ASPIRIN THERAPY

In reply: The letter by Dr. King emphasizes several controversial issues articulated briefly in the guidelines.’ The epidemiology of addiction among patients taking opioids for medical indications is not well described in the geriatric population. Data are often biased in sample and uncontrolled for many confounding variables. Authors do not agree on definitions of dependency and addiction. Whereas physiologic dependence is common, psychological dependence and addictive behaviors are more difficult to evaluate and are often confused with behavior of normal patients seeking effective treatment in an atmosphere of drug regulation and patient distrust. The AGS Panel on Chronic Pain in Older Persons recognized that opioid addiction does occur and the Panel emphasized that opioid analgesic medications should not be prescribed indiscriminately. However, the Panel concluded that fear of addiction and other side-effects do not justify failure to provide effective pain relief in older patients, especially those near the end of life. In fact, the Panel suggested that opioid analgesic medications are probably not prescribed often enough and often represent a better choice than other available drugs for many older patients with chronic pain. There is a growing basic science literature that suggests opioid drugs may have an effect on the immune system. The effects are often nonspecific, indirect, and not entirely understood. The Panel did not deal with this issue because correlation with clinical epidemiology remains unclear, and agerelated implications of these laboratory findings remain speculative. The vast majority of evidence-based literature surrounds the use of antidepressants for the treatment of neuropathic pain. When used for other types of pain, reported benefits are inconsistent among several studies, and the effect size is often reported to be small or moderate at best. In contrast, studies of antidepressants used for neuropathic pain have shown more consistent results and generally higher response rates. Thus, the Panel concluded that although other patients may benefit, most nonopioid analgesic (adjuvant) drugs seem to work best for neuropathic pain. It is also important for clinicians to know that none of these drugs are specifically approved by the FDA for pain indications. Although results of the NIH Consensus Conference on Acupuncture were not available at the time of the AGS Panel’s meetings, results of that conference should be important to clinicians. The NIH Consensus Panel on Acupuncture concluded that the incidence of adverse effects from acupuncture was substantially lower than that of many drugs or other accepted medical procedures for many conditions. They found sufficient evidence to conclude that acupuncture is efficacious for postoperative dental pain. Their report states, “There are reasonable studies (although sometimes only single studies) showing relief of pain with acupuncture on diverse pain conditions such as menstrual cramps, tennis elbow, and fibromyalgia.” However, the NIH consensus panel concluded, “Although many other conditions may have received some attention in the literature and, in fact, the research suggests some exciting potential areas for the use of acupuncture, the quality or quantity of the research evidence is not sufficient to provide firm evidence of efficacy at this time.’’2 Dr. King’s point regarding the classification of psychologically based pain disorders is well taken. Psychologically based pain disorders are classified as a specific type of somatoform disorder distinct from conversion reactions, hypochondriasis, and other somatoform disorders? The term ‘psychogenic pain,’ i.e., pain reports for which no identifiable pathology can be found other than psychologically based mechanisms, is an older term that may be pejorative, suggesting that these patients’ complaints are somehow different from other pain complaints. The AGS Panel’s intention was to focus on the fact that patients with purely psychological conditions may benefit from specific psychiatric interventions, but analgesic medications and other medical procedures for pain are usually of little benefit.