Dr Tony Rao writes the risks of long-term drug treatment and the future of pain management in older people for our guest blog.
A growing problem
Pain is a very subjective experience. The same painful stimulus can produce different responses in different people in how intensely it is felt. The simplistic breakdown at an anatomical level to receptors involved in sensing temperature and pressure obscures the wider picture of other physical, emotional and environmental influences.
Lower-back and neck pain is the leading causes of chronic ill health in people aged 50 and over in the UK. Over 60 per cent of people over the age of 75 experience pain lasting for more than 3 months. This is likely to be associated with both considerable disability and social disadvantage from problems with getting out and about. A poor quality of life often means suffering in silence but with chronic ill health.
The risks of long term drug treatment
Thirty years ago, there was a wide range of drug treatments available to lessen pain. However, two of these drug groups (non-steroidal anti-inflammatory drugs and COX-2 inhibitors) are no longer considered suitable for older people. There have been large rises in the prescription of opioid drugs to older people over the past 15 years, with one study in Scotland showing a 20 per cent rise in prescriptions between 2000 and 2015. This group of drugs includes those derived from codeine or morphine, or else their synthetic and semi-synthetic derivatives. Opioids are not suitable for long-term use in older people but are still more likely to likely to receive an opioid prescription than younger people. Indeed, a recent report on Substance Misuse in Older People has highlighted arise in the inappropriate prescribing of opioids in older people, particularly in the “Baby Boomer” cohort of people born between 1946 and 1964.
Barriers to integrated care
The problem in the effective assessment, treatment and care of older people with chronic pain appears to be the lack of integration between services in addressing the wide range of problems experienced by older people, including accompanying physical and mental disorders. The management of pain in older people is not confined to primary care but includes general medical, surgical, care of the elderly, mental health of older adults and addiction services. Yet, pain remains largely managed in hospital-based pain clinics rather than in the community.
There remains little in the way of guidance or guidelines for clinicians in the management of pain in older people in exploring both physical and psychosocial interventions.
This is compounded by a lack of detection of pain in older people, where ageism contributes to the perception that pain is somehow “inevitable” with ageing, a lack of help-seeking from believing drugs and surgery are the only options, as wells as health professionals often giving pain low priority in the face of managing co-morbid physical disorders.
Older people are also all too commonly excluded from clinical trials. In an analysis of 274 clinical trials for the treatment of lower back pain published between 1992 and 2010, 50 per cent of these excluded people aged 75 and older.
The future of pain management in older people
All is not lost. There are now drugs that have far fewer side-effects than opioids. Gabapentinoids are a new class of drugs that show some promise but are licensed only for the treatment of pain originating from direct damage to nerves rather from mechanical pressure that may be present in disorders such as osteoarthritis. They may also have the potential for misuse and the long-term risk of dependence in older people remains unknown. There may also be the possibility of other treatments on the horizon such as cannabis oil, although a license for its use still appears a long way off.
There is a pressing need to develop home-based services for the long-term management of pain that extends beyond primary care. This should incorporate the input of mental health services in the treatment of depression, but also in the assessment and treatment of pain in dementia. The invaluable role of palliative care in pain management should also play a central role.
Last and by no means least is the provision of psychosocial interventions for pain in older people. This should be flexible, focussed and adapted to take into special considerations for older people. These include dignity, privacy, sensory impairment, mobility, cognitive impairment, bereavement and social isolation.
At present, we have a very long way to look before we can say with confidence that we have tackled the complexity of caring for older people in our society. It is a journey that is not insurmountable but one that we need to make together.
Dr Tony Rao
Consultant and Visiting Lecturer in Old Age Psychiatry
South London and Maudsley NHS Foundation Trust and Institute
of Psychiatry, Psychology and Neuroscience