New guidelines target chronic pain

Improved understanding, assessment and treatment of chronic pain in older people are the goals of new clinical practice pain management guidelines developed by the New York-based American Geriatrics Society.

The clinical practice guidelines are the first to focus specifically on pain management in older Americans.

"As the population matures, there is a growing need for medical information about pain management that is specific to older people," said Bruce Ferrell, M.D., associate professor of medicine at the UCLA School of Medicine and clinical director of the Geriatric Research Education and Clinical Center at the Sepulveda VA Medical Center in Los Angeles. "Pain is the most common symptom of disease and the most common complaint in physicians' offices among older patients."

"One of the main goals of the guidelines is to educate people on how to recognize and assess their pain and to utilize the many treatments available to manage it," said Keela Herr, a pain assessment researcher and associate professor of nursing, College of Nursing at University of Iowa.

Among the key recommendations:

• Pain should be an important part of each assessment of older patients; along with efforts to alleviate the underlying cause, pain itself should be aggressively treated.

• Pain and its response to treatment should be objectively measured, preferably using a validated pain scale.

• Nonsteroidal anti-inflammatory drugs should be used judiciously, so that unintended side effects may be avoided.

• Acetaminophen is the drug of choice for relieving mild to moderate musculoskeletal pain.

• Opioid analgesic drugs are effective for relieving moderate to severe pain.

• Non-opioid analgesic medications may be appropriate for some patients with neuropathic pain and other chronic pain syndromes.

• Nonpharmacologic approaches (such as patient and caregiver education, cognitive-behavioral therapy and exercise), used alone or in combination with appropriate pharmacologic strategies, should be an integral part of care plans for most chronic pain patients.

• Referral to a multidisciplinary pain management center should be considered when pain management efforts do not meet the patient's or the health care provider's goals.

• Regulatory agencies should review existing policies to enhance access to effective opioid analgesic drugs for older patients in pain.

• Pain management education should be improved at all levels for all health care professionals.

Positive reaction

Initial reaction to the guidelines has been positive.

Although the American Society of Consultant Pharmacists, Alexandria, VA, has not officially adopted the society's guidelines, pending a review, the group's initial reaction is favorable, said Tom Clark, director of professional affairs.

"We believe these guidelines will be very useful and we hope that they draw attention to the issue of under-treatment of pain among nursing facility residents," Clark said.

One of the issues addressed by the guidelines is reluctance among prescribers to use narcotic drugs. "The guidelines specifically mention the effect of Drug Enforcement Agency regulations in making prescribers reluctant to use these drugs when they would otherwise be considered appropriate," Clark said.

"That's a particular concern we at the American Society of Consultant Pharmacists have. There is a fine line when you begin using opiates because patients who have taken these drugs can develop tolerance and frequently need high dosages," Clark said.

Clark noted that doses must be tailored to a resident's specific needs.

"A dosage that's lethal for one patient might be adequate for another, so the range of dosages a patient needs can be quite considerable," Clark said. PR