*Nociceptive

*Neuropathic

*Peripheral sensitization

(hyperalgesia, allodynia)

*Central sensitization (NMDA)

*Desensitization (tolerance)

*Disinhibition (GABA)

Mechanisms of Chronic Pain

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)

NON-OPIOID TREATMENT OPTIONS (ADJUVANTS) FOR PAIN IN THE ELDERLY

Drug Description Comments/Side Effects

Acetaminophen

First-line agent for patients with OA and patients with mild to moderate pain.

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

AntidepressantsTCAs, SNRIsStart low dose,increase slowly

Anticholinergic side effects of TCAsBP effects of SNRIs

Local AnestheticsLidocaine patchesCapsaicin

Lidocaine: may apply up to 3 patches q 12 hoursCapsaicin: burning pain intolerable by some patients.

NSAIDS Avoid in elderly if possible (AGS)

Cox-2 probably OK. Avoid combining with opioids

TramadolStart low dose, increase slowly

Drowsiness, nausea, constipationMay not be best option for patients on antidepressants

Muscle Relaxants

Cyclobenzaprine, Carisoprodol; Avoid in elderly if possible (AGS)

Anticholinergic side effects, arrhythmias

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

*Nausea and vomiting (central)

*Delayed gastric emptying

*Constipation

*Hypotension

*Myoclonus

*Respiratory depression

*CNS

*GU

*Pruritus

aEquianalgesic 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.

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.

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.

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

EQUIANALGESIC DOSES OF OPIOID ANALGESICSUSED FOR THE CONTROL OF PAINa

Oral (PO)Dose (mg)

Analgesicb

Intravenous (IV

Dose (mg)

150 Meperidine (Demerol)c – (do not use in elderly) 50

100 Codeine (Tylenol with Codeine)c,d 60

15 Hydrocodone (Vicodin, Lortab, Zydone, Norco, Vicoprofen) c,e -

15 MORPHINE (MSIR, Roxanol, MS Contin, Kadian, Avinza)f 5

10Oxycodone (Percodan, Percocet, Endocet, Roxicodone, OxyIR, OxyContin, OxyFAST, OxyDose)g

-

- Methadone (Dolophine)h - (very difficult to use in elderly) -

4 Hydromorphone (Dilaudid)f 0.752 Levorphanol (Levo-Dromoran)h 1- Fentanyl (Duragesic/Actiq)i -

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.

WHO Ladder Opioid Side Effects