Chronic non-cancer pain in older people

So I think the important thing is we need to shift that mindset, and shift our patient's mindset, to achieve some achievable goal. I might not get you pain free, but I might be able to get you to the shops and back.

[Music] Welcome to the Australian Prescriber podcast. Australia Prescriber, independent, peer-reviewed and free.

Chronic non-cancer pain, that's pain that lasts beyond tissue healing or for greater than three months, is common, increasingly so, and particularly in patients over the age of 65, where one in four people in Australia suffers from it. Despite having a massive impact on the health and the life of our patients, we're yet to figure out a pill that fixes all its ills, and those difficulties mean it's often swept under the carpet, almost, under-recognised and undertreated. It's even harder in patients with increased frailty, where the nonpharmacological measures are harder and the meds that we do have are riskier. So how do we navigate this space?

I'm David Liew, your host for today, and we are speaking to Gloria Wong, who is a clinical pharmacology and general medical registrar at the Royal Brisbane and Women's Hospital in Brisbane and a lecturer at UQ. In the February 2022 edition of Australian Prescriber, she outlines some of the challenges in this space but some also very practical approaches. Gloria, welcome to the program.

Thank you.

Gloria, tell me what makes chronic pain so important in older people, especially those with increased frailty. It always seems like a bit of a balancing act in these patients to try and get them to a pathway to better health.

There's quite a number of elderly patients who are living in chronic pain, especially where they've got lots of other long-term medical issues like osteoarthritis that can cause chronic pain. It impacts activities; their quality of life.

Sometimes, the elderly, they are quite stoic. They don't tell you that they have pain and they just brush it off the carpet. It's important to figure out what is important for them; what can make their quality of life better. At the same time, we need to balance the risk and the benefit of the medication that we're prescribing them.

In terms of risks and benefits, does frailty mean that these patients are at greater risk of problems from the medications that we might use?

The evidence available in elderly populations is always quite limited, unfortunately. However especially in medications like the opiate-based medications, there's definitely good evidence demonstrating it's causing harm in the elderly population. With the increasing frailty, they're more prone to delirium, they're more prone to falls when they're on these tablets.

Yeah. I think all of this is increasingly in the spotlight as we become aware about the potential risks of opioids and then some of the other drugs that we might use as well.

That's right. There's a recent report that a combination of opiates and other medication, like pregabalin, actually causes quite significant harm and deaths, which was recently reported.

I think part of the issue is that this is, like you said, often swept under the carpet and it can be hard to assess pain in a group of patients who are often quite stoic. How do we go about doing this in a population of older people where their frailty is more of an issue?

When I look for evidence that's supporting how to address or assess pain in elderly patients, most still recommend for patient, even with mild-to-moderate cognitive impairment, you can still ask them direct questions or questions related to their activities like, "Does it hurt when you do a particular thing? Does this medication help you to do this thing better?" There are quite a few ways around it, even with the severely cognitively impaired.

In my article, I've listed a few different tools. Some of them are validated. Some of them are widely available in Australia and used and validated as well. There are quite a number of tools that can help clinicians, either in the community or in the nursing home, that can assess patients' pain a lot better. Obviously, technology now can help as well. They are digitalised face-recognition tools that people can use, which I find quite interesting. So there's lots of new things around that can help us to assess these patients better to help them better.

In terms of the old technology first, what kind of tools do we have at our disposal? And should we be using them in specific populations?

I think PAINAD is probably the most available, and most of our Australian colleagues are more familiar with, especially those in nursing home or in the hospital. Some of the hospitals have the table basically incorporated in their nursing assessments so it will help them to assess patients a little bit better. But the old school, "On a scale of 1 to 10, where does it hurt and how would you rate it?" is actually not a bad tool to use, and evidence supports it as well.

So we don't need fancy tools and multidomain tools. We can just ask the question. And obviously, family's feedback or carer feedback is very important. Especially when patients get more cognitively impaired, they can't express their pain better. Carers who know them well can interpret their activity or their response a lot better than we do, so carers' input is important.

There has been a lot of talk about more modern technologies and facial recognition and things like that. Why do we need other things when we've got simple pain scores on a numerical rating scale or that we can look at just functional impact of pain?

I think the pain scale, I mean the electronic facial-recognition one, is more for the quite severely cognitively impaired patient. Especially in the nursing home, we try to improve the care. Now, the Royal Commission is in place, we do try to improve the care in the facilities, and those new tools might be something that we can employ in the future. They can make their life better.

Absolutely. Let's talk about how we might approach this. Your article is entitled Pharmacological Management, and I guess that's not the entire story, is it, really?

No. I have briefly mentioned in the article it's always important to have a holistic approach and incorporate the nonpharmacological management, which is very important and sometimes, for some patients, very useful. At times, we do need help with some of the medications, and I think the idea I want to bring out is what are the options and what are the things that we need to be cautious about when we do use this medication. There is no single tablet that can fix everything, so it is important to think about the nonpharmacological approach and incorporate with the pharmacological approach.

I think it always bears reminding us what kind of challenges there might be in delivering some of these nonpharmacological approaches. Tell us a little bit about what we can do in patients with increased frailty and how their frailty might make some of those things challenging for us.

The usual exercise and weight loss, sometimes even simple things like that are difficult for them. Sometimes we just need to get the pain under a certain amount of control to get those nonpharmacological approach to kickstart. It's hard for some of our elderly patients, when they're frail, to start exercising, or they're just physically not capable to do that anymore with other comorbidities affecting their ability to do that.

We still introduce nonpharmacological approach but in smaller bits and in a more easily digestible size tailored for our patients. Instead of telling a young patient that you walk kilometres, you can start exercising, maybe, around your garden or around your block and around whatever is manageable for that particular patient. To be honest, they might not want to do that much. They just want to be able to do that particular small little bit of activity. If they can achieve that, that's fantastic because the goal shifts for these patients and we just need to tailor our strategy according to what they can do and what they think they would want to do.

Right. I guess medications aren't straightforward in these patients. Why are they challenging in these patients? Why are these medicines not as easy as they are in a non-frail population?

Their metabolism is different. Sometimes, clinical studies might not include those patients that are in a very extreme age or in a very extreme body habitus or in frail patients, so we might not be entirely sure what the outcome would be like. Secondly, they take a lot of medications for different diseases that have potential to interact with them from a pharmacokinetic or pharmacodynamic point of view, but this might be additional. It might be interactional. There can be lots of problems, potentially, from the polypharmacy in this group of patients. They're more prone to falls, delirium, lots of other medical conditions that can exacerbate side effects.

And I guess it means that we are being a little bit more cautious than we would ordinarily be. Probably, we talk one drug at a time, for example.

Yeah, in a small dose and slow incrementation.

Absolutely. The thing that's increasingly in the spotlight as well, of course, is about how to deprescribe these patients. Let's talk a little bit about medications we might use in this setting. Just like in patients without frailty, we still have a bit of a hierarchy of medications we might use.

The same applies for the elderly. It's just each different medication, the side effects or the risks carried might be different, but the hierarchy still stays more or less the same.

Should paracetamol be the first port of call for almost all patients who are looking at pharmacologic therapies for chronic non-cancer pain. Do we need to think about things differently in this population with paracetamol?

It's actually not as strong, especially for long-term use. It does trigger me to think about if the patient has been on this for three months, six months, nine months, doesn't make any difference, we need to think about do they actually need that paracetamol. It's quite a lot of tablets. It does cause side effects, especially for patients who are elderly. With extreme body weight, they can cause hepatotoxicity. So, it's still reasonable to review it periodically.

Oh, well, it sounds like a sensible approach to any medication …

That's true.

... in any patient, let alone in a patient population with increased frailty and then increased risk. With paracetamol, do we change the dosing as far as these patients are concerned?

Dose reduction is recommended in some older patients, especially considering their weight and age. In terms of duration, the evidence around long-duration use of paracetamol is probably not as strong as we thought.

Let's talk about non-steroidal anti-inflammatories now because I think that, certainly in younger postoperative populations, there's been an increasing focus on utilising NSAIDs with opioid sparing in mind. That's clearly not as straightforward in an older population who are more frail, is it?

That's right. They're already more prone to comorbidities like renal disease, so dose adjustment might be needed, or avoidance sometimes might be needed. They're more prone to GI bleeding. Some of the patients are on other anticoagulations that can increase the bleeding risk. It might be very helpful in some particular inflammatory conditions. You just need to have a really short duration and reduce the dose, and review it regularly and stop it when it's not necessary.

The other thing to be considered if it's localised pain, then you can use topical, although the data on absorption is limited, so you need to be mindful when you use these medications.

I guess, at the other end, it seems like drugs like indometacin and ketorolac …

Yeah, I think that the evidence showing harm associated, particularly those two NSAIDs, is pretty strong.

So, there has been a little bit of a spate in terms of the use of gabapentinoids like pregabalin in recent times. I think that, while they're not opioids, there certainly are reasons to be a little bit more cautious in an older population, aren't there? What should we be looking out for? Why aren't these a good consideration in terms of opioid sparing in these patients?

For gabapentinoids, some of them are still renally cleared. Those need to be reduced. Secondly, they do come with side effects, so increasing falls and things like that, which is detrimental in our frail elderly patients. The other thing is they do react with quite a number of medications, so we just need to be mindful when we prescribe.

I guess that brings us to the elephant in the room, so to speak, with opioids. I think we all know our regulatory changes in the last years have really highlighted the issues that we have in terms of using opioids. I guess it's really hard in practice and I think it's often really hard in older patients, especially those with increased frailty. So how do we navigate the space? For starters, are they an appropriate option for older patients?

Yeah, I think the evidence is out there that it does harm, especially in the elderly. There are meta-analyses that have demonstrated falls and fractures and consequences from long-term opiate use in elderly patients. It's difficult for clinicians and it's difficult especially for patients when they're on those medications for so long, it's really hard to stop them.

But I think, with this new evidence available, it does empower clinicians to talk to the patient as a shared decision-making procedure that, "This is the harm that's demonstrated, and we need to look into this and try to see how we can minimise the harm and how we can slowly wean this medication down." It's a difficult and long process. I'm not pretending this is easy, especially for our GP colleagues, but it is something that needs to be done, unfortunately.

We often see certain opioids potentially thought about as a panacea, almost, in older patients because they might have a reduced toxicity profile. I guess I'm thinking about tapentadol and you see a lot of buprenorphine get prescribed as well. Is there anything in particular that you've got in mind there?

Look, there's not many data on the elderly. Most of the randomised trials are in the general population under 65. But one study in the nursing home in Scandinavian elderly patients using buprenorphine patch, they can cause quite significant neurological side effects. I think the evidence is coming out, just taking time, but even with the newer drugs, I think the more we know about them, we have more evidence pointing out about the harm associated with that. Tapentadol is probably the new kid on the board that people seem to think that's benign, but there's no evidence out there to say, in the elderly patient, that it's actually causing no harm.

Tell me a little bit about where we're at in terms of deprescribing because I think that's often hard, especially once you find yourself in a situation where medicines have escalated up. We may not have meant for them to, and our patients are getting side effects or may well even be addicted to these medicines. How do we find our way out?

I think a frank discussion with the patient and the carer, especially if the patient has cognitive impairment, is important. It's important to identify the goal for them because sometimes they want to be pain free, but it's never possible for them. So I think the important thing is we need to shift that mindset, and shift our patient's mindset, to achieve some achievable goal.

I understand it's hard to tell a patient, "I'm going to stop this now." It's impossible, so probably one step at a time and sit down together. "This is what we're trying to wean down to in six weeks time, and then we come back, reassess how this affects you." I think that that would be my strategy. I used that before with some of my patients, especially those who can cognitively appreciate the harm associated with these medicines, and they actually are quite receptive to that. We're trying to help them, we're not trying to harm them, and the reason for this medication reduction is to help them achieve that.

I guess it's the same as any motivational interviewing setting, right? You're trying to find those shared goals and trying to find the benefits that may well emerge from these situations. What kind of things are we talking about? What do you tell your patients in that situation?

The NPS have quite a number of resources that help GPs have this discussion with their patients. There are handouts about how to wean, what we are trying to get to, and literature about the harm associated with these medicines.

What kind of things are you using to motivate patients in this situation to get on board with deprescribing of analgesics?

It's very tailored to the patient. Obviously, when you know the patient it's a lot easier, but some of the patients just want to be able to do a certain task, not necessarily needing that much opiate. Sometimes, they will say, "I always feel nauseous," and then you look at their medication and you know, "This is probably why you feel nauseous, your 18 mg of Targin." Identifying some of the issues associated with medicines may help them to realise that this is actually harmful.

Some of the patients are really stubborn. Sometimes, we get the family to help because the family can see how these medications are affecting them and actually want them to cut down. Sometimes that may be helpful, but sometimes you never get there, unfortunately. But we try.

I guess there's an element of being able to try and assess the effectiveness of analgesia in the situation. How are we going about that in practice?

I think a goal-directed approach is easier. Some patients are like, "I'd be happy if I can go shopping and come back not in agonising pain, then that's terrific." Then we can work towards it. I might not get you pain free, but I might be able to get you to the shops and back.

I think, once you've got to that point and identified the oxycodone or tapentadol or pregabalin and identified the side effects that a patient might be getting, you've got a patient on board with that and you've realised that the analgesic isn't as effective. How do we go about titrating that? Because we're not just scratching it from the drug chart or scratching it from prescribing and going cold turkey, are we? We're slowly reducing.

Yeah. There are different strategies available on eTG. Most of the patients, you can slowly wean it off, halve every three weeks or every month and see how we go. For some of the patients with significant side effects or that are addicted, then a more rapid wean probably can be achieved, but if that's the case, then maybe speak to one of the geriatricians or other pain specialists that will help you to get a weaning regime.

That's equally as applicable to higher doses of pregabalin and gabapentin as to opioids, kind of going that staged approach. So it's a difficult situation, but I guess it just takes that little bit of determination.

Yes, and a lot of time.

Gloria, thanks very much for talking us through the landscape of chronic non-cancer pain in patients with increased frailty.

Not a problem. Thank you very much.

[Music]

No conflicts of interest were declared. The views of the guests and the host on this podcast are their own and may not represent Australian Prescriber or NPS MedicineWise. I'm David Liew. Stay safe and see you next time.