Long-Term Care Survey Alert

Ferret out the nature of a resident's pain so you can individualize treatment.

You've heard the saying "no pain, no gain." But in rehab therapy, too much pain may mean the resident doesn't achieve expected gains. And that sets him--and your facility--up to fail.

That's why your facility needs a best-practice pain management program to keep residents' discomfort in check.

The first rule of thumb: Don't assume the resident's hip replacement or injury requiring therapy is the sole cause of his pain. "A lot of people come in with pre-existing back, joint or other musculoskeletal pain or neuropathic pain, as examples," says Al Barber, PharmD, director of pharmacy for Golden Gate National Senior Care in Akron, OH.
 
Example: Painful diabetic neuropathy may "affect the person's ability to walk, which would obviously be a problem if he was receiving rehab for a joint replacement," says Barber.

As part of the pain assessment, determine whether the person just has incidental pain caused by the therapy work-out, chronic underlying pain or both.

Nail down the pain management goal: Identify and document the patient's goal for pain relief related to therapy. "Assess the person initially and then reassess" him, which may be on a daily basis for someone in an acute rehab program, says Barber. "You don't want to medicate the person to the point where he can't participate in therapy," he stresses.

Clinical tips: Some stoic or macho residents may deny they are having pain. "If the person shows signs of pain and is cognitively intact, share with him your observation" that he seems to be in discomfort, advises Cheryl Boldt, RN, a consultant with Maun-Lemke in Omaha, NE. "Let the person know the team can help him with pain management," she adds. For example, discuss the various pharmacological and non-pharmacological options for pain relief.

If a resident with dementia shows signs of pain, "assume the person has pain and treat it to see if the treatment appears to give the person relief," suggests Boldt.

Select the Right Medication

Residents who suffer only from incidental pain during therapy need pain medication before the rehab treatment. Pre-medication for incidental pain is important because "a lot of pain is anticipatory pain where there's a psychological component to it," says Barber.
Survey heads-up: Attorney Donna Senft knows of one facility that got tagged for not modifying a patient's pain medication regimen to administer medication before therapy. Pain is definitely on surveyors' radar screens, says Senft, who is an attorney with Ober/Kaler in Baltimore.

Therapeutic options: To treat incidental pain, use a short-acting agent, which might include Percocet or Vicodin, suggests Barber. "If you want to stay away from Tylenol [in the latter medications], order the oxycodone or hydrocodone alone. Immediate-release morphine is also very effective--it comes in oral, suppository and liquid form."

Barber recommends administering the medication "about an hour before the resident's therapy treatment." In his view, "30 minutes is often too short of a leeway time for most patients." Evaluate whether the pain medication provided enough relief to meet the resident's goals and allow him to participate in therapy effectively.

Tailor the dosage: Initially, you may have to "play around with the dosage of opioids to see what the person can tolerate--especially if the person is "opiate naïve," Barber adds. That means the person hasn't taken opioids in the hospital or opioid medication previously. If so, "the person will need a lower dose. If they have taken opioids in the hospital or before, they may need a higher dose."

Safety tip: Watch out for rehab patients who had Duragesic patches post-op, especially those who aren't used to opioid medication, advises Barber. "The surgeons tend to like to order them, but it's a difficult drug for a patient to acclimate to if he has no tolerance to opioids." He's seen people with the patches fall due to over sedation. Duragesic is a "long-acting opioid that will take several days to clear from the resident's system."

If the person has chronic underlying pain--for example, due to arthritis or a neuropathy, but also pain worsened by therapy--he might need a long-acting opioid medication to treat the ongoing pain and a short-acting medication before therapy.

Treat neuropathic pain, which  is caused by nerve injury, with an antidepressant, such as  venlafaxine (Effexor) or Cymbalta or an antiepileptic drug such as gabapentin (Neurontin) or Lyrica, suggests Barber. "Lyrica has a better profile in terms of absorption and metabolism and requires less titration to achieve an effective dose." If the rehab patient has an inflammatory cause of pain, he may need a short course of oral steroids, adds Barber.

Tackle Depression

Depression and pain go hand in hand often, says Barber. So assess for depression in people whose pain "seems out of proportion to what you'd expect based on their injury, condition or treatment," he suggests. "Some antidepressants do a good job of treating pain as well as depression--a good example is venlafaxine." The antidepressant "Cymbalta also has an indication for diabetic neuropathic pain," he adds.

Integrate Non-Pharmacological Pain Relief Measures

"The facility shouldn't be too quick to jump on or stay on the drug bandwagon," says Barber. "See what the physical therapy can do in terms of relieving the person's pain with cold and hot therapy, ultrasound and electrical stimulation," he suggests. "Sometimes the PT may be able to augment pain management by using these modalities or even replace drugs--including ones to treat neuropathic pain."

There's more: Other non-pharmacological approaches to pain "can include breathing techniques--the same type you use to manage stress, anger or childbirth," adds Boldt. Rehab patients might also find pain relief by using visual imagery or listening to soothing music, she adds. Laughter can be a pain reliever, Boldt notes.