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, co-morbidities, 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. Co-morbidities 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
- 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
- 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.
- Malec M, Shega JW. Pain management in the elderly. Med Clin N Am 2015;99:337-350.
- 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.
- Tracy B, Morrison RS. Pain management in older adults. Clin Ther. 2013;35(11):1659-1668.
- 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
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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
- 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.
- Smith T, Nicholson RA. Review of duloxetine in the management of diabetic peripheral neuropathic pain. Vasc Health Risk Manag 2007;3(6):833-844.
- Schneider H, Cristian A. Role of Rehabilitation Medicine in the Management of Pain in Older Adults. Clin Geriatr Med.2008;24:313-334.