UMMS CRIT Module II: Opioid Usage in Older Adults Catherine DuBeau, MD Clinical Director of...

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



• 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



• 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?



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



• 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



WHO pain ladder:

• Non-opioids

• Adjuvants

• Opioids

Managing Pain



• 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



• 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



Strong Opioids

• Morphine

• Oxycodone

• Hydromorphone (Dilaudid)

• Fentanyl

• Oxymorphone (Opana, Numorphan)

• Methadone

Step 3- Severe Pain



• Meperidine (Demerol)

• Pentazocine (Talwin)

• Combination with antihistamine (Vistaril)

Avoid



• Key to dosing and changing opiods

• Use calculators

Morphine Equianalgesia

Conversion: http://www.epocrates.com/products/medtools/opioidanalgesicconverter.html

http://www.epocrates.com/products/medtools/opioidanalgesicconverter.html



• 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



• 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



• 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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