Expert Roundtable on Pain Management in Older Adults
On September 30, 2010, CDER’s Safe Use Initiative team convened a roundtable of more than forty experts from academia, health care management, consumer advocacy and government to address the safe use of pain medications in older adults.
Background
Millions of Americans suffer from chronic pain. In a study of 1000 community dwelling seniors (median age 75.3 +/- 6.7 years), 74% reported pain in the last 30 days, 52% had daily pain, and 26% ‘agonizing pain.’1 Despite the high prevalence, pain in this population is often inadequately treated. Health care providers may not fully appreciate the disabling consequences of chronic pain, and concern about adverse effects from pain medications may result in suboptimal treatment and inadequate pain control. Persistent pain is associated with reduced quality of life, depression, decreased cognition, and other sequelae.
Pain in older adults rarely exists in isolation. It is often one of multiple chronic conditions in older adults, including diabetes, depression, heart disease, and chronic obstructive pulmonary disease. These comorbidities often necessitate multiple concomitant medications, referred to as “polypharmacy,” which can lead to dangerous drug-drug interactions.
The multiple comorbidities, multiple medications, heterogeneity of the population, and physiological processes associated with aging expose the older adult to increased risk of harm from pain medications. They may be at risk for further complications if they misuse or overuse readily accessible over-the-counter (OTC) pain medications to compensate for undertreatment.
Purpose
To convene experts in geriatrics, pain management and medication safety to:
- discuss barriers to optimal use of pain medications in older adults
- identify areas of focus for safe use activities
- identify and engage key stakeholders for collaboration.
Goal
To seek and bring into voluntary collaboration key stakeholders from the health care community to develop and implement interventions aimed at quantifiably reducing preventable harm from the use of pain medications in older patients.
Roundtable Discussion
Invited speakers spoke to the challenges of diagnosing, assessing and treating pain in older adults and some of the innovative approaches to reduce harm from pain medications.
- Karen Weiss: Objectives and goals of the Safe Use Initiative
- Barbara Zarowitz: Challenges of diagnosing, assessing and treating pain in older adults
- Joseph Pergolizzi: Treatment of pain in older adults and circumstances that lead to harm
- William Rowe: American Pain Foundation activities to reduce preventable harm from pain medications in older adults
- Marsha Raebel and Linda Weffald: Kaiser Permanente-Colorado activities to reduce preventable harm from pain medications in older adults
The facilitated discussion addressed primarily the gaps in knowledge in treating older adults with pain; the undertreatment of pain; and the use and misuse of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) in older adults.
Some of the challenges identified in the discussion were physician fear in prescribing opioids, the severity of opioid side effects in older people, and the lack of adequate monitoring of patients who receive opioid prescriptions.
For NSAIDs, the challenges identified were the failure to use renal dosing guidelines; chronic use of NSAIDs; the use of multiple NSAID products leading to NSAID overdose; the lack of documentation of OTC NSAIDS intake; and the lack of monitoring for NSAID side effects.
Meeting attendees synthesized a long list of barriers to the safe use of pain medications in older adults into four areas:
- failure to use existing processes, mechanisms and tools effectively;
- failure to engage, communicate and educate relevant stakeholders effectively;
- lack of health care professional training; and
- lack of patient education and awareness
The Safe Use Initiative will focus initially on the safe use of NSAIDs in older adults.
Conclusion
This roundtable was an important first step, not only in providing direction for Safe Use Initiative activities, but also in stimulating enthusiasm for collaboration.
Next Steps
A steering committee composed of six roundtable participants convened for the first meeting in early November 2010, and will meet regularly to chart future steps, engage and recruit participants, and focus on specific cross cutting interventions to improve the safe use of NSAIDs in older adults.
References