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Underutilisation of Opioids in Elderly Patients with Chronic Pain

Approaches to Correcting the Problem

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Abstract

The impact of poorly managed chronic pain on the quality of life of elderly patients and the problems related to its management are widely acknowledged. Underutilisation of opioids is a major component of poor pain management in this group of patients, despite good evidence for the effectiveness of opioids and published guidelines directing their usage.

Reasons for this underutilisation are, among others, poor assessment of pain in this age group; fear of polypharmacy and opiophobia; and avoidance of opioids because of concerns about tolerance, physical dependence, addiction and adverse effects.

This review suggests approaches to overcome these barriers to opioid usage, such as regular pain assessments, education to overcome opiophobia, rational prescribing, utilisation of less conventional opioids and non-oral routes of administration, avoidance of inappropriate opioids, opioid rotation, and education about managing or preventing adverse effects, the reasons why opioid therapy may be unsuccessful, and the effects of psychological factors on the pain experience.

This more rational and knowledge-based approach to the use of opioids in the management of chronic pain in the elderly population should correct the current problems with underprescribing in this age group.

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References

  1. Mantyselka P, Hartikainen S, Louhivuori-Laako K, et al. Effects of dementia on perceived daily pain in home-dwelling elderly people: a population-based study. Age Ageing 2004; 33(5): 496–9

    Article  PubMed  Google Scholar 

  2. Practice guidelines for chronic pain management: a report by the American Society of Anesthesiologists Task Force on Pain Management, Chronic Pain Section. Anesthesiology 1997; 86(4): 995–1004

    Google Scholar 

  3. Chodosh J, Solomon DH, Roth CP, et al. The quality of medical care provided to vulnerable older patients with chronic pain. J Am Geriatr Soc 2004; 52(5): 756–61

    Article  PubMed  Google Scholar 

  4. McClean WJ, Higginbotham NH. Prevalence of pain among nursing home residents in rural New South Wales. Med J Aust 2002; 177(1): 17–20

    PubMed  Google Scholar 

  5. Won AB, Lapane KL, Vallow S, et al. Persistent nonmalignant pain and analgesic prescribing patterns in elderly nursing home residents. J Am Geriatr Soc 2004; 52(6): 867–74

    Article  PubMed  Google Scholar 

  6. Donald IP, Foy C. A longitudinal study of joint pain in older people. Rheumatology (Oxford) 2004; 43(10): 1256–60

    Article  CAS  Google Scholar 

  7. Ferrell BA, Ferrell BR, Rivera L. Pain in cognitively impaired nursing home patients. J Pain Symptom Manage 1995; 10(8): 591–8

    Article  PubMed  CAS  Google Scholar 

  8. Griessinger N, Sittl R, Jost R, et al. The role of opioid analgesics in rheumatoid disease in the elderly population. Drugs Aging 2003; 20(8): 571–83

    Article  PubMed  CAS  Google Scholar 

  9. Cleary JF, Carbone PP. Palliative medicine in the elderly. Cancer 1997; 80(7): 1335–47

    Article  PubMed  CAS  Google Scholar 

  10. Gloth III FM. Pain management in older adults: prevention and treatment. J Am Geriatr Soc 2001; 49(2): 188–99

    Article  PubMed  Google Scholar 

  11. Rao A, Cohen HJ. Symptom management in the elderly cancer patient: fatigue, pain, and depression. J Natl Cancer Inst Monogr 2004; (32): 150–7

    Google Scholar 

  12. Juurlink DN, Herrmann N, Szalai JP, et al. Medical illness and the risk of suicide in the elderly. Arch Intern Med 2004; 164(11): 1179–84

    Article  PubMed  Google Scholar 

  13. Jakobsson U, Rahm Hallberg I, Westergren A. Pain management in elderly persons who require assistance with activities of daily living: a comparison of those living at home with those in special accommodations. Eur J Pain 2004; 8(4): 335–44

    Article  PubMed  Google Scholar 

  14. Bosley BN, Weiner DK, Rudy TE, et al. Is chronic nonmalignant pain associated with decreased appetite in older adults? Preliminary evidence. J Am Geriatr Soc 2004; 52(2): 247–51

    Article  PubMed  Google Scholar 

  15. Vigano A, Bruera E, Suarez-Almazor ME. Age, pain intensity, and opioid dose in patients with advanced cancer. Cancer 1998; 83(6): 1244–50

    Article  PubMed  CAS  Google Scholar 

  16. WHO. Cancer pain relief. Geneva: World Health Organization, 1986

    Google Scholar 

  17. WHO. Cancer pain relief: with a guide to opioid availability. 2nd ed. Geneva: World Health Organization, 1996

    Google Scholar 

  18. Zech DF, Grond S, Lynch J, et al. Validation of World Health Organization guidelines for cancer pain relief: a 10-year prospective study. Pain 1995; 63(1): 65–76

    Article  PubMed  CAS  Google Scholar 

  19. Schug S, Zech D, Grond S, et al. A long-term survey of morphine in cancer pain patients. J Pain Symptom Manage 1992; 7(5): 259–66

    Article  PubMed  CAS  Google Scholar 

  20. Marinangeli F, Ciccozzi A, Leonardis M, et al. Use of strong opioids in advanced cancer pain: a randomized trial. J Pain Symptom Manage 2004; 27(5): 409–16

    Article  PubMed  CAS  Google Scholar 

  21. Buntin-Mushock C, Phillip L, Moriyama K, et al. Age-dependent opioid escalation in chronic pain patients. Anesth Analg 2005; 100: 1740–5

    Article  PubMed  Google Scholar 

  22. Kalso E, McQuay H, Wiesenfeld-Hallin Z. Opioid sensitivity of chronic noncancer pain. Seattle: IASP Press, 1999

    Google Scholar 

  23. Peloso PM. Opioid therapy for osteoarthritis of the hip and knee: use it or lose it? J Rheumatol 2001; 28(1): 6–11

    PubMed  CAS  Google Scholar 

  24. Kalso E, Allan L, Dellemijn PL, et al. Recommendations for using opioids in chronic non-cancer pain. Eur J Pain 2003; 7(5): 381–6

    Article  PubMed  CAS  Google Scholar 

  25. Moore A, Edwards J, Barden J, et al. Bandolier’s little book of pain. Oxford: Oxford University Press, 2003

    Google Scholar 

  26. Gagliese L, Jackson M, Ritvo P, et al. Age is not an impediment to effective use of patient-controlled analgesia by surgical patients. Anesthesiology 2000; 93(3): 601–10

    Article  PubMed  CAS  Google Scholar 

  27. Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 2003; 58(1): 76–81

    Article  PubMed  Google Scholar 

  28. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum 2000; 43(9): 1905–15

    Google Scholar 

  29. Ytterberg SR, Mahowald ML, Woods SR. Codeine and oxycodone use in patients with chronic rheumatic disease pain. Arthritis Rheum 1998; 41(9): 1603–12

    Article  PubMed  CAS  Google Scholar 

  30. Sindrup SH, Jensen TS. Efficacy of pharmacological treatments of neuropathic pain: an update and effect related to mechanism of drug action. Pain 1999; 83(3): 389–400

    Article  PubMed  CAS  Google Scholar 

  31. Duhmke RM, Cornblath DD, Hollingshead JR. Tramadol for neuropathic pain. Cochrane Database Syst Rev 2004; (2): CD003726

    Google Scholar 

  32. Gilron I, Bailey JM, Tu D, et al. Morphine, gabapentin, or their combination for neuropathic pain. N Engl J Med 2005; 352: 1324–34

    Article  PubMed  CAS  Google Scholar 

  33. Schug SA, Large RG. The use of opioids in chronic pain of non-malignant origin. Pain — Clinical Updates 1995; 3(3): 1–4

    Google Scholar 

  34. Portenoy RK. Opioid therapy for chronic nonmalignant pain: a review of the critical issues. J Pain Symptom Manage 1996; 11(4): 203–17

    Article  PubMed  CAS  Google Scholar 

  35. Savage SR. Opioid therapy of chronic pain: assessment of consequences. Acta Anaesthesiol Scand 1999; 43(9): 909–17

    Article  PubMed  CAS  Google Scholar 

  36. Schug SA, Ritchie JE. Use of opioids in chronic pain of nonmalignant origin. New Ethicals J 1999; 2(12): 37–41

    Google Scholar 

  37. Fine PG. Difficulties and challenges in the treatment of chronic pain in the older adult. Am J Pain Manage 2004; 14(2): 2S–8S

    Google Scholar 

  38. AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc 2002; 50 (6 Suppl.): S205–24

    Article  Google Scholar 

  39. Morgan JP. American opiophobia: customary underutilization of opioid analgesics. Adv Alcohol Subst Abuse 1985; 5: 163–73

    Article  PubMed  CAS  Google Scholar 

  40. Zenz M, Willweber-Strumpf A. Opiophobia and cancer pain in Europe. Lancet 1993; 341(8852): 1075–6

    Article  PubMed  CAS  Google Scholar 

  41. Lander J. Fallacies and phobias about addiction and pain. Br J Addict 1990; 85(6): 803–9

    Article  PubMed  CAS  Google Scholar 

  42. McQuay HJ. Opioid clinical pharmacology and routes of administration. Br Med Bull 1991; 47(3): 703–17

    PubMed  CAS  Google Scholar 

  43. Schug SA, Zech D, Grond S. Adverse effects of systemic opioid analgesics. Drug Saf 1992; 7(3): 200–13

    Article  PubMed  CAS  Google Scholar 

  44. Savage SR. Assessment for addiction in pain-treatment settings. Clin J Pain 2002; 18 (4 Suppl.): S28–38

    Article  PubMed  Google Scholar 

  45. Portenoy RK. Chronic opioid therapy in nonmalignant pain. J Pain Symptom Manage 1990; 5 (1 Suppl.): S46–62

    Article  PubMed  CAS  Google Scholar 

  46. Savage SR. Long-term opioid therapy: assessment of consequences and risks. J Pain Symptom Manage 1996; 11(5): 274–86

    Article  PubMed  CAS  Google Scholar 

  47. Cusack BJ. Pharmacokinetics in older persons. Am J Geriatr Pharmacother 2004; 2: 274–302

    Article  PubMed  CAS  Google Scholar 

  48. Fillastre JP, Singlas E. Pharmacokinetics of newer drugs in patients with renal impairment (Part 2). Clin Pharmacokinet 1991; 20(4): 293–310

    Article  PubMed  CAS  Google Scholar 

  49. Kilpatrick GJ, Smith TW. Morphine-6-glucuronide: actions and mechanisms. Med Res Rev. Epub 2005 Jun 10

    Google Scholar 

  50. Regnard CFB, Twycross RG. Metabolism of narcotics [letter]. BMJ 1984; 288(6420): 860

    Article  PubMed  CAS  Google Scholar 

  51. Schug SA, Morgan J. Treatment of cancer pain: special considerations in patients with renal disease. Am J Cancer 2004; 3(4): 247–56

    Article  CAS  Google Scholar 

  52. Turnheim K. Drug dosage in the elderly: is it rational? Drugs Aging 1998; 13(5): 357–79

    Article  PubMed  CAS  Google Scholar 

  53. Christo PJ, Grabow TS, Raja SN. Opioid effectiveness, addiction, and depression in chronic pain. Adv Psychosom Med 2004; 25: 123–37

    Article  PubMed  Google Scholar 

  54. Vainio A, Ollila J, Matikainen E, et al. Driving ability in cancer patients receiving long-term morphine analgesia. Lancet 1995; 346(8976): 667–70

    Article  PubMed  CAS  Google Scholar 

  55. Sabatowski R, Schwalen S, Rettig K, et al. Driving ability under long-term treatment with transdermal fentanyl. J Pain Symptom Manage 2003; 25(1): 38–47

    Article  PubMed  CAS  Google Scholar 

  56. Rosewarne R, Ople J, Bruce A, et al. Care needs of people with dementia and challenging behaviour living in residential facilities. Canberra: Australian Government Publishing Service, 1997

    Google Scholar 

  57. Morrison RS, Siu AL. A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture. J Pain Symptom Manage 2000; 19(4): 240–8

    Article  PubMed  CAS  Google Scholar 

  58. Parmelee PA, Smith B, Katz IR. Pain complaints and cognitive status among elderly institution residents. J Am Geriatr Soc 1993; 41(5): 517–22

    PubMed  CAS  Google Scholar 

  59. Horgas AL, Tsai PF. Analgesic drug prescription and use in cognitively impaired nursing home residents. Nurs Res 1998; 47(4): 235–42

    Article  PubMed  CAS  Google Scholar 

  60. Flaherty JH. ‘Who’s taking your 5th vital sign?’. J Gerontol A Biol Sci Med Sci 2001; 56(7): M397–9

    Article  PubMed  CAS  Google Scholar 

  61. Australian Pain Society (APS). APS residential aged care pain management guidelines [online]. Available from URL: http://www.apsoc.org.au/pdfs/DraftlAPSRACPMG.pdf [Accessed 2005 Jul 5]

  62. Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc 2003; 4(1): 9–15

    Article  PubMed  Google Scholar 

  63. Abbey J, Piller N, De Bellis A, et al. The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. Int J Palliat Nurs 2004; 10(1): 6–13

    PubMed  Google Scholar 

  64. Closs SJ, Barr B, Briggs M, et al. A comparison of five pain assessment scales for nursing home residents with varying degrees of cognitive impairment. J Pain Symptom Manage 2004; 27(3): 196–205

    Article  PubMed  Google Scholar 

  65. Schug S, Dunlop R, Zech D. Pharmacological management of cancer pain. Drugs 1992; 43(1): 44–53

    Article  PubMed  CAS  Google Scholar 

  66. Raffa RB, Friderichs E. The basic science aspect of tramadol hydrochloride. Pain Rev 1996; 3: 249–71

    CAS  Google Scholar 

  67. Wilder-Smith C, Schimke J, Osterwalder B, et al. Oral tramadol, a mu-opioid agonist and monoamine reuptake-blocker, and morphine for strong cancer-related pain. Ann Oncol 1994; 5(2): 141–6

    PubMed  CAS  Google Scholar 

  68. Schug SA. Tramadol in acute pain. Acute Pain 2003; 5(1): 1–2

    Article  Google Scholar 

  69. Sarhill N, Walsh D, Nelson KA. Hydromorphone: pharmacology and clinical applications in cancer patients. Support Care Cancer 2001; 9(2): 84–96

    Article  PubMed  CAS  Google Scholar 

  70. Lee MA, Leng ME, Tiernan EJ. Retrospective study of the use of hydromorphone in palliative care patients with normal and abnormal urea and creatinine. Palliat Med 2001; 15(1): 26–34

    Article  PubMed  CAS  Google Scholar 

  71. Smith MT. Neuroexcitatory effects of morphine and hydromorphone: evidence implicating the 3-glucuronide metabolites. Clin Exp Pharmacol Physiol 2000; 27(7): 524–8

    Article  PubMed  CAS  Google Scholar 

  72. Varvel JR, Shafer SL, Hwang SS, et al. Absorption characteristics of transdermally administered fentanyl. Anesthesiology 1989; 70: 928–34

    Article  PubMed  CAS  Google Scholar 

  73. 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; 13(5): 254–61

    Article  PubMed  CAS  Google Scholar 

  74. Christie JM, Simmonds M, Patt R, et al. Dose-titration, multicenter study of oral transmucosal fentanyl citrate for the treatment of breakthrough pain in cancer patients using trans-dermal fentanyl for persistent pain. J Clin Oncol 1998; 16(10): 3238–45

    PubMed  CAS  Google Scholar 

  75. Thompson JP, Bower S, Liddle AM, et al. Perioperative pharmacokinetics of transdermal fentanyl in elderly and young adult patients. Br J Anaesth 1998; 81(2): 152–4

    Article  PubMed  CAS  Google Scholar 

  76. Corail IM, Moore AR, Strunin L. Plasma concentrations of fentanyl in normal surgical patients and those with severe renal and hepatic disease. Br J Anaesth 1980; 52: 101P

    Google Scholar 

  77. Hanks G. Oral transmucosal fentanyl citrate for the management of breakthrough pain. Eur J Palliat Care 2001; 8(1): 6–9

    Google Scholar 

  78. Sittl R, Griessinger N, Likar R. Analgesic efficacy and tolerability of transdermal buprenorphine in patients with inadequately controlled chronic pain related to cancer and other disorders: a multicenter, randomized, double-blind, placebo-controlled trial. Clin Ther 2003; 25(1): 150–68

    Article  PubMed  CAS  Google Scholar 

  79. Mercadante S. Opioid rotation for cancer pain: rationale and clinical aspects. Cancer 1999; 86(9): 1856–66

    Article  PubMed  CAS  Google Scholar 

  80. Bruera E, Pereira J, Watanabe S, et al. Opioid rotation in patients with cancer pain: a retrospective comparison of dose ratios between methadone, hydromorphone, and morphine. Cancer 1996; 78(4): 852–7

    Article  PubMed  CAS  Google Scholar 

  81. Thomsen AB, Becker N, Eriksen J. Opioid rotation in chronic non-malignant pain patients: a retrospective study. Acta Anaesthesiol Scand 1999; 43(9): 918–23

    Article  PubMed  CAS  Google Scholar 

  82. Quigley C. Opioid switching to improve pain relief and drug tolerability. Cochrane Database Syst Rev 2004; (3): CD004847

    Google Scholar 

  83. Lawlor PG, Turner KS, Hanson J, et al. Dose ratio between morphine and methadone in patients with cancer pain: a retrospective study. Cancer 1998; 82(6): 1167–73

    Article  PubMed  CAS  Google Scholar 

  84. Armstrong PJ, Bersten A. Normeperidine toxicity. Anesth Analg 1986; 65(5): 536–8

    Article  PubMed  CAS  Google Scholar 

  85. Latta KS, Ginsberg B, Barkin RL. Meperidine: a critical review. Am J Ther 2002; 9(1): 53–68

    Article  PubMed  Google Scholar 

  86. Li Wan Po A, Zhang WY. Systematic overview of co-proxamol to assess analgesic effects of addition of dextropropoxyphene to paracetamol. BMJ 1997; 315(7122): 1565–71

    Article  PubMed  CAS  Google Scholar 

  87. Collins SL, Edwards JE, Moore RA, et al. Single-dose dextropropoxyphene in post-operative pain: a quantitative systematic review. Eur J Clin Pharmacol 1998; 54(2): 107–12

    Article  PubMed  CAS  Google Scholar 

  88. Jensen EM, Ginsberg F. Tramadol versus dextropropoxyphene in the treatment of osteoarthritis: a short term double-blind study. Drug Invest 1994; 8(4): 211–8

    Article  Google Scholar 

  89. Lloyd RS, Costello F, Eves MJ, et al. The efficacy and tolerability of controlled-release dihydrocodeine tablets and combination dextropropoxyphene/paracetamol tablets in patients with severe osteoarthritis of the hips. Curr Med Res Opin 1992; 13(1): 37–48

    Article  PubMed  CAS  Google Scholar 

  90. Kamal-Bahl SJ, Doshi JA, Stuart BC, et al. Propoxyphene use by community-dwelling and institutionalized elderly Medicare beneficiaries. J Am Geriatr Soc 2003; 51(8): 1099–104

    Article  PubMed  Google Scholar 

  91. Caraco Y, Sheller J, Wood AJ. Pharmacogenetic determination of the effects of codeine and prediction of drug interactions. J Pharmacol Exp Ther 1996; 278(3): 1165–74

    PubMed  CAS  Google Scholar 

  92. McQuay HJ, Moore RA. An evidence-based resource for pain relief. Oxford: Oxford University Press, 1998

    Google Scholar 

  93. Bruera E, Sweeney C. Methadone use in cancer patients with pain: a review. J Palliat Med 2002; 5(1): 127–38

    Article  PubMed  Google Scholar 

  94. Gourlay GK, Cherry DA, Cousins MJ. A comparative study of the efficacy and pharmacokinetics of oral methadone and morphine in the treatment of severe pain in patients with cancer. Pain 1986; 25(3): 297–312

    Article  PubMed  CAS  Google Scholar 

  95. Vanegas G, Ripamonti C, Sbanotto A, et al. Side effects of morphine administration in cancer patients. Cancer Nurs 1998; 21(4): 289–97

    Article  PubMed  CAS  Google Scholar 

  96. Shorr RI, Griffin MR, Daugherty JR, et al. Opioid analgesics and the risk of hip fracture in the elderly: codeine and propoxyphene. J Gerontol 1992; 47: M111–5

    Article  PubMed  CAS  Google Scholar 

  97. Homsi J, Walsh D, Nelson KA. Psychostimulants in supportive care. Support Care Cancer 2000; 8(5): 385–97

    Article  PubMed  CAS  Google Scholar 

  98. Barkin RL, Barkin D. Pharmacologic management of acute and chronic pain: focus on drug interactions and patient-specific pharmacotherapeutic selection. South Med J 2001; 94: 756–70

    PubMed  CAS  Google Scholar 

  99. Ahmad M, Goucke CR. Management strategies for the treatment of neuropathic pain in the elderly. Drugs Aging 2002; 19(12): 929–45

    Article  PubMed  CAS  Google Scholar 

  100. Sjogren P, Jensen NH, Jensen TS. Disappearance of morphine-induced hyperalgesia after discontinuing or substituting morphine with other opioid agonists. Pain 1994; 59(2): 313–6

    Article  PubMed  CAS  Google Scholar 

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Acknowledgements

The editorial comments of Christine Toye, Edith Cowan University, Perth, Australia, are kindly acknowledged.

No sources of funding were used to assist in the preparation of this review. The authors have no conflicts of interest that are directly relevant to the content of this review.

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  1. School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia

    Kirsten Auret &  Stephan A. Schug

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Auret, K., Schug, S.A. Underutilisation of Opioids in Elderly Patients with Chronic Pain. Drugs Aging 22, 641–654 (2005). https://doi.org/10.2165/00002512-200522080-00002

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