AGS Clinical Practice Guideline:
Pharmacological Management of Persistent Pain in Older Persons
Executive Summary
Persistent pain --painful sensation that continues for a prolonged period of time and may or may not be associated with a well defined disease process -- is prevalent in older adults.
The American Geriatrics Society (AGS) published its first Clinical Practice Guidelines on management of persistent pain in older adults in 1998. This landmark publication became a call to arms for improving pain management in older patients. In 2002, the publication was revised. The current publication updates the evidence base of the 2002 guideline and provides recommendations regarding the use of new pharmacologic approaches. Since 2002, new drugs and treatment approaches have been introduced, and management strategies more fully evaluated. Because the most common strategy for managing persistent pain among older adults is through use of pharmacologic agents, and because this is also the area of greatest risk, this updated guideline focuses on pharmacotherapy. The recommendations in this guideline represent the consensus of a panel of pain experts and were derived from a synthesis of the literature combined with clinical experience in caring for older adults with persistent pain.
The recommendations are grouped under the following headings: non-opioids, including acetaminophen and non-steroidal anti-inflammatory drugs; opioid analgesics; adjuvant drugs; and other medications. General principles are discussed first, followed by the panel's specific recommendations for use of the medications.
The guideline recommends that acetaminophen be considered as initial and ongoing pharmacotherapy of patients with mild to moderate musculoskeletal pain, but -- in a significant departure from the 2002 guideline -- recommends that nonselective NSAIDs and COX-2 selective inhibitors be considered rarely, with caution, in highly selected individuals. The new guideline recommends that all patients with moderate to severe pain, pain-related functional impairment or diminished quality of life due to pain be considered for opioid therapy. The new guideline also provides new references and discussions regarding use and limitations of newer adjuvant, topical, and other drugs for recalcitrant pain problems.
This updated guideline was developed and written under the auspices of the AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, approved by the AGS Executive Committee on April 21, 2009, and will be published in the Journal of the American Geriatrics Society under the title "Pharmacological Management of Persistent Pain in Older Persons". The following organizations with special interest and expertise in the management of pain in older persons provided peer review of a preliminary draft of this guideline: American Academy of Family Physicians; American Academy of Pain Medicine; American Academy of Physical Medicine & Rehabilitation; American College of Clinical Pharmacy; American College of Physicians; American Medical Association; American Medical Directors Association; American Society of Anesthesiologists; Gerontological Society of America; National Academies of Practice, Academy of Pharmacy; and the Oncology Nursing Society.
SOURCE: AGS Panel on Persistent Pain in Older Persons. Pharmacological Management of Persistent Pain in Older Persons. American Geriatrics Society. J Am Geriatr Soc 2009 (in press).
Members of the AGS Panel on the
Pharmacological Management of Persistent Pain in Older Persons
Bruce Ferrell, MD (Chairman):
UCLA School of Medicine, Los Angeles, CA
Charles E. Argoff, MD
Albany Medical Center, Albany, NY
Jerome Epplin, MD
Litchfield Family Practice Center, Litchfield, IL
Perry Fine, MD
University of Utah Pain Management Center, Salt Lake City, UT
F. Michael Gloth, III, MD
Johns Hopkins University School of Medicine, Baltimore, MD
Keela Herr, PhD, RN
University of Iowa, Iowa City, IA
James D. Katz, MD
George Washington University, Washington, D.C.
David R. Mehr, MD, MS:
University of Missouri, Columbia, MO;
M. Carrington Reid, MD, PhD
Weill Cornell Medical College of Cornell University, New York, NY
Lori Reisner, PharmD
University of California, San Francisco School of Pharmacy, San Francisco, CA.
