March/April 2014

Undertreating Pain

By Mark D. Coggins, PharmD, CGP, FASCP
Today’s Geriatric Medicine
Vol. 7 No. 2 P. 8

An estimated 50% of older adults living at home and up to 80% of elderly patients in long term care (LTC) facilities suffer from persistent pain.1 Data suggest pain in the elderly is widely underrecognized and undertreated despite significant physical and social consequences, including the following1,2:

• exacerbation of cognitive impairment;

• functional loss and increased dependency;

• impaired immune function and healing;

• impaired mobility and increased risk of falls/fractures;

• increased health care utilization and costs;

• mental health symptoms (eg, depression, anxiety);

• postoperative complications related to immobility (eg, thrombosis, emboli, pneumonia);

• sleep disturbances; and

• withdrawal and decreased socialization.

Barriers to Adequate Pain Management
Pain management in older adults is complex and fraught with numerous barriers (see sidebar below). Patient-specific issues contributing to the problem include age-related changes, comorbidities, polypharmacy, and cognitive dysfunction. Other commonly cited barriers include inadequate health care provider pain management training, inappropriate pain assessment, and reluctance to use opioids based on misconceptions about opioid tolerance and addiction.1-5 Also, older adults may mistakenly believe that their pain is a normal part of aging or that it can’t be treated, or they may be concerned that treatment will lead to expensive tests or increased medications.

Opioid abuse is a national crisis that has led to increased regulatory scrutiny intended to reduce medication abuse and diversion. However, these same efforts also have, at times, had unintended consequences. The Quality Care Coalition for Patients in Pain released an executive summary that provides insight into LTC regulations that increase the difficulty of accessing controlled pain medications. The summary states that “current U.S. Drug Enforcement Administration (DEA) rules are creating obstacles to the effective, appropriate, and timely administration of medication to frail, chronically ill and dying patients in nursing facilities, including those receiving hospice care in such facilities. These rules are in conflict with current treatment guidelines and standards of practice and leave vulnerable, frail patients to struggle through unimaginable pain for hours and even days, while physicians, nurses, and pharmacists struggle to collect required DEA paperwork.”6

In an effort to restrict access to and the abuse of hydrocodone-containing products (eg, Vicodin), the DEA is close to a decision that would classify these products as schedule II, which would prevent them from being called in to pharmacies or refilled. Physician and pharmacy groups have voiced concern that patients with legitimate pain needs will suffer from such a decision. There is additional fear that rather than using opioids, patients’ pain may be undertreated because of the increased use of less-than-effective noncontrolled medications and/or medications such as NSAIDs that can have significant adverse effects in older patients.7

Pain Assessment
Because of the complexity of pain assessment in geriatric patients, a multidisciplinary team approach that includes the patient, family/caregivers, and health care professionals is recommended. Pain management resources, including pain assessment tools, can be found at www.partnersagainstpain.com.

Assessing pain in patients with dementia is challenging; however, caregivers and family who are aware of the nonverbal cues and other signs of pain (see table below) often are best suited to help with identifying pain in these patients.8

Nonpharmacologic Pain Management
Nonpharmacologic therapies can effectively reduce pain and improve quality of life. They can be used alone or in conjunction with medications and include patient education, cold or warm compresses, environmental interventions such as providing a quiet location, physical therapy, exercise and stretching, and proper positioning. Additionally, activities that promote laughter have been shown to reduce stress, anger, and depression associated with pain; reduce blood pressure; and increase the release of endorphins.

Analgesic Choice
Recommendations on addressing pain management advise a step-wise approach based on pain type and severity. In older patients, the starting dose usually should be lowered to minimize side effects. However, frequent reassessment for dose increases is necessary to ensure pain is adequately treated.

Patients with mild pain (a score of 1 to 3 on a 10-point pain assessment scale) should begin with nonopioid agents such as acetaminophen or NSAIDs with or without adjuvant pain medications.1,9,10

Acetaminophen is recommended for initial and ongoing therapy to treat persistent pain, especially musculoskeletal pain, because of its effectiveness and overall safety profile. Older patients tolerate acetaminophen well, provided that both renal and hepatic functions are normal. But it is important to be aware of the presence and amount of acetaminophen in single-ingredient and combination products to help prevent accidental overdoses that can lead to liver damage.10 A maximum daily acetaminophen dose of 3,000 mg typically is recommended in the elderly.

Taking 3,000 mg of acetaminophen per day for four weeks was found to have a beneficial effect on behavior among nursing home residents with moderate to severe dementia. Residents became more engaged in social interactions, spent less time in their rooms, and required less personal care.11-12

Increasing acetaminophen to 1,000 mg per dose may increase pain relief effectiveness so that stronger medications are not required. In an effort to reduce accidental overdose, the FDA recently changed the maximum amount of acetaminophen contained in combination prescription products to 325 mg.

NSAIDs, including nonselective NSAIDs (eg, ibuprofen, naproxen) and COX-2 selective inhibitors (eg, Celebrex), rarely should be used in older adults and with extreme caution in highly selective individuals because of the significant risk of adverse effects. Older patients selected for NSAID therapies should have failed other safer therapies with evidence that therapeutic goals have not been met. In all cases, ongoing evaluation should be conducted to ensure the therapeutic benefits outweigh the risks of complications.1

All NSAIDs carry boxed warnings outlining cardiovascular and gastrointestinal (GI) risks, particularly in older patients. Risk factors for NSAID-induced GI ulceration include advanced age, rheumatoid arthritis, previous peptic ulcers or ulcer complications, concomitant use of glucocorticoids or anticoagulants, and high-dose or prolonged NSAID administration. Cardiovascular risks include the potential for NSAID-induced thrombotic events such as myocardial infarction and/or stroke. NSAIDs that selectively inhibit COX-2 are associated with a comparatively lower rate of GI ulceration and bleeding.13

In February, the FDA held a two-day meeting to review evidence published in 2013 suggesting that naproxen does not increase the risk of heart problems as much as other NSAIDs, based on results from more than 700 NSAID studies that found fewer heart problems with over-the-counter and prescription naproxen. Because of the difficulty in interpreting the combined data from roughly 350,000 patients across hundreds of unrelated studies, the panel voted not to remove the cardiovascular warning for naproxen at this time. Although the warning will not be removed, the data were sufficient to result in a “duty to inform the public” about the potential differences.

Current NSAID labeling suggests that heart risks appear only after 10 or more days of continuous use. However, a recent analysis by Danish researchers found that heart attack and stroke can occur within less than a week of treatment. A majority of panelists said the FDA should consider revising the label to warn of this short-term risk. The FDA also continues to discuss known NSAID safety concerns, with a potential future recommendation to change the over-the-counter status of some NSAIDs (eg, ibuprofen).

For patients with moderate pain (rated 4 to 6 on a scale of 0 to 10), step 2 involves patients experiencing mild to moderate pain who already are taking a nonopioid with or without an adjuvant analgesic but still are experiencing poor analgesic control. For these patients, consider the use of an opioid such as hydrocodone or oxycodone with or without a nonopioid and/or adjunct analgesic. Keep in mind that combination regimens may be limited due to the maximum daily dose of nonopioids such as acetaminophen.1,10

For patients with severe pain (rated 7 and above on a scale of 0 to10), step 3 typically will require treatment with stronger opioids (eg, morphine, hydromorphone, oxycodone, fentanyl, levorphanol, methadone) with or without nonopiods or adjuvant pain medications.1,10

Short- vs. Long-Acting Formulations
In making selections related to pain medications’ duration, consider the following recommendations14:

• Use short-acting medications for episodic pain and around-the-clock administration for continuous pain.

• Control of persistent pain is best achieved with around-the-clock dosing. If medications require administration at short intervals, such as every four hours, switch to long-acting formulations (eg, MS Contin) so the patient can sleep through the night without breakthrough.

• As-needed dosing with short-acting, rapid-onset medications may be used along with around-the-clock dosing for breakthrough pain or activity-related pain.

• For treatment of nursing home patients with persistent pain, research has shown the use of long-acting opioids results in improved functional status and social engagement compared with the use of short-acting agents. There was no change in cognitive or mood status with analgesic use, but there was a lower risk of falls in the treated group.

General Considerations
Tolerance to opioid analgesic effects may develop and may require additional medication over time. If a patient with previously controlled pain no longer experiences adequate relief, an assessment of worsening pain and disease progression should be considered.

Anticipate drowsiness and possible mild cognitive impairment and sedation until tolerance develops. However, more severe mental status changes with diminished concentration or confusion can lead to delirium and should be reported to a patient’s physician.

Respiratory depression may occur, most likely following the first dose of an opioid and with dose increases. Constipation may occur after several days of therapy and always should be anticipated and treated aggressively, as it can be painful, lead to behavior disturbances, and may require hospitalization.

All patients taking around-the-clock opioids should have a prophylactic bowel management plan, including appropriate medications. Stool softeners should be ordered; however, by themselves, they usually are insufficient. In the absence of adequate fluid intake, bulk laxatives such as psyllium (Metamucil) can cause fecal impaction and should be avoided.

Neuropathic pain may respond better to alternative types of medications, such as anticonvulsants and antidepressants.

Recognize that older adults, as a group, are more sensitive to analgesics and individual side effects may vary considerably. Opioid-related side effects should be anticipated and closely monitored.

— Mark D. Coggins, PharmD, CGP, FASCP, is a director of pharmacy services for more than 300 skilled nursing centers operated by Golden Living and a director on the board of the American Society of Consultant Pharmacists. He was recognized by the Commission for Certification in Geriatric Pharmacy with the 2010 Excellence in Geriatric Pharmacy Practice Award.

Barriers to Pain Management in Older Adults

Health Care Professional Barriers
• Lack of education regarding pain assessment and management

• Concern regarding regulatory scrutiny

• Fear of opioid-related side effects

• Assumption that pain is part of the aging process and cannot be managed

• Lack of ability to assess pain in cognitively impaired

Patient and Family Barriers
• Failure to understand treatment goals

• Fear of medication side effects

• Concerns related to addiction

• Concerns that by discussing pain they will be perceived as a bad patient or drug seeker

• Fatalism that pain is part of the aging process

Health Care System Barriers
• Cost

• Time

• Cultural biases regarding opioid use

— Source: PartnersAgainstPain.com

References
1. AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50(6):S205–S224.

2. Weiner DK, Rudy TE, Gaur S. Are all older adults with persistent pain created equal? Preliminary evidence for a multiaxial taxonomy. Pain Res Manag. 2001;6(3):133-141.

3. Kaye AD, Baluch A, Scott JT. Pain management in the elderly population: a review. Ochsner J. 2010;10(3):179-187.

4. Cavalieri TA. Managing pain in geriatric patients. J Am Osteopath Assoc. 2007;7 Suppl 4:ES10-ES16.
5. Zuccaro SM, Vellucci R, Sarzi-Puttini P, Cherubino P, Labianca R, Fornasari D. Barriers to pain management: focus on opioid therapy. Clin Drug Investig. 2012;32 Suppl 1:11-9.

6. Quality Care Coalition for Patients in Pain. Patients in Pain: How US Drug Enforcement Administration Rules Harm Patients in Nursing Facilities. Alexandria, VA: American Society of Consultant Pharmacists; 2010.

7. Talsma J. FDA calls for reclassification of hydrocodone products to Schedule II. Drug Topics website. http://drugtopics.modernmedicine.com/drug-topics/news/fda-calls-reclassification-hydrocodone-products-schedule-ii. October 24, 2013. Accessed February 2, 2014.

8. Fink R. Pain assessment: the cornerstone to optimal pain management. Proc (Bayl Univ Med Cent). 2000;13(3):236-239.

9. Vargas-Schaffer G. Is the WHO analgesic ladder still valid? Twenty-four years of experience. Can Fam Physician. 2010;56(6):514–517.

10. Temple AR, Benson GD, Zinsenheim JR, Schweinle JE. Multicenter, randomized, double-blind, active-controlled, parallel-group trial of the long-term (6-12 months) safety of acetaminophen in adult patients with osteoarthritis. Clin Ther. 2006;28(2):222-235.

11. Chibnall JT, Tait RC, Harman B, Luebbert RA. Effect of acetaminophen on behavior, well-being, and psychotropic medication use in nursing home residents with moderate-to-severe dementia. J Am Geriatr Soc. 2005;53(11):1921-1929.

12. Zwakhalen SM, Hamers JP, Abu-Saad HH, Berger MP. Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools. BMC Geriatr. 2006;6:3.

13. Antman EM, Bennett JS, Daugherty A, Furberg C, Roberts H, Taubert KA. Use of nonsteroidal antiinflammatory drugs: an update for clinicians: a scientific statement from the American Heart Association. Circulation. 2007;115(12):1634-1642.

14. Won A, Lapane KL, Vallow S, Schein J, Morris JN, Lipsitz LA. Long-term effects of analgesics in a population of elderly nursing home residents with persistent nonmalignant pain. J Gerontol A Biol Sci Med Sci. 2006;61(2):165-169.