New Guidelines for Pain Control in Older Patients

May 13, 2002

NEW YORK (MedscapeWire) May 14 — Because pain is not a normal accompaniment of aging, it should be evaluated thoroughly and treated aggressively, according to updated guidelines published by the American Geriatrics Society (AGS) in the May issue of the Journal of the American Geriatrics Society. The expert panel that revised the 1998 guidelines recommends that no patient be given a placebo for pain control.

A significant change is the panel's use of the term persistent rather than chronic pain, which connotes negative stereotypes of malingering, futility in treatment, or drug-seeking behavior. "The term persistent pain may foster a more positive attitude by patients and professionals for the many effective treatments that are available to help alleviate unnecessary suffering," panel Chairman Bruce Ferrell of the University of California, Los Angeles, says in a news release.

In conjunction with these guidelines for physicians, AGS has developed patient tools to help monitor medications and pain symptoms. "We believe that these educational tools will make it easier for patients to talk to their clinicians and families about pain relief," says AGS president Jerry Johnson, MD.

The pain guidelines offer physicians an algorithm to determine the source, nature, and provoking circumstances of pain through direct observation and history, pain intensity scales, and caregiver assessments. For patients with moderate to severe cognitive impairment, family or caregiver observations are essential.

Treatment recommendations include simplifying the pain regimen, avoiding polypharmacy with its risk of drug interactions, and beginning drugs at lower dosages and titrating upward as needed. Because most clinical trials use younger volunteers, proper dosages of commonly used analgesics have not been tested in the frail elderly.

"Unless pain is so severe that it is a crisis, it seems reasonable to start with a drug that has the highest likelihood of affecting pain relief with the lowest side-effect profile, such as acetaminophen," Ferrell says. "In frail older patients with multiple-system disease, the chronic use of traditional nonselective NSAIDs is associated with an unacceptable rate of life-threatening gastrointestinal bleeding."

However, cyclooxygenase 2 (COX-2) inhibitors or other selective NSAIDs should be second-line therapy when acetaminophen is inadequate. Opioids may be preferable for severe pain, especially in terminal illness.

"In the final analysis, continuous opioid therapy or some other analgesic strategies may have fewer life-threatening risks than do the long-term daily use of high-dose NSAIDs," the panel says. "Reluctance to prescribe [opioid] drugs has probably been overinfluenced by political and social pressures to control illicit drug use."

Although physicians, health systems, and law enforcement should remain vigilant of illicit opioid use, no patient should be deprived of pain relief. Fortunately, addictive behavior is rare in patients taking opioids for legitimate medical indications.

Other mandates in the new guidelines call for patient education in proper drug use and potential adverse effects, in overcoming reluctance to taking medications when needed, and in nonpharmacologic methods of pain control such as biofeedback and exercise. Although alternative therapies lack scientific evidence of efficacy, the panel notes that "patients should not be given a sense of hopelessness" and that individual attention provided by alternative caregivers may be helpful.

"All older persons should be screened for persistent pain on initial evaluation, on admission to any healthcare service, and periodically thereafter," the guidelines state. "Any persistent pain that has an impact on physical function, psychological function, or quality of life should be considered a significant problem."

>> Janssen Pharmaceutica, McNeil Consumer & Specialty Pharmaceuticals, Ortho-McNeil Pharmaceutical, Inc, Pharmacia Corporation, and Purdue Pharma LP financed development of these guidelines.

J Am Geriatr Soc.2002;50(6):1-20

Reviewed by Gary D. Vogin, MD

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