CME: Persistent Pain in Older Patients

CME: Persistent Pain in Older Patients
Author Information (click to view)

Cary Reid, MD, PhD

Associate Professor of Medicine
Irving Sherwood Wright Associate Professor in Geriatrics
Joan and Sanford I. Weill Department of Medicine
Weill Cornell Medical College

Cary Reid, MD, PhD, has indicated to Physician’s Weekly that he has in the past worked as a consultant for Endo Pharmaceuticals but that was more than 3 years ago. He has also received grants/research aid from the National Institute on Aging.

Figure 1 (click to view)
Figure 2 (click to view)
Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:


  1. Explain barriers to persistent pain management among older adults.
  2. Summarize pharmacologic and non-pharmacologic approaches to pain management in older adults.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at

Credit Available(click to view)


CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.


AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)


Keith D’Oria – Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Cary Reid, MD, PhD
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.


Cary Reid, MD, PhD (click to view)

Cary Reid, MD, PhD

Associate Professor of Medicine
Irving Sherwood Wright Associate Professor in Geriatrics
Joan and Sanford I. Weill Department of Medicine
Weill Cornell Medical College

Cary Reid, MD, PhD, has indicated to Physician’s Weekly that he has in the past worked as a consultant for Endo Pharmaceuticals but that was more than 3 years ago. He has also received grants/research aid from the National Institute on Aging.

To adequately treat persistent pain in older individuals, a clear understanding of the patient’s treatment goals and expectations is needed. A combination of approaches is essential and a therapeutic alliance should be made between patients and physicians.
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For older Americans, persistent pain is highly prevalent and costly to manage. Persistent pain most often is attributable to musculoskeletal causes, usually involves multiple sites, and typically occurs in the presence of other comorbidities. “As adults in the United States continue to live longer, there is an increasing need for more physician education on the management of persistent pain among older adults,” says Cary Reid, MD, PhD. “Most doctors, however, receive little training on managing pain, especially for older patient groups. Furthermore, many clinical studies examining various drug therapies exclude older patients.”

In a clinical review published in JAMA, Dr. Reid and colleagues examined barriers to persistent pain management among older adults and summarized pharmacologic and non-pharmacologic approaches for this patient population. The article also provided information on rehabilitative modalities that are important to consider and highlighted aspects of the patient-physician relationship that can help to improve outcomes. “This information is important as efforts are increasing to use age-appropriate approaches to delivering pain care for older adults,” says Dr. Reid.

Potential Barriers

There are several important barriers to managing persistent pain in the geriatric population. Some examples include age-related physiologic changes that alter drug absorption, sensory and cognitive impairments, polypharmacy, and multiple comorbidities. “There is also limited evidence to help guide pain management in older patients,” adds Dr. Reid. “In addition, older adults have varying beliefs about pain and when it requires treatment.” In addition, many physicians have concerns about the potential for treatment-related harm that can result from using pain medications in these patients, which causes them not to treat pain further and further compounds the problem.

 Multimodal Approaches

According to Dr. Reid, it is important for physicians to use a multimodal approach to managing persistent pain in their older patients. “There should be an emphasis on combining both pharmacologic and non-pharmacologic treatments rather than focusing on one or the other,” he says (Table 1). “It’s important to include physical and occupational rehabilitation as well as cognitive-behavioral therapy and movement-based interventions. Unfortunately, research indicates that these treatments are largely underutilized.”

Ideally, an integrated approach will cultivate a strong therapeutic alliance between older patients and their physicians. Dr. Reid says that using a collaborative care strategy is paramount to formulating an effective treatment plan for older patients with persistent pain. “This requires a clear understanding of patients’ comorbidities, cognitive and functional status, and treatment goals and expectations,” he says. It also requires a review of patients’ resources, including both social and family support networks.

 A Stepwise Approach

The article in JAMA recommends using a stepwise approach to managing persistent pain (Table 2). Careful surveillance to monitor for toxicity and efficacy is critical because advancing age increase the risk of adverse effects. Research shows that acetaminophen is typically beneficial as first-line therapy, but a trial of a topical NSAID, tramadol, or both is recommended if treatment goals are not met. Oral NSAIDs are not recommended for long-term use in older patients.

Physicians are recommended to start at the lowest possible dose of pain medication and titrate up based on tolerability and efficacy. Use of two or more analgesic drugs with complementary mechanisms of action—as opposed to higher doses of a single pain medication—may lead to greater pain relief with less toxicity.

Dr. Reid says it is important to consider referring older adults with persistent pain to specific non-pharmacologic modalities that are both accessible and affordable. “Physicians should make efforts to find physical therapy and occupational therapy services for older patients,” he says. “We should encourage the use of non-pharmacologic approaches and engage the patient’s family and caregivers in these efforts. These efforts can help cultivate and reinforce a long-lasting therapeutic alliance that is based on trust, which in turn makes it possible to improve outcomes for patients over the long term.”

Looking Forward

In the future, Dr. Reid says mobile health technology and other interventions are likely to further improve how older patients with persistent pain are managed. “As technology continues to evolve and new interventions emerge,” he says, “there is hope that we’ll be able to enhance our care of older patients in a cost-effective and convenient manner.” He notes that early data suggest that older patients are willing to use mobile technologies to help manage their pain and adds that the need for more skilled professionals to provide non-pharmacologic treatments is likely to increase. “In the meantime,” he says, “physicians should consult established clinical guidelines and make treating persistent pain a greater priority so that older adults can have the best quality of life possible.”

Readings & Resources (click to view)

Makris UE, Abrams RC, Gurland B, Reid MC. Management of persistent pain in the older patient: a clinical review. JAMA. 2014;312:825-837. Available at:

Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012;13:715-724.

Patel KV, Guralnik JM, Dansie EJ, Turk DC. Prevalence and impact of pain among older adults in the United States: findings from the 2011 National Health and Aging Trends Study. Pain. 2013;154:2649-2657.

Nicholas MK, Asghari A, Blyth FM, et al. Self-management intervention for chronic pain in older adults: a randomised controlled trial. Pain. 2013;154:824-835.

Teh CF, Karp JF, Kleinman A, Reynolds Iii CF, Weiner DK, Cleary PD. Older people’s experiences of patient-centered treatment for chronic pain: a qualitative study. Pain Med. 2009;10:521-530.

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