"Pain is a more terrible lord of mankind than even death itself."
-Physician and humanitarian Albert Schweitzer (1875-1965)
When you're in pain, nothing else seems to matter. And if you're an older adult, you are not only more likely to have pain, but also to get less help for it than younger people are.
Chronic pain affects more Americans than diabetes, heart disease and cancer combined, and is the top-cited reason for seeking medical care. The relief of pain is the heart and soul of health care. And while always unwelcome, pain often has an important role to play. It can provide a warning that something is wrong, such as infection or undiagnosed disease. It is sometimes called the "fifth vital sign," as essential as temperature, heart rate, blood pressure and respiratory rate, for assessing health status.
The two kinds of pain
Doctors divide pain into two categories: "acute," which is generally event-related (such as pain from headache, broken bones, surgery or childbirth), and "chronic," often called "persistent" pain. Chronic pain arises from a variety of causes, including acute pain that was not relieved.
Persistent pain is one of modern medicine's more shameful shortfalls. An estimated 116 million Americans endure chronic pain, the most common cause of long-term disability, costing the United States at least $560-635 billion annually. The situation gets worse as we age: Today almost half of people over age 65 routinely live with pain.
"A disease in its own right"
Yet many persistent pain sufferers say their condition remains misunderstood and even stigmatized. The resulting care gap is serious enough that the Institute of Medicine (IOM) recently declared that we need a "transformation in how pain is perceived and judged both by people with pain and by the health care providers who help care for them."
Far from dismissing persistent pain as imagined, exaggerated or inevitable, the IOM report endorses the emerging view that, "because of the physiological and psychological changes that occur in people with chronic pain ... in many cases, chronic pain is a disease in its own right."
The International Association for the Study of Pain agrees, and last year declared access to pain management "a fundamental human right," adding, "there are major deficits in knowledge of health care professionals regarding the mechanisms and management of pain." Sadly, I concur, as would most practitioners, particularly those treating older patients.
Nearly three out of four older adults have multiple chronic illnesses, such as diabetes and arthritis, and often experience chronic pain from these and other disorders. These include back pain from spinal stenosis, cancer and cancer treatments. Yet there is little or no evidence-based care for this pain, as Ken Covinsky, M.D. of the University of San Francisco Medical Center, has persuasively argued. Likewise, pain that clouds the last days of life should always be aggressively treated; tragically, too many Americans still die in pain.
How can caring and competent physicians allow this suffering? For older adults with multiple conditions, the cause of pain can be hard to pin down. Similarly, older adults often take many medications, which put them at risk for adverse reactions, particularly if pain medications are added. Older adults themselves may compound the problem, being reluctant to "complain" to their doctors, who, through ageism, wrongly assume that pain is simply part of growing old. As a result, many physicians, who may not have had any formal education on pain management, may be overly cautious, and thereby not treat their older patients' pain.
Toxicity associated with commonly employed pain medications also complicates treatment. Widely used NSAIDS (such as over-the-counter ibuprofen [Advil]) that work by reducing inflammation, and prescription Cox-2 inhibitors (such as Celebrex) have side effects that may include increased rates of gastrointestinal bleeding, renal failure, heart failure, heart attack and stroke. A recent study by the American Geriatrics Society determined that 23 percent of older adult hospitalizations for drug toxicity implicated NSAIDS. Even opiates (morphine and others), when used to treat chronic pain disorders, increase risk for adverse outcomes and have only moderate effects on severe pain.
Doctors and patients have found some relief from the use of adjuvants (drugs approved for different use, such as anti-depressants and anti-convulsants). Drugs that target newly identified pain receptors are also in the research pipeline and may have better safety profiles than current analgesics, but their success or failure is still far in the future.
For now, we must use what we have, but the common exclusion of older adults from clinical studies means that we lack an evidence base documenting analgesic safety and effectiveness for them. Since older bodies metabolize and respond to drugs differently, results generated from studies of younger subjects are not necessarily interchangeable.
We should enroll older people, especially those with multiple health conditions, in clinical research. Older patients should also consider participating in "clinical registries," which make no changes in their care and involve no experimental drugs, but simply add their health statistics anonymously to a research database. And pain should be measured as an outcome of great interest in all research on new therapeutic agents.
Non-drug options for managing chronic pain
Finally, many older patients and their families want to know what can be done without drugs. The answer is, quite a bit. Chronic pain, like any chronic disease, is best tackled by an empowered and informed patient.
For example, it might be suitable for patients who experience chronic pain to find an appropriate supervised activity program, such as yoga or tai ch'i at a senior center or other community organization, and get moving. Programs such as Stanford University's Chronic Disease Self-Management program offer peer support and coaching, and increase one's ability to manage chronic pain successfully. A version of the program called Better Choices, Better Health is available nationwide.
Patients and their families can help educate their doctors about the possible power of exercise and self-management as a means of managing pain and might suggest they prescribe it to their patients.
The mind and the body both play an important role. As M. Cary Reid, M.D., Ph.D., a researcher working on improving pain management options for older adults at Weill Cornell Medical Center, and recipient of the Paul B. Beeson Career Development Award in Aging Research, puts it, "I have seen the truth of the old saying that 'the best analgesic is an occupied mind.' My patients convince me of it every week."