Some Patients in Pain More Complicated to Treat Than Others

LAS VEGAS ‐ There are several considerations when managing patients with pain, but some patients present greater challenges to the clinician than others. 

Brett Badgley Snodgrass, MSN, APRN, FNP-C, a family nurse practitioner specializing in pain management and palliative care, spoke about the “complex” patient with pain and discussed 3 types of patients who may pose particular challenges for clinicians: those who are at risk of becoming addicted to their pain medications, obese patients, and the elderly.

Discussing patients who are at risk of becoming addicted and abusing their pain medications, Mrs. Snodgrass advised the audience that it is important to avoid stereotyping. Her presentation included a slide that depicted several different types of people: a young person, an older person, a rich person, and a less wealthy looking person. “Which one is the addict?” she asked the audience. Answering her own question, she said that she has had patients who looked like all of the images depicted. 

When dealing with those patients who may be abusing their prescriptions, “risk stratification is vital,” Mrs. Snodgrass said. She encouraged clinicians to screen those patients who may be abusing their medications and to use nonopioid therapies when possible. Signs of medication abuse or addiction may include: purposeful oversedation, negative mood changes, appearing intoxicated, an increasingly unkempt appearance, frequent involvement in motor vehicle accidents, arrest records, and frequent requests for early prescription renewals. 

“Learn to recognize the 4 Cs of addiction,” Mrs. Snodgrass said. “Compulsive use, lack of control, continued use despite harm, and craving for the favored substance.”

Discussing the obese patient in pain, Mrs. Snodgrass explained that obese individuals are at greater risk for fibromyalgia. She urged clinicians to account for adipose tissue when prescribing medication to treat the symptoms of the condition, as it can affect how the medications work. 

Pain management options for obese patients with pain should be multimodal, according to Mrs. Snodgrass, including modalities such as acupuncture, yoga, and pool therapy.  For obese patients, individualized treatment is best, with the ultimate goal to “decrease inflammation.”  She noted that sleep apnea, as well as hepatic and renal function issues should also be considered. 

“Obese patients can tolerate opioids but require careful monitoring,” Mrs. Snodgrass cautioned. “Those patients with apnea issues can be at particular risk of respiratory sedation.”

The elderly population comprises the fastest growing segment of the world's population, and pain is a common—although vastly underreported—symptom in this population.  As patients age, the incidence and prevalence of certain pain syndromes increase, Mrs. Snodgrass explained. 

The most common types of pain noted in the elderly include rheumatoid, neuropathic, ischemic, and osteoarthritic pain, Mrs. Snodgrass said. 

Assessing these painful conditions can be challenging in this population because often patients are reluctant to report their pain. It is key, she said, to conduct a complete history and physical examination. The most important question to ask older patients who may be in pain is: “Has the pain increased or worsened?”

Discussing the location, intensity, and the effect of the pain on the patient's mood and sleep is also key, she said. 

Mrs. Snodgrass recommended several screenings for older patients in whom pain is suspected, including assessment of cognitive impairment, depression, gait, and sensory depression.  

Clinicians must consider certain health issues that may be more commonly seen in older patients when treating their pain, Mrs. Snodgrass explained, such as aging liver, which may affect hepatic function; aging kidneys, which could lead to a decline in renal function; and central nervous system changes.

All of these conditions influence how older people process medication; therefore, clinicians may want to consider a multidisciplinary approach, which may lessen the need for opioids and the potential for adverse events. 

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