Effective treatments for pain in the older patient

Chronic Pain in Older Adults

This review summarizes existing evidence relevant to the epidemiology of chronic pain in older adults, age-related differences relevant to pain, pain assessment, and important considerations regarding pain management in later life. Features unique to pain assessment in older adults include the likelihood of multiple diagnoses contributing to chronic pain, the ability of older adults to self-report, including those with mild to moderate cognitive impairment, and recognition that some older adults with cognitive impairment may demonstrate various behaviors to communicate pain. Management is best accomplished through a multimodal approach, including pharmacologic and nonpharmacologic treatments, physical rehabilitation, and psychological therapies. Interventional pain therapies may be appropriate in select older adults, which may reduce the need for pharmacologic treatments.

Tramadol/paracetamol fixed-dose combination in the treatment of moderate to severe pain

Pain is the most common reason patients seek medical attention and pain relief has been put forward as an ethical obligation of clinicians and a fundamental human right. However, pain management is challenging because the pathophysiology of pain is complex and not completely understood. Widely used analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol (acetaminophen) have been associated with adverse events. Adverse event rates are of concern, especially in long-term treatment or at high doses. Paracetamol and NSAIDs are available by prescription, over the counter, and in combination preparations. Patients may be unaware of the risk associated with high dosages or long-term use of paracetamol and NSAIDs. Clinicians should encourage patients to disclose all medications they take in a “do ask, do tell” approach that includes patient education about the risks and benefits of common pain relievers. The ideal pain reliever would have few risks and enhanced analgesic efficacy. Fixed-dose combination analgesics with two or more agents may offer additive or synergistic benefits to treat the multiple mechanisms of pain. Therefore, pain may be effectively treated while toxicity is reduced due to lower doses. One recent fixed-dose combination analgesic product combines tramadol, a centrally acting weak opioid analgesic, with low-dose paracetamol. Evidence-based guidelines recognize the potential value of combination analgesics in specific situations. The current guideline-based paradigm for pain treatment recommends NSAIDs for ongoing use with analgesics such as opioids to manage flares. However, the treatment model should evolve how to use low-dose combination products to manage pain with occasional use of NSAIDs for flares to avoid long-term and high-dose treatment with these analgesics. A next step in pain management guidelines should be targeted therapy when possible, or low-dose combination therapy or both, to achieve maximal efficacy with minimal toxicity.

Combination Drug Therapy for Pain following Chronic Spinal Cord Injury

A number of mechanisms have been elucidated that maintain neuropathic pain due to spinal cord injury (SCI). While target-based therapeutics are being developed based on elucidation of these mechanisms, treatment for neuropathic SCI pain has not been entirely satisfactory due in part to the significant convergence of neurological and inflammatory processes that maintain the neuropathic pain state. Thus, a combination drug treatment strategy, wherein several pain-related mechanism are simultaneously engaged, could be more efficacious than treatment against individual mechanisms alone. Also, by engaging several targets at once, it may be possible to reduce the doses of the individual drugs, thereby minimizing the potential for adverse side effects. Positive preclinical and clinical studies have demonstrated improved efficacy of combination drug treatment over single drug treatment in neuropathic pain of peripheral origin, and perhaps such combinations could be utilized for neuropathic SCI pain. At the same time, there are mechanisms that distinguish SCI from peripheral neuropathic pain, so novel combination therapies will be needed.

Acute postoperative pain management in the older patient

Acute pain management in the older adult is both challenging and rewarding. This review addresses the difficulty with assessment of pain in the older adult, variations in the pain experience of older adults, physiological differences between the young and old, changes in pharmacokinetics and pharmacodynamics with age, and useful pharmacological treatments for acute pain in older adults. It then presents a few representative cases of pain management in older adults. The goal of this review is to provide relevant information that can be used to manage acute postoperative pain in the older adult.