Is Old Age A Sanctuary For The Use Of Addictive

Substances For Pain Management?

Ross Bryan MS III

Mercer University

August 17 2012

What is a Sanctuary?? The term sanctuary

originally referred to a shrine or holy place

The term has come to mean any place that is a safe haven

What are the implications in calling old age a Sanctuary??

If old age is a sanctuary against the use of addictive medications for pain management, then this must imply that there are harmful adverse effects associated with these medications

Issues with pharmacologic pain management: Abuse

Dependence Addiction

Side effects

Chronic Pain in the Elderly Osteoarthritis Chronic lower back pain Neuropathies

Osteoarthritis Cartilage

degeneration and joint inflammation

Joint space narrowing and bone-bone contact

Lower Back Pain Degenerative disease

of the IV discs and facets of vertebrae

Compromised structural support from muscle (myofascial) atrophy/disease

Spinal stenosis Compression fractures

Treatment of OA and LBP

Neuropathy Dysfunction in the nervous system

Diabetic neuropathy Microvascular damage that supplies nerves Polyol pathway (glucose --> sorbitol)

Post-herpetic neuralgia Viral nerve damage

Trigeminal neuralgia Nerve compression or entrapment

Treatment of Neuropathy

Principles of Addiction Physical dependence vs Mental addiction

Dependence (95%)--> tolerance and withdrawal Occurs invariably with chronic use (Katsung 2009)

Addiction (5%) --> relapse despite (-) conseq.

A physical allergy coupled with a mental obsession

-Alcoholics Anonymous

Addiction (“maladaptive learning”)

Interesting Facts Parkinsonian patients being treated with

dopamine agonists may become pathologic gamblers or develop habits for other recreational activities (sex, eating, etc.)

Many elderly patients enter treatment facilities for drug addiction with symptoms related to various types of psychosis that resolve after long-term sobriety

Synaptic Plasticity in Addiction Synaptic plasticity

Changes in synapse strength between neurons

Long Term Potentiation (LTP) Enhancement of signal

transmission between two or more neurons as a result of simultaneous stimulation

Allows us to link external stimuli to reward center

Triggers can cause relapse

Why is Addiction Bad? Self-Neglect

Muscle wasting Inactivity

Malnutrition Wernicke-Korsakoff (thiamine deficiency)

Wernicke --> confusion and tremor Korsakoff --> memory loss

Social Isolation Neglect of responsibilities

Work/Family Bills/Finances

Tolerance Enzyme systems

in the brain adapt with chronic addictive drug exposure

Increasing doses are required to maintain rewarding and analgesic effects

Why is Tolerance Bad? Many of the side effects of drugs do not

undergo tolerance and can lead to serious conditions (ex. respiratory depression)

Energy and Resource expenditure to obtain more drugs

Withdrawal if drug is discontinued Tends to be opposite the effect of the drug

Ex. CNS depressant will have excitatory withdrawal

Review of Side Effects

Anticonvulsants Somnolence, dizziness, weight gain

Opioids Sedation, constipation, respiratory depression

STATISTICS Tables and charts derived from Substance

Abuse and Mental Health Services Administration (SAMHSA) Data Archive

TEDS Admissions Age 55+

0

20000

40000

60000

80000

100000

120000

1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

AlcoholTotal

TEDS Admission for Opiates (Age 55+)

0500

1000150020002500

300035004000

45005000

1992 1996 2000 2004 2008

Opiates

Conclusions

Is Old Age A Sanctuary for The Use of Addictive Substances in Pain Management?

Citations Weiner, K. Debra, MD. Office Management

of Chronic Pain in the Elderly. The American Journal of Medicine (2007) 120, 306-315.

www.samhsa.gov Katsung. Basic and Clinical Pharmacology

11th edition pg. 553-559