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11 Articles in Volume 18, Issue #8
Challenges & Opportunities for Pain Management In Veterans
Chronic Pain and Psychopathology in the Veteran and Disadvantaged Populations
ESIs: Worth the Benefits?
Letters to the Editor: Recovery Centers Reject MAT, Cannabis for Chronic Headaches, Central Pain
Medication Management in the Aging
Pain Management in the Elderly
Pharmacists as Essential Team Members in Pain Management
Photobiomodulation for the Treatment of Fibromyalgia
Plantar Fasciitis: Diagnosis and Management
Slipping Rib Syndrome: A Case Report
What types of risk screening tests are available to clinicians prescribing opioid therapy?

Medication Management in the Aging

Clinical anecdotes to assist practitioners in medication selection for complex chronic pain problems in the elderly patient population.
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In his recent book, Medication Management of Chronic Pain: What You Need to Know, Gerald M. Aronoff, MD, DABPM, DABPN, medical director of Carolina Pain Associates in Charlotte, NC, presents clinically useful data to assist practitioners in decision-making regarding medication management of complex chronic pain problems. The chapter on medication management in older patients is excerpted below with author permission.*

 

As part of the aging process, there is a gradual physiological decline, which—as it affects hepatic and renal function—may make pharmacological management more challenging by its effect on analgesic pharmacology. The elderly are also more at risk for drug-drug interactions, and clinicians need to be especially careful in those patients receiving polypharmacy. Medications are more likely to lead to complications in older adults.1 Chronic pain has been documented in relation to significant depression and especially losses of spouses, other family members, and friends; decreased daily activity; increased sleep disturbance; decreased mobilization among the elderly community; and increased risk for falls. Even the number of medications being used makes it more likely that an older adult will have an adverse drug event compared to younger ones. The uses of proton pump inhibitors (PPIs), for example, are more likely to interfere with calcium absorption in older adults; and drugs like amitriptyline should be avoided altogether, given the safer option of nortriptyline with comparable efficacy.2

Below are a few other examples of key considerations to keep in mind when using medication to manage pain in the elderly.

(Source: Author provided)

Paracetamol continues to be an effective analgesic for the symptoms of musculoskeletal pain, including osteoarthritis and low back pain… There are relatively few relative cautions and absolute contraindications to prescribing paracetamol. However, it is important that the maximum daily dose (4 g/24 hrs) is not exceeded. Note: The American Geriatrics Society (AGS) guidelines for persistent nonmalignant pain management in older adults recommends acetaminophen as a first-line agent for mild to moderate pain.3-6

NSAIDs and selective COX-2 inhibitors should be used with caution in older people after other safer treatments have not provided sufficient pain relief. The lowest dose should be provided for the shortest duration. For older adults, NSAIDs or cyclooxygenase-2 (COX-2) selective inhibitor should be co-prescribed with a PPI, choosing the one with the lowest acquisition cost. All older individuals taking NSAIDs should be routinely monitored for gastrointestinal (GI), renal, and cardiovascular effects and drug-drug and drug-disease interactions.

Note: The AGS indicates that for inflammatory pain conditions, NSAIDs have been shown to provide better short-term relief compared to acetaminophen.7,8 NSAIDs are more likely to be associated with serious adverse side effects in older adults, such as GI bleeding, renal toxicity, and cardiovascular events, and therefore should be used very cautiously in the vulnerable elderly population.9

Opioid Therapy may be considered for patients with moderate or severe pain, particularly if the pain is causing functional impairment or is reducing their quality of life. Patients with continuous pain should be treated with modified-release oral or transdermal opioid formulations aimed at providing relatively constant plasma concentrations. Appropriate laxative therapy, such as the combination of a stool softener and stimulant laxative, should be prescribed throughout treatment for all older people who are prescribed opioid therapy. Some patients with treatment-resistant, opioid-induced constipation may require peripherally acting mu opioid receptor antagonists (ie, PAMORAs). Regular patient review is required to assess the therapeutic benefit and to monitor adverse events.

In addition, older adults are particularly susceptible to constipation that can be associated with the use of opioid medications. Either using regimens to improve bowel motility or quickly addressing constipation with agents such as methylnaltrexone, which is specifically targeted to counter the constipating effects of such opioids without obviating the analgesic effects, is recommended whenever opioids are used for any extended period.10 Opioids also are notorious for causing urinary retention in some individuals. This can be particularly problematic in men with enlarged prostates who already may have issues with emptying their bladders completely. Some data indicate that the use of methylnaltrexone also can counter the opioid effects on the bladder. This may be particularly helpful if insertion of a catheter into the bladder is difficult or otherwise undesirable or impractical.11

Note: The AGS does not promote improper use of opiates; however, they note that there is no need for the elderly to needlessly suffer, and that opiates should be considered when the pain causes significant interference with daily functional activities and impairs quality of life. The most recent AGS guidelines noted the cardiovascular, renal, and GI risks of ibuprofen, other NSAIDs, and COX-2 inhibitors in the older population and recommended using the lowest clinically effective dose for the shortest time felt to be clinically appropriate.4,9

Transdermal fentanyl may be associated with less constipation than oral oxycodone in older people. The convenience of a transdermal preparation, which requires changing every 72 hours, reduces administration of time and staffing requirements in residential and nursing homes. However, because of the high potency of transdermal fentanyl, it must not be used for opioid initiation and should only be used in the context of opioid rotation or switching and monitored carefully after initiation, titration, and rotation.

Buprenorphine – there is limited data relating specifically to the use of buprenorphine in older people, although a postmarketing surveillance of transdermal buprenorphine in over 13,000 patients (mean and median age of 68 years) demonstrated efficacy and sustained a dose-dependent analgesia. The pharmacokinetics of buprenorphine is not altered in patients with renal failure. The convenience of a transdermal preparation, which requires changing every 7 days, reduces administration time and staffing requirements in residential and nursing homes.

Last updated on: November 12, 2018
Continue Reading:
Are Opioids More Harmful Than NSAIDs for Elderly Patients?
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