September/October 2017

Opioid Use in Older Adults: Care or Crisis?
By Michael R. Wasserman, MD, CMD
Today's Geriatric Medicine
Vol. 10 No. 5 P. 18

The rapid growth in deaths due to opioid abuse has prompted a renewed look at the use of opioids in managing chronic pain. While the risk of abuse and side effects in older adults is important, so is the effective evaluation and management of chronic pain in a complex and vulnerable population that requires person-centered care.

A number of years ago a retired Chicago police detective came to see me for chronic neck pain. He was already taking opioids when I saw him. Unfortunately, he still felt miserable. He was in pain and felt lethargic from the medications. I asked him my typical question: "Have you ever tried regular dosing of acetaminophen for a prolonged period of time?" It became clear that he had typically used acetaminophen on an as-needed basis but never regularly. I told him that studies and clinical experience showed that a trial of regular dosing of maximum strength acetaminophen was successful in 70% of patients. We stopped his opioids and put him on regularly scheduled acetaminophen. One month later he came back to see me and was ecstatic. His pain had improved significantly.

This type of success doesn't happen every time, but it is possible. It's critical to never make assumptions when managing pain in older adults. In a world where person-centered care is paramount, the approach to pain in older individuals requires an in-depth knowledge of what's important to the patient. To my grandfather, who suffered from chronic pain near the end of his life, being in some degree of pain was preferable to having his mind clouded by pain medications. Another dear patient of mine required high doses of opioids due to the most severe osteoarthritis that I'd ever come across. She ambulated with two canes, which she called her "blue sticks," and was quite functional so long as her pain could be controlled.

What's Important to the Patient?
Quality of life and function are the two most important elements to be aware of in the care of older adults. This is the embodiment of person-centered care. Each individual's quality of life is different and has different requirements. A person's ideal function is also very individualized. "Ideal" quality of life and function tend to vary throughout the course of an individual's life. If a clinician does not have a good understanding of these elements and does not keep up with changes to them, effective management of pain becomes problematic.

The opioid crisis in the United States presents some challenges in relation to the management of pain in older adults. From a bioethical perspective, there is little disagreement as to the focus on pain management of those nearing the end of life. Comfort and quality of life are of paramount importance, and concerns about addiction and side effects are quite different. The question then becomes one of "when?" When does the focus change? When does control of pain at all costs supersede the "risks" of such treatment? What are the risks? In someone nearing the end of life and suffering from severe pain or discomfort, does the risk that oversedation might lead to respiratory failure preclude treatment of pain with opioids? Generally not. Other factors come into play, particularly a patient's overall quality of life and function. Is the patient severely demented? Is he or she bed-bound?

Before we address the specific issue of opioid use in older adults, it is worthwhile to look at the various options available for managing pain. Opioids are certainly not the end all and be all of pain management, as alluded to at the beginning of this article. There are certainly a variety of pharmacologic approaches, as well as a growing appreciation of nonpharmacologic options.

Pain in the Past and Present
If we assume that human beings have always felt pain, it is reasonable to assume that attempts to mitigate pain have gone on since antiquity. In fact, the known use of coca goes back to 3000 BC.1 The use of electrical stimulation dates to the Greeks, Romans, and Egyptians.1 Opium has been used for medicinal purposes since the 1600s, and Merck & Co started the industrial production of morphine in 1840.1 Addiction to morphine became a problem as early as during the American Civil War, when it was known as the "soldier's disease."1 Bayer Co. began producing heroin in 1874, and the 20th century saw the development of many more opiates. While the physiologic basis of pain has influenced the development of pain medications, history suggests that in many ways we have not advanced that far in terms of pharmacotherapy over the course of history.

A 2007 study of nursing home residents in the Netherlands found that pain prevalent in this population of frail older adults was associated with depression and anxiety and was not well managed.2 A more recent study on Canadian nursing facilities found a significant percentage of residents nearing the end of life with poorly controlled pain.3 It is not surprising to find that many older adults suffer from chronic pain. Studies have previously shown that pain is often underrecognized and undertreated in older adults, which in no small part led to pain becoming known as "the fifth vital sign" in the 1990s. Pain is also a quality metric for US nursing facilities, with the focus being to reduce the incidence of moderate to severe pain. The increase in the number of older adults has only served to heighten the awareness of this issue, while at the same time the United States has had to deal with an increase in opioid addiction in the general population. This has become a highly charged political issue with a clamor to address this growing problem.

Assessing Pain in Older Adults
How does one assess older adults for pain? It is most important to get to know the patient. Delivering true person-centered care is difficult without a good understanding of who a person is and what is important to him or her. This should guide the clinical evaluation and management of pain. The first step is getting a patient to acknowledge that he or she is actually having pain. There are many social and cultural reasons a patient might either minimize or deny pain. First is the belief that pain is a normal consequence of aging. There is also the fear of pain being related to other problems that might lead to additional diagnostic evaluation and treatment. If a patient is cognitively impaired, it may prove more challenging, but certainly not impossible, to identify pain. Observation of a patient by caregivers can provide useful signs that indicate he or she is experiencing pain or discomfort.

Assessment of quality of life and function are the defining factors in person-centered care and should also be the key to effective evaluation and management of pain. How is pain impacting the patient's quality of life? Has it caused any limitations to his or her functional abilities? Using a pain scale can be helpful, but what is most important is how the pain impacts the patient. The other piece of important clinical information is determining the source of the pain. Obviously, assessing the nature of the pain, its intensity, and frequency are all important factors in helping to determine the etiology of the pain. The etiology and the impact will determine an effective approach to treatment.

Approach to Pain
In older adults it is particularly important to identify the etiology of pain. If the pain is determined to be musculoskeletal in nature, is it due to an inflammatory process? Is it more structural in nature? Is it neuropathic? Is the pain general? Is it localized? It's important to remember that medications have side effects. While pharmacotherapy has been the mainstay for treating pain since antiquity, it is worth considering other modalities, especially when considering the risk of side effects and adverse events from opioids and anti-inflammatory agents.

Acetaminophen given around the clock is the simplest and safest approach to chronic pain management. Historically, the maximum daily dose was 4 g/day. Concerns about excess acetaminophen intake due to its availability in a number of over-the-counter products has led to the suggested maximum daily dose being reduced to 3 g/day. The main concern regarding acetaminophen toxicity is in patients with liver disease or a history of excessive alcohol use. The risks from acetaminophen are significantly lower than the risks from NSAIDs and opioids. The key to the effective use of acetaminophen is that a patient with chronic pain must be instructed to take it around the clock. I have found it useful to tell my patients, "If you just take acetaminophen when you hurt, it won't help. You have to take it regularly. If taken regularly, it will work 70% of the time." This sets up reasonable expectations for the patient, and in patients where it doesn't provide adequate pain control, there is no faith lost in the doctor-patient relationship.

NSAIDs should be reserved primarily for cases where a clinician believes there is evidence of an inflammatory process. Physical exam findings of warmth, erythema, or swelling are indications for a trial of NSAIDs. If regular dosing of acetaminophen doesn't work, a trial of an NSAID may be warranted, although it's important to recognize the risks of chronic NSAID use in relation to gastrointestinal bleeding and other side effects such as renal dysfunction. If long-term use of NSAIDs is believed to be indicated, consideration should be given to concomitant use of a proton pump inhibitor.4

Considering Opioids
In situations where chronic pain is impacting a patient's quality of life or function and nonopioid analgesics or nonpharmacologic therapy have been ineffective, opioids should be considered. Concerns about addiction need to be put in the context of the potential benefit of effective pain management in relation to the risk of side effects. Is the patient's quality of life and/or function improved with the use of an opioid analgesic? The traditional geriatric credo of "start low and go slow" will typically apply. Older adults may be quite sensitive to opioids, especially as they relate to sedation. Historically, opioid addiction has not been much of a problem in older adults, but that appears to be changing, perhaps related to a demographic that came of age in the 1960s. In the context of today's opioid epidemic, clinicians must certainly take this into consideration, but not at the expense of not effectively treating pain.

The advent of longer-acting opioids has had a positive impact on the effectiveness of opioids in managing chronic pain in older adults. Short-acting opioids, such as morphine, are now primarily used for breakthrough pain.

The following goals are key to the effective use of opioids5:
• pain control with limited side effects;
• around-the-clock dosing;
• as needed for breakthrough pain;
• avoidance of polypharmacy;
• recognition of pain triggers, particularly in the cognitively impaired; and
• therapy targeted toward individual pain assessment.

Side Effects of Opioids
Discussion of the use of opioids in older adults would not be complete without a discussion of the common side effects. One of the most common and problematic side effects is constipation. Stool softeners and stimulant laxatives should be started with the initiation of opioid therapy, as there is no tolerance effect. Nausea is a common side effect, as are sedation and cognitive impairment. Respiratory depression is one of the more serious side effects of opioid use and is potentially life threatening. Other side effects include pruritus and urinary retention. In some cases, patients receiving increasing doses of opioids can develop opioid-induced hyperalgesia. Side effects can be managed with dose reduction and symptomatic treatment if opioids are necessary for pain control. Rotating opioids and switching the route of administration are other options.5 One can augment the use of opioids with adjuvant therapy, or alternatives may be tried in lieu of the use of opioids.

Other Approaches to Pain Management
A variety of other medications may be useful, particularly in the case of neuropathic pain. Selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and anticonvulsants such as gabapentin can be considered. Topical NSAIDs provide another alternative for localized musculoskeletal pain, as does topical lidocaine. Corticosteroid injections should be considered for cases of bursitis or tendonitis.4

There is a wide array of complementary and alternative medicine approaches to the management of pain. Osteopathic manipulation and chiropractic treatment can certainly be considered. Acupuncture has a long history in the treatment of pain. Of note, the overall concept of therapeutic touch might be at the core of a variety of treatment approaches, such as massage therapy. Physical and occupational therapy may provide benefit to a patient, depending upon the underlying condition. Using one's mind has a variety of applications, including the use of cognitive behavioral therapy, meditation, and self-management education. Exercise itself may have value, and some specific programs such as tai chi or yoga may be beneficial. Finally, the role of spirituality should not be ignored, particularly from the standpoint of trying to provide a person-centered approach to care.4

Risk of Opioid Abuse in Older Adults
We cannot ignore the risk of opioid abuse in older adults. This is becoming a serious issue in the younger population and, regardless of the incidence in older adults, it is important that clinicians recognize any risk as they approach the management of pain in older adults. One way of identifying patients who might be at risk for abuse would be to use an opioid risk tool such as the SOAPP (Screener and Opioid Assessment for Patients with Pain).6,7

Neither fear of abuse nor concern for potential side effects should keep a clinician from ordering opioids when they are deemed potentially beneficial to a patient. Recent studies continue to suggest that we undertreat pain in older adults. Opioids should not be the first line of treatment, and both pharmacologic and nonpharmacologic alternatives should be strongly considered. On the other hand, opioids provide a tried and true approach to pain treatment, especially in cases of moderate to severe pain. So long as clinicians maintain a person-centered approach, they should ultimately make the best decision for the patient. After all, that's what it's all about.

— Michael R. Wasserman, MD, CMD, is a geriatrician. He is chief medical officer for Rockport Healthcare Services in Los Angeles and previously served as executive director of care continuum for Health Services Advisory Group.

References
1. Sabatowski R, Schäfer D, Kasper SM, Brunsch H, Radbruch L. Pain treatment: a historical overview. Curr Pharm Des. 2004;10(7):701-716.

2. Smalbrugge M, Jongenelis LK, Pot AM, Beekman AT, Eefsting JA. Pain among nursing home patients in the Netherlands: prevalence, course, clinical correlates, recognition and analgesic treatment — an observational cohort study. BMC Geriatr. 2007;7:3.

3. Thompson GN, Doupe M, Reid RC, Baumbusch J, Estabrooks CA. Pain trajectories of nursing home residents nearing death. J Am Med Dir Assoc. 2017;18(8):700-706.

4. Cavalieri TA. Managing pain in geriatric patients. J Am Osteopath Assoc. 2007;107(Suppl 4):ES10-ES16.

5. Chau DL, Walker V, Pai L, Cho LM. Opiates and elderly: use and side effects. Clin Interv Aging. 2008;3(2):273-278.

6. Butler SF, Fernandez K, Benoit C, Budman SH, Jamison RN. Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). J Pain. 2008;9(4):360-372.

7. Inflexxion, Inc. Screener and opioid assessment for patients with pain (SOAPP)® version 1.0-SF. https://www.nhms.org/sites/default/files/Pdfs/SOAPP-5.pdf. Published 2008.