Pain Management for Older Adults

1. Pain Management for Older Adults Miriam B. Rodin, MD, PhD Division of Geriatrics and Gerontology St Louis University Medical School Weeks Conference 5/10/2019

2. No conflicts of interest to declare

3. OBJECTIVES • Describe the different kinds of pain: somatic, visceral, neuropathic • Distinguish acute, cancer and chronic non-cancer pain. • Understand the indications for opioid therapy • Describe at least 2 opiate tolerance syndromes. • Formulate an approach to chronic pain in older adults • Use a guide for titration of opiates.

5. WHO 3-step ladder Source: World Health Organization. Technical Report Series No. 804, Figure 2. Geneva: World Health Organization; 1990. Reprinted with permission.

6. Visceral Somatic • bones, joints • connective tissues • muscles Organs – heart, liver, pancreas, gut, etc. Deafferentation (phantom limb) Sympathetic Maintained Peripheral Types of Pain: NEUROPATHIC MIXED NOCICEPTIVE

8. Visceral Pain • Described as: deep, cramping, squeezing, pressure • Distribution: poorly localized • Referred: Heart attack to stomach or arm • Colicky: Bowel obstruction, gallstone • Diffuse: Peritonitis, liver metastasis • Caused by infiltration or distention of abd or thoracic viscera, or inflammation. • Mediated by the large slow C-fibers • Analgesics: anti-inflammatories includingsteroids; anticholinergics (antispasmodics) VAGOLYTICS

9. Somatic pain • Mediated by A-fibres: nociceptors in MSK tissue. • Descriptors: sharp, or deep, dull, gnawing • Distribution/Examples: • Well localized—patients can often point with one finger to the location of their pain • bone mets, sprained ankle, toothache • Analgesics:NSAIDS, acetaminophen, opioids

10. Neuropathic pain • Due to nerve injury/degeneration, central/peripheral • Described as: burning, shooting or electric • Distribution: • Dermatomal: constant burning, shooting, paroxysmal or lancinating e.g. post-herpetic neuralgia • Stocking-glove regional: burning, pricking, numb e.g. diabetic neuropathy of LEs, • Mononeuropathy or plexopathy: Nerve root compression due to pressure, infiltration: malignancy, fracture • Analgesics: 1st line membrane stabilizers e.g. TCAs or AEDs

12. How the pain gets to your brain

13. In other words it’s really complicated

15. Pain History and Physical • Pain Characteristics – onset, duration, location, quality, intensity, associated symptoms, exacerbating and relieving factors. What have you done for it? • Current medical condition, medications • Physical exam including orthostatic vitals, mood, mobility • Impact of pain on function – work, daily activities, personal relationships, sleep, appetite, emotional state • Patient (and family’s) expected goals/specific fears for treatment

16. Acute vs. Chronic Pain Acute pain Chronic Pain • Etiology is often evident • Accompanied by autonomic nervous system changes: elevated BP, HR, RR & O2 consumption, decreases GI motility, diaphoresis, myardiasis, m spasm • Patient shows sign of pain, like grimacing • Pain which persists beyond 1-3 months • Often fails to demonstrate autonomic symptoms • Pt may look more like they are depressed than in pain • Often associated with MDD • Pt often succumb to pain and may lose hope.

17. Principles of Chronic Pain Management Establish Expections Multimodal Therapy • Identify most important aspect of discomfort • Agree on a metric • How good is better? • Establish a common language of descriptors • Establish expectations for follow up and communications • Non-opiate analgesics • Mind-body work • Physical therapy • Supportive psychotherapy • Complementary therapy • Manipulation and massage • Desensitisation • Local injection • Opiates rotation rather than escalation

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20. Opiates act on mu-receptors • Mu-receptors are located in the brain and in the ascending and descending tracts. • There are sub-types of mu-receptors that mediate opiate responses: • Euphoria • Analgesia • Sedation • Constipation (in the visceral innervation of the bowel) • Nausea • As tolerance develops the first “side effect” to fade is sedation then euphoria. Oxycodone 120mg/d? No I’m not sleepy. It still hurts, increase the dose.

22. Not all opiates are the same • If one “stops working” do not increase it, rotate it. • Methadone is messy but it has NMDA (glutamate is an excitatory NT) blockade activity • Use a validated conversion calculator and don’t trust yourself to remember where the decimal goes. (Fentanyl) • www.globalrph.com • Google: narcotic converter

23. PAIN SCALES

24. Use a standard scale to track the course of pain Numeric and Verbal Analog Pain scale Faces Pain Scale and Pain Thermometer

26. PATIENT WITH COGNITIVE IMPAIRMENT (or small children) PAIN ASSESSMENT IN ADVANCED DEMENTIA (PAINAD) SCALE http://www.uspharmacist.com/publish/images/8_2019_2.jpg

27. Non Verbal Signs of Pain

28. The Chronic Pain Cycle

29. Remodeling of afferent and inhibitory pathways

31. Approach to Chronic Pain in Older Adults • Pain history: Is it acute or chronic? • Standardized pain scale • Comprehensive medical hx & review ALL drugs • What else have you tried for relief? • Social impact of pain: isolation? IADL? Work? • Physical exam: Locate, elicit, soothe, performance • Diagnostic investigations if needed: There is usually quite a thick sheaf of previous labs and imaging. • Set a goal: What level of pain is acceptable to you if ZERO is not an option

32. Approach to Chronic Pain in ALL Adults • Nociceptive component: Tylenol 3-4 g/d scheduled • Neuropathic component: TCA or gabapentin or duloxetine (SNRI) • Revisit after 2-4 weeks. Relief? • NSAIDS, topical agents • Revisit after 2-4 weeks. Relief? • Adjunctive therapies • Physical therapy, supervised exercise, yoga, t’ai ch’i • Massage, TENS, heat or cryo therapy, US • Relief? • Low potency opioids prn to scheduled • Supportive psychotherapy anxiety/depression

33. Mrs. S says her knee hurts:The first mistake in pain management: • Tylenol 500 mg 1-2 tabs po q 4-6hrs prn • Norco 5/325 mg po 1-2 tabs po q 4-6hrs prn

34. The right answer to Mrs. S knee pain: • Examine. Xray if needed. It’s her OA. • Tylenol 650 mg tid while awake scheduled • Can increase to q 6hr scheduled if pain is waking her at night. • Topical mentholated cream, NSAID (if her insurance will pay for it), non-pharmacological interventions • If no contraindication, naprosyn 375 or 500mg bid x 7d • o/w oxycodone nmt 5mg po q 6 prn, revisit pill count in 7d.

35. Suspect Opiate Induced Hyperalgesia when: • Using high potency opioids > 6 months • Taking > equivalent of oxycodone 30 mg/d or MSIR 45 mg/d for > 3 months and asking for escalation • Multiple prescribers

36. Approach to Chronic Pain in Everybody Regardless of Age • When a durable response is achieved: • Negotiate gradual taper of opioids, “Save it for a rainy day.” • Continue adjunctive therapies and non-opiates. • If an adequate dose is not effective • Dose escalation is excessive or ineffective: • Suspect drug diversion • Suspect drug tolerance / dependence • Suspect opiate-induced pain syndromes

37. Suspect drug diversion if • Utox is negative or • Elderly patient is always accompanied by a younger person who verbalizes the pain for them • Multiple prescribers

38. Adjuvant Medications: in order • Topicals • Tylenol • NSAIDS, Celecoxib, steroids • Anticonvulsants • Antidepressants • Anticholinergics • Anxiolytics • Muscle relaxants • Antihistamines

39. Summary • Pain is a normal bodily function. • Chronic pain indicates that normal pain physiology has changed either by pathway remodeling or drug induced changes. • Chronic pain is defined by >3 months duration, no obvious localizable cause • Approach to chronic pain should be systematic and step-wise. • Approach to chronic pain should be multimodal and multidisciplinary.

40. Thanks!