Managing Older Adults' Chronic Pain: Higher-Risk Interventions How to help caregivers promote safe pain management.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. This new group of articles provides practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses. Cite this article as: Arnstein, P., et al. Managing Older Adults' Chronic Pain: Higher-Risk Interventions. Am J Nurs 2023; 123 (4): 56-61.

Managing Older Adults' Chronic Pain: Lower-Risk Interventions Nurses can engage family caregivers in creating, implementing, and evaluating the treatment plan.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. This new group of articles provides practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses. Cite this article as: Arnstein, P., et al. Managing Older Adults' Chronic Pain: Lower-Risk Interventions. Am J Nurs 2023; 123 (2): 46-52.

CE: Overcoming Movement-Evoked Pain to Facilitate Postoperative Recovery.

ABSTRACT: Severe postoperative movement-evoked pain (MEP) can be immobilizing, instilling in patients the fear that further activity will produce unbearable pain. This impedes healing and restoration of function while also extending time to recovery. Therefore, it is critical to manage MEP effectively through timely evaluation and comprehensive care planning. This article builds on recent calls to standardize testing of MEP to inform care planning in a way that both reduces pain and improves functioning. Subsequent reassessment of MEP can guide the refinement of therapy. Although this approach may seem intuitive, it challenges common practices that focus too heavily on pain intensity, resulting in overtreating, undertreating, or not treating pain, while ignoring the risks of immobility and the importance of movement for improving functional capacity. The authors propose a multifaceted approach to overcoming MEP that nurse clinicians, educators, researchers, and compliance professionals can use to enhance the quality and safety of nursing practice.

Managing Older Adults' Chronic Pain: Higher-Risk Interventions.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. This new group of articles provides practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses.

Managing Older Adults' Chronic Pain: Lower-Risk Interventions.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. This new group of articles provides practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses.

CE: Assessing Movement-Evoked Pain.

ABSTRACT: One of the most common and nuanced tasks that nurses perform is pain assessment, particularly in acute postoperative settings where frequent reassessments are needed. Most assessments are limited to obtaining a pain intensity score with little attention paid to the conditions necessitating the assessment or the factors contributing to the pain. Pain is frequently assessed during rest, but seldom during periods of movement or activity, which is a crucial omission given that acute postoperative movement-evoked pain (MEP) is intense and a common barrier to healing and restoration of function. In addition to physical limitations, MEP can impede cognitive, emotional, and social functioning in ways that can contribute to chronic pain, mood disorders, and disability. Professional and regulatory standards are moving away from a focus on pain intensity to an emphasis on its context, impact on function, and associated distress. Thus, there are many driving forces compelling nurses to integrate MEP assessments into practice to expedite the restoration of biopsychosocial functioning in postoperative patients. The authors discuss the clinical significance of a MEP assessment as well as protocols and tools for completing such assessments.

Results of a Team Objective Structured Clinical Examination (OSCE) in a Patient with Pain.

PURPOSE: As rates of chronic pain and opioid use disorder continue to rise, improved pain education is essential. Using an interprofessional team objective structured clinical examination (OSCE) simulation, this study evaluates whether prior exposure to a case-based learning module improves students' assessment and treatment planning of a standardized patient prescribed chronic opioids presenting with acute pain. METHODS: A quasi-experimental mixed method approach using convenience sampling was employed to evaluate student performance and the impact of the educational intervention. RESULTS: Fourteen (intervention) and 16 (control) nurse practitioner, physician assistant, medical, pharmacy, and dental students in the final pre-licensure program years completed the team OSCE. Demographics, OSCE learning scores, Interprofessional Attitudes Scale scores, and pain management plans did not differ between groups. All students evaluated the activity highly. Qualitative analysis did not demonstrate differences between groups, but did identify similar themes: students missed opportunities to establish patient-provider rapport and educate across disciplines; opioid use disorder was assumed with chronic opioid therapy; team discussions improved treatment plans; moderators variably influenced team discussion. CONCLUSIONS: This novel approach to interprofessional training in pain management using a team OSCE is promising, with modifications suggested. A case-based learning module without structured education prior to the OSCE did not improve students' assessment and pain management skills compared to a control group. Nonetheless, important themes emerged including biases towards the standardized patient. Additional research is needed to develop effective curricular initiatives to foster and improve interprofessional collaboration in assessing and managing a standardized patient with acute and chronic pain.

Validating the Functional Pain Scale for Hospitalized Adults.

BACKGROUND: Enhancing pain patient's ability to function and cope is important, but assessing only intensity ignores those aspects of pain. The Functional Pain Scale (FPS), addresses these dimensions but lacked validation in hospitalized adults with chronic pain. AIMS: This research was conducted to establish the FPS psychometric properties in hospitalized adults. DESIGN: A prospective pilot study examined the reliability and validity of the FPS in two acute care hospitals. SETTINGS: Adult inpatients from medical/surgical units at two hospitals. PARTICIPANTS/SUBJECTS: A convenience sample of 93 subjects from an Academic Medical Center and 51 from a tertiary care hospital who were 21-81 years old and primarily Caucasian. METHODS: Hospitalized adults with chronic pain at two facilities provided pain scores from the FPS, Numeric Rating Scale, Pain, Enjoyment of Life, and General Activities Scale, and Quality of Pain Care Scale. Test-retest reliability and construct validity were evaluated using standard correlation methods. RESULTS: Hospitalized adults aged 21-88 years with chronic pain (N = 144) were evaluated. Data supported test-retest reliability of the FPS (r = .84; p < .001), which had strong, statistically significant correlations with the Numeric Rating Scale at different study sites (r = 0.75 and r = 0.45, respectively), indicating acceptable construct validity. Significant weak correlations between the FPS and other measures of mood and functioning failed to support discriminant validity. CONCLUSIONS: Although statistically significant, the reliability and validity of FPS were not as strong in hospitalized chronic pain patients as reported for older adults in other settings.

Pain Relief and the Opioid Crisis in the United States and Canada.

Opioid analgesics hijack the body's innate wellness machinery (eg, naloxone blocks the placebo effect) and alleviate both physical and emotional pain. Starting in the 1980s, marketing and advocacy created an opioid-centric pain relief strategy based on the idea that physicians undermanage pain and worry too much about addiction. The increase of prescription opioids in the ecosystem (along with a resurgence in heroin use) contributed to dependence, misuse, overdoses, and overdose deaths. Laws punishing undermanagement of pain from the opioid crisis combined with more recent laws punishing overprescription of opioids add to the difficulties orthopaedic surgeons have in managing the pain of surgery and acute injury. The substantial variation in pain intensity for nociception (actual or potential tissue damage) and the persistent use of opioids after healing is well established are both accounted for largely by psychosocial factors (stress, distress, and less effective coping strategies). When a patient has more pain than expected, surgeons should first rule out compartment syndrome and infection and then focus on a comprehensive team- and strategy-based approach that addresses these psychosocial factors.

Evidence-Based Practice Guideline: Persistent Pain Management in Older Adults.

More individuals develop and endure constant or recurring pain in older adulthood. Although 40% of these individuals receive no treatment, many evidence-based treatments are available. Accurate assessment of pain, its impact on functioning, and preventing treatment-related harms lay the foundation of safe, effective pain control. Analgesic agents are often necessary, but require a delicate balance to prevent under-treatment, the unnecessary abandonment of therapy, or exposure to potentially serious adverse effects. Nondrug therapies must be better integrated into the treatment plan to ensure overall safety. Evidence-based approaches help older adults thrive and survive longer despite living with persistent pain. [Journal of Gerontological Nursing, 43(7), 20-31.].

Quality Pain Care for Older Adults in an Era of Suspicion and Scrutiny.

In two decades, the pendulum has swung from focusing on the undertreatment of pain by prescribers who fail to use medically necessary opioid agents to an intense focus on overprescribing opioid medications and the harms they cause. Within these two extremes rests the older adult with pain and in need of safe and effective care. Today, health care providers are practicing in an era of scrutiny, with new guidelines and regulations superseding their compassion and clinical judgment about the best treatment options when older adults have pain across the care continuum. Media depicting opioid medications as lethal, unnecessary, and highly addictive that do not distinguish non-medical from therapeutic use or legitimately versus illegally obtained drugs are widely reported. These reports and legislative focus on treating addiction have silenced and further stigmatized older adults with persistent pain. Patients and professionals treating pain need to provide balance of multimodal pain management strategies to safely manage persistent pain based on a comprehensive assessment and personalized approach. [Journal of Gerontological Nursing, 42(12), 31-39.].

Interprofessional Education for the Dentist in Managing Acute and Chronic Pain.

Dental education is at the intersection of affordable health care, opioid-abuse crisis, and collaborative practice benefits. Students must engage in interprofessional education (IPE) for pain management. Graduates must recognize appropriate management of acute dental pain and understand the dentist's role in interprofessional treatment of chronic disease, including management of temporomandibular disorders and orofacial neuropathic pain, chronic pain in general, and the consideration of opioids. This article reviews accreditation standards, compares these standards with recommendations from the International Association for the Study of Pain and regulatory boards, and presents examples of enhanced pain education.

Morphine versus Hydromorphone: Does Choice of Opioid Influence Outcomes?

Morphine has traditionally been considered the first line agent for analgesia in hospitals; however, in the last few years there has been a shift towards the use of hydromorphone as a first line agent. We conducted a hospital population based observational study to evaluate the increasing use of hydromorphone over morphine in both medical and surgical populations. Additionally, we assessed the effect of this trend on three key outcomes, including adverse events, length of stay, and readmission rates. We evaluated data from the University Health Systems Consortium. Data from 38 hospitals from October 2010 to September 2013 was analyzed for patients treated with either hydromorphone or morphine. The use of morphine steadily decreased while use of hydromorphone increased in both medical and surgical groups. Rescue drugs were used more frequently in patients treated with hydromorphone in comparison to patients treated with morphine (p < 0.01). Patients receiving morphine tended to stay in the hospital for almost one day longer than patients receiving hydromorphone. However, 30-day all cause readmission rates were significantly higher in patients treated with hydromorphone (p < 0.01). Our study highlights that the choice of hydromorphone versus morphine may influence outcomes. There are implications related to resource utilization and these outcomes.

Relationship between change in pain intensity and functional outcomes in patients with chronic pain receiving twice daily extended-release hydrocodone bitartrate.

OBJECTIVE: Evaluate levels of pain relief achieved in patients with chronic pain treated with hydrocodone-extended release (HC-ER) up to 48 weeks and show that these levels were associated with secondary functional and global outcomes. DESIGN: Post hoc analyses were based on a previously reported study that started with an open-label conversion/titration phase for ≤ 6 weeks followed by an openlabel 48-week treatment phase. SETTING: Private practice and institutional pain centers. PARTICIPANTS: Three hundred ninety-one opioid-experienced subjects with moderate to severe pain for ≥ 3 months. INTERVENTIONS: Individualized doses (20-300 mg) of extended-release hydrocodone every 12 hours. MAIN OUTCOME: Almost 60 percent (232/391) of subjects achieved moderate or substantial levels of pain relief (≥ 30 percent reduction in pain score) during the study. RESULTS: Subjects who achieved moderate or substantial pain relief demonstrated significant (p <0.001) improvements in Oswestry Disability Inventory (ODI), all pain interference outcomes, and Subject Global Assessment of Medication. Subjects with substantial pain relief had decreases in ODI, Hospital Anxiety and Depression Scale (HADS) anxiety, and HADS depression scores of -13.4 ± 14.92, -1.9 ± 3.37, and -1.7 ± 3.26, respectively. The five most commonly reported treatment-emergent adverse events were constipation (12.5 percent), back pain (11.1 percent), nausea (9.9 percent), vomiting (9.7 percent), and arthralgia (7.8 percent) and are consistent with opioid therapy. CONCLUSIONS: Moderate or substantial levels of pain relief were associated with the greatest functional improvements in patients treated with HC-ER. These results may help define success of opioid therapy and determine if it should be continued or an alternative treatment should be tried.

Opioid use after fracture surgery correlates with pain intensity and satisfaction with pain relief.

BACKGROUND: In 2012, Medicare began to tie reimbursements to inpatient complications, unplanned readmissions, and patient satisfaction, including satisfaction with pain management. QUESTIONS/PURPOSES: We aimed to identify factors that correlate with (1) pain intensity during a 24-hour period after surgery; (2) less than complete satisfaction with pain control; (3) less than complete satisfaction with staff attention to pain relief while in the hospital; and we also wished (4) to compare inpatient and discharge satisfaction scores. METHODS: Ninety-seven inpatients completed measures of pain intensity (numeric rating scale), satisfaction with pain relief, self-efficacy when in pain, and symptoms of depression days after operative fracture repair. The amount of opioid used in oral morphine equivalents taken during the prior 24 hours was calculated. Through initial bivariate and then multivariate analysis, we identified factors that were associated with pain intensity, less than complete satisfaction with pain control, and less than complete satisfaction with staff attention to pain relief. RESULTS: Patients who took more opioids reported greater pain intensity (r = 0.38). No factors representative of greater nociception (fracture type, number of fractures, days from injury to surgery, days from surgery to enrollment, or type of surgery) correlated with greater pain intensity. The best multivariable model for greater pain intensity included: depression or anxiety disorder (p = 0.019), smoking (0.047), and greater opioid intake (p = 0.001). Multivariable analysis for less than ideal satisfaction with pain control included the Pain Self-Efficacy Questionnaire (PSEQ) (odds ratio [OR], 0.95; 95% CI, 0.92-0.99) alone; for less than ideal satisfaction with staff attention to pain control, the PSEQ (OR, 0.96; 95% CI, 0.92-0.99) and opioid medication use before admission (OR, 3.6; 95% CI, 1.1-12) were included. CONCLUSIONS: After operative fracture treatment, patients who take more opioids report greater pain intensity and less satisfaction with pain relief. Greater self-efficacy was the best determinant of satisfaction with pain relief. Evidence-based interventions to increase self-efficacy merit additional study for the management of postoperative pain during recovery from a fracture. LEVEL OF EVIDENCE: Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Risk evaluation and mitigation strategies for older adults with persistent pain.

The U.S. Food and Drug Administration issued Risk Evaluation and Mitigation Strategies for certain analgesic agents, but all medicines for older adults warrant risk-reduction considerations. Although not all older adults have pain, a higher prevalence of persistent pain exists in this population. Nursing actions are needed to minimize the negative impact persistent pain, analgesic agents, or both have on physical, mental, and social functioning. Practices vary considerably, ranging from failing to use analgesic agents for older adults with considerable pain to exposing them to potentially life-threatening toxicities, overdoses, or drug interactions. Older adults tend to be more vulnerable to side effects and drug interactions due to differences in drug distribution, metabolism, and elimination; thus, vigilant assessment and monitoring is needed to mitigate risks whenever analgesic agents are used. This review delineates these vulnerabilities while informing clinicians of the strategies needed to promote safe, effective use of medications when treating pain in older adults.