Opioid use in older adults Is it a good idea? Regional Geriatric Rounds April 26, 2013

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1 Opioid use in older adults Is it a good idea? Regional Geriatric Rounds April 26, 2013 Allen R. Huang, MDCM, FRCPC, FACP, AGSF Division of Geriatric Medicine allenhuang@toh.on.ca

2 I have no conflict of interest to declare

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4 Allen s rule: If a topic gets the attention of New York City mayor Michael Bloomberg then IT REALLY MUST BE IMPORTANT!

5 Papaver somniferum Morphine is most abundant opiate

6 ? First recorded uses (abuses) Sumerians c. 4000BC Morphine isolated in 1804

7 CONFLICT Crime Addiction 15 th most prescribed drug class globally 3 rd in U.S. Accidental poisoning

8 Prescription opioid crisis

9 Eugène Delacroix, 1830 Liberty Leading the People

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11 World population = 7 billion 11% older than 60-years Enough to replace the population of Europe Persistent pain is common 1 in 5 older adults (US, Europe, Canada ) Almost 2/3 taking analgesics for more than 6-months World Health Organization 3-step ladder strategy for pain management American Geriatrics Society 2009 guidelines on the management of persistent pain

12 WHO Pain ladder

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14 New York City recommendations

15 Adequate assessment of pain Special consideration for patients with cognitive impairment Patient kidney function, liver function Format and medication administration Onset and duration of effects, side-effects Goals of treatment Drug potency Psychological state Social situation

16 Codeine (0.1)* needs to be converted to morphine by CYP-2D6 Morphine (1) Oral first-pass liver metabolism, renal clearance M6G active, M3G neuroexcitatory Oxycodone (2)* Active metabolites accumulate in renal insufficiency Hydromorphone (5) First pass metabolism H3G metabolite accumulates in renal insufficiency AVOID MEPERIDINE!!!

17 Methadone(3)* CYP metabolism, renal clearance Tramadol(0.1)* Needs CYP-2D6 conversion to active drug Also has SNRI activity Buprenorphine(40) Patch formulation 7day duration Clearance unaffected by kidney function Fentanyl(50)* Patch formulation -3day duration Inactive metabolite, renal clearance * can be involved in CYP drug interactions

18 Excess sedation Respiratory depression Urinary retention Dizziness, nausea, falls Uncommon side-effects Histamine release flushing, itching, sweating Opiate hyperalgesia syndrome Immunosuppression Male hypogonadism Muscle rigidity & myoclonus (Cognitive impairment)

19 Soluble fibre + adequate fluids Lactulose 15-30cc b.i.d.-t.i.d. Polyethylene glycol preparations Bisacodyl 5-10mg daily Combo product oxycodone+naloxone (2:1) Prucalopride gut 5HT4 prokinetic drug methylnaltrexene blocks peripheral gut μ-opioid receptors

20 Psychology & physiology of pain have a protective effect against addiction Drug tolerance (receptor desensitization) Dependence avoidance of unpleasant withdrawal symptoms Psychological dependence and addiction are slower to develop. Recreational use seeks the attainment of euphoria, NOT pain relief Endogenous opioid peptides (enkephalins, endorphins, dynorphins)

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22 Risk for abuse with score > 18

23 Opioids are appropriate in managing suffering from persistent pain in older adults Monitoring for effectiveness, side effects and frequent review of goals of therapy are mandatory Documentation and communication of changes are important in the detection of adverse drug events Consider referral to specialized pain or Geriatrics service for assistance Add life to years!

24 Huang, A., Mallet, L. Prescribing opioids in older adults. Maturitas 2013; 74: (Reprints available on request) Okie S. A Flood of Opioids, a Rising Tide of Deaths. N Engl J Med 2010; 363(21): Pergolizzi J, Boger RH, Budd K, et al. Opioids and the management of chronic severe pain in the elderly: consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids. Pain Pract 2008; 8(4): AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc 2002; 50(6:Suppl):S Benyamin R, Trescot AM, Datta S, et al. Opioid complications and side effects. Pain Physician 2008; 11(2:Suppl):S105-S120. Butler SF, Fernandez K, Benoit C, Budman SH, Jamison RN. Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). J Pain 2008; 9(4):

25 Thank you