Pain Management in the Elderly

Question 1

Pain Assessment and Aging

Answer 1

• Degenerative diseases of abnormal aging which are accompanied by pain: arthritis, neuromusclar disorders (stroke, DM, peripheral neuropathy, etc)
• Malignant pain from cancer
• Degree of pain control which can be achieved will play a significant role in QOL
• Elderly patients probably have higher pain thresholds than younger people
• Elderly patients tend to have multiple problems such that pain is low on the priority list
• Elderly patients tend to believe that one must bear pain as a part of life
• Elderly patients tend to fear expressing the complaint of pain because of past taboos
• Elderly patients tend not to report pain
• Cognitive impairment may prevent the interpretation of pain and its response to therapy
• 20 to 50% of community dwelling elders and 45 to 80% of nursing home patients have complaints of chronic pain
• Older patients with complaints of chronic pain of vague etiology should be evaluated for depression
• Useful assessment tools for older patients are a pain diary and a visual analog scale

Question 2

Concerns about managing acute pain in the older patient

Answer 2

• Concerns of tolerance or dependence to opioids should not be considered
• Be aware of enhanced toxicity of opioids and other pharmcotherapies due to pharmacokinetic and pharmacodynamic changes
• Opioids should be started with the least potent agents and then move up depending on tolerance and disease progression
• For acute injuries opioids should be used only for 3 to 7 days.

Question 3

Describe the WHO analgesics ladder for cancer pain

Answer 3

• Step 1: Nonopioid +- Adjuvant
• Step 2: Nonopioid +- Adjuvant AND opioid for mild to moderate pain
• Step 3: Nonopioid +- Adjuvant AND opioid for moderate to severe pain

Question 4

Concerns about managing post-operative pain in the older patient

Answer 4

• Concerns of dependence and tolerance to narcotic analgesics
  postoperatively are overrated and have left patients suffering needlessly if they are used for short term
• Aggressive treatment with narcotics post-operatively can prevent long term painful sequelae if used for short term (3 to 7 days). Utilize nonopioids as well.

Question 5

Other pharmacologic alternatives for CNCP

Answer 5

• Tramadol
• Morphine
• Antidepressants
• Anxiolytics
• Carbamazepine, Phenytoin, Gabapentin, Pregabalin

Question 6

Tramadol (Ultram*)

Answer 6

◦ µ receptor agonist
◦ Valuable adjunct
◦ Half-life is prolonged in the elderly
◦ Lowers seizure threshold

Question 7

Concerns about the use of opioid analgesics for non-cancer chronic pain in the older patient (CNCP)

Answer 7

• Elderly patients have prolonged elimination of some narcotics
• Elderly patients have increased pharmacodynamic response to narcotics as manifest by EEG (efficacy and toxicity)
• General recommendation is that elderly patients require about one-half the dose of a narcotic than younger people
• Potential for accumulation of morphine active metabolites with reduced renal function of aging
• Fentanyl is potent

Question 8

Morphine

Answer 8

◦ Overcome oral bioavailability problems by giving more drug orally (3 to 6:1)
◦ Extended release formulations
◦ Predictable, reversible, short duration of action

Question 9

Acceptable opioids to use in the older patient based on kinetics and potency.

Answer 9

◦ Codeine
◦ Hydrocodone
◦ Oxycodone
◦ Hydromorphone
◦ Oxymorphone
◦ Methodone
◦ Fentanyl

Question 10

Codeine

Answer 10

• One-tenth as potent as morphine
• good oral to parenteral efficacy ratio
• poor GI tolerability

Question 11

Hydrocodone

Answer 11

Equipotent to oral morphine

Question 12

Oxycodone

Answer 12

• 30 mg chronic oral morphine = 20 mg chronic oral oxycodone.
• Good oral to parenteral efficacy ratio
• 1/3 more potent than morphine

Question 13

Hydromorphone

Answer 13

• More potent than morphine, poor oral to parenteral efficacy ratio.
• Overcome oral bioavailability issue by giving more drug orally than parenterally (5:1)

Question 14

Oxymorphone

Answer 14

30 mg oral morphine = 5 mg oral oxymorphone

Question 15

Methodone

Answer 15

• Equipotent to morphine
• good oral to parenteral efficacy ratio, long duration of action, biphasic half life.
• Change doses slowly.

Question 16

Fentanyl

Answer 16

• 100 times more potent than morphine

- concerns about using this in the elderly

Question 17

Morphine parenteral : oral

Answer 17

10 : 30

Question 18

Oxycodone parenteral : oral

Answer 18

10 : 20

Question 19

What are unacceptable narcotics in the elderly and why?

Answer 19

◦ Meperidine - poor bioavailability, accumulation of normeperidine which produced agitation, tremor, seizures in the elderly; metabolite can cause adverse effects
◦ Pentazocine or butorphanol - delerium, agitation, dysphoria

Question 20

Toxicity of Opioids

Answer 20

• Sedation and confusion
• Nausea and vomiting
• Constipation
• Falls

Question 21

Toxicity of Opioids: Sedation and confusion

Answer 21

◦ Tolerance to these effects usually occurs in several days to weeks
◦ If intolerant of these effects: decrease dose, change agent

Question 22

Toxicity of Opioids: Nausea and vomiting

Answer 22

◦ Tolerance may develop
◦ If intolerant to these effects: change agent or decrease dose, consider anti-nauseant
◦ Use Zofran over Reglan or Compazine
◦ Reglan and Compazine may cause anticholinergic effects and EPS

Question 23

Toxicity of Opioids: Constipation

Answer 23

administer stool softeners / senna extracts for prevention

Question 24

Principles of Opioid Use in CNCP

Answer 24

• CNCP should be managed in a multi-disciplinary manner with active patient involvement.
• Drug therapy is but one slice of the therapeutic pie
• Opioids should be considered as last resort and for short term use only

Question 25

CDC Guidelines for Prescribing Opioids for Chronic Pain

Answer 25

• 1: Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. If opioids are used careful evaluation of risk versus benefit and if used they be used in combination with nonpharmacologic therapy and nonopioid therapy.
• 2: Before beginning opioid therapy establish clear treatment goals (realistic) and continue only if there is clear benefit without risk of ADRs or addiction.
• 3: Before and during opioid therapy discuss risk versus benefit and patient responsibilities.
• 4: When starting
• 5: Start opioids at lowest effective dose and reassess benefit if ≥ 50 MME/day and avoid ≥ 90 MME/day.
• 6: Long term opioid use often begins with treatment of acute pain. Use the lowest possible dose using an IR dosage form. 3 days will usually suffice; more than 7 days will rarely be needed.
• 7: Evaluate risk/benefit within 1 to 4 weeks of starting therapy and when making dose escalations. Careful review of risk/benefit every 3 months. Consider taper at 3 months.
• 8: Evaluate before starting and periodically during continuation of opioid therapy the risk for opioid-related harm. Potentially offering naloxone for those at higher risk of overdose (i.e. ≥ 50 MME/day) or concurrent BZD use.
• 9: Monitor PDMP before therapy and during therapy.
• 10: Consider using urine drug testing before and during chronic opioid therapy.
• 11: Avoid using opioids and BZDs concurrently

Question 26

morphine milligram equivalent limits

Answer 26

avoid ≥ 90 MME/day

Question 27

Guidelines that require justification for daily MME ≥ 90

Answer 27

• Nonopioid treatment failure
• Low-dose opioid treatment failure
• Specific disease or condition that is identified
• If underlying cause is curable or intractable
• Family documents that pt needs it
• Review past medical history for need: medical treatment, diagnostic tests, prescription monitoring, disability determination
• Performing physical exam: make sure PE matches with underlying cause, mental status, alertness, tolerance of opioids
• Evaluate diagnostic tests

Question 28

Other pharmacologic alternatives for CNCP: Antidepressants

Answer 28

• avoid higher doses of tertiary agents (amitriptyline).
• Lower doses work. Other antidepressants that are considered safer for older people may be more acceptable (SSRIs, duloxetine, etc.)

Question 29

Other pharmacologic alternatives for CNCP: Anxiolytics

Answer 29

avoid long acting agents (i.e. diazepam), avoid use with opioids