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[ F R O M P U B L I C AT I O N T O P R A C T I C E ] Addressing the Societal Burden of Opioid Misuse:

FOCUS ON A BALANCED APPROACH TO OLDER ADULTS WITH CHRONIC PAIN [ FACULTY ] Stephen Crystal, PhD Associate Director for Health Services Research ❙ Institute for Health, Health Care Policy and Aging Research ❙ Board of Governors Professor, School of Social Work ❙ Rutgers, The State University of New Jersey Roger B. Fillingim, PhD Distinguished Professor, College of Dentistry ❙ Director, Pain Research and Intervention Center of Excellence ❙ Clinical Translational Science Institute ❙ University of Florida Jeff Gudin, MD Director, Pain Management and Palliative Care ❙ Englewood Hospital and Medical Center, New Jersey ❙ Clinical Instructor of Anesthesiology ❙ Icahn School of Medicine at Mount Sinai Michael Toscani, PharmD Research Professor/ Fellowship Director ❙ Rutgers Institute for Pharmaceutical Industry Fellowships ❙ Ernest Mario School of Pharmacy ❙ Rutgers, The State University of New Jersey

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[ LEARNING OBJECTIVES ] After reading this publication, participants will be able to: [ ] Explain the principles of balanced pain management, including various strategies and modalities that should be incorporated in an individualized treatment plan. [ ] Describe properties of abuse-deterrent formulations of opioids. [ ] Discuss programs and strategies that are designed to support patient and provider education about safe opioid use. [ ] Explain strategies that patients should use to properly store and dispose of opioids and other controlled substances.

Balanced Chronic Pain Management in Older Adults

According to the 2011 Institute of Medicine report, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, chronic pain affects approximately one third of adults in the United States.1 Although a precise definition of chronic pain remains elusive, pain is generally considered chronic when it is unlikely to resolve or lasts longer than the expected healing time. Sometimes, pain is considered chronic if it persists for 3 months or more.2 Chronic pain is common in older adults, who have a greater prevalence of degenerative, oncologic, and neuropathic pain conditions. It is estimated that the prevalence of pain complaints is twice as high in those older than 60 years of age compared with younger adults. Among individuals residing in long-term care facilities, the prevalence of pain has been estimated to range between 45% and 80%, and many of these individuals experience pain on a daily basis.3 Management of chronic pain is challenging and it is often suboptimally assessed and treated. Undertreatment of pain results in unnecessary suffering, decreased quality of life, increased utilization of health care resources, sleep impairment, psychosocial difficulties including anxiety and depression, and reduced patient satisfaction with the health care system.1 A comprehensive approach to pain management should address the patient’s underlying conditions, including psychological conditions such as depression and anxiety that can exacerbate the pain experience. Managing chronic pain in older adults presents additional challenges, including assessment difficulties due to communication barriers, comorbid medical conditions, increased sensitivity to medication side effects, mobility and safety issues, and the ongoing potential for medical, cognitive, and functional decline.3 A comprehensive and thorough evaluation is essential for appropriate pain management in all patients but is particularly crucial for older adults. To develop an effective care plan, the evaluation should include an assessment of the pain complaint, consideration of painful comorbidities as well as issues such as deconditioning, falls, polypharmacy, cognitive dysfunction, and malnutrition—all of which can be exacerbated by pain.3 Many organizations and