Annals of Long Term Care

It’s amazing hearing the stories coming out regarding a celebrity’s ability to gain access to a seemingly limitless supply of pain medications while all-too-many seniors suffer needlessly in pain because of barriers to access. This is a significant problem. Approximately 25-50%1 of community-dwelling older adults experience persistent pain. In nursing homes the problem is even larger, with prevalence ranging from 49% to 83%.2,3

Unfortunately, there are many barriers that stand in the way of proper treatment for older adults with pain. The barriers start with clinical issues such as diagnostic and treatment planning, and continue with medication access issues. However, there are opportunities available to improve pain management, which begins with an understanding of these barriers. Much has already been written with regard to the clinical issues of pain management in this Journal and in others. The American Geriatrics Society (AGS) and the American Medical Directors Association (AMDA) have created guidelines for the treatment of pain in the elderly that incorporate both nonpharmacologic and pharmacologic methods (www.american geriatrics.org/education/final_recommendations.pdf; www.amda.com/tools/cpg/chronicpain.cfm). Because the clinical issues have been extensively covered elsewhere, this article will instead focus on medication access issues, which, unfortunately, are growing.

Right Pain Medication for the Right Patient

There has always been pressure from the Food and Drug Administration (FDA) to limit adverse events from medications. This includes medications that may be appropriate for some patients but not for others. Pain medications are especially prone to these programs, given their wide use and potential for significant adverse events.

The case of rofecoxib can be viewed as an example of a valued pain medication felt by some to have too many risks when left to broad prescribing and use rather than being used more sparingly. Of course, as with all medications, there are patients who benefit from access and those who experience adverse reactions. Rofecoxib was no exception, as some patients saw significant reductions in their pain while others experienced cardiac complications.

As a result of this issue and similar ones, the FDA has focused on regulations to assure that the right medication gets to the right patient and no one else. In the case of rofecoxib, this resulted in its removal from the market. Some may argue that this was appropriate given the risks, yet there are others who have argued that when used properly the risks were outweighed by its benefits.

The take-home message from this is that prescribers need to constantly be evaluating the risks and benefits of every medication for each individual patient. Without this level of care to ensure that the right patient is getting the right medication, the FDA or others may be forced to take action. In some cases, this may mean the inconvenience of Risk Maps (see www.fda.gov/downloads/AboutFDA/CentersOffices/CDER/ucm119346.pdf); in others, it may mean the removal of a medication from the market, causing patients to lose access to a potentially needed medication to control their pain. This debate is currently being argued regarding the most widely utilized pain medication, acetaminophen, which, as with any medication, has benefits and risks associated with its use.

Acetaminophen Headache

Hopefully, the results of the FDA expert panel looking into acetaminophen overdoses will not result in access restrictions. The concerns about acetaminophen arise from patients being harmed by a medication that is safe when utilized by the appropriate person and taken correctly.

These medication management issues have resulted in acetaminophen overdoses that have led to 56,000 emergency room visits annually and approximately 100 accidental overdose deaths per year.