Transcript Aging Q3 Pain Management ACOVE Pharmacological treatment

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 2007 55:S403-S408)
WHO Ladder
Mechanisms of Chronic Pain
Level 3 (Severe pain):
strong opioids – morphine,
hydromorphone, fentanyl,
oxycodone +/- adjuvants
*Nociceptive
*Neuropathic
*Peripheral sensitization
(hyperalgesia, allodynia)
*Central sensitization (NMDA)
*Desensitization (tolerance)
*Disinhibition (GABA)
150
100
15
15
10
4
2
i
*Nausea and vomiting (central)
*Constipation
*Hypotension
Level 1 (mild to moderate pain):
acetaminophen, aspirin, NSAIDS
(cox-2) +/- adjuvants
*GU
Analgesicb
NON-OPIOID TREATMENT OPTIONS (ADJUVANTS)
FOR PAIN IN THE ELDERLY
Drug
*Delayed gastric emptying
Level 2 (moderate to severe pain):
acetaminophen plus opioid
(hydrocodone, codeine,
oxycodone): tramadol +/1
adjuvants
EQUIANALGESIC DOSES OF OPIOID ANALGESICS
USED FOR THE CONTROL OF PAINa
Oral
(PO)
Dose
(mg)
Opioid Side Effects
Acetaminophen
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
Lidocaine patches
Capsaicin
Lidocaine: may
apply up to 3 patches
q 12 hours
Capsaicin: burning
pain intolerable by
some patients.
*Myoclonus
*Respiratory depression
*CNS
*Pruritus
Meperidine (Demerol)c – (do not use in
elderly)
Codeine (Tylenol with Codeine)c,d
Hydrocodone (Vicodin, Lortab, Zydone, Norco,
Vicoprofen) c,e
MORPHINE (MSIR, Roxanol, MS Contin, Kadian,
Avinza)f
Oxycodone (Percodan, Percocet, Endocet,
Roxicodone, OxyIR, OxyContin, OxyFAST,
OxyDose)g
Methadone (Dolophine)h - (very difficult to
use in elderly)
Hydromorphone (Dilaudid)f
Levorphanol (Levo-Dromoran)h
Fentanyl (Duragesic/Actiq)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.
50
60
5
0.75
1
-
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.
Local Anesthetics
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.
NSAIDS
Avoid in elderly if
possible (AGS)
eCombination
tablets contain 2.5-10 mg hydrocodone plus 325
750 mg acetaminophen or 200 mg ibuprofen.
fRectal
suppositories available. Per rectum (P.R.) dose is equal
to PO dose.
Tramadol
Start low dose,
increase slowly
gCombination
tablets contain 2.5-10 mg oxycodone+325-650
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
Comments/Side
Effects
First-line agent for
patients with OA and
patients with mild to
moderate pain.
aEquianalgesic
Intrave
nous
(IV
Dose
(mg)
Description
Cyclobenzaprine,
Carisoprodol; Avoid
Muscle Relaxants
in elderly if possible
(AGS)
Cox-2 probably OK.
Avoid combining
with opioids
Drowsiness, nausea,
constipation
May not be best
option for patients on
antidepressants
Anticholinergic side
effects, arrhythmias