February 20, 2017 | Aging Services Risk, Quality, & Safety Guidance
Every year, millions of Americans experience acute and chronic pain, although estimates on the exact number vary. For example, in 2011, the Institute of Medicine (now the National Academy of Medicine) found that about 100 million American adults are affected by chronic pain, costing about $635 billion per year in medical treatment and lost productivity (IOM). In contrast, the National Institutes of Health found this number to be significantly lower, estimating that about 25.3 million American adults—approximately 11.2% of the population—suffered from daily chronic pain, with an additional 23.4 million (10.3% of the population) suffering from "a lot of pain," based on an analysis of three months of data in the Functioning and Disability Supplement of the 2012 National Health Interview Survey (Nahin). Yet another estimate, analyzing data from 2010, puts the number of American adults experiencing chronic pain (defined as "persistent pain") at 39.4 million per year (Kennedy et al.) And a report from the Society for Post-Acute and Long-Term Care Medicine (formerly the American Medical Directors Association) estimates that 45% to 80% of continuing care residents suffer from chronic pain (Society for Post-Acute and Long-Term Care Medicine). Regardless of the exact number, the fact remains that many Americans suffer from chronic pain; left unmanaged, that pain can have significant negative impact on individuals' quality of life.
Healthcare providers are often concerned about the adverse legal and medical consequences arising from the improper administration of narcotics and pain medications, including opioids (e.g., fentanyl, hydromorphone, morphine, oxycodone, hydrocodone) and other pain medications for older adults. In home care or primary practice settings, because the patient is responsible for following his or her treatment regimen at home, providers may hesitate to prescribe certain controlled substances because of concerns about their addictive properties, as well as fears that the patient will abuse the substances or divert them for sale.
In nursing homes and other aging services setting, physicians often order a resident's pain medications on a pro re nata (PRN) basis (i.e., "as needed"), instructing nurses and other care providers to administer the medication only when the resident needs it, with guidelines for the frequency of administration. Often, older adults with pain may have orders for multiple medications for pain relief and other ailments, requiring the nurse or care provider to determine which prescription is most appropriate for each episode of pain. Providers in the aging services setting may hesitate to provide medication because of fears of oversedation from the medication and other adverse effects of the medication. Some other factors complicating pain medication administration in continuing care settings include difficulties contacting the resident's physician for medication orders, possibly resulting in delayed pain relief for the resident; difficulty or inability of residents with cognitive impairment to communicate pain needs; and the increased risks of adverse medication effects in the elderly.
Physicians and healthcare providers have always had an ethical duty to provide effective pain relief, but pain management is now increasingly recognized as a medical standard of care. Care providers concerned with the adverse effects of prescribing pain medication generally focus on effects that can occur when excessive amounts of pain killers are given. Indeed, opioid overdose is a major public health problem across all healthcare settings in the United States, with the number of deaths involving prescription opioid analgesics tripling to 19,000 per year between 2001 and 2014 (SAMHSA). According to the U.S. Department of Health and Human Services (HHS), prescription opioid-related deaths are considered to be one of the leading preventable public health problems in the United States. ...