1. UMMS CRIT Module II: Opioid Usage in Older Adults Catherine DuBeau, MD Clinical Director of Geriatrics UMMS

2. UMMS CRIT 2012 Module II: Opioid Usage in Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Dr. Stacie Levine, University of Chicago Pain Module, Curriculum for the Hospitalized Aged Medical Patient champ.bsd.uchicago.edu Acknowledgement

3. UMMS CRIT 2012 Module II: Opioid Usage in Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Understand the major categories of pain Implement the WHO pain ladder to manage patients with pain Perform safe and effective opiate dosing, escalation, and conversions Objectives

4. UMMS CRIT 2012 Module II: Opioid Usage in Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Extremely common and undertreated –50% of community dwelling older persons –Only 40% of oncology and 30% of hip fracture patients report “adequate” pain control Education in pain assessment and management mandated by ACGME/RCCs and Joint Commission Undertreated pain leads to functional decline, prolonged length of stay, increased healthcare utilization Why Pain?

5. UMMS CRIT 2012 Module II: Opioid Usage in Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Patient centered approach is the key ASK the patient, regardless of mental status Identify preferred pain terminology –Hurting, aching, stabbing, discomfort, soreness Type: visceral, nocioceptive, neuropathic Functional impact: How is their life changed? Use a pain scale that works for the patient Physiologic measures (eg, HR, BP) not reliable indicators Bedside Assessment of Pain

6. UMMS CRIT 2012 Module II: Opioid Usage in Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Unique pain signature – – Use baseline behavior as frame of reference – Pain can cause hypo- or hyper-activity – Ask caregivers how they know when pt is in pain Possible indicators – Facial expression: frown, blinking, sad/frightened – Vocalizations: grunting, calling out, noisy breathing – Movements: rigid, tense, fidgeting, resistance to being moved, pacing Pain in non-verbal pts

7. UMMS CRIT 2012 Module II: Opioid Usage in Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation WHO pain ladder: Non-opioids Adjuvants Opioids Managing Pain

8. UMMS CRIT 2012 Module II: Opioid Usage in Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Non-opioids – APAP – NSAIDs – COX-2 inhibitors Adjuvants – Topicals – capsaicin cream, lidoderm patch – Anticonvulsants: GABA-nergics – Antidepressants: Cymbalta, tricyclics, SNRIs – Steroids – Non-medication: massage, TENS, PT/OT Step 1 - mild to moderate Pain

9. UMMS CRIT 2012 Module II: Opioid Usage in Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Mild opioids –Codeine: GI upset common –Hydrocodone (Vicodin): no paper Rx needed –Oxycodone (Percocet): actually more potent than morphine, reason for low doses with APAP Opioid-like –Tramadol: analgesia ~ same as T3; max 200 mg/day in elderly Step 2- moderate Pain

10. UMMS CRIT 2012 Module II: Opioid Usage in Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Strong Opioids Morphine Oxycodone Hydromorphone (Dilaudid) Fentanyl Oxymorphone (Opana, Numorphan) Methadone Step 3- Severe Pain

11. UMMS CRIT 2012 Module II: Opioid Usage in Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Meperidine (Demerol) Pentazocine (Talwin) Combination with antihistamine (Vistaril) Avoid

12. UMMS CRIT 2012 Module II: Opioid Usage in Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Key to dosing and changing opiods Use calculators Morphine Equianalgesia Conversion : http://www.epocrates.com/products/medtools/opioidanalgesicconverter.html http://www.epocrates.com/products/medtools/opioidanalgesicconverter.html

13. UMMS CRIT 2012 Module II: Opioid Usage in Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Load – Start low, short-acting: 2-5 mg PO morphine equivalent (~ 1 Percocet q 4 hr) – Dose q peak: po, pr ~ 1 hr SC, IM ~ 30 min IV ~ 6-15 min – Regular dosing, not “prn” – Re-eval in 4 hrs Dosing

14. UMMS CRIT 2012 Module II: Opioid Usage in Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Use percentage increase irrespective of starting dose Mild-mod pain: increase by 25 - 50% Severe: increase by 50 - 100% Frequency of escalation: –Short-acting, single agent – q 2 hr –Long-acting – every 24 hr –Fentanyl patch – q 72 hr –Methadone – every 4-7 days Escalating Doses

15. UMMS CRIT 2012 Module II: Opioid Usage in Older Adults Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Use immediate release opioids only Start: 10% of total 24 hr dose or 33% of one ER dose Frequency: offer after peak effect –PO/ PR - ~ 1 hr –SC/IM ~ 30 min –IV ~ q10-15 min Break-through Pain