Embed Size (px)
Citation preview
I Feel Your PainA Clinical and Regulatory Overview of Pain Management in Long Term Care
William Vaughan BSN RN Vice President Education and Clinical Affairs
Remedi SeniorCare
Disclosure Contact
bull William Vaughan is a shareholder at Remedi SeniorCare a consultant to CMS currently working on QAPI and on the advisory board of the Institute for Safe Medication Practicesrsquo long-term care newsletter
bull WilliamVaughanRemedirxcom
Objectives
Describe several common myths regarding pain management in the elderly
Cite several different tools for assessing pain in addition to explaining which may be more appropriate in certain situations
Evaluate resident family and facility concerns surrounding pain management issues
Identify opportunities to improverefine the facilityrsquos pain management process
Definitions
ldquoPain is a complex subjective and unpleasant sensation derived from sensory stimuli and modified by memory expectations and emotionsrdquo
The Merck Manual of Geriatric
ldquoPain is just what the patient says it isrdquoAmerican Geriatric Society
Scope of the Problem
bull Pain management in Long Term Care is a nationwide problem
bull 45-80 of Nursing Home residents have substantial pain
bull 41 of residents assessed with pain are still in persistent pain at the next assessment
bull A study found that 26 of nursing home residents experienced pain on a daily basis
bull 60 disagreement between patient statements and caregiver assessment
Scope of the Problem
Another study suggests that most patients have more than one type of painbull 20 of patients have one type of painbull 80 have 2 or more types of painbull 33 have four different types of pain
Twycross
Consequences of Untreated Pain
Decreased Quality of Life for the PatientLosses General Health Functional Cognitive
Increased health care utilization Increased impact on all care givers Decreased ability of a health care center to
compete Regulatory and legal liability
Why focus on pain Pain Impacts
Physical
Psychological
Social
Spiritual
Physical Impact
bull Decreased functional capability
bull Diminished strength or endurance
bull Nausea poor appetitebull Poor or interrupted sleepbull Impairs healing
Psychological Impact
bull Diminished leisure enjoymentbull Increased anxiety fearbull Depression personal distressbull Difficulty concentratingbull Somatic preoccupationbull Loss of control
Social
bull Diminished social relationships
bull Decreased sexual function affection
bull Altered appearancebull Increased caregiver burden
Spiritual
bull Increased sufferingbull Altered meaningbull Re-evaluation of
religious beliefs
Areas Pain May Impact
Painbull Pain Symptomsbull Pain site
Mood sleepbull Sleep cyclebull Sad apathetic anxious
appearancebull Change in moodbull Resisting carebull Change in behavior
Depressionbull Loss of sense of initiative
or involvement
Ability functionbull Functional limitation in range
of motionbull Changes in ADL bull Range of motionbull Rehabilitationbull Restorative Care
Nutritionbull Mouth painbull Weight Loss
Skinbull Skin lesionsbull Other skin problemsbull Foot problems
Impact The Patientrsquos Point of View
Inability to enjoy social activitybull 54
Feelings of depressionbull 32
Anxietybull 26
Impaired memorybull 12
Adapted from JAGS 2006
What is Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
Pain is always subjective
In LTC residents do no always verbalize their pain but express it is other ways
Pain is whatever the resident says it is
Acute vs Persistent Pain
Acute Short term bull Surgery sprain laceration
Persistent Continues for a prolonged period of timebull May or may not be associated with a recognizable disease
processbull The term chronic pain is no longer recommended due to
negative connotation (eg chronic whiner chronic complainer)
Types of Pain
Musculoskeletal problemsbull Arthritis wounds dental problems
Bone - Often worse on movementbull Osteoporotic fractures cancer
Neuropathic painnerve compressionbull Neuropathy herpes zoster
Spasms
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Disclosure Contact
bull William Vaughan is a shareholder at Remedi SeniorCare a consultant to CMS currently working on QAPI and on the advisory board of the Institute for Safe Medication Practicesrsquo long-term care newsletter
bull WilliamVaughanRemedirxcom
Objectives
Describe several common myths regarding pain management in the elderly
Cite several different tools for assessing pain in addition to explaining which may be more appropriate in certain situations
Evaluate resident family and facility concerns surrounding pain management issues
Identify opportunities to improverefine the facilityrsquos pain management process
Definitions
ldquoPain is a complex subjective and unpleasant sensation derived from sensory stimuli and modified by memory expectations and emotionsrdquo
The Merck Manual of Geriatric
ldquoPain is just what the patient says it isrdquoAmerican Geriatric Society
Scope of the Problem
bull Pain management in Long Term Care is a nationwide problem
bull 45-80 of Nursing Home residents have substantial pain
bull 41 of residents assessed with pain are still in persistent pain at the next assessment
bull A study found that 26 of nursing home residents experienced pain on a daily basis
bull 60 disagreement between patient statements and caregiver assessment
Scope of the Problem
Another study suggests that most patients have more than one type of painbull 20 of patients have one type of painbull 80 have 2 or more types of painbull 33 have four different types of pain
Twycross
Consequences of Untreated Pain
Decreased Quality of Life for the PatientLosses General Health Functional Cognitive
Increased health care utilization Increased impact on all care givers Decreased ability of a health care center to
compete Regulatory and legal liability
Why focus on pain Pain Impacts
Physical
Psychological
Social
Spiritual
Physical Impact
bull Decreased functional capability
bull Diminished strength or endurance
bull Nausea poor appetitebull Poor or interrupted sleepbull Impairs healing
Psychological Impact
bull Diminished leisure enjoymentbull Increased anxiety fearbull Depression personal distressbull Difficulty concentratingbull Somatic preoccupationbull Loss of control
Social
bull Diminished social relationships
bull Decreased sexual function affection
bull Altered appearancebull Increased caregiver burden
Spiritual
bull Increased sufferingbull Altered meaningbull Re-evaluation of
religious beliefs
Areas Pain May Impact
Painbull Pain Symptomsbull Pain site
Mood sleepbull Sleep cyclebull Sad apathetic anxious
appearancebull Change in moodbull Resisting carebull Change in behavior
Depressionbull Loss of sense of initiative
or involvement
Ability functionbull Functional limitation in range
of motionbull Changes in ADL bull Range of motionbull Rehabilitationbull Restorative Care
Nutritionbull Mouth painbull Weight Loss
Skinbull Skin lesionsbull Other skin problemsbull Foot problems
Impact The Patientrsquos Point of View
Inability to enjoy social activitybull 54
Feelings of depressionbull 32
Anxietybull 26
Impaired memorybull 12
Adapted from JAGS 2006
What is Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
Pain is always subjective
In LTC residents do no always verbalize their pain but express it is other ways
Pain is whatever the resident says it is
Acute vs Persistent Pain
Acute Short term bull Surgery sprain laceration
Persistent Continues for a prolonged period of timebull May or may not be associated with a recognizable disease
processbull The term chronic pain is no longer recommended due to
negative connotation (eg chronic whiner chronic complainer)
Types of Pain
Musculoskeletal problemsbull Arthritis wounds dental problems
Bone - Often worse on movementbull Osteoporotic fractures cancer
Neuropathic painnerve compressionbull Neuropathy herpes zoster
Spasms
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Objectives
Describe several common myths regarding pain management in the elderly
Cite several different tools for assessing pain in addition to explaining which may be more appropriate in certain situations
Evaluate resident family and facility concerns surrounding pain management issues
Identify opportunities to improverefine the facilityrsquos pain management process
Definitions
ldquoPain is a complex subjective and unpleasant sensation derived from sensory stimuli and modified by memory expectations and emotionsrdquo
The Merck Manual of Geriatric
ldquoPain is just what the patient says it isrdquoAmerican Geriatric Society
Scope of the Problem
bull Pain management in Long Term Care is a nationwide problem
bull 45-80 of Nursing Home residents have substantial pain
bull 41 of residents assessed with pain are still in persistent pain at the next assessment
bull A study found that 26 of nursing home residents experienced pain on a daily basis
bull 60 disagreement between patient statements and caregiver assessment
Scope of the Problem
Another study suggests that most patients have more than one type of painbull 20 of patients have one type of painbull 80 have 2 or more types of painbull 33 have four different types of pain
Twycross
Consequences of Untreated Pain
Decreased Quality of Life for the PatientLosses General Health Functional Cognitive
Increased health care utilization Increased impact on all care givers Decreased ability of a health care center to
compete Regulatory and legal liability
Why focus on pain Pain Impacts
Physical
Psychological
Social
Spiritual
Physical Impact
bull Decreased functional capability
bull Diminished strength or endurance
bull Nausea poor appetitebull Poor or interrupted sleepbull Impairs healing
Psychological Impact
bull Diminished leisure enjoymentbull Increased anxiety fearbull Depression personal distressbull Difficulty concentratingbull Somatic preoccupationbull Loss of control
Social
bull Diminished social relationships
bull Decreased sexual function affection
bull Altered appearancebull Increased caregiver burden
Spiritual
bull Increased sufferingbull Altered meaningbull Re-evaluation of
religious beliefs
Areas Pain May Impact
Painbull Pain Symptomsbull Pain site
Mood sleepbull Sleep cyclebull Sad apathetic anxious
appearancebull Change in moodbull Resisting carebull Change in behavior
Depressionbull Loss of sense of initiative
or involvement
Ability functionbull Functional limitation in range
of motionbull Changes in ADL bull Range of motionbull Rehabilitationbull Restorative Care
Nutritionbull Mouth painbull Weight Loss
Skinbull Skin lesionsbull Other skin problemsbull Foot problems
Impact The Patientrsquos Point of View
Inability to enjoy social activitybull 54
Feelings of depressionbull 32
Anxietybull 26
Impaired memorybull 12
Adapted from JAGS 2006
What is Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
Pain is always subjective
In LTC residents do no always verbalize their pain but express it is other ways
Pain is whatever the resident says it is
Acute vs Persistent Pain
Acute Short term bull Surgery sprain laceration
Persistent Continues for a prolonged period of timebull May or may not be associated with a recognizable disease
processbull The term chronic pain is no longer recommended due to
negative connotation (eg chronic whiner chronic complainer)
Types of Pain
Musculoskeletal problemsbull Arthritis wounds dental problems
Bone - Often worse on movementbull Osteoporotic fractures cancer
Neuropathic painnerve compressionbull Neuropathy herpes zoster
Spasms
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Definitions
ldquoPain is a complex subjective and unpleasant sensation derived from sensory stimuli and modified by memory expectations and emotionsrdquo
The Merck Manual of Geriatric
ldquoPain is just what the patient says it isrdquoAmerican Geriatric Society
Scope of the Problem
bull Pain management in Long Term Care is a nationwide problem
bull 45-80 of Nursing Home residents have substantial pain
bull 41 of residents assessed with pain are still in persistent pain at the next assessment
bull A study found that 26 of nursing home residents experienced pain on a daily basis
bull 60 disagreement between patient statements and caregiver assessment
Scope of the Problem
Another study suggests that most patients have more than one type of painbull 20 of patients have one type of painbull 80 have 2 or more types of painbull 33 have four different types of pain
Twycross
Consequences of Untreated Pain
Decreased Quality of Life for the PatientLosses General Health Functional Cognitive
Increased health care utilization Increased impact on all care givers Decreased ability of a health care center to
compete Regulatory and legal liability
Why focus on pain Pain Impacts
Physical
Psychological
Social
Spiritual
Physical Impact
bull Decreased functional capability
bull Diminished strength or endurance
bull Nausea poor appetitebull Poor or interrupted sleepbull Impairs healing
Psychological Impact
bull Diminished leisure enjoymentbull Increased anxiety fearbull Depression personal distressbull Difficulty concentratingbull Somatic preoccupationbull Loss of control
Social
bull Diminished social relationships
bull Decreased sexual function affection
bull Altered appearancebull Increased caregiver burden
Spiritual
bull Increased sufferingbull Altered meaningbull Re-evaluation of
religious beliefs
Areas Pain May Impact
Painbull Pain Symptomsbull Pain site
Mood sleepbull Sleep cyclebull Sad apathetic anxious
appearancebull Change in moodbull Resisting carebull Change in behavior
Depressionbull Loss of sense of initiative
or involvement
Ability functionbull Functional limitation in range
of motionbull Changes in ADL bull Range of motionbull Rehabilitationbull Restorative Care
Nutritionbull Mouth painbull Weight Loss
Skinbull Skin lesionsbull Other skin problemsbull Foot problems
Impact The Patientrsquos Point of View
Inability to enjoy social activitybull 54
Feelings of depressionbull 32
Anxietybull 26
Impaired memorybull 12
Adapted from JAGS 2006
What is Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
Pain is always subjective
In LTC residents do no always verbalize their pain but express it is other ways
Pain is whatever the resident says it is
Acute vs Persistent Pain
Acute Short term bull Surgery sprain laceration
Persistent Continues for a prolonged period of timebull May or may not be associated with a recognizable disease
processbull The term chronic pain is no longer recommended due to
negative connotation (eg chronic whiner chronic complainer)
Types of Pain
Musculoskeletal problemsbull Arthritis wounds dental problems
Bone - Often worse on movementbull Osteoporotic fractures cancer
Neuropathic painnerve compressionbull Neuropathy herpes zoster
Spasms
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Scope of the Problem
bull Pain management in Long Term Care is a nationwide problem
bull 45-80 of Nursing Home residents have substantial pain
bull 41 of residents assessed with pain are still in persistent pain at the next assessment
bull A study found that 26 of nursing home residents experienced pain on a daily basis
bull 60 disagreement between patient statements and caregiver assessment
Scope of the Problem
Another study suggests that most patients have more than one type of painbull 20 of patients have one type of painbull 80 have 2 or more types of painbull 33 have four different types of pain
Twycross
Consequences of Untreated Pain
Decreased Quality of Life for the PatientLosses General Health Functional Cognitive
Increased health care utilization Increased impact on all care givers Decreased ability of a health care center to
compete Regulatory and legal liability
Why focus on pain Pain Impacts
Physical
Psychological
Social
Spiritual
Physical Impact
bull Decreased functional capability
bull Diminished strength or endurance
bull Nausea poor appetitebull Poor or interrupted sleepbull Impairs healing
Psychological Impact
bull Diminished leisure enjoymentbull Increased anxiety fearbull Depression personal distressbull Difficulty concentratingbull Somatic preoccupationbull Loss of control
Social
bull Diminished social relationships
bull Decreased sexual function affection
bull Altered appearancebull Increased caregiver burden
Spiritual
bull Increased sufferingbull Altered meaningbull Re-evaluation of
religious beliefs
Areas Pain May Impact
Painbull Pain Symptomsbull Pain site
Mood sleepbull Sleep cyclebull Sad apathetic anxious
appearancebull Change in moodbull Resisting carebull Change in behavior
Depressionbull Loss of sense of initiative
or involvement
Ability functionbull Functional limitation in range
of motionbull Changes in ADL bull Range of motionbull Rehabilitationbull Restorative Care
Nutritionbull Mouth painbull Weight Loss
Skinbull Skin lesionsbull Other skin problemsbull Foot problems
Impact The Patientrsquos Point of View
Inability to enjoy social activitybull 54
Feelings of depressionbull 32
Anxietybull 26
Impaired memorybull 12
Adapted from JAGS 2006
What is Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
Pain is always subjective
In LTC residents do no always verbalize their pain but express it is other ways
Pain is whatever the resident says it is
Acute vs Persistent Pain
Acute Short term bull Surgery sprain laceration
Persistent Continues for a prolonged period of timebull May or may not be associated with a recognizable disease
processbull The term chronic pain is no longer recommended due to
negative connotation (eg chronic whiner chronic complainer)
Types of Pain
Musculoskeletal problemsbull Arthritis wounds dental problems
Bone - Often worse on movementbull Osteoporotic fractures cancer
Neuropathic painnerve compressionbull Neuropathy herpes zoster
Spasms
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Scope of the Problem
Another study suggests that most patients have more than one type of painbull 20 of patients have one type of painbull 80 have 2 or more types of painbull 33 have four different types of pain
Twycross
Consequences of Untreated Pain
Decreased Quality of Life for the PatientLosses General Health Functional Cognitive
Increased health care utilization Increased impact on all care givers Decreased ability of a health care center to
compete Regulatory and legal liability
Why focus on pain Pain Impacts
Physical
Psychological
Social
Spiritual
Physical Impact
bull Decreased functional capability
bull Diminished strength or endurance
bull Nausea poor appetitebull Poor or interrupted sleepbull Impairs healing
Psychological Impact
bull Diminished leisure enjoymentbull Increased anxiety fearbull Depression personal distressbull Difficulty concentratingbull Somatic preoccupationbull Loss of control
Social
bull Diminished social relationships
bull Decreased sexual function affection
bull Altered appearancebull Increased caregiver burden
Spiritual
bull Increased sufferingbull Altered meaningbull Re-evaluation of
religious beliefs
Areas Pain May Impact
Painbull Pain Symptomsbull Pain site
Mood sleepbull Sleep cyclebull Sad apathetic anxious
appearancebull Change in moodbull Resisting carebull Change in behavior
Depressionbull Loss of sense of initiative
or involvement
Ability functionbull Functional limitation in range
of motionbull Changes in ADL bull Range of motionbull Rehabilitationbull Restorative Care
Nutritionbull Mouth painbull Weight Loss
Skinbull Skin lesionsbull Other skin problemsbull Foot problems
Impact The Patientrsquos Point of View
Inability to enjoy social activitybull 54
Feelings of depressionbull 32
Anxietybull 26
Impaired memorybull 12
Adapted from JAGS 2006
What is Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
Pain is always subjective
In LTC residents do no always verbalize their pain but express it is other ways
Pain is whatever the resident says it is
Acute vs Persistent Pain
Acute Short term bull Surgery sprain laceration
Persistent Continues for a prolonged period of timebull May or may not be associated with a recognizable disease
processbull The term chronic pain is no longer recommended due to
negative connotation (eg chronic whiner chronic complainer)
Types of Pain
Musculoskeletal problemsbull Arthritis wounds dental problems
Bone - Often worse on movementbull Osteoporotic fractures cancer
Neuropathic painnerve compressionbull Neuropathy herpes zoster
Spasms
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Consequences of Untreated Pain
Decreased Quality of Life for the PatientLosses General Health Functional Cognitive
Increased health care utilization Increased impact on all care givers Decreased ability of a health care center to
compete Regulatory and legal liability
Why focus on pain Pain Impacts
Physical
Psychological
Social
Spiritual
Physical Impact
bull Decreased functional capability
bull Diminished strength or endurance
bull Nausea poor appetitebull Poor or interrupted sleepbull Impairs healing
Psychological Impact
bull Diminished leisure enjoymentbull Increased anxiety fearbull Depression personal distressbull Difficulty concentratingbull Somatic preoccupationbull Loss of control
Social
bull Diminished social relationships
bull Decreased sexual function affection
bull Altered appearancebull Increased caregiver burden
Spiritual
bull Increased sufferingbull Altered meaningbull Re-evaluation of
religious beliefs
Areas Pain May Impact
Painbull Pain Symptomsbull Pain site
Mood sleepbull Sleep cyclebull Sad apathetic anxious
appearancebull Change in moodbull Resisting carebull Change in behavior
Depressionbull Loss of sense of initiative
or involvement
Ability functionbull Functional limitation in range
of motionbull Changes in ADL bull Range of motionbull Rehabilitationbull Restorative Care
Nutritionbull Mouth painbull Weight Loss
Skinbull Skin lesionsbull Other skin problemsbull Foot problems
Impact The Patientrsquos Point of View
Inability to enjoy social activitybull 54
Feelings of depressionbull 32
Anxietybull 26
Impaired memorybull 12
Adapted from JAGS 2006
What is Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
Pain is always subjective
In LTC residents do no always verbalize their pain but express it is other ways
Pain is whatever the resident says it is
Acute vs Persistent Pain
Acute Short term bull Surgery sprain laceration
Persistent Continues for a prolonged period of timebull May or may not be associated with a recognizable disease
processbull The term chronic pain is no longer recommended due to
negative connotation (eg chronic whiner chronic complainer)
Types of Pain
Musculoskeletal problemsbull Arthritis wounds dental problems
Bone - Often worse on movementbull Osteoporotic fractures cancer
Neuropathic painnerve compressionbull Neuropathy herpes zoster
Spasms
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Why focus on pain Pain Impacts
Physical
Psychological
Social
Spiritual
Physical Impact
bull Decreased functional capability
bull Diminished strength or endurance
bull Nausea poor appetitebull Poor or interrupted sleepbull Impairs healing
Psychological Impact
bull Diminished leisure enjoymentbull Increased anxiety fearbull Depression personal distressbull Difficulty concentratingbull Somatic preoccupationbull Loss of control
Social
bull Diminished social relationships
bull Decreased sexual function affection
bull Altered appearancebull Increased caregiver burden
Spiritual
bull Increased sufferingbull Altered meaningbull Re-evaluation of
religious beliefs
Areas Pain May Impact
Painbull Pain Symptomsbull Pain site
Mood sleepbull Sleep cyclebull Sad apathetic anxious
appearancebull Change in moodbull Resisting carebull Change in behavior
Depressionbull Loss of sense of initiative
or involvement
Ability functionbull Functional limitation in range
of motionbull Changes in ADL bull Range of motionbull Rehabilitationbull Restorative Care
Nutritionbull Mouth painbull Weight Loss
Skinbull Skin lesionsbull Other skin problemsbull Foot problems
Impact The Patientrsquos Point of View
Inability to enjoy social activitybull 54
Feelings of depressionbull 32
Anxietybull 26
Impaired memorybull 12
Adapted from JAGS 2006
What is Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
Pain is always subjective
In LTC residents do no always verbalize their pain but express it is other ways
Pain is whatever the resident says it is
Acute vs Persistent Pain
Acute Short term bull Surgery sprain laceration
Persistent Continues for a prolonged period of timebull May or may not be associated with a recognizable disease
processbull The term chronic pain is no longer recommended due to
negative connotation (eg chronic whiner chronic complainer)
Types of Pain
Musculoskeletal problemsbull Arthritis wounds dental problems
Bone - Often worse on movementbull Osteoporotic fractures cancer
Neuropathic painnerve compressionbull Neuropathy herpes zoster
Spasms
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Physical Impact
bull Decreased functional capability
bull Diminished strength or endurance
bull Nausea poor appetitebull Poor or interrupted sleepbull Impairs healing
Psychological Impact
bull Diminished leisure enjoymentbull Increased anxiety fearbull Depression personal distressbull Difficulty concentratingbull Somatic preoccupationbull Loss of control
Social
bull Diminished social relationships
bull Decreased sexual function affection
bull Altered appearancebull Increased caregiver burden
Spiritual
bull Increased sufferingbull Altered meaningbull Re-evaluation of
religious beliefs
Areas Pain May Impact
Painbull Pain Symptomsbull Pain site
Mood sleepbull Sleep cyclebull Sad apathetic anxious
appearancebull Change in moodbull Resisting carebull Change in behavior
Depressionbull Loss of sense of initiative
or involvement
Ability functionbull Functional limitation in range
of motionbull Changes in ADL bull Range of motionbull Rehabilitationbull Restorative Care
Nutritionbull Mouth painbull Weight Loss
Skinbull Skin lesionsbull Other skin problemsbull Foot problems
Impact The Patientrsquos Point of View
Inability to enjoy social activitybull 54
Feelings of depressionbull 32
Anxietybull 26
Impaired memorybull 12
Adapted from JAGS 2006
What is Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
Pain is always subjective
In LTC residents do no always verbalize their pain but express it is other ways
Pain is whatever the resident says it is
Acute vs Persistent Pain
Acute Short term bull Surgery sprain laceration
Persistent Continues for a prolonged period of timebull May or may not be associated with a recognizable disease
processbull The term chronic pain is no longer recommended due to
negative connotation (eg chronic whiner chronic complainer)
Types of Pain
Musculoskeletal problemsbull Arthritis wounds dental problems
Bone - Often worse on movementbull Osteoporotic fractures cancer
Neuropathic painnerve compressionbull Neuropathy herpes zoster
Spasms
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Psychological Impact
bull Diminished leisure enjoymentbull Increased anxiety fearbull Depression personal distressbull Difficulty concentratingbull Somatic preoccupationbull Loss of control
Social
bull Diminished social relationships
bull Decreased sexual function affection
bull Altered appearancebull Increased caregiver burden
Spiritual
bull Increased sufferingbull Altered meaningbull Re-evaluation of
religious beliefs
Areas Pain May Impact
Painbull Pain Symptomsbull Pain site
Mood sleepbull Sleep cyclebull Sad apathetic anxious
appearancebull Change in moodbull Resisting carebull Change in behavior
Depressionbull Loss of sense of initiative
or involvement
Ability functionbull Functional limitation in range
of motionbull Changes in ADL bull Range of motionbull Rehabilitationbull Restorative Care
Nutritionbull Mouth painbull Weight Loss
Skinbull Skin lesionsbull Other skin problemsbull Foot problems
Impact The Patientrsquos Point of View
Inability to enjoy social activitybull 54
Feelings of depressionbull 32
Anxietybull 26
Impaired memorybull 12
Adapted from JAGS 2006
What is Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
Pain is always subjective
In LTC residents do no always verbalize their pain but express it is other ways
Pain is whatever the resident says it is
Acute vs Persistent Pain
Acute Short term bull Surgery sprain laceration
Persistent Continues for a prolonged period of timebull May or may not be associated with a recognizable disease
processbull The term chronic pain is no longer recommended due to
negative connotation (eg chronic whiner chronic complainer)
Types of Pain
Musculoskeletal problemsbull Arthritis wounds dental problems
Bone - Often worse on movementbull Osteoporotic fractures cancer
Neuropathic painnerve compressionbull Neuropathy herpes zoster
Spasms
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Social
bull Diminished social relationships
bull Decreased sexual function affection
bull Altered appearancebull Increased caregiver burden
Spiritual
bull Increased sufferingbull Altered meaningbull Re-evaluation of
religious beliefs
Areas Pain May Impact
Painbull Pain Symptomsbull Pain site
Mood sleepbull Sleep cyclebull Sad apathetic anxious
appearancebull Change in moodbull Resisting carebull Change in behavior
Depressionbull Loss of sense of initiative
or involvement
Ability functionbull Functional limitation in range
of motionbull Changes in ADL bull Range of motionbull Rehabilitationbull Restorative Care
Nutritionbull Mouth painbull Weight Loss
Skinbull Skin lesionsbull Other skin problemsbull Foot problems
Impact The Patientrsquos Point of View
Inability to enjoy social activitybull 54
Feelings of depressionbull 32
Anxietybull 26
Impaired memorybull 12
Adapted from JAGS 2006
What is Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
Pain is always subjective
In LTC residents do no always verbalize their pain but express it is other ways
Pain is whatever the resident says it is
Acute vs Persistent Pain
Acute Short term bull Surgery sprain laceration
Persistent Continues for a prolonged period of timebull May or may not be associated with a recognizable disease
processbull The term chronic pain is no longer recommended due to
negative connotation (eg chronic whiner chronic complainer)
Types of Pain
Musculoskeletal problemsbull Arthritis wounds dental problems
Bone - Often worse on movementbull Osteoporotic fractures cancer
Neuropathic painnerve compressionbull Neuropathy herpes zoster
Spasms
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Spiritual
bull Increased sufferingbull Altered meaningbull Re-evaluation of
religious beliefs
Areas Pain May Impact
Painbull Pain Symptomsbull Pain site
Mood sleepbull Sleep cyclebull Sad apathetic anxious
appearancebull Change in moodbull Resisting carebull Change in behavior
Depressionbull Loss of sense of initiative
or involvement
Ability functionbull Functional limitation in range
of motionbull Changes in ADL bull Range of motionbull Rehabilitationbull Restorative Care
Nutritionbull Mouth painbull Weight Loss
Skinbull Skin lesionsbull Other skin problemsbull Foot problems
Impact The Patientrsquos Point of View
Inability to enjoy social activitybull 54
Feelings of depressionbull 32
Anxietybull 26
Impaired memorybull 12
Adapted from JAGS 2006
What is Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
Pain is always subjective
In LTC residents do no always verbalize their pain but express it is other ways
Pain is whatever the resident says it is
Acute vs Persistent Pain
Acute Short term bull Surgery sprain laceration
Persistent Continues for a prolonged period of timebull May or may not be associated with a recognizable disease
processbull The term chronic pain is no longer recommended due to
negative connotation (eg chronic whiner chronic complainer)
Types of Pain
Musculoskeletal problemsbull Arthritis wounds dental problems
Bone - Often worse on movementbull Osteoporotic fractures cancer
Neuropathic painnerve compressionbull Neuropathy herpes zoster
Spasms
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Areas Pain May Impact
Painbull Pain Symptomsbull Pain site
Mood sleepbull Sleep cyclebull Sad apathetic anxious
appearancebull Change in moodbull Resisting carebull Change in behavior
Depressionbull Loss of sense of initiative
or involvement
Ability functionbull Functional limitation in range
of motionbull Changes in ADL bull Range of motionbull Rehabilitationbull Restorative Care
Nutritionbull Mouth painbull Weight Loss
Skinbull Skin lesionsbull Other skin problemsbull Foot problems
Impact The Patientrsquos Point of View
Inability to enjoy social activitybull 54
Feelings of depressionbull 32
Anxietybull 26
Impaired memorybull 12
Adapted from JAGS 2006
What is Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
Pain is always subjective
In LTC residents do no always verbalize their pain but express it is other ways
Pain is whatever the resident says it is
Acute vs Persistent Pain
Acute Short term bull Surgery sprain laceration
Persistent Continues for a prolonged period of timebull May or may not be associated with a recognizable disease
processbull The term chronic pain is no longer recommended due to
negative connotation (eg chronic whiner chronic complainer)
Types of Pain
Musculoskeletal problemsbull Arthritis wounds dental problems
Bone - Often worse on movementbull Osteoporotic fractures cancer
Neuropathic painnerve compressionbull Neuropathy herpes zoster
Spasms
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Impact The Patientrsquos Point of View
Inability to enjoy social activitybull 54
Feelings of depressionbull 32
Anxietybull 26
Impaired memorybull 12
Adapted from JAGS 2006
What is Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
Pain is always subjective
In LTC residents do no always verbalize their pain but express it is other ways
Pain is whatever the resident says it is
Acute vs Persistent Pain
Acute Short term bull Surgery sprain laceration
Persistent Continues for a prolonged period of timebull May or may not be associated with a recognizable disease
processbull The term chronic pain is no longer recommended due to
negative connotation (eg chronic whiner chronic complainer)
Types of Pain
Musculoskeletal problemsbull Arthritis wounds dental problems
Bone - Often worse on movementbull Osteoporotic fractures cancer
Neuropathic painnerve compressionbull Neuropathy herpes zoster
Spasms
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
What is Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
Pain is always subjective
In LTC residents do no always verbalize their pain but express it is other ways
Pain is whatever the resident says it is
Acute vs Persistent Pain
Acute Short term bull Surgery sprain laceration
Persistent Continues for a prolonged period of timebull May or may not be associated with a recognizable disease
processbull The term chronic pain is no longer recommended due to
negative connotation (eg chronic whiner chronic complainer)
Types of Pain
Musculoskeletal problemsbull Arthritis wounds dental problems
Bone - Often worse on movementbull Osteoporotic fractures cancer
Neuropathic painnerve compressionbull Neuropathy herpes zoster
Spasms
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Acute vs Persistent Pain
Acute Short term bull Surgery sprain laceration
Persistent Continues for a prolonged period of timebull May or may not be associated with a recognizable disease
processbull The term chronic pain is no longer recommended due to
negative connotation (eg chronic whiner chronic complainer)
Types of Pain
Musculoskeletal problemsbull Arthritis wounds dental problems
Bone - Often worse on movementbull Osteoporotic fractures cancer
Neuropathic painnerve compressionbull Neuropathy herpes zoster
Spasms
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Types of Pain
Musculoskeletal problemsbull Arthritis wounds dental problems
Bone - Often worse on movementbull Osteoporotic fractures cancer
Neuropathic painnerve compressionbull Neuropathy herpes zoster
Spasms
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Pain is Not Recognized Because
bull Residents and caregivers believe that pain is a part of aging
bull Pain is not adequately assessed and treated bull Fear of bothering or annoying staff or family
membersbull Perception that having pain means that they are
really sick or imminently dying
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Pain is Not Recognized Because
bull Concerns regarding side effects of medicines
bull Communication problems (aphasia amp hearing)
bull Cognitive impairment
bull Addiction fears
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Quiz time
Myth vs FactHow will you rate
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Pain Management Questionnaire
1 Lying and complaining about pain are common in the elderly
2 The nurse and physician are the best authority on the residentrsquos pain
3 Pain perception decreases with age because the elderly have a higher pain threshold than younger people
4 Pain is whatever the resident says it is existing whenever heshe says it does
5 Pain management is a residentrsquos right
NO
NO
NO
YES
YES
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Pain Management Questionnaire
6 As many as 40 to 80 of the elderly in nursing home may suffer from pain on a daily basis
7 Drug therapy could provide adequate relief of cancer pain in 70 to 90 of residents
8 Although elderly people suffer chronic pain more frequently than do other populations their pain is under-reported and under-treated
9 All pain has an identifiable cause such as cancer or arthritis
10 A resident with pain who watches the clock is addicted
NO
YES
YES
NO
YES
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Pain Management Questionnaire
11 Having pain is a natural part of getting old (or an inevitable consequence of aging)
12 Assessment of pain (type severity frequency etc) is the one of the most important factors in proper pain management
13 Management of pain may include drug therapy or non-drug methods such as heat or cold application distraction surgery and relaxation techniques
14 Elderly residents are usually given too much pain medicine
NO
NO
YES
YES
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Pain Management Questionnaire
15 With chronic pain the resident should learn to live with it
16 In the cognitively impaired elderly (example dementia Alzheimerrsquos disease) complaints of pain are often false
17 Uncontrolled pain can decrease the residentrsquos functional level and impair their quality of life
NO
NO
YES
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Pain Experiment
We Need a Volunteer
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Pain Experiment
bull Watch closely for non-verbal signs of pain
bull On a scale of 1-10 (1 being least 10 being most) what level of pain is our volunteer experiencing
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Non-Verbal Pain Cues
bull Frowning grimacing fearful lookbull Grinding of teethbull Bracing guarding rubbingbull Fidgeting agitation increasing restlessnessbull Poor eating or sleeping habitsbull Sighing groaning crying heavy breathingbull Decreasing activity levelsbull Resisting carebull Change in gaitbull Change in behavior
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Verbal Signs of Pain
bull Sighingbull Moaningbull Groaningbull Cryingbull Blowingbull Screamingbull Requests for helpbull Requests for medication
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Why are we so Concerned
bull Resident comfort and quality of lifebull Increasing complexity of residentsbull Heightened public awareness of painbull F309Joint Commission Pain Management
Standardsbull Increasing liability for under treatment of pain
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Which Leads Us To F-309
Regulations
ldquoEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of carerdquo
Surveyors may review any resident whobull States they have pain symptomsbull Displays possible indicators of pain that cannot readily be
attributed to another causebull Residents being treated for painbull Residents with the potential for pain
ndash Comorbid conditions or treatmentsndash So consider risk for pain
bull Residents with orders for pain managementbull Hospice residents
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
F-309 Compliance Facility Key Components
bull Care process for pain managementbull Pain Recognition bull Effective consistent assessment of painbull Management of pain
ndash Non-drugndash Drug
bull Monitoring reassessing and revising of care plan
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
F-309 Facility Needs
bull Prevent or manage painndash Comprehensive assessment and plan of care
bull Identify and address barriers to effective pain managementndash Facilityndash Staffndash Resident familyndash Regulatory
bull Provide for optimal patient comfort
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Assessing Pain
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
MDS- Section J
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Assessment Tools
bull Numerical Scale
bull Faces
bull Descriptors
bull Verbal expressions
bull Non verbal evidence
bull The Fifth Vital Sign
What tools do your facilities use to assess pain
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
A Pain Assessment Scale
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
A ldquoFacesrdquo Pain Assessment Scale
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Assessing Cognitively Impaired Residents
Available on the internet at wwwhartfordignorg andor wwwConsultGeriRNorg
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Consider the Whole Patient
bull Always askbull Always respectbull Use ldquoYesrdquo or ldquoNordquo questions when possiblebull Keep questions in the presentbull Look for behavior displaysbull Combine questions with other scalesbull Include family members
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Questions to ask
Location Where does it hurtQuality What does it feel likeTiming When does it occurSeverity How bad is the painExacerbation What makes it worsePalliative What makes it betterConsequences What does it do to you
What questions do you ask residents to assess pain
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Managing Pain
Non-Drug and Drug based interventions
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Non-Drug InterventionsIt gets down to comfort
DistractionHeat ColdMassageExercisePhysical TherapyTENSAcupressure
AcupunctureAromatherapyBiofeedbackMagneticsOther Therapies
bull Petbull Artbull Music
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
What Everyone Can do to Manage Pain
bull Show that you carebull Talk to the resident even if heshe doesnrsquot
understandbull Talk to not around the residentbull Make the room pleasantbull Take care of the basics-glasses hearing aides
dry clothes toileting food fluidsbull Communicate with the team-let others know
what works
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Drug Interventions
Drugs are a mainstay of pain managementbull Choice of Drugbull Administration of Drugbull Establish Pain Management Goalbull Monitoringbull Benefits
bull Effectivebull Efficacious
bull Risksbull Adverse Drug Reactions (ADRs) bull Changing needs
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Principles for Analgesic Selection
Administrationbull Use the appropriate medicationbull Give adequate dosesbull Titrate to individual needs
ndash Patient response and satisfactionndash Drug itself
bull Onsetbull Peakbull Duration
bull Dose Around The Clock (ATC)bull KISS Prefer oral route
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Drug Interventions
World Health Organization (WHO) stepladder Severe
Moderate
MildStep 1 drugs
Step 3 drugs
Step 2 drugs
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Drugs - Step 1 (Mild Pain)
Non-narcotic drugsbull Acetaminophenbull NSAIDs
-COX-2 Inhibitorsbull Tramadolbull Adjuvant Drugs
Ensure total daily APAP levels do not exceed 4000 mg day
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Drugs - Step 2 (Moderate to Severe Pain)
Recommendedbull Hydrocodonebull Oxycodonebull Codeine
- With cautionbull Combinations with acetaminophen or aspirinbull Adjuvant Drugs
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Drugs - Step 3 (Severe Pain)
Recommendedbull Morphinebull Oxycodonebull Hydromorphonebull Fentanylbull Adjuvant Drugs
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Narcotic Drugs to Avoid in the Elderly
Meperidine (Demerolreg)bull Weak analgesicbull Euphorigenicbull Toxicities accumulation
Avoid mixed agonist-antagonistsbull Pentazocine (Talwin-NXreg)bull Butorphanolbull Nalbuphine
Methadone - difficult to titrate
Caution - Fentanylbull Opiate tolerant residents only (receiving for at least a
week)bull Tolerant= opiates equivalent to at least 60 mgday oral
morphine 30 mgday oral oxycodone or 8 mgday oral hydromorphone
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Adjuvant Drugs
Neuropathic pain is a prime area where adjuvants can be powerful co-analgesics
General Usesbull Enhance the efficacy of opioids or other analgesicsbull Treat concurrent symptoms that exacerbate painbull Treat pain not receptive to traditional analgesics
May be used at any stage of WHO ladder
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Adjuvant Drugs
Anticonvulsantsbull Gabapentin (Neurontinreg)bull Pregabalin (Lyricareg)bull Carbamazepine (Tegretolreg)
Antidepressantsbull Duloxetinebull Amitriptyline
Antihistaminesbull Hydroxyzine
Miscellaneousbull Baclofenbull Bisphosphonatesbull Calcitoninbull Corticosteroidsbull Anticholinergicsbull Topicals
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Local and other anesthetics
bull EMLAreg (Eutectic Mixture of Local Anesthetics)bull Lidocaine topical patches (Lidodermreg)
- Remember 12 hours on 12 hours off
bull Liposomal lidocainebull Coolant sprays and creamsbull Compounded products
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
WHAT are the Barriers to an Effective Pain Management Program
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Barriers to Effective Pain Control
bull Patientbull Familybull Caregiversbull Prescribersbull Healthcare Systembull Legal constraints
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Resident and Family Barriers
Patient familybull ldquoOlder people are supposed to have painrdquobull Pain medication
- Does not really work- Save it until pain is really bad
bull Fear of ADRsbull Fear of addictionbull Multiple medicationsbull Comorbid conditionsbull Pain means that things are worse
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Financial and Regulatory Barriers
bull Controlled substance prescribing and documentation
bull Risk of theft diversion abusebull State or Third-party payorsbull Other Inadequate reimbursement
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Facility Challenges to Pain Management
System problems bull high staff turnover resident load per employee
Myths and Misconceptions about Painbull adverse effects of analgesicsbull patient tolerance to analgesicsbull patient addiction
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Facility Challenges to Pain
Regulation of controlled substances
Lack of training in pain assessment of ALL personnelbull Inadequate knowledge of pain assessmentbull Poor assessment of painbull Taking short-cuts in assessing pain
Residents with impaired cognition or communication skills are more difficult to assess
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Addiction vs Dependence
Addiction is the continued use of a substance DESPITE adverse consequences
Physical dependence is NOT Addictionbull Escalating doses of a pain medication may be
needed due to physiological tolerance of the substance
bull Undertreated pain may result in a clock watcher
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Developing a Pain Management Program in Your Facility
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Basic Concepts in Pain Management
Identify knowledge base attitudes and competencies of personnelbull Identify educational needs beliefs and expectations
about pain managementEducate and dispel false beliefs about pain
treatment and addictionMeasurement and objective data documentation
with regular review in all realms of treatment and activities
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Pain Management is a TEAM Effort
AdministratorMedical DirectorDONAttending MDConsultant pharmacistTherapistsSocial workersResident and familyNursing staffEnvironmental servicesDietaryActivities
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
8 Steps to Developing a Pain Management System(Joint Commission)
1 Develop an interdisciplinary work group2 Analyze current pain management practices3 Articulate and implement a standard of practice4 Establish accountability for pain management5 Provide information about pharmacologic and non-
pharmacologic interventions to facilitate order writing and order interpretation
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
8 Steps to Developing a Pain Management System(Joint
6 Promise individuals a quick response to their reports of pain
7 Provide education for staff
8 Continuously evaluate and work to improve the quality of pain management
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
The PDSA Cycle
PLAN
ACT DO
STUDY
ObjectivesMeasurable goals Trained members
Standard processEffective leadersCollaborationQuality data
SortingOrganizing
InterpretationDisseminating
Make changesImprove PlanRestart
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Creating a Pain Assessment Program Topics to Consider
When to SCREEN for painbull Upon Admission any change in condition monthly upon complaint of pain
How to CYCLE residents thru screeningbull Routine screening monthly for all residents Weekly evaluation for sub-
acute
How to provide IN-DEPTH assessmentbull Standardized tools training the assessor pain education time allotment for
assessment
CHANGE OF CONDITION formsbull Does you facility have one Pain specific
HOW to report to physiciansbull Quick responses nurse expectations communication of necessary
information
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
What TYPES of drugs are used to treat painbull Education on types of pain different medications available
How to manage common SIDE EFFECTSbull Education of staff and residents on expected side effects treating
constipation
Treating ACUTE and END-OF-LIFE painbull Plans for quick assessment and treatment changes
How to MONITOR once treatment is initiatedbull Pain flow sheet chart documentation results documentation
RE-EVALUATE regularlybull Schedule of review of pain medications team rounds outside consults
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Use a Standard Tool on a Scheduled Basis
Develop Standards for residentsbull With current pain interventions
bull Without current pain- iesurveillance
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Documentation of Assessment
Pain Presence Routine Pain Assessmentbull Residents with Painbull Residents Without Painbull Daily Q Shiftbull Verbal residentsbull Non-Verbal residentsbull Effect on ADLsbull Non-drug therapybull Drug therapy
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Documentation of Assessment
wwwmed-passcom
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Questions
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
References
Improving the Quality of Pain Management through Measurement and Action JCAHO Monograph 2001
Pasero et al The Undertreatment of Pain Pain Control 2001101(11)62-65
The Management of Persistent Pain in Older Adults AGS JAGS 200250S205-S224
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
Web Resources
wwwhpnaorgwwwaapcomwwwapsorgwwwpainmanageorgwwwampainsocorgwwwpaincomwwwpainfoundationorgwwwpainmedorgwwwpartnersagainstpaincomwwwahrqgov
