Philip Chan, MD, FRCPC (Anesthesiology, Pain Medicine), FIPP,

CLINICAL TOOLS

• Abstract
• Visual Aids
• Key Points
• Clinical Pearls
• Premium Content

Abstract: There is increasing concern in Canada about the overuse and misuse of opioids. While there are no simple answers to this complex societal problem, adequate and timely access to proper multidisciplinary chronic pain care is important in decreasing the reliance on opioids when treating chronic pain in Canada. Neuromodulation therapy, especially spinal cord stimulation (SCS), offers patients the potential for pain relief without repeated injections or ongoing medication use. SCS is effective in the treatment of persistent postoperative neuropathic pain and complex regional pain syndrome. Prospective SCS candidates should undergo a full multidisciplinary assessment to evaluate both physical and psychological factors that may adversely affect results.

Key Words: chronic pain, spinal cord stimulation, opioids, neuropathic pain, persistent postoperative neuropathic pain.

• 
• 
• 

The best studied indications for SCS are persistent postoperative neuropathic pain (so-called failed back surgery syndrome [FBSS]) and complex regional pain syndrome (CRPS).

The key to success with SCS is to generate a pattern of paresthesia that overlaps with the patient’s area of pain while avoiding extraneous paresthesia that may cause discomfort.

SCS is a cost-effective treatment, whereby the long-term savings in terms of diagnostic imaging, physician visits, medications, and rehabilitative services outweighed the higher upfront cost.

Contraindications for SCS implantation include: systemic infection, cognitive impairment, and low platelet counts.

Well-accepted positive predictive factors for long-term success with SCS include: patients whose etiology of pain have a predominately peripheral neuropathic pain component, treatment early in the course of the pain syndrome, and the presence of allodynia and other features suggestive of neuropathic pain. Significantly depressed mood, low energy levels, somatization, anxiety, and poor coping skills are important predictors of poor outcome.

SCS is a non-destructive procedure; the device can be explanted at any point if it no longer provides pain relief, and it does not preclude other treatment modalities, including spinal surgery, in the future.

To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.

Eric Widera, MD, Division of Geriatrics, University of California at San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
Alex Smith, MD, Division of Geriatrics, University of California at San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.

This article highlights the complex challenges seen when managing pain in patients with moderate or advanced dementia. Recent evidence demonstrates that pain is often poorly recognized and treated in patients with cognitive impairment. The progressive decline in cognitive function often leads to difficulties in expressing and recalling painful experiences. Making pain assessments routine and combining patient reports, caregiver reports, and direct observation may help alleviate this poor recognition of pain. Once pain is confirmed, a comprehensive history and physical examination are central in determining the underlying cause of pain and in choosing the best modality to treat the pain.
Key words: dementia, cognitive impairment, pain, opioids, assessment.

Marc Ginsburg, RN, MScN, NP, Medical Student, University of Sint Eustatius School of Medicine, Sint Eustatius, Netherlands-Antilles.
Shawna Silver, MD, PEng, Resident, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON.
Hershl Berman, MD, FRCPC, Assistant Professor, Faculty of Medicine, University of Toronto; Staff Physician, Department of Medicine, University Health Network; Associated Medical Services Fellow in End-of-Life Care Education, University of Toronto; Centre for Innovation In Complex Care, University Health Network, Toronto, ON.

The use of opioid medications and converting among them in the older adult population can often be challenging. Physiological changes in older adults may affect metabolism and cognitive abilities. Due to renally cleared metabolites, some opioids, such as morphine, should be used with caution among older adults. Others, such as meperidine, should never be used at all. When prescribing or changing opioids, the choice of the correct formulation, appropriate counselling, and close follow-up are essential for optimal pain management and in order to prevent adverse outcomes.
Key words: opioids, pain management, older adults, analgesia, opioid conversion.

Hershl Berman, MD, FRCPC, Assistant Professor, University of Toronto Faculty of Medicine, Department of Medicine, University Health Network, Toronto, ON.
Laura Brooks, RegN, MscN, APN, Advanced Practice Nurse in Palliative Care, Department of Psychosocial Oncology and Palliative Care, University Health Network, Toronto, ON.
Shawna Silver, MD, PEng, Hospital for Sick Children; University of Toronto, Toronto, ON.

Constipation is a common complaint, especially in older adults. It results in millions of physician visits per year, with hundreds of millions of dollars spent on laxatives. Untreated it can lead to serious morbidity and can be a contributing factor in mortality. A rational approach to the patient presenting with constipation includes a detailed history, general and focused physical examination, specific investigations, and appropriate therapy. Treatment should aim to address the underlying cause, as should the choice of laxative. In general, it is best to clear out hard stool in the distal bowel before using an aggressive oral regimen.
Key words: constipation, laxatives, older adults, opioids.

Deborah Dillon McDonald, RN, PhD, Associate Professor, University of Connecticut School of Nursing, Storrs, CT.

Older adults experience moderate to severe postoperative pain during and after their hospital stay. Preoperative education about pain management decreases postoperative pain. Postoperative pain management should generally include concurrent treatment of pre-existing chronic pain problems and a multimodal approach that incorporates postoperative opioids, nonopioids, and nonpharmacologic pain treatments. Opioids should be started at 25-50% of the adult dose and titrated until pain is reduced to a mild level. Older adults should be monitored closely to prevent side effects from opioid accumulation. A consistent pain scale that the older adult understands should be used to evaluate the pain response.
Key words: postoperative pain, pain assessment, opioids, nonopioids, nonpharmacologic treatments.

Hershl Berman, MD, FRCPC, Department of Internal Medicine, Department of Psychosocial Oncology and Palliative Care, University Health Network, Toronto, ON.
Shawna Silver, BASc, PEng, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON.

Pain in the older adult can present unique challenges. Cognitive impairment and polypharmacy can make assessment and treatment difficult. An interdisciplinary team that includes family caregivers is essential. A rational approach to the ambulatory older patient with nociceptive pain would be to begin with regularly dosed acetaminophen, then add an NSAID if appropriate. The next step would be to add a low-dose opioid. If the patient uses a sufficient quantity of the opiate, dosing should be spread out throughout the day. Once a stable dose is reached, one can use a sustained-release formulation. Nonopioids should be continued throughout the titration process.
Key words: pain, analgesia, opioids, older adult, pain assessment.

Paul J. Christo, MD, Assistant Professor; Director, Pain Treatment Center & Multidisciplinary Pain Fellowship, Division of Pain Medicine, Department of Anesthesiology and Critical Care, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Greg Hobelmann, MD, Postdoctoral Fellow, Division of Pain Medicine, Department of Anesthesiology and Critical Care, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Amit Sharma, MD, Postdoctoral Fellow, Division of Pain Medicine, Department of Anesthesiology and Critical Care, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. *Current Address: Assistant Professor, College of Physicians & Surgeons of Columbia University, New York, NY.

Jacqueline Gardner-Nix, MBBS, PhD, MRCP(UK), Assistant Professor, Department of Anaesthesia, University of Toronto; Chronic Pain Consultant, Sunnybrook & Women’s College Health Sciences Centre; St. Michael’s Hospital Pain Clinic, Department of Anaesthesia, Toronto, ON.

Older adults pose additional challenges in pain management when noncancer pain has become chronic. Health care professionals are increasingly aware of the effect of past and current life stressors on the pain experience, and the roles of gender, genetics and culture. Reduced activity as individuals age often amplifies the disabling effects of pain. Pain medications are more problematic in this age group due to many factors, including polypharmacy, comorbidities and reduced renal function. However, judicious use of opioid analgesics in a subset of the population may allow increased function and access to activities, which become part of their pain management.
Key words: older adults, opioids, pain management, noncancer pain, holistic.