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Pain Management and Older Adults

Pain Management and Older Adults. Module development: Lynne E. Kallenbach MD Asst. Professor of Medicine. Objectives. Demographics of pain in older adults Overview of pain physiology Discussion of appropriate use of opioids in older adults

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Pain Management and Older Adults

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  1. Pain Management and Older Adults Module development: Lynne E. Kallenbach MD Asst. Professor of Medicine

  2. 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

  3. 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

  4. 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

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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. Reasons for Undertreatment • Both physician and patient based concerns - regulatory - “ it’s just because I’m old” - concerns about cost, possible side effects - addiction / tolerance concerns - problems with assessment

  12. 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

  13. 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

  14. 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

  15. Pain • Pain categorized as - Nociceptive * somatic * visceral - Neuropathic

  16. 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 Nociceptive Pain

  17. 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

  18. http://www.perioperativepain.com/Neuroanatomy_of_Pain.htm

  19. 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

  20. 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

  21. So what works where? • Peripheral nociceptors local anesthetics, anti-inflammatories • Dorsal horn local anesthetics, opioids, alpha2 antagonists • Central opiods, alpha 2 antagonists

  22. 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

  23. Non-pharmacologic/ non-systemic • Pain education programs • Behavioral modification • Physical therapy- massage, heat, ice, ultrasound • Other exercise therapy • Topical analgesics • Neurostimulation

  24. 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

  25. Adapted from WHO 1990

  26. 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 @ significant risk for recurrent disease and complications Annals of Internal Medicine Oct. 16, 2001 Vol. 135 No.8 pp 731-5

  27. 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?

  28. Case, cont’d • Pain assessment - Including complete H&P - 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.

  29. 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

  30. A Brief Review, cont’d • 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

  31. 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 doesn’t fire • Where are the mu receptors? - periphery, dorsal root ganglia of spinal cord, periaqueductal grey of brainstem, midbrain, gut

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

  33. Opioids • “weak” opioids - codeine - hydrocodone - oxycodone • “strong” opioids - hydromorphone - fentanyl - morphine

  34. Opioids • Distribution • Hydrophilic * morphine, oxycodone, hydromorphone • Lipophilic * fentanyl, methadone

  35. 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

  36. Intravenous Opioids • Morphine - “gold standard” • Fentanyl - synthetic - 80-100 x potency of morphine - no histamine release thus less hemodynamic effect • Hydromorphone - semisynthetic morphine derivative

  37. 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

  38. 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

  39. Case, cont’d • 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?

  40. 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

  41. 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

  42. Case, cont’d • 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

  43. 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

  44. Special Notes • Hydromorphone - Generally considered to have inactive metabolites - Drug of choice with renal failure

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

  46. Special Notes • Hydrocodone - Dosing limited by combination agent - half life elimination ~ 4 hours - onset of analgesia ~ 10-20 min

  47. 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

  48. Potential opioid side effects • Nausea • CNS depression/ sedation • Pruritis • Constipation • Delirium • Endocrine dysfunction with long term use

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