Pain Management and Older Adults

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Pain Management and Older Adults

• Module development
• Lynne E. Kallenbach MD
• Asst. Professor of Medicine

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Objectives

• Demographics of pain in older adults
• Overview of pain physiology
• Discussion of appropriate use of opioids in older
  adults
• Discussion of other pain treatment modalities for
  older adults
• Overview of ACOVE indicators on pain management

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Persistent Pain

• Painful experience continuing for prolonged
  period of time
• May or may not be associated with a recognizable
  disease process
• Common in older adults
• - 1 in 5 older Americans are taking analgesic
  meds regularly
• - 63 of them had taken prescription pain meds
  for 6 months

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Persistent Pain

• Degenerative joint disease
• Chronic back pain
• Myofascial pain syndromes
• Peripheral vascular disease
• Neuropathic pain
• Post-stroke syndromes
• Headache
• Crystal arthropodies
• Osteoporosis with fracture
• Oral pathology
• RLS

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Persistent Pain

• Very little research focuses on pain syndromes in
  the elderly
• Multiple treatment options are available
• Opioid use can be safe

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ACOVE Indicators

• Assessing Care of Vulnerable Elders
• Comprehensive set of quality assessment tools for
  ill older adults
• - Covering domains of prevention, diagnosis,
  treatment, and follow up
• - Both hospital based and ambulatory based
  indicators
• Designed to evaluate health care at system level
  rather than individual level

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ACOVE Indicator

• ALL vulnerable elders should be screened during
  the initial evaluation period
• BECAUSE older people commonly have pain that
  goes unrecognized by health care providers

Annals of Internal Medicine Oct. 16, 2001 Vol.
135 No.8 pp 731-5
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ACOVE Indicator

• ALL vulnerable elders should be screened for
  chronic pain every 2 years
• BECAUSE older people commonly have pain that
  goes unrecognized by health care providers

Annals of Internal Medicine Oct. 16, 2001 Vol.
135 No.8 pp 731-5
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ACOVE Indicator

• IF a vulnerable elder has a newly reported
  chronic painful condition
• THEN treatment should be offered
• BECAUSE treatment may provide significant relief
  and improve quality of life and health status

Annals of Internal Medicine Oct. 16, 2001 Vol.
135 No.8 pp 731-5
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Persistent pain

• In general, pain is under-treated in older adults
• Untreated pain is associated with
• - decreased function
• - depression/ anxiety
• - sleep disturbances
• Being used as quality indicator

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Reasons for Undertreatment

• Both physician and patient based concerns
• - regulatory
• - its just because Im old
• - concerns about cost, possible side effects
• - addiction / tolerance concerns
• - problems with assessment

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ACOVE Indicator

• IF a vulnerable elder has a newly reported
  chronic painful condition
• THEN a targeted history and physical examination
  should be initiated within 1 month
• BECAUSE appropriate treatment of the condition
  and pain management require that the nature of
  the condition be understood

Annals of Internal Medicine Oct. 16, 2001 Vol.
135 No.8 pp 731-5
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Pain Assessment

• History
• Can be difficult to assess in demented patients
• Evaluate pain by self-report (tools below),
  behavioral, or physiologic measures
• Most tools / graphs frequently assess pain
  intensity

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Assessment Tools

• Visual Analogue Scales
• Facial Pain Scales
• Numeric Rating Scales
• Verbal Rating Scales
• Multidimensional tools
• McGill
• Pain map
• May be more of a global view, effect on function
• Multiple others at least 12 different
  behavioral based tools for patients with dementia

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Pain

• Pain categorized as
• - Nociceptive
• somatic
• visceral
• - Neuropathic

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Nociceptive Pain

• Somatic
• Somatic NS
• Skin, muscle, soft tissue, bone
• Easier to localize
• Sharp, throbbing, constant, aching

• Visceral
• Autonomic NS
• More stretch/ chemical receptors
• Harder to describe and localize may be
  constant or come in waves
• Cardiac, lung, GI, GU tracts

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Pain Pathways - Up

• Stimulation of peripheral nociceptors
• Travel along small myelinated A and unmyelinated
  C fibers to DRG
• Signals travel from dorsal horn to thalamus along
  spinothalamic tract
• Then on to the primary and secondary
  somatosensory cortices, amygdala

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http//www.perioperativepain.com/Neuroanatomy_of_P
ain.htm
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Pain Pathways

• Descending pathways can modulate activity in
  dorsal horn gating
• Wind-up phenomenon in DRG
• NMDA receptor fires in response to repeated pain
  stimulus
• Releases glutamate, activating other secondary
  pain receptors in spinal cord
• Augmentation of pain stimulus in spinal cord
  going up
• Arborization in DRG

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Pain

• Sensitization occurs with chronic pain
• Injured/ chronically stimulated nerves fire w/o
  stimulus
• Happens when pain inadequately treated over time
• Can explain why chronic pain may not seem to
  have direct cause clinically

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So what works where?

• Peripheral nociceptors
• local anesthetics, anti-inflammatories
• Dorsal horn
• local anesthetics, opioids, alpha2 antagonists
• Central
• opiods, alpha 2 antagonists

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Modalities for Rx

• Non- pharmacologic/ Non- systemic
• Non-opioid
• - acetominophen
• - NSAIDs/ COX-2 I
• may require caution in older adults
• - Steroids
• Opioids
• Adjunctive (neuropathic)
• - Anti-convulsants
• - Steroids
• - TCAs
• Interventional modalities

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Non-pharmacologic/ non-systemic

• Pain education programs
• Behavioral modification
• Physical therapy- massage, heat, ice, ultrasound
• Other exercise therapy
• Topical analgesics
• Neurostimulation

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General Principles

• Chronic pain needs chronic medicine
• Stepwise approach
• Nociceptive pain generally responds to
  acetominophen, opioids, anti-inflammatories
• Neuropathic pain responds to neuropathic agents
  and, less well, to opioids
• Mechanism Na channel blockade, upregulation of
  GABA in spinal cord, upregulation of norepi/
  serotonin in cord and cortex all modulate
  transmission of pain signal on peripheral nerve
  or in CNS

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Adapted from WHO 1990
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ACOVE Indicator

• IF a vulnerable elder has been prescribed a
  nonselective non-steroidal anti-inflammatory drug
  (NSAID) for the treatment of chronic pain
• THEN the medical record should indicate whether
  he or she has a h/o of PUD and, if hx is present,
  justification of NSAID use should be documented
• BECAUSE older patient with a hx of PUD who
  receive NSAIDs are _at_ significant risk for
  recurrent disease and complications

Annals of Internal Medicine Oct. 16, 2001 Vol.
135 No.8 pp 731-5
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Case

• The patient is an 82 year old frail female,
  hospitalized for pain control after several acute
  vertebral compression fractures. Outpatient pain
  management has not been successful. She has lost
  some weight and has early dementia. Where do you
  start?

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Case, contd

• Pain assessment
• - Including complete HP
• - Nature and severity of pain
• Analgesia history
• Other considerations?
• She is started on a continuous morphine IV
  infusion given chronicity of the pain in the
  acute phase.

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A Brief Review

• Pharmacodynamics
• - Change with age
• numbers of receptors
• sensitivity of receptors
• Counter regulatory mechanisms
• - Increase in receptor response is noted with
  opioids
• - Not as well understood as pharmacokinetics

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A Brief Review, contd

• Pharmacokinetics
• - Absorption
• overall amt unchanged
• - Distribution
• increased Vd for lipophilic drugs
• - Metabolism
• generally prefer phase 2, less interaction and
  active metabolites
• - Elimination
• decreased renal function

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And now a little about opioids

• Bind to one or more of the opiate receptors (mu,
  kappa, delta)
• Mu receptor is 7 transmembrance G protein coupled
  receptor
• - binding stabilizes the membrane so neuron
  doesnt fire
• Where are the mu receptors?
• - periphery, dorsal root ganglia of spinal
  cord, periaqueductal grey of brainstem,
  midbrain, gut

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Opioids

• Metabolism mostly in liver
• - First pass may take away significant amt of
  oral drug
• - But with advanced liver dz, 1st pass is
  bypassed

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Opioids

• weak opioids
• - codeine
• - hydrocodone
• - oxycodone
• strong opioids
• - hydromorphone
• - fentanyl
• - morphine

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Opioids

• Distribution
• Hydrophilic
• morphine, oxycodone, hydromorphone
• Lipophilic
• fentanyl, methadone

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Opioids

• IV- morphine, hydromorphone, fentanyl
• PO- morphine (LA SA), oxycodone (LA SA),
  hydromorphone, methadone, fentanyl, hydrocodone
• Transdermal- fentanyl
• Initial decisions based on
• - route of administration
• - need for continuous vs. intermittent dosing
• - severity of pain
• LA long acting
• SA short acting

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Intravenous Opioids

• Morphine
• - gold standard
• Fentanyl
• - synthetic
• - 80-100 x potency of morphine
• - no histamine release thus less hemodynamic
  effect
• Hydromorphone
• - semisynthetic morphine derivative

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Oral Therapy

• Oxycodone and hydrocodone combinations common
• - dosing limited by acetominophen content
• When titrating for relief, will need close
  follow-up
• - then can convert short acting needs to long
  acting needs if required

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Opioids-Pharmacology

• All water soluble opioids behave similarly
• Cmax is 60-90 minutes after PO dose
• 30 minutes after SQ or IM
• 6-10 minutes after IV dose
• All are conjugated in liver and 90 excreted via
  the kidney
• With normal renal fx, all have ½ life of 3-4
  hours, reach steady state in 4-5 ½ lives

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Case, contd

• You are rounding on your patient and note that
  she seems agitated. Her family has noted that she
  has been twitching. What is your assessment? What
  can you do?

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ACOVE Indicator

• IF a vulnerable elder is treated for a chronic
  painful condition
• THEN s/he should be assessed for a response
  within 6 months
• BECAUSE initial treatment is often incompletely
  successful, and reassessment may be needed to
  achieve the most favorable outcome.

Annals of Internal Medicine Oct. 16, 2001 Vol.
135 No.8 pp 731-5
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Special Notes

• Morphine
• - low protein binding
• - dialyzes off
• - active metabolite is morphine 6- glucuronide
  (10)
• accumulates in renal failure and causes
  neuroexcitation
• prolonged CNS effects

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Case, contd

• Your patient has mildly decreased renal function
• The twitching is myoclonus related to the
  metabolites from the morphine
• You change her to a dilaudid infusion and
  ultimately to sustained release oxycodone

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Special Notes

• Fentanyl
• - little or no active metabolites
• - Not dialyzable
• - Elderly more sensitive to effects
• lipophilic so larger Vd
• - Unclear how TD route is affected by low
  subcutaneous fat

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Special Notes

• Hydromorphone
• - Generally considered to have inactive
  metabolites
• - Drug of choice with renal failure

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Special Notes

• Oxycodone
• - Undergoes phase I metabolism
• - 10 of the metabolites are oxymorphone, which
  is 14x as strong as oxycodone

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Special Notes

• Hydrocodone
• - Dosing limited by combination agent
• - half life elimination 4 hours
• - onset of analgesia 10-20 min

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Special Notes

• Methadone
• binds mu and blocks NMDA receptors
• highly protein bound
• older adults may have more free/ active drug
• highly variable and prolonged half life
• Phase I metabolism and may prolong the QT
  interval
• caution when changing from another opioid to
  methadone
• non-linear conversion

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Potential opioid side effects

• Nausea
• CNS depression/ sedation
• Pruritis
• Constipation
• Delirium
• Endocrine dysfunction with long term use

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ACOVE Indicators

• IF a vulnerable elder with chronic pain is
  treated with opioids
• THEN s/he should be offered a bowel regimen or
  the medical record should document with potential
  for constipation or explain why bowel treatment
  is not needed
• BECAUSE opiate analgesics produce constipation
  that may cause severe discomfort and may
  contribute to inadequate pain treatment because
  patients may then minimize analgesic use

Annals of Internal Medicine Oct. 16, 2001 Vol.
135 No.8 pp 731-5
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Other Notes

• Certain opioids generally avoided in the elderly
• - propoxyphene
• not any more effective, more cognitive side
  effects
• - meperidine
• metabolite with long T ½ and no analgesic
  qualities, stacking phenom lower seizure
  threshold
• - tramadol
• lowers seizure threshold, increases risk for
  interaction serotonin syndrome

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Opioids and Older Adults

• Appropriate for persistent pain, both malignant
  and non-malignant
• Generally utilized for non-malignant pain after
  other options have failed

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Opioids and Older Adults

• Should always be accompanied by a bowel regimen
• May need to clarify with patients and facilities
  about extended release formulations
• Do not crush! Long acting preps available for
  PEG tubes
• If utilizing long acting preparations, may still
  need breakthrough doses

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Pain Management and Older Adults

• Prescribing decisions based on
• - chronicity of pain
• - severity of pain
• - type of pain
• - other p-dynamic and p-kinetic concerns
• - side effect profiles
• And the geriatricians mantra
• - START LOW AND GO SLOW

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Pain Management and Older Adults

• Need frequent re-assessment
• - effectiveness of analgesia
• - ADLs/ functional status
• - adverse effects
• constipation
• - ? unusual behaviors
• may be a sign of an adverse drug effect

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If we know that pain and suffering can be
alleviated, and we do nothing about it, then we
ourselves become the tormentors.

Primo LeviI must die. But must I die
groaning? Epictetus, 135 AD
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Acknowledgements/ References

• AGS Panel on Persistent Pain in Older Persons,
  The Management of Persistent Pain in Older
  Persons, JAGS, 50S205-224, 2002.
• Dr. Karin Porter-Williamson, Medical Director of
  Palliative Care Consultation Team at KUMC
• Ballantyne and Mao, Opioid Therapy for Chronic
  Pain, NEJM, 34920, Nov. 2003.
• Burris J, Pharmacologic Approaches to Geriatric
  Pain Management, Arch Phys Med Rehabil Vol 85,
  Suppl. 3, July 2004.
• Chodosh J et al, Quality Indicators for Pain
  Management in Vulnerable Elders, Annals of
  Internal Medicine, Vol. 135 No.8, Oct. 16, 2001.
• Dworkin et al, Pharmacologic Treatment of
  Chronic Pain in Elderly, Annals of Long-Term
  Care, 12(6)S1-S10, 2004.
• Fick et al, Upadating the Beers Criteria for
  Potentially Inappropriate Medications in Older
  Adults, Archives of Internal Medicine, Vol. 163,
  Dec. 2003.
• Fine P., Pharmacological Management of
  Persistent Pain in Older Adults, Clin J Pain,
  Vol 20 No.4, July/August 2004.
• Journal of the American Geriatrics Society
  50S205-S224, 2002
• Podichetty et al, Chronic non-malignant
  musculoskeletal pain in older adults clinical
  issues and opioid intervention, Postgraduate
  Medicine, 2003.
• Schneider J, Chronic pain management in older
  adults, Geriatrics, 605, May 2005.
• Zwakhalen S et al, Pain in elderly people with
  severe dementia A systematic review of
  behavioural pain assessment tools, BMC
  Geriatrics, Vol6, No.3, Jan. 2006.