Opioids

The use of opioids for nonmalignant pain has increased over recent years. There have been several publications regarding opioid use66[V], 67[V], 68 and other organizations have published consensus documents. There are theoretical reasons why older patients may have an altered response to opioids and the adage of "start low and go slow'' with regard to titration is important. This does not negate the requirement for adequate analgesia. An earlier paper by Aubrun et al.69 demonstrated lower subcutaneous dosing with morphine on the wards in older patients, but not intravenous dosing titrated to effect in the recovery ward. There have been studies demonstrating reduced opioid requirements in elderly patients, but the variability of dose is wide and individual titration is suggested.70[V]

When opioids are used chronically, there is a potential for dose escalation, possibly as a result of tolerance. A small retrospective review of 206 patients demonstrated that initial opioid doses were the same, but that escalation over approximately 15 months was almost 50 percent lower in the older population (60 years and above). The older patients also had a sustained reduction in visual analog pain score compared to the younger patients. The postulate is that older patients may have a reduced rate of tolerance.71 The use of slow-release opioids over a six-month period demonstrated improved functional ability and social engagement and failed to demonstrate a higher rate of side effects in a nursing home population compared to short-acting opioids. The authors suggest that slow-release opioids may have a role in the long-term management of nonmalignant pain in the nursing home population.58

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