AGS panel offers advice: How to get a grip on pain

Group releases nation's first guidelines

Ethics committees grappling with the issue of providing adequate pain relief for patients just got some expert help.

The American Geriatrics Society (AGS) in New York City released the nation's first clinical practice guidelines for managing chronic pain in older patients. Clinical Practice Guidelines for the Management of Chronic Pain in Older Persons was published in the May issue of the Journal of the American Geriatrics Society. The society's panel on chronic pain also presented the guidelines at the AGS' annual meeting in May in Seattle.

While the main focus of the guidelines is on identifying and treating persistent chronic pain, the group also included a section on dealing with moderate to severe pain. The group identified two areas for improvement in treating severe pain: improved access to opioid analgesics and health care provider education on appropriate pain relief. (For a list of recommendations, see story, p. 68.) The AGS previously published position papers on end-of-life pain management and physician-assisted suicide. (See editor's note, p. 68, for ordering information.)

"During the development of these guidelines, we recognized that opioids as a classification of drugs are under-prescribed when other medications prove ineffective. Using these guidelines as written will allow treatment with specific goals in mind to create a balance and efficacious use of opioids," says Perry Fine, MD, professor at the University of Utah in Salt Lake City and member of the AGS panel on chronic pain.

The group didn't consult with the U.S. Depart ment of Justice's Drug Enforcement Agency regarding potential legal risks associated with using opioids, says Fine, but he sees a different outcome from further prosecution of physicians who prescribe such medications. "It is our hope that once these guidelines are published and as consumers become more empowered and knowledgeable regarding pain relief, the regulatory agencies will see that there is no need to be concerned," he says.

"Regardless of the potency of the drug, there really is no need for any older person to suffer. There need not be a stigma associated with the use of these drugs," notes Paul Katz, MD, associate professor at the University of Rochester in New York and a member of the panel on chronic pain.

Another important recommendation from the guidelines involves the payers. "We've recommended that health systems that care for older people allow for more aggressive treatment of severe pain, including the use of opioids," says Fine.

Becoming a bigger problem

Physicians, nurses, and other health care providers will need to be educated on providing appropriate pain relief because the problem will only increase in magnitude, says Gregg Warshaw, MD, professor of family medicine at the University of Cincinnati Medical Center and chairman of the AGS board of directors.

According to the organization's statistics, 97 million Americans experience chronic pain. More importantly, however, is that the fastest-growing population group in America consists of people age 65 and over, Warshaw notes.

"Currently, this group comprises 13% of the overall population, but in 15 years, this group will account for more than 20% of the population," he warns.

"What may seem mundane, such as daily activities, should have serious consideration on the physician's part when they discuss pain with their patients. Since there are no biological markers for indicating pain, we must teach physicians and other caregivers to seek the information about pain from their patients and take that information seriously," Fine says.

The AGS guidelines consist of four main components: assessment, pharmacological treatments, nonpharmacological treatments, and recommendations for health systems and providers.

Development of the guidelines was made possible through an unrestricted educational grant from McNeil Consumer Products Company. The panel, which spent more than a year to complete the guidelines, consisted of experts in the fields of geriatrics, pain management, psychology, pharmacology, and nursing.

[Editor's note: Patient information about the AGS Clinical Practice Guidelines for the Management of Chronic Pain in Older Persons is available from the American Geriatrics Society. Information on ordering position papers previously published by the organization also is available.

Write to the AGS at 770 Lexington Ave., Suite 300, New York, NY 10021. Telephone: (888) 432-7246. Fax: (212)-832-8646. E-mail: info.amger World Wide Web:]