1. How to Use Pain Medicine Safely: Tips for Seniors
Tatyana Gurvich, Pharm.D., BCGP
Assistant Professor of Clinical Pharmacy
USC School of Pharmacy
UCI Department of Geriatrics

2. Historical Perspective
1950’s-1980’s: A multidisciplinary approach
1990’s: Pain is the 5th Vital Sign
2000’s: DEA’s Balanced Policy
: OPIOID CRISIS!!
John Bonica, MD
Hospital- and clinic-based programs with physicians, psychologists, PT/OT.
Narcotics were used sparingly
Problems with insurance coverage emerge…
“Pain is whatever the patient says it is”
“Treatment of Pain is a Universal Right” - WHO
Cancer pain/terminal care pain management guidelines
Long-acting medicines like Oxycontin emerge…
JCAHO (accredits and certifies health care facilities) mandates pain assessment and treatment
JG, Compton P. Providing chronic pain management in the "Fifth Vital Sign" Era: Historical and treatment perspectives on a modern-day medical dilemma. Drug Alcohol Depend Apr 1;173 Suppl 1:S11-S21.

3. The Numbers behind the Opioid Crisis
20% of patients with chronic pain receive an opioid prescription
>420,000 emergency department visits related to the misuse or abuse of opioids in 2011
259 million prescriptions written for opioids in 2012
* Updated CDC guidelines for prescribing opioids
Enough for every adult in the United States to have a bottle of pills

4. The Opioid Crisis and Seniors
Opioid misuse among older Americans is also on the rise
Older adults who misuse opioids is expected to double by 2020
In 2016, more than 500,000 Seniors received opioids in doses higher than recommended by the manufacturer
*SAMHSA: State Technical Assistance Contract

5. Pain is a common medical problem
50% of older Americans suffer from chronic pain
Arthritis
Fibromyalgia
Nerve pain
Chronic back pain
Other chronic musculoskeletal conditions
*SAMHSA: State Technical Assistance Contract

6. Strong Pain Medicines related to Morphine
All work on the same receptors in the brain to relieve pain
Tramadol
Tylenol with Codeine
Norco/Vicodin
Percocet
Morphine/MS Contin
Oxycodone/Oxycontin
Dilaudid
Fentanyl Patch

7. All Opioids are NOT the SAME
Short acting (4-6hrs)
Long acting (12-72hrs)
Combinations with Tylenol
Norco, Percocet, Tylenol w/Codeine (Tylenol #3)
All Have Different Potencies
If Dilaudid were a Hamburger....
5 to 7mg of Morphine equals 1mg Dilaudid
Tramadol & Codeine < Hydrocodone & Morphine < Oxycodone < Dilaudid < Fentanyl
(LEAST) (MOST)

8. Side Effects & How to Mitigate
Constipation
Chronic: laxatives (Senna/Dulcolax) + ↑ fiber intake & hydration, ↑ physical activity, stool softeners
Dry Mouth
Chronic: Practice regular dental hygiene, have regular dental visits, Biotene, ice cubes, drinking water
Nausea/Vomiting
Usually transient (2-3 days)
Anti-nausea medicine can be used as necessary
Consider switching to another opioid
Drowsiness
Usually transient when starting therapy or increasing dose
Avoid drinking alcohol, operating heavy machinery, or driving
Confusion
Usually transient but in frail seniors may persist

9. But, am I an Addict?
Tolerance: Need a higher dose to get the same pain relief
Dependence: Withdrawal symptoms if stopped abruptly
Addiction: Dependence with abusive pleasure-seeking behavior

10. Additional Risks Associated with Opioid Uses
Physical side effects : Mood changes, urination difficulties, depressed breathing, itching, osteoporosis, sexual dysfunction
Symptoms of withdrawal: Abdominal cramping, pain, diarrhea, sweating, irritability
Victimization: Risk of theft, deceit, assault, or abuse by persons seeking to obtain the patient’s opioids
Hyperalgesia: Increased sensitivity to and/or increasing experience of pain and may require change or discontinuation
Sleep apnea may be caused or worsened
Driving under the influence of drugs: Especially at initiation of therapy or with changes in doses opioids can impair ability to drive or operate machinery. It is against the law and unsafe to drive or operate machinery when impaired.
Life-threatening irregular heartbeat with methadone, EKG monitoring required
Overdose or using with alcohol or other drugs can result in slowed breathing, coma, brain damage, death

11. Factors that increase risk of dangerous side effects
History of substance abuse
History mental disease
High dose of Opioids:(>50 Mg Morphine/day)
First time opioid user
Anti-anxiety/ sleep medicine
Heart and lung disease
Kidney and liver disease
Sleep apnea

12. Seniors face additional risks
Reduced kidney function
Long history of lung disease
Increased risk of overdose
Increased confusion
Increased fall risk
Polypharmacy concerns
Increased risk of side effects and drug interactions
Medication errors

13. Recognizing Emergencies
Seek Medical Attention Urgently:
CALL 911!
Severe dizziness
Inability to stay awake
Hallucinations
Heavy or unusual snoring
Slow breathing
Slow or no heartbeat
Aren’t breathing
Others can’t wake you up
Lips are blue
Can’t speak clearly
While asleep making gasping, gurgling, or snorting sounds

14. How to Use Opioids Safely
DO: FOLLOW SAFE PRACTICES
DO NOT USE WITH OPIOIDS!
Use:
As needed only
For as short a time as possible
Don’t:
Drive or operate machinery until you know how the medication affects you
Never:
Take more than prescribed
Take someone else’s medicine
Share your medicine
Alcohol
Anti-Anxiety medicines: Xanax, Ativan, Klonopin, Valium
Sleep Aids: Ambien, Lunesta, Sonata, Restoril, Halcion
Muscle Relaxants: Soma, Flexeril, Robaxin
Other Opioids

15. Talk to Your Doctor!
Establish treatment goals for pain relief and function
A plan should be in place for stopping opioids if treatment is unsuccessful
Continue opioids only if meaningful improvement in pain AND function is observed by you and your doctor
Discuss any side effects you have promptly

16. It is now harder to get Opioid prescriptions
Physician’s offices
Have protocols in place
May require more frequent appointments
Reluctant to prescribe for prolonged period of time
Stay away from long acting opioids: Oxycontin/MS Contin/Fentanyl
Pharmacies
Reluctant to refill opioids long term
Insurance companies may only pay for a 7 day supply
Extra authorization is needed
Delays in getting your medicine

17. Tools your doctor may use when prescribing Opioids
A pain contract between you and your doctor
Risks and realistic benefits of opioid therapy
Patient AND Provider responsibilities for managing this therapy
A pain diary to document when you use medicines
Is your pain relieved?
Are you better able to move about and do your activities?
24-hour recall of medication use
Adjuvant Pain Medications
A CURES report is now a requirement
Urine drug testing
Naloxone to keep you safe

18. Naloxone (Narcan)
It is a medication which quickly reverses the effect of an opioid medication
It should ONLY be used when overdose is suspected
Comes as an Injection, Spray or an Auto-Injector
IF Naloxone is used you must call 911 immediately

19. Who will get a Prescription for Naloxone (Narcan)
Higher-dose opioid prescription
Receiving ANY opioid prescription PLUS anti-anxiety or insomnia medicine
Voluntary request from patient or caregiver
Patients who may have difficulty accessing emergency medical services (distance, remoteness)
If you have been in an overdose situation before
Suspected history of substance abuse
Starting a treatment program for addiction

20. Safer Alternatives

21. Non-Opioid Pain Medicines
Drug Name
Comments
Acetaminophen (Tylenol)
Doesn’t relieve inflammation
Caution with liver disease
Maximum dose 2-3gm daily (4 to 6, 500 mg tablets)
NSAIDS
Naproxen (Aleve)
Also relieve inflammation
Caution with kidney disease and stomach problems.
Can increase blood pressure, cause fluid retention and worsening of heart failure
Use lowest effective dose
Ibuprofen (Motrin)
Celecoxib (Celebrex)
Meloxicam (Mobic)

22. Selected Topical Medicines
Drug
Start Dose
Max Dose
Concerns
Lidocaine
4% Patch
1-3 patches for 12 hrs/day
Rash, skin irritation
4% Gel/ Cream
Apply to affected area 3-4x/day
5% Ointment & Patch
Single application (5 gm or ~6 inches)
17-20 grams/day
Diclofenac (Voltaren) 1% Gel
2-4 grams topically 4x/day
(2g = ~1.25 inches)
8 grams/day (arms/hands)
16 grams/day (legs/feet)
Application site
reactions
Capsaicin (Zostrix, Salonpas- HOT) Cream/ patch
Thin film to affected area 3-4x/day
No MAX dose
Burning sensation
Misc agents: Camphor oil/Menthol
Biofreeze, Bengay, Tiger Balm
Apply liberally
Generally well tolerated

23. Medicines which Prevent Pain
Drug
Concerns
Duloxetine (Cymbalta)
Increased BP, drug/drug interactions; kidney disease; Low sodium, falls
Venlafaxine (Effexor)
Gabapentin (Neurontin)
Sedation, dizziness, risk of falling, water retention, kidney disease
Pregabalin (Lyrica)
Dosages start low and increase slowly

24. Where does this leave us?
Opioid use can be a problem, especially for older adults
If they are necessary, they should be used with extra caution for as short a time as possible
Adjuvants medications must be tried
They are effective
They should reduce the amount of opioids you take, and in some cases,can completely eliminate them

25. Contributors to this Lecture Presentation
Ana Barron, Pharm. D. Candidate 2019
Amy Nham, Pharm.D. Candidate 2019
Liana So, Pharm.D. Candidate 2019
Katelyn Swafford, Pharm.D. Candidate 2019
USC School of Pharmacy