The American Geriatrics Society (AGS) released new guidelines from their Annual Scientific Meeting in Chicago, Illinois addressing the pharmacological management of persistent pain in older persons. Persistent pain is common among older people, especially those suffering from degenerative spine conditions, arthritis, nightly leg pain or pain as a result of cancer.
When ongoing pain is ignored or incorrectly treated, this can cause adverse outcomes including falls, disruptions in sleep, depression and anxiety – adding to an increase in unnecessary health care costs. With these updated guidelines, it’s the hope of the AGS and its membership that older persons will receive a more strategic pain management system of care.
“Persistent pain isn’t a “normal” part of aging and should not be ignored. As seniors become susceptible to more complex health ailments, the need for a clear and precise pain management plan is key,” says Cheryl Phillips, president of the AGS.
Originally created in 1998, the guidelines became a call to arms for improving pain management, quality of life and quality of care for older persons. The guidelines were updated in 2002, but since then, new drugs and treatment approaches have been introduced and pain management strategies more thoroughly evaluated. As a result, the AGS convened with a Panel on Pharmacological Management of Persistent Pain in Older Persons to update the guidelines again, this time focusing on pharmacotherapy. Panel members included in the guideline revisions were experts in geriatric pain management, pharmacology, rheumatology, neurology, nursing, palliative care, and geriatric clinical practice. The Panel focused on senior’s 75-years and older, as this group tends to be more frail and suffers from multiple chronic illnesses – all causes of persistent pain.
A major change stemming from the new guidelines is the near elimination of utilizing non-steroidal anti-inflammatory drugs (NSAIDs). Original guidelines recommended seniors use over-the-counter or prescription NSAIDs or COX-2 inhibitors such as aspirin or ibuprofen before being prescribed an opioid drug. The updated guidelines point to newer information suggesting that this is a risky strategy in older persons. The Panel states that the risks of NSAIDs in older patients — which include increased cardiovascular risk and gastrointestinal toxicity — usually outweigh the benefits and as a result, has revised the guidelines to reflect the findings. Based on newer clinical trials as well as clinical observation, the panel recommends that NSAIDs and COX-2s be considered rarely, and with extreme caution, in highly selected individuals. The guidelines recommend that all patients with moderate-severe pain or diminished quality of life due to pain should be considered for opioid therapy, which may be safer for many patients than long term use of NSAIDs. The guidelines also provide some discussions and recommendations about the use of adjuvant and other drugs for older persons with recalcitrant pain problems.
“Because the most common strategy for management of persistent pain among older persons is the use of pharmacologic agents, and because this is also the area of greatest risk, we chose to focus on pharmacotherapy in this update,” says Bruce Ferrell, chair, AGS Panel on Pharmacological Management of Persistent Pain in Older Persons. “Since the two previous AGS publications, new drugs have been introduced and management strategies have been more fully evaluated, so we felt it was important to focus on pharmacotherapy in this update.”