Pharmacological Management of Persistent Pain in Older Persons

Drugs without a strong evidence base and outside of recommendations are too often pre- scribed for older adults. Established guidelines such as Beers criteria have identified both specific medications and certain drug classes as inappropriate for older adults, primarily due to adverse effects. Age-related physiological changes in distribution, metabolism, and elimination often alter the effects of pharmacotherapies in older adults. When designing a therapeutic program, all elements contributing to the pathophysiology of painful conditions should be considered, as well as the mechanisms of action of analgesic drug classes. Both appropriate and inappropriate medica- tions for older adults are detailed herein, as well as their contraindications and potential drug- drug or drug-disease interactions. The number needed to treat (NNT) can be useful in considering efficacy, while the safety of a pharmacotherapy is indicated by the calculated number needed to harm (NNH). The NNT is a measure describing the number of patients who require treatment for every 1 who reaches the therapeutic goal, and the NNH describes the number of participants who manifest side effects; these can further be segregated into numbers who withdraw from studies due to intol- erable side effects. These parameters, along with a patient's comorbidities and concomitant medica- tions, should be considered when selecting an analgesic and dose regimen. In addition, practitioners should avoid prescribing multiple-drug therapies that have overlapping pharmacodynamics or that may have an adverse pharmacokinetic interaction. Perspective: The pharmacotherapeutic armamentarium for treating pain has continued to grow. Both opioids and adjuvants are important options for treating persistent pain in older adults, a pop- ulation prone to individualistic differences requiring greater treatment tailoring and optimization. a 2011 by the American Pain Society