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Title: Available Treatment Options for Pain in Elderly Cancer Patients

URL: http://www.mmhc.com/engine.pl?station=mmhc&template=cgfull.html&id=1687

Clin Geriatr 2003 Jul;11:7:34-40. "Management of Cancer Pain in the Older Patient"
09/03/2003 04:14:19 PM
By Deanna M. Green

A number of options are available for treatment of pain in elderly patients with cancer, depending upon the severity of pain and location of pain. Pain is one of the most common and most feared symptoms of cancer, particularly in advanced disease. Elderly cancer patients have a greater propensity of developing cancer-related pain, yet they are the least likely to receive proper treatment. Jane A. Driver, MD, and Robert I. Cohen, MD, at the Harvard Medical School, Boston, Massachusetts, reviewed the available treatment options for the management of pain in elderly cancer patients. The authors support that analgesic agents should be chosen based on the severity of the patient's pain. For mild pain, non-opioids such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended. Specifically, the COX-2 inhibitor NSAIDS are the best NSAID choice for elderly patients because of reduced gastrointestinal adverse events. Moderate and severe pain is most often treated with opiates at low and high doses, respectively. Oxycodone and hydrocodone at low doses have proven very effective and well tolerated. Furthermore, Tramadol has shown similar efficacy to hydrocodone and is well tolerated. For severe pain, oxycodone and hydromorphone are initially recommended. If stronger treatment is needed, methadone is the morphine of choice and should be used with caution. Typical opiate-related side effects include constipation, nausea, pruritus, sedation, confusion, and urinary retention, which can each be concomitantly treated. A number of options are also available for the treatment of cancer-related neuropathic and bone pain. Low-dose gabapentin is the first-line therapy used to effectively and safely treat painful neuropathies in the elderly. Other options include corticosteroids, levorphanol, and lidocaine. Opioids, NSAIDs, and occasionally corticosteroids are most effective for bone pain. Bisphosphonates, including pamidronate and zoledronic acid, have also been shown to be effective in the prevention and treatment of cancer-related bone pain. Patients in whom opioids cause excessive sedation and other intolerable side effects may also benefit from invasive anaesthetic techniques, such as epidural and spinal infusion catheters, which tend to be underutilised. The authors recommend that "when a patient's pain does not respond to the drugs and dose ranges a clinician is comfortable prescribing, consultation of a pain specialist should be considered." They further conclude that "general practitioners, geriatricians, and oncologists should feel comfortable reassuring patients that a diagnosis of cancer does not mean living and dying in pain."

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