Transcript Etzioni, et al. JAGS 2007 55:S403-S408

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)
Mechanisms of Chronic Pain
*Nociceptive
*Neuropathic
*Peripheral sensitization
(hyperalgesia, allodynia)
*Central sensitization (NMDA)
*Desensitization (tolerance)
WHO Ladder
Level 3 (Severe pain):
strong opioids – morphine,
hydromorphone, fentanyl,
oxycodone +/- adjuvants
Level 2 (moderate to severe pain):
acetaminophen plus opioid
(hydrocodone, codeine,
oxycodone): tramadol +/1
adjuvants
Level 1 (mild to moderate pain):
acetaminophen, aspirin, NSAIDS
(cox-2) +/- adjuvants
Opioid Side Effects
*Nausea and vomiting (central)
NON-OPIOID TREATMENT OPTIONS (ADJUVANTS)
FOR PAIN IN THE ELDERLY
Drug
*Delayed gastric emptying
*Constipation
*Hypotension
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.
*Respiratory depression
*CNS
*Pruritus
*Disinhibition (GABA)
http://www.geriatricpain.org/Content/Manageme
nt/Interventions/Documents/WHO%20ladder.pdf
Equianalgesic Doses of Opioid Analgesics Used for the Control of Pain
Local Anesthetics
NSAIDS
Tramadol
http://www.musc.edu/pharmacyservices/medusepol/OpioidAnalgesicConversionChart.pdf
Comments/Side
Effects
First-line agent for
patients with OA and
patients with mild to
moderate pain.
*Myoclonus
*GU
Description
Avoid in elderly if
possible (AGS)
Start low dose,
increase slowly
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