CLINICAL PRACTICE IN LONG-TERM CARE

Section Editor: Daniel Swagerty, MD, MPH, CMD

Effective Pain Management in the

Long-Term Care Setting
Peter A. S. Winn, MD, CMD, and Andrew N. Dentino, MD, CMD

It is essential that physicians and midlevel practitioners fectively manage, prevent, and/or minimize the occur-
who care for residents in long-term care facilities be rence of acute pain, breakthrough pain, incidental
proficient in the recognition, assessment, and treat- pain, and disturbance pain that frequently are super-
ment of chronic pain. A holistic approach to the phys- imposed on a resident’s chronic pain. (J Am Med Dir
ical, emotional, social, and spiritual components of a Assoc 2004; 5: 342–352)
resident’s total pain and distress must be integrated
into the palliative aspects of long-term care medicine. Keywords: Pain management; long-term care
Furthermore, all practitioners must recognize and ef-

Effective pain management is the cornerstone to providing must not be considered as an inevitable consequence of nor-
both high-quality and palliative care in long-term care facil- mal aging, but must be routinely evaluated for its occurrence
ities and to achieving excellence in end-of-life care for resi- in all residents, aggressively treated when found, and analgesic
dents. Residents, their families, healthcare providers, and ad- efficacy and other interventions regularly monitored.
vocates, as well as policymakers and federal and state The potential consequences of inadequately treated pain in
regulatory agencies, are all concerned about untreated and long-term care populations include physical deconditioning, gait
undertreated pain in long-term care and expect physicians to disturbances, falls, slower rehabilitation, multiple medication
have acquired proficient skills in pain management. Under- use (polypharmacy), cognitive impairment/confusion, and mal-
treatment of pain and suffering can pose legal liability to nutrition,5 as well as sleep disturbances, decreased socialization,
physicians.1 and increased healthcare utilization and costs.6 These condi-
Studies have shown that 45% to 80% of residents in nurs- tions can contribute to significant morbidity, premature decline,
ing facilities could have chronic pain,2 which is two to three increased dependency, loss of well-being and dignity, and po-
times more prevalent than that reported in community-dwell- tentially premature death. Physicians must anticipate such po-
ing elderly populations.3 Pain can be constant (24%), inter- tentially avoidable outcomes. Effective management of acute
mittent (47%), or not present (29%).2 For those residents
and chronic pain in long-term care can decrease the likelihood
with intermittent pain, up to 51% had pain on a daily basis
of these adverse outcomes and attenuate their negative impact
and although 84% of these residents had physician orders for
on residents’ health and well-being.
(as-needed) pain medication, but the nursing staff had only
In 2003, the Center for Medicare and Medicaid Services
administered pain medication to 15% of the residents.2 An-
(CMS, formerly knows as HCFA), introduced the Nursing
other study has reported that 14.7% of nursing home residents
had moderate to severe pain at the time of their initial nurse Home Quality Initiative (NHQI). The primary goal of this
assessment on admission to the nursing facility.4 Chronic pain initiative is to improve care related to several quality measures
in nursing facilities, one of which is the prevalence of pain in
residents of chronic and postacute-care facilities. In each
Geriatrics Program, Residency Division, Department of Family Medicine, Uni-
state, the local quality improvement organization (QIO, un-
versity of Oklahoma Health Science Center, Oklahoma City, Oklahoma der contract with CMS), state surveyors of nursing facilities,
(P.A.S.W.); and Internal Medicine and Psychiatry, and the Program in Medical and some state chapters of the American Medical Directors
Ethics, LSU Health Science Center, Shreveport, Louisiana (A.N.D.).
Association (AMDA) are collaborating with the NHQI. Each
Address correspondence to: Andrew N. Dentino, MD, CMD, Associate Profes-
sor, Internal Medicine and Psychiatry, Director, Program in Medical Ethics, LSU
state QIO is actively spearheading educational and consulta-
Health Science Center, 1501 Kings Highway, PO Box 33932, Shreveport, LA tive activities with individual nursing facilities. Attending
71130 –3932. E-mail: [email protected] physicians and other healthcare practitioners are encouraged
Copyright ©2004 American Medical Directors Association to be proactive and inquire about the NHQI in the nursing
DOI: 10.1097/01.JAM.0000138578.42275.F1 facilities where they practice.

342 Winn and Dentino JAMDA – September/October 2004

Table 1. Cultural Sensitivity Guidelines
Self-check for cross-cultural medical care:
Understand your own personal, family, and cultural values, biases, and assumptions.
Acquire basic knowledge of cultural values and beliefs of those ethnic groups provided care.
Be empathic and respectful and acknowledge differences and similarities in perceptions.
General questions to ask:
“How do you describe the problem, and what do you think has caused your illness?
“Do you have family or cultural remedies to treat this problem?”
“Do you know of any family member or healer that can help?”
“Have you seen anyone else and what have they recommended?”
Specific questions to ask:
“What do you call your pain and do you have a name for it?”
“What do you think is causing your pain?”
“Why do you think it began when it did?”
“What does your pain do to you? And how does it work?”
Adapted from references 20 and 21

This article is based in part on AMDA’s Clinical Care physicians develop competencies related to the cultural as-
Curriculum Series on Geriatric Clinical Practice in Long- pects of pain management20 and cross-cultural medical care.21
Term Care7 and AMDA’s Clinical Practice Guideline on Table 1 reviews some general cultural sensitivity guidelines
Chronic Pain Management in the Long-Term Care Setting.8 when inquiring about pain.
Additional resources include several noteworthy articles spe- Proficient communication skills that respond to different
cifically written on pain management in nursing facili- cultural, spiritual, and existential perspectives are essential for
ties,5,9,10 and multiple guidelines on the assessment and treat- physicians who practice in long-term care settings, and this
ment of nonmalignant and malignant pain,8,11–14 as well as has already been reviewed in a previous article as part of
curricula for physicians.15–18 JAMDA’s Clinical Care Curriculum Series on Geriatric Clin-
This article reviews the definition of pain, pain terminol- ical Practice in Long-Term Care.22 An excellent user-friendly
ogy, the common causes and less common causes of pain in web-based grid of guidelines on cross-cultural and religious
residents of long-term care facilities, pain assessment, the issues related to medical care is available to physicians.23
World Health Organization (WHO) three-step analgesic lad-
COMMON AND LESS COMMON CAUSES OF PAIN
der, nonpharmacologic interventions and modalities used to
treat pain, the pharmacologic management of pain with em- Although the type and etiology of pain could vary, the majority
phasis on the appropriate use of opioids and opioid equianal- of pain in residents (see Table 2) is related to musculoskeletal
gesic dosing, the use of adjuvant analgesics, and pain man- conditions, especially low back pain (40%), arthritis involving the
agement at end of life. knees, shoulders, hips, or neck (29%), and previous fractures
(14%). Other causes include neuropathies, leg cramps, claudica-
DEFINITION OF PAIN AND SCOPE OF EVALUATION tion, headache, and generalized pain.9,10 Although cancer pain
Pain is defined as an individual’s unpleasant sensory or was reported to be relatively uncommon (3% of residents), 75% of
emotional experience that can be acute, recurrent, or persis- patients with advanced cancer have pain.13
tent.8 A resident’s experience of pain is highly subjective and Other less common causes of pain are summarized in Table
unfortunately there are no objective biologic markers with 3.8 Many residents can have multiple conditions that cause
which to assess pain severity.
All pain must always be assessed with respect to the four
components of total pain.15,16 That is, physical pain, which is
Table 2. More Common Causes of Pain in the Nursing Home
often related to multiple medical conditions. Emotional pain
such as anxiety, depression, and anger. Social pain resulting Sources of Pain Frequency of Pain
from interpersonal problems such as loneliness, financial (%)
stress, and strained family relationships. Spiritual pain that Low back 40%
could stem from the nonacceptance of the terminality of one’s Arthritic (knee, hip, shoulder, neck) 29%
life, a sense of hopelessness and isolation or abandonment, Previous fractures 14%
Neuropathies 11%
and the search for meaning in one’s life, and the leaving or
Leg cramps 9%
not of a legacy, be it personal, financial, or philanthropic. Foot 8%
A person’s cultural background can also influence the Claudication 8%
meaning and expression of pain. Studies have shown that Headache 6%
patients with ethnicity and culture different from that of the Generalized 3%
Neoplasm 3%
healthcare professionals treating them will often receive in-
adequate pain management.19 Thus, it is imperative that Adapted from references 9 and 10.

CLINICAL PRACTICE IN LONG-TERM CARE Winn and Dentino 343

Table 3. Less Common Causes of Pain Nociceptive pain is classified either as somatic pain (typically
Improper positioning, use of restraints described as aching, squeezing, stabbing, or throbbing) or as
Gout, pseudogout visceral pain, which is often cramping or gnawing and fre-
Temporal arteritis, Polymyalgia rheumatica quently associated with referred pain. Nociceptive pain could
Lumbar spinal stenosis involve acute or chronic inflammation modulated by sub-
Postherpetic neuralgia
Vertebral osteoporotic fractures stance P, serotonin, histamine, bradykinin, and prostaglan-
Thrombophlebitis dins. Inadequately treated acute pain could result in neuronal
Tic douloureux changes that can then lead to chronic pain.
Dental pain Neuropathic pain occurs when either neural or nonneural
Constipation, fecal impaction
tissues undergo permanent pathophysiological changes inde-
Urinary retention
Wounds pendent of the initial tissue injury that then precedes to a
Myocardial (eg, angina) chronic pain state. Neuropathic pain is often described as a
Postoperative, postprocedural continuous burning sensation or as “shooting,” “knife-like,” or
Adapted from reference 8. a “pins and needles” feeling. Neuropathic pain syndromes
include allodynia (pain induced by light touch), hyperalgesia
(increased pain response out of proportion to the intensity of
the noxious stimulus), and hyperpathia (the exaggerated re-
acute and/or chronic pain, each of which can fluctuate in its sponse to a painful stimulus that continues after the stimulus
occurrence, character, and intensity over time. Physicians has stopped).
must thoroughly assess each resident with new-onset pain or Several caveats should be noted. First, remember that the
worsening pain. The more accurate the clinician’s assessment nonphysical components of total pain should always be
as to the pathophysiology and diagnosis of conditions that are sought, identified, assessed, and treated. Second, some physical
contributing to the resident’s pain, the more appropriate and pain can be cancer-related and would thus more effectively
successful the treatment will be. All pain must be assessed respond to specific modalities (ie, radiation treatment). Third,
from multiple perspectives (refer to Table 4). the diagnosis of a resident’s type of pain is important in
PATHOPHYSIOLOGY AND CLASSIFICATION OF determining which treatments are more likely to be effective.
PAIN For example, nociceptive pain usually responds well to opioids
and nonsteroidal antiinflammatory drugs (NSAIDs), whereas
Understanding both the pathophysiology underlying a res- neuropathic pain is more likely to respond to anticonvulsants
ident’s pain and the various types of pain will aid physicians and possibly tricyclic antidepressants. Finally, always consider
in prescribing appropriate nonpharmacologic modalities and an emotional or affective component to a resident’s pain
pharmacologic treatments. Each specific type of pain will when the intensity of pain is more than expected given the
usually respond better to some treatments and not others. resident’s stage of disease or when progressively increasing
The pathophysiology of pain can be classified into nocicep-
dosages of analgesics only partially relieve a resident’s pain.
tive, neuropathic, and psychological causes24 (refer to Table 5).
Physical pain can also be classified as either “incidental”
Nociceptive pain is caused by the normal activation of tissue
when it occurs with patient-initiated movement or changes in
pain receptors (found in skin, muscle, joints, and viscera) by
position, or “iatrogenic” or “disturbance” pain when it is
noxious stimuli that can cause tissue injury. Normal process-
precipitated by moving the patient for the purposes of thera-
ing of noxious stimuli includes their transmission from the
peutic and/or diagnostic interventions or in providing per-
periphery through A delta and C fibers to the dorsal horns of
sonal care.25
the spinal cord with ascending pathways to the thalamus, a
process that is modulated by endorphins, serotonin, and nor- CHALLENGES TO EFFECTIVE PAIN MANAGEMENT
epinephrine. Endorphins are endogenous opioid compounds IN LONG-TERM CARE
that stimulate opioid receptor sites known as mu, delta, and
Challenges to effective pain management in long-term care
kappa. These receptors are probably an important component
settings are multiple, often demanding, and interrelated.
of the “gate control” theory of pain modulation at the level of
These challenges can be considered in the context of the
the spinal cord.
physician, patient, staff, the facility, the healthcare system in
general, as well as regulatory and legal standpoints.8,24,26
These have been summarized in Table 6.
Table 4. Assess for Pain From Multiple Perspectives Attending physicians must recognize these complex and
often burdensome issues as a challenge to achieving high-
Acute, chronic, persistent, intermittent
quality patient care and, in particular, effective pain manage-
Incidental, procedural, breakthrough, or disturbance pain
Noncancer-related physical condition ment. The acquisition of a positive attitude, skills, and com-
Cancer-related physical pain petencies in pain management and the recognition of
Nociceptive or neuropathic personal and professional biases, preferences, and limitations
Nonphysical causes: emotional, social, spiritual, existential are critical to successfully working with the long-term care
Multiple causes
interdisciplinary team, as well as with providers contracted

344 Winn and Dentino JAMDA – September/October 2004

Table 5. Classification of Pain
A. Physical pain
Nociceptive pain Descriptors
Somatic pain, eg, arthritis, bone metastases Sharp, tender, deep, aching
Visceral pain, eg, pancreatic, biliary obstruction Spasms, cramping, colicky
Neuropathic pain Shooting, burning, stabbing, pins and needles, numb
B. Nonphysical pain
Emotional/psychologic
Social/interpersonal
Spiritual/religious/existional
C. Iatrogenic
Pain induced by therapeutic interventions, diagnoses, personal care
D. Other pain syndromes
Chronic pain syndrome (greater than 6 months)
Myofascial pain
Raised intracranial pressure
Headaches
Adapted from references 15, 21, and 24.

with the facility (consultant pharmacists, hospice, and reha- sought when the physician is talking to the nurse on the
bilitation services). phone or at the time of the physician visit. The MDS section
When a difficult case on pain management occurs, the on the presence of pain symptoms (J2) should be reviewed by
physician should consider requesting a consultation with the the physician at the time of each patient visit and addressed
facility medical director, the medical director of the facility- accordingly. Whenever there is a change in a patient’s con-
contracted hospice,15 or with a specialist in pain management dition, the nurse and physician should assess whether a pain-
or hospice and palliative medicine. ful condition could be a contributing factor.
Physicians and facility staff often misunderstand the nature Remember that residents could be reluctant to acknowl-
of addiction and its risks whereby their biases can result in the edge pain or even deny having pain, but could acknowledge
undertreatment of pain in residents in long-term care facili- “discomfort” or “distress” in different terms such as aching,
ties. Pseudoaddiction is a term used to describe patient behav- soreness, burning, or tingling. Nonspecific signs and symptoms
iors such as drug-seeking or requests for increased doses of could suggest pain8 (refer to Table 9), and nurses should be
analgesics that could occur when pain is undertreated. Al- trained to report these to physicians, whereas physicians
though residents could develop physical dependence (a normal should note their presence at the time of any patient visit.
state of adaptation manifested by a drug withdrawal syn- Assessment of pain in cognitively impaired residents is
drome), residents afflicted with chronic pain rarely manifest problematic and can result in the undertreatment of pain.28
psychologic dependency, which is the hallmark of addiction. Rather than asking such a resident how long he or she has had
Residents could develop tolerance to an analgesic drug as a the pain, framing the question to the moment of the visit (eg,
result of either adaptation that results in lessened drug effects “Are you in pain?”) could increase the validity of pain assess-
over time or progression of disease.
ment,29 or by asking “Are you in any discomfort or distress
ASSESSMENT AND MEASUREMENT OF PAIN today?” The physician might want to substitute “discomfort”
Optimal pain management requires a comprehensive his- or “distress” with a pain descriptor (eg, burning, aching) and
tory that includes assessment of pain characteristics and in- “right now” for “today.” Studies have also found that over
tensity (as well as previous analgesic use and its efficacy), a 80% of residents in a nursing home were able to have their
physical examination that emphasizes its musculoskeletal and pain assessed by at least one of five assessment tools tested.29
neurologic components, an evaluation of the potential psy- The presence of pain can result in a decline in resident
chosocial dimensions to a resident’s total pain, and an appro- functional status such as worsened gait and balance, increased
priate diagnostic workup. dependence for basic and instrumental activities of daily liv-
Physicians are well indoctrinated as to the key elements of ing, and decreased participation in social activities and facil-
pain assessment and these are reviewed in Table 7. However, ity-organized recreational activities. Underlying depression
the uniqueness of the long-term care setting does pose chal- and anxiety or other psychologic disorders must also be iden-
lenges to physicians.27 First and foremost, facility nurses must tified and treated.
be trained to perform an accurate pain assessment before The use of standardized pain scales and pain documenta-
contacting the physician and have developed good commu- tion flow sheets can be very helpful to effective pain manage-
nication skills with physicians. Facility nurses and physicians ment in long-term care settings. Their use has been an inte-
need to be aware that several elements of the Minimum Data gral part of the CMS Nursing Home Quality Initiative.
Set (MDS) could indicate the presence of pain in residents8 Several standardized pain scales are listed in Table 10. The
(refer to Table 8). The presence of these indicators should be success of any facility pain initiative will depend on “trial and

CLINICAL PRACTICE IN LONG-TERM CARE Winn and Dentino 345

Table 6. Challenges to Effective Pain Management in Long-Term Table 7. Key Elements of Pain Assessment
Care Settings
Location
Physician-related Quality (descriptors)
Need in-depth knowledge on pain/palliative care Intensity (including use of scales)
Dispel myths, biases (addiction, dependence) Onset
Fear of regulation (controlled substance laws) Duration
Fear of legal liability (elder abuse, over- Alleviating factors
underprescribing) Aggravating factors
Fear of disciplinary action by licensing boards History of present illness
Knowledgeable JCAHO standards on pain management Radiation of pain
Concern over “double effect” Meaning of pain
Accept pain complaint as valid Comorbidities
Patient-related Pain medication history and effectiveness
Multiple medical problems
Adapted from reference 21, p. 160.
Multiple medication use
Sensory, cognitive, communication impairments
Bias: accepts pain as part of normal aging
Bias: accepts pain as normal part of disease
Right to appropriate assessment and management the patient marks the point that best describes their pain;
Cultural, ethnic, and social beliefs then the length of the line is measured from the no pain point
Concerns about potential side effects of medications
Unwillingness to take more medications (costs)
to their mark measured in millimeters. For the Verbal Rating
Limited routes of drug administration Scale, the patient chooses from descriptors of progressively
Fears of addiction to opioids worse pain: from no pain, to mild, moderate, severe, very
Staff-related severe, and the worst possible pain. The Faces Pain Scale
Staff training/education shows seven numbered and different facial expressions that
Use of appropriate assessment tools
Fear of causing resident addiction
depict a range of emotions. This scale could be useful in young
Facility-related children, as well as in residents with mild to moderate cog-
Staff turnover nitive impairment or others with a language impairment or
Interdisciplinary care team barrier.
Access to diagnostics For those residents who are cognitively impaired, other
Access to pharmacy services
Access to OT/PT/ST services
scales could be more appropriate. Although the FLACC scale
Leadership/commitment to pain intervention has been validated for the assessment of postoperative pain in
Pain management education programs (continuous) the pediatric population,30 clinically, it is frequently being
Regulatory burden used on geropsychiatric units and by hospices to evaluate pain
Healthcare systems severity in cognitively impaired adults, although this could be
Need for practice standards
Promulgate pain relief as a priority
an invalid application of this scale. As depicted in Table 11,
Reinforce accountability for pain management practices each of five categories of behavior is scored from 0 to 2,
Regulatory resulting in a total score of between 0 (no behavior that
Cumbersome laws and regulations
Potential for fines; lack of accreditation
Medicare/Medicaid provider status
Pain as the fifth vital sign (JCAHO) Table 8. Possible Indicators of Chronic Pain in the Patient
Legal
Minimum Data Set
Civil liability
Criminal liability Sleep cycle (E1)
Disciplinary action by licensing authorities Sad, apathetic, anxious appearance (E1)
Change in mood (E3)
Resources: references 8, 24, and 26.
Resisting care (E4)
Change in behavior (E5)
Loss of sense of initiative or involvement (F1)
Functional limitation in range of motion (G4)
Change in activities of daily living function (G9)
error” as to which scale works better for their facility and Any disease associated with pain (I1)
individual residents. Physicians should inquire which scales Pain symptoms (J2)
and pain documentation protocols are in place in each facility Pain site (J3)
where they visit patients and become familiar with their use Mouth pain (K1)
Weight loss (K3)
in assessing and monitoring pain.
Oral status (L1)
Each scale is briefly reviewed here. The Numeric Rating Skin lesions (M1)
Scale indicates pain intensity on a scale of 0 to 10, with 0 Other skin problems (M4)
being no pain, 1– 4 mild pain, 5– 6 moderate pain, 7–9 severe Foot problems (M6)
pain, and 10, “the worst pain imaginable.” The Visual Analog Range-of-motion restorative care (P3)
Restlessness, repetitive movements (B5)
Scale consists of a 10-cm line labeled “no pain” on one end
and “the worst pain imaginable” on the other end on which Taken from reference 8; Table 5; with permission.

346 Winn and Dentino JAMDA – September/October 2004

Table 9. Nonspecific Signs and Symptoms That Could Suggest Pain Table 11. FLACC Scale
Frowning, grimacing, fearful facial expressions, grinding of Category Scoring Intensity
teeth
0 1 2
Bracing, guarding, rubbing
Fidgeting, increasing or recurring restlessness Face Calm Frowning Grimacing
Striking out, increasing or recurring agitation Legs Relaxed Restless Thrashing
Eating or sleeping poorly Arms Relaxed Restless Thrashing
Sighing, groaning, crying, breathing heavily Consolability By verbal By touch Cannot
Decreasing activity levels Cry None Moaning Crying
Resisting certain movements during care
Change in gait or behavior Adapted from reference 30.
Loss of function
Taken from reference 8; Table 4; with permission.

of their illness trajectory. Every physician has the responsibil-

ity to be self-informed on the proficiency of the facility staff to
assess and monitor pain as well as to which treatment inter-
indicates pain) to 10 (that indicates severe pain as manifested
ventions are available in each facility.
by facial grimacing, thrashing movements of the arms and
legs, inconsolability, and crying). NONPHARMACOLOGIC AND COMPLEMENTARY
The Discomfort Scale measures the presence of seven be- THERAPIES
havioral indicators for frequency, intensity, and duration that There are many physical, nonphysical, and behavioral ther-
are observed in a patient over a 5-minute period.31,32 It has apies available for the treatment of pain.8,18 When these are
been proposed as an objective measure of discomfort in pa- used in combination with an appropriate drug regime, these
tients with advanced dementia who are aphasic. therapies could reduce pain and lower both the need and
The PAINAD Scale33 is a similar scale based on categories dosage of analgesic medications as well as reduce or prevent
and behaviors from the FLACC Scale and the Discomfort potential medication side effects. Many patients and their
Scale. Its clinical applicability will require further research. families believe in the effectiveness of these treatments. At-
The FLACC Scale could be the easiest for nurses and physi- tending physicians in long-term care need to research and
cians to use in the long-term care setting. decide which modalities could be of benefit, safe, and of
The AMDA Clinical Practice Guideline8 on pain recom- reasonable cost to families, the facility, or third party payers.
mends a stepped and interdisciplinary approach to the assess- Some modalities might not be available to residents of long-
ment and treatment of chronic pain and this is summarized in term care facilities unless the resident can be transported to
Table 12. It is crucial that physicians initiate appropriate pain another clinical setting, which in itself could be a significant
treatment while the workup and any diagnostic testing are burden and cost.
being performed. It is also important to effectively communi- Physical modalities can include application of heat or cold,
cate with the patient, their families, and facility staff to muscle stretching and massage, ultrasound, transcutaneous
establish appropriate goals of pain relief in the context of the nerve stimulation, chiropractic or osteopathic manipulation,
patient’s diagnoses, prognosis, benefits, and burdens of treat- acupuncture or acupressure, and magnets. Other physical mo-
ment and diagnostic testing, desired and achieved outcomes dalities include physical and occupational therapy and proper
of interventions, the patient’s advance directives for health positioning with the use of braces, splints, and wedges.
care, regulatory and legal constraints, as well as the patient’s Nonphysical modalities can include meditation and relax-
cultural and spiritual beliefs, wishes, and preferences, espe- ation, spiritual counseling and prayer, hypnosis, aroma-
cially for those patients who are in the late or terminal phase

Table 12. Stepped Approach to Chronic Pain Management

Table 10. Examples of Standardized Scales for Assessing Pain
Intensity in Long-Term Care Ask or recognize if pain, discomfort, or distress is present
Assess its impact on function and quality of living
For cognitively intact residents, consider: Define key elements and potential causes for pain
Numeric rating scale (0–10) Provide interim treatment
Visual analog scale (10-cm line) Perform follow-up history and physical examination
Verbal rating scale (no, mild, mod, severe, very severe, Assess whether causes of pain have been identified
worst possible) Consider further diagnostic testing or not
FACES pain scale Reassess whether causes of pain now identified
For cognitively impaired residents, consider: Consider consultation, if pain unrelieved
FACES pain scale Negotiate goals for pain relief (with patient, family, staff)
FLACC scale (refer to Table 11) Individualize pharmacologic and nonpharmacologic
Discomfort scale treatments
PAINAD scale Continually evaluate pain and adjust treatments
References: 8, 12, 13, 24, 30, and 33. Adapted from reference 8.

CLINICAL PRACTICE IN LONG-TERM CARE Winn and Dentino 347

therapy, music and art therapy, biofeedback, peer support, the most appropriate route of administration. Drug pharma-
herbal therapies, and naturopathic and homeopathic codynamics and pharmacokinetics are important consider-
therapies. ations, especially if renal insufficiency is present. If pure opi-
oids are being used, consider discontinuing weaker or mixed
PHARMACOLOGIC MANAGEMENT OF PAIN
opioids, whereas NSAIDs and steroids might no longer be
Although the specific cause of pain might not be identified, needed. Provide adequate dose titration. The total daily dose
pain must always be treated to ensure the comfort of every of an opioid can be increased 25% each day for mild pain,
resident. Analgesic medications are the mainstay of pain 25% to 50% for moderate pain, 50% for severe pain, and
management in the long-term care setting.8 A consensus 100% for excruciating, uncontrolled pain. Breakthrough pain
panel has recently reviewed and updated the Beers criteria for can be treated by administering a short-acting opioid at 10%
potentially inappropriate medication use in older adults (and of the total daily dosage of opioid, as often as every 1 to 2
persons residing in long-term care facilities), several of which hours. Physicians must be proficient with equianalgesic dosing
are related to the use of analgesics or adjuvant analgesics.34 of opioids (oral morphine equivalents).
These include propoxyphene, indomethacin, pentazocine, Precautions should be taken when prescribing acetamino-
muscle relaxants, antispasmodics, amitriptyline, meperidine,
phen, NSAIDs, and Cox-2 inhibitors.36 Acetaminophen is
ketorolac, long-term use of NSAIDs with a long half-life used
indicated for mild pain only (step 1). Because of its potential
at maximum dosages (naproxen, oxaprozin, and piroxicam),
for liver toxicity, the daily dosage should not exceed 4 g,
as well as fluoxetine when prescribed daily. These medications
although 2 to 3 g is not considered the maximum safe dose in
should generally be avoided as a result of their ineffectiveness,
the elderly. Chronic use could increase the odds ratio of
high risk for adverse events, or when a safer alternative is
developing end-stage renal disease to between 2.0 and 2.4.37
available.
Carefully calculate the total 24-hour dose of acetaminophen
The World Health Organization three-stepped analgesic
when using opioid/acetaminophen combination drugs.
ladder and its underlying five basic principles are widely
NSAIDs have antiinflammatory and antipyretic activity in
accepted as the foundation to effective management of both
noncancer and cancer pain despite it being initially adopted addition to their analgesic properties. NSAIDs are often pre-
to treat chronic cancer pain.35 The basic principles to using ferred over opioids in the short-term treatment of acute, mild
the analgesic ladder include the following in that analgesic to moderate pain (step 1 and step 2). They can be very
medications should be administered: effective when combined with opioids in the treatment of
1. By Mouth: Whenever possible, prescribe an analgesic severe pain, especially bone pain resulting from metastatic
medication either orally or sublingually (or inside the cheek) cancer. NSAIDs still pose significant risks for gastrointestinal
that can be easily administered by the nursing staff. Avoid and renal toxicity and drug– drug interactions. They could
intramuscular injections, which can be painful. Subcutaneous peripheral edema, congestive heart failure, and hypertension.
injections are less painful and just as effective as intramuscu- Lower than maximal doses should be used in the elderly to
lar. Highly concentrated opioids in liquid form can be admin- adjust for the decline in renal function that occurs with
istered sublingually. normal aging.
2. By the Clock: Analgesics should be prescribed by the COX-2 selective NSAIDs offer less gastrointestinal tract
clock (routine dosing, not as-needed) to prevent break- toxicity, although gastrointestinal bleeds can still occur. The
through pain or end-dose pain. An appropriate dosing interval renal toxicity of COX-2 inhibitors remains similar to that
is critical. Short-acting opioids have an analgesic effect of seen with nonselective NSAIDs. There have been case re-
only 3 to 4 hours. ports of increases in blood pressure when used in stable hy-
3. By the Ladder: pertensive patients.38 A large clinical trial has reported an
Step 1: For relief of mild to moderate pain: Use a nonopioid increase in the incidence of myocardial infarction but no
such as acetaminophen, aspirin, or a NSAID. difference in the cardiovascular death rate.39
Step 2: For relief of persistent mild to moderate or increasing
OPIOID ANALGESICS
pain: Add an opioid or change to an opioid combined with
acetaminophen. Consider an adjuvant medication(s). The effective use of opioids in the treatment of acute and
Step 3: For relief of a severe pain: Discontinue/transition chronic pain is an important component of palliative care in
from a mixed opioid to a pure opioid. Continue/consider the long-term care setting. All types of pain will at least
addition of an adjuvant medication(s). partially respond to opioids. Soft tissue pain usually responds
4. For the Individual: Adjuvant analgesics could be started well to opioids, whereas bone pain could require an adjuvant
at any step to enhance pain relief, to treat any symptoms that drug (eg, NSAIDs and/or steroids). Adjuvant drugs such as
exacerbate pain, or to treat specific types of pain. Patients who tricyclic antidepressants and anticonvulsants are usually nec-
initially present with moderate to severe pain should be essary to successfully treat neuropathic pain. Visceral pain
started at step 2 or step 3, not step 1. Choice of an analgesic often responds well to opioids, although anticholinergics can
should also be based on the patient condition, comorbidities, also be helpful. Pain caused by raised intracranial pressure
drug safety and toxicity profiles, ease of administration, quality only partially responds to opioids and usually requires the use
of life, and the overall treatment plan and goals of care. of steroids (eg, dexamethasone). Use of opioids is appropriate
5. With Attention to Detail: Ensure correct dosing and use for the treatment of acute and chronic pain, whether the pain

348 Winn and Dentino JAMDA – September/October 2004

is cancer-related or not. Opioids have no analgesic ceiling effects Table 13. Equianalgesic Doses of Opioids
and are only effective when prescribed in effective doses. Drug Oral Equianalgesic Dose
Opioid formulations combined with acetaminophen will (compared with 30 mg oral
often result in a subtherapeutic daily dosage of opioid or morphine)
exceed the maximum recommended dosage of acetamino- Morphine PO 30 mg
phen. Because of this limitation, consideration is being given Morphine SC or IV 10 mg (1/3 of PO dose)
to changing the World Health Organization three-stepped Oxycodone PO 20–30 mg
analgesic ladder to recommending an opioid combination for Hydrocodone PO 30 mg
step 1 mild pain and a pure opioid for step 2 moderate pain, Hydromorphone PO 7.5 mg
Hydromorphone SC or IV 1.5 mg (1/5 of PO dose)
whereas step 3 will then include modalities used to treat Codeine PO 180–200 mg
refractory pain such as selective nerve blocks, spinal/epidural Meperidine PO 300 mg
administrations of opioids with/without clonidine, and local Meperidine IM or IV 75 mg (1/4 of PO dose)
anesthetics and intravenous ketamine (Fine PG, personal Note: Use of codeine, meperidine, and propoxyphene are not
communication, 2003).40 recommended in the elderly.
Many physicians are unaware that opioids with mixed Note: Transdermal fentanyl patch 25 ␮g/hr has an oral morphine
equivalent of 50 mg over each 24-hour period.
agonist–antagonist properties (eg, nalbuphine or Nubain, Adapted from references 13, 14, and 42.
Endo, Chaddis Ford, PA; butorphanol or Stadol, Novartis, PO ⫽ by mouth; SC ⫽ subcutaneous; IV ⫽ intravenous; IM ⫽ in-
East Hanover, NJ; and pentazocine or Talwin, Sanofi, New tramuscular.
York, NY) can result in an opioid withdrawal syndrome when
coadministered with an opioid with pure agonist properties
such as morphine, oxycodone, or hydromorphone (Dilaudid,
Abbott, Abbott Park, IL). Advanced age, frailty, and renal Clinically significant respiratory depression is uncommon
insufficiency all prolong the serum half-life of opioids and in opioid-dependent patients, although it can occur in the
increase the likelihood for adverse effects, especially central “opioid-naïve” patient being started on opioids. Here the
nervous system toxicity. The efficacy of transdermal fentanyl traditional rule of prescribing “start low and go slow” is ad-
can be considerably diminished when a patient has inade- monished, although if pain is severe, the physician might
quate subcutaneous fat stores that are necessary for effective need to “go fast” while diligently monitoring for the emer-
transfer of fentanyl from the patch to subcutaneous fat and its gence of side effects.
subsequent release into the bloodstream. Certain opioids are inappropriate for use in the elderly and
The occurrence of rapid drug tolerance to opioids is rare. for patients in the long-term care setting.8,36 Codeine is too
Opioids have no analgesic ceiling effect, so rapidly increasing sedating, very constipating, and a weak analgesic. Propoxy-
the opioid dose would be indicated in this scenario, provided phene is one third as potent as codeine and 65 mg propoxy-
patients are carefully monitored for emergence of adverse phene 65 mg is equianalgesic to 1000 mg acetaminophen. It
effects. The slow development of drug tolerance to opioids is can cause altered mental status. Pentazocine frequently pre-
often the result of disease progression. Drug tolerance could cipitates delirium and agitation in the elderly. Meperidine and
also occur when high doses of pure opioids are used to treat its metabolite, normeperidine, are particularly likely to accu-
chronic pain. Switching or rotating to another opioid could mulate in the elderly and in patients with renal insufficiency
achieve adequate analgesia. As a result of incomplete cross- and has also been associated with delirium and seizures. Tra-
tolerance between different opioids, it is recommended that madol, a weak opioid agonist, can cause seizures, especially
the estimated dose of the newly prescribed opioid be de- with concomitant use of tricyclic antidepressants or selective
creased by one third to one half in opioid-tolerant patients. serotonin reuptake inhibitors or if there is a history of seizures.
Rotation of opioids can also be useful in patients who are Dependence and a withdrawal syndrome can occur with
experiencing unacceptable side effects from one opioid. Not tramadol.
infrequently, changing to another opioid could result in more
effective analgesia with a lower equivalent dose of opioid. EQUIANALGESIC DOSING OF OPIOIDS
When prescribing opioids long-term, exercise caution to When converting from one opioid to another, it is neces-
ensure that all conditions and diagnoses contributing to the sary to calculate the relative potency of each opioid compared
patient’s pain have been adequately assessed.8 A patient can with their oral morphine equivalent (OME). This can pre-
have both multiple conditions contributing to their pain and vent either overdosing or underdosing. Table 13 summarizes
different types of pain, all of which will necessitate a broad- an equianalgesic dosing conversion schedule.13,14,41,42 Several
spectrum approach to analgesia that can include the use of cautions are noteworthy. First, codeine and meperidine are
nonopioids, opioids, adjuvants as well as nonpharmacologic weak opioids, and the increased dosage required to provide
modalities. Aggressive pain management, although appropri- adequate analgesia will result in increased adverse effects such
ate, can potentially result in problems of polypharmacy. So as nausea, vomiting, constipation, lethargy, and central ner-
when prescribing an additional drug, determine the following: vous system depression. Second, these are general guidelines
What is the treatment goal? How can it be monitored? What and the clinical response to any opioid could vary among
is the risk of adverse effects? What is the risk of drug inter- patients. Third, the OME dosage required for analgesia could
actions? It is possible to stop any current medications? be less than the calculated dose if patients have either renal or

CLINICAL PRACTICE IN LONG-TERM CARE Winn and Dentino 349

hepatic insufficiency or other medical conditions that could Continuous subcutaneous infusions of opioids could benefit
effect opioid metabolism and kinetics. For example, the dos- patients with persistent nausea and vomiting, severe dyspha-
age of morphine might need to be decreased as much as 25% gia, confusion, or when high doses of oral opioids require
to 50% in renal failure.15 Finally, as a result of first-pass swallowing an excessive number of tablets.15 This mode of
metabolism in the liver, the oral dosage of morphine is three administration, as well as patient-controlled analgesia (PCA)
times its parenteral dose and that for oral hydromorphone five and intraspinal administration (epidural and intrathecal) of
times its parenteral dose. analgesics is beyond the scope of this article, and physicians
Overall, the oral route of administration of opioids is pre- are encouraged to consult additional resources.14,15,44
ferred because it is convenient and less costly than other Methadone has several benefits over other opioids and could
routes. Pure opioids are recommended for the treatment of be useful as an analgesic in select patients.44 – 47 Advantages
pain that is of moderate intensity or worse. Both morphine include a high oral bioavailability (40 –99% vs. 30% for oral
and oxycodone are available in immediate and controlled- morphine), it is primarily metabolized in the liver and fecally
release formulations, as well as concentrated liquids (20 mg/ excreted, does not accumulate significantly in renal insuffi-
mL) that can be administered sublingually or transbuccally. ciency and is associated with less nausea, vomiting, constipa-
The sublingual formulations will be less effective if swallowed tion, and sedation. However, its disadvantages include its long
or administered through a percutaneous endoscopic gastros- half-life (up to 190 hours), short duration of analgesic effect
tomy (PEG) tube because of their significant first-pass metab- (needs every 6- to 8-hour dosing), and its nonlinear equian-
olism in the liver. For patients unable to take oral medica- algesic dosing schedule. Physician experience and diligence
tions, morphine, oxycodone, and hydromorphone could be are required to ensure its safe use for pain control. It is very
administered rectally either in tablet or suppository form, start inexpensive and thus its use can result in significant cost
with the same dosage as oral and titrate up or down as needed. savings. Possible indications to its use include the presence of
Immediate-release oral opioids require regular or as-needed opioid tolerance or resistance to opioids (inadequate pain
dosing every 3 to 4 hours while sustained-release preparations relief despite high doses of other opioids), opioid-induced
are prescribed every 12 hours, although end-dose break- neurotoxicity (sedation, confusion, delirium, myoclonus, sei-
through pain could require dosing every 8 hours. Sustained- zures, hyperalgesia), neuropathic pain, second-line treatment
release capsules of morphine (Kadian, Alpharma, Elizabeth, of cancer pain, and for the opioid-addicted patient.45,46
NJ; Avinza, Ligand, San Diego, CA) can be opened and
ANTICIPATE AND MANAGE SIDE EFFECTS OF
sprinkled on applesauce for oral administration or the beads
flushed down a PEG tube. OPIOIDS
The transdermal administration of opioids bypasses both Common adverse side effects to opioids include constipa-
gastrointestinal absorption and liver metabolism and depends tion, nausea/vomiting, sedation, confusion, and hallucina-
on adequate subcutaneous tissue for adequate deposition in fat tions. Less common side effects include pruritus, diaphoresis,
and its subsequent release from the fat stores into the blood urinary retention, and myoclonic jerks.44 To improve patient
circulation. Fentanyl is currently the only opioid available in compliance to the use of opioids, these side effects must be
transdermal form. The lowest dose patch is 25 ␮g/hour, which anticipated and aggressively prevented and/or treated (refer to
has an OME of 50 mg over a 24-hour period.43 Ideally, each Table 14).
patch has an analgesic effect that lasts 72 hours, although on Always anticipate the development of constipation, so
occasion, breakthrough pain occurs between 48 to 72 hours, when initially prescribing an opioid, concomitantly prescribe a
which could be overcome by changing the patch every 48 laxative regime (routine, not as-needed) that should include a
hours rather than every 72 hours. When starting the fentanyl stool softener and a bowel stimulant (“pusher”) such as senna
patch, one will often need to prescribe a short-acting opioid or bisacodyl. Remember to continue to increase the laxative reg-
for breakthrough pain during the first 24 to 48 hours until a imen in a stepwise manner as the opioid dosage is increased.
steady state level of fentanyl is achieved in the blood. Fent- Osmotic agents such as sorbitol or lactulose can also be
anyl is also available in a oral transmucosal preparation (eg, effective and are often used as an “add-on” to a combined
Actiq, Cephalon, West Chester, PA) that the U.S. Food and stool softener/stimulant preparation. The occurrence of “opi-
Drug Administration has approved for the treatment of mod- oid bowel syndrome” could respond to metoclopramide. It is
erate to severe cancer-related breakthrough pain that provides always important to understand the pathophysiological pro-
relief within 5 to 10 minutes. cess(es) that contribute to constipation to prescribe the most
The intravenous administration of opioids is appropriate appropriate bowel regime. If the stool is hard, prescribe a stool
when the patient already has intravenous access. Although softener. If peristalsis is diminished, prescribe a stimulant. If
intravenous opioids an provide onset of analgesia within 5 to the stool is firm as a result of inadequate oral fluid intake, then
10 minutes, their peak effect can vary from 1 to 5 minutes for consider an osmotic agent.
fentanyl to 15 to 30 minutes for morphine. The duration of Opioids can induce nausea and vomiting in 10% to 40% of
action of intravenous morphine is still no longer than orally patients and usually subsides within 3 to 4 days of initiation of
administered morphine, ie, 3 to 4 hours. Subcutaneous mor- the opioid. Consider prochlorperazine or promethazine (PO/
phine has a slower onset (10 –20 minutes), slower peak PR) or transdermal scopolamine. The antiemetic can often be
(30 – 60 minutes), but similar duration of analgesia (3– 4 discontinued after several days or in a few weeks. Be careful
hours). not to automatically attribute these symptoms to opioids.

350 Winn and Dentino JAMDA – September/October 2004

Table 14. Pharmacologic Management of Side Effects of Opioids
Side Effect Suggested Medications
Constipation Start/titrate up:
● Stool softener: docusate 100–200 mg PO twice a day
● Stimulant: senna 2–4 tabs PO 2 to 4 times per day
● Osmotic agent: sorbitol 15–30 cc PO 2 to 4 times per day
Nausea/vomiting ● Prochlorperazine (PO, PR, IM, IV) 5–10 mg PO/IM 3 to 4 times per day, 25 mg PR twice
per day, 5–10 mg IV (over 2 minutes)
● Promethazine (PO, PR, IM, IV) 12.5–25 mg PO/PR/IM/IV every 4–6 hours
● Transderm scopolamine patch every 48–72 hours
● Metoclopramide 5–10 mg PO/IM/IV every 6–8 hours
● Ondansetron 4–8 mg PO/IV every 4 hours
Sedation/fatigue ● Methylphenidate 2.5–5 mg early/late AM
● Caffeinated beverages
Confusion/delusions ● Lorazepam 0.5–1 mg PO/IM/IV every 6–8 hours
● Lorazepam 0.5–1 mg SL every 4–8 hours
● Haloperidol 0.5–1 mg PO/SL/IM/IV 2 to 3 times per day
Opioid bowel syndrome ● Metoclopramide 5–10 mg PO/IM/IV every 6–8 hours
● Naloxone PO (?)49–51
Adapted from references 15 and 42.
PO ⫽ by mouth; PR ⫽ per rectum; IM ⫽ intramuscular; IV ⫽ intravenous; SL ⫽ sublingual.

Always perform an adequate assessment to guide the most hours/days of life. If a patient’s opioid-induced respiratory rate
appropriate treatment. For example, common causes of nau- is below 6, some physicians might want to partially reverse
sea/vomiting can include fecal impaction, opioid bowel syn- this with the use of naloxone. This can be done by diluting one
drome, urinary retention, infection (usually a urinary tract ampoule of naloxone (0.4 mg/mL) with 1:10 normal saline
infection), or raised intracranial pressure. and then administering 1 cc of the diluted naloxone subcuta-
Sedation is usually worse during the first 48 hours of pre- neously or intravenously every 5 minutes until a satisfactory
scribing an opioid or as the opioid dosage is increased. Con- respiratory rate is achieved without reversing analgesia. The
sider decreasing the dosage of the opioid, although adequate dosage of other central nervous system-depressant drugs
pain control could be jeopardized. Patients do tend to become should also be decreased or discontinued when sedation is a
tolerant to this side effect within 2 to 5 days. Low doses of concern.
methylphenidate in the early and late morning could be
helpful. Continued drowsiness is not an indication for the use SUMMARY
of naloxone, which if used can precipitate a painful opioid It is important to proficiently assess, treat, and monitor pain
withdrawal crisis. Consider adding a nonsedating coanalgesic in the long-term care setting. Be attentive to the high likeli-
like a NSAID while decreasing the dosage of the opioid. hood of pain in residents. Consider prescribing an appropriate
Opioids could precipitate or aggravate confusion, delusions, analgesic regime on a routine schedule with as-needed doses
and hallucinations. Use a short-acting benzodiazepine such as for breakthrough pain. Dosing analgesics on an as-needed
lorazepam and/or an antipsychotic such as haloperidol, either basis alone will often result in the resident not receiving the
of which can be administered orally, sublingually, or paren- medication or an excessive delay in it being administered.
terally. Remember that a plethora of medical conditions can Remember those nonpain signs and symptoms that could
cause neuropsychiatric symptoms and that an accurate diag- suggest a resident is suffering pain or discomfort. Do not
nosis for such symptoms should always be sought. overtreat pain without adequately assessing and determining
Pruritus or itching is quite common and is not considered the cause of a resident’s pain. Adequate treatment of pain can
to be a true allergy unless a rash develops. Consider use of an result in the decreased use of other medications, especially
antihistamine. Troublesome sweating could require a trial use psychotropics. Consider consulting the facility medical direc-
of another opioid. Myoclonic jerks are not infrequent. Con- tor, hospice medical director, or a palliative care specialist for
sider lowering the opioid dose or changing to another opioid. comanagement of difficult cases. Anticipate what kind of pain
Myoclonic jerks could respond to a low dose of clonazepam, a resident is likely to be experiencing given each resident’s
such as 0.25 to 0.5 mg two to three times a day. various medical conditions. As much as is possible, avoid
Although transient sedation is common when an opioid is intentionally prescribing suboptimal dosages of opioids in
started, respiratory depression is rare in the opioid-tolerant response to fears of causing physical dependence or respiratory
patient, but can occur more commonly when initiating an depression. It is imperative that physicians become proficient
opioid in the opioid-naïve patient or at end of life as renal in pain management, particularly the use of nonopioids and
insufficiency worsens. Be aware that opioids can induce a deep opioids and equianalgesic dosing of opioids (oral morphine
sleep in a sleep-deprived patient. Also, respiratory depression equivalents). Complementary therapies could augment phar-
can occur as part of the normal dying process during the last macologic therapies and usually have few adverse effects.

CLINICAL PRACTICE IN LONG-TERM CARE Winn and Dentino 351

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352 Winn and Dentino JAMDA – September/October 2004