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Treatment of Chronic Pain in Older People

Evidence-Based Choice of Strong-Acting Opioids

  • Therapy In Practice
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Abstract

In the treatment of chronic malignant and non-malignant pain, opioids are used as strong analgesics. Frail elderly patients often have multiple comorbidities and use multiple medicines, leading to an increased risk of clinically relevant drug-drug and drug-disease interactions. Age-related changes and increased frailty may lead to a less predictable drug response, increased drug sensitivity, and potential harmful drug effects. As a result, physicians face a complex task in prescribing medication to elderly patients. In this review, the appropriateness of the strong-acting opioids buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone and tapentadol is determined for use in elderly patients. Evidence-based recommendations for prescribing strong opioids to the frail elderly are presented.

A literature search was performed for all individual drugs, using a validated and published set of 23 criteria concerning effectiveness, safety, pharmacokinetics and pharmacodynamics, experience, and convenience in elderly patients. First, information on the criteria was obtained from pharmaceutical reference books and a MEDLINE search. The information obtained on the individual drugs in the class of opioids was compared with the reference drug morphine. Evidence-based recommendations were formulated on the basis of the pros and cons for the frail elderly.

Using the set of 23 criteria, no differentiation can be made between the appropriateness of buprenorphine, fentanyl, hydromorphone, morphine and oxycodone for use in elderly patients.

Methadone has strong negative considerations in the treatment of chronic pain in the frail elderly. Methadone has a high drug-drug interaction potential and is associated with prolongation of the QT interval and a potential risk of accumulation due to a long elimination half-life. In addition, methadone is difficult to titrate because of its large inter-individual variability in pharmacokinetics, particularly in the frail elderly. Because of a lack of empiric knowledge, the use of tapentadol is not recommended in frail elderly persons. Nevertheless, tapentadol may prove to be a useful analgesic for the treatment of chronic pain in frail elderly persons because of its possible better gastrointestinal tolerability.

In the treatment of chronic pain in the frail elderly, the opioids of first choice are buprenorphine, fentanyl, hydromorphone, morphine and oxycodone. In order to improve the convenience for elderly patients, the controlled-release oral dosage forms and transdermal formulations are preferred.

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References

  1. Gianni W, Ceci M, Bustacchini S, et al. Opioids for the treatment of chronic non-cancer pain in older people. Drugs Aging 2009; 26 Suppl. 1: 63–73.

    Article  PubMed  CAS  Google Scholar 

  2. Moore RA, Straube S, Eccleston C, et al. Estimate at your peril: imputation methods for patient withdrawal can bias efficacy outcomes in chronic pain trials using responder analysis. Pain 2012; 153: 265–8.

    Article  PubMed  Google Scholar 

  3. Gomes T, Mamdani MM, Dhalla IA, et al. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med 2011; 171 (7): 686–91.

    Article  PubMed  CAS  Google Scholar 

  4. Tumer N, Scarpace PJ, Lowenthal DT. Geriatric pharmacology: basic and clinical considerations. Ann Rev Pharmacol Toxicol 1992; 32: 271–302.

    Article  CAS  Google Scholar 

  5. Turnheim K. Drug therapy in the elderly. Exp Gerontol 2004; 39: 1731–8.

    Article  PubMed  CAS  Google Scholar 

  6. Bowie MW, Slattum PW. Pharmacodynamics in older adults: a review. Am J Geriatr Pharmacother 2007; 5 (3): 263–303.

    Article  PubMed  CAS  Google Scholar 

  7. Hammerlein A, Derendorf H, Lowenthal DT. Pharmacokinetic and pharmacodynamic changes in the elderly: clinical implications. Clin Pharmacokinet 1998; 34 (1): 49–64.

    Article  Google Scholar 

  8. Huisman-Baron M, van der Veen L, Jansen PAF, et al. Criteria for drug selection in frail elderly persons. Drugs Aging 2011; 28 (5): 391–402.

    Article  PubMed  Google Scholar 

  9. Beers MH, Ouslander JG, Rollingher I, et al. Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med 1991; 151 (9): 1825–32.

    Article  CAS  Google Scholar 

  10. Griessinger N, Sittl R, Likar R. Transdermal buprenorphine in clinical practice: a post-marketing surveillance study in 13179 patients. Cur Med Res Opin 2005; 21 (8): 1147–56.

    Article  CAS  Google Scholar 

  11. Gianni W, Madaio AR, Geci M, et al. Transdermal buprenorphine for the treatment of chronic noncancer pain in the oldest old. J Pain Symptom Manage 2011; 41: 707–14.

    Article  PubMed  CAS  Google Scholar 

  12. Yu SY, Sun Y, Zhang HC, et al. Transdermal fentanyl for the management of cancer pain: a survey of 1,664 elderly patients [abstract]. Zhongua Yi Xue Za Zhi 2003 Nov; 83 (22): 1931–5.

    CAS  Google Scholar 

  13. Vorsanger G, Xiang J, Biondi D, et al. Post hoc analyses of data from a 90-day clinical trial evaluating the tolerability and efficacy of tapentadol immediate release and oxycodone immediate release for the relief of moderate to severe pain in elderly and nonelderly patients. Pain Res Manage 2011; 16 (4): 245–51.

    Google Scholar 

  14. Hale M, Upmalis D, Okamoto A, et al. Tolerability of tapentadol immediate release in patients with lower back pain or osteoarthritis of the hip or knee over 90 days: a randomized, double-blind study. Curr Med Res Opin 2009; 25 (5); 1095–104.

    Article  PubMed  CAS  Google Scholar 

  15. Moore RA, McQuay HJ. Prevalence of opioid adverse events in chronic non-malignant pain: systematic review of randomised trials of oral opioids. Arthritis Res Ther 2005; 7 (5): R1046–50.

    Article  PubMed  CAS  Google Scholar 

  16. McNicol E, Horowicz-Mehler N, Fisk RA, et al. Management of opioid side effects in cancer-related and chronic noncancer pain: a systematic review. J Pain 2003; 4 (5): 231–56.

    Article  PubMed  Google Scholar 

  17. Nicholson B. Responsible prescribing of opioids for the management of chronic pain. Drugs 2003; 63 (1): 17–32.

    Article  PubMed  Google Scholar 

  18. Clark AJ, Ahmedzai SH, Allan LG, et al. Efficacy and safety of transdermal fentanyl and sustained-release oral morphine in patients with cancer and chronic non-cancer pain. Cur Med Res Opin 2004; 20 (9): 1419–28.

    Article  CAS  Google Scholar 

  19. Ahmedzai S, Brooks D. Transdermal fentanyl versus sustained-release oral morphine in cancer pain: preference, efficacy and quality of life. J Pain Symptom Manage 1997 May; 13 (5): 254–61.

    Article  PubMed  CAS  Google Scholar 

  20. Hartrick GT, Rozek RJ. Tapentadol in pain management, a μ-opioid receptor agonist and noradrenaline reuptake inhibitor. CNS Drugs 2011; 25 (5): 359–70.

    Article  PubMed  CAS  Google Scholar 

  21. Leppert W. The role of opioid receptor antagonists in the treatment of opioid-induced constipation: a review. Adv Ther 2010; 27 (10): 714–30.

    Article  PubMed  CAS  Google Scholar 

  22. Dahan A, Aarts L, Smith TW. Incidence, reversal, and prevention of opioid-induced respiratory depression. Anesthesiology 2010; 112: 226–38.

    Article  PubMed  Google Scholar 

  23. Mucci-LoRusso P, Berman BS, Silverstein PT, et al. Controlled-release oxycodone compared with controlled-release morphine in the treatment of cancer pain: a randomized, double blind, parallel-group study. Eur J Pain 1998; 2: 239–49.

    Article  PubMed  CAS  Google Scholar 

  24. Kalso E, Vainio A. Morphine and oxycodone in the management of cancer pain. Clin Pharmacol Ther 1990 May; 47(5): 639–46.

    Article  PubMed  CAS  Google Scholar 

  25. Maddocks I, Somogyi A, Abott F, et al. Attenuation of morphine-induced delirium in palliative care by substitution with infusion of oxycodone. J Pain Symptom Manage 1996 Sep; 12 (3): 182–9.

    Article  PubMed  CAS  Google Scholar 

  26. Slatkin NE. Opioid switching and rotation in primary care: implementation and clinical utility. Cur Med Res Opin 2009; 25 (9): 2133–50.

    Article  CAS  Google Scholar 

  27. Rosow CE, Moss J, Philbin DM, et al. Histamine release during morphine and fentanyl anesthesia. Anesthesiology 1982; 56: 93–6.

    Article  PubMed  CAS  Google Scholar 

  28. Smith H, Bruckenthal P. Implications of opioid analgesia for medically complicated patients. Drugs Aging 2010; 27 (5): 417–33.

    Article  PubMed  CAS  Google Scholar 

  29. Goodarzi M, Narasimhan RR. The effect of large-dose intrathecal opioids on the autonomic nervous system. Anesth Analg 2001; 93: 456–9.

    PubMed  CAS  Google Scholar 

  30. Harris JD. Management of expected and unexpected opioidrelated side effects. Clin J Pain 2008; 24 (4): S8–13.

    Article  PubMed  Google Scholar 

  31. Andrews CM, Krantz MJ, Wedam EF, et al. Methadone-induced mortality in the treatment of chronic pain: role of QT prolongation. Cardiol J 2009; 16 (3): 210–7.

    PubMed  Google Scholar 

  32. van Roon EN, Flikweert S, le Comte M, et al. Clinical relevance of drug-drug interactions: a structured assessment procedure. Drug Safety 2005; 28 (12): 1131–9.

    Article  PubMed  Google Scholar 

  33. Li Y, Kantelip JP, Gerritsen-van Schieveen P, et al. Inter-individual variability of methadone response: impact of genetic polymorphism. Mol Diagn Ther 2008; 12 (2): 109–24.

    Article  PubMed  CAS  Google Scholar 

  34. Baxter K, editor. Stockley’s drug interactions. 9th ed. London: Pharmaceutical Press, 2010.

    Google Scholar 

  35. Nucynta® (tapentadol) immediate release oral tablets: US prescribing information. Raritan: Ortho-McNeil-Janssen Pharmaceuticals Inc., 2008.

  36. Durnin C, Hind ID, Ghani SP, et al. Pharmacokinetics of oral immediate-release hydromorphone (Dilaudid® IR) in young and elderly subjects. Proc West Pharmacol Soc 2001; 44: 79–80.

    PubMed  CAS  Google Scholar 

  37. Fainsinger R, Schoeller T, Bruera E. Methadone in the management of cancer pain: a review. Pain 1993; 52: 137–47.

    Article  PubMed  CAS  Google Scholar 

  38. Lugo RA, Satterfiel KL, Kern SE. Pharmacokinetics of methadone. J Pain Palliat Care Pharmacother 2005; 19 (4): 13–24.

    Article  PubMed  Google Scholar 

  39. Nicholson AB. Methadone for cancer pain. Cochrane Database Syst Rev 2007; 4: CD003971.

    PubMed  Google Scholar 

  40. Hand CW, Sear JW, Uppington J, et al. Buprenorphine disposition in patients with renal impairment: single and continuous dosing, with special reference to metabolites. Br J Anaesth 1990 Mar; 64 (3): 276–82.

    Article  PubMed  CAS  Google Scholar 

  41. Böger RH. Renal impairment: a challenge for opioid treatment? The role of buprenorphine. Palliat Med 2006; 20 Suppl. 1: s17–23.

    Article  PubMed  Google Scholar 

  42. Durnin C, Hind ID, Wickens MM, et al. Pharmacokinetics of oral immediate-release hydromorphone (Dilaudid IR) in subjects with renal impairment. Proc West Pharmacol Soc 2001; 44: 81–2.

    PubMed  CAS  Google Scholar 

  43. Pergolizzi J, Aloisi AM, Dahan A, et al. Current knowledge of buprenorphine and its unique pharmacological profile. Pain Pract 2010; 10 (5): 428–50.

    Article  PubMed  Google Scholar 

  44. Vadivelu N, Hines RL. Management of chronic pain in the elderly: focus on transdermal buprenorphine. Clin Interv Aging 2008; 3 (3): 421–30.

    PubMed  CAS  Google Scholar 

  45. Plosker GL. Buprenorphine 5, 10 and 20 μg/h transdermal patch: a review of its use in the management of chronic non-malignant pain. Drugs 2011; 71 (18): 2491–509.

    Article  PubMed  CAS  Google Scholar 

  46. Holdsworth MT, Forman WB, Killilea TA, et al. Transdermal fentanyl disposition in elderly subjects. Gerontology 1994; 40: 32–7.

    Article  PubMed  CAS  Google Scholar 

  47. Vaughan C. Development and implementation of a process to ensure safe use of morphine sulfate extended-release liposome injection. Am J Health Syst Pharm 2008; 65 (5): 458–61.

    Article  PubMed  Google Scholar 

  48. Chou R, Fanciullo GJ, Fine PG, et al. American Pain Society — American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use chronic opioid therapy in chronic noncancer pain. J Pain 2009; 10 (2): 113–30.

    Article  PubMed  CAS  Google Scholar 

  49. Barber JB, Gibson SJ. Treatment of chronic non-malignant pain in the elderly. Drug Saf 2009; 32 (6): 457–74.

    Article  PubMed  CAS  Google Scholar 

  50. McLachlan AJ, Bath S, Naganathan V, et al. Clinical pharmacology of analgesic medicines in older people: impact of frailty and cognitive impairment. Brit J Clin Pharmacol 2011; 71 (3): 351–64.

    Article  CAS  Google Scholar 

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Acknowledgements

This research was funded by a Grant of the Governmental Dutch Research Organization ZONMw at the Expertise Centre for Pharmacotherapy in Old Persons (Ephor), University Medical Centre Utrecht, the Netherlands. The authors have no conflicts of interest that are directly relevant to the content of this article.

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Authors and Affiliations

  1. Expertise Centre for Pharmacotherapy in Old Persons (Ephor), University Medical Center, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands

    Annette L. van Ojik,  Paul A. F. Jansen, Jacobus R. B. J. Brouwers & Eric N. van Roon

  2. Department of Clinical Pharmacy & Pharmacology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands

    Annette L. van Ojik & Eric N. van Roon

  3. Department of Geriatrics, University Medical Centre, Utrecht, The Netherlands

    Paul A. F. Jansen

  4. Department of Pharmacotherapeutics and Pharmaceutical Care, University of Groningen, Groningen, The Netherlands

    Jacobus R. B. J. Brouwers

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  1. Annette L. van Ojik
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  3. Jacobus R. B. J. Brouwers
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  4. Eric N. van Roon
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Correspondence to Paul A. F. Jansen.

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van Ojik, A.L., Jansen, P.A.F., Brouwers, J.R.B.J. et al. Treatment of Chronic Pain in Older People. Drugs Aging 29, 615–625 (2012). https://doi.org/10.1007/BF03262278

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