AMDA – The Society for Post-Acute and Long-Term Care Medicine

View all recommendations from this society

November 20, 2020

Don’t provide long-term opioid therapy for chronic non-cancer pain in the absence of clear and documented benefits to functional status and quality of life.

Long-term use of opioids is common in the PALTC setting. The Society’s 2018 Position Statement on the use of opioids states that nursing home practitioners who prescribe opioids should do so based on thoughtful inter-professional assessment indicating a clear indication for opioid use.

For admitted residents on long term opioid therapy for chronic pain (not for cancer, palliative care, or end-of-life), tapering plans should be individualized and should minimize symptoms of opioid withdrawal while maximizing pain treatment with non-pharmacologic therapies and non-opioid medications.

Periodic review to evaluate risk factors for potential harms should be incorporated into the individualized plan of care. In addition, clinicians should offer alternative behavioral therapies, non-opioid analgesics and other non-pharmacologic treatments whenever available and appropriate.


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

1–5: AMDA – The Society for Post -Acute and Long-Term Care Medicine convened a work group made up of members from the Clinical Practice Steering Committee (CPSC). Members of the CPSC include board certified geriatricians, certified medical directors, multi-facility medical directors, attending practitioners, physicians practicing in both office-based and nursing facility practice, physicians in rural, suburban and academic settings, those with university appointments, and more. It was important to AMDA that the workgroup chosen represent the core base of the AMDA membership. Ideas for the “five things” were solicited from the workgroup. Suggested elements were considered for appropriateness, relevance to the core of the specialty and opportunities to improve patient care. They were further refined to maximize impact and eliminate overlap, and then ranked in order of potential importance both for the specialty and for the public. A literature search was conducted to provide supporting evidence or refute the activities. The list was modified and a second round of selection of the refined list was sent to the workgroup for paring down to the final “top five” list. Finally, the work group chose its top five recommendations before submitting a final draft to the AMDA Executive Committee, which were then approved.

6–10: The AMDA Choosing Wisely® endeavor utilized a similar procedure as published in JAMA Intern Med. 2014;174(4):509-515 – A Top 5 List for Emergency Medicine for our five items.

The AMDA Clinical Practice Committee acted as the Technical Expert Panel (TEP).

Phase 1 – The Clinical Practice Steering Committee (CPSC) along with the Infection Advisory Committee clinicians brainstormed an initial list of low-value clinical decisions that are under control of PA/LTC physicians that were thought to have a potential for cost savings.

Phase 2 – Each member of the CPSC selected five low-value tests considering the perceived contribution to cost (how commonly the item is ordered and the individual expense of the test/treatment/action), benefit of the item (scientific evidence to support use of the item in the literature or in guidelines); and highly actionable (use decided by PA/LTC clinicians only).

Phase 3 – A survey was sent to all AMDA members. Statements were phrased as specific overuse statements by using the word “don’t,” thereby reflecting the action necessary to improve the value of care.

Phase 4 – CPSC members reviewed survey results and chose the five items.

(11–15)
The AMDA Choosing Wisely project utilized procedures similar to previous workgroups.
In Phase 1 – The Clinical Practice Steering Committee (CPSC) solicited recommendations from members of the Society’s five subcommittees.

In Phase 2 – Each member of the CPSC reviewed the submitted recommendations (with the goal to selecting the best five recommendations) considering the
perceived contribution to cost, benefit of the item and scientific evidence to support use of the item in the literature or in guidelines. Based on the feedback of the CPSC, the recommendations were narrowed to five, revised, and supporting evidence was added.

Phase 3 – The revised five recommendations and sources were reviewed by the CPSC for final approval, and then approved by the Board of Directors.
Sources

For more information, visit www.paltc.org.

Sources

Opioids in Nursing Homes. AMDA Resolution & Position Statement 12/2018. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, Dana T, Bougatsos C, Deyo RA. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015;1-62(4):276

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1-49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1external icon

Pimentel, C. B., Gurwitz, J. H., Tjia, J., Hume, A. L., & Lapane, K. L. (2016). New Initiation of Long-Acting Opioids in Long-Stay Nursing Home Residents. Journal of the American Geriatrics
Society, 64(9), 1772–1778. https://doi.org/10.1111/jgs.14306

Hunnicutt, J. N., Chrysanthopoulou, S. A., Ulbricht, C. M., Hume, A. L., Tjia, J., & Lapane, K. L. (2018). Prevalence of Long-Term Opioid Use in Long-Stay Nursing Home Residents. Journal of the American Geriatrics Society, 66(1), 48–55. https://doi.org/10.1111/jgs.15080

Fain, KM, Alexander, GC, Dore, DD, Segal, JB, Zullo, AR, Castillo-Salgado, C. Frequency and Predictors of Analgesic Prescribing in U.S. Nursing Home Residents with Persistent Pain. J Am Geriatr Soc. 2017 Feb;65(2):286-293. doi: 10.1111/jgs.14512. Epub 2016 Nov 7.

PALTC Practitioners Step Up to Address Opioid Crisis: Joanne Kaldy Caring for the Ages, Volume 20, ISSUE 4, P19, May 01, 2019 DOI:https://doi.org/10.1016/j.carage.2019.03.014

Tapering Long Term Opioid Therapy in Chronic Noncancer pain: www.mayoclinicproceedings.org/article/S0025-6196(15)00303-1/fulltext