Treatment of Pain in Patients With Complicating Disorders: Case Report From Norway, With Commentaries From Germany and Belgium

ABSTRACT

A 70-year-old male with a history of bipolar disorder, alcohol misuse, and polyneuropathy is presented. His treatment was complicated by multiple drugs, and by instability and falls. The advantages and disadvantages and dosing considerations with short- and long-acting analgesics are discussed.

KEYWORDS :

• anticonvulsants
• case
• comorbidities
• falls
• instability
• long-acting
• opioids
• pain

COMMENTARY FROM GERMANY

Stefan Wirz^a

The four main problems of pain therapy in the elderly are outlined in this case: compound pain phenotypes, multimorbidity with pharmacokinetic limitations, psychosocial problems, and deficiencies of therapy with the danger of complications due to pharmacological interaction.

Short-acting opioids are inconvenient for the treatment of persistent pain; furthermore, tramadol reveals a dual mechanism with an impact on the noradrenaline and serotonin reuptake. Thus, it acts like an antidepressant, adding a further reason for cognitive impairments of an elderly patient with multiple disorders and sensory-motor damages. The renal impairment will cause elevated blood levels of most of the drugs in use. Moreover, centrally acting substances such as neuroleptics, which show no analgesic properties, were used, leading to a higher risk of adverse effects and, potentially, to falls in such patients.

The authors of this case report solved these problems by changing the medication with regard to the reduced renal excretion rate, stopping short-acting opioids and neuroleptics, and considering other treatment options (knee replacement). After various complications, the multidisciplinary approach leads to a significant improvement.

This report underlines the need for a pain management in geriatric patients adjusted for multimorbidity status and pharmacological limitations. Therefore, this study of a “common” case is valuable.

COMMENTARY FROM BELGIUM

Bart Morlion^b

The manipulation of neuromodulatory mechanisms in the nociceptive system by pharmacological and nonpharmacological interventions can alter the processing of pain. This can therefore be beneficial in the clinical treatment of patients. This case report is a typical illustration of the multidimensional and multifactorial nature of pain.

Treatment was made very challenging, not only by the mix of nociceptive, neuropathic, and myofascial pain components, but also by the affective disorder and frailty of the patient. In addition, polypharmacy and nonadherence to medication are prevalent issues in the elderly population and can lead to drug-induced complications, including confusion and falls. Apart from the CNS side effects, the treatment of the patient's mood disorder with carbamazepine further complicates matters due to drug interactions and interference with the metabolism of many other drugs. In both the elderly and patients at risk of epilepsy, the tramadol dose should be below 300 mg per day.

Effective management of chronic pain with medication involves careful titration of several analgesics, usually targeting several pain mechanisms. Balancing pain relief with side effects involves tightrope walking for the physician, whose moral duty is to ensure the benefits of treatment outweigh the risks. In this case, careful clinical evaluation and a switch to a low-dose, long-acting opioid reduced the side effects and improved the patient's quality of life.

Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.

Notes

a Dr. Stefan Wirz is Head of Anaesthesiology, CURA Hospitals, Bad Honnef, Germany.

b Professor Dr. Bart Morlion is an anesthesiologist and Director of the Leuven Centre for Algology and Pain Management at the University Hospital, Leuven, Belgium.