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Chronic Pain Insert

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Chronic Pain Insert Chronic Pain Management Outline Management of Chronic Pain in Older Adults OBJECTIVES • Identify Medicare Advantage members who are suffering with chronic pain • Appropriately manage the chronic pain experienced by Medicare Advantage members • Resolve the chronic pain experienced by Medicare Advantage members through appropriate interventions • Reduce as much as possible the Medicare Advantage patient’s pain-associated morbidity BACKGROUND • Older adults are more likely to experience pain as a result of chronic diseases, cancer or injuries, but are less likely to report problems with pain • Older adults may not report problems with pain due to speech, hearing or cognitive deficits or a belief that pain is inevitable, age-related and untreatable • Chronic, unrelieved pain may result in problems with depression, sleep disturbances, decreased socialization, limited mobility, changes in appetite, increased health care utilization and suffering 1 A. STATISTICS • Approximately 80-85 percent of older adults will experience at least one significant health problem that will predispose them to pain • 20 percent of older adults take analgesic medications at least several times a week • 25-50 percent of community-dwelling older adults suffer from painful conditions • 40-80 percent of nursing home patients suffer from significant pain B. RISK FACTORS • As individuals age, they are more likely to develop chronic diseases that will predispose them to pain • Older adults often suffer from the chronic pain of arthritis, back problems and past injuries • Depression is common among older adults and may predispose them to pain or intensify pain that is already present C. ASSESSMENT – HISTORY AND PHYSICAL History – interview patient and family/significant other about: • Pain location – one or more areas • Description of the pain-ache, throb, burn, tingle, tightness, heaviness, soreness, etc. • Quantitate the pain through use of a standard pain scale, avoid the estimate of pain based on chronic impressions or surrogate reports unless the patient cannot reliably make his or her needs known (Refer to “Patient Comfort Assessment Guide,” “Principles of Highly Effective Pain Managers,” “Pain Assessment Scales,” and “Long-Term Care Pain Assessment Tool” at the end of this section or in the Tools Section of the binder.) • Does anything make the pain better or worse – e.g., massage, heat, cold, non-traditional methods? • Is the older adult taking anything for pain now and is it working – include prescription, over-the-counter and “natural” remedies? • Has the pain changed over time and what is the duration of the pain? • Could medications be contributing to increased pain – e.g., beta-blockers sometimes worsen arthritic joint pain, beta-agonist inhalers may worsen the pain of peripheral vascular disease, etc. • For patients with cognitive or language impairments, observe nonverbal pain behavior, such as guarding, moaning, crying, agitation, withdrawal, changes in gait or mobility; also, obtain reports from caregivers Physical Examination • Identify underlying diseases – diabetes, arthritis, CAD, PVD, irritable bowel syndrome, cancer, psychiatric complications, etc., and manage optimally with specialist referrals, as needed • Assess for neurological impairment – weakness, hyperalgesia, hyperpathia, allodynia, numbness, paresthesia • Assess for musculoskeletal impairments – tenderness, inflammation, deformity, trigger points 2 • Evaluate physical function – pain associated disabilities, alteration in the ability to perform ADL’s due to pain, assess range of motion, gait and balance, “Get Up & Go Test” (Refer to “Get Up & Go Test” at the end of this section or in the Tools Section of the binder) • Evaluate psychosocial function – assess for depression, assess social network and support system, including dysfunctional relationships (Refer to “Geriatric Depession Scale” and “Geriatric Depession Scale Scoring Key” at the end of this section or in the Tools section of binder`) Patients with chronic pain should regularly record pain intensity, medications used and response, and activities. Patients with chronic pain should be reassessed regularly for improvement, deterioration or complications attributable to treatment. D. MANAGEMENT & TREATMENT Pharmacologic Management All older adults suffering from chronic pain that is affecting their quality of life are candidates for pharmacological therapy. • Weigh the benefits vs. the risks • “Start low and go slow” • Dosing involves careful titration, frequent assessment and dosage adjustments in order to optimize pain relief • Nonpharmacologic therapy should be added to optimize pain management • More than one drug should be considered in order to minimize the dose-limiting adverse effects of a particular drug (smaller doses of two different drugs may be more effective than one drug at high dosage) • Monitor the effects of the drugs and manage side effects Specific Pain Medications The medications listed are not necessarily in progressive order. Pain management programs should be individualized to the patient and his/her specific conditions. 1. Acetaminophen • Acetaminophen is the drug of choice for relieving mild to moderate musculoskeletal pain – do not exceed 4000 mg per day 2. Aspirin • Avoid high doses for prolonged periods of time • Risk of gastric bleeding, affects platelet function 3 3. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) • Chronic use of NSAIDs – associated with a high frequency of adverse effects, renal impairment • High-dose, long term NSAID use should be avoided • Avoid use in patients with abnormal renal function; in patients with a history of peptic ulcer disease; and in patients with a bleeding diathesis • When used chronically – should be used as needed, not around the clock. • The risk of bleeding associated with NSAIDs use in patients over age 60 is approximately 4 percent and rises to 9 percent in individuals with a history of gastrointestinal bleeding • Do not use more than one NSAID at a time • Cox-2 inhibitor drug may be considered for patients - With prior failure 3 NSAIDs - >65 years old - With history of PUD or GI bleed - With concurrent use of anticoagulants - On low dose aspirin - On long-term oral corticosteroid therapy (Most prescription drug benefits require prior authorization for coverage of a Cox-2 inhibitor) 4. Injections • Local - joint • Epidural analgesia • Nerve blocks 5. Opioid Analgesia • Opioid dosages needed for non-cancer pain are often smaller than those needed for cancer pain • Prescribe opioids on an as-needed basis for intermittent or chronic recurrent pain • Long-acting or sustained-release opioids should only be used for continuous pain • Long-acting formulation may be used in combination with short-acting formulation for break-through pain • Chronic opioid use can produce CNS changes resulting in increased pain sensitivity • Dermal Patch Delivery System – use with caution and start low; avoid use during fever or whenever delivery of drug may be affected, dose adjustments should be made only at three-day intervals • Monitor for side effects of opioid therapy – focus on neurological and psychologic functions – e.g., sedation, concentration, ability to drive, etc. • Control the side effects: Constipation - Initiate a prophylactic bowel regimen - Avoid bulking agents - Encourage adequate fluid intake, exercise, ambulation - Rectal exam and disimpaction should occur before use of motility agents - Evaluate bowel function regularly - If indicated, an osmotic, a stimulant, or motility agent should be prescribed to provide regular bowel evacuation 4 Sedation - Instruct patients not to drive - Instruct patients about risk of falls - Always titrate the drugs slowly – consider the propensity for drug accumulation - Meperidine (Demerol) has a metabolite, normeperidine, which can accumulate and cause delirium, therefore, should not be used in the elderly Nausea - Mild nausea usually resolves spontaneously - For persistent nausea, a trial of an alternative opioid may be appropriate - Choose anti-emetic drugs with the lowest side-effect profiles Pruritis - May treat severe pruritis with antihistamine medications Myoclonus - Try an alternate opioid drug or clonazepam in severe cases 6. Adjuvant Analgesia These are drugs not formally classified as analgesics, but may reduce pain in certain circumstances. • Tricyclic antidepressants – used for neuropathic pain • Anticonvulsants – carbamazepine, valproic acid, and gabapentin are used to manage the pain of trigeminal neuralgia and other neuropathic pain • Choose agents with the lowest side effect profiles • Agents may be used alone, but may be more effective when used to augment other pain management strategies • Calcitonin may provide relief in osteoporotic vertebral fractures Timing • Continuous pain give pain medication on regular schedule • Pain should be controlled so that the individual may be able to participate in appropriate exercise, activities and to receive a good night’s sleep Economics • Be aware of economic barriers • Consider economic limitations of health insurance plans and lack of supply of some opioid analgesics at local pharmacies 5 Monitoring Patients taking analgesic medications should be monitored closely. • Re-evaluate frequently for drug efficacy and side effects during initiation and titration • Re-evaluate patient frequently for drug effectiveness and side effects • Patients on long-term opioid therapy should be evaluated periodically for inappropriate or dangerous drug-use patterns – Watch for
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