Aging Q3 Pain Management ACOVE  Pharmacological treatment with analgesics for pain is the most common in the elderly, however, the use of alternative medications and non-pharmacological interventions should also be considered. Treatment decisions require continuous weighing of risks and benefits. (Etzioni, et al. JAGS 2007 55:S403-S408) Mechanisms of Chronic Pain *Nociceptive *Neuropathic *Peripheral sensitization (hyperalgesia, allodynia) *Central sensitization (NMDA) *Desensitization (tolerance) *Disinhibition (GABA) WHO Ladder Level 3 (Severe pain): strong opioids – morphine, hydromorphone, fentanyl, oxycodone +/- adjuvants Level 2 (moderate to severe pain): acetaminophen plus opioid (hydrocodone, codeine, oxycodone): tramadol +/1 adjuvants Level 1 (mild to moderate pain): acetaminophen, aspirin, NSAIDS (cox-2) +/- adjuvants     *Nausea and vomiting (central) *Delayed gastric emptying *Constipation *Hypotension *Myoclonus *Respiratory depression *CNS *GU *Pruritus Opioid Side Effects NON-OPIOID TREATMENT OPTIONS (ADJUVANTS) FOR PAIN IN THE ELDERLY Drug Description Comments/Side Effects Acetaminophen First-line agent for patients with OA and patients with mild to moderate pain. Limit dose in elderly. Avoid combining with opioids. Anticonvulsants Primarily in neuropathic pain (carbamazepine divalproex, gabapentin, pregabalin, topiramate) Carbamazepine: blood dyscrasias, Gabapentin/ Pregabalin: Ataxia, dizziness, somnolence Antidepressants TCAs, SNRIs Start low dose,increase slowly Anticholinergic side effects of TCAs BP effects of SNRIs Local Anesthetics Lidocaine patches Capsaicin Lidocaine: may apply up to 3 patches q 12 hours Capsaicin: burning pain intolerable by some patients. NSAIDS Avoid in elderly if possible (AGS) Cox-2 probably OK. Avoid combining with opioids Tramadol Start low dose, increase slowly Drowsiness, nausea, constipation May not be best option for patients on antidepressants Muscle Relaxants Cyclobenzaprine, Carisoprodol; Avoid in elderly if possible (AGS) Anticholinergic side effects, arrhythmias EQUIANALGESIC DOSES OF OPIOID ANALGESICS USED FOR THE CONTROL OF PAINa Oral (PO) Dose (mg) Analgesicb Intravenous (IV 150 Meperidine (Demerol)c – (do not use in elderly) 50 100 Codeine (Tylenol with Codeine)c,d 60 15 Hydrocodone (Vicodin, Lortab, Zydone, Norco, Vicoprofen) c,e - MORPHINE (MSIR, Roxanol, MS Contin, Kadian, Avinza)f 5 10 Oxycodone (Percodan, Percocet, Endocet, Roxicodone, OxyIR, OxyContin, OxyFAST, OxyDose)g Methadone (Dolophine)h - (very difficult to use in elderly) 4 Hydromorphone (Dilaudid)f 0.75 2 Levorphanol (Levo-Dromoran)h 1 Fentanyl (Duragesic/Actiq)i i Duragesic fentanyl transdermal system: mcg/h patch q 3 days=mg morphine PO q12th. Actiq: 1 unit buccally over 15 minutes pm breakthrough pain. aEquianalgesic doses listed were obtained from a variety of studies and experiences and are meant only as guidelines bDose interval: q4h, except for: meperidine=q2-3h, levorphanol=q4=6h, methadone=q6-12h. MS Contin=q8-12h, Kadian=q12-24h, Avinza=q24h, OxyContin=q12h, Duragesic=q48-72h. cNot recommended for severe pain – neurotoxic with repeated dosing. dTylenol #2=15mg codeine, Tylenol #3=30 mg codeine, Tylenol #4=60mg codeine. All contain 325 mg acetaminophen. eCombination tablets contain 2.5-10 mg hydrocodone plus 325 750 mg acetaminophen or 200 mg ibuprofen. fRectal suppositories available. Per rectum (P.R.) dose is equal to PO dose. gCombination tablets contain 2.5-10 mg oxycodone+325-650 mg acetaminophen or 325 mg aspirin. hCaution: Risk of toxicity from delayed accumulation. In opioid rotation, start methadone at 25-50% of equianalgesic dose calculated from table FCCC PMC 3/23/0