of a limp is, of course, a telling sign, and contractures associated with stroke often cause severe pain in the associated limb.

Peck: What is the most common error made in treatment of the nursing home resident in pain?

Dr. Kinzel: The most common error is undertreatment, due to a misplaced concern about drug dependence. This is true not only of cancer patients with limited life expectancies, but of patients with conditions, such as stroke, lasting many years. Our concern should be with relieving these patients' pain as safely and effectively as possible.

Peck: Does this mean treating them with powerful analgesics, such as morphine or other opiates, as soon as possible?

Dr. Kinzel: Not really. Rather, you should explore your options. If the patient is obtaining relief with ibuprofen, and is experiencing no significant side effects, fine. If not, it's time to explore other treatments.

For example, in cancer patients who continually experience pain, I will move to codeine or codeine with acetaminophen. In elderly patients, you start low, and go slow. For example, I'll use Tylenol 3 at the rate of maybe one tablet 3 or 4 times a day, and if necessary and the patient tolerates it, go up to 8 or 10 tablets a day. Side effects to watch for are constipation and nausea.

Another frequently overlooked option is adjunctive therapy with tricyclic anti-depressants. The literature is growing that these have a primary effect on pain. For the elderly, again, I start with half the standard dose; I also try to use those tricyclics less apt to cause confusion, agitation or cardiac arrhythmias, such as desipramine HCl or trazodone HCl (Desyrel). I'll even use Prozac these days in its new lower-dose formulation.

Peck: When using analgesics, do you favor a regular or an as-needed dosing schedule?

Dr. Kinzel: It depends on the patient. If the pain appears to be intermittent, an as-needed schedule is acceptable. For chronic pain, though, regular dosing is preferred because this reduces the risk of having to move to higher and possibly toxic dosages.

Peck: How do the opioids, such as morphine, fit into the treatment picture?

Dr. Kinzel: They're becoming increasingly relevant because we're seeing more and more cancer patients in the nursing home with life expectancies of anywhere from weeks to months. Many have serious pain, and something should be done about it.

I would add that one doesn't necessary start with a codeine preparation or morphine. If a patient has bone metastases, steroids such as prednisone are effective. If smooth muscle spasms are a problem, an anti-spasmodic, such as belladonna, should be employed. As for morphine, which I would use if codeine were ineffective or poorly tolerated, I would start with 5 mg, given orally every four hours. I watch closely for side effects of nausea or constipation.

If a dosage increase is indicated, I would do this every day or two until there is effective relief. In a closely monitored hospital situation, you can push the dosage up every 12 hours or so, but I wouldn't recommend this in the typical nursing home setting.

Apart from the regular dosage of morphine, one can also work in a PRN dosage of morphine of, say, one-third to one-half the regular dosage because this gives one a better shot at maintaining a lower maintenance dosage. The nursing staff, obviously, has to be well-trained in PRN administration of pain medications to do this.

Used in this manner, I have rarely seen a habituation problem caused by morphine. If tolerance seems to be occuring, it may well be that the pain simply isn't morphine-responsive, and you have to move on to other medications. Examples of this would be periostial inflammation with bone metastasis or smooth muscle spasm.

Peck: Before we address those other medications, what about that constipation side effect of morphine? Many nursing home residents have enough of a problem with that already.

Dr. Kinzel: The resident should receive plenty of fluids -- 2 quarts of water a day or more, if possible. Also, since morphine paralyzes the gut, I would use a stool softener, along with hydration. I would also add that, at this stage of the game, most nursing home residents should be allowed to take fluids in virtually any form they want. If they like to drink beer, so be it.

Peck: You mentioned other drugs that might be useful. What might a nursing home consider stocking?

Dr. Kinzel: Generally, I think the staff should learn how to use a fairly small selection of drugs and use them well. I'd say over 90% of my patients are on codeine, morphine or hydromorphone HCl (Dilaudid). I would recommend considering stocking morphine in the liquid form because it can be titrated so much more easily than the tablets; if you want to move from 10 mg. to 12 mg., you can do so. Also, morphine can be given sub-cutaneously when oral administration is impractical; this is a highly effective mode of administration, and the doses are lower -- about one-half the oral dose.

The Dilaudid is useful in patients who don't like or are unable to tolerate morphine for whatever reason. Also, it comes in a relatively small tablet which is easier for some elderly patients to take.

Peck: Don't families give you trouble when you propose using a "possibly addictive" medication like morphine?

Dr. Kinzel: Addiction is indeed a major concern for many of them, and one has to take the time to educate them. You explain that dependence is not a concern in these cases, that you're using the lowest dosages possible to give complete relief, and that you're monitoring closely for side effects. I have never had trouble with families who understand all this, and they can be very grateful that their relative doesn't have to suffer unnecessarily.

I actually have more problems with patients on this. Some don't want to "risk it," and some think it's wrong to complain and that they d 6. should try to make the most of it. If they feel strongly about this, I don't browbeat them to take morphine.

Peck: Doesn't the nursing staff require fairly intensive training to use these medications properly?

Dr. Kinzel: Yes, it does. In-service training given by someone familiar with and comfortable using these drugs is essential. As a rather humbling example of just how essential this is, I recall a few years back giving a quiz to my staff on various aspects of pain management, including medications. l asked them what is the maximum daily dosage of morphine that should be given. At the time we had a prostate cancer patient who was doing very well, with no ill effect, on 720 mg. a day. The staff said 120 mg. a day was the maximum one should go. There was that mental block there, and it's a common one.

Peck: You mentioned other aspects of pain management. What are some of the important ones in the nursing home?

Dr. Kinzel: The nursing staff can provide relief from suffering, in the broadest sense. That means getting to know the patients, and communicating with them about their problems and concerns. If they are dying, usually they will want to know, and it's best to be honest about this and provide as much emotional support as possible.

The staff itself should openly address its own problems with death and dying, because these can lead to avoidance of the patient and undertreatment of pain.

If patients are worried that their treatment, especially some expensive medical or surgical procedure, is going to burden their families unduly, these concerns should be addressed during treatment planning. In any event, patients should be reassured that neither the staff nor the physician will abandon them to their pain.

One of the advantages of the nursing home setting is that the staff does, typically, get to know the patients as people, and even form close relationships with them. This can be of great help in the overall relief of pain.

Terry Kinzel, MD, is medical director of a 40-bed skilled care unit and director of the Pallative Care Program at the Iron Mountain Veterans Administration Medical Center, Iron Mountain, MI.