Handbook of Pain Relief in Older Adults (Aging Medicine)

283 Pages·2003·4.59 MB·English

by  F. Michael Gloth III

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Handbook of Pain Relief
in Older Adults
A M
GING EDICINE
Handbook of Pain Relief in Older Adults: An Evidence-Based Approach,
edited by F. Michael Gloth, III, 2004
Handbook of Pain Relief
in Older Adults
An Evidence-Based Approach
Edited by
F. Michael Gloth, III, ,
MD FACP
Johns Hopkins University School of Medicine, Baltimore MD
and Victory Springs Senior Health Associates, Reisterstown, MD
© 2004 Humana Press Inc.
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Library of Congress Cataloging in Publication Data
Handbook of pain relief in older adults : an evidence-based approach /edited by F. Michael Gloth, III.
p. ; cm. -- (Aging medicine)
Includes bibliographical references and index.
ISBN 1-58829-217-7 (alk. paper)
1. Pain in old age--Handbooks, manuals, etc. 2. Analgesia--Handbooks, manuals, etc.
[DNLM: 1. Pain--therapy--Aged. 2. Pain--diagnosis--Aged. 3. Pain--prevention & control--Aged. WL 704
H24376 2004] I. Gloth, F. Michael. II. Series.
RB127.H357 2004
618.97--dc21
2003008442
Preface
As one reads this, it should be recognized that many people are aggressively
involved in efforts to eliminate pain and suffering. The Handbook of Pain Relief in
Older Adults provides useful information from some of the leading experts in the
pain field from around the United States. The information is based on evidence that
has been gleaned from the scientific literature or from the research of the respective
authors. Where data are inadequate to form definitive conclusions, the text incorpo-
rates what is based on solid evidence and expert opinion, assimilating the knowl-
edge from the rich clinical experience available to the authors along with the
available clinical research experience.
The pain field is changing rapidly, and new interventions are becoming avail-
able continuously. However, the guiding principles of the Handbook of Pain Relief
in Older Adults will persist long after the pages on the text are worn and frayed. An
integral component of this work is the recognition that pain can always be treated
and that treatment will be most effective when the etiology for the pain is under-
stood. In addition to treatment for pain, we cannot overlook the importance of inter-
ventions to prevent or minimize the onset of pain. Pain assessment must be a
primary focus of any care plan aimed at managing pain.
Pain affects people from all walks of life and, so too, all walks of life must be
included in endeavors to eradicate pain. Medications and medical science are only
a small part of the equation for controlling pain in our society. I am confident that
anyone who reads the Handbook of Pain Relief in Older Adults will identify new
strategies for helping to provide comfort and dignity for those who suffer from
pain.
Finally, it is important to publicly acknowledge and thank those who contributed so
much to allowing this book to become a reality. Mr. Thomas Moore, who recognized
the need for such a text and my ability to complete such an endeavor, has certainly
earned my gratitude. Additionally, all of the contributing authors, without whom this
text would have never become a reality, also have my unending gratitude. To my
incredibly supportive parents and siblings who have always exemplified compas-
sion, caring, integrity, and pursuit of knowledge as a tool for spreading God’s love,
I can’t extend enough appreciation. My wife, Maybian, and all of my children, who
have allowed me to experience some small piece of heaven while on earth, I thank
for their inexhaustible support. Finally, I must thank everyone at Victory Springs
Senior Health Associates, who provided so much coverage and support as this book
was being written. I am truly blessed to have the privilege of working with such
v
vi Preface
wonderful friends. Let me also especially acknowledge in print my everlasting grati-
tude to Sherry Buchman, whose untiring efforts, integrity, and dedication have
helped more people than I can count to have better lives. I am blessed to be one of
those people.
F. Michael Gloth, III, MD, FACP
Introduction
F. Michael Gloth, III, MD, FACP
The greater the ignorance, the greater the dogmatism.
—Sir William Osler
For many physicians the reason to enter medicine was primarily motivated by a
desire to relieve suffering. Pain is often a key component of suffering and, as such,
has been defined in many ways. The International Association for the Study of Pain
defines “pain” as “an unpleasant sensory and emotional experience associated with
actual or potential tissue damage, or described in terms of such damage or both”(1).
There are many subclasses that have been proposed (e.g., acute, chronic, or persis-
tent). There have also been suggestions that pain be described in such terms as
visceral, neuropathic, nociceptive, psychological, musculoskeletal, psychosomatic,
and so on. Some of these terms are used in this text as well. Such terms are useful
only if they help to describe the etiology of the pain or discomfort, and, thus, facili-
tate treatment. Another area of frequently inordinate expenditures of discussion
time in the literature involves the terms opioids and opiates. Opioid is defined as,
“Designating synthetic narcotics that resemble opiates in action but are not derived
from opium” (2). Therefore, drugs like fentanyl, hydrocodone, and oxycodone are
classified as opioids, whereas morphine would be an opiate. For the sake of sim-
plicity, we use the term opioid for both. Because of the negative connotation of the
term narcotic in association with illicit drug use, that term is avoided throughout
this text, and it is recommended that it not be used in clinical practice. Regardless
of the terminology chosen, pain of longer duration and/or of an unremitting nature
has the potential to wear down an individual in every conceivable way, including
emotionally, physically, spiritually, and socially.
Regrettably, data indicate that all too often, health care professionals fail in re-
solving pain, one of the clearest factors associated with suffering (3,4). This is
especially true when the person in pain is an older adult. Saying “I feel your pain,”
reflects only part of the solution, for simply knowing that pain exists is not suffi-
cient. There must also be proper assessment, and, of course, proper intervention
Even this approach is incomplete. To be complete, there must also be attention to
prevention of pain as well. The Handbook of Pain Relief in Older Adults was writ-
ten to provide a comprehensive approach to relieving suffering in older adults
through relief of their pain.
Through an evidence-based approach, the contributors provide information on
the scope of the problem, insight into assessing pain status, and practical guidance
vii
viii Introduction
for treatment. Somewhat unique is the discussion of steps to prevent pain in seniors.
It is not adequate for caregivers to act after pain has developed. Rather, efforts must
be made to prevent, or at least minimize, pain when circumstances that are likely to
produce this devil are identifiable. This text addresses many of the standard issues
in pain management. Most importantly, however, is the effort to address other as-
pects of pain. There is not only a fairly critical analysis of the issues around assess-
ment, but also other factors, which have not had adequate attention in the pain field
and elsewhere, are also addressed. Dr. Mulligan’s team, for example, provides use-
ful insight into the role of spirituality as an adjunct to pain management. The poten-
tial of using the internet and computerized patient records to foster improved care
is also addressed.
The recognition that direct efforts targeted at pain management comprise only
part of the approach to pain resolution has moved this text up to the next level in
literary efforts aimed at controlling pain. Other indirect factors, such as availability
of resources and excessive regulation, are of paramount importance in achieving
success in the war against pain. For the older adult, where Medicare is only one of
the regulatory agencies overseeing care, the process can be more challenging, since
well-intended regulations are sometimes responsible for inflicting more pain than
they resolve. The impact of legislation and public policy must also be appreciated
in an even broader sense with the older adult. When clinicians are unimpeded by
laws and regulations, it is likely that pain relief will become tenable.
Other strategies must also recognize patient autonomy and that patients in pain
will independently struggle for more information and, hopefully, more relief. The
chapter devoted to internet resources and electronic medical records should prove a
valuable addition for clinician as well as patient. Helping patients and caregivers to
advocate for adequate pain management is also addressed in the later chapters. It is
recognized that all clinicians cannot be experts. It is important for individuals to
recognize that if adequate pain relief is not obtained, there are other options, which
may include other physicians. Hopefully, such referrals can be directed by primary
care clinicians with appropriate understanding and humility to make those referrals
early and often.
The politics of pain management are addressed as well as the impact of the media.
The politics of pain are by no means confined to legislation debated on Capitol Hill
nor at state capitols throughout the country (or in any other country for that matter).
The politics of pain ensnares even the most ardent pain management advocate and
the discussion of this issue should help in the battle to provide better pain relief
everywhere. How this plays out in the media is not always under control. At times,
media resources not only contribute to poor pain management, but as later chapters
illustrate, may actually exacerbate pain, albeit indirectly. As an author, I recognize
another media contribution herein, yet am optimistic that there are still some op-
portunities for positive and, dare I speculate, even responsible contributions. It is
my fervent hope that the Handbook of Pain Relief in Older Adults achieves such a
level of contribution to the literature.
ix Introduction
Finally, there is a chapter for the future. This chapter provides suggestions to
accomplish pain relief over a broad spectrum. Suggestions target individuals as
well as large-scale endeavors. The challenge of pain relief for the rapidly increas-
ing body of seniors must be addressed now if we are to have any hope of living in
comfort in the days and years ahead. It is a challenge for all of us. This book is only
one of many sparks that must be lit to ignite a blazing effort to eliminate the omni-
present shadow of pain throughout the world. To move forward in the fiery and
passionate advocacy of pain relief, we must recognize that one of the worst mar-
riages is that of ignorance and arrogance; and, thus, it will be important to maintain
an open perspective and to fill the knowledge void with as much factual informa-
tion as possible. With steadfast efforts from all who read these words, all of us can
look forward to a much brighter future as we meet the pain relief challenge.
REFERENCES
1. Merskey H, Bogduk N, eds. Classification of Chronic Pain, 2nd ed. Seattle:
IASP Press, 1994, pp xi–xv.
2. Stedman TL. Stedman’s Medical Dictionary. Baltimore: The Williams &
Wilkins Company, 1979, p. 988.
3. Gloth III FM. Pain management in older adults: Prevention and treatment. J Am
Geriatr Soc. 2001; 49:188–199.
4. CDC. Prevalence of disabilities and associated health conditions among adults -
United States, 1999. MMWR 2001; 50:120–125.