Chapter 58 Geriatric Pain Flashcards

1
Q

Practitioners should be guided by two overarching principles when evaluating
the older adult with pain.

A

First, the rules of multiplicity rather than Occam’s razor should drive the assessment of the causes and contributors to pain. That is, pain should be
conceptualized as a syndrome potentially “caused by a multiplicity of pathologies in multiple organ systems. The second principle follows in that the symptom with which a patient presents may represent the
weakest link, but not necessarily the treatment target

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2
Q

Low back pain in older adults commonly contributed to by

A

hip osteoarthritis, fibromyalgia syndrome, and myofascial pain

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3
Q

Myofascial pain may be contributed to by

A

axial spondylosis, degenerative scoliosis, leg length discrepancy, and anxiety

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4
Q

pain may present subtly as

A

loss of function, or change in mood or cognition

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5
Q

Treatment may require targeting

A

biomechanics, insomnia, depression, and/or other

long-standing chronic disease often coexisting with persistent pain to optimize function and quality of life

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6
Q

Older patients with persistent pain conditions should be screened routinely for

A

concurrent mental health conditions (e.g., depression, anxiety, and dementia). Failure to treat comorbid psychiatric illness will likely result in ineffective analgesia

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7
Q

Other diseases common in older adults that may cause or exacerbate pain include

A

osteoporosis and osteoarthritis, diabetes, cancer, cardiovascular disease, and dementia.

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8
Q

Alzheimer’s disease (AD) may pose a significant

challenge to the treating practitioner for a number of reasons:

A

(1) Patients with AD may have difficulty communicating their pain. (2) Anxiety/fear of pain may amplify the experience and expression of pain in patients with AD,
thus the most appropriate treatment may be uncertain.
(3) Patients with AD may perseverate on, but not suffer from, their pain, thus use of pain self-report as the gold standard
for guiding treatment becomes complicated.
(4) As dementia progresses, patients with AD may lose treatment
expectancy that may compromise analgesic efficacy.

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9
Q

Risk factors for the development of disability include

A

high burden of medical comorbidities, depression, sensory impairments related to vision and hearing, and musculoskeletal disorders such as arthritis. Smoking, level of alcohol use, inactivity, and lack of social support also contribute significantly

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10
Q

morphologic and functional changes in the peripheral and central nervous system that may impact pain processing

A

decline in the number of myelinated and unmyelinated fibers, an increase in the number of damaged nerve fibers, slowed nerve conduction velocity, loss of serotonergic and noradrenergic neurons in the dorsal horn, and a reduction in serotonergic receptor density in the anterior cingulate and prefrontal cortex, among others

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11
Q

Neuropsychological performance (NP)

A

declines with age and brain volume loss, senile plaques, and neurofibrillary tangles occur in the absence of AD. Persistent pain itself is associated with deterioration of NP and evidence indicates that pain reduction is associated with improved NP

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12
Q

Because provider–patient communication is an essential component in the treatment of pain

A

impairments in vision and hearing may alter treatment efficacy and require modified assessments. Vision and hearing change both structurally and functionally with age

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13
Q

Common eye diseases

A

cataract, glaucoma, macular degeneration, and

diabetic retinopathy) associated with aging may result in moderate to severe vision loss

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14
Q

Presbycusis

A

loss of hearing with age. Assistive technologies such as hearing aids and a frequency modulation (FM) device for those patients with speech
recognition difficulty, may be helpful when practitioners evaluate these patients, as they afford the opportunity to engage in more meaningful conversation and improved care

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15
Q

Postural control abnormalities leading to

A

increased risk of falls. pain adds to this risk. assessment of balance should be a routine part of assessing the older adult with pain.

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16
Q

Common changes in the musculoskeletal system include

A

sarcopenia (i.e., progressive loss of lean body mass associated with muscle cell atrophy and infiltration of fat), degenerative arthritis, and decreased bone density. Pain practitioners need to be acutely aware of the fact that radiographic evidence of degeneration without pain is exceedingly common

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17
Q

Management of changes in the musculoskeletal system

A

Over half of older adults with radiographic evidence of hip osteoarthritis (OA) are without hip pain. Thus, the history and physical examination should provide strong evidence of disease before imaging is ordered to avoid unnecessary procedures such as injections and surgery that carry the potential for morbidity.

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18
Q

majority of older adults with chronic low back with or without leg pain have a combination of pathologies responsible for their symptoms. Ex

A

hip OA, fibromyalgia, iliotibial band pain

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19
Q

Vertebral compression

fractures

A

occur in the absence of acute pain, but

as kyphosis develops, they may contribute to pain in the upper and lower back

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20
Q

vitamin D deficiency

A

common in older adults and may contribute to muscular pain and falls. Assessment of serum 25-OH vitamin D may be considered as part of pain
assessment in older adults and correction of insufficiency a routine part of treatment.

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21
Q

Pharmacokinetics

Absorption

A

Remains unchanged
Increase Gastric pH

Decrease Secretory capacity and GI blood flow

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22
Q

Pharmacokinetics

Distribution

A

Decrease Plasma albumin, Protein affinity, Total body water

Increase alpha 1-acid glycoprotein, Expression and activity of
P-glycoprotein in live

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23
Q

Pharmacokinetics

Metabolism

A

Decrease Liver volume, Hepatic blood flow, First-pass metabolism, Phase I metabolism, Phase II metabolism in frail

Increase Interindividual variability with age

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24
Q

Pharmacokinetics

Elimination

A

Measurable and predictable decline
in renal function with age
Decrease Glomerular filtration rate and Renal plasma flow

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25
Body Composition
Increase Body fat | Decrease Lean and total body mass
26
Central Nervous System
Decrease Blood supply to brain and Baroreceptor activity
27
Cardiovascular Function
Decrease Resting heart rate, stroke volume, and cardiac output
28
Renin-Angiotensin- | Aldosterone System
Decrease Plasma renin and Urine aldosterone
29
Medications that have a high hepatic extraction ratio may undergo
decreased clearance and experience a longer half life in older adults because of diminished liver size and blood flow
30
Meperidine and Morphine use in older patient
Meperidine (contraindicated in older adults because of its renally cleared active metabolite that can cause seizures) and morphine are high extraction ratio analgesics whose first-pass effect and clearance is reduced with age.
31
long half-life nonsteroidal antiinflammatory drugs are hepatically metabolized and their clearance may be reduced in older adults:
celecoxib, diflunisal, | naproxen, oxaprozin, prioxican, salsalate, and sulindac
32
Analgesics that are affected by aging-associated decline in | renal function include
codeine, duloxetine, gabapentin, meperidine, pregabalin, propoxyphene, salicylate, tramadol, and the opioids morphine, oxycodone, hydromorphone, fentanyl, and methadone
33
Cockcroft-Gault equation, shown below, to estimate creatinine clearance (CrCl) that helps to guide dose adjustment of renally cleared medications
CrCl = ( (140 ¬- age) * (Wt in kg) * (0.85 if female)) / | 72 *Cr
34
Pharmacodynamics refers to
tissue sensitivity and how a drug interacts with its end organ. The body’s response to medications may be therapeutic or adverse
35
Opioid sensitivity increases with associated decline
in mu opioid receptor density and increase in opioid affinity. Thus older adults may respond to opioid doses that are significantly smaller than those in younger individuals.
36
The purpose of pain assessment is twofold:
(1) to identify contributors to pain that are usually multiple, and (2) to identify outcome measures to follow during the course of treatment, that is, each patient’s individual “pain signature
37
Pain assessment in older adults
Pain assessment should be an ongoing process to measure change in pain over time as this will affect any necessary modifications in the treatment course. Assessment of pain alone is not sufficient; providers should inquire about changes in appetite, sleep, and/or mood, loss of mobility, and diminished activity level.
38
indicative of an acute | pain event
Abnormalities in traditional vital signs such as abrupt changes in respiratory rate or heart rate
39
For cognitively intact older adults, there are many pain rating tools from which to choose
Numeric rating scales (NRS) and verbal descriptor scales (VDS)
40
Medication that enhance fall risk
opioids, tricyclic antidepressants, gabapentin, and pregabalin
41
How to manage patient who are taking Medication that enhance fall risk
it is prudent to optimize mobility (e.g., by referring the patient to a physiatrist or physical therapist for instruction in using the appropriate assistive device and gait/balance training) prior to prescribing medications that may further increase this risk
42
Assessment of cognitive function is critical. Mini-Cognitive Assessment Instrument (Mini-Cog)
Step 1 Ask the patient to repeat three unrelated words, such as “ball,” “dog,” and “television.” Step 2 Ask the patient to draw a simple clock set to 10 min after 11 o’clock (11:10). A correct response is a drawing of a circle with all of the numbers placed in approximately the correct positions, with the hands point to the 11 and 2. Step 3 Ask the patient to recall the three words from Step 1. One point is given for each item that is recalled correctly.
43
On Mini-Cognitive Assessment Instrument | (Mini-Cog) If there is evidence of dementia
in addition to treating the patient’s pain, the provider should refer the patient for neuropsychological testing or to a specialist who can address this important problem such as a geriatrician or neurologist.
44
Cognitively impaired older adults are at increased risk of pain undertreatment because of
the belief among many health-care workers that their pain ratings are unreliable. In fact, patients with mild to moderate cognitive impairment can reliably report pain using verbal descriptor scales. In patients with more advanced dementia who have difficulty using self-report instruments, caregivers rely on behavioral cues to determine the presence and severity of pain
45
one of the most sensitive and reliable behavioral indicators of pain in patients with dementia or poor verbal communication
Facial grimacing
46
other indicators of pain in patients with dementia or poor verbal communication
guarding, bracing, rubbing and sighing
47
Common Pain Behaviors in Cognitively Impaired | Elderly Persons
Facial expressions - Frown; sad, frightened face, Grimace, wrinkled forehead, tightened eyes Verbalizations/ vocalizations - Sighing, moaning, groaning, grunting Calling out, asking for help Noisy breathing; verbally abusive Body movements Rigid, tense body posture; guarding, fidgeting Pacing, rocking; restricted movement Gait or mobility changes
48
Common Pain Behaviors in Cognitively Impaired | Elderly Persons
Changes in interpersonal interactions Changes in activity patterns or routines Mental status changes Changes in interpersonal interactions Aggressive, combative, resisting care Decreased social interactions, withdrawn Socially inappropriate, disruptive Changes in activity patterns or routines Refuses food, appetite change Sleep, rest pattern changes Sudden cessation of common routines Mental status changes Crying, tears Increased confusion Irritability or distress
49
For all patients presenting with pain ruling out serious | conditions (i.e., red flag symptoms) that require immediate attention is paramount
fever, sudden unexplained weight loss, acute onset of severe pain, neural compression, loss of bowel or bladder function, jaw claudication, new headaches, bone pain in a patient with a history of malignancy or that awakens the patient from sleep, and sudden pain in an extremity that is associated with pallor, pulselessness, and paresthesias
50
After determining the older adult’s pain signature, multifaceted treatment should be designed
an antidepressant, cognitive behavioral | therapy, and physical therapy may be the most appropriate components of the treatment regimen.
51
For the older adult with dementia and excessive fear of pain because of social isolation
placement in an assisted living facility may most effectively improve quality of life. If the practitioner determines that pain itself requires treatment, a stepped care approach should be utilized
52
EXERCISE
participation in regular exercise improves psychological well-being, reduces pain, and increases functional capacity in older adults with persistent pain. A combination of endurance, resistance, balance, and flexibility exercises may yield important health benefits
53
exercise prescribed for treating osteoarthritic pain
individualized programs should be created to meet the patient’s unique needs. It has been demonstrated in older adults with knee OA that both low-intensity and high-intensity stationary bicycling for 25 min three times a week promote decreased pain and improved function
54
Goal of Physical therapy
Reducing pain, optimizing fitness, and promoting functional dependence should be the goals of treatment. It is critical that the patients view themselves as taking an active role in treatment rather than as a passive recipient.
55
key to successful pain rehabilitation in Physical therapy
being committed to maintaining a home exercise program, learning how to pace activities and self-manage pain flares
56
Assistive devices for older adults with pain serve the following purposes:
(1) pain relief, (2) enhancement of mobility | and stability, and (3) modification of painful activities.
57
Assistive devices
canes and walkers exert their analgesic effect by reducing load (e.g., canes for lower extremity arthritis, walkers for low back pain). Canes are generally used for those patients with mild to moderate mobility impairment; walkers tend to be prescribed for those patients with “generalized weakness, extreme inability for lower-limb weight bearing, debilitating conditions or poor balance control
58
Upper extremity assistive devices can help | to modify painful activities
Reachers, jar openers, button aids, and zipper pulls are often prescribed for patients with osteoarthritis
59
Topical therapies for pain are an attractive option for older adults given
their mild side effect profile, less systemic | absorption compared to oral medications, and ease of application
60
Topical therapies for pain
capsaicin cream and a topical lidocaine patch 5% for joint and low back pain, postherpetic neuralgia, and other neuropathic symptoms; diclofenac gel for osteoarthritis; and a topical diclofenac epolamine patch for acute pain associated with minor strains and sprains
61
side effects of Topical therapies
local irritation or rash and a burning sensation, the latter occurring most commonly with capsaicin cream
62
intra-articular corticosteroid and/or hyaluronic acid injections may be beneficial
patients with pauciarticular joint pain associated with inflammatory and noninflammatory arthritides
63
Patient with neuropathic pain (e.g., postherpetic neuralgia) treated with
nerve blocks may aid in reducing pain but their benefits are typically shortlived, lasting only a few days or weeks
64
Trigger-point injections with local anesthetic have proven effective in alleviating
myofascial pain
65
Epidural steroid injections (ESI) have been used to treat pain conditions associated with
lumbar spinal stenosis involving the central and/or lateral canal. Patients with herniated discs, spondylolisthesis, scoliosis, and degenerative disc disease may see benefits following ESI
66
Two of the most commonly used medications in the older adult with mild to moderate pain are
acetaminophen (APAP) and nonsteroidal anti-inflammatory drugs (NSAIDs)
67
first-line treatment in patients with osteoarthritis and other types of musculoskeletal pain
Acetaminophen
68
a risk of unintentional acetaminophen overdose
>4000 mg/day
69
treatment of patients with inflammatory pain (e.g., gout, pseudogout
NSAIDs may be indicated for short-term use although intra-articular corticosteroid injections may be used when one or two joints are involved.
70
Chronic use of NSAIDs may be fraught with a number of risks including
congestive heart failure, exacerbation of hypertension, renal insufficiency, and gastrointestinal bleeding.
71
risk factors for GI bleeding
age 75 and older, peptic ulcer disease, GI bleed, and use of glucocorticosteroids.
72
Risk factors associated with renal insufficiency include
age 75 and older, diabetes mellitus, hypertension, and use of angiotension-converting enzyme inhibitor or diuretics.
73
Avoiding NSAIDs in patients with congestive heart failure due to
the possibility of exacerbation and in patients with renal dysfunction who have serum Cr concentration over 150 mmol or glomerular filtration rate of less than 50 ml/hr.
74
Corticosteroids are commonly prescribed in older adults with
inflammatory disorders (e.g., giant cell arteritis, polymyalgia rheumatica, rheumatoid arthritis).
75
Corticosteroids are indicated for pain associated with malignancy because they
reduce tumor-associated edema that can cause spinal cord compression, brain herniation, and compressive neuropathy
76
Corticosteroids common side effects include
glucose intolerance, | hypertension, psychosis, and osteoporosis,
77
Consider using opioids for the treatment of
moderate to severe pain (both nociceptive and neuropathic), earlier in the course of disease than previously recommended to avoid the multiple potential toxicities associated with NSAIDs
78
A general rule is that long-acting opioids should
never be initiated in the older adult who is opioid-naïve. A short-acting preparation should always be initiated and once the total daily dose requirement is determined, the patient can then be switched to a long-acting preparation, supplemented with an as-needed short-acting drug for breakthrough pain
79
adverse effects of opioids
constipation, falls and fractures, urinary retention (e.g., in the patient with prostatic enlargement) and delirium
80
Buprenorphine has been shown to be both effective | and well-tolerated in patients with
cancer and nonmalignant | persistent pain such as neuropathic pain
81
Fentanyl patches vs. transdermal buprenorphine
Fentanyl patches have been used increasingly to treat persistent pain in the older adult; while it appears that transdermal buprenorphine may have a better side effect profile, therapeutic index, and ease of titration, inadequate data exist to support recommending its use in older adults
82
Contraindications of using | buprenorphine
Patients with opioid dependence, myasthenia gravis, respiratory depression, and delirium tremens
83
methadone may be very useful
Given its low cost, long-acting properties, and efficacy when used in small doses in frail older adults
84
Risk of metahdone
its very long and variable half-life. In addition to having all of the same potential adverse effects as the other opioids, patients on methadone may suffer from QTc prolongation. patients being started on methadone should receive an EKG at baseline, 30 days after initiating methadone, and then annually and sleep-disordered breathing.
85
first-line treatment for Neuropathic Pain
antidepressants with both norepinephrine and serotonin reuptake inhibition properties (SNRIs), calcium channel a2-d ligands, and topical lidocaine
86
second line treatment for Neuropathic Pain
opioids and tramadol
87
Most commonly studied SNRI antidepressants for treating neuropathic pain
duloxetine and venlafaxine. Both have evidence of efficacy for painful diabetic neuropathy
88
Venlafaxine
used in cases of painful polyneuropathies, although caution should be exercised in patients with cardiovascular disease
89
Treatment of trigeminal neuralgia | is different from that of other neuropathic pain states
For this disorder, carbamazepine or oxcarbazepine are recommended as first line
90
Treatment of postherpetic | neuralgia
gabapentin, pregabalin, and tricyclic antidepressants
91
Tertiary amines should be avoided | in older adults because of
``` Tertiary amines (amitriptyline, imipramine, trimipramine, doxepin, clomipramine) should be avoided in older adults because of their anticholinergic side effects (sedation, delirium, urinary retention, constipation, glaucoma exacerbation, and dizziness). ```
92
Secondary amines have been shown to have more tolerable side effect profiles
nortriptyline, desipramine, protriptyline, amoxapine
93
a baseline EKG should be obtained prior to starting | a tricyclic antidepressant and monitored periodically with dose titration
Because of their potential for QT prolongation
94
For Neuropathic pain opioids | have proved efficacious in patients with
postherpetic neuralgia | and painful peripheral neuropathy
95
Tramadol
weak mu-opioid receptor agonist that also inhibits the reuptake of norepinephrine and serotonin, may fare better in older adults at reducing neuropathic pain.
96
Benzodiazepines have been used to treat
Muscular spasms, neuropathic pain, and anxiety related to pain crises.
97
Benzodiazepines should generally be avoided in older adults for the treatment of neuropathic pain because of
the risk of symptomatic rebound, dizziness, falls, and confusion
98
Fibromyalgia
symptoms occurring for longer than 3 months varying | from morning stiffness, fatigue, and nonrestorative sleep to headaches, myofascial pain, and pelvic pain
99
Treatments for fibromyalgia
low-dose tricyclic antidepressants, cyclobenzaprine, aerobic exercise, cognitive behavioral therapy, or a combination of these treatment methods
100
Food and Drug Administration (FDA) approved for the treatments of fibromyalgia
Duloxetine, pregabalin, and | milnacipra
101
Outcomes used to monitor treatment efficacy in patients with fibromyalgia include
pain intensity and physical and emotional functioning
102
complementary and alternative medicine (CAM) approaches to persistent pain
Meditation, vitamin and mineral supplements, herbs, and chiropractic medicine are commonly used in older adults with back pain, arthritis, and mental illness.
103
eight common behavioral modalities in treating | persistent pain in older adults
biofeedback, progressive muscle relaxation, meditation, guided imagery, hypnosis, tai chi, qi gong, and yoga. The benefits of complementary therapies such as these improve not only the self-reported pain but also pain related comorbidities such as depression, anxiety, and disability.
104
In the practice of interdisciplinary pain medicine
it is important to consider geriatricians, geriatric psychiatrists, physiatrists, rheumatologists, neurologists, and endocrinologists as important potential collaborators in the care of frail older adults with complex conditions.
105
Anticonvulsant | Carbamazepine (Tegretol)
100 mg daily SE: Monitor hepatic transaminases (aspartate transaminase, alanine transaminase), complete blood count, creatinine, blood urea nitrogen, electrolytes, serum carbamazepine levels. Multiple drug-drug interactions
106
Anticonvulsant | Gabapentin (Neurontin)
100 mg at bedtime | Monitor sedation, ataxia, edema
107
Anticonvulsant | Pregabalin (Lyrica)
50 mg at bedtime Monitor sedation, ataxia, edema
108
Anticonvulsant | Lamotrigine (Lamictal)
25 mg at bedtime Monitor sedation, ataxia, cognition. | Associated with rare cases of Stevens-Johnson syndrome
109
Antiarrhythmic | Mexiletine (Mexitil)
150 mg twice daily Monitor electrocardiogram at baseline and after dose stabilization. Avoid use in patients with conduction block, bradyarrhythmia
110
Corticosteroids (prednisone, methylprednisolone, e.g., | Deltasone, Medrol dose pak Liquid Pred, Orasone)
5 mg prednisone daily and taper as soon as feasible. Use lowest possible dose to prevent steroid effects. Anticipate fluid retention and glycemic effects in short-term use and cardiovascular and bone demineralization with long-term use.
111
Lidocaine (topical) | Lidoderm 5%
1–3 patches for 12 hr per day | Monitor for rash or skin irritation
112
Muscle Relaxants | Baclofen (Lioresal)
5 mg up to 3 times daily Monitor muscle weakness, urinary function, cognitive effects, sedation. Avoid abrupt discontinuation because of central nervous system irritability. Older persons rarely tolerate doses greater than 30 to 40 mg per day
113
Muscle Relaxants | Tizanidine (Zanafex)
2 mg up to 3 times daily Monitor muscle weakness, urinary function, cognitive effects, sedation, orthostasis. Potential for many drug–drug interactions.
114
Muscle Relaxants | Clonazepam (Klonopin)
0.25–0.5 mg at bedtime Monitor sedation, memory, complete blood count
115
Cannabinoid | Nabilone (Cesamet)
1 mg 1 or 2 times daily Monitor ataxia, cognitive effects, sedation. High incidence of dizziness or drowsiness. Cardiovascular effects with tetrahydrocannabinol or cannabidiol. Older persons may be prone to postural hypotension. Nabilone is approved for nausea and vomiting but may help with some pain syndromes.
116
Cannabinoid | Dronabinol (Marinol)
2.5 mg 1 or 2 times daily Dizziness, somnolence, cognitive impairment, dysphoria
117
Tramadol (Ultram/Ultram ER)
12.5–25 mg every 4–6 hr Mixed opioid and norepinephrine or serotonin reuptake inhibitor mechanisms of action. Monitor for opioid side effects, including drowsiness, constipation, and nausea. Risk of seizures if used in high doses or in predisposed patients. May precipitate serotonin syndrome if used with selective serotonin reuptake inhibitors.
118
Tapentadol (Nucynta)
50 mg every 4–6 hr by mouth (equivalent to oxycodone 10 mg every 4–6 hr by mouth) Clinical trials of tapentadol suggest lower incidence of gastrointestinal adverse events than comparator opioids.
119
Sustained release (Avinza, Kadian, MSContin, Oramorph SR)
15 mg every 8–24 hr Usually started after initial dose determined by effects of immediate-release opioid or as an alternative in a different long-acting opioid due to indications for opioid rotation. Toxic metabolites of morphine may limit usefulness in patients with renal insufficiency or when high-dose therapy is required. Continuous-release formulations may require more-frequent dosing if end-of-dose failure occurs regularly. Significant interactions with food and alcohol toxicity
120
Hydromorphone (Dilaudid, Hydrostat) Methadone (Dolophine)
1–2 mg every 3–4 hr For breakthrough pain or for around-the-clock dosing. Highly variable half-life and nonlinear dose equivalencies when switching from other opioids. Not recommended as first-line agent.
121
Tricyclic Antidepressant Desipramine (Norpramine), Nortryptyline (Aventyl, Pamelor), Amitriptyline (Elavil)
``` 10 mg at bedtime Significant risk of adverse effects in older patients. Anticholinergic effects (visual, urinary, gastrointestinal); cardiovascular effects (orthostasis, atrioventricular blockade). Older persons rarely tolerate doses greater than 75 to 100 mg per day. ```
122
Duloxetine (Cymbalta
30 mg daily Monitor blood pressure, dizziness, cognitive effects, and memory. Has multiple drug-drug interactions.
123
Venlafaxine (Effexor)
37.5 mg daily Venlafaxine associated with dose-related increases in blood pressure and heart rate.