Introduction

One in 5 older Americans take pain-killing drugs regularly (i.e. several times a week or more). Four out of 5 nursing home residents have persistent pain that is under-treated. Clearly, the treatment of pain is an important area for medical expertise. A panel assembled by the American Geriatrics Society has recently issued recommendations on how to treat persistent pain in older people. Here's a summary of their recommendations.

Assessing the pain

The doctor will try to assess the pain as carefully as possible at the first visit. It's useful to have a scoring method for the severity of pain, so as to be able to measure how well the treatment is working. A question like this is suitable: "On a scale of zero to 10, with zero meaning no pain and 10 meaning the worst pain possible, how much pain do you now have?" Sometimes a picture of a thermometer with a pain scale or a series of smiley faces can be used. Whichever method is chosen, it is should be used at each visit during treatment.

Details of the pain must be recorded -- its severity (using the chosen scale), it's character (stabbing, burning, aching, etc.), where it's located, how often it comes and how long it lasts, and whatever seems to precipitate it or relieve it. It's important to make a full list of all medications being taken (including over-the-counter drugs, supplements, and herbal remedies), as well as a description of all previous medical conditions. Sometimes the patient can't communicate well, in which case the chief family member or caregiver should provide the necessary information.

A full medical examination must be done, along with an assessment of the patient's ability to take care of her- or himself. Sometimes lab tests will be ordered, and possibly an assessment of depression, anxiety, or mental ability.

Drugs for pain

It's unlikely that people with persistent pain will obtain complete, total relief in all cases. However, choosing the right drug, at the right dosage, given at the right intervals, can make life quite tolerable in spite of the underlying disease process. Patients may be encouraged to use a pain diary or a pain log during treatment, so that it can be seen if the treatment is working as expected.

All drugs have side effects as well as their desired beneficial actions. The lowest dose that is likely to be effective should be used to begin with, and increased at intervals until the pain is relieved, or a side effect occurs that prevents a dosage increase. This "titration" may take a day or two, or even a week. Sometimes a maximum dose for a drug is recommended by the authorities, beyond which side effects are likely, and may be severe.

There are two major types of pain-killing drugs (or analgesics) -- non-opioids and opioids. The opioids are considered to be more powerful, but also to have more severe side effects. Therefore treatment should begin with non-opioids.

The panel recommends round-the-clock use of acetaminophen (Tylenol, Panadol, and many other brands) for persistent mild to moderate pain. The maximum dose used should not be more than 4,000 mg a day. The traditional non-steroidal-anti-inflammatory drugs (NSAIDs), like ibuprofen or naproxen, are not recommended for prolonged use in frail or elderly patients, because they can cause bleeding from the stomach and intestines.

If maximum doses of acetaminophen don't control the pain adequately, the panel recommends using the newer sorts of NSAIDs, the selective COX-2 inhibitors, such as Vioxx or Celebrex. These are as effective as the traditional NSAIDs, and don't cause gastrointestinal bleeding to the same extent, but they are much more expensive (see link below).

Opioids analgesics should be used if stronger pain control is required. Physicians may be reluctant to prescribe them because of worries about addiction. It's true that physical addiction is likely with all opoid drugs given for any length of time, but the symptoms of withdrawal can be largely avoided if the dose is reduced gradually over a considerable time. True addiction -- i.e. intense mental craving - is quite rare when these drugs are used for treating persistent pain.

Sometimes it may seem that a drug is losing its effectiveness. In this case, it's more likely that the disease is progressing, rather than the drug being truly less effective. However, if drug tolerance does develop, the dose may be increased or an alternative opioid prescribed.

Side effects of opioids include: dizziness, walking difficulties, nausea, constipation, and sedation. Constipation is perhaps the most trying of these; it can be prevented to a large extent by an appropriate diet, exercise, fiber supplements, and occasional bowel stimulants like senna-containing preparations.

More drugs

Apart from analgesics, there are other drugs that can influence the perception of pain. Sometimes antidepressants are used, but they have unpleasant side effects in older people. The newer 'SSRI' drugs have fewer side effects, but they don't work well against pain. There are newer drugs that can be helpful, some coming from a class of drugs used for epilepsy. Sometimes muscle relaxants are required. If the pain is very localized (e.g. post-herpetic neuralgia or shingles) skin applications can be helpful (e.g. capsaicin cream or a lidocaine patch).

When to give drugs

It's best if long-acting forms of drugs can be used. (The morphine patch, which contains fentanyl, lasts for 2 to 4 days.) The general approach is to provide around-the-clock pain control. If there is break-through pain, which may be due to 'wearing-off' of the long-acting drug or a particular physical challenge, a short-acting drug should be added to provide immediate relief.

Non-drug approaches

Depression and anxiety, both features of persistent pain, should be treated along with the use of analgesics, if necessary with specific drugs. However, there are non-drug ways to help patients with persistent pain. One is cognitive-behavioral therapy. In cognitive therapy patients are taught to use various thought processes to divert attention away from the pain. Behavioral strategies mean that patients control or downplay exacerbations of their pain by doing something pleasurable or using relaxation methods. Combined cognitive-behavioral therapy usually involves 6 to 10 sessions with a trained therapist, either alone or in a group, maybe together with caregivers.

Exercise is important for people with persistent pain. It can improve function that is otherwise limited by the pain, and it helps to improve morale. The purpose is to improve the range of joint movements, increase muscle strength, improve stability to prevent falls, and strengthen the heart. Water exercises are safe and enjoyable.

Alternative medicines and techniques such as acupuncture can be used, so long as they do not impose any risk. It is always best to check with the physicians before starting such type of therapy. Spiritual practices and religious attendances can often be extremely helpful in combating persistent pain.

Comment

The panel's recommendations are not revolutionary, but rather a summary of what is presently practiced by good pain management teams. The central role given to acetaminophen and the recommendation for COX-2 inhibitors over traditional NSAIDs are the only unexpected features of the report. Nevertheless, this publication is a useful reminder of how one should be optimistic about how well persistent pain can be managed, obviously something of comfort to older people.