UMMS CRIT Module II: Opioid Usage in Older Adults
Catherine DuBeau, MDClinical Director of Geriatrics UMMS
UMMS CRIT 2012 Module II: Opioid Usage in Older Adults
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Dr. Stacie Levine, University of Chicago
Pain Module, Curriculum for the Hospitalized Aged
Medical Patient
champ.bsd.uchicago.edu
Acknowledgement
UMMS CRIT 2012 Module II: Opioid Usage in Older Adults
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Understand the major categories of pain
• Implement the WHO pain ladder to manage patients with
pain
• Perform safe and effective opiate dosing, escalation, and
conversions
Objectives
UMMS CRIT 2012 Module II: Opioid Usage in Older Adults
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Extremely common and undertreated
– 50% of community dwelling older persons
– Only 40% of oncology and 30% of hip fracture patients
report “adequate” pain control
• Education in pain assessment and management mandated by
ACGME/RCCs and Joint Commission
• Undertreated pain leads to functional decline, prolonged
length of stay, increased healthcare utilization
Why Pain?
UMMS CRIT 2012 Module II: Opioid Usage in Older Adults
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Patient centered approach is the key• ASK the patient, regardless of mental
status• Identify preferred pain terminology
– Hurting, aching, stabbing, discomfort, soreness
• Type: visceral, nocioceptive, neuropathic• Functional impact: How is their life
changed?• Use a pain scale that works for the patient• Physiologic measures (eg, HR, BP) not
reliable indicators
Bedside Assessment of Pain
UMMS CRIT 2012 Module II: Opioid Usage in Older Adults
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Unique pain signature –
– Use baseline behavior as frame of reference
– Pain can cause hypo- or hyper-activity
– Ask caregivers how they know when pt is in pain
• Possible indicators
– Facial expression: frown, blinking, sad/frightened
– Vocalizations: grunting, calling out, noisy breathing
– Movements: rigid, tense, fidgeting, resistance to being
moved, pacing
Pain in non-verbal pts
UMMS CRIT 2012 Module II: Opioid Usage in Older Adults
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
WHO pain ladder:
• Non-opioids
• Adjuvants
• Opioids
Managing Pain
UMMS CRIT 2012 Module II: Opioid Usage in Older Adults
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Non-opioids
– APAP
– NSAIDs
– COX-2 inhibitors
• Adjuvants
– Topicals – capsaicin cream, lidoderm patch
– Anticonvulsants: GABA-nergics
– Antidepressants: Cymbalta, tricyclics, SNRIs
– Steroids
– Non-medication: massage, TENS, PT/OT
Step 1 - mild to moderate Pain
UMMS CRIT 2012 Module II: Opioid Usage in Older Adults
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Mild opioids
– Codeine: GI upset common
– Hydrocodone (Vicodin): no paper Rx needed
– Oxycodone (Percocet): actually more potent than
morphine, reason for low doses with APAP
• Opioid-like
– Tramadol: analgesia ~ same as T3; max 200 mg/day in
elderly
Step 2- moderate Pain
UMMS CRIT 2012 Module II: Opioid Usage in Older Adults
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Strong Opioids
• Morphine
• Oxycodone
• Hydromorphone (Dilaudid)
• Fentanyl
• Oxymorphone (Opana, Numorphan)
• Methadone
Step 3- Severe Pain
UMMS CRIT 2012 Module II: Opioid Usage in Older Adults
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Meperidine (Demerol)
• Pentazocine (Talwin)
• Combination with antihistamine (Vistaril)
Avoid
UMMS CRIT 2012 Module II: Opioid Usage in Older Adults
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Key to dosing and changing opiods
• Use calculators
Morphine Equianalgesia
Conversion: http://www.epocrates.com/products/medtools/opioidanalgesicconverter.html
UMMS CRIT 2012 Module II: Opioid Usage in Older Adults
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Load
– Start low, short-acting: 2-5 mg PO morphine equivalent (~ 1 Percocet q 4 hr)
– Dose q peak:
• po, pr ~ 1 hr
• SC, IM ~ 30 min
• IV ~ 6-15 min
– Regular dosing, not “prn”
– Re-eval in 4 hrs
Dosing
UMMS CRIT 2012 Module II: Opioid Usage in Older Adults
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Use percentage increase irrespective of starting dose
• Mild-mod pain: increase by 25 - 50%
• Severe: increase by 50 - 100%
• Frequency of escalation:
– Short-acting, single agent – q 2 hr
– Long-acting – every 24 hr
– Fentanyl patch – q 72 hr
– Methadone – every 4-7 days
Escalating Doses
UMMS CRIT 2012 Module II: Opioid Usage in Older Adults
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Use immediate release opioids only
• Start: 10% of total 24 hr dose or 33% of one ER dose
• Frequency: offer after peak effect
– PO/ PR - ~ 1 hr
– SC/IM ~ 30 min
– IV ~ q10-15 min
Break-through Pain
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