Older People Do Not Have to Live In Pain

Developed in collaboration with the AGS Foundation for Health in Aging (FHA), these patient education resources are intended to help older adults and their caregivers better manage persistent pain in consultation with their physicians and other health care providers:

Patient Education Forum (PEF): Frequently asked questions with answers on the assessment and management of persistent pain.
My Pain Diary: A tool to help describe and keep track of how and when pain is experienced.
My Medication and Supplement Diary A tool to help record and keep track of all prescription drugs, over-the-counter medications and natural remedies being used.
Know Your Medications: A guide to the different types of pain medication and their possible drug - drug interactions. [COMING SOON! Available in June 2002 online or by calling the FHA at 800-563-4916.]
Assessing Pain in Loved Ones With Dementia: This brochure for family members and other caregivers provides advice from the experts on assessing pain in older adults with dementia.
Eldercare at Home is the FHA's free comprehensive online guide for family caregivers. Chapter 11 offers an orderly problem-solving approach to managing pain at home and working cooperatively with health care providers.

May 15, 2002 - The American Geriatrics Society's (AGS) Panel on Persistent Pain in Older Persons is calling on all clinicians - and concerned family members - to evaluate and treat pain symptoms in older patients, without regard to age or condition. Most importantly for all older patients is the panel's admonition to clinicians that pain not be associated with aging, and that no patient be given a placebo for pain.

Today's statement reflects revisions the Society has made to its 1998 clinical practice guidelines on managing pain in older adults. The new guidelines, released today during the AGS annual scientific meeting in Washington, will impact the way physicians evaluate and treat older patients suffering with pain, particularly those with dementia or those residing in nursing homes.

The Management of Persistent Pain in Older Persons was developed following an extensive review of existing literature on managing persistent pain in seniors. A significant change to the guideline is the panel's use of the term persistent rather than chronic pain. According to Dr. Bruce Ferrell, Chair of the Pain Panel and Associate Professor of Medicine at the University of California at Los Angeles School of Medicine, the term chronic pain connotes negative images and stereotypes often associated with malingering, futility in treatment, or drug-seeking behavior. "The term persistent pain may foster a more positive attitude by patients and professionals for the many effective treatments that are available to help alleviate unnecessary suffering."

The guideline states that simplifying a patient's regimen is an important part of prescribing for pain management. The panel notes that common economic barriers, including lack of Medicare reimbursement for outpatient oral medications, limited formularies and delays related to managed care pharmacy programs along with the lack of access to opioids in low income neighborhood pharmacies, could all contribute to a patient's inability to get the drugs he or she needs to relieve pain.

American Geriatrics Society President Jerry Johnson, MD, calls the guideline an "essential tool" for all levels of health care providers, as well as for families and for health care systems. In conjunction with the new guideline, AGS will provide patients with tools to help them track their medications and to monitor their pain symptoms. "We believe that these educational tools will make it easier for patients to talk to their clinicians and families about pain relief."

As a first step, the pain guideline offers clinicians an algorithm to assess the source of a patient's pain through direct observation and patient history. The guideline also assists the clinician in determining the nature of the pain by providing guidance on how to examine when and where the pain is initiated and under what circumstances.

Dr. Johnson notes that the AGS expects that the guideline will help the Center for Medicaid and Medicare Services in monitoring pain management in nursing homes under its quality indicators program. Another important recommendation to health care financing systems, including government and private payers, calls for more resources for pain management. Now, says the panel, pain relief is associated with a specific diagnosis. In the future, pain relief programs that require clinician time without a specific diagnosis should be reimbursable along with patient education programs. The guideline also looks at various issues that are common among older persons including multiple prescriptions or "polypharmacy" and the potential for drug interactions. The panel notes that few clinical trials include older persons among their volunteers, and as a result the proper dosages of the most frequently used pain relievers have not been tested among populations of older patients, and most particularly among the frail elderly.

The panel makes strong recommendations to begin pharmaceutical intervention for most pain at lower dosages, adjusting them as dictated by the patient's response. Similarly, it recommends prescribing acetaminophen as the first intervention in managing mild to moderate musculoskeletal pain before moving to the new class of drugs known as selective nonsteroidal anti inflammatory drugs (selective NSAIDs, e.g., Cox 2 inhibitors).

"Unless pain is so severe that it is a crisis, it seems reasonable to start with a drug that has the highest likelihood of affecting pain relief with the lowest side-effect profile, such as acetaminophen." said Dr. Ferrell. "In frail older patients, with multiple-system disease, the chronic use of traditional nonselective NSAIDs is associated with an unacceptable rate of life-threatening gastrointestinal bleeding."

Cox-2 or selective NSAIDs are recommended as the next pharmacological solution when acetaminophen is not adequate. Because the Cox-2 inhibitors "remain a highly active area of research," particularly in the area of drug-drug and drug-disease interactions, the panel advises clinicians to stay informed about new findings as they prescribe these drugs.

The panel advises clinicians and patients not to exclude opioid therapy. "In the final analysis," the panel said, "continuous opioid therapy or some other analgesic strategies may have fewer life-threatening risks than do the long-term daily use of high-dose NSAIDS."

The panel also advises clinicians that opioid drugs may be the correct pain reliever when a patient is suffering from severe pain, particularly those near the end of life. According to Dr. Johnson, "Reluctance to prescribe these drugs has probably been overinfluenced by political and social pressures to control illicit drug use. While society has a distinct interest in curbing the illicit use of opioid drugs," says Johnson, "it can have no interest in people suffering needlessly." In fact, the guideline states that, "the incidence of addictive behavior among patients taking opioid drugs for medical indications appears to be very low." Moreover, it adds, the exercise of careful professional responsibility reduces the risk of abuse.

Dr. Johnson also noted that the guideline urges health systems and law enforcement to carefully assess their approach to curbing the illegal use of opioids so as not to interfere with a patient's legitimate access to needed pain medication. The physician or other caregiver needs to pay special attention to patient education and make efforts to train the patient in non-pharmacologic methods of controlling pain, including biofeedback and exercise. While it does not discount alternative therapies, the panel notes there is a lack of scientific evidence to support their efficacy; however, the panel reports that "patients should not be given a sense of hopelessness" and perhaps the individual attention provided by alternative caregivers may be helpful.

Patients on opioids and other pain relievers need to receive complete education about their use and potential side effects without making the patient and the patient's family averse to alleviating pain by taking drugs. The emphasis of the panel was to help older patients relieve pain in order to live full and complete lives and to provide the best quality of life for patients in nursing homes or those with severe end of life pain.

The AGS Pain Panel includes experts in ethics, family medicine, geriatrics, nursing, pain management, pharmacy, psychiatry, psychology, rehabilitation medicine, rheumatology, and social work.

A news briefing to announce the release of the persistent pain guideline is being held on Thursday, May 9, 2002, at 10 a.m. in the Taft Room of the Marriott Wardman Park Hotel. A Plenary Symposium for The Management of Persistent Pain in Older Persons is scheduled for that afternoon from 3:30 - 5:00 p.m., Marriott Salons 1 & 2, Marriott Wardman Park Hotel. Both presentations are open to all media. A Web cast of the symposium will be posted on the AGS Web site on May 10, 2002.

Founded in 1942, the American Geriatrics Society (AGS) is a nationwide, not-for-profit association of geriatrics health care professionals dedicated to improving the health, independence, and quality of life of all older people. The society supports this mission in many ways through activities in: clinical practice; professional education on the clinical care of older people; research; public education and information; public policy efforts; and through collaborative relationships with other organizations.

Health care providers and consumers can receive information about the new AGS guideline as well as free public education resources on pain management by calling (866) 788-3939, or by visiting the following Web sites: www.americangeriatrics.org and www.healthinaging.org.