AMDA Guideline for Pain
Management in LTC
April 2015
CMDA
Alan Miller RPh MS CGP
How to Use
Definition
Recognition
Assessment
Treatment
Monitoring
Criteria
 Quality
of Evidence
– High: usually RCT
– Moderate: room for uncertainty
– Low: results doubtful
 Strength
of Recommendation
– Strong: benefit outweighs risk
– Weak: benefits balanced
– Insufficient:
Hospice/Palliative Care
AMDA Tool Kit
Palliative Care in the Long
Term Care Setting
Persistent Pain
 Functional
Impairment
 Falls
 Slow
Rehabilitation
 Mood Changes
 Depression
 Anxiety
 Sleep and Appetite Disturbance
 Greater Healthcare Use
Pain with Dementia
Dementia Patients are often
able to report pain
PAIN-AD: Pain assessment in
Advanced Dementia
PACSLAC: Pain assessment
check list for seniors with limited
ability to communicate
Barriers to Recognition and
Treatment
Patient
Related
Cultural and Social
Provider related
Facility related
Facility Preparedness
Communication
Education
Staffing
Recognition
Evaluate
the patient for
pain
Have likely causes been
defined
Provide Appropriate
Interim Treatment for Pain
Assessment
Perform
a pertinent
history and physical
examination
Assessment
Are
the causes of pain
identified ?
If Yes proceed to
summarize
Assessment
If
No
Perform further
diagnostic testing as
indicated
Assessment
Have
the probably
causes of pain been
identified?
If yes proceed to
Summarize
Assessment
 Obtain
additional evaluation
or consultation as necessary
 Have the probably causes of
pain been identified
 If no repeat the sections of
assessment
Assessment
Summarize
the
characteristics and causes
of the patient’s pain and
assess the impact of pain
on function and quality of
life
Treatment
Review
of nonpharmacologic options
Treatment
Adopt
a patient centered
interdisciplinary care
plan
Treatment
Set
goals for pain relief
Treatment
Implement
the care plan
Treatment
 Extensive
discussion of:
Principles of Analgesic Use
Monitoring
 Re-evaluate
the patient’s pain
 Adjust treatment as necessary
 Is pain controlled?
 Resolving Conflicts and
Challenges in Pain
Management
Monitoring
Monitor
the facility’s
performance in the
management of pain
Appendix
 Examples
of Pain Scales
 Opioid Initiation and Titration
Worksheet
 Model Transdermal Fentanyl
Policy
 Methadone Use in LTC setting
Appendix
Adjuvant
Analgesic
Medications
Algorithm of the
Guideline
Algorithm
Two
page algorithm of
the guideline
Add in this slide
Principles of Analgesic Use
General
Principles for
Prescribing
WHO pain relief ladder
Non Opioid Analgesics
Recommendations for
NSAID use
Principles of Analgesic Use
 Topical
Analgesics
 Opioid Analgesics
 Equianalgesic Dosing
 General Principles for
prescribing and titrating
opioids
 Opioid Titration Options
Principles of Analgesic Use
Treatment
of
Neuropathic Pain
Table of Medications
Principles of Analgesic Use
Preventing
and
managing opioid induce
bowel dysfunction and
constipation
Analgesics to Avoid in LTC
NSAIDS:
indomethacin,
meclofenamate, piroxicam
tolmetin due to GI and CNS
side effects
Meperidine: CNS and
accumulation
Analgesics to Avoid in LTC
 Partial
opioid agonists
butorphanol, nalbuphine,
pentazocine due to ceiling effects
associated with dysphoria and
hallucinations
 May precipitate withdrawal in
opioid dependent patients
CAM
Complementary
and
Alternative Medicine
Therapies for Pain
Opioid Induced Hyperalgesia
 Opioid
Tolerance or Hyperalgesia?
Key Symptoms Offer
Clues. Medscape. Sep 16, 2013.
 Dr. Silverman is medical director
of Comprehensive Pain Medicine
in Pompano Beach, Florida.
 Findings of the clinical prevalence
of OIH are not available
"When
a chronic pain
patient isn't getting better,
a clinician asks: is the
patient developing a
tolerance and needs more
opioid or does he have
opioid-induced
hyperalgesia?"
Key symptoms offer important
clues Patients with opioid-induced
hyperalgesia will develop an
increased sensitization to pain that
may be unlike their original pain.
"The first thing to understand is
this is a diffuse, spreading kind of
pain," "Patients develop an acute
insensitivity to pain even though
they may be stable and functioning
on their opiates."
The distinction from the
development of a tolerance should
be clear. "This is not just a lack of
efficacy of the pain medicine —
that's tolerance, and everybody
develops a tolerance to almost
every exogenous thing. It's a
defense mechanism your body
engages in and is not
hyperalgesia."
A stabilizing of symptoms when
opioids are increased should be a
tip-off that the patient has in fact
developed a tolerance to the drugs,
and the response should help to
disprove a diagnosis of
hyperalgesia.
Conversely, with hyperalgesia, there
may also be an initial response, but
the relief is typically fleeting
Importantly, clinicians should rule
out other factors, including the
progression of a disease, such as
cancer, or a new injury causing new
pain.
Additionally, hyperalgesia should not
be mistaken for allodynia. Whereas
hyperalgesia is characterized as a
painful response to painful stimuli,
allodynia involves oversensitized,
increased pain in response to even
nonpainful stimuli, such as just
brushing against the skin.
AMDA Elements of C-II Fax

To expedite filling of a controlled
substance prescription:
Always carry a prescription pad that
meets your state’s requirements.
 Know what information is required for
a controlled substance prescription to
be legal.

C-II required elements:
Date of issue
Patient’s name and address (a nursing
facility is the address for the resident)
Practitioner’s name, address and DEA #
Drug name
Drug strength
Dosage form
Quantity prescribed
Directions for use
Number of refills (if any) authorized
Manual signature of prescriber
Colorado Regulation for Faxed C-II
 Must
be faxed by the prescriber or
their agent
 Must
have “LCTF” or “Hospice”
written on prescription when
received by the pharmacy
C-II Control Medications
A
Prescriber with a DEA license
can request an emergency supply
by calling the pharmacy and
talking to a pharmacist
 Electronic Prescribing is possible
 EPCS (electron prescribing of control substances)
 Surescripts and OmniviewDr are
current options