To put the hot-button topic of opioids in perspective for the long term and post-acute care (LT/PAC) community, Provider spoke to a pair of clinical care thought leaders on pain management.

Steven Levenson, MDThe first, Steven Levenson, MD, regional medical director with Genesis HealthCare, says the opioid crisis didn’t come without warning and is best served in the LT/PAC care setting by sticking to the fundamentals of more precise diagnosis and care planning.

“Regardless of whether we agree that it is a ‘crisis,’ the challenges posed by opioid dependency and the need for safe and effective opioid prescribing have permeated the entire country,” Levenson says. “Illicit and excessive use of controlled substances now impact virtually every suburban, urban, and rural locale in the U.S. There is no escape from having to face the opioid problem.”

To ensure providers are on top of the issue, he says the clinical care team, as well as administrative overseers, must take an orderly approach to managing pain, regardless of whether opioids are part of the pain management plan.

This, Levenson says, may seem intuitive for providers, but from his experience in working as a regional medical director and case reviewer in several dozen states around the country, it became clear that vital steps were being missed.

“We started looking at data and realized that facilities that have a lot of patients on opioids not only often had worse pain measures, but also had more falls and tended to have a lot of psych meds in use as well,” he says. “We realized there was something wrong with this picture.

“That is when we also realized that a lot of the time people were not connecting opioids as a major cause of behavior issues. They were shortchanging some key steps in the care delivery process, including problem definition and cause identification. There was a rush to get to the bottom line by giving things [many times opioids] that may not be indicated or don’t work.”

Opioids Not Evil

Levenson cautions that as he speaks about opioids and pain management within his own organization and as a speaker before groups like the American Health Care Association/National Center for Assisted Living, he does not believe opioids are inherently “evil,” but he also recognizes that these medications have limits and major risks, and they are often not indicated or could be used more sparingly.

“We realized that we needed to try and get control of it, and we put a number of processes in place looking at pain management, not just treating it acutely or in isolation but also viewing it more broadly,” he says.

A Puzzle in Need of Solving

Care planning is like trying to solve an intricate puzzle. “Use of the care delivery process is all-important,” Levenson says. He notes that a description of the full care delivery process is actually embedded in Chapter 4 of the Resident Assessment Instrument (RAI) Manual, which also warns everyone that the Minimum Data Set and RAI alone are often not enough to manage complex problems.

The interdisciplinary team must view all symptoms—including pain—in the proper context, not just in silos. And, from understanding what is needed to treat pain and the general issue of caring for a resident, Levenson and others he worked with put together a plan.

The process works and does not require a facility to use a special pain team. “You simply need pain management to follow the care delivery process,” he says. “And that includes the critical step of recognition and problem definition, and number two, cause identification and diagnosis. Number three is management of both pharmacological and nonpharmacological methods, and four is monitoring, which is sort of like rebooting the whole process.

“Opioids may fit in when you have gone through the steps and asked what issues and causes are in play, and then you come up with a plan, ruling out other things and narrowing it down to opioids that are indeed appropriate for these patients,” he says.

Rethinking Plays a Role

Providers in the LT/PAC setting know that pain management is challenging under the best of circumstances. While treating a simple headache could be a case of giving someone Tylenol, a resident with chronic diseases or complications may present an array of issues. And, Levenson says, unlike in days gone by, the challenges are multiplied by the bevy of drugs available, often leading to serious interactions with drugs in many other categories given for unrelated reasons such as muscle relaxants, antiepileptics, and anxiolytics. 

“There is also the political and regulatory pressure to treat pain,” he says. “The politicization of medical issues is invariably problematic because it typically leads to unintended consequences that are often not recognized, or may be ignored in the rush to deal with the problem.”

While all analgesics have limitations and risks, and opioids definitely have an important place in treating pain, the tendency in recent years was to downplay or overlook complications of long-term opioids that go well beyond addiction, such as anorexia, apathy, cognitive impairment, psychotic symptoms, and urinary retention.

“Ultimately,” Levenson says, “pain can be managed safely and effectively in most cases—but only by taking a systematic, thoughtful approach that addresses the symptom and uses all medications and treatments judiciously.”

Measuring the ImpactKarl Steinberg, MD

Another voice on the issue of opioids is Karl Steinberg, MD, CMD, chief medical officer, Mariner Health Central. He works often in the palliative care space and says that while opioids and the abuse of the drugs in general are very worrying and in need of action, there is also a need to not “throw the baby out with the bath water” when it comes to pain management in LT/PAC.

“Yes, historically the drugs have been overutilized, but on the other hand they are exceptionally useful meds, and we shouldn’t let scrutiny and overregulation and other roadblocks for prescribers get in the way of giving our patients what they need,” he says.

Steinberg says he has seen people who really need strong pain medicine and instead of getting opioids, are being managed with treatments or Tylenol or ibuprofen. “I think that is of concern,” he says.

To his point, while there is an opioid crisis in the country, “we don’t have an opioid crisis in nursing homes.” Steinberg says that is because the medications are administered by nursing staff, so patients can’t just take a handful of pills and overdose. Also, while diversion of meds by nursing staff is known to occur occasionally, “Fear of diversion is overblown. Most facilities have really good policies on destruction of unused meds.”

The needs of a skilled nursing resident demand efforts to manage pain, and that means providers must be smart on strong medications but not shy about assisting when the situation calls for it, Steinberg says.

“There are also lots of good other medications [or therapies] that we can use, sometimes in conjunction with opioids and sometimes alone,” he says. “There is the geriatric principle, ‘start low, go slow,’ but go. 
That has to apply to opioids too. Start with something else and climb the ladder. If you need opioids, give them, and if that does not work, kick it up, and if that doesn’t work at all go to something else.”

Avoiding Drugs Altogether

Steinberg says nonpharmacological methods are a definite positive in many cases, with “pretty good evidence” some of these programs work. “There is clinical evidence about some of the manipulative therapies and modalities that a physical therapist may do, as well as acupuncture and cognitive behavioral therapy, which can be super helpful.”

Out of all the possible medication management plans, it is important for the clinical team to create realistic expectations for residents and their loved ones.

“This is true of everything, not just pain,” Steinberg says. An example would be if the facility has an 80-year-old with severe osteoarthritis, there is not much likelihood of getting the pain level to zero, he says.
“So, you say let’s talk and have a Plan B,” he says. Such a plan might consist of giving them medications they need to live out the final stages of their life without pain, versus concerns about addiction or being able to participate in various resident activities.