Read A99020RCK:- text version

TREATING PAIN IN THE ELDERLY

SIDE ONE

LIST OF POSSIBLE PAIN MEDICATIONS*

GENERIC NAME

© 2009 American Society of Consultant Pharmacists

BRAND NAME

Tylenol Excedrin Cephadyn, Phrenilin, Promacet, Sedapap Fioricet with Codeine, Phrenilin with Caffeine and Codeine Panlor DC, Panlor SS, Tylenol w/Codeine No. 2, Tylenol w/Codeine No. 3, Tylenol w/Codeine No. 4

GENERIC NAME

Benzocaine Solarcaine Benzocaine, Butamben, and Tetracaine Bromfenac Bupivacaine Bupivacaine and Epinephrine Buprenorphine Butorphanol Capsaicin Cetylpyridinium and Benzocaine Chloroprocaine Cocaine topical solution Codeine Celecoxib Dibucaine Diclofenac Diclofenac and Misoprostol Diflunisal Duloxetine Ethyl Chloride Ethyl Chloride and Dichlorotetrafluorethane Etodolac Fenoprofen Fentanyl Floctafenine Flurbiprofen Gabapentin Hexylresorcinol Hydrocodone and Ibuprofen Hydromorphone Ibuprofen Indomethacin

BRAND NAME

Dermoplast, Lanacane, Cetacaine, Exactacain Xibrom Bupivacaine Spinal, Marcaine, Marcaine Spinal, Sensorcaine Marcaine with Epinephrine, Sensorcaine with Epinephrine, Buprenex or Subutex Arthricare, Capzasin-P

GENERIC NAME

Ketoprofen Ketorolac

BRAND NAME

GENERIC NAME

Opium Tincture Oxaprozin Oxycodone Oxycodone and Acetaminophen Oxycodone and Aspirin Oxycodone and Ibuprofen Oxymorphone Paregoric Pentazocine Pentazocine and APAP Pentazocine and Naloxone Phenazopyridine Piroxicam Pramoxine

BRAND NAME

Daypro Oxycontin, Roxicodone, OxyIR, Endocet, Percocet, Roxicet, Tylox Endodan, Percodan Combunox Opana, Opana ER

Acetaminophen Acetaminophen, Aspirin, and Caffeine Acetaminophen and Butalbital Acetaminophen, Butalbital, Caffeine, and Codeine Acetaminophen, Caffeine, and Dihydrocodeine Acetaminophen and Codeine

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Acetaminophen, Codeine, and Doxylamine Acetaminophen and Excedrin PM, Tylenol PM Diphenhydramine Acetaminophen and Lortab, Lorcet, Norco, Vicodin, Hydrocodone Vicodin ES, Vicodin HP, Lortab Elixir Acetaminophen, Amidrine, Duradrin, Midrin, Isometheptene, Miratine and Dichloralphenazone Acetaminophen and Midol, Tylenol Women's Pamabrom Menstrual Relief Acetaminophen and Alpain, BeFlex, Flextra-DS Phenyltoloxamine Acetaminophen and Ornex Maximum Strength, Pseudoephedrine Ornex Acetaminophen and Ultracet Tramadol Articaine and Epinephrine Septocaine with epinephrine, Zorcaine Aspirin Aspirin, Butalbital, Fiorinal with Codeine Caffeine, and Codeine Aspirin, Caffeine and Synalgos-DC Dihydrocodeine Aspirin and Codeine Aspirin w/Codeine No. 3, Aspirin w/Codeine No. 4 Aspirin and Hydrocodone Lortab ASA Belladonna and Opium B&O Supprettes

Nesacaine, Nesacaine-MPF

Celebrex Nupercainal Voltaren, Voltaren-XR Arthrotec Dolobid Cymbalta Gebauer's Ethyl Chloride Fluro-Ethyl Lodine, Lodine XL Nalfon Actiq, Duragesic, Sublimaze Idarac Ocufen Neurontin Sucrets Original Ibudone, Reprexain, Vicoprofen Dilaudid Advil, Ibu, Midol, Motrin, NeoProfen Indocin

Sprix, Acular LS, Acular, Acular PF, Acuvail Levorphanol Levo-Dromoran Lidocaine Lidoderm, Topicaine, Xylocaine Lidocaine and Epinephrine LidoSite, Lignospan Forte Lidocaine and Prilocaine EMLA, Oraqix Lidocaine and Tetracaine Pliaglis, Synera Maltodextrin Carrington Oral Wound Rinse, Multidex Meclofenamate Meclomen Mefenamic Acid Ponstel Meloxicam Mobic Menthol Absorbine Jr, Flexall, Vicks (w/ or w/out Camphor) VapoRub Meperidine Demerol Mepivacaine Carbocaine, Polocaine, Polocaine Dental, Polocaine MPF, Scandonest 3% Plain Mepivacaine and Carbocaine 2% with Neo Levonordefrin Cobefrin, Polocaine Dental with Levonordefrin, Methadone Dolophine, Methadone Diskets Methotrimeprazine Methyl salicylate Banalg, BenGay, Icy Hot, (w/ or w/out Menthol) Salonpas, Thera-Gesic Milnacipran Savella Morphine MS Contin, Oramorph SR, Avinza, Kadian Morphine and Naltrexone Embeda Nabumetone Relafen Nalbuphine Nubain Nepafenac Nevanac Naproxen Aleve, Anaprox, Naprelan, Naprosyn Naproxen and Vimovo Esomeprazole Naproxen and Prevacid, NapraPAC Lansoprazole

Talwin Talacen Talwin Nx Azo-Standard, Podium Feldene Caladryl Clear, Itch-X, Proctofoam NS, Sarna Ultra Pregabalin Lyrica Prilocaine Citanest Plain Dental Prilocaine and Epinephrine Citanest Forte Dental Procaine Novocain Proparacaine and Flucaine Fluorescein Propoxyphene Darvon Ropivacaine Naropin Sulindac Clinoril Sumatriptan and Treximet Naproxen Tapentadol Nucynta Tetracaine Pontocaine Niphanoid, Pontocaine Tetrahydrocannabinol and Cannabidiol Tiaprofenic Acid Tolmetin Tolectin Tramadol Ultram, Ultram ER, Ryzolt, Rybix ODT Trolamine salicylate Aspercreme Ziconotide Prialt

A99020RCK

(Rev. 12/10)

*This list has not been created nor endorsed by the Centers for Medicare & Medicaid Services (CMS). Some medications fall into a "grey" area, and the only clarification provided by CMS is: "Code a medication in Section J if it is primarily being used to treat pain." Therefore, some medications not on the list may be coded as a pain medication if it meets the definition provided in the RAI User's Manual and is primarily used to treat pain. Alternatively, some medications on this list may be used for non-analgesic indications, and in those situations, they should not be coded in Section J of the MDS 3.0.

SIDE TWO

NON-OPIOID ANALGESICS

Acetaminophen First line of therapy in treating mild to moderate pain of musculoskeletal origin. Total dose should not exceed 4 grams/day. In patients with renal or hepatic dysfunction, the dose should be reduced by 50% to 75%. Effective for minor pain and arthritis in most patients. Important to monitor for gastrointestinal effects such as bleeding. Further research is needed to confirm the efficacy and toxicity of glucosamine therapy in treating pain associated with osteoarthritis.

Avoid in renal dysfunction. May be associated with gastric toxicity, edema, and hyper-tension in the elderly. Use of more selective COX-2 inhibitors is associated with an increased cardiovascular risk.

ADJUVANT ANALGESICS (continued)

Anticonvulsants Clonazepam

(Klonopin®) Clonazepam may cause gait disturbances, incoordination, ataxia, and behavior changes and is NOT recommended in the elderly.

Aspirin Glucosamine NSAIDs (non-steroidal anti-inflammatory drugs) ­ ibuprofen, indomethacin, naproxen, celecoxib, etc.

Gabapentin (Neurontin®) Lyrica (Pregabalin®) Topical Analgesics Lidocaine patch 5% Capsaicin

Monitor for sedation, ataxia, and edema. In one study*, combination therapy of gabapentin and morphine achieved better analgesia at lower doses of each drug than either as a single agent. The gabapentin dose should be adjusted based on creatinine clearance. FDA approved for diabetic peripheral neuropathy and postherpetic neuralgia. The pregabalin dose should be adjusted based on creatinine clearance. For relief of pain associated with postherpetic neuralgia. Apply only to intact skin. Maximum of 3 patches can be applied at one time. Cover most painful areas up to 12 hours per day. May cut to size. Produces a burning sensation at the application site with minimal pain relief. Avoid eye area. May take 14 days to reach maximum effect. Painful bone metastases may be managed with bisphosphonates. However, there is concern about the development of osteonecrosis of the jaw associated with the use of bisphosphonates. Bisphosphonates may also be associated with causing bone, joint, and/or musculoskeletal pain. Used for the treatment of skeletal muscle spasms. Monitor for sedation and anticholinergic effects (urinary retention, constipation, dry mouth, memory impairment, blurred vision, orthostatic hypotension, etc.). Avoid stopping medication abruptly. Use lowest possible dose to prevent chronic steroid effects; monitor for fluid retention and glycemic effects.

ADJUVANT ANALGESICS

Tricyclic Antidepressants Amitriptyline

Avoid in elderly due to its possible cardiac arrhythmias, sedation and anticholinergic effects (urinary retention, constipation, dry mouth, delirium, blurred vision, orthostatic hypotension, etc.) which may increase fall risks.

Other Analgesics Bisphosphonates (Actonel®, Aredia®, Fosamax®, Zometa®) Baclofen (Lioresal®) Carisoprodol (Soma®) Methocarbamol (Robaxin®) Cyclobenzaprine (Flexeril®) Corticosteroids

= Avoid use in the elderly

References: · *Raja SN, Haythornthwaite JA. Combination therapy for neuropathic pain-Which drugs, which combination, which patients? N Engl J Med. 2005;352:1373-1375. · Clegg DO, Reda DJ, Harris CL. Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med. 2006;354(8):795-808. · Fine PG. Benefits of pain management in the elderly. P&T Digest. 2005;30(12):46-55. · Davis MP, Srivastava M. Demographic assessment and management of pain in the elderly. Drug aging. 2003;20(1):23-57. · Pfizer Inc. Neurontin [package insert online]. December 2005. Available at: http://www.pfizer.com/download/uspi_neurontin.pdf. Accessed May 25, 2006. · Pfizer Inc. Lyrica [package insert online]. March 2006. Available at: http://www.pfizer.com/pfizer/download/uspi_lyrica.pdf. Accessed May 25, 2006. · Woo SB, Hellstein JW, Kalmar JR. Systematic review: bisphosphonates and osteonecrosis of the jaws. Ann Intern Med. 2006;144(10):753-61. · Food and Drug Administration, Center for Drug Evaluation and Research. FDA Alert, January 7, 2008. Information for Health Care Professionals: Bisphosphonates. Available at: http://www.fda.gov/cder/drug/InfoSheets/HCP/bisphosphonatesHCP.htm. Accessed, April 7, 2008.

Nortriptyline (Pamelor®) SSRIs

Nortriptyline (a metabolite of amitriptyline), is often effective for neuropathic pain and is better tolerated than amitriptyline in the elderly.

Paroxetine (Paxil®), Fuloxetine (Prozac®), Sertraline Data for use in neuropathic pain is conflicting. (Zoloft®), Citalopram (Celexa®), Fluvoxamine (Luvox®) SSNRIs Venlafaxine (Effexor®) Duloxetine (Cymbalta®) Carbamazepine (Tegretol®) Milnacipran (Savella®)

NOT recommended for elderly due to high rate of hypertension at effective dose of 175mg-220mg for neuropathic pain.*

FDA approved for diabetic neuropathic pain. Monitor for sedation, nausea, and ataxia. Use caution if the patient has a seizure disorder. For treatment of trigeminal neuralgia. Monitor LFTs, CBC, BUN, and serum creatinine. May cause leukopenia and thrombocytopenia. A selective serotonin and norepinephrine reuptake inhibitor indicated for the management of fibromyalgia.

OPIOID ANALGESICS: Equianalgesic Dosing

Drug

Codeine

IV Morphine Oral Morphine Onset of Usual Dosing Interval Dose Equivalent* Dose Equivalent* Action (route)

120mg 200mg 30-60 min 4-6 h

Initial Dosage in Opioid-naïve Patient

15mg every 4-6 h

Renal Dysfunction

CrCl 10-50ml/min, reduce dose by 25%; CrCl < 10ml/min, reduce dose by 50%

Hepatic Dysfunction

Conversion to active metabolite may be reduced in patients with cirrhosis; avoid use in patients with severe liver disease Conversion to active metabolite may be reduced in patients with cirrhosis; avoid use in patients with severe liver disease

Dosage Forms

inj, tab, soln

Comments

Codeine alone is a weak analgesic, doses adequate to control pain may increase side effects such as constipation. Ceiling effect occurs at doses > 60mg/dose. See Note 1 Codeine in combination with acetaminophen is more effective than codeine alone. See Note 2

Codeine & acetaminophen (Tylenol with Codeine®)

N/A

200mg

30-60 min

4-6 h

1-2 (15/325) tabs every 4-6 h

CrCl 10-50ml/min, reduce dose by 25%; CrCl < 10ml/min, reduce dose by 50%

cap, elixir, susp, tab

Fentanyl transmucosal (Actiq®)

**

**

10 min

1-2 h

Suck on 200mcg lozenge over 15 min

Insufficient information; use with caution Insufficient information; use with caution lozenge

Only for breakthrough pain in opiate-tolerant patients. Dose: 2.5-5mcg/kg. Max: 4 units/day. Dissolve in mouth, do not chew/swallow.

© 2009 American Society of Consultant Pharmacists

Reorder From: MED-PASS, Inc. 800-438-8884 / 937-438-8884

A99020RCK

SIDE THREE

OPIOID ANALGESICS: Equianalgesic Dosing (continued)

Drug

Fentanyl transdermal (Duragesic®)

IV Morphine Oral Morphine Onset of Usual Dosing Interval Dose Equivalent* Dose Equivalent* Action (route)

** ** 12-24 h 72 h

Initial Dosage in Opioid-naïve Patient

25mcg/h or higher (if able to tolerate 50mg oral morphine equivalent/24h) 5-10mg every 4-6 h 1 tab every 4-6 h as needed

Renal Dysfunction

Hepatic Dysfunction

Dosage Forms

Comments

Insufficient information; use with caution Insufficient information; use with caution transdermal Do not use for acute pain or in opioid-naïve patients. Pain relief patch takes 12-24 h with the first patch. Effects may last >17 h after patch removal. Increase dose based on average amount of shortacting opioid needed in a 72 h period. Caution: Do not cut or apply heat to patches. Fever may increase release of fentanyl. Use with caution Avoid in severe renal dysfunction Use with caution in patients with severe acetaliver disease. See Note 2 Avoid in severe hepatic dysfunction cap, elixir, soln, tab tab See Note 1 and Note 2 Use with caution in debilitated elderly. Maximum: 5 tab/day. Use lowest effective dose for the shortest treatment duration. Monitor blood pressure/edema. May increase risk of bleeding due to ibuprofen content. Initiate opioid therapy with a 25% to 50% lower dose than usual adult dosage and slowly increase by 25% on an individual basis 10mg PR suppository = 10mg PO. See Note 3

Hydrocodone & acetaminophen (Lorcet®, Lortab®, Vicodin®) Hydrocodone & ibuprofen (Vicoprofen®, ReprexainTM)

N/A N/A

30mg 30mg

1-2 h 1-2 h

3h 3-4 h

Hydromorphone (Dilaudid®) Morphine (Astramorph PFTM, Duramorph®, Infumorph®, Roxanol®, RMS®)

1.5mg (IV, IM, SC) 10mg (IV, IM, SC)

7.5mg (PO); 6mg (PR) 30mg

15-30 min (PO) 15-30 min (PO)

3-4 h 3-4 h

2-4mg every 3-4 h 5mg (PO), 1-2mg (IV) every 4-6 h

Use with caution Reduce dose or avoid use in severe renal impairment

Use with caution

inj, tab, soln, supp

Use caution in patients with cirrhosis inj, tab, and consider reducing dose or extending soln, supp dosing interval by 1.5 to 2 times; half-life may be doubled (3 to 4 h) and bioavailability is increased tab, cap Use caution in patients with cirrhosis and consider reducing dose or extending dosing interval by 1.5 to 2 times; half-life may be doubled (3 to 4 h) and bioavailability is increased In patients with stable chronic liver disease or mild to moderate hepatic dysfunction, no dosage adjustments are required Use with caution inj, soln, tab

Morphine ER (MS Contin®, Kadian®, Oramorph SR®) Morphine ER (Avinza®)

N/A N/A

30mg (PO) 60mg (PO)

Varied 30 min

8-12 h 24 h

20-30mg every 24 h (Refer to individual package inserts for exact dose) 2.5-10mg every 3-6 h (PO); 2.5mg10mg every 8-12 h (SC or IM) 5mg every 3-4 h

Reduce dose or avoid use in severe renal impairment

Tablet must be swallowed whole. See Note 3

Methadone (Dolophine®, Methadose®, Methadone IntensolTM)

2.5mg (See Note 4) 5mg (See Note 4)

30-60 min (PO)

4-12 h

Methadone and its metabolites do not accumulate in patients with renal failure; however, dosage reduction by up to 50% is recommended in end-stage renal failure or dialysis patients CrCl < 60, reduce dose

The only long-acting opioid available as an oral solution. Urinary excretion decreases and elimination half-life increases when urinary pH exceeds 6. Delayed analgesia or toxicity may occur due to drug accumulation after repeated doses (e.g., on days 2 to 5). See Note 4 In debilitated, non-opioid tolerant patients, the starting dose should be reduced to 1/3 or 1/2 of the usual dosage. See Note 1 The ratio of CR oxycodone to PO morphine can be 1:2 or 2:3 depending on clinician preference

Oxycodone (Oxy IR®, Oxydose®, RoxicodoneTM) Oxycodone ER (OxyContin®)

N/A

20-30mg

10-30 min (IR)

3-4 h (IR)

cap, soln, tab tab

N/A

20-30mg (PO)

60 min

12-24 h

20mg every 24 h, 10mg every 12 h 2.5-5mg oxycodone every 6 h 2.25-4.5mg oxycodone every 6 h 0.5mg every 4-6 h (IM, IV, SC); 5mg every 4-6 h (PR)

CrCl < 60, reduce dose

Clearance may be decreased. Initiate at 1/3 to 1/2 of the usual dose. Dose titration should proceed carefully Use with caution in patients with severe liver disease. See Note 2 Use with caution Reduce dose in severe hepatic impairment

A99020RCK

Oxycodone & acetaminophen (Endocet®, Percocet®, RoxicetTM, Tylox®) Oxycodone & aspirin (Percodan®) Oxymorphone (Numorphan®)

N/A

20mg

15-30 min

4-6 h

CrCl < 60, reduce dose

caplet, cap, See Note 1 and Note 2 soln, tab tab inj, supp Avoid in elderly or debilitated patients with bleeding potential. See Note 1 Respiratory depression is a potential problem in the elderly

N/A 1mg (IV, IM, SC)

20mg 10mg (PR)

15-30 min 5-10 min

4-6 h 3-6 h

CrCl < 60, reduce dose Reduce dose in severe renal impairment

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© 2009 American Society of Consultant Pharmacists

SIDE FOUR

OPIOID ANALGESICS: Equianalgesic Dosing (continued)

Drug

Tramadol (Ryzolt ERTM, Ultram®, Ultram ER®)

© 2009 American Society of Consultant Pharmacists

IV Morphine Oral Morphine Onset of Usual Dosing Interval Dose Equivalent* Dose Equivalent* Action (route)

N/A 150-300mg 60 min 4-6 h

Initial Dosage in Opioid-naïve Patient

25-50mg every 4-6 h; not > 300mg for age 75+

Renal Dysfunction

CrCl < 30 ml/min, increase dosing interval to 12 h and decrease maximum daily dose to 200mg. Dialysis patients can receive their regular dose on the day of dialysis (< 7% of a dose is removed by hemodialysis). CrCl < 30 ml/min, increase dosing interval to 12 h and decrease maximum daily dose to 200mg. Dialysis patients can receive their regular dose on the day of dialysis (< 7% of a dose is removed by hemodialysis). Abbreviations: cap = capsule CrCl = creatinine clearance ER = extended release h = hour IM inj IR IV = = = =

Hepatic Dysfunction

Reduce dosage to 50mg every 12 h in patients with cirrhosis

Dosage Forms

tab

Comments

Use with caution in debilitated elderly, give < 300mg/day in divided doses. See Note 5 ER version should not be used when CrCl is less than 30ml/min.

Tramadol & acetaminophen (Ultracet®)

N/A

37.5/325mg

60 min

4-6 h

2 tabs (PO) every 4-6 h; maximum 8 tabs/day

Reduce dosage to 50mg every 12 h in patients with cirrhosis

tab

Starting with a lower dose and titrating slowly improves tolerability. See Note 5

*Morphine dose equivalent is the dose of opioid equivalent to 10mg of IV morphine sulfate or 30mg of PO morphine sulfate under conditions of chronic dosing. Example: Morphine 30mg = Hydrocodone (Vicodin®,Lortab®) 30mg = Hydromorphone (Dilaudid®) 7.5mg = Oxycodone (OxyContin®) 20mg ** Refer to fentanyl conversion chart in the package insert or online at www.duragesic.com

intramuscular route injectable immediate release intravenous route

M3G = M6G = MAOI = min =

morphine-3-glucuronide morphine-6-glucuronide monoamine oxidase inhibitor minute

N/A PO PR SC

= = = =

not applicable oral route rectal route subcutaneous route

soln = SSRI = supp = susp =

solution tab = tablet selective serotonin reuptake inhibitor suppository suspension

Note 1: Note 2: Note 3: Note 4: Note 5:

In patients with decreased CYP-2D6 activity, conversion to the active metabolite may be decreased (due to poor CYP-2D6 metabolism or CYP-2D6 inhibiting drugs). The significance of this reaction on the analgesic effect is unknown. Maximum dose of acetaminophen is 4000mg/day unless patient has hepatic dysfunction, then maximum dose is 2000mg/day. M6G (an active metabolite) may accumulate in renal impairment and contribute to toxic effects while M3G (a metabolite with little analgesic effect) may contribute to neurotoxicity, hyperalgesia, and allodynia. The equianalgesic relationship of methadone with morphine is curvilinear and the equianalgesic dose ratio increases as the dose of morphine increases. (Example: At oral morphine doses between 30-300mg the equianalgesic ratio to oral methadone is 4:1 to 6:1; at oral morphine doses > than 300mg the equianalgesic ratio to oral methadone is 10:1 to 12:1) Risks of seizures may be increased in patients with epilepsy; patients with risk factors for seizure (head trauma, metabolic disorders, alcohol and drug withdrawal; CNS infections); or those taking MAOIs, SSRIs, and tricyclic antidepressants.

TO

References: · Drug Facts and Comparisons. St. Louis, MO: Facts and Comparisons; 2007. · Jochimen PR, Noyes R Jr. Appraisal of codeine as an analgesic in older patients. J Am Geriatr Soc. 1978;26(11):521-3. · American Geriatrics Society. Geriatrics at Your Fingertips: Pain. Available at: http://www.geriatricsatyourfingertips.org/. Accessed March 2006. · Pauli-Magnus C, Hofmann U, Mikus G, et al. Pharmacokinetics of morphine and its glucuronides following intravenous administration of morphine in patients undergoing continuous ambulatory peritoneal dialysis. Nephrol Dial Transplant. 1999;14: 903-909. · Pereira J, et al. Equianalgesic dose ratios for opioids. J Pain Symptom Mgmt. 2001;22(2):672-687. · VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain, 2003. Available at: http://www.oqp.med.va.gov/cpq/cpq.htm. Accessed March 2008.

The Pain Management Investigative Protocol is to be used by surveyors for any resident: Who states he/she has pain or discomfort; Who displays possible indicators of pain that cannot be readily attributed to another cause; Who has a disease or condition or who receives treatments that cause or can reasonably be anticipated to cause pain; Whose assessment indicates that he/she experiences pain; Who receives or has orders for treatment for pain; and/or Who has elected a hospice benefit for pain management.

A99020RCK

F-TAG 309: GUIDANCE

SURVEYORS

ON

PAIN MANAGEMENT

IN

NURSING FACILITIES

Intent of new guidance: In order to help a resident attain or maintain his or her highest practicable level of well-being and to prevent or manage pain, the facility, to the extent possible: Recognizes when the resident is experiencing pain and identifies circumstances when pain can be anticipated; Evaluates the existing pain and the cause(s), and Manages or prevents pain, consistent with the comprehensive assessment and plan of care, current clinical standards of practice, and the resident's goals and preferences.

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Key Components of Pain Management Mentioned in F-Tag 309: Care Process for Pain Management Pain Recognition Assessment Management of Pain Non-Pharmacological Interventions Pharmacological Interventions Monitoring, Reassessment, and Care Plan Revision

References: · Centers for Medicare and Medicaid Services (CMS) Survey and Certification Memo S&C-09-22; F-Tag 309, Appendix PP, CMS State Operations Manual

CODING TIPS FROM THE RAI USER'S MANUAL

Definition of "Pain Medication Regimen" Pharmacologic agent(s) prescribed to relieve or prevent the recurrence of pain. Include all medications used for pain management by any route and any frequency during the look-back period. Include oral, transcutaneous, subcutaneous, intramuscular, rectal, intravenous injections, or intraspinal delivery. This item does NOT include medications that primarily target treatment of the underlying condition, such as chemotherapy or steroids, although such treatments may lead to pain reduction. Definition of "Scheduled Pain Medication Regimen" Pain medication order that defines dose and specific time interval for pain medication administration. For example, "once a day," "every 12 hours." Definition of "PRN Pain Medication" Pain medication order that specifies dose and indicates that pain medication may be given on an as needed basis, including a time interval, such as "every 4 hours as needed for pain" or "every 6 hours as needed for pain." Definition of "Non-Medication Pain Intervention" Scheduled and implemented non-pharmacological interventions include, but are not limited to: bio-feedback, application of heat/cold, massage, physical therapy, nerve block, stretching and strengthening exercises, chiropractic, electrical stimulation, radiotherapy, ultrasound, and acupuncture. Herbal medications are not included in this category.

Also Available - Assessing Pain in the Elderly clinical reference card (item # A99010RCK) provides a valuable complementary pain management information resource. Contact MED-PASS at 800-438-8884 for more information.

Exclusively Distributed By:

Content edited and updated by Charlie Waters, PharmD, BCPS, CGP, FASCP

www.ascp.com

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