Training nursing home doctors and nursing staff to treat chronic pain from osteoarthritis and other disorders through safer means than nonsteroidal anti-inflammatory drugs (NSAIDS) could reduce the incidence of drug-induced complications and even death in elderly residents without increasing their pain and disability, according to a new study sponsored by the Agency for Healthcare Research and Quality (AHRQ). The educational program provided instructions for substituting acetaminophen for NSAIDs, as well as for using topical agents, such as salicylic acid and capsaicin creams, and non-drug therapies like stretching and strengthening exercises.
An estimated 45 to 80 percent of nursing home residents suffer from chronic pain. Although guidelines for the initial management of osteoarthritis recommend prescribing acetaminophen and using non-drug treatments, use of NSAIDs in nursing homes remains high. While acetaminophen is no more effective than NSAIDs, it does not cause the latter's complications, which include peptic ulceration and gastrointestinal bleeding.
Researchers led by Wayne A. Ray, Ph.D., of Vanderbilt University School of Medicine, found that use of NSAIDs decreased by approximately 70 percent in the three months following the initiation of the program without compromising pain control. The average number of days a week nursing home residents used NSAIDs declined from 7 at the start of the study to 1.9 at its end three months later. By comparison, average use of NSAIDs among residents of facilities not provided the educational program declined from 7 days to only 6.2 during the same period. The decrease in NSAID use was accompanied by a significant increase among study subjects in the use of acetaminophen. Three months after the program began, acetaminophen was used by study subjects an average of 5.1 days a week and by the control group 2.1 days a week.
Physicians and nursing staff also were given an algorithm for stopping NSAID use, substituting 650 mg. of acetaminophen three times a day and if needed, at bedtime. The algorithm included suggestions for continual re-evaluation of the resident's pain and measures to follow if the pain was not adequately controlled.
The size of the study did not permit the researchers to determine if the reduction in NSAID use achieved by their educational intervention led to a decrease in gastrointestinal complications. However, they believe that, in the long term, such a program would be expected to reduce the risk of gastrointestinal morbidity and mortality and decrease the costs of investigation, treatment and prevention of NSAID complications.
The randomized controlled trial involved 20 Tennessee nursing homes and 147 residents age 65 and older who took NSAIDs regularly. For details, see "An Educational Program for Nursing Home Patients and Staff to Reduce Use on Non-Steroidal Anti-Inflammatory Drugs Among Nursing Home Residents: A Randomized Controlled Trial," in the May 2001 issue of the journal, Medical Care.