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14 Articles in Volume 12, Issue #2
Chronic Pain in the Elderly: Special Challenges
Chronic Pain School
Diagnosis and Management Of Myofascial Pain Syndrome
ECG Screening Prior to Initiating Methadone: Is it Really Necessary?
HCG and Testosterone
How to Manage Unmotivated Pain Patients
March 2012 Pain Research Updates
Methadone for Pain Management
PPM Editorial Board Discusses Methadone Prescription Safety Measures
PPM Launches Online Opioid Calculator
Spontaneous Low Back Pain, Radiculopathy, And Weakness in a 28-Year-Old
Tapering a Patient Off Opioids
The Comorbidity of Chronic Pain and Mental Health Disorders: How to Manage Both
What Are Best Safety Practices For Use of Methadone In the Treatment Of Pain?

Chronic Pain in the Elderly: Special Challenges

The best approach to treatment for this patient population is a biopsychosocial approach geared toward improving function while cautiously using medication.

People aged 65 years and older are the fastest-growing demographic in the United States. By 2040, they will make up about 25% of the population.1 Medical science, technology, and changes in attitudes about aging have increased the amount of time this population can expect to maintain active and productive lives.

The incidence of chronic pain will increase in older patients. The most common causes of chronic pain in this patient population include arthritis, cancer, diabetes mellitus, and cardiovascular and neurologic diseases. In addition, as we learn more about a biopsychosocial approach to pain management instead of a purely medical approach, it is important to look at changes in lifestyles as people age that also may contribute to worsening pain syndromes.

Older patients frequently are on multiple medications for concomitant medical problems, increasing the risks for side effects and even mortality from pharmacologic agents. In addition, there are some key dynamics of pharmacotherapy that need to be understood and compensated for as decisions about medication management are undertaken.2 These include the following:

  1. Older adults have a higher percentage of body fat and decreases in body water and muscle mass. This means that water-soluble drugs become more concentrated and have higher initial concentrations. Fat-soluble drugs have longer half-lives due to slower release from the body’s fat stores.
  2. The livers of older patients are frequently smaller and have less blood flow, resulting in a decrease in the number of functioning hepatocytes. This, along with medications affecting the cytochrome P450 system, leads to changes impacting drug metabolism that need to be carefully individualized for each patient.
  3. An increase in the incidence of renal disease impacts decisions about medications affected by renal clearance or known to increase the risk for renal damage. Even in the absence of known renal disease, renal clearance can decline significantly in older patients, impacting the adverse event profile of a number of medications used without problems in younger patients.

Despite the complexity of treating chronic pain in older individuals, the benefits of addressing and treating pain are clear. Chronic pain decreases function, increases the incidence of depression, creates kinesiophobia (fear of movement), and may worsen other chronic diseases that require ongoing management for maximal control, such as diabetes, hypertension, and heart disease.

Pain can decrease the ability of patients to focus, sleep, and cope with the common stressors of life.3 As a result, poorly treated pain not only decreases the quality of life for patients, but also increases healthcare costs significantly. Unfortunately, however, a desire for rapid, inexpensive pain relief has frequently led to an increase in potentially dangerous polypharmacy without a full use of nonpharmacologic options.

This article reviews many options for chronic pain treatment in older patients, with a focus on the use of nonpharmacologic as well as pharmacologic options to increase the chance for pain reduction with improvement in patient function.

Pain Assessment
The importance of pain assessment and reassessment cannot be overemphasized. However, finding the time to accomplish this in a typical primary care visit can sometimes be quite difficult in the context of managing many of the other problems that an older patient may have. In a recent survey of Veterans Affairs (VA) primary care providers, the following factors were listed as barriers to effective pain management in primary care: 1) inadequacies in education and training; 2) lack of consultant support; 3) psychosocial complexity; 4) time pressures; 5) skepticism; and 6) systems limitations.This is echoed in non-VA primary care settings as well.

Setting up a separate time to review pain-related problems or getting help from other members of the primary care team may be necessary to effectively manage pain. Getting a good history is frequently more challenging in the older patient and may be complicated by a number of factors. Many older patients think that pain is expected as they get older and something they just have to live with. In addition, even with new programs for prescription payment, many older patients on fixed incomes remain concerned about spending money for medications or medication copays.

There remain concerns on the patient’s part that complaints of pain may result in unwanted testing, a diagnosis such as cancer, or a medication regimen that may not be tolerated. In addition, patients with cognitive problems may have difficulty expressing their pain, so other clues may be necessary to determine the extent of difficulty the patient is having.

Taking a Careful History
There are many pain scales, such as a numeric rating scale or a verbal descriptor scale, that may be helpful, but in many patients other cues may be necessary. These can include changes in behavior, decreases in activity level, facial grimacing, or gait changes. Each pain history should include provocative or palliative features of the pain, quality of the pain, whether the pain radiates, the severity of the pain in terms of ability to function, and the timing of the pain both in terms of total length of pain as well as times of the day that the pain is better or worse. In addition, mental health concerns, such as depression or anxiety as well as substance abuse problems, not only exacerbate an underlying pain problem but also impact treatment decisions. These underlying comorbidities may not be easily diagnosable with simple lab tests, and a history geared toward these diagnoses should also be included.

A physical examination focused on areas of pain is important. However, examination of lungs, heart, and abdomen as well as a neurologic exam may be equally important in determining the best approach to diagnostic and treatment options.

Further laboratory diagnostic studies to be considered include vitamin D levels, screening for appropriate inflammatory rheumatologic disorders, complete blood count, metabolic profile, and thyroid function testing. There are some studies that indicate significant vitamin D deficiency can make pain worse.5 At a minimum, vitamin D replacement in deficient individuals can help with osteoporosis prevention and decrease the risk for painful fractures in the future.6

X-rays of the painful areas to assess pathology can be instructive for the provider as well as the patient. However, it is frequently unnecessary to do a magnetic resonance imaging of these areas unless it is felt to be important for potential intervention if conservative treatment fails. Dual-energy x-ray absorptiometry scanning is helpful in men as well as women to determine if treatment for osteoporosis is indicated.

Nonpharmacologic Treatment Options
Once a diagnosis is made, there may be some general principles that can help with nonpharmacologic as well as pharmacologic treatment options. Nonpharmacologic treatment options are frequently underused and should be considered in every patient with chronic pain. Even when pharmacologic therapies are considered important, nonpharmacologic options can serve as a helpful adjunct to decrease the dosage and duration of medication when it is used.

Physical therapy options include the use of a transcutaneous electrical nerve stimulation unit, acupuncture, strength training, aerobic exercise, and gait training. Massage therapy can be used intermittently and as a way to demonstrate to patients the benefits of massage to help with pain exacerbations. Osteoarthritis and muscle spasm may respond to cold or heat. Warm paraffin baths may decrease hand pain in rheumatoid arthritis. Other nonpharmacologic options that have recently been shown to be helpful compared with usual care include yoga for low back pain as well as a structured exercise program for generalized pain.7,8

Cognitive-behavioral therapy may help patients with relaxation techniques, imagery techniques, and coping skills.7 In addition, the combination of physical therapy and behavioral therapy increases the likelihood of increasing patient activity levels both physically and intellectually. Many patients have Internet access and are very comfortable with looking up information. The use of informational Websites, such as www.painaction.com—a Website fully developed with funding from the National Institute of Drug Abuse—can be very helpful to give patients some ideas concerning nonpharmacologic options for pain as well as medication safety hints. In addition, cognitive therapy has been shown to be helpful when delivered by trained therapists over the phone, decreasing the need for frequent office visits and improving compliance.7

When indicated, interventional techniques for back pain, neck pain, and joint pain may be helpful, and appropriate referral to physiatrists, orthopedists, and back specialists may enable patients to receive enough relief from pain to more effectively participate in other aspects of pain care. In some patients, joint replacement may be life changing.

The biggest drawback to nonpharmacologic treatment options is the time and commitment it takes for patients as well as healthcare practitioners.Sometimes creative solutions need to be used. In the VA, pain schools offer cognitive skills training and education to patients being seen for chronic pain by primary care providers as well as specialists (see sidebar). This approach can be adapted by any large healthcare delivery system or even a multi-physician practice. This can improve the efficiency of each physician visit by providing chronic pain patients with needed education in a classroom setting that also provides a forum for patients to share success stories with each other. In addition, case management by other members of the primary care or pain team can decrease medication errors, encourage healthy activities, and answer questions. Older patients may frequently have questions they feel are too insignificant to warrant a call to a medical office but may be critical for their safe and effective pain treatment.

Nonopioid Pharmacologic Therapy
For many patients, pharmacologic therapy is necessary, either for a short time or chronically. In older patients, it is important to look at topical agents as the safest approach for those who may be on multiple other oral medications or who have comorbidities that may increase the risk for medication adverse reactions or drug interactions.

Topical agents can include topical lidocaine, capsaicin cream, topical analgesic agents, or topical nonsteroidal anti-inflammatory drugs (NSAIDs) (see Table 1).10,11

Lidocaine ointment is an inexpensive option and can be used for patients with neuropathic and arthritic pain. It is frequently easier for many patients to use lidocaine patches, which only need to be applied once per day compared with the four-times-daily dosing of lidocaine ointment. Formulary concerns may limit the ability to prescribe patches for some patients. Although the only FDA-approved indication for lidocaine patches is postherpetic neuralgia, recent studies have indicated the effectiveness of lidocaine patches in other neuropathic conditions, back pain, and arthritis pain.10,12

Other topical agents, such as capsaicin cream and topical menthol creams, may provide significant pain improvement with minimal risk if there is no allergy to the agents topically.

NSAIDs
Many patients may benefit from intermittent NSAID use. NSAIDs cannot be used in patients with impaired renal function or heart failure. Older patients are more sensitive to the nephrotoxic effects of NSAIDs and must be advised to use them only when needed and to remain well hydrated. Cyclooxygenase (COX)-1 NSAIDs have gastrointestinal (GI) and coagulation effects. However, all NSAIDs have some unique properties. Ibuprofen has the least GI toxicity but interferes with the cardioprotective effect of aspirin. Naproxen has an intermediate risk for GI toxicity without interfering with aspirin. Piroxicam (Feldane) and ketorolac have the highest risk for GI toxicity. COX-2 NSAIDs, such as celecoxib (Celebrex) and low-dose meloxicam (Mobic), have the lowest risk for GI toxicity, but questions have been raised about cardiotoxicity, especially in higher doses. Meloxicam has COX-1 properties at higher doses.

All NSAIDs worsen hypertension, congestive heart failure (CHF), and renal impairment. They are contraindicated in patients with renal disease, those on anticoagulation therapy, or those with CHF. Many patients are taking NSAIDs over-the-counter (OTC) (see Table 2), and every patient needs to be questioned about their OTC medication use.

Anticonvulsants
Gabapentin and pregabalin (Lyrica) have labeled indications for specific neuropathic pain disorders. Lower toxicity and fewer drug–drug interactions increase these drugs’ usefulness in the older population. Like other medications with a risk for increased sleepiness, doses should be started at a low dose and titrated upward slowly.13,14

Antidepressants
Dual-acting antidepressants have been shown to improve chronic pain even without a diagnosis of depression. Duloxetine (Cymbalta), a selective serotonin-norepinephrine reuptake inhibitor (SSNRI), has approved labeling for certain painful conditions and appears to be a better tolerated antidepressant for older adults. Venlafaxine requires slow titration to the usual therapeutic dose of 150 mg. It also has a significant discontinuation syndrome when abruptly stopped. The immediate-release formulation of venlafaxine can result in significant GI toxicity and hypertension at doses higher than 75 mg.15,16

Tramadol
Low-dose tramadol in doses of 25 to 50 mg can be helpful and represents an intermediate risk in patients compared with opioids. Older patients taking tramadol have been shown to have a lower incidence of falls and hip fractures. Tramadol needs to be used cautiously in patients on antidepressants but frequently can be used in low doses even in that setting. Tramadol may increase the risk for both seizure activity and serotonin syndrome in patients taking selective serotonin reuptake inhibitors, SSNRIs, and serotonin-norepinephrine reuptake inhibitors.17,18 There is significant synergy when tramadol is mixed with acetaminophen (APAP).

APAP
APAP, when used in low doses, can be a safe and effective option for patients, especially when combined with other modalities. There is no GI toxicity or effect on platelets. However, there are some warnings that need to be followed when using this alone or with other medications. It is important to monitor the international normalized ratio carefully when this is used with warfarin. The safest dose is up to 3 g per day in divided doses. Also, APAP is found in many OTC medications, and the patient (or caregiver) needs to be questioned about his or her OTC medication use. The FDA recently requested that makers of prescription combination products containing APAP limit the dose to 325 mg because of concerns about liver toxicity in higher doses of APAP. Recently, an APAP manufacturer has suggested an upper daily limit of 3 g per day in divided doses, also because of concerns about liver toxicity. The dose of APAP in patients with renal disease or liver disease also needs to be lowered to 2 g per day.19

Opioid Therapy for Nonmalignant Pain
An issue of the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report indicated that the worsening rates of overdoses and adverse events related to prescription opioids is at epidemic proportions and creates a complex public health crisis.20 Its recommendations regarding the use of opioids for chronic noncancer pain were that healthcare providers should use only opioid pain relievers (OPR) in carefully screened and monitored patients when non-OPR treatments are insufficient to manage pain.20 This is especially true in the elderly, in whom added risks associated with recognized opioid-related adverse events might be magnified. These adverse events include constipation, cognitive decline, increased risk for falling, increased risk for overdose, increased risk for hip fracture, and increased risk for exacerbation of sleep apnea. Recent articles include age greater than 65 years as a risk factor for overdose as well as increased risk for heart disease and GI bleeding when opioids are used (see Table 3).21,22

Despite the risks, opioids may be helpful in selected patients when used with caution and when full patient education about the risks and benefits is provided. Many providers do not think that opioid agreements are needed in older patients, but it is important to observe “universal precautions” in all patients, including those older than 65 years. This includes the use of an opioid agreement and urine drug screening in all patients. In addition, each patient should have a diagnosis with an appropriate differential, a full assessment of psychiatric and substance abuse risk factors, and a pre- and post-intervention assessment of level of pain and functioning with proper documentation. Documentation should include assessment of analgesia, activity level, adverse events, and any evidence of aberrant behavior.23

An opioid agreement serves a number of purposes and is equally important in older patients as well as in those who are younger. The opioid agreement serves as a way to have an open and honest discussion with patients about the fact that although opioids may be helpful, it is critical to pay attention to the warnings while using them. It is an opportunity to review side effects and what to do if they occur. It is also an opportunity to review office policies and procedures about opioid prescribing that must be adhered to during treatment.

We live in a world where there are warnings on just about everything we do. Patients can become quite blasé about a cursory warning. This is our chance to say, “We really mean it this time,” and review enough data about risks to be helpful yet not overwhelming. If possible, it is helpful to have a family member sign the agreement as well, but it is mandatory to have a responsible family member understand what is being discussed if the patient has someone else managing his or her medications. Urine drug screens also can be quite informative in older patients and mandatory to obtain prior to the first opioid prescription and repeated as felt to be appropriate.

High-risk behaviors can occur in older as well as younger patients and need to be discussed and reviewed regularly. Behaviors important to note in older patients are the following:

  1. Sharing medications can be felt to be a normal part of life by many patients. The medical community has been remiss in pointing out the dangers of mixing many medications with opioids, and the need to reinforce this is very clear as we look at adverse events associated with opioid usage.
  2. As patients retire, there are some situations in which alcohol use may increase, and previous use of illicit substances such as marijuana may resume. These drugs represent significant drug interactions with even more problematic outcomes in older patients, and this needs to be reviewed and discussed with all older patients on or off of opioid therapy, especially when there are chronic pain symptoms.
  3. As financial burdens increase, there have been a number of older patients who have supplemented their retirement incomes with the sale of opioids, which remains a crime in all 50 states.
  4. Unused opioids can be found by family members and diverted.
  5. Caregivers other than family members may take opioids from the patient and substitute non-opioid medications in their place without the patient’s knowledge.
  6. Many patients do not think that OTC medications are an important part of the history. Many OTC medications may complicate pain therapy, including the use of sedating antihistamines, NSAIDs, APAP-containing products when one is used as part of a prescription, and many herbal remedies that may increase the risk for a drug interaction.

When using opioids in the elderly, the caveat to start low and go slow remains important. Opioids tied into fixed APAP dosing such as hydrocodone/APAP should be avoided, and it may be best to start with low-dose morphine or oxycodone. The use of buprenorphine in the elderly has been extensively written about and may represent an option for providers familiar with its use, as it has been associated with less respiratory depression and cognitive impairment than other opioid analgesics. It is now currently available as a patch, improving ease of use for many patients.24

Methadone use represents even greater risks in the elderly and should be used with extreme caution. It has greater efficacy for neuropathic pain than other opioids; however, it has a number of drawbacks. It has a long and variable half-life, making serum levels difficult to predict. The half-life may vary from 8 to 59 hours. Methadone also has a number of drug interactions and can cause problems in patients taking a number of medications that may interact with methadone. This is further exacerbated by changing drug metabolism related to age. In addition, it can be responsible for fatal ventricular arrhythmias in patients with prolonged QTc intervals due to a torsades de pointes arrhythmia. In general, patients with a QTc interval greater than 500 milliseconds represent an absolute contraindication to methadone therapy, and QTc intervals between 450 and 500 milliseconds represent patients with whom extreme caution needs to be exercised if methadone is used at all.25

Older patients are more sensitive to the effects of opioids, especially in the presence of renal or hepatic dysfunction. The most serious risk is respiratory depression, which occurs less frequently when opioids are dosed and titrated cautiously. Although long-acting opioid use decreases the risk for end-of-dose failure (breakthrough pain) and treatment failure, it is important to understand the therapeutic response of patients to each formulation. As with impaired metabolism and excretion in older patients, the shorter-acting agents may, in fact, remain helpful for more prolonged periods of time than in younger patients.26 It is, therefore, important to ask patients about pain exacerbations and their relationships to dosing to determine if end-of-dose worsening of pain indicates the need for a longer-acting formulation.

The patient is at the most risk for respiratory depression during the first day of opioid therapy and during periods of dose escalation. Patients with chronic obstructive pulmonary disease, obesity, kyphoscoliosis, or sleep apnea are at greatest risk for developing respiratory depression during opioid therapy. Opioids also can increase the risk for falling due to cognitive problems and/or peripheral vasodilation. Immune suppression can lead to an increased risk for infection in susceptible individuals.

Constipation is the most common side effect of opioids in the elderly, and patients do not develop a tolerance to this side effect with prolonged opioid therapy. Treatment with a stool softener, increase in fiber, and occasional use of cathartics, such as lactulose or polyethylene glycol, frequently become necessary. Untreated constipation can sometimes present as acute abdominal pain.

Summary
Chronic pain in the elderly can be a complex but rewarding problem to treat. Sole reliance on oral medications alone may result in significant side effects and drug interactions. The best approach is a full biopsychosocial approach geared toward improving patient function with cautious medication use. Nonpharmacologic therapies can be critical in improving symptoms and functional capacity and minimizing medication use and associated side effects. When medications are used, opioids should be reserved for patients who are unable to improve significantly without opioid therapy. However, patient selection and monitoring are important to minimize adverse events. Opioid dosing should be kept to the lowest effective dose, because increased opioid doses, especially those greater than morphine equivalents of 100 mg per day, have been associated with an increased risk for morbidity and mortality.

Last updated on: December 12, 2014
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