Aging Q3 Pain Management ACOVE
Pain-related problems are present in 25% - 50% of community-dwelling elderly people.
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)
 Disinhibition (GABA)
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 +/adjuvants
 Level 1 (mild to moderate
pain): acetaminophen,
aspirin, NSAIDS (cox-2) +/adjuvants
Opioid Side Effects
 Nausea and vomiting
(central)
 Delayed gastric emptying
 Constipation
 Hypotension
 Myoclonus
 Respiratory depression
 CNS
 GU
 Pruritus
Non-opioid Treatment Options (Adjuvants) for Pain in the Elderly
Drug
Acetaminophen
Anticonvulsants
Antidepressants
Local Anesthetics
NSAIDS
Tramadol
Muscle Relaxants
Description
Comments/Side Effects
First-line agent for patients with OA
and patients with mild to moderate
pain.
Primarily in neuropathic pain
(carbamazepine divalproex,
gabapentin, pregabalin, topiramate,
duloxetine)
Limit dose in elderly. Avoid
combining with opioids.
TCAs, SNRIs
Start low dose,increase slowly:
Anticholinergic side effects of
TCAs
BP effects of SNRIs
Lidocaine: may apply up to 3
patches q 12 hours
Capsaicin: burning pain intolerable
by some patients.
Cox-2 probably OK. Avoid
combining with opioids
Lidocaine patches
Capsaicin
Avoid in elderly if possible (AGS)
Start low dose, increase slowly
Cyclobenzaprine, carisoprodol
Avoid in elderly if possible (AGS)
Carbamazepine: blood
dyscrasias,Gabapentin/Pregabalin:
Ataxia, dizziness, somnolence
Drowsiness, nausea, constipation
May not be best option for patients
on antidepressants
Anticholinergic side effects,
arrhythmias
EQUIANALGESIC DOSES OF OPIOID ANALGESICS
USED FOR THE CONTROL OF PAINa
Oral (PO)
Dose (mg)
Analgesicb
Intravenous
(IV
Dose (mg)
50
150
Meperidine (Demerol)c – (do not use in elderly)
100
Codeine (Tylenol with Codeine)c,d
15
Hydrocodone (Vicodin, Lortab, Zydone, Norco, Vicoprofen) c,e
-
15
MORPHINE (MSIR, Roxanol, MS Contin, Kadian, Avinza)f
5
Oxycodone (Percodan, Percocet, Endocet, Roxicodone, OxyIR,
OxyContin, OxyFAST, OxyDose)g
-
10
10
Methadone (Dolophine)h - (very difficult to use in elderly)
5
4
Hydromorphone (Dilaudid)f
2
-
Levorphanol (Levo-Dromoran)
Fentanyl (Duragesic/Actiq)i
60
1.5
h
1
-
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.
Opioid treatment of chronic pain should be initiated in opioid-naïve patients with a short acting opioid
(e.g. oxycodone) and converted to a long-acting opioid (e.g. fentanyl patches) when the desired analgesic
effect is achieved.
a
Equianalgesic doses listed were obtained from a variety of studies and experiences and are meant only
as guidelines
b
Dose 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.
c
Not recommended for severe pain – neurotoxic with repeated dosing.
d
Tylenol #2=15mg codeine, Tylenol #3=30 mg codeine, Tylenol #4=60mg codeine. All contain 325 mg
acetaminophen.
e
Combination tablets contain 2.5-10 mg hydrocodone plus 325-750 mg acetaminophen or 200 mg
ibuprofen.
f
Rectal suppositories available. Per rectum (P.R.) dose is equal to PO dose.
g
Combination tablets contain 2.5-10 mg oxycodone+325-650 mg acetaminophen or 325 mg aspirin.
h
Caution: 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
Funding provided by
D.W. Reynolds Foundation
UIM chronic opioid management policy (complies with Board of Medicine recommendations)
Patients on chronic opioid therapy pain must be assessed every three months and complete a “Patient
Agreement” annually and the patient agrees:
 That opioids are part of an overall pain management plan and patients must adhere to other
recommendations such as physical therapy, use of pharmacologic adjuncts etc.
 Opioids will be written by UIM only and acquired from one pharmacy
 Prescriptions will NOT be re-written or written early under any circumstances
 Not use illegal substances and agree to random urine drug screens
 Patient will not sell or give opioids to others
 Violation of agreement for chronic pain management will result in dismissal from the UIM practice