Treating persistent pain in the elderly can be…painful. On this episode Matt and Paul interview Dr. Marissa Galicia-Castillo, a Professor of Geriatrics from Eastern Virginia Medical School board certified in Internal Medicine, Geriatrics, Hospice/Palliative Medicine. Are we being too stingy with opioid prescriptions? How do you assess and treat pain in patients with advanced dementia? We’ve got your answers.
- Persistent pain in the elderly is underrecognized and undertreated
- Nonpharmacologic therapy is still first line (get off the couch!)
- Scheduled acetaminophen is a valid first line
- Consider low dose oxycodone IR as a second line (assuming NSAIDS contraindicated)
- Diversion of medication by family members is a concern and may cause treatment failure
- Opiates can be a great tool. Don’t be afraid to use them with careful patient selection.
- Follow quality of life and functional status as your end points for pain control.
- Pain in cognitively impaired may present as behavior problems. Treat the pain and treat the behavior.
Dr. Galicia-Castillo reports no relevant financial disclosures.
By the end of this podcast listeners will be able to:
- Recognize that pain in the elderly is often underrecognized and undertreated.
- Recognize the signs and symptoms of pain in patients with cognitive impairment.
- Utilize opiates safely and effectively for the management of noncancer pain in the elderly
- Formulate a basic therapeutic approach to noncancer pain utilizing nonpharmacologic and pharmacologic therapy
Links from the show:
- Dr. Galicia-Castillo’s article on use of opioids for persistent noncancer pain in older adults
- CDC guidelines on prescribing opioids for chronic pain (#8 discusses criteria for naloxone prescribing)
- World Health Organization Pain Ladder
- Observational study of Naloxone administration along with opiate prescriptions (NEJM Journal Watch 2016).
- Effect size seen with opiates and tramadol were small in this review, but adverse event rates were high. This is why a trial with monitoring of functional status is recommended.
- A RCT looking at Tramadol for knee osteoarthritis with underwhelming results.
- EULAR 2016 guidelines for treatment of fibromyalgia
- Dr. Clauw’s YouTube Video
Chronic Pain: Is it all in their head?
- Dr. Clauw’s University of Michigan website for patient self education on fibromyalgia
Surprised no mention of topical lidocaine (patch, gel) as a modality. Good side effect profile and worth a try as adjunct. Also my opinion that physical therapy should be used much more often as well as meditation and guided imagery. Thanks! Enjoying the show