Abstract
Despite the dynamic demands in the nursing home (NH), a definitive approach to managing
chronic pain in older adults has yet to be established. Due to concerns for potential
adverse pharmacologic effects, balancing appropriate pain management is a challenge
among NH residents. The challenges encompass but are not limited to medical complexities,
functional disabilities, and physical frailty. Barriers to the successful implementation
of a comprehensive chronic pain management at the NH may include ambiguous directions
on specific therapeutic interventions, insufficient guidance on treatment duration,
and limited available treatment options. The Centers for Medicare and Medicaid Services’
reporting requirement of adequate pain control among NH residents coupled with widely
variable clinician-prescribing habits highlights the difficulties in overcoming the
preceding challenges and barriers. The Coronavirus Disease 2019 (COVID-19) pandemic
has further complicated pain management due to its negative consequences on well-being
of residents of NHs. Associated symptoms of psychosocial stress, anxiety and depression,
and chronic pain symptoms can exacerbate during the COVID-19 pandemic, leading to
increased requirement for pain medications including but not limited to opioids.
Pain is a multidimensional symptom and requires a strategic multimodal approach for
its management. Nonpharmacologic modalities are underutilized in the NH setting and
are the preferred first steps for mild pain, and nonopioid pharmacological agents
can be added as a second step for a synergistic effect for moderate to severe pain.
Opioids should be used as a last resort. Short-acting opioids are preferred over extended-release/long-acting
opioids for chronic pain. Clinicians are encouraged to engage residents in proactive
strategies in managing their pain, and to set realistic expectations toward improving
their quality of life, as complete elimination of pain is not feasible in most cases.
This review article provides the interdisciplinary team with a contemporary perspective
of the multitude of changes and challenges influencing the prescribing as well as
deprescribing of various pain medications.
Keywords
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Article info
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Published online: January 23, 2021
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© 2020 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
