Opioid Use in the Elderly

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1 Opioid Use in the Elderly CRIT in the Care of Older Adults Mellissa Ubbens, PharmD, BCPS Clinical Pharmacist, Duke University Hospital Acknowledgements Thank you to Jason Moss, PharmD, CGP and Jen Gommer, PharmD, BCPS, for the preparation of the majority of the slides shown today. May 30,2015 Postoperative Pain in the Elderly In US, ~ 50% of surgery in adults aged >65 years Postop pain associated with increase postop complications Literature shows older patients are asked about pain less often receive analgesia less frequently when hospitalized patients with hip fracture and severe cognitive impairment receive 3X less analgesia than cognitively intact patients with similar fractures Prevalence of Chronic Pain 25-50% community dwelling elderly 45-80% nursing home elderly Low cognitive performance is independent predictor of failure to receive analgesia despite presence of daily recorded pain (Bernabei R. JAMA 1998) 60% 50% 40% 30% 20% 10% 0% Age Group Jakobsson U et al. J Pain Symptom Manage 2003 Severe Less Severe N = 4,093 Aged Pain Assessment Age-related Considerations Pain Assessment: pain history, location, intensity and interference with activities Brief Pain Inventory Geriatric Pain Measure Multiple concurrent illnesses Under-reporting of symptoms Expect pain with aging Do not want to bother their physician Do not want to be viewed as a bad patient Do not think their pain can be alleviated Fear diagnostic tests Fear addiction Cognitive impairment 1

2 Pain In The Setting Of Cognitive Impairment As dementia progresses, the intensity of painful conditions usually increase while the administration of analgesics decrease Patients may not have the ability to express their pain Cognitively impaired may show more facial expressiveness Pain Assessment Tools Pain scales Visual analog scale Numeric rating scales Pain thermometer Facial pain scale Pain Behaviors Cognitively Impaired Older Adults Facial expressions Verbalizations, vocalizations Body movements Changes in interpersonal interactions Changes in activity patterns or routines Mental status changes Pharmacotherapy Age-related Considerations Decline in therapeutic index Age-related predisposition to adverse drug effects 2-3 times higher Drug-drug interactions Drug-disease interactions CHF, chronic liver and renal disease Dementia Fine PG. Pain Medicine 2012 Age-related Considerations in Opiates Pharmacodynamic changes Increased sensitivity to analgesics Neuropeptide and neurotransmitter production tend to decrease with increasing age. Increased sensitivity to adverse effects Pharmacokinetic changes Increased variability of function between individuals makes predicting drug effects more difficult Age Related Changes to Opioid Pharmacokinetics Absorption GI motility, gastric acidity Distribution TBW, proportion adipose tissue, lean body mass serum albumin Metabolism liver mass, hepatic enzyme activity Elimination Age related declines in renal and hepatic function 2

3 Pharmacotherapy General Principles Start low and go slow BUT monitor frequently Increase in gradual increments Combine medications so doses can be decreased minimizing side effects rational polypharmacy Choose agents that work on different points for additive or synergistic results When Are Opioids Indicated? For acute and chronic use Pain is moderate to severe Pain has significant impact on function Pain has significant impact on quality of life For chronic use Non-opioid pharmacotherapy has been tried and failed Patient agreeable to have opioid use closely monitored (e.g. pill counts, urine screens) Opioid Effectiveness Medication Selection Opioid responsiveness varies Varies among different types of pain Acute ~100% > Chronic ~50% Nociceptive > Neuropathic Varies among individuals Good Pain History key North Carolina Controlled Substance Reporting System https://nccsrsph.hidinc.com Sign up through Medical Board Website Target to the type of pain Neuropathic vs. nociceptive Consider non-pharmacologic therapies Adjuvants NSAIDs/Acetaminophen Topical Preparations Acetaminophen Max dose decreased to 3 gms/daily NSAIDs Anticonvulsants Gabapentin/pregabalin- careful cause significant sedation and renally cleared Antidepressants Example would be tricyclic (amitriptyline) but have anticholinergic side effects (urinary retention) Non-pharmacologic (TENS, PT/OT) Ceiling analgesic effects No known analgesic tolerance Additive role Adverse effects common at high doses Epidemiologic studies identify association between NSAIDs, advanced age and risk of ulceration and CHF Usually ineffective for neuropathic pain Topical NSAIDs ( systemic levels) may be safer but no long-term studies 3

4 Opiate Selection Pain severity Duration of drug activity Short acting: hydrocodone, morphine, hydromorphone, oxycodone, oxymorphone Long acting: fentanyl transdermal, extended release formulations Route of administration Side effect profile Opioid Selection Weak Full Agonists Codeine Hydrocodone Weak Agonist/Reuptake Inhibitor Tramadol Tapentadol Strong Full Agonist Morphine Oxycodone Hydromorphone Fentanyl Methadone Oxymorphone Opioids To Avoid In The Elderly: Codeine Opioids To Avoid In The Elderly: Tramadol Synthetic so may have a role in patients with true opioid allergies Inhibits reuptake on serotonin and norepinephrine receptors Very weak Mu-opioid agonist Side-effects Dizziness, lowers seizure threshold, confusion Can precipitate a serotonin crisis in patients taking high dose SSRI Opioid Safety and Risks Side effects are common Nausea, sedation, constipation, urinary retention, sweating Organ toxicities are rare Suppression of hypothalamicpituitary-gonadal axis >50 mg (MSO 4 equivalents) assoc w/ 2X increase in fracture risk Addiction 3-19% when treating chronic pain Exceedingly low (<1%) when treating acute pain Overdose especially at high doses and when combined w/ other sedatives >100 mg (MSO 4 equivalents) assoc w/ 9x increase in overdose risk Opioid Side Effects- GI Constipation Never resolves Prevent with scheduled softners plus stimulants (not bulkforming) Nausea and vomiting Been reported that 30% of patients experience nausea- often listed as allergy History of motion sickness- try scopolamine patch or meclizine Saunders KW et al. J Gen Med 2010 Dunn KM et al. Ann Intern Med 2010 Li X et al. Brain Res Mol Brain Res 2001 Doverty M et al. Pain 2001 Angst MS, Clark JD. Anesthesiology

5 Opioid Side Effects Opioid Side Effects Sedation If pain controlled, consider decreasing dose by 25% Look at other classes of medication- benzos, antidepressants Rotate to a different opioid Delirium Non-sedating anti-psychotics for delerium such as haloperidol or risperidone. Pruritis 2-10 %of all patients Usually resolves within a week Centrally mediated Urinary Retention Respiratory Depression Especially when combined with other sedating medications Myoclonus (at high doses) Especially with morphine metabolite build up Side Effect Management Time is your ally: tolerance develops to many side effects: not to constipation Multimodal therapy (non-drug therapies, combining drugs that work by different mechanisms) Dose reduction or route change Opioid rotation: side effects may be less with one drug than another Symptom management Chronic Pain Management Goal Setting (Six As) improve Analgesia (pain control) improve ADLs (function) improve Affective state improve Adaptive behaviors avoid Adverse effects avoid Addiction NOT necessarily decrease drug dose Chronic Opioid Monitoring Plan Universal Precautions Agreements contracts, informed consent Monitor for benefit and harm with frequent face-toface visits Monitor for adherence, addiction and diversion Urine drug testing Pill counts Prescription monitoring program data Opioid Use in the Elderly Questions? FSMB Guidelines Gourlay DL, Heit HA. Pain Medicine 2005 Chou R et al. J Pain

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