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Pain Management: How Communities Can Ensure Safe, Effective Relief

February 8, 2024

An estimated 45%-80% of post-acute and long-term care (PALTC) residents suffer from some kind of pain. But for a variety of reasons, it is often underdiagnosed and/or undertreated. Striking a balance between effectively alleviating pain and minimizing the risk of opioid-related complications should be the goal of every community and care team.


Pain Points
The prevalence of pain is significant in senior living communities, but when people use the word “pain,” they may mean different things – everything from occasional, temporary discomfort to acute pain or debilitating pain syndromes. This can make it challenging to recognize and address pain.

Further complicating diagnosis and treatment, many residents may be limited in their ability to report and/or describe their pain. At the same time, because of their cultural background, upbringing, or other factors, they may be hesitant to talk about pain or even deny having any discomfort. “There also are misperceptions that pain is part of just a part of aging,” said Barbara Resnick, PhD, RN, CRNP, FAAN, FAANP, professor at the University of Maryland
School of Nursing and AALNA member.


“We need to do a better job of assessing, diagnosing, and managing pain,” Resnick suggested. The first step is periodic screening and recording pain levels, particularly when individuals are engaged in some level of activity. For those who are in long-term care settings, the recommendations is that they be screened for pain on admission and at least quarterly, annually, and whenever there is a change of condition.

Assessments should involve more than the use of pain scales and verbal inquiries. The care team needs to be vigilant for nonverbal and subtle signs of pain, such as grimacing, resistance to care, hitting or crying. “Watch people when they walk and observe them during times of activity,” suggested Resnick.


It also is important to identify side effects of opioid use as such and not misdiagnose them as new symptoms of pain from other causes that lead to additional drugs being prescribed. For example, constipation – a common side effect of opioid use – can be very painful and some pain medications can cause terrible headaches.


Team Takes the Field; Pain Takes a Hike
While federal efforts to reduce opioid use have resulted in lower levels of prescribing and an enhanced focus on dose reduction and weaning, there are situations where opioids are the most effective treatment. The key to appropriate pain management is to have a team approach that involves everyone. These should be a few areas of focus:


1. Side effects and complications of opioid use. These may include confusion, delirium, loss of appetite, and sedation. When people are sleeping all the time, cautioned Resnick, they may get dehydrated and experience kidney problems. Constipation and itching also are common, and these may persist throughout treatment. Constipation, in particular, may cause tremendous discomfort and should be recognized and addressed promptly.  Side effects vary from person to person. Some people tolerate these drugs quite well. However, when side effects occur, they can be devastating,” Resnick observed.

2. Risk factors for opioid use disorder and identifying individuals at high risk. “It’s important to find out if someone has a lifelong addiction to drugs or alcohol,” said Resnick. Some key questions to ask include: Have you been on these drugs before? For what condition and how long? What other interventions have you used to address pain?

3. The need to monitor, monitor, and monitor some more. “Unfortunately, people sometimes get put on opioids and left on them. No one evaluates them to determine if there are opportunities or attempts to wean them off the medications,” said Resnick. She added, “You need a system with efforts such as regular pain rounds and assessments.” There needs to be an ongoing effort to assess that you are using the lowest possible opioid dose for effectiveness, if you are achieving goals (such as the person being able to walk up or down steps so they can go home), and the presence of any side effects such as constipation or sedation.

4. The importance of understanding and prioritizing nonpharmacologic interventions. It is important to make sure the teams know how to use person-centered approaches to identify appropriate interventions. “A big part of implementation of nonpharmacologic approaches is believing there is a benefit. You need buy-in on the provider and patient side,” said Resnick. For instance, team members need to realize that an ice pack may be effective for something like an inflamed joint. and doesn’t take any longer to give than a pill. “We need to identify and treat the underlying cause of the pain. That is key,” she said.

5. The need to document in detail. It is essential to document for care planning and regulatory purposes evidence of someone’s pain, the underlying causes/diagnoses, results of assessments, attempts to treat underlying causes with nonpharmacologic, and pharmacologic interventions and attempts to reduce or eliminate dosages.

6. Dangers of respiratory depression. Teams should be instructed to monitor residents for signs of respiratory depression, which can be caused by opioid overdose and may lead to death. Signs include fast heart rate, dizziness, slow and shallow or labored breathing and blueish skin, lips, or nails.

7. The need for family communication. It is important to keep families informed about what you’re doing to manage their loved one’s pain and why. Conversations with family members also can help identify risks for opioid addiction as well as nonpharmacologic interventions that might help.


“Education doesn’t necessarily change behavior. That said, it is an important first step,” said Resnick. The good news is that you don’t have to reinvent the wheel. There are numerous tools and resources such as AMDA’s clinical practice guideline on Pain Management in the Post-Acute and Long-Term Care Setting. Such tools can help you teach staff what they need to know about pain to keep residents safe and comfortable and comply with regulations. The consultant pharmacist can play a significant role as well, not only in educating staff but also assisting with dose reduction, weaning people off opioids, and transitioning from opioids to other, safer medications. “The pharmacist’s expertise is critical. We need to actively engage them in our efforts to manage pain appropriately,” Resnick said.


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