chronic pain management in the older person

CHRONIC PAIN MANAGEMENT IN THE

OLDER PERSON - A PALLIATIVE APPROACH

A/Prof Michael Murray Medical Director, Continuing Care CSU, Head of Geriatric Medicine Austin Health & A/Prof Benny Katz Director of Geriatric Medicine, St Vincent’s

PART 1 Physiology of Pain

“To have great pain is to have certainty, to hear that another person has pain is to have doubt.”

Scarry, 1985

Pain Is…

• Subjective

• What the patient says it is

• Influenced by many factors

• More than physical

• Often misinterpreted by both the patient and the

health professional

noxious stimulus = pain

No dependable relationship between the

extent of a pathological wound and the pain experienced. Beecher JAMA 1956 Comparison of narcotic requirements of civilians compared with similar wartime injuries Radiological changes Vs Pain

Herniation of the lumbar disk, • found in 25 - 50 % asymptomatic subjects; • extrusion of the disk material in 1-18%. Degeneration of the lumbar disk • increases with age • found in 25-70% of asymptomatic subjects. EJ Carragee. N Engl J Med 2005; 352:1891-1898

Images of the Spine from Normal Volunteers Despite the high prevalence in healthy persons

these findings are often described as causing serious low back pain

Epidemiology - Pain in the Elderly Helme RD & Gibson SJ in Epidemiology of Pain. IASP Press. 1999

Increased prevalence of pain with age • articular, leg and foot pain • neuropathic pains

• postherpetic neuralgia • central post stroke pain • painful peripheral neuropathies

Reduced prevalence of pain with age • headaches (peak 45-50 years) • facial / dental pain • abdominal / stomach pain • chest pain

The Challenge of Pain in the Elderly

• Chronic pain - 50% of the elderly - 80% of nursing home residents.

• 19% of older people admitted to hospital have moderately

or extremely severe pain.

• Cancer pain affects 70% of 10 million cancer patients diagnosed annually.

• Fewer than 50% of patients with acute, chronic or cancer pain receive adequate relief.

Cousins MJ 2004 Lussier D 2006

Overview of Pain Types

Acute pain:

• Temporary; has a limited time frame, may be self limiting

• Related to tissue damage

• Decreases during healing phase

Overview of Pain Types

Persistent (chronic) pain:

• Duration beyond the healing phase, persistent

• May not have known injury or disease

• Associated with progressive disease

Adapted from Ashburn MA, Staats PS. Lancet 1999;353:1856-69

Acute pain Persistent (chronic) pain

Cancer related pain

Duration hours/days months/years unpredictable

Associated pathology

present often none present

Emotional problems

uncommon depression, anxiety, 2o gain

many

Autonomic involvement

present generally absent present or absent

Biological value high low low

Social effects few profound variable, usually profound

Treatment analgesics multimodal, largely behavioural, moderate role for

drugs

multimodal, major role for drugs

Expectation Pain will subside Pain will persist Pain control

Somatic pain

• Somatic

• Well localised

• Constant

• Described as throbbing, aching, gnawing

Visceral pain

• Visceral

• Results from sympathetic injury; stretching of organ capsule

• Vague in nature

• Described as dull, deep, aching. If acute may be colicky or

paroxysmal

Neuropathic Pain

• Results from injury to the nervous system

• Central nervous system

• Nerve plexus pain

• Phantom pain

• Invasion of sympathetic chain

• Demonstrated in discomfort or altered sensation (burning,

tingling, numbness, itching, shooting)

PART 2 Pain Assessment and Management

Modification of its perception is key to its treatment

Chronic pain - Palliative approach

Pain Assessment Aims

Obtain a story from the patient which allows us to;

• Understand the underlying disease factors or

possible causes for the pain

• Determine the patient’s understandings and

expectations of pain management

• Determine if there are other contributing factors

• Clarify if there is more than one pain?

Aim of pain assessment tools

• Provide a framework for clinical diagnosis

• Establish a shared view of the pain experience

• Provide a vehicle for team communication

• Develop a baseline from which to evaluate pain

interventions

Pain Assessment Tool Provide information on pains; • Onset/pattern • Determine the site of pain e.g. body chart • Type or Quality of pain (dull, aching, sharp) • Subjective degree of pain • Radiation (can mark on body map) • How the pain is affected by and in turn affects such things as (movement, sleep, activity, rest, emotions, relationships, concentration, bowels)

How should it be used??

Is it the patients self impression of pain or is it the identikit a nurse uses to evaluate the patients pain

ACEBAC Pain Chart Edvardsson, Katz, Nay

6 3 2 E B F 2 1 1 Z - V

Patricia May 2010

• 89yo lady with mild / moderate dementia with 5 years of

progressively worsening pain 2ry to osteoarthritis

• In LLC, assistance with pADLs, largely continent

• MMSE 19/30, history not 100% reliable

• past R THJR “made her worse”

• Worst pain affects R knee – refuses surgery

• Aching quality. Average pain 6/10

• Aggravated by standing 9/10 for 1 hour per day

Patricia

Management

• Non Pharmacological

• Pharmacological

Non-Pharmacological Therapies

• Mobility aids and equipment (e.g. Frame, cutlery)

• Application of heat or cold

• Acupuncture

• TENS (Transcutaneous electrical nerve stim)

• Therapeutic Massage

Non-Pharmacological Therapies

• Relaxation, diversion

• Cognitive / behavioural techniques

• Focused breathing, muscle relaxation, meditation

• Hypnosis, Music, Reiki, reflexology, aromatherapy

Patricia

• Pharmacological

• What options are there?

Pharmacological Management

• Great deal of criticism of drug management, some of

which is clearly justified

• 30% of patients report suboptimal relief, even when the WHO

guidelines for management are followed

Jadad AR; Browman GP JAMA 1995 Dec 20;274(23):1870-3

• Is the WHO pain ladder defunct?

• Newer European guidelines recommend that opioids can be first

line therapy

Caraceni, A. EAPC Lancet Oncol 2012; 13: e58–68

Principles of Pharmacological Management

Issues to consider with medication

• Pharmacokinetics, i.e. how it works

• Rational Use of Medicines (Polypharmacy)

• Drug interactions

• Compliance

• Adverse drug reactions

• Attitudes to certain drugs, e.g. opioids

Principles of Pharmacological Management

• Choice of drug and dosing determined by type of pain

• Avoid complex regimens (keep it simple)

• Do not use multiple drugs of one class

• Tailor medication to type of pain & goals of

management

• Start low and go slow

• Keep Patient and Carers in ‘control’

• Be aware of allergies

• Frequent review (How?)

Patricia

• Regular Paracetamol

• Slow release opioids

P Tugwell et al. BMJ 2004;328:1362-1363

Paracetamol • First line treatment for mild to moderate pain. • This recommendation is based on safety over efficacy

• 500 – 1000mg 4 hourly to a maximum of 4g per day.

• The duration of action of paracetamol is short

• Plateau analgesic effect following a singe dose of

600mg.

• When pain relief is not sustained consider • a lower dose more frequently e.g. 500mg 3 hrly, or • extended release paracetamol

Zhang, W et al. Ann Rheum Dis 2004;63:901-907

Paracetamol and NSAIDs for osteoarthritis pain Meta-analysis of RCTs

Patricia

• Issues:

• Role of maintenance opioids in chronic non-malignant pain

• What’s the end game?

• Role of NSAID in the elderly

• Evaluating effectiveness

• Pain is still 6/10!

• Risk of aggravating confusion with morphine

• Risk of tolerance/dependence/addiction

Patricia

• October 2012. Worsening pain control ? 2ry to

dementia or depression

• Now 91yrs old.

• Oxycontin 15mg BD Durogesic 12mcg/hr 3 months

earlier without benefit

• Worst pain L hip, then R hip, then lumbar spine.

• Worse at night – unable to sleep

• “knees not too bad”

Algorithm for pain assessment & management in severely cognitively impaired persons

American Geriatrics Society Panel Guidelines on Persistent Pain in Older Persons. JAGS 50: S205-S224, 2002.

Presence of pain behaviours during movement? YES • consider pre-emptive analgesia • strategies to alter inducing pain • reassurance

Presence of non-movement specific pain behaviours • are basic needs being met? • exclude pathology • trial of analgesia

NO

Patricia

• Why is she worse?

• What would you do next?

• What information might you consider relevant?

Patricia • 4-5 months of weight loss

• May 2010 58.4Kg • July 2012 56.9Kg • Oct 2012 53.4Kg

• Small L posterior Cx lymph node, nil elsewhere • No breast lumps, chest and abdo NAD • Tender++ lumbar spine, L hip and upper femur

Patricia

• RED Flags

• ?

Patricia

• Age

• Increasing analgesic requirements

• Constitutional symptoms/ weight loss

• Pain worse at night

Patricia

• Hb 123 WCC 14.9 Pl 614 ESR 54 • X-ray lumbar spine, pelvis & L femur NAD

• CT and Isotope scans:

• Lytic lesions and infiltration L1, L3 vertebral bodies and pedicles • Malignant lesion in porta hepatis

• Opioids • Palliative radiotherapy • Mx in conjunction with palliative care team & GP at

facility

Patricia

• Lessons

• Patients with dementia can often give valuable histories

• Beware of changing symptoms

• Red flags

• Management of chronic versus cancer pain

When is care, or when should care be Palliative?

Dementia as an example

Dementia and the trajectory to death

• What do we need to know?

• Why do we need to know?

• What information do we need to provide to our

patients?

Dementia

• characterized by slow progressive decline;

• slight increase in functional loss as death approaches (Covinsky

et al. 2000).

Implications: “No abrupt changes that signal the onset of a terminal

phase...” Different to the path of someone with untreatable cancer

(Covinsky et al. 2000).

Sometimes it is difficult to recognise the dying phase.

Copyright © 1999 American Academy of Neurology. Published by Lippincott Williams & Wilkins, Inc. 5

Dementia is a major predictor of death among the Italian elderly. Baldereschi, M; Di Carlo, A; Maggi, S; Grigoletto, F; Scarlato, G; Amaducci, L; Inzitari, D Neurology. 52(4):709-713, March 10, 1999.

Figure. Kaplan -Meier plot of survival in nondemented (solid line), AD (long dashes), and vascular dementia (short dashes) cases.

Copyright © 1999 American Academy of Neurology. Published by Lippincott Williams & Wilkins, Inc. 4

Dementia is a major predictor of death among the Italian elderly. Baldereschi, M; Di Carlo, A; Maggi, S; Grigoletto, F; Scarlato, G; Amaducci, L; Inzitari, D Neurology. 52(4):709-713, March 10, 1999.

Table 3 Significant predictors of mortality at multivariate analysis (Cox proportional hazards model)

Understanding dementia as a terminal illness

• ‘At nursing home admission, only 1.1% of residents with advanced dementia were perceived to have a life expectancy of less than 6 months; however, 71.0% died within that period’ (Mitchell, Kiely, Hamel 2005).

Understanding dementia as a terminal illness

• This means difficulty in recognising that end-of-life was near, and: o Residents with dementia are less likely than those

with cancer to have discussions and plans for life expectancy and comfort care.

o Residents with advanced dementia are more likely to experience burdensome interventions e.g. hospitalisation and procedures.

o Moving people with advanced dementia to hospital can cause more distress to the person than caring for them in their ‘home’ environment.

Beryl

Mrs B, aged 85, recently admitted to aged care facility. moderate dementia. MMSE 17/30 On admission: needing assistance with all personal care, meal supervision given recent weight loss and poor oral intake, BMI 18.5 some faecal incontinence, unable to fully manage her pads, mostly chair / bed related to chronic pain (low back and hip pain) wheelchair to get out of room (family visits fortnightly)

Beryl

Four months post admission:

one bout of CCF and urine infection treated, with

some minimal delirium (extra confusion),

mobility reduced, more unsteady needing two or hoist

for transfers

Regular Paracetamol and Targin 5mg bd

Worsening oral intake

Case study cont... Eight months later:

dementia has advanced

What would we expect?

engages with conversation appropriately, smiles, easily

involved in some activities (presents well),

however urinary and faecal incontinence,

requiring full assistance to eat and drink with worsening

swallow

Pain more problematic

Then…

becomes progressively confused and calling out,

complaining of pain - everywhere

Abn FWT ? urine infection,

What does an abn FWT mean

given oral antibiotics

more confused

Climbing out of bed, two falls, worsening pain ++

Case study cont... Over two weeks her condition worsens: bed-bound unable to transfer – calling out no longer smiling, distressed Poor oral intake

Staff all feel marked decline in QOL

Family wanting treatment, stating that Mrs B “was always a

fighter” “when she last had an infection she got over it” Transferred to hospital

Outcomes • Cognitive changes post delirium suggest the pathological

process • associated with neuronal toxicity

• poorer outcomes with pre-existing dementia (Gross 2012)

• Adjusted hazards ratio death at 12 months 1.95 (95% CI 1.51 - 2.52) to 2.11 (95% CI 1.18-3.77)

(Witlox JAMA 2010, McCusker Arch Int Med 2002)

• Independent predictor of all cause mortality and stroke post CABG (Martin 2012)

• Cumulative 1 yr mortality 39% independent of age, sex, comorbidity, functional status and dementia (Kiely D JAGS 2009)

In hospital: Treat Vs Do no harm? Intravenous (IV) antibiotics

IV fluids (a drip)

agitation and distress increases

Commenced on olanzapine

Worsening delirium restraint applied intermittently for “patient safety”

Dies

Death certificate – aspiration pneumonia

Results

• Patient suffering

• Patient death

• Family distress

• Staff unsettled

• No person centered benefit

• Negative resource utilisation

Was this in anyway predictable or preventable?

What do we know?

•Dementia is a terminal disease,

What do we know?

• Dementia causes death

• people with dementia, especially advanced dementia

inevitably have multiple comorbidities

• Not surprising as they are almost inevitably elderly

What do we know?

• ‘Nursing home (NH) residents with advanced dementia

whose family members understand that their prognosis is

poor have reduced likelihood of receiving burdensome

interventions in the last 90 days of life’ (Mitchell 2009)

• An ability to prognosticate assists families and patients plan

and decide on appropriate management / interventions

(Mitchell 2010)

Mrs B Recent admission with Dementia and 85 years 5 Functionally dependant 2.1 Mostly Bedfast 2.1 Underweight / low BMI 1.8 Weight loss 1.6 Poor oral intake 2.0 Faecally incontinent 1.9 CCF 1.6 Recent admission 3.3 (Mitchell 2010)

Recent admission and Dementia and 85 years 5 Functionally dependant 2.1 Mostly Bedfast 2.1 Underweight / low BMI 1.8 Weight loss 1.6 Poor oral intake 2.0 Faecally incontinent 1.9 CCF 1.6 Recent admission 3.3 Total 21.4 On average 77% dead in 6 months, 87% dead in 1 year (Mitchell 2010)

(Mitchell 2010)

What we know? • What are the implications of a prognosis worse than almost all cancers for person centred management?

Pain Assessment in the Elderly / Cognitively Impaired

Risk of under treatment in these people due to:

• Underestimation of the impact of pain on activities or enjoyment of daily living

• Acceptance that it is a part of ‘being old’

• Unrealistic expectations of treatments

• Fear regarding use of medication/side effects

• Inability to communicate the meaningful subjective experience of pain

Recognition of pain in the cognitively impaired

• Increased agitation, restlessness occasionally aggression

• Decreased activity or refusal to participate in ADLs

• Altered gait

• Increased confusion

• Guarding of certain body parts

• Changes to behaviour

Management Principles

Aims of treatment

• Optimal reduction in pain

• Improve quality of life

• Improve function

• Maximise independence / ‘owner operated control’

Management Principles

• Both pharmacological and non-pharmacological

approaches need to be considered as studies combining

multiple modalities (cognitive, drug education stress

management etc.) produce significantly better results

Non-opioid Medications

• Paracetamol

• NSAIDs

• Aspirin

• Antidepressants

• Anticonvulsants

• Anxiolytics

• Anaesthetic agents

• Steroids

Non-opioid Medications

COX-2 and other newer generation NSAID

• Cyclo-oxygenase 2 specific with less GI effects

– E.g. celecoxib (Celebrex),

• Cyclo-oxygenase and lipoxygenase inhibitor

– meloxicam (Mobic)

Opioid Analgesics • Oral opioids of demonstrated benefit in a wide range of

neuropathic conditions, in trials up to 8 weeks

• Use with adjuvants such as Paracetamol, NSAIDS

• Be aware that inappropriate fear of dependence & addiction can

limit clinical use

• Increased sensitivity in older people – start with small doses &

fixed dosing schedules

• Addiction not a problem in persistent pain but abuse (5-50%)

Opioid Analgesics

Codeine (forget it!)

• A weak opioid

• Can be effective as an analgesic, antitussive and has

antidiarrhoeal action

• High incidence of constipation

• Doesn’t work at all in some people

• Has toxic metabolites

Opioid Analgesics

All of the opioids are essentially equal in terms of efficacy and toxicity in the opioid naïve

Morphine

• Half-life 2.5 to 3 hrs. • Liquid well absorbed but bitter taste • Commence liquid morphine and from this calculate 24 hourly

requirements then convert to sustained release. • Nausea usually settles within a week

Other Opioids Oxycodone (may have less cognitive adverse effects but

less clear in tablet or SR form) • oral (endone, oxynorm) • slow release – oxycontin • PR - proladone

Tramadol • Centrally acting analgesic • weak μ opioid agonist • Rarely used in the Elderly

• Side effects include somnolence, constipation, dizziness, gait abnormalities, sweating, serotonin syndrome

Fentanyl (Durogesic)

Buprenorphine (Norspan)

Patch sizes 12, 25, 50, 75, 100 mcg/hr

5, 10, 20 mcg/hr

Oral morphine equivalent

~135mg for 25mcg/hr patch

Unknown. Patches cover 20 – 90mg

Acute pain X X

Persistent pain √ √

Cancer pain √ X

Duration 3 days 7 days

Steady state 1 – 3 days 3 days

T1/2 after patch removal

1 days 12 hrs

Topical Lignocaine patches (5%) Lidoderm ®

RCTs for PHN and DPN when allodynia is present.

Not readily available in Australia (SAS).

~$200/month is a barrier.

Other Options • Surgery

• Joint replacements • Vascular surgery • Spinal surgery- e.g. decompression

• Blocks • local anaesthetics, neurolytics (e.g. phenol) for

neuropathic & ischaemic pain • Epidurals • Implantable devices • Infusions

James

• 87 yr old man who now lives alone • Post herpetic neuralgia following shingles 4

months ago - R T7 • Treated with famciclovir ~ 48 hours of the onset

• Describes his pain as ‘terrible’ • Pain wakes him 2 – 3 times per night • Current analgesics is useless : Panadeine forte ii QID,

James

• Lost 3 kg and is struggling to transfer assist x1 • Can only walk ~15m due to OA, COPD and deconditioning.

• Medications: • Panadeine forte ii QID • inhalers • SSRI

James

• What issues need to be considered?

• How are you going to manage him?

• Will you use carbamazepine (Tegretol)?

• Natural history of postherpetic neuralgia • Can PHN be prevented

• Effectiveness of codeine • Treatments for postherpetic neuralgia

Prevention of PHN

• Adult vaccination to reduce acute zoster (stimulates T cell immunity) • expensive

• Treatment of acute zoster to prevent PHN • Amitriptyline 25mg

• reduced PHN at 6 months by 50% D.Bowsher. J Pain Symptom Manage. 1997

• Early antiviral therapy Acyclovir, Valacyclovir , Famcicylovir Initiated within 72 hours of onset in pts >50 yrs

• Reduces time to healing of acute zoster • Reduces incidence of PHN by ~50%

• Analgesia • ? Steroids acutely

Uptodate.com

Numbers Needed To Treat for > 50% Pain Relief N.B. Finnerup et al. Pain 2005;118: 289–305

NNT Neuropathic

pain

Central Pain

Painful Neuropathy

PHN Trigeminal Neuralgia

NNH

TCA 3.1 4.0 2.1 2.8 14.7 SSRI 6.8 6.8 ns SNRI 5.5 5.5 ns Carbemazep. 2.0 3.4 2.3 1.7 21.7 Phenytoin 2.1 2.1 ns Valproate 2.8 ns 2.5 2.1 2.1 ns Gabapentin/ pregabalin

4.7 NA 3.9 4.6 17.8

Opioids 2.5 2.6 2.6 17.1 Tramadol 3.9 3.5 4.8 9.0 Cannabinoids ns 3.4 ns

NNT for Neuropathic Pain (Postherpetic Neuralgia and Painful Peripheral Neuropathy) Sindrup 1999, Collins 2000, Meier 2003, Dworkin 2003, Rowbotham 2004

0 1 2 3 4 5 6 7 8 9 10

Tricyclic antidepressantsSNRISSRI

GabapentinPregabalinMexilitene

CarbemazepineTramadol

OxycodoneLignocaine patches

Capsaicin topical

Side effects of antidepressants

Anti- cholinerg

Drowsy Agitation Insomnia

Hypo-tension

Cardiac arrhyth

GI Weight gain

Amitriptyline 4+ 4+ 0 4+ 3+ 0 4+

Imipramine 3+ 3+ 1+ 4+ 3+ 1+ 3+

Mirtazapine 1+ 4+ 0 0 0 0 3+

Sertraline 0 0 2+ 0 0 3+ 0

Citalopram 0 0 1+ 0 0 3+ 0

Venlafaxine 0 0 2+ 0 0 3+ 0

Prevalence of Postherpetic Neuralgia

0%

20%

40%

60%

80%

100%

0 1 2 3 4 5 6 7

60 - 90 years0 - 59 years

S.Helgason et al BMJ 2000; 321: 794-6

>40% will have pain

~20% ~50% chance of improving in 3 months

years

Algorithm for treatment of neuropathic pain

PHN in the old old 1. Tricyclic antidepressant 2. Opioids 3. Gabapentin or pregabalin (low dose) 4. Lignocaine 5% patch (access is imp issue)

Diabetic related in the old old 1.Tricyclic antidepressant 2.Opioids 3.Duloxetine 4.Gabapentin or pregabalin

Modified from Australian Medicines Handbook 2013

Calcium channel ά2-δ ligands

Pregabalin • RCTs: PHN, DPN, spinal cord injury

• No important drug interactions dose reduce in renal disease

• Easier to titrate than gabapentin

• More rapid analgesia

• Start 75mg nocte 150mg BD

• Side effects are common esp elderly (dizziness, drowsiness)

• Expensive.

• PBS Authority Refractory neuropathic pain not controlled by other drugs

Calcium channel ά2-δ ligands

• Gabapentin (expensive) • RCTs: PHN, painful DPN, phantom limb, cancer pain, spinal cord

injuries. Some negative trials.

• Not PBS listed for pain. Generics.

• Takes months to titrate to 1800 – 3600mg/day

• Analgesia ~2 weeks after therapeutic dose

• Significant side effects

• Somnolence, dizziness, peripheral oedema,

• Aggravate or cause cognitive impairment

Neuropathic Pain Agents

• Tricyclic antidepressants • Multiple positive trials for Post Herpetic Neuralgia (PHN) and

painful Diabetic Peripheral Neuropathy (DPN)

• doxepin probably better in the elderly

• 40 – 60% of patients respond

• If antidepressant required, use SSRIs, e.g. Sertraline (Zoloft)

Venlafaxine (Efexor)

• No or less clear demonstrable benefit for TCA in HIV neuropathy,

spinal cord injury, cancer neuropathy, phantom limb pain and chronic

lumbar root pain

Serotonin, noradrenaline reuptake inhibitors • Duloxetine

• PBS Depression and Diabetic neuropathic pain only

• 3 positive trials in DPN. Not trialled in other NP

• Easily titrated & well tolerated

• Venlafaxine

• Low doses – serotonin reuptake inhibitor

• Higher doses – serotonin and NADR reuptake inhibition

• +ve RCTs: DPNs and other neuropathies in doses on 150 – 225mg per

day (2 – 4 weeks titration)

• Inconclusive/negative results in post-mastectomy pain, PHN and

central neuropathic pain

Other Agents

Topical analgesia –

• Capsaicin (3rd line)

• Can be difficult to use • NSAID gels

• Topical anaesthetics, e.g. Emla cream

Betty Brown • 83 yr old HLC resident, referred with severe pain following a recent # humerus.

• PH: • Vascular dementia MMSE 18/30 • Frequent falls - used a 4 wheel frame. • Osteoarthritis and lumbar canal stenosis.

Back pain effectively controlled with MS Contin 20mg BD for past 2 years.

Betty Brown

• What issues need to be considered?

• How would you manage Mrs Brown?

• Acute pain management in a person on

maintenance opioids

• Management of her #

• Opioids and confusion

• Opioids and falls

28/12/06 8/2/07 25/2/07

• Older individuals are more sensitive to opioids, and achieve analgesia at lower doses than younger individuals

• Generally start at ½ usual dose, review and adjust dose as required

• She has been using opioids for 2 years and is likely to have a degree of tolerance.

• Higher opioid doses will be required for her acute pain

• Has a fall • Family upset, who’s to blame?

Medication use is one of the most modifiable risk factors for falls

• benzodiazepines (OR 1.51) • antidepressants (OR 1.54) • antiepileptics (OR 2.56) • NO increased risk with opioids (OR 0.99).

Ensrud et al. J Am Geriatr Soc 2002

Fracture risk associated with the use of morphine and opiates Vestergaard et al, Journal of Internal Medicine 2006; 260: 76–87

• Case–control study of subjects from Danish nationwide register with any fracture sustained during the year 2000. n = 124 655 fractures and 373 962 matched controls Morphine and other opiates used by 10 015 (8.0%) of subjects and 12 108 (3.2%) of the controls

•

Fracture risk associated with the use of morphine and opiates

Vestergaard et al, Journal of Internal Medicine 2006; 260: 76–87

RR 95% CI

Morphine 1.47 1.37–1.58

Fentanyl 2.23 1.89–2.64

Oxycodone 1.36 1.08–1.69

Tramadol 1.54 1.49–1.58

Codeine 1.16 1.12–1.20

opioid efficacy for persistent pain • Have opioids been demonstrated to be efficacious for

persistent pain?

• Has the long term efficacy been demonstrated?

Trials of opioids in chronic pain

• Good short term efficacy in both neuropathic and musculoskeletal pain.

• Average pain reduction with long-term opioid therapy ~32% • Only 44% remained on treatment for 7 to 24 months • Daily doses of Morphine >180mg, or equivalent, have not

been validated • 80% of patients experienced at least one adverse event

Balantyne JC, Mao J. N Engl J Med. 2003:349;1943-1953 Turk DC. Clin J Pain. 2002;18:355-365 Lalso E. Edwards JE. Moore RA. McQuay HJ. Pain 2004; 112: 372-80

Opioids for persistent non-cancer pain Eriksen et al. Pain 2006

Danish survey of 1,906 chronic pain patients. Compared with non-users, opioid users reported

• more pain • poorer self-rated health • lower quality of life scores • low levels of physical activity • low levels of employment • high levels of healthcare utilization

Epidemiological studies cannot assess causation

Summary • Pain is subjective, complex experience

• The management of complex pain can be frustrating for

the patient, family and treating team

• Essential to assess, reassess and evaluate

• Important to set realistic goals

• Ensure the treatment is appropriate for the cause of the

patient’s pain