Pain management in a long-term care facility: compliance with JCAHO standards.

An analysis of the treatment of nonmalignant pain in the elderly at a long-term facility was conducted to allow development of a pain management program that complies with both JCAHO guidelines for pain management and with the Tennessee Medicaid (TennCare) reimbursement schedule, and to determine if tramadol can meet the standards of pain management under these new guidelines. Inclusion criteria were residence in our long-term care facility; a pain intensity score > 4 on a modified Wong Baker Pain Scale; the patient having prescription orders for one or more of the following drugs: propoxyphene, meperidine, or high dosages of acetaminophen (approaching 4 g/day); suspected neuropathic or mixed nociceptive/neuropathic pain; and/or a diagnosis of diabetes, osteoarthritis, or degenerative joint disease. Exclusion criteria were history of seizures, history of opioid or alcohol abuse, and demonstrated hypersensitivity to tramadol or opioids. Tramadol administration began at a dose of 25 mg/day titrated up to a maximum of 300 mg/day over a 16-day period. Data were collected from computer records, dispensing reports, medication administration reports (MARs), current federal minimum data set (MDS) data, and weekly care plan meetings. Data were tabulated at baseline and 4-6 weeks after a stable dose of tramadol had been established. Fourteen residents (mean age 85 years, 1 male, 13 female) met the criteria and received tramadol up to 300 mg/day (qid). Tramadol reduced the residents' pain scores from an average of 6 to 2 using the Modified Wong Baker Pain Scale, reduced the percentage of residents taking propoxyphene from 50% to 14%, and reduced those taking high doses of APAP or APAP products from 43% to 14%. Tramadol reduced the percentage of residents falling, losing weight, showing no change or decline in activities in daily living (ADLs), displaying inappropriate behavioral symptoms, suffering depression, and/or taking psychotropic medications. In the state of Tennessee, new reimbursement schedules by TennCare have allowed our hospital to comply with the JCAHO standards of "optimal achievable care" for the treatment of pain by allowing the hospital staff to treat patients with newer, safer, more effective analgesics such as tramadol. Early results from this ongoing study have shown that tramadol can provide a safe and effective treatment on non-malignant pain in a long-term care facility and improve adherence to JCAHO and TennCare standards for proper pain management.