1. 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 :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 mg hydrocodone plus mg acetaminophen or 200 mg ibuprofen.
fRectal suppositories available. Per rectum (P.R.) dose is equal to PO dose.
gCombination tablets contain mg oxycodone 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