By: Alex Chu & Joseph Eskandrous (PharmD Candidates c/o 2019)

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The geriatric population grows older with each passing day and is more likely to experience chronic pain due to shifts in body composition and pathological diseases.¹ Chronic geriatric pain may be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage for persons who are either aged (65 to 79 years old) or very aged (80 and over) and who have had pain for greater than 3 months. ¹ Treatment of chronic pain in the geriatric population is complicated by both age-related decline in cytochrome P-450 function and polypharmacy. There is an increased risk of adverse effects secondary to drug-drug interactions between medications. Treatment of chronic pain can generally be classified into three categories – physical, medicinal, and psychological.

Chronic pain can either be nociceptive or neuropathic in nature which makes determining its source a daunting task.² Drug pharmacotherapy is the first and most widely used treatment modality to treat chronic pain.¹ In terms of safety profile and ease of access, first line treatment for chronic pain begins with over-the-counter drugs. Acetaminophen is considered first line for initial and ongoing pharmacotherapy in the treatment of persistent pain due to its effectiveness and good safety profile. Acetaminophen is contraindicated in patients with liver failure and should be used with caution in patients with chronic alcohol abuse or dependence.¹ It is important to keep track of hidden sources of acetaminophen that patients may be taking in combination products. For mild to moderate pain that is uncontrolled with acetaminophen, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) is appropriate.¹ Gastroduodenal ulceration and bleeding are the major limitations to the use of non-steroidal anti-inflammatory drugs (NSAIDs). It is recommended that older patients taking NSAIDs use a proton pump inhibitor or misoprostol for gastrointestinal protection.¹ Due to the increased risk of heart attacks and strokes with NSAIDs, they should be used more cautiously in patients with heart disease or risk factors for heart disease. For initial moderate to severe pain or pain uncontrolled by NSAIDs, weaker opioids such as tramadol can be used with or without acetaminophen.

For pain refractory to NSAIDs or pain rated as moderate initially, opioids are an appropriate choice in the relief of moderate to severe pain.¹ Opioids exert their analgesic effects primarily on the µ-opioid receptor which is responsible for the subsequent analgesic effects that are produced.² Common opioids include oxycodone, hydrocodone, morphine, and buprenorphine. Buprenorphine is a potent semi-synthetic opioid that is believed to be at least 75 times stronger than morphine.³ Overall, buprenorphine seems to have a better safety profile than other opioids due to less severe side effects as well as decreased tolerance to the drug making it a more suitable form of opioid treatment for chronic pain in the elderly. Transdermal buprenorphine patches have been shown to have a long duration of onset and action with no apparent respiratory depression at clinical doses, taking as long as 24 hours to act while lasting for up to 3 days.³ Its high affinity for the µ-opioid receptor with no ceiling effect for analgesia allows concomitant use of other opioids for breakthrough pain.³ It has also been shown to be safely metabolized in the liver by people with mild to moderate hepatic impairment and does not induce down regulation of opioid receptors on the cell surface.³

Physical rehabilitation is another form of chronic pain treatment, although it is difficult to measure the exact benefit one may receive from it. Physical therapy varies with factors such as patient race, physician-patient communication, and results are often obtained based on patient opinion, all of which factor in a degree of bias. Many studies that examine the use of physical therapy for chronic pain treatment have inconsistent findings, making it difficult to reach a concrete conclusion. A recent study in the Journal of Neuroscience evaluated the use of mindfulness-based meditative practices as an alternative to pain medications. The researchers repeatedly exposed the subjects to a noxious heat at 49 degrees Celsius in two MRI sessions. Unlike the first session, in the second session subjects were told to focus on the changing sensations of breath. ⁴ After four days of mindfulness meditation training, meditating in the presence of noxious stimuli significantly reduced pain unpleasantness by fifty-seven percent and pain intensity ratings by forty percent when compared to rest. ⁴ Although the experiment reported the significant changes in average pain intensity felt from both conditions, the authors acknowledged external bias factors that may have influenced their results, such as unconscious bias toward self-reporting consistent with stated benefits as well as expectation bias.⁴

Although lacking in rigorous evidence-based studies to document their efficacy, several nonpharmacologic modalities have been implicated in the treatment of chronic pain in the elderly. These nonpharmacologic treatments are especially useful when used in combination with drug therapy. The movement towards implementing non-pharmacologic treatment is especially critical in the geriatric population due to the fact that these approaches have a lower frequency of adverse reactions compared to drug therapy.⁵ At any given time, an elderly patient takes four or five prescription drugs and two over-the-counter (OTC) medications, on average.⁶ Through the utilization of non-pharmacologic treatment, one can decrease the amount of potential drug-drug interactions and reduce polypharmacy. The main nonpharmacologic modalities to discuss include osteopathic manipulative medicine, physical activity, and psychological support. Osteopathic manipulative medicine (OMM) is an umbrella term that includes a wide array of hands-on, body manipulation therapies utilized in the treatment of chronic pain.⁷ Choices concerning OMM techniques and goals depend on each individual’s unique pain presentation, the suspected pathways involved in that presentation, and the regions diagnosed as containing somatic dysfunction.⁷ Evidence supports that participation in regular physical activity can reduce pain and enhance the functional capacity of older adults with persistent pain.⁵ A physical exercise study that was published in the Journal of the American Osteopathic Association in 2011 which examined the effects of physical exercise on pain intensity and mobility found that those in the pain group that participated in an eight week physical exercise program exhibited significantly decreased pain intensity and increased mobility.⁷ Exercise also has added benefit for elderly patients with comorbid hypertension and diabetes. Applying osteopathic principles as part of an effective treatment strategy for patients with chronic pain results in an individualized care plan combining nondrug treatment strategies with pharmacotherapy.⁷ Patient education included in the comprehensive plan helps improve quality of life and break the vicious cycle seen in the pathophysiology of persistent pain.⁷

Chronic pain spans a multitude of conditions, presents in different ways, and requires an individualized, multifaceted approach. Individualized chronic pain care is more appropriate than a “one-size-fits-all” approach, as patient development of tolerance to medication and risk of addiction varies. Therefore, the effectiveness of chronic pain management is multifactorial, and involves physician-patient perception, culture, and technology, along with other external factors.

 

SOURCES:

1. Kaye AD, Baluch A, Scott JT. Pain management in the elderly population: a review. Ochsner J. 2010;10(3):179-87. Accessed 3/20/17.
2. Rosenblum A, Marsch LA, Joseph H, Portenoy RK. Opioids and the treatment of chronic pain: controversies, current status, and future directions. Exp Clin Psychopharmacol. 2008;16(5):405-16. doi: 10.1037/a0013628. Accessed 3/20/17.
3. Vadivelu N, Hines RL. Management of chronic pain in the elderly: focus on transdermal buprenorphine. Clin Interv Aging. 2;3(3):421-30. Accessed 3/20/17.
4. Salomons T, Kucyi A. Does meditation reduce pain through a unique neural mechanism? The Journal of Neuroscience. Published 07/21/2011. Accessed 3/20/17.
5. Thomas A. Cavalieri, Management of Pain in Older Adults. The Journal of the American Osteopathic Association, 2005; 105, 12S-17S. Accessed 3/20/17.
6. Paul A. F. Jansen, Jacobus R. B. J. Brouwers Clinical Pharmacology in Old Persons. Scientifica (Cairo). 2012; 2012: 723678. Accessed 3/20/17.
7. Michael L. Kuchera. Osteopathic Manipulative Medicine Considerations in Patients With Chronic Pain. The Journal of the American Osteopathic Association, September 2005. 105, S29-S36. Accessed 3/20/17.

Published by Rho Chi Post