Pain Management in the Elderly Flashcards
Pain Assessment and Aging
- 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
Concerns about managing acute pain in the older patient
- 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.
Describe the WHO analgesics ladder for cancer pain
- 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
Concerns about managing post-operative pain in the older patient
- 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.
Other pharmacologic alternatives for CNCP
- Tramadol
- Morphine
- Antidepressants
- Anxiolytics
- Carbamazepine, Phenytoin, Gabapentin, Pregabalin
Tramadol (Ultram*)
◦ µ receptor agonist
◦ Valuable adjunct
◦ Half-life is prolonged in the elderly
◦ Lowers seizure threshold
Concerns about the use of opioid analgesics for non-cancer chronic pain in the older patient (CNCP)
- 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
Morphine
◦ Overcome oral bioavailability problems by giving more drug orally (3 to 6:1)
◦ Extended release formulations
◦ Predictable, reversible, short duration of action
Acceptable opioids to use in the older patient based on kinetics and potency.
◦ Codeine ◦ Hydrocodone ◦ Oxycodone ◦ Hydromorphone ◦ Oxymorphone ◦ Methodone ◦ Fentanyl
Codeine
- One-tenth as potent as morphine
- good oral to parenteral efficacy ratio
- poor GI tolerability
Hydrocodone
Equipotent to oral morphine
Oxycodone
- 30 mg chronic oral morphine = 20 mg chronic oral oxycodone.
- Good oral to parenteral efficacy ratio
- 1/3 more potent than morphine
Hydromorphone
- More potent than morphine, poor oral to parenteral efficacy ratio.
- Overcome oral bioavailability issue by giving more drug orally than parenterally (5:1)
Oxymorphone
30 mg oral morphine = 5 mg oral oxymorphone
Methodone
- Equipotent to morphine
- good oral to parenteral efficacy ratio, long duration of action, biphasic half life.
- Change doses slowly.
Fentanyl
- 100 times more potent than morphine
- concerns about using this in the elderly
Morphine parenteral : oral
10 : 30
Oxycodone parenteral : oral
10 : 20
What are unacceptable narcotics in the elderly and why?
◦ 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
Toxicity of Opioids
- Sedation and confusion
- Nausea and vomiting
- Constipation
- Falls
Toxicity of Opioids: Sedation and confusion
◦ Tolerance to these effects usually occurs in several days to weeks
◦ If intolerant of these effects: decrease dose, change agent
Toxicity of Opioids: Nausea and vomiting
◦ 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
Toxicity of Opioids: Constipation
administer stool softeners / senna extracts for prevention
Principles of Opioid Use in CNCP
- 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
CDC Guidelines for Prescribing Opioids for Chronic Pain
- 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
morphine milligram equivalent limits
avoid ≥ 90 MME/day
Guidelines that require justification for daily MME ≥ 90
- 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
Other pharmacologic alternatives for CNCP: Antidepressants
- 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.)
Other pharmacologic alternatives for CNCP: Anxiolytics
avoid long acting agents (i.e. diazepam), avoid use with opioids
