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Pain Management for the Geriatric Patient Geriatrics Grand Rounds August 7, 2015 Deborah Way MD

Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

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Page 1: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

PainManagementfortheGeriatricPatientGeriatrics Grand RoundsAugust 7, 2015Deborah Way MD

Page 2: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Disclosures• Dr. Way has no potential or actual conflict of interest to disclose

Page 3: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Objectives• Identify and discuss causes of pain in the geriatric patient population• aging and immobility• disease states including dementia, frailty, osteoarthritis

• Define pharmacologic and non‐pharmacologic treatments for pain• Formulate  a plan of care for pain relief in the geriatric patient

• Use knowledge of different pain medication mechanisms to provide adequate pain relief to at risk geriatric populations

Page 4: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Identify and discuss causes of pain in the geriatric patient populationaging and immobilitydisease states including dementia, frailty, osteoarthritis

Page 5: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Mary• 70 year old female• PMH spinal stenosis with left leg pain and weakness.  Not a surgical candidate

• Lives alone in 3 story home. Independent ADLs and IADLs, but uses single point cane successfully for balance

Page 6: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

DoesMaryhavepain?• How would one describe it?• What else does Mary need to tell us?

Page 7: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Joe• 90 year old man recently admitted to nursing home for rehabilitation post hospitalization for fall.

• PMH moderate dementia.  Dependent in IADLs, able to feed and dress self if set up provided.  Ambulation/transfers not steady, but he is impulsive and cannot use a walker.  He keeps leaving it behind and “wall walks” using rails in halls.  Requires extensive assistance of one person with toileting and bathing

• “New” diagnosis of prostate cancer with local invasion to bladder and distant metastases to bone.  When asked, he denies pain, but he has been losing weight and is frequently seen grimacing and rubbing his upper legs.

Page 8: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

DoesJoehavepain?• How would one describe it?• Is there anything else we can do to assess his pain?• Is there anything else we need to know in addition to confirming goals of care?

Page 9: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

David• 86 year old nursing home resident with end stage dementia

• Bed bound, contracted, dependent in all ADLs• FAST stage 7C• Eating less, accelerating weight loss, moans with care• New Stage 3 sacral decubitus ulcer

Page 10: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

DoesDavidhavepain?• How would one describe it?• What else can we do to assess his pain?• Is there anything else we need to know in addition to confirming goals of care?

Page 11: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Pain– averybriefreview• Acute pain• Chronic Persistent pain• Nociceptive pain• Neuropathic pain• Total pain

Page 12: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Paincausedbydiseasestates• Degenerative joint disease

• Degenerative disc disease• Spinal stenosis• Diabetes mellitus• Cerebrovascular disease• Osteoporosis

• Cancer• Heart disease• Polymyalgia rheumatica• Wounds• PHN• PAD• End of life

Page 13: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Paincausedbyimmobility• Loss of functional status due to• Dementia• CVA• DJD• Fracture• Surgery• Amputation

• Neuropathy• Peripheral vascular disease• Edema• Pain

Geriatric Palliative Care 2014

Page 14: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Redflags• Constitutional symptoms• Pain that wakes patient up• Immunosuppression• Severe or progressive neurologic deficit• Cold, pale mottled or cyanotic limb• New bowel/bladder dysfunction• Severe abdominal pain or signs of shock/peritonitis

Geriatric Palliative Care. 2014.

Page 15: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Whatisthelivingsituationoftheperson?• Home• Long term care continuum• Frequent medical visits

• Physician office• Emergency department 

Page 16: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Whatarethesupportsystems?• Is the person independent?• If not, who provides support and care?• Who is the provider of medical care?

Page 17: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Whatcomesnext?• What might pain management look like as a person moves along the care continuum?

Page 18: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

A brief reviewof pharmacology and aging

Page 19: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Aging:Absorption• Reduced GI motility and GI blood flow• Gastric acid secretion decreased ‐ elevated gastric pH• Increased use of medications alter pH• First‐pass metabolism drugs • Aging and absorption => minimal effect

McLean, Allan J., and David G. Le Courteur., “Aging Biology and Geriatric Clinical Pharmacology”. The American Society for Pharmacology and Experimental  Therapeutics. 56.2 (2004) :163‐184. Print.

Page 20: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Aging:Distribution• Proportion relates the amount of drug in the body to concentration measured in biological fluid• Protein binding• pH• Molecular size• Water• Lipid solubility

McLean,AllanJ.,andDavidG.LeCourteur.,“AgingBiologyandGeriatricClinicalPharmacology”.TheAmericanSocietyforPharmacologyandExperimentalTherapeutics.56.2(2004):163‐184.Print.

Page 21: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Aging:Distribution• Muscle mass

• Proportion of body fat increases

• Total body water‐ water soluble drugs• Albumin – protein bound drugs

McLean,AllanJ.,andDavidG.LeCourteur.,“AgingBiologyandGeriatricClinicalPharmacology”.TheAmericanSocietyforPharmacologyandExperimentalTherapeutics.56.2(2004):163‐184.

Page 22: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Aging:Metabolism

• Liver primary organ – convert substances believed to be harmful into form that can easily be eliminated

• Aging‐ hepatic blood flow• Aging‐ liver mass and intrinsic metabolic activity

McLean,AllanJ.,andDavidG.LeCourteur.,“AgingBiologyandGeriatricClinicalPharmacology”.TheAmericanSocietyforPharmacologyandExperimentalTherapeutics.56.2(2004):163‐184.

Page 23: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Aging:Excretion/Elimination• Kidney‐ primary organ 

• blood flow, kidney mass, number of functioning nephrons

• glomerular filtration rate‐ considered one of the most important changes with aging• Cockcroft‐Gault & MDRD

McLean,AllanJ.,andDavidG.LeCourteur.,“AgingBiologyandGeriatricClinicalPharmacology”.TheAmericanSocietyforPharmacologyandExperimentalTherapeutics.56.2(2004):163‐184.

Page 24: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Define the difference between opioid vs non‐opioids, types of pain medications, and appropriate uses for each type

Page 25: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

http://www.avert.org/hiv‐related‐pain.htm

Page 26: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Analgesics‐ AtaglanceOpioid (Narcotic) Analgesics Non‐Opioid (Non‐Narcotic) Analgesic

Act centrally Act peripherally

Addiction, dependence, tolerance Not‐habit forming

Schedule II,III controlled drugs Not controlled drugs

Notable adverse effects: sedation, respiratory depression, constipation

Notable adverse effects: gastric irritation, bleeding, renal toxicity

No anti‐inflammatory effects Anti‐inflammatory effects

No ceiling effects Ceiling effects: increase in dose doesn’t increase analgesia but increases side effects

TaskForceonChronicPainManagementandtheAmericanSocietyofRegionalAnesthesiaandPainMedicine.Anesthesiology.2010Apr;112(4):810‐33.

Page 27: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

ReceptorEffectsofOpioidAnalgesicsReceptors: Responses:

Mu (μ) Analgesia, respiratory depression, euphoria, reduced GI motility

Kappa  Analgesia, dysphoria, psychosis,delusion/delirium,miosis, respiratory depression

Delta AnalgesiaTaskForceonChronicPainManagementandtheAmericanSocietyofRegionalAnesthesiaandPainMedicine.Anesthesiology.2010

Apr;112(4):810‐33.

Page 28: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Opioids• Derived/related to opium• Bind to opioid receptors – 4 groups• Act directly on CNS system• Reduce the perception of pain

Page 29: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Opioids• Codeine (Tylenol#3®)• Fentanyl (Duragesic patch®)• Hydrocodone (Lortab®, Vicodin®)• Hydromorphone (Dilaudid®)• Methadone (Dolophine®)• Morphine (MSIR® , MsContin® Kadian®)• Oxycodone (OxyIR®, Percocet®, Percodan®, Oxycontin®)

Page 30: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Thepersonwhocannotswallow• Parenteral routes of delivery

• Topical• Rectal• IV• Subcutaneous• “Trans mucosal”• Transdermal

Page 31: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Opioids‐ Parenteral• Morphine sulfate:

• 10mg/1ml, 4mg/1ml, 2mg/1ml, 1mg/1ml , • Hydromorphone:

• 10mg/1ml, 4mg/1ml, 2mg/1ml , 6mg/30ml pca• Fentanyl:

• 1,250mcg/125ml (10mcg/1ml)                                                         • Methadone:

• 10mg/1ml

Page 32: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Long‐TermUseBenefits Risks

• Pain reduction• Fewer episodes of severe pain “spikes”

• Increase in functionality

• Dependence• Addiction• Overdose• Withdrawal• Constipation• Delirium• Worsening of pain

TaskForceonChronicPainManagementandtheAmericanSocietyofRegionalAnesthesiaandPainMedicine.Anesthesiology.2010Apr;112(4):810‐33

Page 33: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Preventionandtreatmentofsideeffects• Choosing the “two‐fer”• Opioid rotation• Pharmacologic interventions• Non‐pharmacologic interventions

• Education

Page 34: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Awordabouttramadol• Binds to mu opioid receptors• Inhibits reuptake of serotonin and norepinephrine

• Serotonin syndrome• Parent drug and metabolites renally excreted• Schedule IV drug

• Has potential for abuse• New suggestions that use may lead to hypoglycemia• May cause seizures even at therapeutic doses

Lewis. Tramadol and Hypoglycemia: One More Thing to Worry About JAMA Intern Med 2015

Page 35: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Opioidsparingmedications• Medications that are used to treat pain

• Analgesics• Adjuvant medications

Page 36: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Non‐Opioids• Analgesic, anti‐ inflammatory, antipyretic • Peripheral tissues to inhibit formation of pain causing substances  

• NSAIDS : block production and inhibits cyclooxygenase (COX)

• Do not bind to receptors

TaskForceonChronicPainManagementandtheAmericanSocietyofRegionalAnesthesiaandPainMedicine.Anesthesiology.2010Apr;112(4):810‐33

Page 37: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Non‐Opioids• Salicylates• Acetaminophen (Tylenol®) 

• Pain and fever • Good first line, little anti‐inflammatory

• Caution: alcohol use, liver, kidney impairment

• NSAIDs• COX‐2 Inhibitors

• Decreases inflammation• Abdominal side effects, constipation, cramps

• Should take with food• Steroids• Other 

TaskForceonChronicPainManagementandtheAmericanSocietyofRegionalAnesthesiaandPainMedicine.Anesthesiology.2010Apr;112(4):810‐33.

Page 38: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Recommendedstartingdoses• Salicylates

• Choline magnesium trisalicylate 500 mg every 8 hours• Acetaminophen 325‐500 mg every 4 hours• NSAIDs

• Ibuprofen 200 mg three times daily• Celecoxib 100 mg daily• Naproxen 220 mg twice daily• Diclofenac 50 mg twice daily

American Geriatrics Society, Pharmacologic Management of Persistent Pain in Older Persons. JAGS 2009

Page 39: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

AdjuvantMedications• Antidepressants

• Increase transmission in spinal cord to reduce pain signals

• Nerve pain• Does not work right away, dizziness, drowsiness, decreased appetite, dry mouth

• Anticonvulsants• Gabapentin (Neurontin®)Phenytoin (Dilantin®), Carbamazepine(Tegretol®) Topiramate(Topamax ®)

• Nerve pain• Drowsiness, dizziness, headache, weight gain

TaskForceonChronicPainManagementandtheAmericanSocietyofRegionalAnesthesiaandPainMedicine.Anesthesiology.2010Apr;112(4):810‐33

Page 40: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

AdjuvantMedications• Skeletal Muscle Relaxants

• Baclofen( Lioresal®), Carisoprodol(Soma®), Cyclobenzaprine(Flexeril®) Methocarbamol(Robaxin®), Tizanidine(Zanaflex®)

• Muscle pain, tension headaches, lower back pain

• Drowsiness, dizziness, dry mouth, constipation

• Topical• Capsaicin Cream• Menthol‐Methyl Salicylate Cream (Bengay®)

• Lidoderm 5% Patch

*all work for shorter period of time

TaskForceonChronicPainManagementandtheAmericanSocietyofRegionalAnesthesiaandPainMedicine.Anesthesiology.2010Apr;112(4):810‐33

Page 41: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Non‐pharmacologicconsiderations

• Topical menthol• Massage/Range of motion• Physical therapy• Relaxation techniques• Hypnosis• Acupuncture/Acupressure

• Radiation• Nerve blocks• Heat/Cold• Aromatherapy• Psychotherapy• Yoga/Tai Chi

Page 42: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Opioid Conversion

Page 43: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Barrierstotheuseofopioids• Fear of side effects• Fear of addiction

• Concept of pseudo‐addiction• The patient with current or past substance abuse

• Fear of death• Care plan adherence due to functional limitations• Not the best drug for chronic pain

Page 44: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Opioiddosingintheelderly• Initial dosing• Up‐titration• “Maximum dose”

• For acute pain• For persistent pain• For cancer pain• For other end of life pain

Guay, Opioid Analgesics for Persistent Pain in the Older Patient: Parts I and II. Clinical Geriatrics 2010.

Page 45: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Recommendedstartingdoses• Morphine, oxycodone, hydrocodone

• 2.5 mg every 4 hours• Scheduled vs scrupulous prn dosing• When do you start long acting opioids?

American Geriatrics Society, Pharmacologic Management of Persistent Pain in Older Persons. JAGS 2009

Page 46: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Patientcontrolledanalgesia• Barriers• The built in safety

• Negated by proxy dosing• Consider provider administered bolus

• Hospital• Post op• Pain crisis

• End of life• Transition to home

Page 47: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

OpioidConversionEquianalgesic Dose

Parenteral  Oral

Morphine 10mg 30mg

Hydromorphone 1.5mg  7.5mg

Oxycodone ‐‐‐‐‐ 20‐30mg*

Codeine 130mg 200mg

Hydrocodone ‐‐‐‐‐ 30mg

Methadone 1.5‐2.5mg 3‐5mg

Fentanyl 0.1mg ‐‐‐‐*Above 300mg morphine, oxycodone and morphine are 1:1

‐Adapted from Gordan DB et al. Opioid Equianalgesic Calculations. J. Pali. Med. Agency for Healthcare Policy and Research, Management of Cancer Pain Guidelines. Facts and Comparisons

Page 48: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Formulate a plan of care for pain relief in the geriatric patient

Define pharmacologic and non‐pharmacologic treatments for pain

Page 49: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Cases

Page 50: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Mary• 70 year old female• PMH spinal stenosis with left leg pain and weakness.  Not a surgical candidate

• Lives alone in 3 story home. Independent ADLs and IADLs, but uses single point cane successfully for balance

Page 51: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

DoesMaryhavepain?• How would one describe it?• What else does Mary need to tell us?• What can we give Mary for her pain?

Page 52: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Joe• 90 year old man recently admitted to nursing home for rehabilitation post hospitalization for fall.

• PMH moderate dementia.  Dependent in IADLs, able to feed and dress self if set up provided.  Ambulation/transfers not steady, but he is impulsive and cannot use a walker.  He keeps leaving it behind and “wall walks” using rails in halls.  Requires extensive assistance of one person with toileting and bathing

• “New” diagnosis of prostate cancer with local invasion to bladder and distant metastases to bone.  When asked, he denies pain, but he has been losing weight and is frequently seen grimacing and rubbing his upper legs.

Page 53: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

DoesJoehavepain?• How would one describe it?• Is there anything else we can do to assess his pain?• Is there anything else we need to know in addition to confirming goals of care?

• What can we give Joe for his pain?

Page 54: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

David• 86 year old nursing home resident with end stage dementia

• Bed bound, contracted, dependent in all ADLs• FAST stage 7C• Eating less, accelerating weight loss, moans with care• New Stage 3 sacral decubitus ulcer

Page 55: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

DoesDavidhavepain?• How would one describe it?• What else can we do to assess his pain?• Is there anything else we need to know in addition to confirming goals of care?

• What can we give David for his pain?

Page 56: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Jack65 year old man with squamous cell lung cancer with progressive right sided pelvic pain in region of known pelvic metastases.  He describes dull aching pain rated at 8/10 in the lateral pelvis and sharp shooting pain that radiates down the right leg.  The pain limits mobility and awakens him from sleep.He has no focal motor or sensory deficits. An X‐ray shows a large lytic metastasis in the lateral pelvis.  He is referred to radiation oncology who recommends a course of palliative XRT.

Page 57: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

JackcontinuedJack has been taking immediate release morphine, 30 mg every four hours.  This worked until last week.He currently takes this dose every four hours.  However, his pain only decreases from 8/10 to 6/10 for one to two hours at best.

Page 58: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Jackcontinued• What type of pain is he having?• How can you change his opioid prescription to provide better pain control?

• Would you use an anti‐depressant as an adjuvant?• What other adjuvant drugs might you consider?• What non‐pharmacologic treatments might you consider?

Page 59: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

John• John is taking 12 oxycodone/acetaminophen tablets (5/325) per day with only partial relief.  The most appropriate next step in drug therapy for this patient would be to discontinue this medication and start…..

Page 60: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Conversion• For patients on chronic opioids, the most appropriate equi‐analgesic conversion ratio between oral and intravenous morphine is:

Page 61: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

Martha• An 87 year old woman with advanced osteoporosis who has chronic back and hip pain, poorly controlled on 2 tablets of oxycodone 5/acetaminophen 325  6 times each day.

• The single best reason NOT to increase the number of these tablets is:

Page 62: Pain Management for the Geriatric Formulate a plan of care for pain relief in the geriatric patient • Use knowledge of different pain medication mechanisms to provide adequate pain

References• Chou et. al. “Methadone Safety Guidelines”. The Journal of Pain. 15.4 (2014): 321‐337• Franklin. “Opioids for Chronic Non‐cancer Pain”.  American Academy of Neurology. 83 (2014): 1277‐1284• Guay. “Opioid Analgesics for Persistent Pain in the Older Patient Parts I and II”, Clinical Geriatrics 2010• Kaye, Baluch, Amir., Scott. “Pain Management in the Elderly Population: A Review”, The Ochsner Journal. 10.3 (2010): 

179‐187• Nelson, Juurlink. “ Tramadol and Hypoglycemia: One More Thing to Worry About. JAMA Intern Med. 

2015;175(2):194‐195. • McLean, Le Courteur., “Aging Biology and Geriatric Clinical Pharmacology”. The American Society for Pharmacology 

and Experimental  Therapeutics. 56.2 (2004) :163‐184• Pain Management in the Longterm Care Setting: Guideline Summary AMDA 2009• Pharmacologic Management of Persistent Pain in Older Persons AGS 2009• Scimeca, Savage, Portenoy, Lawinson. “Treatment of Pain in Methadone‐Maintained Patients.”  The Mount Sinai 

Journal of Medicine  67.5 &6 (2000):412‐422• Statement on the Use of Opioids in the Treatment of Persistent Pain in Older Adults AGS 2012• Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. 

Anesthesiology. 2010 Apr;112(4):810‐33• Toombs, Kral. “Methadone Treatment for Pain States.” American Family Physicians.  71.7  (2005): 1353‐1358• Weissman. An Examination of Knowledge in Palliative Care. Eperc.mcw.edu 2001• Weissman. Pain Management Case Studies. Improving End of Life Care. Medical College of Wisconsin 2004

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WebReferences• http://www.deadiversion.usdoj.gov/pubs/manuals/pract/section5.html• http://www.bpac.org.nz/BPJ/2008/December/docs/bpj18_methadone_pages_24‐

29.pdf• http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html


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