Pain Management


Chronic Pain

Chronic pain is one of the most common conditions encountered by healthcare professionals, particularly among the senior population. All older adults with chronic pain should undergo a comprehensive geriatric pain assessment. A multimodal approach that includes both drug and non-drug treatments for pain is recommended. Pain is associated with substantial disability from reduced mobility, avoidance of activity, falls, depression and anxiety, sleep impairment, and isolation

Although no universally accepted definition exists for chronic pain, it is often defined as pain that persists beyond the expected time of healing (typically 12 weeks) and may or may not be associated with an identifiable cause or actual tissue damage. Musculoskeletal disorders are common in later life, and increasingly common are painful neuropathies from diabetes, herpes zoster, chemotherapy, and surgery. Other types of pain are also prevalent among older adults, including pain due to cancer as well as cancer treatments. Pain is also common in the advanced stages of many chronic diseases, including congestive heart failure, end stage renal disease, and chronic obstructive pulmonary disease. Furthermore, millions of joint repair and replacement surgeries are performed annually, and some patients undergoing these procedures report chronic pain despite surgery. Vertebral compression fractures are also highly prevalent and cause substantial pain and discomfort, particularly among older women.

Effective Pain Treatment

Prescribing effective treatment starts with an accurate and comprehensive history that defines the older adult's "pain signature" (the parameters affected by pain and the severity of their impact), highlights key comorbidities that contribute to pain or influence its treatment, and identifies treatment targets. Older adults may under-report the severity of pain because of misconceptions that pain is a normal part of aging, a tendency toward trying to remain strong, or fears of addiction. The coexistence of sensory (vision and/or hearing deficits) and/or cognitive impairment also may make the evaluation of pain more challenging in the older patient.

Managing Pain

Dealing with pain takes more than endurance; for chronic pain, it requires strategy and persistence. Pain relief is a long-term project, but with an understanding of the nature of pain and new tools, managing pain can actually be easier at home than in a health care setting.

Pain scales are great for rating pain in acute or emergency situations where a treatment and change are eminent. In that case, knowing that a dose of medicine lowers a patient’s pain from an “8” to a “3” is useful. At home, unlike in an acute or emergency situation, the regular use of pain scales for rating pain draws focus to it, magnifying the brain’s perception. Pain eases when focus is placed on something else.

In order to manage pain at home, it’s important to make a plan. Pain without a way to treat it leads to fear and vulnerability. Fear increases the perception of pain and makes it hard to focus on anything else. In a more intense form, fear of pain is sometimes called “catastrophizing.” All the possible ramifications of untreated pain run through the mind, leading to depression, fear of attempting activities and lack of movement. Studies show that people who tend to catastrophize require more pain medications, are more likely to become addicted to medication and take longer to heal.

Treating Pain in the Elderly

Safe pain treatment is available for older adults. While they are more likely to experience pain than the general population, in many cases, older adults are under-treated. Many older adults feel pain is just a natural part of aging and don't tell their doctors about their problem. If you or someone you love is in pain, talk to a doctor.

NonPharmacologic Treatments

Nonpharmacological approaches to the management of persistent pain are often beneficial, in place of or in addition to pharmacological treatments. Nonpharmacologic therapies encompass a wide array of treatments that may be grouped into the physical interventions (including physical therapy, acupuncture, chiropractic manipulation, massage, and others) and the psychoeducational interventions (such as cognitive-behavioral therapy, meditation, and patient education). Many of these therapies are low cost, with minimal side effects, and may decrease the dose and therefore the risk from any needed medications. Treatments with associated cost or potential side effects should be used only when there is evidence of benefit in patients with similar painful conditions. General therapies such as self-management education, physical therapy/exercise, and cognitive behavioral therapy may be used for all persistent pain conditions.

Pharmacologic Treatments

Patients whose pain causes functional impairment or diminished quality of life despite nonpharmacologic treatments may require pharmacologic therapy. Routes of administration, medications, and doses should be selected that are the least likely to lead to toxicity, side effects, or interactions with other medications.

Pharmacologic treatments may include the following: non-opioids, topical and injected analgesics, acetaminophen, nonsteroidal anti-inflammatory drugs, antidepressants, anticonvulsants, muscle relaxants, opioids, cannabis and cannabinoids.

In most cases, non-opioid medications are preferred to opioids for non-cancer pain, due to side effects in older patients. Analgesics should be initiated at the lowest effective dose, and titrated to achieve pain control with minimal adverse effects; this requires frequent reassessment of patients for pain relief and side effects as doses are adjusted. Localized use of medication (eg, joint injections, trigger point injections) may be preferable to systemic medications (eg, oral analgesics) when applicable.

Nonpharmacologic treatments that have improved analgesia should be continued when medications are added, to improve pain control and minimize medication doses.

If you are an older person experiencing pain, keep in mind that you run a higher-than-average risk of side effects from all drugs, including analgesics like nonsteroidal anti-inflammatory drugs NSAIDs. NSAIDs also are not recommended for people with kidney, liver, or heart issues and definitely should not be taken without first discussing it with your doctor.

There is also a risk that any medications may interact with those that you are already on. But having chronic medical problems and an increased risk of side effects does not mean that your pain cannot, or should not, be aggressively treated. You may be a candidate for any of the pain-relieving therapies available. But talk to your doctor before taking any over-the-counter medications. You may need to take a lower dose than recommended on the label.

Although there are a number of pain relievers that are safe for older people, doctors must take special precautions when prescribing pain medication; older patients handle pain medication differently than younger patients. For example, because kidneys become smaller with age, there is decreased blood flow and less effective filtration (removal of the drug). In addition, the liver undergoes a decrease in mass and blood flow with aging, making it harder for the liver to break down some medications. The way drugs are administered to older people also can become a challenge. Decreased saliva may interfere with swallowing, and injections may be more difficult in decreased muscle mass. Also, oral drugs may be absorbed differently because of changes in stomach acid levels.

To overcome these challenges, doctors often start their older patients on the lowest recommended dose and then increase the amount of medication if necessary.

Recommendation

Pharmacologic therapy should begin with the routes of administration, medications, and doses which are the least likely to lead to toxicity, side effects, or interactions with other medications. Localized use of medication (eg, joint or spinal injections, trigger point injections, topical analgesics) may be preferable to systemic medications (eg, oral analgesics) when applicable. In most cases a non-opioid medication is the initial choice.

Treatment Goals

The main goal in the treatment of persistent pain is to maximize function and quality of life while minimizing adverse effects that may be associated with treatment. Identifying the impact that the pain has upon all aspects of the patient's life allows the provider to determine treatment targets and evaluate response to treatment in a way that is meaningful to the individual.

Due to the multifaceted nature of persistent pain, total pain elimination is not a realistic goal. It is therefore important to ensure that the older patient understands three general principles in the expectations of optimal pain management:
  • Persistent pain is multifactorial, requiring an approach that addresses a variety of etiologies and includes both pharmacologic and nonpharmacologic strategies
  • Persistent pain is treatable, with improvement anticipated, but it is not curable
  • Although pain may not be totally eliminated; substantial improvement in function is realistic
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