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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.

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.

Methadone – due to its multiple mechanisms of action and unusual pharmacokinetics, prescribing methadone should be restricted to those with experience of its use.

Tricyclic antidepressants and antiepileptics have demonstrated efficacy in several types of neuropathic pain, but tolerability and adverse effects limit their use in older individuals.

Note: Sedating tricyclic antidepressants, such as amitriptyline or doxepin, may cause adverse side effects in the elderly population, such as urinary retention, glaucoma, cardiac arrhythmias, and increased somnolence and hypotension, which may put them at increased risk for falls. Therefore, when an antidepressant is felt to be indicated for neuropathic pain, either consider nortriptyline, which has a lower incidence of anticholinergic effects, or duloxetine, one of the SNRI antidepressants that also is FDA approved for fibromyalgia, musculoskeletal pain, osteoarthritis of the knee, and diabetic peripheral neuropathy and has a lower incidence of adverse side effects than tricyclic antidepressants.

Gabapentin and pregabalin – these newer antiepileptic drugs have become more widely used in neuropathic pain states, as several studies have demonstrated analgesic efficacy and fewer adverse side effects than older antiepileptic drugs. Efficacy has been demonstrated in postherpetic neuralgia, diabetic peripheral neuropathy, and central pain syndromes. Although the potential for drug-drug interactions is lower, elimination of gabapentin and pregabalin is dependent on renal function, and dose adjustment is required in renal impairment. Regular patient review is required to assess therapeutic benefit and to monitor adverse effects.

Topical NSAIDs may provide an alternative to oral NSAIDs, particularly if pain is localized. Since older patients are more susceptible to side effects from medications and are likely to be on more medications than their younger counterparts, judicious selection of medications is important. A list of medications to be avoided in older adults has been developed by a group that included experts in pharmacology, geriatrics, nursing, and pain management (among others).4 In addition to avoiding the use of certain medications in older patients and reducing the number of medications being used, whenever possible, there are steps to be taken to minimize the adverse complications of certain medications that may be deemed necessary to control pain in some of our more experienced citizens. For example, if an NSAID is felt necessary, using naproxen 500 mg twice each day with a PPI daily may be a way to minimize the cardiovascular and GI risks. A better solution may be to use the topical diclofenac, which has not been demonstrated to have the same GI or cardiovascular risk as other NSAIDs and will not require a PPI, which may interfere with the absorption of some calcium supplements.

Overall, older adults require special care when managing pain. Selection of pharmacological interventions must take into account the physiological changes associated with aging, as well as chronic medical conditions.

*Excerpted content has been edited for style and clarity (2017, Trafford Publishing).

...

PLUS: Advise Patients What to Do, and Not Do, with Leftover Opioids–Reported

Additional detail reported by Rosemary Black with Lawrence W. Epstein, MD, FIPP, Pain Management, Mount Sinai Medical Center, NYC 

Almost one-third of older Americans filled a prescription for opioids in the past two years, but many did not receive adequate counseling on the risks of taking them, how to reduce their use, and what to do with unused pills, according to a 2018 University of Michigan poll. About half (49%) of the adults had leftover medication and 86% of these individuals said they kept the pills in case their pain returned. Approximately 9% threw the pills in the trash or ushed them down the toilet, while just 13% took them to an approved disposal facility.

As prescribing clinicians know, diversion of unused opioids, especially to a teenager or child, can have fatal consequences. Below are a few best practices you may share with your patients.

• Keep prescribed opioids in a locked cabinet/ storage space.

• Dispose of any unused opioid medication properly (ie, not down the toilet or in the trash). Many pharmacies and police stations offer 
“give back” programs. In addition, the National Association of Boards of Pharmacy offers an online search tool, allowing patients to locate the nearest disposal site via zipcode. 
If a disposal site is not available, pills may be crushed, mixed with coffee grounds or cat litter, and placed into the trash. 


• Avoid saving leftover opioids for anticipated future pain. Remind patients that drug-drug interactions and comorbidities may increase risk and that these should always be checked in advance. 


• For patients on chronic opioid therapy, consider prescribing take-home naloxone should an overdose occur in the patient or in the household. 


 

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