By S. Van McCrary, Health Law & Policy Institute
A recent study published in the Journal of the American Medical Association suggests that untreated pain is a serious problem in nursing home residents, and is especially prevalent among older residents and members of ethnic minorities.*
Despite clear evidence that appropriate use of analgesics can relieve pain in over 90 percent of cases, a high prevalence of unrelieved cancer pain has been documented in numerous clinical settings including oncology wards, surgical and general medical units, and pediatric wards. Similarly, pain among the aging population has been historically underreported and undertreated, and insufficient attention has been paid to management of pain in nursing homes. In an effort to quantify the prevalence of untreated pain in long term care facilities, an interdisciplinary public health team conducted research in five states (Kansas, Maine, Mississippi, New York, and South Dakota) among a sample of 13,625 patients. Measures of pain levels included self-reports from patients and reports from assessors who observed non-verbal indications such as grimacing and moaning. Amounts and types of analgesics prescribed were also recorded.
Daily pain was noted in 24-38 percent of the nursing home patients, depending on patients' ages. Of the patients with daily pain, only 26 percent received morphine, while 32 percent received an intermediate strength pain reliever, and 26 percent received only aspirin or acetaminophen. Twenty-six percent of nursing home patients in daily pain received no pain-relieving medication at all. Among those patients in daily pain, persons older than 85 years of age or of minority race were more likely than other patients to receive no pain medication. The researchers suggested that financial issues were unlikely to account for this finding because all patients studied had Medicare coverage extended to cover medication costs. The researchers offered no data on social, cultural, or economic factors that might explain these findings.
This study raises numerous policy concerns. Because length of hospital stays are decreasing and the elderly portion of the population is increasing, nursing homes are increasingly likely to treat complex medical problems and face rapidly-growing numbers of residents. If this study is indicative of quality of such facilities, it raises serious questions about the well-being of residents in such facilities, especially older and minority residents. The authors of the study note that a practical approach is needed to address this problem and that known barriers to adequate pain relief should be taken into account and eliminated, for example: unwillingness of many nursing homes to stock opioid pain relievers; inadequate staff to monitor frequent administration of analgesics; and failure of many physicians to use opioid analgesics aggressively. The study's authors boldly state that failure to prevent or relieve pain should be considered a primary indicator of poor quality medical care. It remains for the general public to make the same connection. Once that occurs, public pressure may provide stronger incentives for health care providers and facilities to improve their practices regarding pain control.
* Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer. JAMA 1998; 279 (23): 1877-1882.