Pain Management Strategies in a SNF: Part II
Non-pharmacologic interventions may help manage pain effectively when used either independently or in conjunction with pharmacologic agents. Examples of non-pharmacologic approaches may include, but are not limited to:
Altering the environment for comfort (such as adjusting room temperature, tightening and smoothing linens, using pressure redistributing mattress and positioning, comfortable seating, and assistive devices).
Physical modalities, such as ice packs or cold compresses (to reduce swelling and lessen sensation), mild heat (to decrease joint stiffness and increase blood flow to an area), neutral body alignment and repositioning, baths, transcutaneous electrical nerve stimulation (TENS), massage, acupuncture/acupressure, chiropractic, or rehabilitation therapy.
Exercises to address stiffness and prevent contractures.
Cognitive/Behavioral interventions (e.g., relaxation techniques, reminiscing, diversions, activities, music therapy, coping techniques and education about pain).
Pharmacological interventions considerations:
The regimen considers factors such as the causes, location, and severity of the pain, the potential benefits, risks and adverse consequences of medications; and the patient's desired level of relief and tolerance for adverse consequences. The patient may accept partial pain relief in order to experience fewer significant adverse consequences (e.g., desire to stay alert instead of experiencing drowsiness/confusion). The interdisciplinary team works with the patient to identify the most effective and acceptable route for the administration of analgesics, such as orally, topically, by injection, by infusion pump, and/or transdermally.
It is important to follow a systematic approach for selecting medications and doses to treat pain. Developing an effective pain management regimen may require repeated attempts to identify the right interventions. General guidelines for choosing appropriate categories of medications in various situations are widely available.
Factors influencing the selection and doses of medications include the patient's medical condition, current medication regimen, nature, severity, and cause of the pain and the course of the illness. Analgesics may help manage pain; however, they often do not address the underlying cause of pain. Examples of different approaches may include, but are not limited to: administering lower doses of medication initially and titrating the dose slowly upward, administering medications "around the clock" rather than "on demand" (PRN); or combining longer acting medications with PRN medications for breakthrough pain. Recurrent use of or repeated requests for PRN medications may indicate the need to reevaluate the situation, including the current medication regimen. Some clinical conditions or situations may require using several analgesics and/or adjuvant medications (e.g., antidepressants or anticonvulsants) together. Documentation helps to clarify the rationale for a treatment regimen and to acknowledge associated risks.
As the patient ages, we are faced with a higher potential for multiple drug-drug and drug-disease interactions. When treating pain in this population, the benefits and risks of rational polypharmacy may be more complex compared to the population at large. The most common reason for constipation due to medications is pain medications.