Despite advances in the assessment and management of persistent pain, clinicians commonly under-appreciate and, as a result, under-treat pain in older adults. Seniors residing in assisted living or long term care settings are especially vulnerable to pain undertreatment. In fact, it has been reported that up to 80% of nursing home residents have significant pain. In ALFs, where residents generally are more independent and less rigorously monitored, the incidence of untreated pain is likely to be high as well. Additionally, there is a high incidence of dementia, cognitive impairment of some degree, and other disabilities that limit residents’ ability to self-report pain

Reifsnyder, JoAnne

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Making pain relief a priority ... dispelling the myths about pain and pain management in the older adult.

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November/December 2005 Assisted Living Consult 39Despite advances in the as-sessment and managementof persistent pain, clinicianscommonly under-appreciate and, asa result, under-treat pain in olderadults. Seniors residing in assistedliving or long term care settings areespecially vulnerable to pain under-treatment. In fact, it has been re-ported that up to 80% of nursinghome residents have significantpain. In ALFs, where residents gen-erally are more independent andless rigorously monitored, the inci-dence of untreated pain is likely tobe high as well. Additionally, thereis a high incidence of dementia,cognitive impairment of some de-gree, and other disabilities that limitresidents’ ability to self-report pain. Unrelieved pain can have atremendous impact on residents’quality of life; it even can contributeto depression and other problems.Many health care providers lack theknowledge and skills to assess andtreat pain in older adults. It is wide-ly recognized that pain is a com-pletely subjective phenomenon;therefore, the resident is the expertregarding how much pain he or sheis experiencing. Yet, staff—as wellas family members and friends—of-ten ignore signs that a resident is inpain or they think that complaintsare exaggerated. At the same time,clinicians often are reluctant to pre-scribe opioid analgesics for olderadults with pain, fearing that theywill become “addicted” to this med-ication. Recent Joint Commission forthe Accreditation of Healthcare Or-ganizations (JCAHO) standards and,increasingly, state regulations are re-quiring that facilities implementpolicies and procedures to ensurethe appropriate assessment anddocumentation of pain, prescribingsupport, and education for staff,families, and residents around painand pain management. Legal and ethical problems re-garding pain management can beavoided if staff, practitioners, resi-dents, and families partner to makethe identification and treatment ofpain a priority. As a first step in afacility-wide action plan to addressthe problem of pain, administratorsshould consider implementing edu-cational programs and discussionsto dispel the myths about pain andpain management in older adults.*Myth: “Dying is always painful.”Fact: Most pain can be effectivelytreated effectively using oral drugsthat are readily available. As theend of life nears, oral pain medica-tions can be continued by convert-ing to a concentrated oral liquidform or a suppository. Persistent(chronic) pain is best treated by ad-ministering pain medications at reg-ular intervals, around the clock. Re-searchers have found that people inpain actually require lower overalldoses of pain medications if theirpain is prevented by regular dos-ing, rather than waiting until theresident experiences severe painand administering medication “prn”(as needed). If pain does occur, itcan be relieved safely and rapidly. Myth: “There are some kinds ofpain that can’t be relieved.”Fact: Accurate assessment and per-sistence in modifying the treatmentplan until the resident is comfort-able are the keys to pain manage-ment. There are some types of painthat require “multi-modality” (com-bined approaches) pain relief. Re-cent advances in analgesia assurethat all pain can be relieved by us-ing commonly available medicationsand/or a combination of approach-es that may include chemotherapy,radiation therapy, nerve block,physical therapies, and whateverelse is appropriate. In addition, drugtherapy using different classes ofdrugs is beneficial when the indi-vidual experiences more than onetype of pain. Myth: “Pain medications alwayscause heavy sedation.”Fact: Most people with persistentpain have been unable to sleep be-cause of their pain. Opioid analgesicsMaking Pain Relief a Priority…Dispelling the Myths about Pain and Pain Management in the Older AdultJoAnne Reifsnyder, PhD, APRN, BC-PCMLegal Corner40 Assisted Living Consult November/December 2005(morphine, codeine, etc.) may pro-duce initial sedation (usually about24 hours) that allows residents tocatch up on their lost sleep. Withcontinuing doses of medication theyare able to accommodate the sedat-ing side effect of medication and car-ry on normal mental activities. Seda-tion may occur because of otherdrugs, such as anti-anxiety agentsand tranquilizers that have been pre-scribed for other reasons. Olderadults often have kidney, liver, orother problems that interfere withtheir ability to process and clearsome medications. Despite this, theycan be safely and effectively treatedfor their pain. A rule of thumb indosing is to “start low, and go slow.” Myth: “It is best to save thestronger pain relievers until thevery end.”Fact: If pain is not relieved by thelesser strength analgesics (non-opiods like aspirin, acetaminophenor NSAIDs, or weak opioids suchas codeine, hydrocodone, etc.) thenit is best to change to a strongeranalgesic to bring the pain undercontinuing (24-hour) control. Painthat is only partially or occasionallycontrolled tends to increase inseverity. This leads to two mistakenassumptions: the resident mistaken-ly fears that the pain is so severethat it can never be controlled; thedoctor mistakenly believes that theresident is becoming addicted or isdeveloping tolerance to the anal-gesic medication. In most cases, anadequate dose of a stronger anal-gesic (eg, morphine) prescribed ona regular basis usually brings thepain under control. Myth: “Patients often develop tol-erance to pain medications likemorphine.”Fact: When morphine and otheropioid analgesics are prescribed forthe management of pain, the dose issometimes raised to be sure that painis well-controlled 24 hours a day,seven days a week. Opioids given torelieve pain generally do not lead tothe development of tolerance. Overtime, however, some residents will require larger doses to achieve thesame physiologic effect. This is some-times related to development of tol-erance, or it might be related to pro-gression of a disease, like cancer. Ineither case, the need for increasingdoses of medication to control paindoes not signal addiction. Myth: “Once you start pain medi-cines, you always have to increasethe dose.”Fact: The converse is sometimestrue. Once pain is under control andthe dose of opioid held at a steadylevel for several days, the dose ofopioid analgesic sometimes can belowered without the pain increasingto previous levels. Doses of opioidanalgesics can be raised safely asneeded to control increasing pain.Also, the dose can be lowered grad-ually if pain has been controlled onthe same dose for several days. Thischange in dose to meet residentneeds is known as “titration.” Thefact that the dose of opioid can belowered once pain is controlled isone of the paradoxes of treating se-vere, chronic pain. It does NOTmean that the resident’s pain wasn’treal or that he or she doesn’t needto continue the pain medication. Myth: “To get good pain relief,you have to take injections.”Fact: Until the mid-1970s it wasbelieved that morphine was not aneffective analgesic when adminis-tered by mouth, so it was universal-ly administered by injection. Wenow know that morphine is effec-tive when given by mouth or evenby suppository. Residents generallydo not like injections, as they arepainful in themselves. There areseveral excellent long-acting opioidanalgesic preparations. Morphineand related opioids are availablethat control pain for 12 hours whenused on a regular basis twice daily.Other long-acting opioid prepara-tions available for transdermal (viaa patch that is placed on the skin)delivery are available with a 72-hour (3-day) duration of action. Myth: “Pain medications alwayslead to addiction.”Fact: Addiction is defined as the“overwhelming involvement withobtaining and using a drug for psy-chic effects.” (American Pain Society,1989). When prescribed on a regularbasis in a dose sufficient to relievepain, there is no empirically basedevidence that opioids lead to addi-tion. In fact, over-concern about ad-diction leads to under-treatment ofpain, greatly increasing unnecessarysuffering for many residents. Myth: “Withdrawal is always aproblem with pain medications.”Fact: When prescribed for manag-ing severe, chronic pain there is noproblem tapering the dose downand then discontinuing, once pain iscontrolled. Withdrawal from opioidanalgesics is typically not a life-threatening condition as is with-drawal from a number of othercommonly prescribed medications,such as barbiturates. The symptomsof withdrawal from opioids are generally mild and fairly easy tomanage with commonly availablemedications. Many residents whoreceive opioids for severe pain havehad their dose adjusted down with-out experiencing any withdrawalA rule of thumb in pain medicationdosing is to “start low, and go slow.” November/December 2005 Assisted Living Consult 41symptoms. For residents who havereceived large doses of opioids for aprolonged period of time, the doseshould be decreased gradually andin conjunction with careful pain as-sessment, so that residents do notexperience “rebound” pain. Myth: “Enduring pain and suffer-ing can enhance one’s character.”Fact: This myth was developed inthe years before we learned to pro-vide excellent pain management,but it is not appropriate today. Suf-fering does not enhance character orearn people a higher place in thelife hereafter; it merely brings abouta miserable life, a painful death, andneedless anguish in all who seehelpless dying people suffer. Suffer-ing occurs on many levels, and resi-dents who are approaching the endof life may suffer because of spiritu-al distress, social isolation, fearsabout their illness and death, andanticipatory grief. Hospice care canbe very helpful in treating the seri-ously and progressively ill resident’s“total pain.”Myth: “Once you start takingmorphine, the end is always near.”Fact: Morphine does not initiate thefinal phase of life or lead directly todeath. Morphine not only providesrelief of severe, chronic pain; it alsomakes breathing easier. Relief ofpain lets the resident relax andsleep. Appropriately dosed opioidsdo not cloud consciousness or leadto death. Morphine does not kill. Myth: “Pain is a solitary phe-nomenon.”Fact: Severe chronic pain neveroccurs alone, but is usually accom-panied by a number of othersymptoms including (but not limit-ed to) anxiety, depression, fearful-ness, insomnia, anorexia (loss ofappetite), withdrawal, and thoughtsof suicide. All of these symptomsare compounded with memories ofpain already experienced, currentlyperceived pain, and anticipation ofmore pain yet to come. Unman-aged (or inadequately managed)severe, chronic pain is a complexproblem that needlessly aggravatesthe symptoms of the underlyingdisease. Again, hospice care pro-vides comprehensive attention tothe multiple domains of sufferingthat terminally ill residents experi-ence. For residents with severepain who are not terminally ill, in-terdisciplinary pain or palliativecare teams can assist with creatinga plan of care that addresses theresident’s total experience of painand suffering.Myth: “Heroin is needed to pro-vide excellent pain control.”Fact: Morphine is the “gold stan-dard” for pain management with anopioid analgesic. Heroin is a deriva-tive of morphine that is more solublein water than morphine and thereforepasses from the blood to the brainmore rapidly, thus affording the ‘rush’or ‘high’ desired by intravenous drugabusers. Morphine has a longer peri-od of action and can be safely takenby mouth. New preparations for sus-tained release make it possible to ob-tain excellent relief when taken bymouth only twice daily. Combining along-acting morphine preparationwith a short-acting form assures both24-hour coverage for persistent painand that the resident’s “breakthrough”pain can be relieved quickly. Myth: “People have to be in ahospital to receive effective painmanagement.”Fact: It is easier to provide safe,effective relief of severe chronicpain at home than it is in the aver-age hospital. There are fewer med-ication errors when there is onlyone resident to receive medicationsand no other resident emergenciesto interrupt the care. Accurate mes-sages regarding pain managementcan be shared on a regular basis bymeans of a ‘Comfort Control Chart’or Pain Diary on which the residentindicates the date, time, pain level,dose of pain medication, and levelof pain relief by using numbers (0to 10) to let the doctor know theadequacy of pain management. It is important that ALF staff takeresidents’ complaints of pain seri-ously and act on them promptly.This requires staff and resident/fam-ily education, effective ongoingcommunication between caregiversand clinicians, and a clear processfor reporting pain or suspectedpain. Staff should ask residentsabout pain regularly, believe theresident’s reports of pain, help theresident to keep a pain diary, andcommunicate unrelieved pain to theprimary care provider promptly. By working together and dis-pelling the myths surrounding painmanagement and medications, resi-dents and family members will bemore comfortable reporting prob-lems. At the same time, staff will beconfident that their response resultsin relieving pain. ALC*These myths are excerpted from Hos-pice Foundation of America’s ClergyEducation Project Curriculum andreprinted here with permission.JoAnne Reifsnyder, PhD, APRN, BC-PCM,is Senior Vice President, Research and In-novation of excelleRx, Inc., an OmnicareCompany in Philadelphia. She also is Ad-junct Assistant Professor and Coordina-tor, Palliative Care Minor, at the Univer-sity of Pennsylvania School of Nursing inPhiladelphia.It is important that ALFstaff take residents’complaints of painseriously and act onthem promptly. 

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Making pain relief a priority ... dispelling the myths about pain and pain management in the older adult.

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