A drug use evaluation of selected opioid and nonopioid analgesics in the nursing facility setting

OBJECTIVES: To determine the medical conditions for which selected analgesi cs are most frequently prescribed in nursing facilities (NFs), describe the use of pharmacologic and nonpharmacologic pain therapies, and determine th e frequency and quality of pain assessment in NF residents. DESIGN: A multicenter, 3-month retrospective drug use evaluation conducted by consultant pharmacists. SETTING: Eighty-nine NFs having no more than 25% of their patient census re presenting special populations (e.g., head trauma). PARTICIPANTS: A total of 2065 adult NF residents who received at least one selected analgesic. MEASUREMENTS: Primary indication for analgesics, pain type, method of pain assessment, nonpharmacologic therapies for pain, prescribed analgesics and regimens, and comorbid conditions were recorded. RESULTS: A total of 54.3% of residents had one indication for analgesic the rapy, 31.0% had two indications, and 14.7% had three or more indications. A rthritis was the most prevalent indication for analgesics (41.7% of residen ts), followed by bone fracture (12.4%) and other musculoskeletal conditions (9.7%). More residents (76.8%) were reported to have chronic pain than acu te pain (19.9%), and 3.0% had both chronic and acute pain. Pain type was un known for 0.2% of residents. Observational pain assessments were used more frequently (for 55.9% of residents) than objective methods (16.6%), and pai n was not assessed in 40.6% of residents. Most residents (69.4%) received n o nonpharmacologic treatment for pain. Of the 2542 opioid and nonsteroidal anti-inflammatory drug (NSAID) prescriptions, 67.6% were for opioids, 24.8% were for NSAIDs, and 7.6% were for tramadol. Propoxyphene-containing drugs were the most frequently prescribed opioid group, and propoxyphene with ac etaminophen was the most frequently prescribed analgesic (35.6% of all anal gesics). Most analgesics (63.2%) were prescribed on an as-needed (prn) basi s. CONCLUSIONS: The findings show a lack of adequate pain assessments, little use of nonpharmacologic interventions, and inappropriate use of analgesic m edication. The small percentage of residents with chronic pain assessed obj ectively suggests the difficulty of monitoring pain progression in NFs. The prescribing of analgesic for most residents (with propoxyphene used most o ften, long-acting opioids used infrequently, and frequent pm use) was incon sistent with recommended pain therapy in older people and attests to the ur gent need to educate NF practitioners on the appropriate use of analgesics.