1. UMMS CRIT Module III: Opioid Management: Considerations for Older Adults Petra Flock, MD, MSc,CMD Division of Geriatrics University of Massachusetts Medical School

2. UMMS CRIT 2010 Module III: Opiod Management: Considerations for Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Discuss possible pain intervention for CRIT case Describe opioid side effects Initiate opioid therapy, convert from iv to po and calculate breakthrough dosing Goals

3. UMMS CRIT 2010 Module III: Opiod Management: Considerations for Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Mrs. HH. is an 84-year old woman admitted with perforated diverticulitis, awaiting surgery. How do you treat her pain? Case

4. UMMS CRIT 2010 Module III: Opiod Management: Considerations for Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation In opioid naïve patient: Max. effect iv morphine: 5 min Max. effect sc morphine: 30-60 min Max. effect po morphine: 1 hour Once you have steady state: T ½ is 4-6 hours for short acting opioids Opioid initiation

5. UMMS CRIT 2010 Module III: Opiod Management: Considerations for Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Constipation Fatigue/Drowsiness/Sedation Nausea/Vomiting Pruritus Hypotension Confusion/Delirium Urinary retention Myoclonus Respiratory depression Opioid side effects

6. UMMS CRIT 2010 Module III: Opiod Management: Considerations for Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation 2mg/hour x 24 hours = 48 mg/day iv (for ease of calculation let’s assume 50mg/day) Conversion iv:po Morphine: 1:3 50 mg/day iv = 150 mg/day po MS Contin is 12 hourly formulation (divide daily dose by 2) = 75 mg MS Contin bid Breakthrough (10-20% of daily dose): 15-30 mg q 4h PRN breakthrough pain Opioid conversion and breakthrough dosing

7. UMMS CRIT 2010 Module III: Opiod Management: Considerations for Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Treat acute pain with short-acting medication until you achieve pain control, then convert to long-acting Keep it simple (use same opioid for scheduled and PRN) Demented/delirious patients don’t ask for pain medication: if you think they have pain, schedule the analgesia and avoid PRN only Pearls

8. UMMS CRIT 2010 Module III: Opiod Management: Considerations for Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Patients with renal insufficiency become toxic easily – better opioid choices for them are oxycodone and hydromorphone Do not forget to treat constipation Do ask your pharmacist for help if you worry about conversions NEVER use Propoxyphene or Meperidine Pearls

9. UMMS CRIT 2010 Module III: Opiod Management: Considerations for Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Treat pain adequately, ideally by mouth and scheduled Keep it simple Monitor and treat side effects Educate families Summary