The article by Drs. Avorn and Gurwitz [1] highlights the overprescribing of many medications to nursing home residents. Within their data lies a second important problem. The authors acknowledge the potential underuse of "opioid analgesics in patients with metastatic cancer." We argue that the underuse of opioids applies to diagnoses other than metastatic cancer. Medicine has a tradition of underprescribing opioids and other pain medications, particularly for patients who cannot speak clearly about their pain. For example, until recent years, newborns were not thought to experience pain, and surgical procedures were commonly done without anesthesia. When data confirmed better outcomes for babies whose pain was controlled, this practice changed [2].

We are deeply concerned that nursing home residents with Alzheimer disease and other forms of cognitive impairment remain at far greater risk for the underprescribing of analgesic medications. Table 1 of Avorn and Gurwitz's article indicates that only 15% of nursing home residents receive any type of opioid, including acetaminophen with codeine [1]. One previous study of communicative nursing home residents indicated, however, that 71% had chronic painful conditions, primarily low-back pain, fractures, and other musculoskeletal conditions. As confirmed by Avorn and Gurwitz, this study also found that nursing home residents who are given analgesics usually received acetaminophen alone. Only 12% had orders written for acetaminophen with codeine [3]. Of greater concern is the finding that only 17% of noncommunicative elderly persons were identified as having chronic painful conditions, although in this group (members of which also may have contractures, immobility, and pressure ulcers), the prevalence of pain is likely to be even higher. Among the noncommunicative elderly persons studied [4], even fewer patients had any orders for analgesic therapy.

Techniques for assessing pain and symptom control in nursing home residents with cognitive impairment are in their infancy [5]. Clearly, traditional subjective patient report and as-needed dosages based on patient verbal request do not meet the needs for compassionate care of many nursing home residents. More detailed assessment of a furrowed brow, groaning, and other symptoms must be incorporated into assessment of the pain control needs of these patients. Nursing home residents with dementia require careful evaluation, and we propose that opioids and other measures be more generously used to control their unspoken suffering.