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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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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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  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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