WashingtonPlacebos for pain are patently unethical, according to American Geriatrics Society (AGS) guidelines unveiled at the group's annual meeting here in May. "I've been amazed at how many seemingly high quality institutions allow the use of placebos postsurgery or for cancer-related pain," said Perry Fine, MD, professor of anesthesiology at the University of Utah School of Medicine and one of the guideline's coauthors. "They still view pharmacological interventions as so dangerous that they want to fool patients into thinking pain is controlled."

That message, the first such declaration from the group, accompanies a host of other pointers directed at persuading physicians and patients that "pain doesn't have to come with aging." The group is encouraging physicians to evaluate every older patient for pain, paying particular attention to those with cognitive or other disorders that may limit communication.

DON'T GRIN AND BEAR IT

Simple strategies can uncover remediable pain in many patients who may be accustomed to bearing it, said Keela Herr, PhD, RN, a guidelines coauthor from the University of Iowa School of Medicine. Ask about "aching, discomfort, soreness and not just pain," in the "here and now, not compared with pain felt hours or weeks ago," said Herr. The guidelines recommend approaching patients with a standard 10-point pain scale before moving to alternative scales such as "pain thermometers." The important thing, Herr emphasized, is to ensure that patients understand the scale.

Patients with cognitive disorders may simply be unable or unwilling to respond. In such cases, Herr urged physicians to ask caregivers about behavioral changes. Grimacing during movement, frowns, rapid blinking, vocalizations, and body guarding all commonly accompany pain. So does the cessation of routines, increased wandering, difficulty sleeping, and refusing food. But rather than trying to provide a list, Herr said that the changes themselves signal trouble. "Each patient has a unique pain signature. You have to know what the baseline is," she said.

For musculoskeletal pain, the most common type in older patients, the guidelines recommend treatment with acetaminophen before switching to newer and more expensive drugs. And long-term analgesic therapy precludes nonsteroidal anti-inflammatory drugs (NSAIDs), which raise risk for digestive tract adverse effects.
 

OPEN THE DOOR TO OPIOIDS

Opioids are still underused as a result of social stigma, said Fine, adding that, in some situations, opioids can be safer than other classes of pain medication. "Most importantly," say the guidelines, "concerns over drug dependency and addiction do not justify the failure to relieve pain." While the AGS is encouraging opioid use, physicians report harassment from law enforcement. Lawrence Greenfield, MD, a physician in Danville, Pa, said that he received a warning letter from the state after he prescribed, on separate occasions to separate patients, different doses of the much written about drug oxycodone. "Certain prescribing patterns trigger" such letters, he said.

One of the guideline's coauthors said that widespread adoption of the recommendations will help physicians reassert their right to practice without such scrutiny. "We have to educate people that it is not a criminal thing to prescribe opioids," said Paul Katz, MD, University of Rochester School of Medicine and Dentistry. He added that he changed his daily routine after the first AGS guidelines were released in 1998. "Those guidelines changed my life and I'm not ashamed of it. I now think of pain anytime I see a functional change in an older person, something I had not done before. I inquire about pain at every encounter."