Treatment of chronic pain

Admission

According to epidemiological studies, the incidence of chronic pain increases with age and affects up to 55% of people over 85 years of age. Usually, pain is associated with musculoskeletal disorders, but there are also frequent night pain in the lower limbs and pain associated with claudication. In elderly people, a characteristic location of pain is observed – most often around the joints, lumbar part of the spine and lower limbs.

International Association for the Study of Pain recommends multi-directional treatment of patients with chronic pain, paying attention not only to the somatic aspect, but also to the need to improve emotional and social functioning. Chronic pain and its inappropriate treatment are associated with adverse consequences in seniors, but at the same time optimal treatment of pain in people in this age group is a clinical problem due to limitations in the use of pharmacotherapy and access to other methods of treatment.

Clinical case

A 91-year-old patient reported to the Pain Treatment Clinic in Krakow in February 2014 due to pain located within the cross and within the chest wall on the left side. Pain has been present for 30 years, but has been worsening for about a year due to advanced osteoporosis and vertebral and vertebral fractures in this disease. At the time of the examination, the patient assessed pain on the NRS scale at about 6-7 degrees, during the intensification the pain was assessed at 10 degrees, and the aggravating factors were movement and standing upright. Permanent pain with intensities of the type of pricking and jerking significantly hampered everyday functioning, sleep, and also lowered the mood. The patient lived with his family. He had the following comorbidities: ischemic heart disease and hypertension. The current analgesic treatment included the temporary use of various NSAID preparations and tramadol at a dose of 200 mg / day systemically and did not bring satisfactory and long-lasting pain relief. Physiotherapeutic procedures were not performed due to the patient’s difficulty in moving.

Physical examination revealed a significant impairment of the mobility of the cervical and lumbar spine, significant tenderness of the back, tenderness at the site of rib fractures.

X-ray imaging of the spine and chest joints described changes characteristic of osteoarthritis as well as osteoporosis, pathological fractures of L1, L2 vertebrae and ribs VI and VII on the left side. Laboratory tests, such as blood counts, CRP, sodium, potassium, magnesium and uric acid, did not deviate from normal. Life parameters such as blood pressure, heart rate, and number of breaths were within the normal range.

The patient was diagnosed with chronic pain associated with osteoarthritis and pain caused by pathological fractures in the course of advanced osteoporosis.

Pain complaints due to their severity and a negative impact on the quality of life required the use of multimodal drug therapy in combination with other methods of treatment, depending on the availability of these methods and the patient’s options. The basic and urgent problem was the choice of analgesics to ensure optimal pain control with minimal risk of side effects, and the use of a strong opioid was considered due to the severity of pain.

The patient used buprenorphine in the patch, starting from 1/2 a slice of 35 g / h, which was an equivalise dose for 200 mg tramadol. After 48 hours, the dose was increased to 1 patch of 35 g / h. In addition, topical medications were recommended – diclofenac 140 mg in the form of a patch and 5% lidocaine in the patch. Due to the patient’s age and comorbidities, systemic NSAIDs were discontinued. Buprenorphine in the form of sublingual tablets at a dose of 0.2-0.4 mg and paracetamol in a dose of 500 mg in the form of effervescent tablets were proposed for exacerbation.

The first of the follow-up visits took place 48 hours after sticking the patch containing buprenorphine, followed by week and 2 weeks. During the first visit, the patient did not report adverse symptoms characteristic of opioids, while the pain relief was small (by 1 degree on the NRS scale). It was decided to increase the dose to 1 patch of 35 g / h and this dose was recommended for further therapy, because the patient felt about 40% pain relief, while this dose did not cause serious side effects.