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 (HS07768). The study involved an educational program that provided instructions for substituting acetaminophen for NSAIDs, as well as for using topical agents, such as salicylic acid and capsaicin creams, and nondrug therapies like stretching and strengthening exercises. Although acetaminophen is no more effective than NSAIDs, it does not cause the complications sometimes associated with NSAIDs, which include peptic ulceration and gastrointestinal bleeding.
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 nondrug treatments, use of NSAIDs in nursing homes remains high.
Researchers led by Wayne A. Ray, Ph.D., of Vanderbilt University School of Medicine, found that in the 3 months following initiation of the program, use of NSAIDs decreased by approximately 70 percent 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 3 months later when the study ended. 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 (treatment flowchart) 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 could 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 (RCT) 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 of non-steroidal anti-inflammatory drugs among nursing home residents: A randomized controlled trial," by C. Michael Stein, M.B., Ch.B., Marie R. Griffin, M.D., M.P.H., Jo A. Taylor, R.N., M.P.H., and others, in the May 2001 Medical Care 39, pp. 436-445.
Editor's Note: These authors reported similar findings from an RCT involving NSAID use among community-dwelling elderly people. For the results of that study (also supported in part by AHRQ grant HS07768), see "Educational program for physicians to reduce use of non-steroidal anti-inflammatory drugs among community-dwelling elderly persons," by Dr. Ray, C. Michael Stein, M.B., Ch.B., Victor Byrd, M.D., and others, in the May 2001 Medical Care 39, pp. 425-435.