It seems the elderly are getting a raw deal. New research states that almost half of patents once leaving hospital care or just receiving outpatient care in general are not getting the relief they need. This stems from the complications of moderate to severe acute pain.

Under treatment of pain in older adults is a well-known problem in the United States and older adult patients may not receive opioids due to many reasons, including poor assessment of pain and adverse effects, as well as concerns about tolerance, physical dependence, and addiction.

Much is known about opioid metabolism, which is critical in administering these agents to the elderly. Fear of addiction and tolerance are the major barriers to their use among patients as well as health-care professionals. Addressing these issues early in the initiation opioid therapy will help to alleviate these concerns.

Once therapy with an opioid is initiated, the role of renal function is critical. Because many metabolites of the opioids are renally cleared and have activity either in analgesia or as undesired side effects, it is critical to be aware of the creatinine clearance (not just serum creatinine) in the elderly.

The initiating doses of the opioids can be equal to that of younger patients, but the clinician should anticipate using a longer frequency of dosing interval or smaller doses during the course of therapy. Methadone, propoxyphene, and meperidine are not recommended for use in elderly people, because of the toxicity of their metabolites.

Of all the unwanted effects of the opioids, the most difficult to deal with is that of constipation. Here, an aggressive approach using bowel stimulating laxatives is critical in order to prevent this problem. It is anticipated that a variety of newly formulated opioids will shortly be available for clinical use. Finally, as a better understanding of the neurophysiology of pain is gained, the clinician can anticipate having more analgesic opioids that target their receptors without agonist or antagonist effect on other opioid receptors. This will allow the clinician to better relieve pain with a minimum of unwanted side effects.

This particular survey, one of the largest pain management surveys of physicians and patients in the United States, also show that this under treatment was particularly prevalent among adults aged 75 and older at a large 52%.

Results of this survey, including data from 50,869 patients who submitted the survey between September and November 2008, are consistent with previous reports from smaller studies in other settings.

The survey also focused on U.S. physicians and their patients with moderate-to-severe acute pain and was designed to evaluate patient perceptions of the adequacy of analgesia and the influence of opioid-related side effects in outpatient pain management.

Outpatient pain falls into two broad general divisions, acute and chronic. Acute pain is secondary to internal events and lasts a comparatively short time. It is a reflection of the stimulus response effect that results from surgical intervention and assumes the patient’s central nervous system is intact and tissues will heal.

Acute pain may be nociceptive or neuropathic. Nociceptive means it is mediated by nociceptors distributed in cutaneous tissue, muscles, and connective tissue. Patients with this form of pain have difficulty pinpointing a particular site of pain, and they describe a wide range of pain phenomena: aching, throbbing, sharp. The neuropathic form of acute pain is caused by damage to central or peripheral nerves. It is mediated by specific receptors and described by patients as burning or shooting, electric-like.

Neuropathic pain frequently is resistant to opiates. A distinguishing factor between nociceptive and neuropathic pain, in fact, is the patient’s response to opiates. If a patient receives increasing doses of opiates but does not experience relief, the pain most likely is neuropathic.

Written by Sy Kraft