Pain Perception: A Complex Issue in Geriatric Medicine
This issue of Clinical Geriatrics has several articles devoted to the problem of pain in the older person. Pain is the most common reason for physician consultation in the United States and is a major symptom in many medical conditions. It significantly interferes with not only function, but also quality of life. The International Association for the Study of Pain (www.iasp-pain.org) has a classification system to describe pain according to five categories: duration and severity; anatomical location; body system involved; cause; and temporal characteristics.
However one describes it, pain is a very subjective problem with varying thresholds and complaints based on a wide variety of factors. These include person-to-person variability in pain perception, as well as cultural barriers that keep a person from telling someone that he/she is in pain, religious beliefs preventing one from seeking help for pain, and cultural and social expectations as to what is acceptable.
While physiological factors and various neurotransmitters are involved in pain perception, not all is known regarding the mechanisms involved. For years, placebos were given to determine whether pain was “real” or not. As a medical student, I remember witnessing the administration of saline to a patient complaining of pain and being surprised to hear the patient report an improvement in symptoms. I remember the medical team confronting this poor patient, calling her a “liar” with “drug-seeking behavior.” In reality, as many as one-third of persons given a saline injection that they believe to be morphine report improvement in pain symptoms.1,2 Those who are “anxious” have a greater response and those with “intense pain” report more benefit than those with milder forms. While there appears to be a reduced benefit following repeated administration of the “placebo,” there clearly is some effect beyond that resulting from reduced anxiety. The body’s endogenous opiate system, the endorphins, increase in response to the administration of a “placebo,” and perhaps other physiological changes occur as well. Even the administration of saline has a physiological effect that may help reduce pain perception. Is it “mind over matter” or the true integration of biopsychosocial factors? Data demonstrating the beneficial effects of mindfulness training in helping to relieve pain in patients with cancer is just another example of how complex this issue is.3
Reassurance and baseline pain relief with non-narcotic medications may help in many cases to reduce the need for more significant pain medication over time. The reason for the underlying pain, however, will be a major factor in just how successful one can be in managing symptoms with varying treatment regimens. The better we are prepared to identify pain early in its course, treat any underlying reversible condition responsible for the pain, and be able to use both nonpharmacologic and pharmacologic therapies appropriately, the better we can help our patients cope with what may be a devastating and life-changing problem.
I hope that you will enjoy this special series of articles in this issue that explore pain in the older person. Topics include: assessment and classification; pharmacologic management; miscellaneous pain syndromes; nonhernia causes of inguinal pain; and diabetic peripheral neuropathy. As always, we welcome your comments and suggestions. Additional topics available on www.clinicalgeriatrics.com as online exclusive content include alternatives and controversies for pain management in the elderly, among others.
Dr. Gambert is Professor of Medicine and Associate Chair for Clinical Program Development, Co-Director, Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Maryland School of Medicine, Director, Geriatric Medicine, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, and Professor of Medicine, Division of Gerontology and Geriatric Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
References
1. Hróbjartsson A, Gøtzsche PC. Placebo interventions for all clinical conditions. Cochrane Database Syst Rev 2010(1):CD003974.
2. Wampold BE, Minami T, Tierney SC, et al. The placebo is powerful: Estimating placebo effects in medicine and psychotherapy from randomized clinical trials. J Clin Psychol 2005;61(7):835-854.
3. Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med 1985;8(2):163-190.
Send comments to Dr. Gambert at: medwards@hmpcommunications.com