Laura Rhodes, PharmD

Acute pain is the body’s normal response to noxious stimuli. Acute pain typically lasts for days to weeks, but it may last for months during the healing process.

 Because pain is a highly subjective experience, it is important for a thorough assessment to be conducted to determine the cause of pain and the most appropriate course of treatment. A pain management plan should consider the assessment of pain and all pertinent patient factors, as well as drug and nondrug measures that can be employed to relieve a patient’s pain. When a medication is selected to treat pain in a geriatric patient, factors that should be considered include drug metabolism mechanism, renal or kidney function, concomitant medical conditions, and social history, including the potential for drug abuse or history of addiction. If an assessment takes place in a community pharmacy setting, it is important to consider when a patient may require referral to a health care provider for a more in-depth acute pain evaluation.

The assessment of pain requires a multidimensional approach by clinicians because pain can present in many different ways and can affect patients physically and psychologically. A patient’s report of pain, in his or her own words, is the most reliable indicator of pain. A thorough pain assessment should inquire about the characteristics of the pain, past and current management strategies, medical history, family history, psychosocial concerns, and the patient’s goals and expectations for pain management. Characteristics of pain may include location and distribution, duration and periodicity, quality, and associated signs or symptoms.

Pain may be assessed using a unidimensional or multidimensional tool. Unidimensional scales are useful for a quick measurement of the intensity of an individual’s pain. The most common unidimensional pain assessment tools are the numeric rating scale, the visual rating scale, or a categorical rating scale. The 

 provides illustrations of unidimensional pain assessment tools. Because of potential “oversimplification of the pain problem” when using only unidimensional pain assessment tools, experts often prefer to use a multidimensional pain assessment tool. Multidimensional tools offer the advantage of providing information on characteristics of pain, in addition to pain intensity. They may be provided in a visual, verbal, or written format. Examples of multidimensional assessment tools include the initial pain assessment tool, a brief pain inventory, the McGill pain questionnaire, a memorial pain assessment card, and a pain drawing.

Elderly patients, in particular, may have difficulty articulating an accurate description of their pain for several reasons. It is common for this population of patients to underreport their pain due to fear, cultural factors, or stoicism. Changes in the patterns of an individual’s activities of daily living, such as walking or participating in social activities, may be an indicator of unrelieved pain. Elderly patients should be assessed for hearing, vision, or verbal impairments that may affect the assessment technique. When assessing pain in elderly patients, ensure that enough time has been allocated to perform a thorough assessment and that the tool selected is amendable to the needs of the patient.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are best used to treat pain that is inflammatory in nature, such as muscle sprains or strains.

 Particular patients who should be cautious of NSAID use include those who are at risk for cardiovascular events (eg, heart attack, stroke), those with high blood pressure, and those with renal impairment.

 NSAIDs contribute to elevated blood pressure, even if only used for 1 week.

 If an NSAID must be used in someone with a high cardiovascular risk, naproxen is the agent of choice. Patients with a high cardiovascular risk who take aspirin for cardioprotection should use NSAIDs with caution, as they may interfere with the antiplatelet effect of aspirin. Because the clearance of NSAIDs is affected by renal function, individuals with poor renal function should use NSAIDs cautiously. NSAIDs also increase the risk of gastrointestinal (GI) bleeding, and should be used cautiously in patients with a moderate to high GI risk. Selective cyclooxygenase-2 inhibitors pose a lower risk of GI bleeding and are preferred for use in patients with this risk if an NSAID must be used. NSAIDs may also pose a risk of drug interaction with several common medications used in elderly patients, including warfarin, blood pressure agents, and bisphosphonates.

Acetaminophen (APAP) is an excellent agent for treating many types of pain, particularly those that are noninflammatory in nature, such as arthritis. APAP does not bear the same cardiovascular risk as NSAIDs, making it a preferred agent in patients with a medium-to-high cardiovascular risk. In general, APAP has fewer drug interactions than other agents that may be used to treat pain. APAP may increase the risk of bleeding, particularly in patients who are taking concomitant warfarin. This risk of bleeding is lower with APAP compared with NSAIDs or aspirin, making APAP the agent of choice in individuals who take warfarin.

 An important factor regarding APAP is that it may cause liver toxicosis, particularly in patients who already have poor liver function, or in doses in excess of 150 mg/kg/day (~7.5 g in an average-sized adult). Therefore, individuals should not consume more than 3.25 to 4 g of APAP per day. Elderly patients and those with impaired liver function may benefit from a lower maximum daily dose (2 to 3 g) of APAP.

Aspirin is typically used for cardioprotection; however, at higher doses, aspirin may also be used to alleviate pain. Because high doses of aspirin must be used to alleviate pain, it is typically not the agent of choice. Aspirin increases the risk of bleeding, especially if it is used in conjunction with another agent that increases the risk of bleeding. Because aspirin is cleared renally, patients with severe renal impairment, defined as <10 mL/min, should avoid the use of this agent.

Opioid agents may be used to treat acute pain, but they should be reserved for moderate to severe pain. Several organizations have provided position statements discussing their concern over the use of opioid medications due to increasing drug dependence and abuse, in addition to adverse effects and drug interactions.

 In geriatric patients, adverse effects of concern include those that mimic the anticholinergic system, such as constipation, dryness, increased sedation, and decreased respiration. It is important to assess a patient’s other medications that may also increase sedation. A key concern with increased sedation in the elderly is the risk of falls. Decreased respiration is of concern for individuals with underlying respiratory disorders, such as asthma or chronic obstructive pulmonary disease. To minimize opioid use for acute pain, the following suggestions have been proposed

		Use the shortest course of therapy possible

		Never use long-acting or extended-release products

		Use opioids cautiously in elderly patients

		Include shared decision making: educate patients on the benefits and risks of the medication and allow them to make an informed decision

		Maximize appropriate nonopioid therapies

When considering acute pain management in elderly patients, clinicians must keep several factors in mind. Geriatric patients may have hearing, verbal, visual, or mental impairments that may make it difficult to accurately assess their pain; therefore, in affected individuals, the pain assessment technique may require modification. In addition, agents used to treat acute pain in adult patients may not be appropriate in the elderly, depending on the individual’s concomitant disease states and medications. Therefore, in elderly patients, a careful approach is suggested as clinicians assess pain and select an appropriate nondrug or drug treatment regimen. 

Laura Rhodes, PharmD, is a PGY1 community pharmacy resident with the University of North Carolina at Chapel Hill and Moose Pharmacy in Concord, North Carolina.

Ashley Branham, PharmD, is the director of clinical services at Moose Pharmacy, in Concord, North Carolina. 

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		Thorson D, Biewen P, Bonte B, et al. Acute pain assessment and opioid prescribing protocol. Institute for Clinical Systems Improvement website. icsi.org/_asset/dyp5wm/Opioids.pdf. Published January 2014. Accessed May 11, 2016.

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Articles

Acute pain is the body's normal response to noxious stimuli.

Acute Pain: Considerations in Geriatric Patients

In the health-system setting, pharmacists must often prioritize their attention to treating the most acute medical condition a patient presents with. However, it is important to also consider opportunities to prevent disease. Vaccines are life-saving medications that may prevent a disease before it ever occurs. This is particularly true for patients who require hospital admission, as they are typically at high risk for contracting these vaccine-preventable illnesses. Are the patients you care for up-to-date? Before your patient is discharged, consider the TIPS mnemonic to remember 4 key vaccines that all adult patients need: 

Tetanus, Diphtheria, and Acellular Pertussis Vaccine

Pertussis is a highly contagious disease caused by the bacterium 

. More commonly known as whooping cough, pertussis is transmitted by respiratory droplets when coughing or sneezing in proximity to others.

 Pertussis most commonly affects infants younger than 1 year. It usually starts with cold-like symptoms such as a runny nose, low-grade fever, mild cough, and apnea. After 1 to 2 weeks, severe uncontrollable coughing with a loud “whooping” sound may emerge and continue for weeks. This cough is potentially lifethreatening because it may lead babies to stop breathing. Many patients who contract pertussis are infected by grandparents, parents, siblings, or caregivers.

The best way to protect against pertussis is for adults to receive 1 dose of the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine. The vaccine takes 2 weeks to reach maximum effectiveness. Adults should use caution around young children during this time frame.

 The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommends a single Tdap dose for persons 19 to 64 years. Persons 65 years or older who have or who anticipate having close contact with an infant less than 12 months of age and who previously have not received Tdap should receive a single dose of Tdap to protect against pertussis and reduce the likelihood of transmission.

 Another vaccine called Td protects against tetanus and diphtheria, but not pertussis. A Td booster should be administered every 10 years. In individuals who have never received the Tdap vaccine, Tdap should replace 1 Td booster dose.

Influenza, or the flu, is an acute respiratory illness caused by the influenza virus and is transmitted through respiratory secretions. In the United States, flu season spans from October to May each year, with peak infection rates occurring around January.

 The flu is responsible for significant morbidity and mortality. From October 2014 to April 2015, influenza resulted in approximately 65.5 hospitalizations per 100,000 persons and a mortality rate of 6.4%.

 To aid in the prevention of influenza epidemics, it is recommended that all persons 6 months and older receive the annual influenza vaccine, with rare exception. The only persons for whom influenza vaccination is not recommended are children who are less than 6 months of age or those who have a severe, life-threatening allergy to the influenza vaccine.

 provides insight into the clinical use of available influenza vaccines.

Approximately 900,000 Americans contract pneumococcal pneumonia each year; 5% to 7% of these cases result in death. In addition, 400,000 hospitalizations are attributed to pneumococcal pneumonia annually in the United States.

, the most common pathogen associated with pneumococcal pneumonia, is also a leading cause of invasive diseases such as bacteremia and meningitis. Risk factors that can increase a patient’s likelihood for pneumococcal disease include:

		Chronic illnesses (lung, heart, liver, or kidney disease; asthma; diabetes; or alcoholism)

		Weakened immune system (HIV/ AIDS, cancer, long-term steroid use, or damaged/absent spleen)

		Living in nursing homes or other longterm care facilities

		Cochlear implants or cerebrospinal fluid leaks

There are 2 vaccines available for protection against pneumococcal disease: pneumococcal conjugate vaccine (PCV13 [Prevnar 13]) and pneumococcal polysaccharide vaccine (PPSV23 [Pneumovax 23]). On September 4, 2015, the CDC ACIP updated its recommendations on the administration intervals between these 2 vaccines.

 provides an overview of the use of these vaccines in adults.

Table 2: Current Recommendations for PCV13 and PPSV23 Use in Adults

* If PPSV23 was given prior, wait 1 year before giving PCV13.

* If PPSV23 was given prior and group B (see below), wait at least 5 years before giving a second dose of PPSV23.

* If PCV13 was given before 65 years, no additional PCV13 is needed

→ wait 1 year (8 weeks if Group B or Group C) → 

 → wait 1 year AND 5 years from prior PPSV23 → 

PCV13 = pneumococcal conjugate vaccine 13; PPSV23 = pneumococcal polysaccharide vaccine 23.

Herpes zoster infection, or shingles, is the reactivation of the dormant varicella- zoster virus located in the sensory ganglia, which typically manifests as a painful, blister-filled rash wrapped around 1 side of the trunk; it can also appear on the face and scalp. Adults 50 years and older are at the greatest risk for shingles; at age 60, the risk sharply increases for developing post-herpetic neuralgia, defined as pain that persists for 90 days or more after the onset of shingles and can last for years.

 Post-herpetic neuralgia can severely limit the quality of life of the individual and affect all 4 health domains: physical, psychological, functional, and social.

A shingles vaccine (Zostavax) is approved by the FDA for persons 50 years and older without contraindications to the vaccine. However, the CDC ACIP guidelines do not recommend the vaccine until a patient is at least 60 years of age. Contraindications include a severe allergy to gelatin, neomycin, or any other vaccine component; immunosuppression; and pregnancy. (Contact dermatitis to neomycin is not considered a contraindication.) Whereas the risk of shingles is increased at age 50, incidence is lower in the 50-to-59 age group than in adults older than 60 years.

 Factors that might lead a health care professional to immunize an individual at age 50 to 59 years include preexisting chronic pain, severe depression, or other comorbid conditions; inability to tolerate treatment medications because of hypersensitivity or interactions with other chronic medications; and occupational considerations.

In the health-system setting, pharmacists must often prioritize their attention to treating the most acute medical condition a patient presents with; however, it is important to also consider opportunities to prevent disease. 