Pain therapeutics in older adults.

Kenneth Boockvar, MD, MS In recent decades, clinicians have increasingly recognized the importance of symptom control as a health priority on par with treating and controlling disease. Studies indicate that the highest priorities of patients with serious conditions such as cancer or endstage kidney disease are to have their pain and other symptoms relieved, to have their quality of life optimized, to avoid being a burden to their family, and to maintain a sense of control. Symptom management is particularly important for older adults living with multiple chronic conditions for whom optimizing quality of life is a primary goal. Pain is a chief symptom reported by older adults and a common cause of emergency department visits. Pain is associated with serious complications such as disability, depression, falls, and death in older adults. Research on the epidemiology, risk factors, complications, screening, and management of pain caused by conditions that commonly occur in older adults has grown greatly in recent years. This includes research on pharmacologic (including biologic) and nonpharmacologic therapeutics, re-examination of injection procedures in common use, cost analysis studies, and original studies on usage trends and the efficacy and safety of nonopioid and opioid analgesics. Despite the key role that pharmacologic agents, especially opioid analgesics, play in the treatment of severe pain, adverse effects (including accidental overdose) make them risky or intolerable to many older adults and help drive current efforts to improve pain care in this population. In this issue of Clinical Therapeutics, we report on contemporary issues in pain care for older adults, including articles on pain screening, nonpharmacologic management, pharmacologic management, and novel procedures for pain, with state-of-the art original investigations, reviews, and commentaries. First, Tracy and Morrison review the literature on pain management in older adults from 2000 to the present and discuss principles of pain management in this population in the context of pathophysiologic changes associated with aging. Second, Atkinson et al review selected pharmacologic agents for pain that might be particularly useful in older adults based on the ability of these agents to achieve therapeutic tissue levels, their toxicity profiles, and their interactions with other medications. Two articles follow on the important subject of complementary and alternative medicine (CAM) modalities for pain. Yang et al report on patterns of CAM use by older adults with osteoarthritis. They found that over a 4-year study period, one third of older adults used at least 1 CAM modality, but few were persistent users of any single CAM modality, with the exception of glucosamine and chondroitin. This lack of persistent use may reflect not only a lack of efficacy of these agents but also characteristics of the population that uses CAM modalities. Weiner et al report the results of the first efficacy trial of a new CAM modality related to acupuncture: periosteal stimulation therapy, a technique that delivers high-frequency electrical stimulation to the periosteum by using acupuncture needles. In a randomized controlled trial in adults aged 450 years with advanced osteoarthritis, 6 months of periosteal stimulation therapy was well tolerated and reduced pain compared with controls. Bednar et al review controversies over the use of