Hello, and welcome to another episode of the TMF Quality Innovation Network’s podcast series on opioid safety in nursing home patients. I’m Dr. Clifford Moy, the behavioral health medical director at TMF Health Quality Institute, a leading non-profit health care consulting organization based in Austin, Texas.
I'm joined by Dr. Paul Milligan, a clinical pharmacist. Today we are speaking about multimodal pain management.
Good morning, Dr. Milligan. How are you today?
Hi. Good morning, Dr. Moy. Doing well.
Great. In our previous conversation that we had in discussing this particular podcast that we're recording, you talked about multimodal pain management. Tell us about that.
Yeah. It's probably the best choice, I think. The AMDA guidelines in pain talk about use of non-pharmacologic comfort interventions. It kind of sounds like they might not be very effective-- but distraction, relaxation, massage, heat and cold. I talked about ice packs and things before.
Changing patients' positioning-- these are things that nurses are doing all the time. I imagine it's the same reason they bring in pets into the nursing home periodically, to distract patients for a little while. They have story time. They do a lot of different things already.
But those have to be-- yeah, I don't know if you have to prescribe any of those things, like a massage or things like that. But those would be-- or ice packs and cold packs, initially. Those do wonders. And so that probably needs to be the first choice is the non-pharmacologic as kind of your foundation.
And also on your foundation could be some non-opioid foundation to add to that for pain treatment-- maybe topical agents, maybe Bengay, some of those kind of things like that, the warmth, heat and cold massage, pet therapy.
So we used to see providers giving acetaminophen around the clock to work to reduce the opioid burden. And it seems to be it might work in a hospital setting. But it's conflicting data on nursing homes. So I'll leave that up to providers who have tried it.
Again, you'd want to be careful of the dose because of liver toxicity. But again, conflicting in nursing homes-- it, for some reason, doesn't seem to be as effective.
Is it the required frequency of the dosing for--
Well, it might be that. Right. And it may be that it's missed doses, things like that. And it was just unclear why. There were some positive studies, and some that showed that it didn't have any effect in reducing opioids in the nursing home-- but certainly worth a try.
And it has to be around the clock to do that. And then you can add a stepwise order for breakthrough pain, a short-acting opioid for breakthrough pain. So that kind of stepwise process is, again, what we moved to in our hospital. Instead of doing by pain scores, we said, you have to fail this before we go to that. They have to fail this before we go to that, to the next thing.
And it gives the provider a little bit more control and probably get fewer phone calls if you do it that way. You get some synergism with the different therapies and minimizes the opioid use and might be the most effective. And you also get less opportunity for therapeutic duplication if you have another provider involved.
And if I'm going to go from a combination opioid, like Vicodin, to an individual opioid, you would stop the first one and then go on to the next one, without having them both at the same time. And then nurses seem to like it, especially if it works. So there are less parenteral doses. There's improved pain management, sometimes fewer side effects, as well.
It would seem with any type of PRN medication in a nursing home setting, keeping track of that, having regular team meetings to assess moving those-- there's a need to move a PRN to a regular dosing schedule to make it more predictable and simpler for the staff. That would seem to be very important.
And certainly, keeping track of the total acetaminophen dose for a patient is vitally important. I've seen that happen in a lot of cases where, like you had mentioned, there's a prescription for Vicodin and then Tylenol on top of that. And pretty soon, you end up with some significant liver issues.
Right. Yeah. And you've touched on a good point there about this part in all of this about charting it and keeping track and report. I love nurses. My wife's a hospital nurse.
Nurses are really good at charting the medications that are done on a schedule, and they're less good at charting medications that are given PRN. And so it's oftentimes that the PRN dose, which is given at a weird time, 1:30 when they gave all their meds at noon, and they went through and they just click, click, click, click, click and charted all the meds were given.
And now, we've got to remember to go back in the computer and chart that I gave them that 1 o'clock PRN Vicodin. And so that might get skipped. And then the next nurse comes in to the patient. And she looks like, oh, well, they didn't give that PRN dose. I can still give it every four hours or every six hours or whatever it was.
So scheduling them works out pretty well. And they're more likely to get them, too.
Yes. Mm-hmm. And I would assume that at some point, as we discussed earlier, the improved inventory management of medications could help illustrate the documentation of PRN medications also and improve that process.
Yeah. Chief pharmacists are responsible for all of the drugs. All of the opioids either have to be given or returned or wasted. And so that's why they're pretty careful about that. And they get audited frequently on every single dose.
And also, the government has been trying to reduce the supply. So they've given so many kilograms of fentanyl can be made and sold in the United States in 2020, period. And every year, they've been reducing that. So that's why we've had shortages of opioids.
And they've repealed that now because of the shortages that were occurring because of the increased pain medications that were needed on COVID patients. And then they'll probably reinstate it again by, every year, just chopping down the amount that can be in the US. And so that's part of the shortage issue, if providers are seeing shortages in some of the drugs they're prescribing is that they are just controlled.
Earlier, you had mentioned that falls in nursing homes are a really big deal and a leading cause of hospitalizations from nursing homes and other adverse events. Let's talk about falls. What do we know about falls in nursing homes?
Yeah. Without even talking about opioids, nursing home falls are incredibly common, with a lot of patients dying. 1,800 die every year from injuries in nursing homes, nursing facilities. And then the ones who don't die after these falls, you have all these reduced quality of life. They might have a fracture, things like that.
So again, getting back to a number that makes a little bit of sense, a typical nursing home with 100 residents has about 100 to 200 falls a year. And not all of these are related to opioids, but most of them are, they try to get up there. And you know what all the causes are.
There are lots of problems there because of cords and high beds and cushions and trying to go to the bathroom by themselves. But a lot of these result in fractures. Some result in some type of fracture, muscle weakness.
Patients don't have a good gait when they're there. There's poor lighting. There's equipment to trip over. But if you add a sedating medicine to this, like an opioid or a benzo, it really increases the risk of falls.
Studies are pretty clear. Within the first three days of starting one of these new drugs, it really increases the risk of falls within the first three days of initiation. So you want to be really careful with that when you're starting one of those drugs. That's going to happen.
Independent risk factors for falls are vision impairment. Patients who are afraid of falling often fall. Patients who are taking angina meds, because of the lightheadedness, fall a lot. And of course-- pardon me?
Hypotension-- the orthostatic, just getting out of bed. But opioids, the odds ratio is over five. So it's almost five times the relative risk of having a fall if you're on an opioid versus not. So that's the medicine's role in that.
Right. Is poor oral intake also a side effect of opioids?
Yes. Well, I don't know if poor oral intake is a side effect, but adequate nutrition is protective. So if you do eat enough, if the patient's been eating OK-- and that means probably getting good fluids. It might be related to the orthostatic hypotension that you mentioned.
And having a caregiver in there getting you up and taking you is protective. But trying to find some good news in this is that if a patient's nutrition is adequate, which probably I'm sure includes fluids, that is something that was protective.
What's the risk of confusion, both in falls and from opioids?
What was the risk of confusion?
Yes. Are confused patients more likely to fall? And do opioids cause or precipitate more confusion in patients receiving them?
Well, yeah. Any central nervous system drug, including sleeping medications-- and just obviously, being in a nursing home may be a different place for them that they've been before. And so they, especially in the middle of the night, wake up and not sure where they are.
Opioids, benzos, any sedating medication, like I said, anti-epileptics-- anything that affects the sedation level can add to the confusion of it, too. And again, they're additive when you give them together.
Right. Yeah. And regular sleep is the goal of many, many patients and staff in nursing homes.
And it's not to be taken lightly. Sleep is an important component of our health and our mental health. So trying to get that better regulated is important. Your thoughts about trying to achieve that? And are there any medications or therapies that we believe are effective?
Yeah, I think sleep, as you said, is a big deal. Insomnia's pretty high. 2/3 or so people are probably having some type of insomnia. And it gets worse as you get older, whether you're living at home or living in a skilled nursing facility. And it can get chronic in later life. It just decreases your quality of life.
This lack of sleep, it increases your risk of falls, increases dementia. If you're not sleeping, it complicates a lot of these other issues. And so then typically, it's treated pretty regularly with sedative hypnotics. But those have their problems, as well.
Again, they increase risk of falls. They cause memory loss, confusion. And the big one, which I think everybody's aware of, especially in the community, where you do have to get up and maybe drive or get up and fix your own breakfast and things like that, there's this residual morning sedation.
You're almost sleepwalking with some of these long-acting drugs. And it just gets to be worse with elderly who are already metabolizing these drugs slower. And then the risk of tolerance, because if you have chronic sleep issues as you get older, then you take these drugs for longer than they're prescribed-- not longer than they're prescribed, but they take them for a longer period of time because of their prolonged use.
So there is a risk of tolerance, because most of these drugs were studied to be used for short-term insomnia and not for long-term. So there's not very much evidence to support their use for longer-term, because some tolerance comes. You still might get the side effects, but you still might not be able to sleep much. And when you told them to take a half a tablet-- like zolpidem for women is particularly high-risk, another FDA warning asking to give a smaller dose of that.
And then providers are probably pretty familiar with the Beers Criteria. American Geriatrics Society comes out with this Beers Criteria and just recommends drugs that are to be avoided in patients who are elderly and geriatric patients. And they really pooh-pooh these. They have a strong recommendation against using any of these benzos or non-benzo hypnotics in older adults.
So if you're following those, then you might use some other doctors-- I've seen prescriptions for antihistamines, antidepressants, even antipsychotic medications. But they come with some of their own problems. So the Beers Criteria actually recommend no pharmacologic treatment at all.
So again, you don't want to feel helpless. So there are some natural products that you could use, maybe. I know Benadryl is being used. It used to be used pretty commonly. Benadryl and the antihistamines and the other anticholinergic drugs, they have dry mouth, blurred vision, memory problems-- probably constipation even I added into that.
And it's questionable about whether it contributes to respiratory depression with an opioid, because I've wondered it myself. In the inpatient setting, we use Benadryl periodically and trying to figure out if that's something that we should throw into our algorithm. And it's just unclear. We use it a lot. Patients don't like it too much because of the dry mouth and not waking up and residual morning tiredness.
Sure-- builds the sensorium.
Pardon me? Yeah.
Builds the sensorium.
So melatonin is one that might work, too. But it's unregulated. I guess if you prescribe it at your nursing home, you probably are getting maybe not an FDA-approved, but at least a reputable manufacturer. And it can still cause some residual sedation.
And again, the studies that I've looked at on this, small doses might be the best. I've seen doses at Walgreens for up to 10 milligrams. And the initial studies with this, when I looked at this a long time ago, were with a half a milligram. that's 1/20th of the dose.
That's a huge difference.
Right. And these studies, a half a milligram is enough for most people to bring your melatonin levels back to when you were a kid a day. And anything more than that probably is not needed.
And so if I was going to give some guidance on melatonin, if you wanted to try it, I would say the smaller dose is better. It works better. It probably doesn't cause a residual-- fewer adverse drug events. Doesn't seem to have a lot of any interactions or anything like that.
And those are all the medical treatments. And then there are some non-medical treatments, too.
What are some of those?
So again, these are stimulus control, which is really just saying that it's for sleep. When you go to bed, get it dark. Turn off all the lights.
Stimulus control and sleep restriction, which are very similar, are the ones that have the best evidence that it does work. So I just kind of summarize them as "bed is for sleep and not for anything else." So make sure the room's dark.
And then make sure when you do get sleep restriction, that you're not going to bed and watching TV and then turning it off to try to go to sleep, because there's kind of a-- and Dr. Moy, you may know better than me the psychological part of just getting into bed, pulling up the covers. It means it's time for sleep. And if you're doing a lot of things in bed-- laptops and television-- there isn't much difference.
That blue light under the pillow is not a good idea.
Yeah. There are a few things that don't work very well. There's non-medical treatment that doesn't have much evidence. And that's even sleep hygiene.
You would think, just don't drink coffee before you go to bed. And don't eat right before you go to bed doesn't seem to have a lot of evidence. Maybe it's not been studied very well. And just sleep education-- just saying, count sheep and all that kind of stuff.
So I guess overall, with sleep recommendations, combining those two, I would start with the non-medical treatments, I guess, if you can. Reserve the benzos as a last resort. There's a drug, ramelteon. I've only known it as the generic name. I had to look up the brand name, which is Rozerem, is the shortest half-life.
So I guess if you were going to start with one, that at least has the potential to have less residual problems with ramelteon. Probably not use antidepressants unless patients also have underlying depression-- no reason to add those side effects for it. Don't use it antipsychotics, especially with opioids.
And then gabapentin-- I know doctors are prescribing that sometimes for sleep because of restless legs syndrome and patients who have neuropathic pain and insomnia. So that might be useful in patients. Some patients still have morning sedation from it. And be especially careful if you are going to use gabapentin at night with opioids, as well, because I already talked about that interaction.
Well, it's a lot to consider. And we do have some new medications. We've thrown out some old medications. And certainly, at least in my experience, sleep hygiene. Don't exercise before bedtime. Don't smoke or drink, use alcohol, consume alcohol, or caffeine close to bedtime are all important considerations.
But looking at overall where we are today with opioids in the nursing home setting, do we have a crisis? Or have we largely dealt with it?
Well, I guess it depends on your perspective, that pretty clear that we should reserve opioids or reduce or avoid it as much avoid it as much as possible because of the side effect profile of that and increase to falls and some serious, serious adverse events. I don't think we need to worry too much about-- we didn't talk about tolerance and about addiction to them.
But I don't know that we can just-- like all of medicine is, you've got to balance that out. So we don't want to avoid opioids for acute severe pain, not at the expense of the resident's quality of life. So I guess I don't want to give the impression that we should just stop opioids on everybody and avoid them.
But avoid them as much as possible, but not at the expense of the quality of life of the resident. And I know that's what providers always have in mind. And if you do start them on an opioid, have a plan for tapering them off whenever possible. And for acute pain, that works.
You should have a plan on tapering them off. Again, sometimes, nursing homes will force you to do that by having you rewrite all of their orders every certain number of days or weeks. And again, part of the issue is that nursing home patients, it's just not a well-studied area for the role and impact of opioid use in nursing homes. They just don't get in the initial studies. And there could still be some more work done in that area.
Dr. Milligan, thank you for discussing the opioid issue in nursing homes with us today. We wish you well, and we hope our audience has enjoyed this podcast. Thanks again.
My pleasure. Thanks for having me.
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