Pain management in LTC

[bluegeegoo2]

I have a 82 y/o female pt who suffers from severe, chronic back pain. She is also suffering from dementia. Long story short, we've tried several different approaches for pain relief, but none seem to work. We had her on Duragesic patches, but they really increased her confusion. (She's up ad-lib, but VERY unsteady. I had her activity status changed to up c asst, but management jumped all over me because "we don't have the staff to watch her like that"). Anyway, called the MD and rec'd an order for oxycontin 20mg BID. Her pain was well controlled, but she was snowed for the first few days. We held the Klonopin she was getting TID, and she was starting to come around. The problem? Her husband is c/o her being "sleepy" all of the time, and wants her more alert. The other nurse on my unit agreed and has had her Oxy d/c'd. Now, the poor lady is alert all right, but combative d/t her pain level. You can just look at her and see the pain she is enduring. But, so long as she's alert, right? I feel like more time should have been allowed to see if she adjusted, as well as d/c the routine Klonopin and Ambien, and make them prn. Probably wouldn't have hurt to drop the Oxy to 10mg BID and work from there. But, this other nurse is putting her alertness above her pain control, where as I would rather her start out a little sleepy and at least be controlled, then adjust from there. Am I wrong? What else can I do? I am "trumped" on most of my calls on this unit, but will be going back to my old unit in a few weeks. I truly care about this ladys' wellbeing, as my Mom has endured years of chronic back pain and have seen first hand how horrible it can be. If you know of better ways to control pain without knocking her out, please let me know!

[SuesquatchRN, BSN, RN]

One of my most telling moments in LTC came with a very frightened woman who had an extremely flat affect, expressive aphasia, often forgot where she was.

Well, when she couldn't sleep at night and was scared and on the call bell instead of moving it from her reach (when I reported it I was told that the CNA's said I "barked") I would bring her out to sit with me and the aides.

One night, we were at the little table talking about menopause and symptoms. Out of the blue, in a normally inflected voice, she said, "I never went through any of that." She spent the rest of the night in conversation with us.

Of course, they told me that letting her stay in the recliner near us is why she got a boil.

We forget that they are PEOPLE in there.

[Jo Dirt]

I think the last thing medical staff should worry about in old people is addiction.

If they are hurting let them have what they need to be out of pain. I can't stand pain.

[CapeCodMermaid, RN]

I worked with a very old Cape Cod doctor once. He had just a few patients in my facility. One of his patients came in with a newly repaired hip fracture. He wrote for tylenol. I said "He's 3 days postop. He'll never get to rehab on plain tylenol." He said he didn't like prescribing narcotics because "nurses steal them". I must have given him a look because he quickly added "Oh, I didn't me YOU." After much debate and showing him our system to count narcotics he agreed and wrote an order for Tylenol with codeine. Another discussion and finally I convinced him that Percocet was the best medication. We started with a standing dose and tapered off to PRN. The patient did his rehab and went home happy. The doctor was less hesitant after that to order narcotics. The nurses did NOT steal any.

BUT it was a long process just to get the poor guy some pain relief. As nurses and patient advocates we can't give up when trying to get what our patients need.

[CoffeeRTC, BSN, RN]

I am a crazy person when it comes to pain management (okay some of my staff would say I am just plain crazy!) Pain, especially in the dementia population, is sorely undertreated. Nurses are afraid to medicate; doctors are afraid a well and constantly prescribe medications that are not effective for chronic pain.

Start low and go slow is good advice. In a narcotic virgin, 10mg of MS Contin q 12 hours is a place to start. It would be better to start with 10mg of Oxycontin because it has fewer metabolites which can cause confusion, but Medicaid won't pay for Oxycontin unless you show the MS Contin was ineffective. We usually start patients off with 10 mg q 12hours with OXY IR 5 mg q 4hours for breakthrough. We titrate up from there remembering there is no ceiling for morphine. My problem with ONLY PRNs is that most of these residents can't verbalize pain and not every nurse has the assessment skills needed.

Don't forget about other methods to reduce pain. NSAIDs are effective in some pain given with the narcotics. Heat and cold work for some...positioning, music, distraction therapy.

It's amazing how behaviors diminish when the resident's pain is treated. I've seen patients with horrible behaviors (screaming, throwing food, hitting out) become calm and relaxed after a few doses of pain medication.

Explain to the family and the nurses that the sleepiness when first starting a narcotic medication is usually temporary and a bit of lethargy beats pain any day of the week!

Try establishing a pain committee or appoint a pain champion. Call your local hospice and have inservices on pain control.

And....please don't cut a fentanyl patch in half...the medication will not be delivered properly if the patch is cut. The patch comes in as little as 12.5 mcg so there shouldn't be any reason to cut a patch.

And finally, about constipation I knew an NP who specialized in pain control. She said: "The hand that writes the script for the narcotic pain medication better be the hand that is also writing the order for a bowel medication or it should be THAT hand which has to do the disimpaction when the time comes."

Yep....all of that. This is my biggest pet peeve in LTC nursing. On one hand we have docs that will give a vicodin for everything...then we have the others:banghead:

Don't cut the duragesics!

Remember that with the long actings you might need to give a few more prns around the clock till they get a good level in their system

Colace and senna are your friends!!

[Skeetersmom119]

I have had good results with Ultram 50mg q 6hrs for pain or having it scheduled BID at 9am and 5pm. Then she could have something for breakthrough pain (which generally occurs more in the afternoon, evenings.) I work on a skilled unit, where there are a lot of pain management issues. Also, if there are specific areas of pain, the Lidoderm patch does a wonderful job. I have had patients that have 3 at a time. They are on during the day, removed at night. The clonazepam is probably more for anxiety. I can understand that you want to keep the pain managed, and I agree 100%. I can also understand that the spouse does not want her "snowed under." Heavy narcotics stay around longer in the elderly, because their kidneys and liver do not work as well as ours. So you have to find the middle ground to get good results all the way around.

[Furwillfly]

Wow.....shocked that durgesic patches are being cut. Anyhow, Lidoderm has worked well, have you thought about Neurotin? Sometimes when we have a resident who requires a lower dose of narcotic, we add a 500mg. Tylenol to it. (just watch the mg count) We have had success with that. Yes, the husband needed some teaching; could've held a dose or two and started at a lower dose. Don't just take it for granted her pain is from her chronic issue either. Assess her urine...UTI? Bowels? etc.

I'm really concerned about the LTC's that aren't being able to properly medicate for pain! This is absurd! We are very liberal with pain meds with our psych/dementia residents. Pain is a big factor in their behaviors/outbursts etc. Would love to know if the nurses having the pain order troubles are from a rural or urban community? Just curious. Don't know if it's a factor....I guess I'm just amazed. Sorry.

You really need to stress to the husband that it takes time to find the right drug for someone and what will work for her.

[SuesquatchRN, BSN, RN]

Y'know, Earle does hospice, and if she's been cutting Duragesic patches you can bet it's okay. She's got a lot of experience with pain management.

[marachne]

y'know, earle does hospice, and if she's been cutting duragesic patches you can bet it's okay. she's got a lot of experience with pain management.

ok, i'm new here and clearly leslie ("earle") is smart with a lot of experience and knowledge, but that doesn't make anyone infallible. one thing to keep in mind is that practice changes, and while we all do our best to keep up with the newest information, it's a pretty steep challenge.

i just finished a palliative care fellowship. i worked with experienced nps and physicians who have been doing pall. care for over 10 years, and they were not comfortable with the idea of cutting a patch.

here's a quote from medline, within a black box warning: "do not use a fentanyl skin patch that is cut, damaged, or changed in any way. if you use cut or damaged patches, you may receive most or all of the medication at once, instead of slowly over 3 days. this may cause serious problems, including overdose and death." note this was revised 4/2008

the web can be a very helpful tool if you know how to judge for the quality of a site. something sponsored by the nih i feel pretty comfortable with

[bluegeegoo2, LPN]

We had a lady on skilled who rec'd a 12.5 mcg patch cut in half for the first 3 doses, then full strength after that. I called the pharmacist and MD to check and recheck about using them that way, and they both assured me it would be fine. Just to make sure, I charted both calls and responses to cover my butt, and watched her very closely. All turned out well, but it still scared me.

[marachne]

Yeah, I'm not saying it isn't done and done w/o problems, I'm just not comfortable with it (esp in a home setting where monitoring isn't as close, or a LTC setting where there's a high pt/licensed staff ratio). But maybe I'm just too uptight.

[leslie :-D]

Yeah, I'm not saying it isn't done and done w/o problems, I'm just not comfortable with it (esp in a home setting where monitoring isn't as close, or a LTC setting where there's a high pt/licensed staff ratio). But maybe I'm just too uptight.

i agree, and i should not have made that statement about cutting patches.

what we do in our inpt hospice facility, does not always follow the recommendations.

actually, we get downright creative and administer meds that haven't even been approved...

all under the expertise and experiences of our med'l director, as well as our pharmacist.

i do know that cutting is not advised, but like i said, our hospice pts are monitored 24/7 atc.

i need to rescind that statement and don't advise cutting unless a nurse is going to be available at all times.

i certainly have enough experience to feel comfortable w/our collaborative methods...

as is the nature of our hospice facility.

but if i had to make a gen'l statement, i wouldn't recommend doing so.

sorry for any confusion.

and sue, thanks for the vote of confidence.:redpinkhe

leslie

[marachne]

Leslie, thanks for the clarification. I agree that sometimes our creativity (both in house and in the field) can be an incredible help in taking care of our pts.

As I said, I hope that my comments don't in any way look like aspersions cast on your skill, knowledge, good sense, etc. You clearly know your stuff and are generous in sharing your knowledge :redpinkhe