PERSISTENT
PAIN
OBJECTIVES
Know and understand:
• The 3 major types of pain syndromes
• Components of a thorough pain assessment
• Common pain behaviors in cognitively impaired
older persons
• Principles of non-pharmacologic and pharmacologic
treatment of persistent pain
• How to manage the adverse effects of opioids
Slide 2
TOPICS COVERED
• Assessment
• Assessing and Treating Pain in Cognitively
Impaired Persons
• Treatment
 Fundamental Approaches
 Barriers to Using Opioids in Older Persons
 Adverse Effects of Opioids
 Nonopioid Medication to Treat Persistent Pain
 Medications to Avoid in Older Persons
Slide 3
STANDARDS OF EVIDENCE (SOE)
Rating
Basis of Rating
Studies Justifying Rating
A
Consistent and good quality patientoriented evidence
Large cohort studies for risk
factors/prognosis; RCTs for
diagnosis/treatment
B
Somewhat inconsistent or limited
quality patient-oriented evidence
Smaller or single cohort
studies for risk factors/
prognosis; small or single
RCTs or cohort studies for
diagnosis/treatment;
uncontrolled studies
C
Very inconsistent or very limited
patient-oriented evidence, consensus,
disease-oriented evidence, and/or
case series for studies of diagnosis,
treatment, prevention, or screening
Single small cohort study for
risk factors/prognosis; single
small cohort study or RCT for
diagnosis/treatment; case
series
D
Unstudied common practice or opinion No evidence
Slide 4
PREVALENCE OF
PERSISTENT PAIN IN OLDER PERSONS
Substantial pain is experienced by:
25% to 50% of communitydwelling older adults
45% to 80% of nursinghome residents
Slide 5
PAIN IS COMMONLY UNDERTREATED
• Patients may:
 Minimize their symptoms
 Not report pain
 Be unable to report pain because of language
impairment or cognitive impairment
• Clinicians may:
 Inadequately assess pain
 Undertreat pain with ineffective therapies
 Encounter intolerable adverse effects with
otherwise effective therapies
Slide 6
INITIAL ASSESSMENT
• Take a complete history of the pain
 Character
 Course of its onset
 Duration
 Location
• Carefully evaluate patient’s functional status
• Evaluate patient’s cognitive state, participation
in social activities, mood, and quality of life
Slide 7
PAIN INTENSITY SCALES
• Unidimensional scales:
 Numeric Rating Scale—0 is no pain, 10 is worst pain
imaginable
 Faces Pain Scale—patient chooses a facial expression
that corresponds to the pain
 Verbal Descriptor Scale—“no pain” to “pain as bad as it
could be”
• Multidimensional scales:
 McGill Pain Questionnaire
 Pain Disability Scale
Slide 8
PAIN MAP
• Ask patient to indicate the locations of their
pain on a drawing of a human figure
• Consider referral to a mental health specialist
(to evaluate for affective disorder contributing
to the discomfort) if the patient’s pain pattern:
 Is erratic
 Is diffuse
 Does not conform to an anatomic distribution
Slide 9
PHYSICAL EXAMINATION
• Carefully examine the reported site of pain and
locations that may be a source of referred pain
• Perform complete musculoskeletal exam
 Fibromyalgia, osteoarthritis, or myofascial pain is
commonly either the primary source of pain or an
exacerbating process
 Accurate diagnosis is critical to formulating the
correct therapeutic plan
Slide 10
3 TYPES OF PAIN SYNDROMES
• Nociceptive—pain due to activation of nociceptive
sensory receptors; often adequately treated with
common analgesics
 Somatic—well localized in skin, soft tissue, bone
 Visceral—due to cardiac, GI, or lung injury
• Neuropathic—from irritation of components of the CNS
or peripheral nervous system; may respond well to
nonopioid therapies; responds unpredictably to opioids
• Mixed or unspecified—has characteristics of both
nociceptive and neuropathic pain; common in older
adults
Slide 11
TYPES OF PAIN, EXAMPLES,
AND TREATMENT (1 of 3)
Type of Pain
and Examples
Source of Pain
Typical Description
Table 15.1
Effective Drug Classes
and Non-Pharmacologic
Treatments (SOE Rating)
Nociceptive: somatic
Arthritis, bone
metastases
Tissue injury
(eg, bones,
soft tissue,
joints,
muscles)
Well localized, constant;
aching, stabbing, gnawing,
throbbing
Acetaminophen (A), opioids
(B)
Diffuse, poorly localized,
referred to other sites,
intermittent, paroxysmal; dull,
colicky, squeezing, deep,
cramping; often accompanied
by nausea, vomiting,
diaphoresis
Treatment of underlying
cause
Physical and cognitivebehavioral therapies (B)
Nociceptive: visceral
Renal colic,
constipation
Viscera
Physical and cognitivebehavioral therapies (C)
Slide 12
TYPES OF PAIN, EXAMPLES,
AND TREATMENT (2 of 3)
Type of Pain
and Examples
Source of
Pain
TypicalTable
Description
15.1
Effective Drug Classes
and Non-Pharmacologic
Treatments (SOE Rating)
Peripheral
or central
nervous
system
Prolonged, usually constant, but
can have paroxysms; sharp,
burning, pricking, tingling,
squeezing; associated with other
sensory disturbances (eg,
paresthesias and dysesthesias);
allodynia, hyperalgesia, impaired
motor function, atrophy, or
abnormal deep tendon reflexes
Tricyclic antidepressants
(A), anticonvulsants (A),
serotonin-norepinephrine
reuptake inhibitor
antidepressants (A),
opioids (B), topical
anesthetics (C)
Neuropathic
Cervical or lumbar
radiculopathy,
post-herpetic
neuralgia,
trigeminal
neuralgia, diabetic
neuropathy, poststroke syndrome,
herniated
intervertebral disc
Physical and cognitivebehavioral therapies (C)
Slide 13
TYPES OF PAIN, EXAMPLES,
AND TREATMENT (3 of 3)
Type of Pain
and Examples
Source of
Pain
TypicalTable
Description
15.1
Effective Drug Classes and
Non-Pharmacologic
Treatments (SOE Rating)
Poorly
understood
No identifiable pathologic
processes or symptoms
out of proportion to
identifiable organic
pathology; widespread
musculoskeletal pain,
stiffness, and weakness
Antidepressants (B), antianxiety
agents (C)
Undetermined
Myofascial pain
syndrome,
somatoform
pain disorders
Physical, cognitive-behavioral
and psychological therapies (B)
Slide 14
PAIN IN COGNITIVELY
IMPAIRED PERSONS
• Observe for possible pain-related behaviors (next
slide) and ask caregivers for their observations
 Consider trial of analgesia for patients exhibiting
pain-related behaviors
• Validated scales (eg, Hurley Discomfort Scale,
Checklist of Nonverbal Pain Indicators) require
training
• Provide empiric analgesia during procedures and
conditions known to be painful
Slide 15
COMMON PAIN BEHAVIORS IN COGNITIVELY
IMPAIRED ELDERLY PERSONS (1 of 2)
Behavior
Examples
Facial expressions
•
•
•
•
Slight frown; sad, frightened face
Grimacing, wrinkled forehead, closed/tightened eyes
Any distorted expression
Rapid blinking
Verbalizations, vocalizations
•
•
•
•
•
Sighing, moaning, groaning
Grunting, chanting, calling out
Noisy breathing
Asking for help
Verbal abusiveness
Body movements
•
•
•
•
•
Rigid, tense body posture, guarding
Fidgeting
Increased pacing, rocking
Restricted movement
Gait or mobility changes
Slide 16
COMMON PAIN BEHAVIORS IN COGNITIVELY
IMPAIRED ELDERLY PERSONS (2 of 2)
Behavior
Examples
Changes in interpersonal interactions
•
•
•
•
Aggressive, combative, resists care
Decreased social interactions
Socially inappropriate, disruptive
Withdrawn
Changes in activity patterns or routines
•
•
•
•
•
Refusing food, appetite change
Increase in rest periods
Sleep, rest pattern changes
Sudden cessation of common routines
Increased wandering
Mental status changes
• Crying or tears
• Increased confusion
• Irritability or distress
Slide 17
NON-PHARMACOLOGIC THERAPIES
• Patient education and involvement in decisions
 Teach patients to take medications properly and how to
use assessment instruments
 Provide partner-guided pain management training to
caregivers
• Cognitive-behavioral therapy
• Regular physical activity
 Or supervised rehabilitation for frail patients, or regular
repositioning and gentle massage for bed-bound patients
• Referral to an interdisciplinary pain clinic
Slide 18
PRINCIPLES OF
PHARMACOLOGIC THERAPY
• Besides pain relief, the goals are improved function
and enhanced adherence with rehabilitation
• Individualize the initial dose and rate of titration
• In general, start opioids at lowest dose and titrate
slowly, but if patient is in pain crisis, do not withhold
medications
• Try nonsystemic or non-pharmacologic therapies
first if appropriate
Slide 19
TREATING MILD TO MODERATE PAIN
• Acetaminophen
 Particularly for musculoskeletal pain
 No more than 4 g every 24 h
 Lower the dose by 50%, or avoid, in patients at risk of liver
dysfunction, especially with history of heavy alcohol intake
 Know all medications the patient is taking, as acetaminophen
is a common ingredient in prescription and OTC drugs
• NSAIDs
 Many significant adverse effects
 Use COX-2 inhibitor with extreme caution, if at all, in older
persons
 Use judiciously if at all only after acetaminophen has been
tried and only in highly select individuals
Slide 20
TREATING MODERATE TO SEVERE PAIN
• To estimate opioid requirements, conduct a trial of a
short-acting opioid
• Treat continuous pain with 24-hour opioids in longacting or sustained-release formulations
 To cover breakthrough pain, combine with fast-onset
medications that have short half-lives
 Breakthrough pain typically requires 5%–15% of the
daily dose, offered q2h orally
• In general, different opioids are similarly efficacious
 Cost and route of delivery can help guide the choice
Slide 21
USING OPIOIDS IN RENAL FAILURE
• To reduce the risk that the active metabolites
of morphine will accumulate, increase the
dosing interval and reduce the dose
• Hydromorphone is many experts’ first choice
for this population
• Safety of oxycodone in this population is still
controversial
Slide 22
COMBATTING FEAR OF TOLERANCE
AND ADDICTION TO OPIOIDS
• Avoid withdrawal symptoms by tapering carefully over
days to weeks
• If rapid upward titration is required to reduce pain,
suggesting that tolerance has developed:
 Evaluate the cause of pain, including searching for new
pathologies and exacerbation of known sources of pain
 Consider nonphysical causes of pain
• When switching a patient from one opioid to another,
reduce the dose to 50–60% of the equivalent dose
Slide 23
MANAGING THE ADVERSE
EFFECTS OF OPIOIDS (1 of 2)
• Constipation
 Educate patient about probable need for long-term
laxative treatment
 In most cases, start with a stimulant laxative
 Encourage exercise and hydration
 Consider methylnaltrexone for patients with opioidinduced constipation despite laxative therapy
• Nausea and vomiting—evaluate for reversible
causes; then try a different opioid or treat with
chronic antiemetics
Slide 24
MANAGING THE ADVERSE
EFFECTS OF OPIOIDS (2 of 2)
• Sedation, fatigue, mild cognitive impairment
 Educate the patient that these changes generally
subside days to weeks after dose adjustment
 Warn against driving or operating heavy equipment
when medication is initiated
 Warn of the risk of falls
 For incessant fatigue, try a stimulant such as low-dose
methylphenidate or rotation to a different opioid
• Respiratory depression—use naloxone sparingly,
at the lowest dose, and titrate carefully
Slide 25
NONOPIOID MEDICATION
• TCAs (off-label) are the best-studied drugs for
neuropathic pain
• Optimal analgesia requires treatment of depression
 SSRIs are less well studied than TCAs as analgesics, but they
are better tolerated in antidepressant doses
 Duloxetine is approved as both an antidepressant and for
treatment of pain from diabetic neuropathy
• Anticonvulsants—commonly used for neuropathic pain
• Corticosteroids are useful adjuvants for neuropathic
pain and pain associated with swelling, inflammation,
and tissue infiltration (SOE=C)
Slide 26
MEDICATIONS TO AVOID
IN OLDER PERSONS
• Propoxyphene
• Meperidine
• Mixed agonist-antagonists such as nalbuphine
and butorphanol
• COX-2 inhibitors
• Other NSAIDs and use rarely if ever
Slide 27
SUMMARY (1 of 2)
• Pain requires a thorough assessment to determine its
source, severity, and impact on the well-being of the
patient
• Cognitively impaired patients who cannot communicate
about pain should receive empiric analgesia during
procedures and conditions known to be painful
• A stepped approach to pain treatment is advised,
starting with local and non-pharmacologic approaches
• Systemic analgesics should not be withheld if needed
initially
Slide 28
SUMMARY (2 of 2)
• In general, different opioids have similar efficacy and
limited cross-tolerance
• Patients being treated with opioids usually develop
tolerance to the respiratory depression, fatigue, and
sedation, but not to the constipating effect
• Optimal analgesia requires treatment of any
associated clinical depression
• COX-2 inhibitors should be avoided in older patients,
and nonselective NSAIDs should be used cautiously
Slide 29
CASE 1 (1 of 3)
• A 72-year-old woman comes to the office because of
persistent pain in her left hip.
• Her history includes osteoarthritis, as well as a lifethreatening episode of GI bleeding related to the
use of NSAIDs.
• Oral acetaminophen 1000 mg q6h decreases the
pain for a short time.
• The patient follows her physical therapy regimen
routinely.
Slide 30
CASE 1 (2 of 3)
Which of the following is the most appropriate
intervention?
(A) Increase acetaminophen to 1000 mg q4h.
(B) Start ibuprofen 600 mg q6h.
(C) Start oxycodone 2.5 mg q4h as needed.
(D) Start long-acting morphine 15 mg q12h.
Slide 31
CASE 1 (3 of 3)
Which of the following is the most appropriate
intervention?
(A) Increase acetaminophen to 1000 mg q4h.
(B) Start ibuprofen 600 mg q6h.
(C) Start oxycodone 2.5 mg q4h as needed.
(D) Start long-acting morphine 15 mg q12h.
Slide 32
CASE 2 (1 of 3)
• An 80-year-old man with diabetes and osteoporosis
comes to the office for consultation regarding his
pain regimen.
• He has severe pain related to diabetic neuropathy
and back pain related to multiple compression
fractures.
• He takes hydrocodone/acetaminophen 2 tablets
q6h, which helps the back pain but does little for the
neuropathic pain.
Slide 33
CASE 2 (2 of 3)
Which of the following is an appropriate
alternative to hydrocodone/acetaminophen
for control of this patient’s pain?
(A) Meperidine
(B) Propoxyphene
(C) Butorphanol
(D) Nalbuphine
(E) Methadone
Slide 34
CASE 2 (3 of 3)
Which of the following is an appropriate
alternative to hydrocodone/acetaminophen
for control of this patient’s pain?
(A) Meperidine
(B) Propoxyphene
(C) Butorphanol
(D) Nalbuphine
(E) Methadone
Slide 35
CASE 3 (1 of 3)
• A 65-year-old woman with breast cancer metastatic
to bone is evaluated in preparation for hospital
discharge.
• She is on a continuous IV infusion of morphine 4
mg/hr, and she has received 3 breakthrough rescue
doses of 4 mg each over the past 24 h.
• Her pain is generally well controlled on this regimen,
and she is alert and talkative.
Slide 36
CASE 3 (2 of 3)
Which of the following oral regimens is most
likely to provide appropriate pain relief?
(A) Oxycodone 20 mg q3h as needed
(B) Short-acting morphine 30 mg q3h
(C) Long-acting morphine 30 mg q12h, with
short-acting morphine 15 mg q2h for
breakthrough pain
(D) Long-acting morphine 150 mg q12h, with
short-acting morphine 30 mg q2h for
breakthrough pain
Slide 37
CASE 3 (3 of 3)
Which of the following oral regimens is most
likely to provide appropriate pain relief?
(A) Oxycodone 20 mg q3h as needed
(B) Short-acting morphine 30 mg q3h
(C) Long-acting morphine 30 mg q12h, with
short-acting morphine 15 mg q2h for
breakthrough pain
(D) Long-acting morphine 150 mg q12h, with
short-acting morphine 30 mg q2h for
breakthrough pain
Slide 38
ACKNOWLEDGMENTS
Editor:
Annette Medina-Walpole, MD
GRS7 Chapter Authors:
Jennifer M. Kapo, MD
GRS Question Writer:
Rachelle Bernacki, MD, MS
Pharmacotherapy Editor: Judith L. Beizer, PharmD
Medical Writers:
Beverly A. Caley
Faith Reidenbach
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2010 American Geriatrics Society
Slide 39