Panel Recommendations for Persistent Pain

Summarized by Robert W. Griffith, MD
August 1, 2002 (Reviewed: August 20, 2004)

Introduction

A panel assembled by the American Geriatrics Society has recently issued recommendations on the management of persistent pain in older people. (They prefer the term 'persistent pain' to 'chronic pain', which has become associated with long-standing stereotypes of psychiatric problems, futility in treatment, or drug-seeking behavior.) This is a summary of their recommendations.

Pain is a complex phenomenon, originating as sensory stimuli, which can be modified by individual emotions, expectations, or memories. It is common in older people, largely because they are more likely to suffer from arthritis, back problems, and other chronic conditions. One in five older Americans take analgesics regularly (i.e. several times a week or more). Up to 80% of nursing home residents have substantial persistent pain that is under-treated; the picture here is complicated by the high prevalence of dementia and disability, making assessment and management more difficult.

Persistent pain is often associated with depression, anxiety, withdrawal, and sleep disruption. There may also be adverse effects due to multiple drug treatments.

Methods used by the Panel

The recommendations by the panel are based on a synthesis of existing literature and a consensus among experts familiar with clinical pain management in older persons. The experts were recruited from a wide variety of specialties. Review of existing literature (over 4,000 citations) led to a text draft that was submitted to external review by experts from other organizations.

The recommendations are divided into four sections -- assessment of persistent pain, pharmacological treatment, non-pharmacological approaches, and proposals for health system improvements. The latter are not summarized here, as they obviously vary from one country to another.

Assessments of persistent pain

The presence of persistent pain should be established by interviewing the patient. Any persistent pain that has an impact on physical or mental functioning is a significant problem, requiring active management.

The severity of the pain should be assessed at the first interview. A simple question such as "On a scale of zero to 10, with zero meaning no pain and 10 meaning the worst pain possible, how much pain do you have now?" Some older people may have difficulty replying to this, in which case a verbal descriptor scale, such as a pain thermometer or a series of 'smiley faces' may be used. The same scale should be used at each assessment during treatment.

Sometimes older people will not refer to 'pain', assuming it is part of aging, or accepting it as part of atonement for past actions. These patients will often acknowledge discomfort, hurting or aching. Again, an attempt at quantification should be made.

As part of the assessment a full history should be taken of the pain characteristics -- intensity, character, frequency, location, duration, and precipitating/relieving factors. The effect of pain on activities of daily living should be measured with an appropriate scale (e.g. ADL, IADL). An analgesic history outlining the effectiveness and/or side effects of current and previous medications is required, and a listing of all existing and previous medical conditions should be obtained. An attempt should be made to determine the patient's attitudes and beliefs regarding pain and its management.

The physical examination should focus on the site of the reported pain as well as the common sites for referred pain. The exam will concentrate on the musculoskeletal and neurologic systems, and assess physical function. Laboratory tests should be done if their results would affect decisions about treatment. If necessary, a psychological assessment should be made, including evaluation of cognitive function.

In most patients, pain can be adequately assessed by direct questions to the patient. However, for those with moderate to severe dementia or who cannot talk, the information must be obtained by direct observation or questioning the principal caregiver. The initial assessment should include evaluation of the patient's environment (social support, available caregivers, family members, spirituality, etc.).

Pharmacological treatment

All drug interventions carry a balance of benefits and risks. This should be explained to the patient, along with the expectation that treatment will be successful in relieving the pain. However, it is a mistake to encourage patients to expect complete absence of pain for some persistent pain conditions. The use of a pain log or diary during treatment is helpful in demonstrating progress, or revealing the inadequacies of different interventions.

Treatment must be individualized for each patient. Older persons are generally more susceptible to adverse drug reactions, as well as being more sensitive to central nervous system drugs. One should expect age-associated differences in efficacy, as well as toxicity, in every case.

The lowest anticipated effective dose should be used initially, and then titrated up on the basis of clinical effects. This may take one to two days for some drugs, or a full week for long-lasting preparations. Combining pharmacological and non-pharmacological treatments, or combining two or more drugs with complementary mechanisms of action, will probably give the best results. However, there is always the increased possibility of drug-drug and drug-disease interaction in elderly patients with every additional drug taken. Awareness of over-the-counter drugs and herbal medications being taken is important.

In the majority of cases there should be a progression from non-opioid analgesics, such as acetaminophen, to anti-inflammatory drugs, neurotransmitter-modulating and membrane-stabilizing drugs, and finally opioids, in order to balance the medical risks against progressively more severe pain.

Non-opioid analgesics
Around-the-clock acetaminophen is usually able to suppress persistent mild to moderate musculoskeletal pain. The maximum dose acetaminophen is 4,000 mg daily. Traditional nonselective NSAIDs, such as ibuprofen, are not recommended for frail or elderly patients, because of the unacceptable rates of gastrointestinal bleeding; in some cases, this risk can be reduced by addition of a proton-pump inhibitor.

When maximum doses of acetaminophen don't control the pain adequately, and continuous treatment is called for, current information supports the use of cyclo-oxygenase (COX)-2 selective agents. Non-acetylated related salicylates (e.g. salsalate, choline magnesium trisilicate) may be less expensive alternatives to COX-2 inhibitors.

Opioid analgesics
Use of these agents is becoming more acceptable. Physical dependency is inevitable with prolonged use, but can be managed by tapering the dose over several days to weeks if the drug is no longer required. True addiction is rare. Opioids given for persistent pain have fewer life-threatening risks than the long-term daily use of high-dose nonselective NSAIDs.

Tolerance is also unusual. A change in a patient's drug requirements signals the need for reassessment of the condition looking for new or progressing disease, before drug tolerance is diagnosed.

The panel recommends against prescribing propoxyphene, tramadol and methadone. These drugs are not easy to use in older people, and carry a higher risk of side effects.

Managing opioid side effects
Opioid therapy requires careful monitoring for potential side effects, which include dizziness, disturbances of gait, constipation, nausea, sedation, and impaired concentration. Patients on opioids should not drive until they have become accustomed to the drug. Constipation can be prevented, to a certain degree, by appropriate diet, high fluid intake, and occasional use of bulking agents. Exercise, ambulation and regular toileting habits should be encourage. Possibly a stimulant (e.g. senna) should be used. Severe or persistent nausea may require anti-emetic medication, or a switch to a different opioid.

Adjuvant drugs
Some drugs can alter or modulate pain perception, even though they are not analgesic. They may be given in combination with non-opioid or opioid analgesics. Traditional antidepressants are often used, but they have unacceptable side effects in older people. Selective serotonin reuptake inhibitor (SSRI) drugs have a low side-effect profile, but they are not effective against pain. Newer anticonvulsant drugs with low side-affect profiles may prove a better choice. Muscle relaxants (e.g. baclofen) help in some patients. There is no place for placebos in the assessment or management of pain.

It should be noted that all pain-modulating drugs, including antidepressants, anticonvulsants, antispasmodics, antiarrhythmics, and local anesthetics have their own pattern of side effects, and require careful titration and monitoring, similar to that for the analgesics. Localized or regional pain syndromes (e.g. post-herpetic neuralgia) can benefit from topical medications (e.g. capsaicin cream, lidocaine patch).

Drug regimens
For continuous pain, drugs are best given on a time-contingent around-the-clock basis. Occasionally supplemental doses of an immediate-release, short-acting analgesic may be added, for instance before a patients engages in an activity known to exacerbate pain.

Long-acting or sustained-release preparations should be used where possible for continuous pain. Transdermal morphine -- a fentanyl patch -- has a duration of action ranging from 48 to 96 hours. Breakthrough pain should be identified and treated using short-acting preparations. All patients on analgesics should be monitored closely, and re-evaluated frequently for efficacy and side effects, so that it this is can the modified accordingly.

Non-pharmacological approaches

It's important that patients and family caregivers are educated about the approaches to management of persistent pain. Depression and anxiety should be anticipated, and treated in tandem with other medical approaches. Antidepressant or anti-anxiety agents are not a substitute for analgesics, and vice versa.

Cognitive-behavior therapy is a valuable way of helping patients deal with their pain. Cognitive distraction methods can divert attention from pain, and strategies can be developed to alter the pertinent thought patterns. Behavioral strategies can help patients control or downplay exacerbations of pain by pacing their activities, increasing pleasurable activities, and using relaxation methods. Cognitive strategies are often combined with behavioral strategies. Cognitive-behavioral therapy usually involves 6 to 10 sessions with a trained therapist.

Physical activity is extremely important. It can be used to optimize function that is impaired by pain, and can improve mood accordingly. Exercise components of programs for older adults include exercises to improve joint range of motion, increase muscle strength, improve postural and gait stability, and develop cardiovascular reserve. Water exercising is safe, and popular with older people.

Patients with persistent pain may seek alternative medicines, and the health team should not stand in their way, unless there are clear risks. Clinicians must not leave patients with a sense of hopelessness, so that benign therapies or spiritual practices may be allowed, as they may produce beneficial effects, even if their mechanisms of action are not recognized or understood.

Vioxx (rofecoxib), a COX-2 anti-inflammatory drug, has recently been withdrawn from all world markets by Merck, its manufacturer. Merck found that there was an increased risk of heart attack or stroke for people taking a standard dose (25 mg per day) for 18 months or more. The risk of such problems was twice that of people taking a placebo. However, someone's risk of having a heart attack or stroke is relatively low; double the risk means the chance of such an event is still "small," according to the USA Food and Drug Administration (FDA). Celebrex (celecoxib) and Bextra (valdecoxib) are other prescribed COX-2 inhibitors. Studies have so far indicated that only Vioxx poses a risk of heart problems. The FDA will examine the other two drugs to see if there is any cause for concern. Robert Griffith, Editor.

Source

• AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Amer Geriatr Soc 2002;50:S205-S224

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