Managing Chronic Pain in Older Adults, In Brief and At Length

Reid MC, Eccleston C, Pillemer K. Management of chronic pain in older adults. BMJ. 2015; 350:h532 http://dx.doi.org/10.1136/bmj.h532.

How detailed should a pain assessment be, in the limited time of an [[{"type":"media","view_mode":"media_crop","fid":"32141","attributes":{"alt":"chronic pain","class":"media-image media-image-right","id":"media_crop_8296930638376","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3395","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"width: 113px; height: 140px; margin: 3px; float: right;","title":" ","typeof":"foaf:Image"}}]]office visit?

These authors (a UK pain specialist and two Americans in geriatrics) recommend standard validated assessment tools, many of which patients can fill out for themselves.

Their comprehensive and useful review is evidence-based, up-to-date, and covers the full range of pain management issues, with selected resources for further information.

Unfortunately, the evidence base is limited.

(Click here for the recommended pain assessment scales.)

Recommended pain assessment scales:

Brief pain inventory-short form (n=9)

Geriatric pain measure (n=24)

(n=7)

Short-form McGill pain questionnaire (n=15)

PROMIS measures* on pain interference, behavior, intensity

WOMAC (n=24)

Roland Morris disability questionnaire (n=24)w7

Unidimensional measures:

Numeric rating scale (n=1)

Verbal rating scale (n=1)

Visual analog scale (n=1)

Faces pain scale (n=1)

LANSS pain scale (n=7)

DN4 (n=4)
 

Recommendations about intervention are summarized on the next page.

The authors also review interventions.

Medication: 

Acetaminophen is the preferred choice for older patients.

The article offers specific recommendations for choosing and monitoring nonsteroidal anti-inflammatory drugs (NSAIDs). The evidence suggests that naproxen is the most appropriate NSAID in this group, but the authors recommend using it and other NSAIDs only for flares. If renal and gastrointestinal issues are a concern, they advise asking the patient to return within two weeks for assessment of NSAID effects including renal function testing.

The evidence base for opioid treatment is surprisingly sparse. The latest systematic review of opioids for chronic pain, published only last month (January 2015), found only limited evidence to favor long-term opioid treatment.¹

Psychological:  Cognitive behavioral therapy is “promising,” though the quality of early trials is “poor.”

Self-management: Evidence for self-management programs (such as one offered by the Stanford School of Medicine) is “mixed.”

Exercise:  Simple physician advice to keep active is ineffective, but structured programs do help.

References:

1.  Chou R, Turner JA, Devine EB et al.The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop . Annals of Internal Medicine. Online 13 January 2015 doi:10.7326/M14-2559