CONSENSUS - Opioids and the management of chronic severe pain in the elderly

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Pain Pract. 2008 Jul-Aug;8(4):287-313. Epub 2008 May 23.

Opioids and the management of chronic severe pain in the elderly:

consensus statement of an International Expert Panel with focus on the

six clinically most often used World Health Organization step III

opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine,

oxycodone).

Pergolizzi J, Böger RH, Budd K, Dahan A, Erdine S, Hans G, Kress HG,

Langford R, Likar R, Raffa RB, Sacerdote P.

s Hopkins University, Baltimore, land, USA.

SUMMARY OF CONSENSUS:

1. The use of opioids in cancer pain: The criteria for selecting

analgesics for pain treatment in the elderly include, but are not

limited to, overall efficacy, overall side-effect profile, onset of

action, drug interactions, abuse potential, and practical issues, such

as cost and availability of the drug, as well as the severity and type

of pain (nociceptive, acute/chronic, etc.). At any given time, the

order of choice in the decision-making process can change. This

consensus is based on evidence-based literature (extended data are not

included and chronic, extended-release opioids are not covered). There

are various driving factors relating to prescribing medication,

including availability of the compound and cost, which may, at times,

be the main driving factor. The transdermal formulation of

buprenorphine is available in most European countries, particularly

those with high opioid usage, with the exception of France; however,

the availability of the sublingual formulation of buprenorphine in

Europe is limited, as it is marketed in only a few countries,

including Germany and Belgium. The opioid patch is experimental at

present in U.S.A. and the sublingual formulation has dispensing

restrictions, therefore, its use is limited. It is evident that the

population pyramid is upturned. Globally, there is going to be an

older population that needs to be cared for in the future. This older

population has expectations in life, in that a retiree is no longer an

individual who decreases their lifestyle activities. The

" baby-boomers " in their 60s and 70s are " baby zoomers " ; they want to

have a functional active lifestyle. They are willing to make

trade-offs regarding treatment choices and understand that they may

experience pain, providing that can have increased quality of life and

functionality. Therefore, comorbidities--including cancer and

noncancer pain, osteoarthritis, rheumatoid arthritis, and postherpetic

neuralgia--and patient functional status need to be taken carefully

into account when addressing pain in the elderly. World Health

Organization step III opioids are the mainstay of pain treatment for

cancer patients and morphine has been the most commonly used for

decades. In general, high level evidence data (Ib or IIb) exist,

although many studies have included only few patients. Based on these

studies, all opioids are considered effective in cancer pain

management (although parts of cancer pain are not or only partially

opioid sensitive), but no well-designed specific studies in the

elderly cancer patient are available. Of the 2 opioids that are

available in transdermal formulation--fentanyl and

buprenorphine--fentanyl is the most investigated, but based on the

published data both seem to be effective, with low toxicity and good

tolerability profiles, especially at low doses.

2. The use of opioids in noncancer-related pain: Evidence is growing

that opioids are efficacious in noncancer pain (treatment data mostly

level Ib or IIb), but need individual dose titration and consideration

of the respective tolerability profiles. Again no specific studies in

the elderly have been performed, but it can be concluded that opioids

have shown efficacy in noncancer pain, which is often due to diseases

typical for an elderly population. When it is not clear which drugs

and which regimes are superior in terms of maintaining analgesic

efficacy, the appropriate drug should be chosen based on safety and

tolerability considerations. Evidence-based medicine, which has been

incorporated into best clinical practice guidelines, should serve as a

foundation for the decision-making processes in patient care; however,

in practice, the art of medicine is realized when we individualize

care to the patient. This strikes a balance between the evidence-based

medicine and anecdotal experience. Factual recommendations and expert

opinion both have a value when applying guidelines in clinical

practice.

3. The use of opioids in neuropathic pain: The role of opioids in

neuropathic pain has been under debate in the past but is nowadays

more and more accepted; however, higher opioid doses are often needed

for neuropathic pain than for nociceptive pain. Most of the treatment

data are level II or III, and suggest that incorporation of opioids

earlier on might be beneficial. Buprenorphine shows a distinct benefit

in improving neuropathic pain symptoms, which is considered a result

of its specific pharmacological profile.

4. The use of opioids in elderly patients with impaired hepatic and

renal function: Functional impairment of excretory organs is common in

the elderly, especially with respect to renal function. For all

opioids except buprenorphine, half-life of the active drug and

metabolites is increased in the elderly and in patients with renal

dysfunction. It is, therefore, recommended that--except for

buprenorphine--doses be reduced, a longer time interval be used

between doses, and creatinine clearance be monitored. Thus,

buprenorphine appears to be the top-line choice for opioid treatment

in the elderly.

5. Opioids and respiratory depression: Respiratory depression is a

significant threat for opioid-treated patients with underlying

pulmonary condition or receiving concomitant central nervous system

(CNS) drugs associated with hypoventilation. Not all opioids show

equal effects on respiratory depression: buprenorphine is the only

opioid demonstrating a ceiling for respiratory depression when used

without other CNS depressants. The different features of opioids

regarding respiratory effects should be considered when treating

patients at risk for respiratory problems, therefore careful dosing

must be maintained.

6. Opioids and immunosuppression: Age is related to a gradual decline

in the immune system: immunosenescence, which is associated with

increased morbidity and mortality from infectious diseases, autoimmune

diseases, and cancer, and decreased efficacy of immunotherapy, such as

vaccination. The clinical relevance of the immunosuppressant effects

of opioids in the elderly is not fully understood, and pain itself may

also cause immunosuppression. Providing adequate analgesia can be

achieved without significant adverse events, opioids with minimal

immunosuppressive characteristics should be used in the elderly. The

immunosuppressive effects of most opioids are poorly described and

this is one of the problems in assessing true effect of the opioid

spectrum, but there is some indication that higher doses of opioids

correlate with increased immunosuppressant effects. Taking into

consideration all the very limited available evidence from preclinical

and clinical work, buprenorphine can be recommended, while morphine

and fentanyl cannot.

7. Safety and tolerability profile of opioids: The adverse event

profile varies greatly between opioids. As the consequences of adverse

events in the elderly can be serious, agents should be used that have

a good tolerability profile (especially regarding CNS and

gastrointestinal effects) and that are as safe as possible in overdose

especially regarding effects on respiration. Slow dose titration helps

to reduce the incidence of typical initial adverse events such as

nausea and vomiting. Sustained release preparations, including

transdermal formulations, increase patient compliance.

PMID: 18503626

http://www.ncbi.nlm.nih.gov/pubmed/18503626

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