Opioids and the Older Adult -When, Why & How Masil George, MD Associate Professor, UAMS Department of Geriatrics Associate Professor, UAMS Division of Medical Humanities Director, Geriatric Palliative Care Program, UAMS Medical Director, Baptist Hospice

Disclosure No financial interests

Objectives Provide framework for assessing chronic pain in the older adult. Understand role of opioids in managing chronic non-malignant pain in the outpatient clinic for the elderly. Create an individualized treatment plan including initiating, titrating, tapering and discontinuing opioids in the elderly.

The opioid epidemic

A brief history of opioids 3400 BC to 300 AD Hippocrates, Alexander 1500s- Laudanum 1800s- Morphine isolated from opium & heroin synthesized from morphine 1970- Opioid schedules 1973- War on drugs

Recent history 1990s- Several new opioid options, extensive marketing 2001- Pain “the fifth vital sign” 2014- More people die of opioid overdose than any other year on record, Hydrocodone to schedule II 2016- CDC released guidelines for prescribing opioids for chronic pain

Common conditions that cause persistent pain in older adults Mechanical or Compressive : Low back pain, neck pain, musculoskeletal pain, visceral pain from expanding tumor mass Musculoskeletal : Myofascial pain syndrome Neuropathic : Peripheral (CRPS), HIV, sensory neuropathy, metabolic disorders, phantom limb, pain, post-herpetic neuralgia, diabetic neuropathy) Central (poststroke pain, MS, Parkinsons disease, myelopathies, fibromyalgia) Inflammatory : Inflammatory arthropathies, infection, postoperative pain, tissue injury Opioids for persistent pain in older adults Cleveland Clinic Journal of Medicine. 2016 June;83(6):443-451 Castillo, MG

Pathophysiology of chronic pain Acute pain- Strong relationship between peripheral stimulation and pain perception Chronic pain- created by nervous system secondary to nociceptor activation

Chronic pain- It is all in their head Sensitization of pain transmission fibers Death of inhibitory cells Loss of tonic inhibition Structural neuroplastic changes

Psychology of pain Psychological factors can dramatically modulate pain related suffering and dysfunction. Expectation of pain, and reinforcement of pain behavior increase pain behavior, and it has now been demonstrated that these factors increase cortical activation associated with experimental pains. Conversely, distraction reduces pain.

Tip of the iceberg Acute Pain Chronic Pain Depression Anxiety Addiction Somatoform disorders Personality disorders

Why Opioids? Works really well (APAP is a mild pain reliever) Usually well tolerated (NSAIDS have GI, Cardiac and Renal side effects, especially in the elderly) Works for pretty much for any type of pain (Antidepressants and antiepileptics work for neuropathic pain) No ceiling effect (only dose limiting side effects) Opioids and the management of chronic severe pain in the elderly Pergolizzi J, et al

When to start opioids?- 1 When diagnosis of chronic non-malignant pain has been established. When non-pharmacological, & non-opioid pharmacological pain management options have been explored and exhausted. When patient has persistent & significant pain that limits function.

When to start opioids? -2 When the patient understands potential benefits & burdens. When the patient is able to understand and abide by a pain management agreement. When patient can be expected to be compliant with dose and responsible in storing medications.

WHO pain ladder

Starting Opioids in the Elderly Start low… (Tramadol 25 mg HS, Hydrocodone 5/325 ½ a pill HS) Go slow… (Frequent follow up and gradual increase in dose) Dose to effect… (Establish pain relief goals and attempt to achieve them)

Realistic goals for pain management S- specific M- measureable A- action-oriented R- realistic T- time-sensitive Source: Scope of pain: safe and competent opioid prescribing education

6 A’s for follow up Analgesia Activities (pain journal, sleep journal) Adverse effects Aberrant behaviors Affect Adherence

Starting/ titrating/ rotating Tramadol 50 mg, Hydrocodone 5/325, Oxycodone 5 mg Reassure that addiction risk minimal if uses appropriately Advise on side effects and duration of action and dose appropriately (every 4 hours/ PRN oral) Bowel program- Miralax and Senna Titrate to goal every 3 to 5 days, follow up every 3 months- pill counts, PMP Use opioid conversion table and reduce dose by 33 to 50% when rotating from one opioid to another

Screening for opioid misuse ORT- opioid risk tool PDMP- Prescription drug monitoring program SOAPP- Screener and opioid assessment for patients with pain DIRE- Diagnosis, intractability, risk, efficiency instrument UDT- Urine drug test PPA- Patient/ prescriber agreement

Opioid Conversions Morphine PO = Oxydocone PO 1 mg IV Morphine = 3 mg PO Morphine 25 mcg/hr Fentanyl patch = 1 mg/hr IV Morphine = 50-75 mg PO Morphine/day 5 mg PO Morphine = 1 mg PO Dilaudid 5 mg IV Morphine = 1 mg IV Dilaudid 1 mg IV Dilaudid = 4-5 mg PO Dilaudid 10 mg PO Morphine = 1 mg PO Methadone (average) 20 mg PO Morphine = 1 mg PO Methadone (when >1000 mg MS in 24 hrs)

CDC guidelines for prescribing opioids for chronic pain Non pharmacological and non opioid pharmacologic therapy is preferred for chronic pain. Only consider opioids if benefits anticipated to outweigh risks Establish realistic treatment goals for pain and function before starting opioids and consider how opioids will be discontinued if benefits do not outweigh risks Discuss known risks and realistic benefits before starting and periodically during therapy When starting opioids for chronic pain, prescribe IR opioids instead of ER/LA Prescribe lowest effective dose, try to keep below 90 MME per day When treating acute pain, try to prescribe for 3 days or less

CDC guidelines for prescribing opioids for chronic pain 7. Evaluate within 1 to 4 weeks of starting opioids or dose escalation and every 3 months 8. Mitigate risk- consider naloxone if risk of opioid overdose such as previous history, higher dose (> 50 MMEs) or concurrent benzodiazipines 9. Review state prescription monitoring program when starting opioids and periodically 10. Consider urine drug testing at least annually 11. Avoid prescribing opioids and benzodiazepines concurrently 12. For patients with opioid use disorder, offer or arrange evidence-based medication assisted treatment programs

Special considerations Renal Failure –Fentanyl and Methadone are safest, use morphine and oxycodone cautiously, avoid codeine and meperidine Liver Failure- Fentanyl is the safest, Use morphine, oxycodone and dilaudid cautiously and avoid methadone and Codeine Allergy- Find out what patient actually means Source: Pain treatment topics. Opioid safety in patients with hepatic or renal dysfunction, Sarah J Johnson, Pharm D

Safety and function Sleep and function Driving Cognitive evaluation

Discontinuing chronic opioid therapy Opioid withdrawal is associated with physical pain, this does not represent progression of underlying disease. Decrease dose by 5 to 10% each visit that patient is ready for dose reduction- individualize plan Taper opioid over several months A. Lembke, Weighing the risks and benefits of chronic opioid therapy; American Family Physician June 15, 2016

Clinical Case- 1 Mr. Smith is a 67 y/o with DM (poorly controlled), COPD, PVD, HTN, current smoker, OSA (not compliant with CPAP). He complains of pain in shoulder/ knee/ hip. Also has neuropathic pain his feet.

Audience question- 1 Is Mr. Smith an appropriate candidate for long term opioid therapy? A- Yes B- No C- Maybe

Clinical Case- 2 Ms. Harvey is a 78 y/o retired professor with HTN, Hypothyroidism, & Spinal stenosis. She has been on stable dose of opioids (Fentanyl 37.5 mcg transdermal patch every 3 days, Hydrocodone 5/325 Q 4 hourly/ PRN for 6 years.

Audience Question- 2 Is Ms. Harvey an appropriate candidate for long term opioid therapy? A- Yes B- No C- Maybe

Clinical Case- 3 Ms. Jones is a 83y/o s/p CVA, also has CHF, HTN, DM, unintentional weight loss, AFTT. She is bed bound, total care, contracted and non- verbal. She appears to be in pain when she is turned and cries out when she is getting a bed bath.

Audience Question- 3 Is Ms. Harvey an appropriate candidate for long term opioid therapy? A- Yes B- No C- Maybe

Questions?