Management of Chronic Non-cancer Pain in Older Adults

Dina Baras CPSA, Optimized Prescribing with Seniors 9 Comments

Contributed by: Dr. Darren Burback

John is a 78-year-old man who has experienced chronic low-back pain for several years, with gradual worsening over time. He has a history of degenerative disc disease and moderate lumbar spinal stenosis. There is no indication for surgical intervention. His history includes mild cognitive impairment, hypertension, diabetes mellitus type 2, mild chronic renal impairment and falls. His current medication regimen includes acetaminophen 500 milligrams (mg) PRN and naproxen 200 mg twice daily (over the counter supply). He comes to your office with complaints of pain, wondering if there is a stronger medication that can be prescribed.

Issue: Chronic pain is common in older adults. There are concerns regarding the potential adverse effects of analgesics in this population.

Bottom Line: Treatment of chronic, non-cancer pain in older adults should include consideration of underlying physiologic changes, comorbidities, polypharmacy, treatment goals and expectations, and social supports.1,2 A multimodal approach that includes pharmacologic and nonpharmacologic treatments is recommended.2

Background: Chronic pain in older adults is often underrecognized and undertreated.3 It has been associated with increased functional impairment, falls, depression, decreased appetite, impaired sleep and social isolation. 1,4-6

The first step is assessing the pain. Collateral history from a family member or caregiver can often be helpful to corroborate the history, particularly for patients with cognitive impairment. 1

Management of pain in older patients is complicated by normal physiologic changes associated with aging, which can result in altered drug distribution and decreased renal excretion. Pharmacodynamic changes can result in increased sensitivity to certain analgesics. Comorbidities frequently found in older patients need to be considered, including cognitive impairment, falls, polypharmacy and liver, kidney, lung and cardiovascular disease.2,7

Shared decision-making between physicians and patients and their families is key to balancing the potential benefits and risks of the management options.1 Pain management goals and expectations should be established prior to initiation of therapy.1 Patients and families should be educated that pain can be reduced with treatment, but the complete elimination of pain is usually not achievable.1 Treatment-related goals should generally be directed toward improvements in function rather than in pain intensity as function-related goals are often more evident in patients with chronic pain.1 A surveillance plan should be implemented to monitor efficacy, tolerability and adherence to each new treatment.2 Treatment goals should be reviewed; if goals are not met, the medication should be tapered and discontinued, and nonpharmacologic approaches should be modified.2

Pharmacologic Management:

  • Acetaminophen is the first line therapy for older adults with mild-to-moderate pain. 8,9 Acetaminophen at recommended doses is considered safe, but unintentional overdose is a common cause of acute liver failure. Given this risk, the US Food and Drug administration (FDA) recommended maximum daily dose is now 3,000 mg. Professional discretion is allowed to increase the dose to 4,000 mg per day if necessary. It is recommended that the dose is ≤2,000 mg/day for patients with an underlying liver disease or those who consume three or more alcoholic beverages daily, with a contraindication to its use in patients with severe hepatic impairment.
  • Oral non-steroidal anti-inflammatory drugs (NSAIDS) are recommended to be used with caution and for the shortest time possible.8,9 This recommendation stems from the high risk of adverse effects, particularly with long-term use, including gastrointestinal, cardiovascular and renal risks.10 Topical NSAIDS, such as diclofenac gel, are generally preferred for localized musculoskeletal pain such as osteoarthritis.1,8,9
  • Opioid use in older adults with chronic non-cancer pain has been associated with decreased pain intensity and improved function.11 However, there is a lack of data on long-term efficacy as existing studies have been only short-term.2 In addition, there is increasing evidence of associated adverse effects of opioid use in chronic non-cancer pain in older adults, including an increased risk of falls, fractures, hospitalization and all-cause mortality.1,2,12-14 There has been a dramatic increase in their use over the past 15 years.  Associated with this usage increase is an increase in fatal overdoses, drug diversion (sharing or use by others) and opioid abuse or misuse.2 A trial of an opioid could be considered in cases where there has been no response to other treatments and when significant functional impairments due to pain are present despite treatment.2 Any decision to use opioids must be individualized with consideration given to the risks and benefits, drug-drug and drug-disease interactions, and an assessment of the risk of diversion and addiction.1 Starting doses of opioids in older adults should generally be about 25-50% of the recommended dose for younger adults.15 Recommended first-line opioid treatment for mild to moderate pain is codeine or tramadol.16 Second-line opioid treatment for mild-to-moderate pain, and first-line for severe pain, is morphine, oxycodone or hydromorphone.16
  • Antidepressants such as the serotonin-norepinephrine reuptake inhibitors should be considered in cases of co-existing depression and pain.1,2 Although the randomized controlled trials primarily included younger patients, duloxetine has been shown to have analgesic efficacy in diabetic peripheral neuropathy, fibromyalgia, chronic low back pain and osteoarthritis knee pain.17,18
  • Tricyclic antidepressants have been used to treat depression and pain, but their use in older adults is limited due to their significant anticholinergic effects.2
  • Gabapentin and pre-gabalin are recommended for use in older patients with neuropathic pain.1 In an older patient, the recommended starting dose of gabapentin is 100 mg q.h.s., with slow titration by 100 mg increments every three-to-seven days, as necessary/tolerated. In patients with normal renal function, treatment could move to TID dosing, up to a maximum of 3,600 mg per day.1,2
  • Use of medication combinations (in which each medication works by a different mechanism) is recommended to enhance analgesic effectiveness and to potentially lessen the toxicity seen with high-dose individual agents.2

Nonpharmacologic Management:

  • Cognitive techniques (e.g., distraction) and behavioral techniques (e.g., goal setting, exercise) are safe, can reduce pain and can improve function. 2 Psychologists and social workers can be helpful in terms of teaching coping strategies, providing emotional support and accessing appropriate programs.19
  • Physical activity programs such as general exercise (which includes strengthening, flexibility, balance and endurance exercises), tai chi or yoga are recommended.2,4,8 Physiotherapy and occupational therapy involvement can be helpful in terms of providing rehabilitation and optimizing function.2

Back to the Case: Based on the recommendations, you meet with John and his wife to provide education about chronic pain management. Goals are established, including the ability to walk at least one block. John is placed on regular acetaminophen 1,000 mg three times daily. The naproxen is stopped due to concerns about worsening blood pressure and renal function. John is given information about a self-referral to the Alberta Healthy Living Program for group exercises and further education. A follow-up appointment is planned for two months from now to review treatment efficacy and adherence.

References

  1. Malec M, Shega JW. Pain management in the elderly. Med Clin N Am 2015;99:337-350.
  2. Makris UE, Abrams RC, Gurland B, et al. Management of persistent pain in the older adult: a clinical review. JAMA. 2014;312(8):825-836.
  3. Tracy B, Morrison RS. Pain management in older adults. Clin Ther. 2013;35(11):1659-1668.
  4. AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc 2002;50(Suppl 6):S205-224
  5. Weiner, DK, Haggerty CL, Kritchvesky SB, et al. How does low back pain impact physical function in independent, well-functioning older adults? Evidence from the Health ABC Cohort and implications for the future. Pain Med 2003;4(4):311-320.
  6. Bosley BN, Weiner DK, Rudy TE, et al. Is chronic non-malignant pain associated with decreased appetite in older adults? Preliminary evidence. J Am Geriatr Soc 2004;52:247-251.
  7. Reid MC, Bennett DA, Chen WG, et al. Improving the pharmacologic management of pain in older adults: identifying the research gaps and methods to address them. Pain med. 2011;12(9):1336-1357.
  8. Abdulla A, Adams N, Bone M, et al. British Geriatric Society. Guidance on the management of pain in older people. Age Aging 2013;42(suppl 1):i1-i57.
  9. American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc 2009;57(8):1331-1346.
  10. Barkin RL, Beckerman M, Blum SL, et al. Should non-steroidal anti-inflammatory drugs (NSAIDS) be prescribed to the older adult? Drugs Aging 2010;27(10):775-89.
  11. Papaleontiou M, Henderson CR Jr, Turner BJ et al. Outcomes associated with opioid use in the treatment of chronic non-cancer pain in older adults: a systematic review and meta-analysis. J Am Geriatr Soc 2010;58(7):1353-69.
  12. Buckeridge D, Huang A, Hanley J, et al. Risk of injury associated with opioid use in older adults. J Am Geratr Soc. 2010;58(9):1664-1670.
  13. Miller M, Sturmer T, Azrael D, et al. Opioid analgesics and the risk of fractures in older adults with arthritis. J Am Geriatr Soc. 2011;59(3):430-438.
  14. O’Neil CK, Hanlon JT, Marcum ZA. Adverse effects of analgesics commonly used by older adults with osteoarthritis: focus on non-opioid and opioid analgesics. Am J Geriatr Pharmacother. 2012;10(6):331-342.
  15. Gupta KD, Avram MJ. Rational opioid dosing in the elderly: dose and dosing intervals when initiating opioid therapy. Clin Pharmacol Ther. 2012;91(2):339-43.
  16. Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. http://nation alpaincentre.mcmaster.ca/opioid/. April 30 2010 Version 5.6
  17. Brown JP, Boulay LJ. Clinical experience with duloxetine in the management of chronic musculoskeletal pain. A focus on osteoarthritis of the knee. Ther Adv Musculoskelet Dis. 2013;5(6):291-304.
  18. Smith T, Nicholson RA. Review of duloxetine in the management of diabetic peripheral neuropathic pain. Vasc Health Risk Manag 2007;3(6):833-844.
  19. Schneider H, Cristian A. Role of Rehabilitation Medicine in the Management of Pain in Older Adults. Clin Geriatr Med.2008;24:313-334.

9 Comments on Management of Chronic Non-cancer Pain in Older Adults

Sherry McLaren said : Subscribe May 18, 2017 at 4:11 PM

I would appreciate a list of psychologists and social workers that my seniors with limited financial resources can access.  I would also like to know where I can refer my seniors for occupational therapy.  Physiotherapy benefits covered by AHS are restricted and there were discussions of further service reductions. Information about affordable resources available to seniors in a timely fashion is something that I feel woefully uninformed about.  Please illuminate me.

Darren Burback said : Subscribe May 29, 2017 at 2:31 PM

Unfortunately, I cannot provide a complete list of these resources across the province. However, Home Care is one option to access an initial assessment and management plan by professionals in areas such as social work, occupational therapy, and physiotherapy. In terms of counseling regarding pain management, there is a chronic pain self management workshop, and chronic pain group education classes, available through the Alberta Healthy Living Program. Some counseling services in the province, such as Carya (formerly Calgary Family Services), offer fees based on a sliding scale according to annual income.

Mat Rose said : Subscribe May 11, 2017 at 10:54 AM

You very properly mention the issue of drug diversion and addiction. In my experience, there is a tendency to deny, avoid or diminish the likelihood and severity of both these issues in the older population.

Seniors face at least the same risks as the general population of relying on medications to cope (cf. benzodiazepine use in the geriatric set), and perhaps a greater risk of unintentional diversion; i.e., family, caregivers, visitors helping themselves to others' meds.

It is necessary to do a personal AND family history of substance use or disorder, with a focus on kids, grandchildren or others in the household/extended family who may have issues. Limited dispensing, urine drug testing and all the other appropriate measures to ensure safe and effective prescribing should be part of a thoughtful management plan. 

Hubert Kammerer said : Subscribe May 08, 2017 at 7:29 AM

Thank you for the article on The Management of Chronic Non-Cancer Pain in Older Adults which was generally useful. There is I however an aspect of the article that I would like to comment on.  

Under Opioid use when you state “Recommended first line opioid treatment for mild to moderate pain is codeine or tramadol”:

In codeine there is great individual variability in its effectiveness dependent upon drug metabolism into its seven active metabolites. Up to 30% of the population has reported to be poor hyroxylators of debrisoquine required for codeine activation (Yue et al 2001). Codeine is also a weak analgesic with the same side effect profile of more potent opioids such as hydromorphone and oxycodone. Why prescribe a weak analgesic with significant side effects that is ineffective in up to 30% of the population? In over 25 years of practicing geriatrics and attending numerous Geriatric conferences I have never heard a speaker or Geriatrician recommend codeine as first line opioid treatment in the elderly. In our institution the use of codeine as an analgesic in the elderly does not meet the standard of care expected in this patient population.

As it is common to have chronic depression concomitant with chronic pain syndromes tramadol needs to be used cautiously as there is an increased risk of Serotonin Syndrome when used with SRIs and NSRIs.

Thank you for an otherwise interesting review.

 

Hubert Kammerer MD

Co-Chief Specialized Geriatric Program

Glenrose Rehabilitation Hospital.

Darren Burback said : Subscribe May 10, 2017 at 10:26 AM

Thank you for your comments regarding the use of codeine and tramadol. The recommendation for first line opioid treatment for mild to moderate pain comes from the Canadian Guideline for Safe and Effective use of Opioids for Chronic Non-Cancer Pain, Table B-8.1 Stepped Approach to Opioid Selection. However, I agree with the limitations and considerations that you have stated regarding these medications.

Darren Burback said : Subscribe May 17, 2017 at 12:48 PM

As an addendum to my earlier reply regarding recommendations for choice of opioid when initiating this class of medication, the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain has just been released. Table 3 (page 28) lists the opioid options for initiating a trial of therapy for patients with chronic non-cancer pain. The recommendation has been changed from the 2010 version in that it does not mention tramadol or codeine as the specific agents to consider initially for mild to moderate pain.

Dr. Karnik said : Subscribe May 05, 2017 at 9:10 AM

I regards to Tai Chi.  Can you please provide a list of places offering this in Alberta that seniors can access easily?

Darren Burback said : Subscribe May 17, 2017 at 12:34 PM

I am not aware of a complete list of available options for Tai Chi in Alberta. One option found online is http://western.canada.taoist.org/faq.htm. However, I have not referred a patient to a program sponsored by this group, and I therefore cannot provide a definite recommendation. I would suggest checking with your local resources.

Paul Marner said : Subscribe May 04, 2017 at 6:16 PM

Too much emphasis is placed on relief of pain, and patients and family expect COMPLETE elimination of pain.

You and I know this is not practical, in part, as the medications to achieve this will be at doses to cause significant side effects, particularly in the elderly.

Emphasis should be on FUNCTION as you have suggested.

As this article hints at the use of "pot", I will address that. The most benefit is derived from smoking this drug. The ill effects are not too dissimilar to tobacco with the added problem of drowsiness, inattentiveness and euphoria. There is also the loss of judgement of time and space.

The judicious use of the pharmaceuticals that we have available, as well as other non-pharmaceutical strategies are plentiful and adequate. I do not believe that marijuana use in the elderly is of significance relating to dependence or addiction. However the concept of recreational marijuana in our permissive society and the idea of elimination of all unpleasant sensation is unreasonable. We certainly live amongst people who believe it is reasonable to 'pop a pill' for everything. This attitude is fostered by some physicians who will not take the time to explain rational therapy and apply it.

Va con dios.

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