Pharmacotherapy of Pain in Older Adults

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Pain is a universal part of being human, and yet, there is ample evidence that many people from all backgrounds, stages of life, and levels of health care experience receive less than optimal treatment of their pain. This article reviews the pharmacotherapy of pain in older adults, with a focus on salicylates, nonsteroidal anti-inflammatory drugs, and opioids.

Section snippets

Definitions

Before a useful discussion of this topic can be undertaken, it is important to ensure that a common lexicon is being used. The words used to define and describe pain are powerful and emotionally charged. They also often are used incorrectly or unclearly. A brief discussion of terms related to pain follows; the reader is referred to the International Association for the Study of Pain (IASP) for a more complete list.

Pain is a subjective, unpleasant, sensory, and emotional experience associated

Dependence, tolerance, addiction, and pseudoaddiction

If a person on a drug develops a withdrawal syndrome when that substance is removed suddenly, the individual is physically dependent on that substance [37]. For opioid analgesics, the withdrawal syndrome generally includes signs of central arousal, such as insomnia, irritability, and agitation. Patients also may experience autonomic symptoms, including diarrhea, rhinorrhea, and sweating, as well as muscle spasms, gastrointestinal (GI) cramping, and other painful phenomena. Although typically

Clinically important age-related pharmacokinetic and pharmacodynamic changes

Pharmacokinetics refers to the effect of physiologic processes on drug disposition [50]. In general, the processes of most interest are absorption, distribution, metabolism, and excretion. Absorption is important in pain management, because the oral route of administration is preferred when it is available. Typically, however, the effect of age on passively absorbed drugs is thought to be small [51], [52]. Drug distribution is a function of several parameters that can be affected by age, such

Adverse effects of opioids

Few data support differences in adverse effects among opioids at equianalgesic dosages for postoperative pain [67], [77], [78], [79]. Study results are often difficult to interpret because of the use of nonequianalgesic dosages or by the fact that pain itself can cause adverse effects, including nausea. Differences in the rate of adverse effects may be a consequence of individual patient characteristics [80]. Opioid metabolites also may cause adverse effects [78], [79]. For example,

Summary

The promise of relief from suffering exerts a powerful attraction, calling people in distress to seek medical care. Pain is a universal part of being human, and yet, there is ample evidence that many people from all backgrounds, stages of life, and levels of health care experience receive less than optimal treatment of their pain. Pharmacotherapy is an important part of its treatment, and through better understanding of how these tools are used, there are important opportunities to help reduce

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      Drug-drug interactions are another important factor to consider when using NSAIDs, because these medications are highly protein bound. When they compete with other drugs (e.g., warfarin, methotrexate) for protein-binding sites, the bioavailability of NSAIDs can rise sharply and increase the risk of bleeding or renal toxicity (Patrono, Garcia Rodriguez, Landolfi, & Baigent, 2005; Strassels et al., 2008). Herb-drug interactions (e.g., between ginseng or ginkgo biloba and NSAIDs) can also have undesired effects that put patients at risk for bleeding (Wirth, Hudgins, & Paice, 2005).

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    Dr. Strassels has received research funding from excelleRx, Incorporated, and has served on advisory boards for Cephalon, King, Pricara, Ortho-McNeil, and Valeant Pharmaceuticals.

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