1. PERSISTENT PAIN Topic Suggestions for Lecturer -1-hour lecture
-Use slides alone or to supplement your own teaching materials.
-Refer to the GRS chapter on persistent pain for additional material.
-Refer to Geriatrics At Your Fingertips for updated information on evaluation and management.
-Supplement lecture with handouts, such as the table in the GRS chapter on persistent pain that is entitled “Systemic Pharmacotherapy for Persistent Pain Management.”
-See GRS7 questions 18, 106, 107, and 240 for case vignettes.
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2. OBJECTIVES Know and understand: The 3 major types of pain syndromes
Components of a thorough pain assessment
Common pain behaviors in cognitively impaired older persons
Principles of non-pharmacologic and pharmacologic treatment of persistent pain
How to manage the adverse effects of opioids
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3. TOPICS COVERED Assessment
Assessing and Treating Pain in Cognitively Impaired Persons
Treatment
Fundamental Approaches
Barriers to Using Opioids in Older Persons
Adverse Effects of Opioids
Nonopioid Medication to Treat Persistent Pain
Medications to Avoid in Older Persons
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4. STANDARDS OF EVIDENCE (SOE)
Rating
Basis of Rating
Studies Justifying Rating A
Consistent and good quality patient-oriented evidence
Large cohort studies for risk factors/prognosis; RCTs for diagnosis/treatment B
Somewhat inconsistent or limited quality patient-oriented evidence
Smaller or single cohort studies for risk factors/ prognosis; small or single RCTs or cohort studies for diagnosis/treatment; uncontrolled studies C
Very inconsistent or very limited patient-oriented evidence, consensus, disease-oriented evidence, and/or case series for studies of diagnosis, treatment, prevention, or screening
Single small cohort study for risk factors/prognosis; single small cohort study or RCT for diagnosis/treatment; case series D
Unstudied common practice or opinion
No evidence
RCT = randomized controlled trial
Patient-oriented evidence measures outcomes that matter to patients: morbidity, mortality, symptom improvement, cost reduction, quality of life.
Disease-oriented evidence measures intermediate, physiologic, or surrogate endpoints that may or may not reflect improvements in patient outcomes (ie, blood pressure, blood chemistry, physiological function, and pathological findings).
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5. PREVALENCE OF PERSISTENT PAIN IN OLDER PERSONS
Substantial pain is experienced by:
Pain, defined as an unpleasant sensory and emotional experience, is common in older persons aged 65 and older.
Chronic or persistent pain, in contrast to acute pain, is pain lasting 3 to 6 months or more after the original injury has healed, pain that is associated with a chronic medical condition, or pain that recurs at intervals of a month to years.
25% to 50% of community-dwelling older adults
45% to 80% of nursing-home residents
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6. PAIN IS COMMONLY UNDERTREATED
Patients may:
Minimize their symptoms
Not report pain
Be unable to report pain because of language impairment or cognitive impairment
Clinicians may:
Inadequately assess pain
Undertreat pain with ineffective therapies
Encounter intolerable adverse effects with otherwise effective therapies
Persistent pain is complex, involving an amalgamation of physical, social, and psychologic factors. Untreated, it can result in difficulty performing activities of daily living, cognitive dysfunction, depression, anxiety, social isolation, appetite impairment, and sleep disorders. Lastly, patients with chronic pain accrue greater health care costs than do patients who are pain-free.
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7. INITIAL ASSESSMENT Take a complete history of the pain
Character
Course of its onset
Duration
Location
Carefully evaluate patient’s functional status
Evaluate patient’s cognitive state, participation in social activities, mood, and quality of life
A major barrier to effective pain treatment is inadequate assessment. A thorough assessment is necessary to formulate a plan to successfully treat persistent pain. This assessment should include an examination of physical, emotional, and social function, recognizing the considerable impact that each of these domains has on the experience of pain and suffering and the impact of chronic pain on each of these domains of well-being.
Since there are no blood tests or imaging modalities to measure pain objectively, clinicians must rely on the patient’s or caregiver’s description of the pain and on the findings of a thorough physical examination. The goal of the assessment is to identify the source of the pain so that it can be treated with the most effective, targeted, and specific treatment known.
The evaluation of older persons is complicated by several challenges, including under-reporting of symptoms by many older persons, the existence of multiple medical comorbidities exacerbating the pain and impairing the function of the patient, and the increased prevalence of cognitive impairment as people age.
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8. PAIN INTENSITY SCALES Unidimensional scales: Multidimensional scales:
Numeric Rating Scale—0 is no pain, 10 is worst pain imaginable
Faces Pain Scale—patient chooses a facial expression that corresponds to the pain
Verbal Descriptor Scale—“no pain” to “pain as bad as it could be”
Multidimensional scales:
McGill Pain Questionnaire
Pain Disability Scale
The choice of scale depends on the presence of a particular language or sensory impairment. For example, if the patient does not speak English well, the Faces Scale may be the best choice because it relies on pictures rather than words or numbers. The same scale should be used at follow-up examinations to evaluate how the pain has changed since the initial assessment.
Although lengthy, scales measuring multiple domains can provide a wealth of information about the patient’s unique experience of pain.
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9. PAIN MAP
Ask patient to indicate the locations of their pain on a drawing of a human figure
Consider referral to a mental health specialist (to evaluate for affective disorder contributing to the discomfort) if the patient’s pain pattern:
Is erratic
Is diffuse
Does not conform to an anatomic distribution
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10. PHYSICAL EXAMINATION
Carefully examine the reported site of pain and locations that may be a source of referred pain
Perform complete musculoskeletal exam
Fibromyalgia, osteoarthritis, or myofascial pain is commonly either the primary source of pain or an exacerbating process
Accurate diagnosis is critical to formulating the correct therapeutic plan
Fibromyalgia may be under-recognized in older adults. It is typically characterized by multiple tender points, sleep disturbance, fatigue, generalized pain (often with a strong axial component), and morning stiffness.
Myofascial pain is present in the vast majority of patients with persistent pain and is diagnosed by the presence of taut bands of muscles and trigger points (ie, pain that may radiate distally upon application of firm pressure to a muscle, as opposed to tender points, in which radiation of pain is absent).
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11. 3 TYPES OF PAIN SYNDROMES
Nociceptive—pain due to activation of nociceptive sensory receptors; often adequately treated with common analgesics
Somatic—well localized in skin, soft tissue, bone
Visceral—due to cardiac, GI, or lung injury
Neuropathic—from irritation of components of the CNS or peripheral nervous system; may respond well to nonopioid therapies; responds unpredictably to opioids
Mixed or unspecified—has characteristics of both nociceptive and neuropathic pain; common in older adults
Nociceptive pain describes pain due to the activation of nociceptive sensory receptors by noxious stimuli resulting from inflammation, swelling, and injury to tissues. Somatic pain is commonly described as throbbing, aching, and stabbing. Visceral pain is not well localized and difficult to describe. Patients describe visceral pain as crampy, tearing, dull, and aching.
With neuropathic pain, patients typically report burning, numbness with “pins and needles” sensations, and shooting pains. Common causes of neuropathic pain include diabetic neuropathy and post-herpetic neuralgia, while post-stroke central pain and phantom limb pain experienced following amputation are less common but often severe. Confusion between neuropathic pain and myofascial pain is possible, as patients may describe both as “burning.” Careful physical examination will help to differentiate these disorders (ie, taut bands and trigger points with myofascial pain and allodynia or hyperalgesia with either disorder), although both may exist in the same patient.
An example of a mixed pain syndrome is chronic headaches of unknown causes. Lower back pain is often a combination of spinal malalignment, myofascial pathology, and neurologic impingement. Patients with mixed pain syndromes may need trials of different medications or combinations of medicines.
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12. TYPES OF PAIN, EXAMPLES, AND TREATMENT (1 of 3)
Type of Pain and Examples
Source of Pain
Typical Description
Effective Drug Classes and Non-Pharmacologic Treatments (SOE Rating)
Nociceptive: somatic
Arthritis, bone metastases
Tissue injury (eg, bones, soft tissue, joints, muscles)
Well localized, constant; aching, stabbing, gnawing, throbbing
Acetaminophen (A), opioids (B)
Physical and cognitive-behavioral therapies (B)
Nociceptive: visceral
Renal colic, constipation
Viscera
Diffuse, poorly localized, referred to other sites, intermittent, paroxysmal; dull, colicky, squeezing, deep, cramping; often accompanied by nausea, vomiting, diaphoresis
Treatment of underlying cause
Physical and cognitive-behavioral therapies (C)
Table 15.1
Source: Adapted with permission. Reuben DB, Herr KA, Pacala JT, et al. Geriatrics At Your Fingertips. New York: American Geriatrics Society; 2010:180.
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13. TYPES OF PAIN, EXAMPLES, AND TREATMENT (2 of 3)
Type of Pain and Examples
Source of Pain
Typical Description
Effective Drug Classes and Non-Pharmacologic Treatments (SOE Rating)
Neuropathic
Cervical or lumbar radiculopathy, post-herpetic neuralgia, trigeminal neuralgia, diabetic neuropathy, post-stroke syndrome, herniated intervertebral disc
Peripheral or central nervous system
Prolonged, usually constant, but can have paroxysms; sharp, burning, pricking, tingling, squeezing; associated with other sensory disturbances (eg, paresthesias and dysesthesias); allodynia, hyperalgesia, impaired motor function, atrophy, or abnormal deep tendon reflexes
Tricyclic antidepressants (A), anticonvulsants (A), serotonin-norepinephrine reuptake inhibitor antidepressants (A), opioids (B), topical anesthetics (C)
Physical and cognitive-behavioral therapies (C)
Table 15.1
Source: Adapted with permission. Reuben DB, Herr KA, Pacala JT, et al. Geriatrics At Your Fingertips. New York: American Geriatrics Society; 2010:180.
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14. TYPES OF PAIN, EXAMPLES, AND TREATMENT (3 of 3)
Type of Pain and Examples
Source of Pain
Typical Description
Effective Drug Classes and Non-Pharmacologic Treatments (SOE Rating)
Undetermined
Myofascial pain syndrome, somatoform pain disorders
Poorly understood
No identifiable pathologic processes or symptoms out of proportion to identifiable organic pathology; widespread musculoskeletal pain, stiffness, and weakness
Antidepressants (B), antianxiety agents (C)
Physical, cognitive-behavioral and psychological therapies (B)
Table 15.1
Source: Adapted with permission. Reuben DB, Herr KA, Pacala JT, et al. Geriatrics At Your Fingertips. New York: American Geriatrics Society; 2010:180.
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15. PAIN IN COGNITIVELY IMPAIRED PERSONS
Observe for possible pain-related behaviors (next slide) and ask caregivers for their observations
Consider trial of analgesia for patients exhibiting pain-related behaviors
Validated scales (eg, Hurley Discomfort Scale, Checklist of Nonverbal Pain Indicators) require training
Provide empiric analgesia during procedures and conditions known to be painful
Patients with severe cognitive impairment who are unable to verbally express pain pose a challenge to the clinicians who care for them. Not only are they unable to describe the pain and request analgesia, but clinicians may be hesitant to administer pain medications, fearing that drugs will worsen the patients’ mental status.
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16. COMMON PAIN BEHAVIORS IN COGNITIVELY IMPAIRED ELDERLY PERSONS (1 of 2)
Examples
Facial expressions
Slight frown; sad, frightened face
Grimacing, wrinkled forehead, closed/tightened eyes
Any distorted expression
Rapid blinking
Verbalizations, vocalizations
Sighing, moaning, groaning
Grunting, chanting, calling out
Noisy breathing
Asking for help
Verbal abusiveness
Body movements
Rigid, tense body posture, guarding
Fidgeting
Increased pacing, rocking
Restricted movement
Gait or mobility changes
NOTE: Some patients demonstrate little or no specific behavior associated with severe pain.
SOURCE: Adapted with permission from American Geriatrics Society Panel on the Pharmacologic Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57(8):13311346.
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17. COMMON PAIN BEHAVIORS IN COGNITIVELY IMPAIRED ELDERLY PERSONS (2 of 2)
Examples
Changes in interpersonal interactions
Aggressive, combative, resists care
Decreased social interactions
Socially inappropriate, disruptive
Withdrawn
Changes in activity patterns or routines
Refusing food, appetite change
Increase in rest periods
Sleep, rest pattern changes
Sudden cessation of common routines
Increased wandering
Mental status changes
Crying or tears
Increased confusion
Irritability or distress
NOTE: Some patients demonstrate little or no specific behavior associated with severe pain.
SOURCE: Adapted with permission from American Geriatrics Society Panel on the Pharmacologic Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57(8):13311346.
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18. NON-PHARMACOLOGIC THERAPIES
Patient education and involvement in decisions
Teach patients to take medications properly and how to use assessment instruments
Provide partner-guided pain management training to caregivers
Cognitive-behavioral therapy
Regular physical activity
Or supervised rehabilitation for frail patients, or regular repositioning and gentle massage for bed-bound patients
Referral to an interdisciplinary pain clinic
A comprehensive review of nonpharmacologic therapies for persistent pain is beyond the scope of this slide set. However, many of the strategies mentioned on this slide are appropriate suggestions for all patients’ treatment plans.
The common overlap of depression, anxiety, and other mood disturbance should prompt early consultation with a mental health professional. Cognitive- behavioral therapy involves asking a patient to track the pain and record associated thoughts to identify maladaptive coping strategies. By trading these for positive coping strategies, patients may increase control over pain and self- efficacy, leading to decreased perception of pain. When possible, family members and caregivers should be included in the therapy.
Regular physical activity has been shown to decrease pain scores, improve mood, boost functional status, and stabilize gait (SOE=A). For patients of any ability level, the goals should include improvements in flexibility, strength, endurance, and function.
Referral to an interdisciplinary pain clinic may be useful for patients with complex pain or who are poorly responsive to first-line treatments. Data support the use of many physical therapies such as massage therapy, acupuncture, the use of heat/cold therapy, and transcutaneous electrical nerve stimulation units (SOE=B). The clinic may incorporate other cognitive techniques into the treatment plan, such as hypnosis, aromatherapy, biofeedback, music and pet therapy, and systematic desensitization. Suboptimal treatment response should not be viewed as a permanent state, but as an opportunity for input from specialists.
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19. PRINCIPLES OF PHARMACOLOGIC THERAPY
Besides pain relief, the goals are improved function and enhanced adherence with rehabilitation
Individualize the initial dose and rate of titration
In general, start opioids at lowest dose and titrate slowly, but if patient is in pain crisis, do not withhold medications
Try nonsystemic or non-pharmacologic therapies first if appropriate
When initiating pharmacologic therapy in older adults, it is important to consider the balance of risks and benefits of the treatment. If appropriate, nonsystemic therapies should be tried first. For example, patients who primarily have knee pain might respond to intra-articular corticosteroid injections, avoiding the need for systemic analgesics. Convincing data supporting the utility of intra-articular injections for knee pain are lacking, however.
Patients with myofascial pain often respond to local modalities such as massage, gentle stretching exercises, ultrasound, and trigger-point injections (SOE=B). Topical preparations such as capsaicin or ketamine gel (off-label) or lidocaine patches might be effective as primary or adjunctive therapy in the treatment of patients with neuropathic or myofascial pain syndromes.
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20. TREATING MILD TO MODERATE PAIN
Acetaminophen
Particularly for musculoskeletal pain
No more than 4 g every 24 h
Lower the dose by 50%, or avoid, in patients at risk of liver dysfunction, especially with history of heavy alcohol intake
Know all medications the patient is taking, as acetaminophen is a common ingredient in prescription and OTC drugs
NSAIDs
Many significant adverse effects
Use COX-2 inhibitor with extreme caution, if at all, in older persons
Use judiciously if at all only after acetaminophen has been tried and only in highly select individuals
Acetaminophen provides adequate analgesia for many mild to moderate pain syndromes, particularly musculoskeletal pain from osteoarthritis, and it is recommended as first-line therapy for persistent pain. No more than 4 g of acetaminophen every 24 hours should be administered to patients with normal hepatic and renal function, given the risk of hepatotoxicity at higher doses. Patients at risk of liver dysfunction, particularly those who have a history of heavy alcohol intake, should be treated cautiously; the dosage should be decreased by 50%, or acetaminophen should be avoided. Acetaminophen is commonly contained in many OTC and prescription products; therefore, it is critical to review all medications a patient is taking, to avoid toxicity.
NSAIDs tend to be more effective than acetaminophen in chronic inflammatory pain but pose significantly higher threats to older adults. They must be used judiciously, if at all, and only after acetaminophen has been tried and only in highly select individuals. Significant adverse events, including renal dysfunction, GI bleeding, platelet dysfunction, fluid retention, precipitation of heart failure, and precipitation of delirium, limit their use for treating chronic pain in older adults. The FDA cautions against using ibuprofen with aspirin, owing to an interaction that blocks the antiplatelet effect of the aspirin. Several studies have confirmed high cardiovascular risks associated with COX-2 inhibitors, now believed to be a class effect. Although one is currently still on the market, the COX-2s should be considered with caution—if at all—in older adults.
Nonacetylated salicylates such as salsalate and trisalicylate may have less renal toxicity and antiplatelet activity than other NSAIDs and therefore may be preferable in older adults, although evidence supporting this theory is sparse. Topical NSAIDs appear to be safe and effective in the short term, but longer- term studies are lacking.
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21. TREATING MODERATE TO SEVERE PAIN
To estimate opioid requirements, conduct a trial of a short-acting opioid
Treat continuous pain with 24-hour opioids in long- acting or sustained-release formulations
To cover breakthrough pain, combine with fast-onset medications that have short half-lives
Breakthrough pain typically requires 5%–15% of the daily dose, offered q2h orally
In general, different opioids are similarly efficacious
Cost and route of delivery can help guide the choice
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22. USING OPIOIDS IN RENAL FAILURE
To reduce the risk that the active metabolites of morphine will accumulate, increase the dosing interval and reduce the dose
Hydromorphone is many experts’ first choice for this population
Safety of oxycodone in this population is still controversial
Opioids are metabolized by the liver and excreted by the kidney. In kidney failure, the active metabolites of morphine, including morphine-6-glucuronide and morphine-3-glucuronide, can accumulate, which places the patient at increased risk for prolonged sedation and possible neurotoxicity.
Hydromorphone has been shown to have fewer side effects in patients with renal failure, and it is therefore many experts’ first choice for this population (SOE=C).
Some experts and limited data suggest that oxycodone is safer in kidney failure because its metabolism results in fewer active metabolites, but this remains controversial (SOE=C).
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23. COMBATTING FEAR OF TOLERANCE AND ADDICTION TO OPIOIDS
Avoid withdrawal symptoms by tapering carefully over days to weeks
If rapid upward titration is required to reduce pain, suggesting that tolerance has developed:
Evaluate the cause of pain, including searching for new pathologies and exacerbation of known sources of pain
Consider nonphysical causes of pain
When switching a patient from one opioid to another, reduce the dose to 50–60% of the equivalent dose
Patients may fear that taking opioid therapy for their current level of pain will result in the pain medicines’ losing their effectiveness in the future when pain becomes more severe. They may also fear addiction to the medicines. In fact, fear of addiction is a major obstacle to prescribing medications to older adults. A frank discussion of these concerns may help to alleviate these fears.
Physical dependence is an expected change in a patient’s physiology that occurs while a patient is receiving chronic, continuous opioid medications. If opioids are discontinued suddenly, a patient who is physically dependent will experience a withdrawal syndrome that may include restlessness, tachycardia, hypertension, fever, tremors, and lacrimation.
Tolerance refers to a change in physiology resulting in the need to increase opioid medicines over time to achieve adequate analgesic effect. Experts note that tolerance to analgesia, as opposed to tolerance to sedation and respiratory depression, develops slowly in stable disease.
Psychological dependence, or true addiction, refers to a psychiatric state defined by compulsive drug seeking and drug using with disregard for adverse social, physical, and economic consequences. It is very rare for patients who have chronic pain to become addicted to opioids. Addiction must be distinguished from pseudo-addiction, which refers to a patient with significant unrelieved pain who adopts behaviors similar to those of truly addicted patients while seeking relief from suffering, but generally with less prominent disregard for adverse social, physical, and economic consequences.
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24. MANAGING THE ADVERSE EFFECTS OF OPIOIDS (1 of 2)
Constipation
Educate patient about probable need for long-term laxative treatment
In most cases, start with a stimulant laxative
Encourage exercise and hydration
Consider methylnaltrexone for patients with opioid-induced constipation despite laxative therapy
Nausea and vomiting—evaluate for reversible causes; then try a different opioid or treat with chronic antiemetics
Opioid-induced constipation is due to multiple mechanisms, including dehydration, decreased GI tract secretions, and decreased motility of the GI tract. Although tolerance develops fairly rapidly to other adverse effects of opioids, such as respiratory depression and sedation, constipation usually complicates opioid use for the duration of treatment.
Many experts recommend starting therapy with a stimulant laxative (such as bisacodyl or senna); however, these should be avoided in any patient with signs or symptoms of bowel obstruction. Bulking agents such as fiber and psyllium should be avoided in patients who are inactive and who have poor oral fluid intake, given the risk of causing stool impaction and obstruction. For patients who develop opioid-induced constipation despite laxative therapy, recent data suggest that treatment with methylnaltrexone, a mu-opioid receptor antagonist, may be effective at relieving the constipation without precipitating withdrawal symptoms or pain crisis (SOE=B).
Opioids have a direct effect on the part of the brain associated with the sensation of vomiting called the chemoreceptor trigger zone. Other common causes of nausea and vomiting in patients taking opioids include gastroparesis, constipation, and metabolic disorders such as renal and hepatic failure. Although the nausea and vomiting is usually self-limited to the first few doses, some patients experience chronic nausea. After evaluation for reversible causes of nausea such as constipation, some patients benefit from changing to an alternative opioid. (SOE=D) Others may need to be treated with chronic antiemetics, accepting the high prevalence of adverse effects in older adults treated with these medications, including drowsiness, delirium, and anticholinergic effects.
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25. MANAGING THE ADVERSE EFFECTS OF OPIOIDS (2 of 2)
Sedation, fatigue, mild cognitive impairment
Educate the patient that these changes generally subside days to weeks after dose adjustment
Warn against driving or operating heavy equipment when medication is initiated
Warn of the risk of falls
For incessant fatigue, try a stimulant such as low-dose methylphenidate or rotation to a different opioid
Respiratory depression—use naloxone sparingly, at the lowest dose, and titrate carefully
Respiratory depression is a feared complication of opioid therapy. Older persons and persons with a history of lung dysfunction are at particular risk when opioid doses are increased too rapidly. Naloxone, an opioid receptor antagonist, can reverse opioid-induced respiratory depression; however, when it is given to a patient who has been treated chronically with opioids, it can precipitate a pain crisis and acute withdrawal symptoms.
Experts suggest withholding naloxone unless the patient’s respiratory rate decreases to less than 8 breaths per minute or the oxygen saturation drops to below 90%. When it is needed, naloxone should be titrated carefully, using the lowest dose possible.
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26. NONOPIOID MEDICATION
TCAs (off-label) are the best-studied drugs for neuropathic pain
Optimal analgesia requires treatment of depression
SSRIs are less well studied than TCAs as analgesics, but they are better tolerated in antidepressant doses
Duloxetine is approved as both an antidepressant and for treatment of pain from diabetic neuropathy
Anticonvulsants—commonly used for neuropathic pain
Corticosteroids are useful adjuvants for neuropathic pain and pain associated with swelling, inflammation, and tissue infiltration (SOE=C)
The efficacy of TCAs for treating post-herpetic neuralgia and diabetic neuropathy has been exhibited in numerous placebo-controlled studies (SOE=A). However, TCAs are associated with significant anticholinergic adverse effects in older persons. Desipramine and nortriptyline may have fewer adverse effects than amitriptyline (all used off-label).
Anticonvulsants such as carbamazepine (approved for some types of neuropathic pain), pregabalin, gabapentin, and clonazepam (off-label) are commonly used as treatments for neuropathic pain. Gabapentin has demonstrated efficacy in the treatment of post-herpetic neuralgia, and it has fewer adverse effects than TCAs, although it costs substantially more. The main side effects of gabapentin and pregabalin are sedation and dizziness, which frequently limit dose escalation.
In addition to their analgesic properties, corticosteroids may increase appetite and improve energy. Adverse effects occurring with short-term use include psychosis, fluid retention, hair loss, loss of skin integrity, hyperglycemia, and immunosuppression.
Intravenous bisphosphonates may substantially reduce pain from malignant bone metastases (SOE=B).
Tramadol has combined mechanisms of opioid-receptor binding and norepinephrine- and serotonin-reuptake inhibition. It can lower the seizure threshold and is therefore not recommended for patients who have a history of seizures or are taking other medications that could lower the seizure threshold. Caution should also be exercised in patients taking other medications with serotonergic properties to avoid serotonin syndrome (myoclonus, agitation, abdominal cramping, hyperpyrexia, hypertension, and potentially death).
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27. MEDICATIONS TO AVOID IN OLDER PERSONS
Propoxyphene
Meperidine
Mixed agonist-antagonists such as nalbuphine and butorphanol
COX-2 inhibitors
Other NSAIDs and use rarely if ever
Propoxyphene is an older opioid medication used to treat mild to moderate pain. However, research and clinical experience has shown that the drug may accumulate in older persons and cause ataxia and dizziness as well as tremulousness and seizures. It has also never been shown to be more a more effective analgesic than placebo (SOE=B).
Meperidine is metabolized to normeperidine, a substance that has no analgesic properties but that can accumulate in patients with decreased kidney function and cause tremulousness, myoclonus, and seizures. Neither of these medications is recommended for use in older persons.
Mixed agonist-antagonists such as nalbuphine and butorphanol also have the potential to cause restlessness and tremulousness and therefore should be avoided in older persons.
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28. SUMMARY (1 of 2)
Pain requires a thorough assessment to determine its source, severity, and impact on the well-being of the patient
Cognitively impaired patients who cannot communicate about pain should receive empiric analgesia during procedures and conditions known to be painful
A stepped approach to pain treatment is advised, starting with local and non-pharmacologic approaches
Systemic analgesics should not be withheld if needed initially
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29. SUMMARY (2 of 2)
In general, different opioids have similar efficacy and limited cross-tolerance
Patients being treated with opioids usually develop tolerance to the respiratory depression, fatigue, and sedation, but not to the constipating effect
Optimal analgesia requires treatment of any associated clinical depression
COX-2 inhibitors should be avoided in older patients, and nonselective NSAIDs should be used cautiously
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30. CASE 1 (1 of 3)
A 72-year-old woman comes to the office because of persistent pain in her left hip.
Her history includes osteoarthritis, as well as a life- threatening episode of GI bleeding related to the use of NSAIDs.
Oral acetaminophen 1000 mg q6h decreases the pain for a short time.
The patient follows her physical therapy regimen routinely.
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31. CASE 1 (2 of 3)
Which of the following is the most appropriate intervention?
Increase acetaminophen to 1000 mg q4h.
Start ibuprofen 600 mg q6h.
Start oxycodone 2.5 mg q4h as needed.
(D) Start long-acting morphine 15 mg q12h.
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32. CASE 1 (3 of 3)
Which of the following is the most appropriate intervention?
Increase acetaminophen to 1000 mg q4h.
Start ibuprofen 600 mg q6h.
Start oxycodone 2.5 mg q4h as needed.
(D) Start long-acting morphine 15 mg q12h.
ANSWER: C
Following the dosage dictum to “start low and go slow” for older adults, the most appropriate next step is to prescribe oral oxycodone 2.5 mg q4h as needed. If the pain relief remains inadequate, then the dosage can be increased to 5 mg q4h. If the pain relief is adequate and adverse events are tolerable, a long-acting regimen can be introduced. All patients beginning opioid therapy should also be started on a scheduled bowel regimen of an osmotic laxative (eg, lactulose) and a stimulant laxative (eg, senna), with a rescue regimen (eg, Dulcolax suppository or enema).
Increasing the acetaminophen dosage to q4h would be incorrect because the total daily dose would be above the limit for liver toxicity of 4000 mg/d. Starting ibuprofen is inappropriate given this patient’s history of life-threatening GI bleeding with NSAIDs. In an opioid-naive patient, starting long-acting morphine is unsafe before completing a dose-finding trial with a short-acting opioid. If long- acting morphine is started, the patient may have excessive drowsiness or respiratory depression. Once an effective opioid dose is found, changing the patient to a long-acting opioid would be appropriate.
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33. CASE 2 (1 of 3)
An 80-year-old man with diabetes and osteoporosis comes to the office for consultation regarding his pain regimen.
He has severe pain related to diabetic neuropathy and back pain related to multiple compression fractures.
He takes hydrocodone/acetaminophen 2 tablets q6h, which helps the back pain but does little for the neuropathic pain.
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34. CASE 2 (2 of 3)
Which of the following is an appropriate alternative to hydrocodone/acetaminophen for control of this patient’s pain?
(A) Meperidine
(B) Propoxyphene
(C) Butorphanol
(D) Nalbuphine
(E) Methadone
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35. CASE 2 (3 of 3)
Which of the following is an appropriate alternative to hydrocodone/acetaminophen for control of this patient’s pain?
(A) Meperidine
(B) Propoxyphene
(C) Butorphanol
(D) Nalbuphine
(E) Methadone
ANSWER: E
Using a single agent for this patient’s two different types of pain—nociceptive and neuropathic—would be ideal. Opioids have some efficacy in treating neuropathic pain, although tricyclic antidepressants and anticonvulsants are more effective (SOE=A).
Of the medications listed, methadone is the most appropriate. In addition to having mu-opioid receptor activity, methadone has antagonist activity at the NMDA (N-methyl-D-aspartate) receptor, making it useful in cases of opioid tolerance and neurotoxicity. Methadone inhibits reuptake of both norepinephrine and serotonin, making it potentially more effective than other opioids in the treatment of neuropathic pain, although this claim is debated (SOE=C). Methadone should be used cautiously because it has complicated pharmacokinetics and can cause prolongation of the QTc interval (SOE=C).
Neither propoxyphene nor meperidine is recommended for use in older adults. (SOE=B). Propoxyphene can accumulate in older adults and cause ataxia, dizziness, tremulousness, and seizures; it has never been shown to offer more analgesia than placebo. Meperidine is metabolized to normeperidine, which has no analgesic properties and can accumulate in patients with decreased kidney function, causing tremulousness, myoclonus, and seizures. Mixed agonist- antagonist agents such as nalbuphine and butorphanol can cause restlessness and tremulousness; therefore, they should be avoided in older adults (SOE=C).
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36. CASE 3 (1 of 3)
A 65-year-old woman with breast cancer metastatic to bone is evaluated in preparation for hospital discharge.
She is on a continuous IV infusion of morphine 4 mg/hr, and she has received 3 breakthrough rescue doses of 4 mg each over the past 24 h.
Her pain is generally well controlled on this regimen, and she is alert and talkative.
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37. CASE 3 (2 of 3)
Which of the following oral regimens is most likely to provide appropriate pain relief?
(A) Oxycodone 20 mg q3h as needed
Short-acting morphine 30 mg q3h
Long-acting morphine 30 mg q12h, with
short-acting morphine 15 mg q2h for
breakthrough pain
(D) Long-acting morphine 150 mg q12h, with
short-acting morphine 30 mg q2h for
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38. CASE 3 (3 of 3)
Which of the following oral regimens is most likely to provide appropriate pain relief?
(A) Oxycodone 20 mg q3h as needed
Short-acting morphine 30 mg q3h
Long-acting morphine 30 mg q12h, with
short-acting morphine 15 mg q2h for
breakthrough pain
(D) Long-acting morphine 150 mg q12h, with
short-acting morphine 30 mg q2h for
ANSWER: D
Practitioners should have a systematic approach to opioid conversion. Although many equianalgesic calculators are available, many conversion tables represent an oversimplification of pharmacologic principles that cannot substitute for clinical experience and caution.
Conversion from intravenous to oral morphine first requires calculation of the total IV dose of opioid that the patient has received over the past 24 h, and then multiplication by 3. In this case, the patient has received 108 mg IV in the past 24 h (4 mg/h × 24 h [96 mg/d] plus 3 × 4 mg [12 mg]). The oral equivalent is 324 mg (108 mg × 3) over 24 h.
Long-acting morphine comes in 30-mg capsules that cannot be split; they can be administered q8h or q12h. Therefore, the best oral standing dosage would be long-acting morphine 150 mg q12h (total dose 300 mg, close to the total of 324 mg above).
Breakthrough doses should be 10% of the daily equivalent of oral morphine. For this patient, 10% of the total oral dose is 30 mg. Her breakthrough dose should be 30 mg q2h as needed.
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39. Copyright © 2010 American Geriatrics Society
ACKNOWLEDGMENTS
Editor: Annette Medina-Walpole, MD
GRS7 Chapter Authors: Jennifer M. Kapo, MD
GRS Question Writer: Rachelle Bernacki, MD, MS
Pharmacotherapy Editor: Judith L. Beizer, PharmD
Medical Writers: Beverly A. Caley
Faith Reidenbach
Managing Editor: Andrea N. Sherman, MS
Copyright © 2010 American Geriatrics Society
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