#14 Use more opioids?! How to treat noncancer pain in the elderly.

September 26, 2016 | By Matthew Watto, MD

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.

Clinical Pearls:

1. Persistent pain in the elderly is underrecognized and undertreated
2. Nonpharmacologic therapy is still first line (get off the couch!)
3. Scheduled acetaminophen is a valid first line
4. Consider low dose oxycodone IR as a second line (assuming NSAIDS contraindicated)
5. Diversion of medication by family members is a concern and may cause treatment failure
6. Opiates can be a great tool. Don’t be afraid to use them with careful patient selection.
7. Follow quality of life and functional status as your end points for pain control.
8. Pain in cognitively impaired may present as behavior problems. Treat the pain and treat the behavior.

Disclosures:
Dr. Galicia-Castillo reports no relevant financial disclosures.

Learning objectives:
By the end of this podcast listeners will be able to:

1. Recognize that pain in the elderly is often underrecognized and undertreated.
2. Recognize the signs and symptoms of pain in patients with cognitive impairment.
3. Utilize opiates safely and effectively for the management of noncancer pain in the elderly
4. Formulate a basic therapeutic approach to noncancer pain utilizing nonpharmacologic and pharmacologic therapy

Links from the show:

1. Dr. Galicia-Castillo’s article on use of opioids for persistent noncancer pain in older adults
   http://www.ccjm.org/current-issue/issue-single-view/opioids-for-persistent-pain-in-older-adults/a136ddc8a922abd74237073a1ab89d4f.html
2. CDC guidelines on prescribing opioids for chronic pain (#8 discusses criteria for naloxone prescribing)
   https://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf
3. World Health Organization Pain Ladder
   http://www.geriatricpain.org/Content/Management/Interventions/Documents/WHO%20ladder.pdf
4. Observational study of Naloxone administration along with opiate prescriptions (NEJM Journal Watch 2016).
   http://www.jwatch.org/na41676/2016/07/19/should-naloxone-be-prescribed-patients-taking-opioids
5. 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.
   http://www.ncbi.nlm.nih.gov/pubmed/21472151
6. A RCT looking at Tramadol for knee osteoarthritis with underwhelming results.
   http://www.ncbi.nlm.nih.gov/pubmed/20215961
7. EULAR 2016 guidelines for treatment of fibromyalgia
   http://ard.bmj.com/content/early/2016/07/04/annrheumdis-2016-209724.abstract
8. Dr. Clauw’s YouTube Video
   Chronic Pain: Is it all in their head?
9. Dr. Clauw’s University of Michigan website for patient self education on fibromyalgia
   Fibroguide.com