Page 119 Complete Your CE Test Online - Click Here population and may be under-reported and undertreated (Prostran et al., 2016). The under-reporting of pain by older patients may be secondary to the belief that pain is inevitable as one ages, or a fear their condition is worsening (Prostran et al., 2016). The undertreatment of pain may be secondary to the challenge of treating elderly patients who are at risk for adverse events (Atkinson, Fudin, Pandula, & Mirza, 2013). The elderly population is prone to painful conditions, including fibromyalgia, diabetic neuropathy, osteoarthritis, degenerative joint disease, cancer, postherpetic neuralgia, and rheumatoid disorders (Atkinson, Fudin, Pandula, & Mirza, 2013). Pain in the aging population can be a challenge to manage because of many factors: comorbidities and associated medication interactions, decreased liver and renal function, cognitive impairments, decreased mobility, and increased risk for falls. Before administering or prescribing opioids for pain relief in the geriatric population, the patient should be evaluated for cognitive impairment, risk for falls, and respiratory or renal malfunction (ICSI, 2016). Lowering the dosage of opioid medication in the older population may be necessary to avoid falls, respiratory depression, and renal failure. Complementary therapies—such as TENS, acupuncture, massage, exercise, guided imagery, and relaxation techniques—can be useful in the aging population (Abdulla et al., 2013). Reassessment of the effectiveness of pain management therapies and side effects is necessary to ensure optimal pain relief. Pharmacological considerations that occur with aging Older patients may process medications differently than younger patients do as a result of the normal aging process. As mentioned previously, older adults may experience decreased renal excretion, which allows for an increase in medication half-life, or renal toxicity (American Geriatrics Society [AGS], 2009). Liver metabolism may be slower resulting in prolonged medication half-life (AGS). Slowing of gastrointestinal motility may prolong the effects of continuous-release enteral medications, and older adults may have more pronounced difficulty with bowel dysmotility secondary to opioids (AGS). Anticholinergic side effects of medications—such as confusion, constipation, and urinary retention—are more pronounced in the older population (AGS). Care must be taken to thoroughly evaluate elderly patients with pain because of the complex clinical picture they present. Self-assessment question 9 What aspects of the treatment of pain should be considered before starting a plan of care for pain management in the older population? a. Liver and renal function may be decreased in the older adult. b. Lower dosages of pain medication may be necessary. c. Comorbidities and potential medication interactions should be carefully evaluated. d. All of the above. Pediatric population Pediatric pain may be undertreated for a variety of reasons. In some cases, children react to their pain differently than adults. For example, a child may deny pain because of fear of treatment or not wanting to disappoint a caregiver (Matthews, 2011). Children’s perception of pain varies greatly even in children of the same age group (Matthews, 2011). Even though children suffer pain postoperatively the same as adults do, such factors as fear, anxiety, and lack of coping skills can compound the perception of pain (Verghese & Hannallah, 2010). Children may have trouble verbalizing their pain, depending on verbal, intellectual, and social abilities (Verghese & Hannallah). It is therefore important that nurses use the most appropriate pain scale in evaluating the pediatric patient and reassess pain relief after pain medication administration and at regular intervals. Chronic pain is estimated to affect 20% to 40% of children worldwide, with the most common complaints of pain musculoskeletal pain, headaches, and abdominal pain (ACPA, 2016). Expression of pain in children Children express pain in different ways according to their age group. Newborns may express pain by moving less than normal, crying more frequently, and acting restless. They appear sweaty and pale (Canbulat & Kurt, 2012). Toddlers may cry more than normal, can be restless, and may move less than normal (Canbulat & Kurt). Toddlers may be able to show where their pain is located but may not be able to express verbally when they are experiencing pain. And they may be uncooperative (Canbulat & Kurt). School-age children may be able to verbalize their pain and objectively rate their pain (Canbulat & Kurt, 2012). They may also display similar characteristics of pain expression as younger children do, and may be influenced by cultural beliefs about pain (Canbulat & Kurt). Adolescents may show the same signs of pain adults do. Even though adolescents may appear calm, they may have sleep difficulties, loss of appetite, withdrawal from friends and family, and anxiety or anger. They may be hesitant to admit to pain secondary to a fear of getting addicted to pain medication (Canbulat & Kurt, 2012). Adolescents are typically able to verbalize and rate their pain more reliably than younger children can. Children experiencing pain can benefit from a family-centered approach to pain management, especially in the child suffering from chronic pain. Parental involvement can provide comfort for the child and relieve anxiety (Canbulat & Kurt, 2012). Communication with families and age-appropriate communication with the child are important to ensure trust and reduce anxiety when possible. Opioid-tolerant patients or those at risk for addiction Patients tolerant of opioids, have a previous history of addiction, or are at risk for addiction may be difficult to properly treat, and it may be difficult to manage their pain. Patients may need to be monitored via drug screening. A thorough evaluation of the type of addiction should be performed, and a consultation with a pain management specialist should be considered (Marks & Rodgers, 2014). Other recommendations for those at risk for addiction include the following (O’Brien, 2014): ● ● Involving patients’ families to increase supervision and support. ● ● Having one prescriber and one pharmacy. ● ● Prescribing long-acting opioids when possible. ● ● Using nonopioids and complementary therapies when possible. Patients who are opioid tolerant may need high doses of medication to achieve pain relief. It may be useful to use adjuvant medications, such as acetaminophen or NSAIDS (Marks & Rodgers, 2014). Misuse of prescription opioids The opioid epidemic in the United States has been referred to as “one of America’s greatest public health challenges” (BCBS, 2017). The misuse of prescription opioids includes taking opioids in a manner or dose other than prescribed, taking someone else’s opioid medication (even if it is for pain), and taking a medication to induce feelings of euphoria or a “high” (National Institute on Drug Abuse [NIDA], 2016). Deaths secondary to unintentional overdose from pain medications have more than quadrupled since 1999 and are greater than those secondary to heroin and cocaine since 2002 (CDC, n.d.). The main source for misuse of prescription opioids is physician prescriptions for the patient who is misusing the drug or giving it to someone else—this is known as drug diversion (Shei et al., 2015). Opioids are similar to heroin in chemical makeup. In addition to providing pain relief, they induce feelings of euphoria as they act on reward regions of the brain (NIDA, 2016). Those who use opioids for an extended time can become dependent, tolerant, and addicted. Dependence involves physiological adaptations by the body when exposed to a drug for extended periods (NIDA, 2016). It is a physical dependence on a medication whereby unpleasant withdrawal symptoms occur when the drug is reduced or stopped abruptly