1. Is Old Age A Sanctuary For The Use Of Addictive Substances For Pain Management? Ross Bryan MS III Mercer University August 17 2012

2. 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

3. 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

4. Chronic Pain in the Elderly Osteoarthritis Chronic lower back pain Neuropathies

5. Osteoarthritis Cartilage degeneration and joint inflammation Joint space narrowing and bone-bone contact

6. 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

7. Treatment of OA and LBP

8. 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

9. Treatment of Neuropathy

10. 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

11. Addiction (maladaptive learning)

12. 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

13. 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

14. 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

15. Tolerance Enzyme systems in the brain adapt with chronic addictive drug exposure Increasing doses are required to maintain rewarding and analgesic effects

16. 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

17. Review of Side Effects AnticonvulsantsSomnolence, dizziness, weight gain OpioidsSedation, constipation, respiratory depression

18. STATISTICS Tables and charts derived from Substance Abuse and Mental Health Services Administration (SAMHSA) Data Archive

19. TEDS Admissions Age 55+

20. TEDS Admission for Opiates (Age 55+)

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

22. 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