The Policies of Pain

Standards & guidelines for treating pain in the nursing home

by Duncan S. MacLean, MD, CMD

November 13, 2002, was a turning point for pain management in nursing homes (NHs). On that day, the Centers for Medicare and Medicaid Services (CMS) posted on its Web site a pain control report card for every CMS-certified facility across the nation.

These report cards showed that 11% of approximately 1.7 million U.S. NH residents feel moderately severe or worse pain every day. Based on my perusal of 10 states' report cards, state averages for pain prevalence range from 9% to 18%. The prevalence of pain in individual facilities ranges from 0% (hardly believable) to 66%.

More importantly, these report cards signal a growing public intolerance for the undertreatment of pain by health professionals in NHs--and probably in other health-care settings as well. And the public intends to watch us.

Increasingly, patients demand treatment not only of acute pain from trauma and surgery, but for terminal cancer pain; they want treatment of chronic pain, also. They aren't satisfied when told, "You must learn to live with the pain." They expect pain treatment and will resort to herbs, acupuncture, and other nontraditional treatments to get it.

What are the regulatory, accreditation, and emerging medico-legal "standards of care" for pain management? What are common misconceptions about pain in NHs? How should NH professionals approach pain? How can medical policies and clinical practice guidelines help guide pain management in NHs?

Roots of Pain Management

Physicians have dedicated themselves to the relief of suffering since antiquity; however, until after World War II, they possessed few effective drugs for this purpose. For example, phenothiazines, benzodiazepines, tricyclic antidepressants, and synthetic steroids became available only during the 1950s. Cicely Saunders, a former nurse and social-worker-turned-physician, innovated using these new medications for relief of terminal symptoms at St. Joseph's and St. Christopher's Hospices in London in 1958. She championed the oral administration of morphine--a drug first purified in 1803--for treating pain in hospice patients beginning in 1962.

During the two decades that followed the enactment of Medicare in 1965, research in chemotherapy, surgical oncology, and radiation therapy overshadowed palliative care; however, several milestones in palliative care occurred during this period. Elizabeth Kubler-Ross published On Death and Dying in 1969. Congress passed the Medicare hospice benefit in 1983. Sustained-release morphine (MS Contin) became available in 1984.

The World Health Organization provided a major impetus to treating cancer pain with its publication of Cancer Pain Relief and Palliative Care in 1986 and 1990. The newly formed Agency for Health Care Policy and Research (now renamed Agency for Healthcare Research and Quality, AHRQ) followed with clinical practice guidelines on acute pain in 1992 and cancer pain in 1994.

The year 1992 also marked the release of the transdermal fentanyl (Duragesic patch) as an alternative to intravenous morphine pumps. Sustained-release oral oxycodone (OxyContin) appeared three years later in 1995. Gabapentin (Neurontin) was the first--and so far only--drug to receive Food and Drug Administration approval for treatment of post-herpetic neuralgia in May 2002, although other anticonvulsants and tricyclic antidepressants have been used off-label for neuropathic pain during the last decade.

The American Pain Society issued a consensus statement on chronic pain in 1997. The American Geriatrics Society (AGS) published clinical practice guidelines on managing chronic pain in 1998, and updated them in 2002. The American Medical Directors Association (AMDA) followed suit with guidelines on chronic pain in the nursing home setting in 1999. These three guidelines were the first to formally endorse the use of opioids for non-malignant chronic pain.

Standards for Pain Management

Federal NH regulations do not directly address pain under requirements for resident rights, resident assessment, quality of care, or quality of life. The only reference to pain management is at Tag F330 on antipsychotic drugs. The interpretive guidelines accompanying that Tag tell surveyors to check whether facilities investigate underlying medical causes of behavior problems, including pain, before starting an antipsychotic drug. However, the regulations indirectly require pain assessment at least quarterly as part of the Minimum Data Set 2.0 at Section J2.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) first proposed its new accreditation standard on pain management in 1999 and implemented it on January 1, 2001. The standard for all JCAHO-accredited health-care organizations, including NHs, is that "the resident has a right to appropriate assessment and management of pain."

JCAHO does not require pain assessment as a "fifth vital sign," according to John Harringer, associate director of JCAHO's Standards Interpretation. "Asking about pain every time blood pressure is taken would annoy patients," he explained. Instead, JCAHO recommends assessing pain when appropriate to the patient's situation.

Some commentators discern an emerging legal "standard of care" for pain management based on three developments. First, in 1997, the U.S. Supreme Court, in denying a Constitutional right to assisted suicide in two cases, strongly affirmed a physician's obligation to relieve pain. The Supreme Court acknowledged that treating pain could unintentionally hasten death, but was still licit providing that the physician does not directly intend to cause the death. (Pellegrino ED. Emerging ethical issues in palliative care. JAMA. 1998; 279:1521).

Second, in two NH civil cases, inadequately treated cancer pain was cited not just as a consequence of an injury but as the injury itself, one in North Carolina (Estate of Henry James v. Hillhaven Corp., 1990) and another in California (Bergman v. Eden Medical Center, 2001) (Tucker KL. A new risk emerges: Provider accountability for inadequate treatment of pain. Annals of LTC. 2001; 9:52-56).

Third, in 1999 the Oregon Medical Board took disciplinary action against a pulmonologist for inadequate treatment of cancer pain. [Tucker, ibid] Overall, the risk of a malpractice lawsuit for failing to treat pain is low at present, according to Chicago Pharmacist-Attorney Nicholas Lynn, JD, RPh, but NH professionals should watch future trends (Lynn NJ. Understanding legal risks in pain management. Long-Term Care Interface. 2002;8:22-23.).

Pain Misconceptions

One of the main barriers to effective treatment of pain in NHs remains physician and staff misconceptions about pain. Bruce Ferrell, MD, AHRQ consultant, and speaker at AMDA annual symposiums, has identified seven key misconceptions, which he outlined at AMDA's 1994 Symposium:

1. Pain is a normal, expected part of aging. Pain is common--but not normal.
2. Pain sensitivity and perception decreases with age. Disease presentation may be altered in the elderly, such as painless myocardial infarction or perforated viscus, and disease states, such as diabetes, may diminish sensory acuity. However, in the absence of disease, aging does not alter pain sensitivity and threshold.
3. Patient self-report of pain is unreliable. Self-report is accurate for 99% of patients, even those with mild to moderate dementia. However, a recent report by Caring editorial board member Jiska Cohen-Mansfield, PhD, and colleagues demonstrated that even expert geriatricians have difficulty with accurately evaluating pain in non-communicative patients with advanced dementia (Pain in cognitively impaired nursing home residents: How well are physicians diagnosing it? J Am Geriatr Soc. 2002; 50:1039). Research on pain assessment in advanced dementia is a "work in progress," according to Mary Cadogan RN, DrPH (Assessing pain in cognitively impaired nursing home residents: The state of the science and the state we're in. JAMDA. 2003; 4: 50-51).
4. Premature administration of analgesics will obscure the diagnosis. This lore arose from a few isolated case reports most cases encountered in practice.
5. No complaint of pain means no pain. Clinicians will fail to detect pain unless they ask and listen attentively. This is especially true of the current generation of elders, who are culturally conditioned to suffer silently.
6. Much pain seen in clinical practice is a "good" kind of hurt. Studies in neonates and animal models prove that untreated pain independently increases mortality. Pain also adversely affects nutrition, sleep, function, mood, and behavior.
7. Overuse of opioids causes addiction. Fewer than 1% of patients treated with opioids develop addiction, that is, drug-seeking behavior for non-medicinal purposes. Physiologic dependence is more common, and necessitates gradual tapering to avoid withdrawal symptoms.

Guidelines for Managing Chronic Pain

The AHRQ guidelines and American Pain Society guidelines remain the most frequently cited guides for the management for cancer pain and acute pain (see Resources, below).

Cancer pain and acute pain account for only about 5% apiece of the pain in NHs. The other 90% is chronic, of which 80% is musculoskeletal and 10% neuropathic (Sabine von Preyss-Friedman, MD, CMD. University of Washington. Pain management in LTC. March 16, 2001). For managing this chronic pain, AGS and AMDA guidelines list currently accepted principles, including the following components:

• Implement a facility-wide standard pain assessment measure. Because many NH patients are cognitively impaired, a simple tool is preferred, such as a five-point scale or faces scale. Facilities should also adopt a non-verbal pain assessment tool for assessing the severely cognitively impaired, such as one developed by Karen Feldt, PhD, RN. (The checklist of non-verbal pain indicators. Pain Management Nursing. 2000; 1:13-21)
• Educate patients and families to report pain; train staff to ask about pain and to listen.
• Perform a comprehensive medical assessment to diagnose the causes of pain, including mouth inspection, diagnostic testing, and specialty consultation when appropriate to the patient's overall condition.
• Adopt an interdisciplinary care plan that sets goals, delegates responsibilities to team members, and incorporates pharmacologic and non-pharmacologic strategies. The plan should be explained to and accepted by the patient or responsible party.
• Give acetaminophen for mild chronic pain at scheduled times--not as needed.
• Remember that non-steroidal anti-inflammatories, including selective COX-2 inhibitors, are relatively toxic in the frail elderly and should usually be given only in short courses.
• Bear in mind that opioids are coming into increasing acceptance for treating moderate to severe chronic pain. Start the patient on low doses of short-acting opioids, such as oxycodone or morphine. Once the daily dose requirement is determined, convert the patient to a sustained-release formulation at scheduled intervals with rescue doses as needed for breakthrough pain.
• Take into account that, "The hand that prescribes the opioid should also prescribe a laxative regimen."
• Propoxyphene, meperidine, and agonist-antagonist opioids are not recommended for chronic pain management.
• Consider adjuvant treatments, such as gabapentin, for neuropathic pain.
• Avoid the use of placebos, which have no place in pain management, and are justifiable only within controlled research trials with proper consent by study subjects.
• Document responses to the management plan systematically using the facility's standard pain ratings recorded in standard formats at regular intervals.
• Train staff and offer periodic in-service updates.
• Monitor program effectiveness. Facilities should check the accuracy of MDS Section J2 on pain symptoms for each resident because this data ends up in the facility's pain control report card on the CMS Web site.

Medical directors should review the published guidelines for a fuller discussion of these principles (see Resources, below).

Medical Policy

Some facilities adopt pain guidelines as a means of setting standards for managing pain; however, policies and procedures may offer more effective means to turn guideline concepts into specific performance expectations for individual physicians and staff members. Options for facilities are:

• A facility-wide pain management policy;
• Individual departmental policies on pain management; and
• Medical policies on pain management.

Physician requirements can be incorporated into medical policies on resident assessment and care planning, or can be described in a separate policy on pain.

By applying these principles, all NHs can help relieve residents' pain and improve the facility's pain control report card.

A member of Caring's editorial board, Dr. MacLean is the medical director of Delaware's state-owned nursing home system.

The opinions expressed in this column are those of the authors and do not necessarily reflect those of the American Medical Directors Association.

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