Noncancer pain management in seriously ill older adults: Practical considerations with opioid use
Attitude to Health
Elders commonly report noncancer pain, with up to 50% of communitydwelling elders describing uncontrolled moderate to severe pain. Although adequate pain management is possible in most of these patients and numerous guidelines are available to guide pain management strategies, pain remains undertreated in this population. The general principles of noncancer pain management include the use of opioids for moderate to severe pain that is not alleviated by acetaminophen or by nonsteroidal anti-inflammatory drugs. There are safety concerns regarding the use of opioids, however, especially by older adults; the many physiologic changes that accompany normal aging and the high prevalence of comorbidities in this population increase the propensity for drug-drug and drug-disease interactions. These concerns may lead to underuse of these agents or to premature discontinuation. The authors review the characteristics of commonly used opioids, outline proper opioid starting doses for older adults, discuss opioid pharmacokinetics and pharmacodynamics, and review opioid-related side effects and approaches to effective management.