ORLANDO — Despite a high prevalence of chronic pain in older adults, adherence to pain medications is low—fueled largely by patients' stoicism, beliefs about pain and aging, and concerns about safety and addiction, according to Dr. Stephen Thielke, a psychiatrist at the University of Washington, Seattle.
Chronic pain not only results in suffering but also is strongly associated with depression and declines in health status, he reported at the annual meeting of the American Association for Geriatric Psychiatry. Recent work by his group has demonstrated that people who report more pain are less likely to respond to integrated depression treatment, compared with those with less pain (Am. J. Geriatr. Psychiatry 2007;15:699-707).
Although 75% of seniors in Medicare surveys report having arthritis (the most common cause of pain in this population), only about 40% of them report actively treating it. In other samples, only about half of patients who report functional impairments from pain take any medication for it, Dr. Thielke noted, which differs from seniors' use of treatments for other chronic medical conditions.
“There is clearly something different about treating arthritis pain, compared [with] treating other medical problems,” he said.
Research about the experience of seniors who have arthritis pain has helped to identify some of the factors involved in seniors' use of medications. In a recent qualitative study of 19 older adults with arthritis pain, only 4 subjects (21%) were taking pain medications as directed; the remaining 79% “purposefully did not take their OA [osteoarthritis] medications as prescribed” (Arthritis Rheum. 2006;55:272-8).
Many of them “described treatment behaviors that we might consider irrational,” noted Dr. Thielke, such as filling prescriptions and then throwing the medication away, putting lower dose pills into a bottle with a higher dose on the label, and hiding their nonadherence from family members. Stoicism was a common theme, he said, with patients minimizing their pain and reporting high pain tolerance. Fear of addiction was reported by many patients as a key barrier to using stronger painkillers. At the same time, 18 of 19 of the participants (95%) were taking at least one herbal remedy and/or vitamin for their arthritis.
Further insights have come from focus groups of older patients with osteoarthritis, which revealed that many of them considered pain “a normal part of getting older,” felt that medications are potentially harmful, and saw medication as masking rather than curing their pain (Arthritis Rheum. 2006;55:905-12).
“Patients placed more emphasis on acceptance, rather than treatment, of pain, and safety, rather than effectiveness, of treatments, and they tended to see pain medications as high risk,” noted Dr. Thielke. He also reported other research findings that suggested the elderly have limited knowledge about arthritis medications, with few individuals being able to list potential side effects or to describe preventive use of medications (Rheumatology 2006;46:796-800).
He speculated that recent publicized safety concerns about NSAIDs and opioid analgesics further complicate patients' efforts to choose treatments that are safe and that patients might conclude that all pain-relieving medications are too risky to try.
Physicians may be complicit in fostering the expectation that pain should be accepted rather than treated by avoiding direct conversations with patients about the consequences of pain and their concerns about treatments for it, Dr. Thielke said. This can add to the patients' perception that they should tough it out. Patients may consider their need for pain medication as wasteful, rash, hedonistic, or selfish, and their ability to forgo analgesia as stoical, patient, thrifty, and selfless, he said.
Prescription directions that advise taking “as needed” also are interpreted differently by patients and physicians. “Many patients will interpret 'as needed' as 'when desperate' or 'when all else fails',” he said, while the provider intends it to mean 'to improve symptoms' or 'to enhance quality of life'. The goal is to make patients understand that their use of pain medication is not a statement about their character strength or toughness; rather, they are trying to improve their health, functioning, overall well-being, and safety. Focus on functioning, not just pain.”