Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
University of Maryland School of Pharmacy, Peter Lamy Center on Drug Therapy and Aging, and Center for Successful Aging at MedStar Good Samaritan Hospital, Baltimore, MD, USA.
J Am Med Dir Assoc. 2021 Jun;22(6):1199-1205. doi: 10.1016/j.jamda.2020.12.029. Epub 2021 Jan 23.
Despite the dynamic demands in the nursing home (NH), a definitive approach to managing chronic pain in older adults has yet to be established. Due to concerns for potential adverse pharmacologic effects, balancing appropriate pain management is a challenge among NH residents. The challenges encompass but are not limited to medical complexities, functional disabilities, and physical frailty. Barriers to the successful implementation of a comprehensive chronic pain management at the NH may include ambiguous directions on specific therapeutic interventions, insufficient guidance on treatment duration, and limited available treatment options. The Centers for Medicare and Medicaid Services' reporting requirement of adequate pain control among NH residents coupled with widely variable clinician-prescribing habits highlights the difficulties in overcoming the preceding challenges and barriers. The Coronavirus Disease 2019 (COVID-19) pandemic has further complicated pain management due to its negative consequences on well-being of residents of NHs. Associated symptoms of psychosocial stress, anxiety and depression, and chronic pain symptoms can exacerbate during the COVID-19 pandemic, leading to increased requirement for pain medications including but not limited to opioids. Pain is a multidimensional symptom and requires a strategic multimodal approach for its management. 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. Short-acting opioids are preferred over extended-release/long-acting opioids for chronic pain. Clinicians are encouraged to engage residents in proactive strategies in managing their pain, and to set realistic expectations toward improving their quality of life, as complete elimination of pain is not feasible in most cases. This review article provides the interdisciplinary team with a contemporary perspective of the multitude of changes and challenges influencing the prescribing as well as deprescribing of various pain medications.
尽管养老院（NH）的需求不断变化，但尚未确定管理老年人慢性疼痛的方法。由于担心潜在的药物不良反应，平衡适当的疼痛管理是 NH 居民面临的挑战。这些挑战不仅包括医疗复杂性、功能障碍和身体虚弱，还包括但不限于这些。在 NH 成功实施全面慢性疼痛管理的障碍可能包括特定治疗干预措施的方向不明确、治疗持续时间的指导不足以及可用治疗选择有限。医疗保险和医疗补助服务中心（Centers for Medicare and Medicaid Services）对 NH 居民充分控制疼痛的报告要求，加上临床医生处方习惯的广泛差异，突出了克服前面提到的挑战和障碍的困难。2019 年冠状病毒病（COVID-19）大流行对 NH 居民的幸福感产生了负面影响，进一步使疼痛管理复杂化。与 COVID-19 大流行相关的心理社会压力、焦虑和抑郁以及慢性疼痛症状的症状会加剧，导致对疼痛药物的需求增加，包括但不限于阿片类药物。疼痛是一种多维症状，需要采用战略多模式方法进行管理。非药物模式在 NH 环境中未得到充分利用，是轻度疼痛的首选第一步，非阿片类药物可以作为第二步添加，以产生中度至重度疼痛的协同作用。阿片类药物应作为最后的手段。对于慢性疼痛，短效阿片类药物优于缓释/长效阿片类药物。鼓励临床医生让居民参与积极主动的策略来管理他们的疼痛，并对改善他们的生活质量设定现实的期望，因为在大多数情况下，完全消除疼痛是不可行的。这篇综述文章为跨学科团队提供了一个当代视角，了解影响各种疼痛药物处方和停药的众多变化和挑战。
