Next Steps Toward Pain Management
Next Steps Toward Pain Management
Learn about the steps that follow pain screening, including treatment and reassessment. Check out other resources that can help nursing home staff better manage pain among residents.
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Take The Next Step(s)
“…Nothing is less necessary than pain,” wrote Joseph De Maistre, a French diplomat and philosopher, in 1821. That observation is even truer today, when physicians and patients alike have access to a growing wealth of information about pain management and a rapidly expanding array of pharmacological painkillers.
In nursing homes, effective pain management creates a win-win-win scenario for residents, staff, and administrators. For residents, the immediate benefits are as compelling as they are obvious: freedom from pain and improved quality of life. For their part, nursing staff report that problem behaviors among some residents subside when pain is better controlled. Pain relief may also improve a resident’s functional ability, thereby reducing the daily care burden on staff. And for administrators, there’s ample evidence, say experts, that “treating pain saves money in the long run (1).”
While our work has focused on pain screening, as described in this module’s first section, other experts have delineated the next steps in pain management. The following summary of some of their work is intended to point you in the right direction for taking these next steps.
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For Effective Pain Management, Involve Your Physicians
If you can do only one thing to improve your facility’s pain management program, it should be this: Involve your physicians in the assessment and documentation of pain. Experience shows that when physicians are actively involved in this first assessment step, all the other steps—treatment, reassessment, ongoing monitoring—follow. Physician participation, apparently, helps to set high expectations for pain management among other nursing home staff. With the stage set, the work gets done.
A note to nurses: Before you call a physician to report a resident in pain, gather patient information that the physician will likely ask for. This preliminary work will speed the treatment process and bring relief to the resident faster. Information needed includes the resident’s:
Assessment Of Pain Intensity
If a resident reports pain during an initial screening interview, then further assessment of pain intensity, location, quality and associated symptoms is needed to guide diagnosis and treatment decisions. Our pain interview includes items about presence, frequency, and effect of pain on residents’ daily lives, but does not have enough specific items upon which to base diagnosis and treatment. Here are options for follow-up assessments:
Treatment
WHO’s Pain Ladder
The World Health Organization (WHO) has developed a three-step "ladder" for cancer pain relief that healthcare providers often use to guide treatment of other types of chronic pain (2). Here’s a summary from WHO’s website:
“If pain occurs, there should be prompt oral administration of drugs in the following order: nonopioids (aspirin and paracetamol [or acetaminophen]); then, as necessary, mild opioids (codeine); then strong opioids such as morphine, until the patient is free of pain. To calm fears and anxiety, additional drugs …should be used. To maintain freedom from pain, drugs should be given ‘by the clock’, that is every 3-6 hours, rather than ‘on demand.’ This three-step approach of administering the right drug in the right dose at the right time is inexpensive and 80-90% effective. Surgical intervention on appropriate nerves may provide further pain relief if drugs are not wholly effective.”
Keep in mind that where you start on this ladder depends on the resident’s pain intensity. The greater the pain, the higher up the ladder you should start.
From: www.who.int/cancer/palliative/painladder/en/
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AGS Panel on Persistent Pain in Older Persons
Among its recommendations, the American Geriatrics Society’s (AGS) Panel on Persistent Pain in Older Persons offers these guidelines for the treatment of pain (3):
Exercise Effects on Pain in Nursing Home Residents
Clinical practice guidelines for the treatment of pain recommend exercise as an important adjunct to treatment and essential to rehabilitation for arthritis and other chronic, non-cancer pain problems (3-5). These guidelines are based largely on evidence that exercise reduces pain symptoms in young and old populations with arthritis (6-8). In a recent study, however, we found that exercise does not alleviate pain among nursing home residents, and indeed, may tend to increase pain in this frail population (9).
Our findings suggest that exercise alone may be ineffective for pain management among nursing home residents. Care providers should consider that exercise to improve physical function (e.g., walking assistance, range-of-motion) may increase pain complaints, thereby requiring pre-emptive analgesia, other pain control strategies, or modified exercise techniques. A summary of this study can be found on our Related Studies page.
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Reassessment
The AGS Panel on Persistent Pain in Older Adults offers these guidelines for reassessment of pain (3):
For More Information...
The following organizations have published clinical practice guidelines for pain management. In addition to offering advice on pain assessment, treatment, and monitoring, the guidelines offer helpful information for structuring pain management programs.
• American Geriatrics Society – Management of Persistent Pain
• American Medical Director’s Association: Guidelines for Chronic Pain Management in the Long Term Care Setting
• American Pain Society: Clinical Practice Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis and Juvenile Chronic Arthritis
• American Society of Anesthesiologists: Practice Guidelines for Chronic Pain Management
• Joint Commission on Accreditation of Healthcare Organizations: Publishes two monographs: Pain: Current Understanding of Assessment, Management and Treatments and Improving the Quality of Pain Management through Measurement and Action
Additionally, other pages in this module—Links, FAQs, Related Studies. If you still have questions or need assistance, please feel free to contact us.
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Try This Assignment
Click on one of the following topics to skip to that section:
- Take the Next Step(s)
- For Effective Pain Management, Involve Your Physicians
- Assessment Of Pain Intensity
- Treatment
- AGS Panel on Persistent Pain in Older Persons
- Exercise Effects on Pain in Nursing Home Residents
- Reassessment
- For More Information...
- Try This Assignment
Take The Next Step(s)
“…Nothing is less necessary than pain,” wrote Joseph De Maistre, a French diplomat and philosopher, in 1821. That observation is even truer today, when physicians and patients alike have access to a growing wealth of information about pain management and a rapidly expanding array of pharmacological painkillers.
In nursing homes, effective pain management creates a win-win-win scenario for residents, staff, and administrators. For residents, the immediate benefits are as compelling as they are obvious: freedom from pain and improved quality of life. For their part, nursing staff report that problem behaviors among some residents subside when pain is better controlled. Pain relief may also improve a resident’s functional ability, thereby reducing the daily care burden on staff. And for administrators, there’s ample evidence, say experts, that “treating pain saves money in the long run (1).”
While our work has focused on pain screening, as described in this module’s first section, other experts have delineated the next steps in pain management. The following summary of some of their work is intended to point you in the right direction for taking these next steps.
Back to Top
For Effective Pain Management, Involve Your Physicians
If you can do only one thing to improve your facility’s pain management program, it should be this: Involve your physicians in the assessment and documentation of pain. Experience shows that when physicians are actively involved in this first assessment step, all the other steps—treatment, reassessment, ongoing monitoring—follow. Physician participation, apparently, helps to set high expectations for pain management among other nursing home staff. With the stage set, the work gets done.
A note to nurses: Before you call a physician to report a resident in pain, gather patient information that the physician will likely ask for. This preliminary work will speed the treatment process and bring relief to the resident faster. Information needed includes the resident’s:
- Age
- Blood pressure range
- Pulse range
- All current medications
- Active medical diagnoses
- Patterns of pain and analgesic use, especially “as needed” use – although, it is important to note that “as needed” pain medication delivery is typically infrequent because nurses do not routinely ask residents if they need it, so infrequent use of such medications does not necessarily equate to a lack of need on behalf the resident. Patterns of use, ideally, should be based on use when nurses are routinely asking residents about pain (e.g., “Do you have pain anywhere right now?” and, if yes, “Would you like to take something for your pain?” during medication passes). See previous section, Advantages Of Our Pain Screening Tool.
Assessment Of Pain Intensity
If a resident reports pain during an initial screening interview, then further assessment of pain intensity, location, quality and associated symptoms is needed to guide diagnosis and treatment decisions. Our pain interview includes items about presence, frequency, and effect of pain on residents’ daily lives, but does not have enough specific items upon which to base diagnosis and treatment. Here are options for follow-up assessments:
- Pain intensity can be assessed with the verbally administered zero-to-ten pain scale (where 0 represents “no pain at all” and 10 signifies “the worst pain I have ever experienced”), or, for residents with mild to moderate cognitive impairment, a word descriptor scale, faces scale, or pain thermometer.
- For residents with more severe cognitive impairment, an assessment of behaviors and family or caregiver's observations are essential, especially observations of pain symptoms during ADL care delivery (e.g., facial grimacing or groaning when being transferred out of bed). Consider also, the resident’s history of pain and current pain-related diagnoses.
- For uncommunicative residents, use an observational tool such as the five-item Pain Assessment in Advanced Dementia, also known as PAINAD. DO NOT, however, use the PAINAD to assess pain in patients who can communicate. This is a common but inappropriate use of the tool.
- For an observational assessment, be sure to observe the resident while he or she is moving; most pain in nursing home residents is musculoskeletal and at its worst when the resident is in motion (i.e., during ADL care activities). Some of the best times for these observations are during morning care, physical therapy appointments, and range of motion exercises.
Treatment
WHO’s Pain Ladder
The World Health Organization (WHO) has developed a three-step "ladder" for cancer pain relief that healthcare providers often use to guide treatment of other types of chronic pain (2). Here’s a summary from WHO’s website:
“If pain occurs, there should be prompt oral administration of drugs in the following order: nonopioids (aspirin and paracetamol [or acetaminophen]); then, as necessary, mild opioids (codeine); then strong opioids such as morphine, until the patient is free of pain. To calm fears and anxiety, additional drugs …should be used. To maintain freedom from pain, drugs should be given ‘by the clock’, that is every 3-6 hours, rather than ‘on demand.’ This three-step approach of administering the right drug in the right dose at the right time is inexpensive and 80-90% effective. Surgical intervention on appropriate nerves may provide further pain relief if drugs are not wholly effective.”
Keep in mind that where you start on this ladder depends on the resident’s pain intensity. The greater the pain, the higher up the ladder you should start.
Back to Top
AGS Panel on Persistent Pain in Older Persons
Among its recommendations, the American Geriatrics Society’s (AGS) Panel on Persistent Pain in Older Persons offers these guidelines for the treatment of pain (3):
- “Acetaminophen should be the first drug to consider in the treatment of mild to moderate pain of musculoskeletal origin.
- “Traditional (i.e., nonselective) non-steroidal anti-inflammatory drugs (NSAIDS) should be avoided in those who require long-term daily analgesic therapy. The selective NSAIDs, i.e., the COX-2 inhibitors, are preferable.
- “Opioid analgesic drugs are effective, associated with a low potential for addiction, and overall may have fewer long-term risks than other analgesic drug regimens in older persons with persistent pain. As with all medication, careful monitoring for the development of adverse side effects is important.”
Exercise Effects on Pain in Nursing Home Residents
Clinical practice guidelines for the treatment of pain recommend exercise as an important adjunct to treatment and essential to rehabilitation for arthritis and other chronic, non-cancer pain problems (3-5). These guidelines are based largely on evidence that exercise reduces pain symptoms in young and old populations with arthritis (6-8). In a recent study, however, we found that exercise does not alleviate pain among nursing home residents, and indeed, may tend to increase pain in this frail population (9).
Our findings suggest that exercise alone may be ineffective for pain management among nursing home residents. Care providers should consider that exercise to improve physical function (e.g., walking assistance, range-of-motion) may increase pain complaints, thereby requiring pre-emptive analgesia, other pain control strategies, or modified exercise techniques. A summary of this study can be found on our Related Studies page.
Back to Top
Reassessment
The AGS Panel on Persistent Pain in Older Adults offers these guidelines for reassessment of pain (3):
- Reassess regularly for improvement, deterioration or complications.
- Evaluate significant issues identified in the initial evaluation.
- Repeat the same quantitative assessment scales in follow-up.
- Evaluate analgesic use, side effects, and compliance.
For More Information...
The following organizations have published clinical practice guidelines for pain management. In addition to offering advice on pain assessment, treatment, and monitoring, the guidelines offer helpful information for structuring pain management programs.
• American Geriatrics Society – Management of Persistent Pain
• American Medical Director’s Association: Guidelines for Chronic Pain Management in the Long Term Care Setting
• American Pain Society: Clinical Practice Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis and Juvenile Chronic Arthritis
• American Society of Anesthesiologists: Practice Guidelines for Chronic Pain Management
• Joint Commission on Accreditation of Healthcare Organizations: Publishes two monographs: Pain: Current Understanding of Assessment, Management and Treatments and Improving the Quality of Pain Management through Measurement and Action
Additionally, other pages in this module—Links, FAQs, Related Studies. If you still have questions or need assistance, please feel free to contact us.
Back to Top
Try This Assignment
- From the list above, print out and read through at least one of the clinical practice guidelines for pain management. What did you learn that you didn’t know before? Share your thoughts with us; please contact us. We hope to share your feedback with others in future updates to this site.
