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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