Ask the Expert
Ask the Expert

Stephen Thielke, MD, MSPH: Pain Management & Aging


Stephen Thielke

Stephen Thielke, MD, MSPH
Assistant Professor
University of Washington

According to the National Institutes of Health, pain is the most common reason Americans access medical care and a leading cause of disability. As common as pain is, many misconceptions about pain management persist. Geriatric pain expert Dr. Stephen Thielke answered some of Infoaging’s questions about pain management. Dr. Thielke is assistant professor of Psychiatry and Behavioral Sciences at the University of Washington and the recipient of a 2010 Paul B. Beeson Career Development Award in Aging Research.

What are common misconceptions about aging and pain?

We have identified four misconceptions about pain:  (1) that pain is a natural part of getting older, (2) that once pain is present, it always gets worse, (3) that people who tough it out become accustomed to pain, and (4) that pain medications are highly addictive.  There is little factual basis for these ideas, and the real evidence about pain during aging suggests that pain does not increase with advancing age, that it often improves, that stoicism is not an effective way of dealing with pain, and that pain medications are not highly addictive.

How concerned should older adults be about getting addicted to pain medications?

Research has consistently shown that older adults are less likely than younger adults to develop addiction to prescription opioids for chronic pain.  While estimates vary depending on the population, it appears that no more than 5% of older adults receiving opioids show significant signs of addiction.  Most older adults who use prescription pain medications do so for short periods of time, and are able to stop without any problems.  While addiction can be a serious problem, there is no evidence that people who take prescription pain medications are likely to get “hooked” on them.

When patients feel that their doctors’ attitudes about aging and pain are impacting their care, what is the best way to address the issue with their doctors?

It can be difficult to challenge other people’s stereotypes.  It would be hard to know what to say if your doctor told you (as was reported in an interview with a patient about her pain[1]), “What do you expect?  You’re just getting older.”  Being knowledgeable about what treatment options exist is a first step.  Different forms of exercise, non-prescription medications, prescription medications, ultrasound, massage, and heat/ice therapy all have shown clear benefits[2], and patients can ask specifically for treatment modalities that interest them.  Sharing personal success stories can also help challenge stereotypes, by letting providers know that pain can get better and people can find ways of coping actively with it.

What is the connection between depression and pain? Does one put you at greater risk for the other?

Pain and depression influence each other strongly.  Depression can be thought of as a type of psychological pain, and having persistent pain undermines well-being.  As the author William Styron noted, “The gray drizzle of horrors induced by depression takes on the quality of physical pain.”[3]  People with chronic pain are two to four times more likely to have major depression than those without pain, and two-thirds of people with chronic pain have symptoms of depression.  Pain gets in the way of treatments for depression.[4]

The exact connections between depression and pain are still being established through research.  We hypothesize that being depressed results in stoicism and fatalism about managing pain, with less interest in finding ways to manage pain, less energy for initiating or sustaining therapeutic activities, and more pessimistic expectations about the risks and benefits of treatments.

 

Are there attitudes or beliefs that can be protective or beneficial when managing and treating pain?

Because pain is a powerful natural warning system, it demands attention and can undermine positive expectations.  Yet people sustain the ability to heal and adapt, and expecting recovery can have a powerful protective effect.  The facts about how pain persists and remits[5] encourage optimism even among people with multiple pain sites or longstanding pain.  The mainstay of treating chronic pain is focusing on functioning rather than pain – “doing what I want, even though I hurt a bit” rather than “doing everything to make the pain go away”.

 

Are there any ways in which new technologies or treatments may help older adults to manage pain?

Even though the experience of pain seems universal and obvious, it can be hard to measure and track, especially in the setting of the many other factors that influence an individual’s health and functional status.  New technologies are being developed to help give context to the experience of pain:

1. New ways of tracking pain and pain treatments over time.  It can be hard to remember longer-term changes in pain over time, and to correlate them with treatments.  Pain tracking software can give patients and providers meaningful data displays to help them figure out long-term trends, and what treatments are working.

2.  New ways of monitoring functioning.  The goal of pain treatments is to reduce pain and improve functioning.  As with pain, it can be hard to measure how someone is functioning.  Sensor-based technologies can monitor different forms of activity, such as walking speed, time spent out of house, and sleep.  Having this objective information across time can help in the understanding of pain’s effects, how it changes over time, and what treatments might help.

09/11/12

[1] Gignac, M., A. Davis, et al. (2006). ""What do you expect? You're just getting older": A comparison of perceived osteoarthritis-related and aging-related health experiences in middle- and older-age adults." Arthritis Rheum 55(6): 905-912.

[2] Zhang W, Moskowitz RW, Nuki G et al. OARSI recommendations for the management of hip and knee osteoarthritis, part I: Critical appraisal of existing treatment guidelines and systematic review of current research evidence. Osteoarthritis Cartilage 2007;15:981–1000.

[3] Styron W.  Darkness Visible:  A Memoir of Madness.  London:  Jonathon Cape, 1991.

[4] Thielke SM, Fan MY, Sullivan M, Unützer J.  Pain limits the effectiveness of collaborative care for depression.  Am J Geriatr Psychiatry. 2007 Aug;15(8):699-707.

[5]Thielke SM, Whitson H, Diehr P, et al. Persistence and remission of musculoskeletal pain in community-dwelling older adults: results from the cardiovascular health study.  J Am Geriatr Soc. 2012 Aug;60(8):1393-400.

 





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