Figure:

A health care provider reviews medications with a family caregiver and his partner. Photo courtesy of the AARP Public Policy Institute.

For health care providers, family caregivers, and care recipients, treating chronic pain while balancing concerns about adequate pain relief, functional improvement, and harm avoidance can be challenging. When lower-risk treatment approaches (such as acetaminophen, topical medications, heat or cold, and massage) don't sufficiently alleviate older adults' pain, riskier treatments (such as nonsteroidal antiinflammatory drugs [NSAIDs], adjuvant analgesics, opioids, and interventional procedures) may be needed. This article discusses evidence-based, higher-risk strategies to control chronic pain and considerations for caregiver involvement in treatment planning and monitoring. (See “Managing Older Adults' Chronic Pain: Lower-Risk Interventions,” February, for a description of the use of lower-risk strategies.)

BACKGROUND

The prevalence of chronic pain increases with age, affecting 28% of adults ages 65 to 84 years and 34% of those 85 and older, with high-impact chronic pain (chronic pain that regularly limits daily activities) affecting the latter more than any other age group.1 Chronic pain impairs older adults physically, mentally, and socially; diminishes general health, biopsychosocial functioning, and longevity; and accelerates brain aging.2, 3 Older adults are also more likely to transition from acute pain to chronic, disabling, treatment-resistant pain due to neuroimmune changes seen with aging.4 People with chronic pain face stigma and discrimination and are increasingly denied access to treatment.5, 6

Family caregivers often handle medical and nursing tasks for the person they care for, often assisting with pain management.7 Bearing witness to the care recipient's pain is stressful for most caregivers, who also worry about administering pain medication.7 To ease the burden of care, nurses can promote caregivers' pain management knowledge and self-efficacy.8 They can also help caregivers develop routines to promote safe pain management and educate them on recognizing and reporting undesired treatment effects. This counseling should address the caregiver and care recipient's concerns and build on their existing knowledge and strengths. Additionally, nurses can offer suggestions (such as dose timing) to minimize adverse effects during the titration, therapeutic, and tapering phases of medication use.

TREATMENT PLANNING

Treatment plans for severe chronic pain should integrate self-management and lower-risk methods while safely exploring higher-risk therapies until an optimal treatment regimen is established. When considering higher-risk therapies, it is crucial for health care providers to review the limitations of lower-risk treatments with the care recipient and caregiver and use shared decision-making to establish achievable therapeutic goals. Risks, benefits, and trade-offs should be discussed based on how pain or its treatment affects the person's well-being and engagement in what matters to them. Concerns about barriers to access must also be addressed.

Traditional approaches to treating severe, persistent pain typically start with nonopioids and restorative therapy; then weak opioids, adjuvant treatments, and/or invasive procedures; and finally stronger opioids and/or other higher-risk therapies. However, individualized regimens for treating persistent pain in older adults are needed, given the American Geriatrics Society Beers Criteria recommendations to avoid drug–disease interactions, chronic NSAID use, and many common adjuvant analgesics in this population.9 In exploring higher-risk therapies, health care providers should consider the older adult's overall health, biopsychosocial functioning, comorbidities, and pain type; other medications they take; and the caregiver's ability to recognize and respond to adverse effects. The person's prior responses to pain medications, whether they were used alone or in conjunction with other medications, should also be reviewed, with the caveat that aging increases sensitivity to both desired and undesired medication effects.10 Thus, a previously ineffective medication may become effective in the older adult, whereas a previously tolerated medication may subsequently be unsafe or harmful.

Medication combinations are riskier in older adults, so multimodal therapy using three or more central nervous system (CNS)–active drugs (such as opioids, anticonvulsants, hypnotics, and antidepressants) should be avoided.9, 10 Polypharmacy is a key safety concern; medication discontinuation or dose reduction should be considered before a new medication is added. Each medication should be prescribed at its lowest effective dose with periodic evaluations of its continued necessity. Although a single low-dose medication is ideal, multimodal regimens with up-titrated doses are often needed.

Research establishing analgesic effectiveness, which often excludes older adults, shows that medications have a small to moderate effect on chronic pain relief.2, 11, 12 Interventional approaches offer partial, temporary relief for many, but may present risks for older adults.10 The care recipient and caregiver may need counseling to adjust expectations to realistically balance pain reduction (not elimination) with better physical and mental functioning and the avoidance of harm.

Family caregivers may possess fears and misconceptions about pain treatment; they may also have different beliefs than the care recipient or health care team about issues such as the appropriateness of treatment.13 This may undermine treatment adherence if not recognized and addressed. Nurses can help caregivers align their values and expectations regarding pain treatment and facilitate conflict resolution with other health care professionals.

HIGHER-RISK MEDICATIONS FOR TREATING CHRONIC PAIN

Nonopioid analgesics. NSAIDs such as ibuprofen, naproxen, and meloxicam are identified by the Beers Criteria as potentially inappropriate for older adults.9 Sustained NSAID use has been linked to gastrointestinal, renal, and cardiovascular events,12 and NSAIDs account for more hospitalizations of older adults for adverse events than other analgesics.14 Gastroprotective therapies, like proton pump inhibitors, can be helpful in conjunction with NSAIDs, but carry their own risks (bone loss, fractures, Clostridium difficile infections) without lowering cardiovascular or renal risks.15 Nurses should reinforce the need to monitor vital signs, laboratory tests, and early signs of harm from ongoing NSAID use. The analgesic ceiling effect—in which increases in dose don't produce increases in pain relief—should also be discussed, as a two-week trial at a lower dose may result in the same relief with less risk of harm.

Adjuvant analgesics. Antidepressants with analgesic properties, including tricyclic antidepressants such as nortriptyline or desipramine, which have fewer cardiac and anticholinergic effects, or serotonin–norepinephrine reuptake inhibitors (SNRIs) such as duloxetine or venlafaxine, may be considered in treating some older adults' pain.16, 17 It is important to note, however, that antidepressants used to treat pain have substantial potential for harm, including cognitive adverse effects, nausea, and sedation with SNRIs, and cardiac arrythmias, cognitive effects, weight gain, and urinary retention with tricyclics.12 SNRIs should be avoided in older adults with a history of falls or fractures, and amitriptyline should be avoided because of its strong anticholinergic effects.9

Anticonvulsants, such as gabapentin and pregabalin, can relieve specific types of pain (neuropathic or widespread), but their adverse effects (dizziness, somnolence, and edema) prevent many from reaching the dose and duration needed for appreciable pain control.18 Older anticonvulsants such as carbamazepine are unsuitable for older adults owing to their potential for drug interactions, hyponatremia, and toxicity.9 Muscle relaxants or antispasmodics are often used for pain, but they also have dose-limiting side effects, with tizanidine preferred for most older adults.19

Many adjuvant analgesics have associated withdrawal syndromes if doses are skipped, lowered, or abruptly discontinued; thus, a medically supervised taper plan is advised.12, 20

Opioid analgesics. While the potentially fatal or life-changing harms associated with opioids (such as oxycodone, fentanyl, and tramadol) have been widely publicized, less attention has been paid to their ability to provide relief and improve functioning when other pain treatments have been unable to. Reports associating opioids with addiction and overdose deaths often fail to distinguish therapeutic use from misuse or recreational use. In the past decade, opioid prescribing in the United States declined by 43%, while fatal opioid overdoses more than doubled.21 In 2019, over 80% of overdose deaths resulted from illicit drug use or drug combinations, rather than from a prescribed opioid alone.22

For most people, opioid effectiveness wanes over time as the patient develops tolerance, and risks of adverse effects increase at higher doses and with a longer duration of therapy.11 A subset of opioid recipients tolerate common adverse effects while reporting less pain and disability with stable doses beyond six months of therapy.23

In older adults, opioids initially increase the risk of falls and other injuries. Caregivers of older adults prescribed opioids should avoid potentially hazardous physical activities, alcohol, and opioid use with other CNS-active drugs.9 Caregivers may also have insights to share with health care providers on impairments (visual, memory), comorbidities (sleep apnea, psychiatric instability), and medication use (herbal, nonprescription, and prescription drugs) that may raise safety concerns regarding opioid use. If opioids are deemed medically necessary, caregivers, care recipients, and health care providers should discuss concerns about adverse effects, misuse, and opioid use disorder.

Although fatal opioid overdoses occur less often among older adults, it is crucial to educate caregivers on risk mitigation, including which adverse effects or behavioral changes (craving, misuse) to monitor for and report, and which warrant immediate attention.22 Nurses should emphasize safe opioid use—specifically, using the medication exactly as prescribed—as well as secure storage and proper disposal. Nurses can also review environmental safety and security measures to reduce the risk of coercion or theft by others seeking to misuse opioids.

The Centers for Disease Control and Prevention's opioid prescribing guidelines advises reevaluating risks and benefits during the first month of opioid therapy, then every few months thereafter, to ensure that the treatment response is aligned with realistic comfort and function goals.24 If chronic opioid therapy needs to be tapered or discontinued, a mutually established, medically supervised plan should be used to minimize the risk of mental health crises or suicidality.25

INTERVENTIONAL PROCEDURES

When medication fails or is inappropriate, interventional approaches, such as steroid injections, surgery, and implanted nerve stimulators, can be used to treat pain in older adults.26 These interventions require appropriate patient selection, skilled professionals to perform with precision, and ongoing vigilant monitoring.

Safeguards for older adults undergoing interventional procedures for pain include evaluating anticoagulation status and comorbidities, limiting procedural sedation, and taking steps to prevent infections.10, 27, 28 Additionally, for certain steroid injections, it is recommended that image guidance and nonparticulate steroids be used.27 Nurses should discuss with caregivers how interventional procedures may affect the older adult's daily activities and provide information on postprocedure care and follow-up.

Newer spinal cord stimulator technologies for back and leg pain and less invasive neuromodulators hold promise to control pain while reducing the need for analgesics.26 Reimbursement limitations are barriers to accessing many of these therapies, so working with case managers or advocacy groups may be required.

CAREGIVER ENGAGEMENT

Caregivers play a key role in helping to implement and refine the treatment plan, including monitoring therapy adherence and safety, tracking treatment effects, facilitating dose and medication transitions, and seeking professional guidance when needed. Nurses should reinforce with caregivers that establishing the safest, most effective plan may necessitate several trials of various therapies. Pain interventions typically provide partial, temporary relief, and their full effect may take months to become apparent.12 Even after an effective plan is implemented, caregivers must still monitor for changes to the care recipient's condition and the effects of treatment; this can facilitate ongoing refinement of treatment goals and strategies.

To optimize overall health and quality of life, nurses can encourage caregivers to use a daily written or digital treatment response log (see Figure 1) to monitor desired and undesired effects. The health care team can review the log with the caregiver and care recipient at appointments and use it to guide decisions about what treatments to continue, discontinue, or change. The caregiver can also use the log to record each administered medication—including the dose and day and time it was given—to ensure doses are not missed or accidentally doubled. (Although treatment response logs typically contain medication information, a separate medication log may also be used.)

Figure 1.:

Treatment Response Log Template

Communication platforms available in some health care settings, such as MyChart, can facilitate patient–provider communication and expedite evaluation and refinement of the treatment plan. Additionally, smartphone pain management apps and watch-based sensing technology apps can be used to capture health data to share with the health care team.29, 30

RESOURCES FOR CLINICIANS AND CAREGIVERS

Visit https://geriatricpain.org/higher-risk-pain-treatments for additional details on the treatment strategies described in this article. Nurses can refer family caregivers to the tear sheet, Information for Family Caregivers, for tips on safely using higher-risk pain control approaches and links to other resources.

Box 1:

Information for Family Caregivers

Resources for Nurses Higher-Risk Treatments for Managing Pain https://links.lww.com/AJN/A244

Note: Family caregivers can access this video, as well as additional information and resources, on AARP's Home Alone Alliance web page: www.aarp.org/nolongeralone.

REFERENCES 1. Dahlhamer J, et al. Prevalence of chronic pain and high-impact chronic pain among adults—United States, 2016. MMWR Morb Mortal Wkly Rep 2018;67(36):1001–6. 2. Domenichiello AF, Ramsden CE. The silent epidemic of chronic pain in older adults. Prog Neuropsychopharmacol Biol Psychiatry 2019;93:284–90. 3. Hung PS, et al. Differential expression of a brain aging biomarker across discrete chronic pain disorders. Pain 2022;163(8):1468–78. 4. Paladini A, et al. Chronic pain in the elderly: the case for new therapeutic strategies. Pain Physician 2015;18(5):E863–E876. 5. Booker SQ, et al. Interrupting biases in the experience and management of pain. Am J Nurs 2022;122(9):48–54. 6. Lagisetty PA, et al. Access to primary care clinics for patients with chronic pain receiving opioids. JAMA Netw Open 2019;2(7):e196928. 7. Reinhard SC, et al. Home alone revisited: family caregivers providing complex care. Washington, DC: AARP Public Policy Institute; 2019. https://www.aarp.org/content/dam/aarp/ppi/2019/04/home-alone-revisited-family-caregivers-providing-complex-care.pdf. 8. Kizza IB, Muliira JK. Determinants of quality of life among family caregivers of adult cancer patients in a resource-limited setting. Support Care Cancer 2020;28(3):1295–304. 9. American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2019;67(4):674–94. 10. Schwan J, et al. Chronic pain management in the elderly. Anesthesiol Clin 2019;37(3):547–60. 11. Chou R, et al. Opioid treatments for chronic pain: comparative effectiveness review, no. 229. Rockville, MD: Agency for Healthcare Research and Quality; 2020. AHRQ comparative effectiveness reviews (report no.: 20-EHC011). https://www.ncbi.nlm.nih.gov/pubmed/32338848. 12. McDonagh MS, et al. Nonopioid pharmacologic treatments for chronic pain: comparative effectiveness review, no. 228. Rockville, MD: Agency for Healthcare Research and Quality; 2020. AHRQ comparative effectiveness reviews (report no.: 20-EHC010). https://www.ncbi.nlm.nih.gov/books/NBK556277. 13. Shalev A, et al. The prevalence and potential role of pain beliefs when managing later-life pain. Clin J Pain 2021;37(4):251–8. 14. Oscanoa TJ, et al. Hospital admissions due to adverse drug reactions in the elderly. a meta-analysis. Eur J Clin Pharmacol 2017;73(6):759–70. 15. Maes ML, et al. Adverse effects of proton-pump inhibitor use in older adults: a review of the evidence. Ther Adv Drug Saf 2017;8(9):273–97. 16. National Comprehensive Cancer Network. Adult cancer pain; 2022 Jun 27. Version 2.2022. NCCN clinical practice guidelines in oncology (NCCN Guidelines). 17. Riediger C, et al. Adverse effects of antidepressants for chronic pain: a systematic review and meta-analysis. Front Neurol 2017;8:307. 18. Chiu T, et al. Patterns of pregabalin initiation and discontinuation after its subsidy in Australia. Br J Clin Pharmacol 2020;86(9):1882–7. 19. Fu JL, Perloff MD. Pharmacotherapy for spine-related pain in older adults. Drugs Aging 2022;39(7):523–50. 20. Marsden J, et al. Medicines associated with dependence or withdrawal: a mixed-methods public health review and national database study in England. Lancet Psychiatry 2019;6(11):935–50. 21. Alexander GC, et al. Effect of reductions in opioid prescribing on opioid use disorder and fatal overdose in the United States: a dynamic Markov model. Addiction 2022;117(4):969–76. 22. O'Donnell J, et al. Vital signs: characteristics of drug overdose deaths involving opioids and stimulants—24 states and the District of Columbia, January-June 2019. MMWR Morb Mortal Wkly Rep 2020;69(35):1189–97. 23. Bialas P, et al. Efficacy and harms of long-term opioid therapy in chronic non-cancer pain: systematic review and meta-analysis of open-label extension trials with a study duration >/=26 weeks. Eur J Pain 2020;24(2):265–78. 24. Dowell D, et al. CDC clinical practice guideline for prescribing opioids for pain—United States, 2022. MMWR Recomm Rep 2022;71(3):1–95. 25. Agnoli A, et al. Association of dose tapering with overdose or mental health crisis among patients prescribed long-term opioids. JAMA 2021;326(5):411–9. 26. Deer TR, et al. Passive recharge burst spinal cord stimulation provides sustainable improvements in pain and psychosocial function: 2-year results from the TRIUMPH study. Spine (Phila Pa 1976) 2022;47(7):548–56. 27. Abrecht CR, et al. A contemporary medicolegal analysis of outpatient interventional pain procedures: 2009-2016. Anesth Analg 2019;129(1):255–62. 28. Goel V, et al. Procedure-related outcomes including readmission following spinal cord stimulator implant procedures: a retrospective cohort study. Anesth Analg 2022;134(4):843–52. 29. MacPherson M, et al. Do pain management apps use evidence-based psychological components? A systematic review of app content and quality. Can J Pain 2022;6(1):33–44. 30. Ross EL, et al. Clinical integration of a smartphone app for patients with chronic pain: retrospective analysis of predictors of benefits and patient engagement between clinic visits. J Med Internet Res 2020;22(4):e16939.