Pain Control in the Elderly
Talsma, Julia, Drug Topics
Your role in opioid therapy management of chronic nonmalignant conditions
Chronic nonmalignant pain is a common, costly problem in the United States. In the elderly - adults 65 years and older - more than 50% have reported pain lasting more than one year. In a survey of nursing-home residents, approximately half noted persistent pain.
The cost of treating back pain, the most common nonmalignant pain condition, reached almost $91 billion in the United States in 1998. Despite these expenditures, approximately 25% of nursing-home residents reported inadequate pain control and were receiving no analgesics.
So, in 2000, the U.S. Congress designated 2001-2010 as the "Decade of Pain Control and Research." That same year, the Joint Commission on Accreditation of Healthcare Organizations released standards for pain management that recognized the need for appropriate assessment and management of patients with pain. The judicious use of opioids was recommended in several published guidelines for patients with chronic nonmalignant pain who had not responded to other analgesic agents.
"There remains uncertainty about the optimal use of opioids for chronic noncancer pain. Some patients do not experience significant improvements in pain or function even on high doses of opioids," stated the APS-AAPM Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain, published February 10, 2009.
However, prescribers of opioid pain relievers continue to use opioids for Medicare beneficiaries with chronic nonmalignant pain. According to the 2012 Drug Trend Report from Express Scripts Inc., there was a 4.1% increase in opiate use last year among Medicare recipients in the commercially insured population.
"We did a retrospective analysis and looked at the use of narcotics among the large commercially insured U.S. population with data from 2010. What we found was, in general, patients 65 and older were using more narcotics, and the gender difference is that women were using more than men. Older members tend to fill more opioid prescriptions," said Keith Widmer, a neuroscience specialist pharmacist and senior manager for ESI's neurospecialist practice, overseeing clinical specialists who work with pain medications.
The good news is that although there had been a rise in opioid use among the elderly, in 2008 drug over- dose death rates in those 65 years and older were among the lowest in age-adjusted rates, with 1.0 death per 100,000 population, age-adjusted to the 2000 U.S. standard population. The lowest risk was among children 0 to 14 years of age, with 0.1 death per 100,000 population. The highest risk was seen among adults 45 to 54 years old, with 10.4 deaths from opioid pain relievers per 100,000 population, according to the Morbidity and Mortality Weekly Report of November 4, 2011.
Best candidates for pain relief
The best candidates for treatment of chronic nonmalignant pain with opioid pain relievers, according to Trinh Pham, PharmD, BCOP, are individuals with:
* Chronic back pain of somatic origin that does not respond to nonopioids
* Chronic back pain requiring a third-line adjuvant to help with neuropathic pain
* Osteoarthritis pain that does not respond to acetaminophen or in patients who cannot take nonsteroidal anti-inflammatory drugs
* Neuropathic pain that has not fully responded to first - and second-line antineuropathic therapies.
Pham, associate clinical professor, University of Connecticut School of Pharmacy, Storrs, Conn., discussed these indications for opioids in the management of pain, as well as the pharmacist's role in pain management with opioids, in her article, "Pharmacology and therapeutics of pain medications: Part 2," in the June 2013 issue of Drug Topics.
"Pharmacists have a vital role in the management of patients who are receiving opioid analgesics for pain control," Pham wrote. "The active involvement of pharmacists in the assessment, monitoring, and management of response to pain therapy ensures decreased risk of opioid misuse, successful pain control, and minimal development of side effects. …