Analgesics: Management of Pain In the Elderly Handout Package
Analgesics: Management of Pain in the Elderly Each patient or resident and their pain problem is unique. A complete assessment should be performed for all patients. Successful Pain Management Create the total pain picture Education Listen to your patient Be flexible DO not delay Utilize an interdisciplinary team approach 1
Appropriate prescribing of pain medication: Titrate dose to effect Start low Remember the exception: Acetaminophen and NSAIDS have recommended dose ceilings ANALGESIC STEPPED APPROACH IN PAIN MANAGEMENT Pain persisting or increasing Non-Opioid ASA Acetaminophen NSAID s Analgesic Ladder Pain persisting or increasing Opioid for Mild to Moderate Pain Codeine - Oxycodone Pharmacological Opioid for Moderate to Severe Pain Oxycodone Hydromorphone Morphine - Fentanyl *Modified after WHO Draft Interim Guidelines Handbook on Relief of Cancer Pain, World Health Organization, Geneva 1990 2
In challenging pain problems, a combination of drugs with different mechanisms of action can increase efficacy while minimizing side effects. Drug therapy will augment and be a part of the total pain treatment program. Acetaminophen and non-steroidal anti-inflammatory drugs are usually prescribed first for mild pain. Chronic pain is common in the elderly and is undertreated. 25 50% of elderly in the community have significant pain and 45 80% of residents in LTC have chronic and more significant pain 3
Acetaminophen is often our first choice Use of the COX-2 Inhibitors NSAIDs of Choice 1 out of 3 sufferers with chronic pain are treated successfully with an NSAID Co-Analgesics are drugs developed primarily to treat other conditions The basic principles in choosing an adjunct therapy plan: The pain type Side effects Analgesic dosage 4
Co-Analgesic Options Antidepressants Anticonvulsants Benzodiazepines Muscle relaxants More Co-Analgesics Options Marijuana Herbals and/or supplements Glucosamine Second Step of the Analgesic Step Ladder Tylenol 2s and 3s, Percocet and Percodan Third Step of the Analgesic Ladder For moderate to severe pain Fentanyl, Hydromorphone, Morphine and Oxycodone 5
Opioid Therapy Round-the-clock pain should be treated with a long-acting product Short acting opioid, dosing every 4 to 6 hours Start directly with a low dose sustained release opioid and gradually titrate up every 4 to 7 days Medication for breakthrough pain should be used as needed right from the start Breakthrough dose should be 5 to 15% of the 24 hour dose Breakthrough dose can be offered once every hour Dosage titration should continue until: 1. Effective pain control or 2. Persistent unacceptable side effects There is NO pharmacological rationale for a dose ceiling for the opioid analgesics. 6
Utilize the preferred dosing schedule recommended by the manufacturers. Increase the dose before decreasing the dosing interval. Consider alternative adjunct therapy Recommend asymmetric dosing when appropriate EQUIVALENCY CHART OPIOIDS Opioid Morphine Oral Dose (mg) 30-60 Dose Interval (hr) 3-4 SR product Yes Codeine 180-240 3-4 Yes Hydromorphone 4-6 3-4 Yes Oxycodone 15-30 3-4 Yes Fentanyl patch 25-50 mcg/hr Q48-72 hrs Yes 7
Opioids For Mild to Moderate Pain Codeine Oxycodone Opioids For Severe Pain Morphine Hydromorphone Fentanyl Transdermal System Fentanyl Patches Indicated for chronic pain Assessed at regular intervals Maintained at the lowest dose providing acceptable pain control Fentanyl patches are a viable alternative in pain therapy Compliance is good Studies have shown sleep quality and quality of life improvements 8
ADDICTION Methadone Not highly recommended in the elderly Respiratory depression and cardiac arrhythmias Canadian physicians must have a special license So in conclusion let s review 10 points when prescribing and utilizing OPIOIDS 1. Take a good pain history 2. Do a relevant physical examination 3. Try to establish a working diagnosis 4. Eliminate unnecessary and ineffective medications 5. Try adjuvant co-analgesics 9
6. Round-the-clock pain 7. Manage opioid-related side effects 8. Provide regular follow-up 9. Decrease the risk of drug diversion 10. Use extra care and monitoring to provide better pain control 10