PAIN MANAGEMENT: Elderly Often Untreated For Pain
Authors of a "troubling" study released today in the Journal of the American Medical Association have found that a significant percentage of elderly nursing home patients suffering from cancer are "severely undertreated for their pain," the New York Times reports. The study is the first information on the "epidemiology and the ethnography of pain in the elderly population." Age and racial disparities were clearly apparent: 30% of patients over 85 received no pain medication -- "not even aspirin" -- as opposed to 21% between the ages of 65 and 74. Thirty-four percent of African-American patients had untreated pain, compared to 25% of whites (Stolberg, 6/17). The study's lead researcher, Dr. Giovanni Gambassi, said: "Hispanic, Asian and American Indian [patients] were all less likely to receive anesthesia when they were compared to Caucasian patients" ("Morning Edition", NPR, 6/17). Researchers offer several explanations: "Older patients might be reluctant to complain; few nursing homes have enough staff to administer and monitor painkillers; and few doctors use the drugs aggressively," USA Today reports (Rubin, 6/17). The reasons for the racial differences in treatment were possibly due to "language barriers," and the fact that some minorities "are more reluctant to report pain" and are "less willing to complete advanced directives" (Bernabei et al, JAMA, 6/17 issue). Click here to see an abstract of the study.
Untrained Medical Workforce
The study examined "13,625 cancer patients 65 and older who were discharged from hospitals to nursing homes between 1992 and 1995," the Philadelphia Inquirer reports. The study's authors interviewed patients at nearly 10% of U.S. nursing homes within the first 14 days of their stay. They found that 26% of patients received no pain medication, 16% were given a non-narcotic analgesic, 32% got weak opioids, and 26% received morphine. "People should not be in pain," said Gambassi. "Cancer pain can be relieved effectively and safely using medication available in 90% to 100% of cases, even among nursing home patients," he said (Vitez, 6/17). Dr. Charles Cleeland, director of pain research at M.D. Anderson Cancer Center in Houston, said: "We're doing a lousy job of educating pharmacists, nurses and physicians in the management of pain. ... So, you have a symptom which is going to be present and going to be a problem in the majority of cancer patients ... and you have essentially a work force untrained to deal with that" ("Morning Edition," 6/17). Dr. Mathy Mezey, a New York University gerontologist, said: "In the nursing home, there is not a lot of knowledge about how to manage pain. Most of the staff has not been prepared in good palliative care, and that is both the nursing home staff and the primary care physicians who are managing the residents" (New York Times, 6/17).
Indicator Of Poor Medical Care
The study's conclusion states that "[f]ailure to prevent and/or treat pain effectively at virtually all times is no longer acceptable and should be considered a first-line indicator of poor quality of medical care" (JAMA, 6/17 issue). Tom Burke, spokesperson for the American Heath Care Association, which represents 11,000 nursing homes, responds that "[i]f cancer wards don't handle pain management well, I think it's unrealistic to expect nursing homes to outperform the cancer specialists." Burke goes on to suggest that hospices have the most experience with pain management, and that many nursing homes are incorporating hospice care for cancer patients (Philadelphia Inquirer, 6/17). An editorial accompanying the JAMA study and authored by Dr. Cleeland, states that "patients, their families, and the public are becoming less tolerant of poor pain management. That intolerance may prove to be the ultimate driving force behind improving care of patients with pain" (6/17 issue).
Efforts are underway in Oregon and New Jersey to improve pain management. The Bergen Record reports that New Jerseyans are struggling to get state pharmacists to comply with a loosening of New Jersey's painkiller regulations. The state Department of Health recently "lifted a 120-dose restriction on prescribing" drugs such as Percocet and morphine. However, many pharmacists have been unwilling or unaware of the new regulations. Said state Assemblywoman Charlotte Vandervalk (R), "[Pharmacists] have no authority to turn down a prescription if it complies with the law. ... [I]f a doctor feels a certain quantity is essential, it should be sufficient" (Wiggins, 6/17). In Oregon, the Robert Wood Johnson Foundation has awarded almost $600,000 to Oregon Health Sciences University to "knock down barriers to good care for dying patients," the Portland Oregonian reports. The money will go to studying how to "change policies at hospitals, home health agencies, hospices, nursing homes and adult foster care homes to improve dying Oregonians' experiences, as well as to teach other states about initiatives that have worked for Oregon" (Hoover, 6/17).