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Clinical Management of Pain in the Elderly

CME (continuing medical education) credit available from Harvard Medical School through December 2017.

Published Materials

This educational program presents the most recent evidence for effectively treating pain in the elderly. The emphasis is on non-pharmacologic and non-opioid pharmacologic options, with the goal of minimizing or avoiding the use of opioid analgesics in this population.

The use of opioids by elderly patients has risen significantly in recent years.1

However, opioid use in the elderly is complicated by a greater vulnerability to harm from falls, fractures, and constipation.

A functional approach to pain management can optimize outcomes. Functional goals (e.g., increasing ranges of movement or activity) provide objective measures by which to assess a patient’s response to treatment. Non-pharmacologic, and non-opioid options should be optimized, or at least considered, before an opioid analgesic is used.

A functional approach to chronic pain management2

If opioid therapy is considered, patients should be screened for risk factors, including abuse and vulnerability to potential side effects, prior to initiating opioids.3

Careful and consistent monitoring is essential for elderly patients prescribed an opioid analgesic. Consider a monitoring plan that incorporates the four A’s:  activity, analgesia, adverse effects and abuse. At each visit, consider whether the opioid dose can be reduced or discontinued. If patients exhibit problematic or abusive behaviors, consider referral to an addiction or pain specialist.

Algorithm for tapering opioids4


Information current at time of publication, December 2014.

The content of this website is educational in nature and includes general recommendations only; specific clinical decisions should only be made by a treating physician based on the individual patient’s clinical condition.


References
  1. Campbell CI, Weisner C, Leresche L, et al. Age and gender trends in long-term opioid analgesic use for noncancer pain. American journal of public health. 2010;100(12):2541-2547.
  2. Randall KE, McEwen IR. Writing patient-centered functional goals. Physical therapy. 2000;80(12):1197-1203.
  3. Thorson D, Biewen P, Bonte B, Epstein H, Haake B, Hansen C, Hooten M, Hora J, Johnson C, Keeling F, Kokayeff A, Krebs E, Myers C, Nelson B, Noonan MP, Reznikoff C, Thiel M, Trujillo A, Van Pelt S, Wainio J. Institute for Clinical Systems Improvement. Acute Pain Assessment and Opioid Prescribing Protocol. Published January 2014.
  4. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.