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