Not just opioids: Multidimensional pain requires multipronged treatment, study finds

Nursing homes need to change how they manage and treat chronic pain, shifting from an approach that favors immediate prescribing of opioids to a multi-pronged team approach, according to a new study.

The study, published in the Journal of Post-Acute and Long-Term Care Medicine, walks through non-drug methods being underutilized in nursing homes and emphasizes such methods as preferred first steps to manage mild, chronic pain.

Alternatives include acupuncture, therapeutic exercises, osteopathic manipulative treatment and heat therapy.

“Pain is a multidimensional symptom and requires a strategic multimodal approach for its management,” wrote the authors, led by Fatima Sheikh, M.D. of Johns Hopkins University School of Medicine. “Nonpharmacologic modalities are underutilized in the NH setting and are the preferred first steps for mild pain, and nonopioid pharmacological agents can be added as a second step for a synergistic effect for moderate to severe pain. Opioids should be used as a last resort.”

Co-authors of “Chronic Pain Management in Nursing Homes: Navigating the Challenges to Improve Person-Centered Care” are Nicole Brandt, PharmD, of the University of Maryland School of Pharmacy; and Dominique Vinh, MD, and Rebecca D. Elon, MD, of Johns Hopkins University School of Medicine.

They reiterated that opioids are still a viable option for patients in chronic pain. The fears and myths associated with opioids have caused an unnecessary decrease in the prescription of opioids to nursing home residents who need them.

But according to the study, opioid-naive residents with “intermediate to severe pain” usually do well on small doses of short-acting opioids, taken on an as-needed basis. Mild persistent pain patients do best with scheduled around-the-clock short-acting opioids with “rescue doses” for breakout pain. The only situation in which long-acting opioids should be considered is with severe and persistent pain unaffected by short-acting opioids, the researchers found.  

Medical professionals and clinicians should carefully evaluate patients and assign them the correct treatment and, at each visit, evaluate whether medications need to be continued and weigh other options.

The study also recognizes that the recent COVID-19 pandemic has heightened the effects of chronic pain on those afflicted, whether because of psychosocial stress, anxiety or an increase in pain. This has led to an escalation in the need for effective pain treatment and prescriptions. 

The authors said the elderly sometimes receive ambiguous direction from their providers, inadequate guidance once starting treatment or may lack access to some treatment options. Incorporating pain management techniques aside from medication may help to solve these difficulties, they reported.