Illustration by Sara Andreasson for HuffPost
This story is part of Pain in America, a nine-part series looking at some of the underlying causes of the opioid addiction crisis and how we treat pain.
With age comes pain. Whether caused by injury, arthritis, cancer or any number of conditions, persistent pain affects up to four out of every five people age 65 and older.
While many turn to opioids and other medications, their risks, including the potential for abuse and overdose, are well known. Less well known (at least among the general public) are the added issues older adults can face when taking these drugs.
“The older you are, the more likely you are to develop an adverse side effect from a pain medication,” said Cary Reid, associate professor of medicine in the division of geriatric and palliative medicine at Weill Cornell Medicine and director at Cornell’s Translational Research Institute on Pain in Later Life (TRIPLL).
Those side effects, such as confusion and a heightened risk of falls, can be severe and can make doctors hesitant to prescribe pain medications to older adults. These drugs can also take longer to metabolize with age, meaning they can be more potent or stay in an elderly person’s system longer than expected. And because many older adults take other medications too, there’s also the risk of problematic drug interactions.
With the number of American seniors expected to almost double by 2060 — to nearly a quarter of the population — this all adds up to a growing need to find alternative treatments.
That’s where researchers like those at TRIPLL come in. One of 13 Roybal Centers that the U.S. government’s National Institute on Aging has funded to improve the lives of older Americans, TRIPLL focuses on nondrug approaches to managing and preventing chronic pain.
It’s casting a wide net, looking into alternatives that range from acupuncture and meditation to physical therapy, cognitive behavioral therapy and even mobile technologies.
Reporting Pain With Digital Health Technology
In one TRIPLL-funded project, Elizabeth Murnane, a postdoctoral scholar in the computer science department at Stanford University, and a team of researchers developed smartphone-based technology that adults 55 and older can use to self-report the intensity of chronic pain. The idea is to capture information about pain as it happens without burdening the patient, while serving as an alternative to pen-and-paper and verbal self-reporting measures commonly used in clinical settings or at-home methods that often suffer from low adherence or misreporting.
The test used nine different measures to capture the patient’s experience of pain, including a circle that fills with color when the interface is touched, and a widget for reporting pain with a numerical range of 0 to 10 that can be adjusted by tapping the screen. Early testing revealed some usability issues for older adults with low digital skills or motor, cognitive and visual impairments, so the researchers changed the design to be more touch and pressure-oriented, “in part motivated by how we’d sometimes observe our participants instinctually grasping the hand of a loved one or a chair or other object nearby in moments of pain,” Murnane explained.
Now Murnane and her collaborators are working on a pain assessment tool that examines rhythms of pain intensity.
Many factors can influence the experience of pain — age, gender, genes and how much sleep a person needs (and how much they actually get), Murnane said. “Healthy functioning and synchronization of the circadian system is known to deteriorate with age, contributing to a vicious cycle of sleep disruption and exacerbated pain in older adults.”
The researchers hope the data can be used to advance the basic understanding of pain and how it manifests in everyday life — behaviorally, psychologically and physiologically — as well as to design new tools for pain monitoring and management. For example, they hope to discover digital biomarkers of pain, which are bits of data collected with digital devices and wearables like smartwatches that can be used to explain or predict the presence of illness or disease. In Murnane’s case, these markers could be someone’s degree of forward flexion or how far they’ve walked on an inclined path, which researchers expect would correlate with pain severity, she said.
Emotion Regulation Therapy
Negative emotions are also associated with chronic pain — typically, the more depression, anger, negativity and irritability that a patient feels, the more pain they report experiencing, Reid explained.
Weill Cornell Medicine psychologist Dimitris Kiosses and a multidisciplinary team of researchers have been working on a psychosocial treatment called “problem adaptation therapy” that aims to provide elderly patients suffering from chronic pain with techniques — like deep breathing, relaxation and changing their perspective on a situation — to decrease the impact of negative emotions and increase the impact of positive ones.
“The goal there is to have people recognize the kinds of emotions they experience and to develop strategies to minimize negative emotions, because research has demonstrated a strong link between negative emotions and increased pain and pain-related disability,” Reid said.
Barbara Chase, an 81-year-old New York City resident, learned valuable techniques for managing chronic back and nerve pain she experiences from Parkinson’s disease by participating in this program. She’s never liked taking medicine, she said, and is amazed by how helpful some nondrug alternatives — like listening to music and relaxing her body and mind — can be in managing pain. Chase now likes to go to the gym, turn off the lights, and listen to music through her phone while stretching and doing other movement exercises, which she says takes her to another place.
“It makes me relax and I just forget,” Chase said. “I don’t think about it.”
Relaxing by lying on the floor, closing her eyes, and spreading out like a bird has a similar effect, she said, adding that she can often feel her pain coming on ahead of time, and now knows to use these emotion-regulation techniques to get rid of it.
“It’s amazing,” she said. “And it’s free.”
Behavioral Treatment For Older Adults With HIV
Older adults with HIV are a growing population with high rates of chronic pain and substance use, and decreased physical function. To address these issues, researchers supported by TRIPLL developed an eight-week behavioral pilot study in 2016 that incorporated weekly tai chi and cognitive behavioral therapy sessions and used text messaging to facilitate behavior change.
Results from a small randomized control trial were positive — participants who took part in the CBT, tai chi and texting program experienced more pain relief, reduced substance use and improved physical performance compared to a control group who received standard care. Now the researchers are trying to obtain funding from the National Institutes of Health to support a similar but much larger trial.
Looking To The Future
Because many clinicians were trained to manage pain primarily with medication, educating them about nondrug approaches to pain management can be difficult, Reid said.
Another challenge is getting insurers to cover nonpharmacological pain management techniques, and without insurance coverage, many treatments become inaccessible for patients who can’t afford the out-of-pocket costs.
Even finding places that offer those alternatives can be tough. “It’s often difficult in New York City, and if it’s difficult in New York City, imagine what it must be like if you’re living in a very rural state,” Reid said. “We’ve got to enhance the availability and dissemination of these kinds of tools.”