Pharmacotherapy of Pain in the Older Population: The Place of Opioids

Abstract

Pain is a common symptom in older people. It is possible that pain is underreported in older persons due to an incorrect belief that it is an inevitable part of aging. Opioid analgesics are potent medications, with confirmed efficacy for the treatment of moderate to severe pain. These drugs are commonly used in older persons. However, there is insufficient evidence regarding safety of opioids in older patients. One of the reasons for this is the lack of randomized, controlled clinical trials. People of advanced age often have comorbidites and use other prescription drugs, as well as over-the-counter (OTC) compounds, thus making them more suceptible to the risk of interactions with opioids. Significant pharmacokinetic and pharmacodynamic changes that occur with advancing age increase the risk of adverse effects of opioids. There are also some discrepancies between guidelines, which recommend the use of lower doses of opioids in older patients, and the findings in the literature which suggest that pain is often undertreated in this age group. It seems that there are significant variations in the tolerability of different opioid analgesics in older people. Morphine, fentanyl, oxycodone, and buprenorphine are still the preferred evidence-based choices for add-on opioid therapy for these patients. However, the safety and efficacy of other opioids in older patients, especially if comorbidities and polypharmacy are present, is still questionable. This review addresses the most important aspects of the use of opioids in older persons, focusing on pharmacokinetics, pharmacodynamics, adverse effects, and interactions.

Predictors of Long‐Term Opioid Effectiveness in Patients With Chronic Non‐Cancer Pain Attending Multidisciplinary Pain Treatment Clinics: A Quebec Pain Registry Study

“…Older age, for example, has been identified as a predictor of opioid treatment response in some studies 47–49 but not in others 21,22,49 . These conflicting findings could result from the mixed changes that occur with ageing, such as increased pain sensitivity, higher level of opioid active metabolites in plasma, and decreases in µ‐opioid receptor densities accompanied by an increase in affinity 50–52 . In addition, a history of alcohol or drug problems has been shown to influence treatment response 53 or pain/opioid tolerance, 54–56 which could result in decreased efficacy of pain treatment as reported in our study.…”

Sacral nerve stimulation with optimized parameters improves visceral hypersensitivity in rats mediated via the autonomic pathway

“…The opioid pathway is typically involved in the analgesic effects of various medications [44][45][46] and in fact opioids are the most common medical therapies for pain. It had been reported that the sympathetic nervous system could be inhibited by opioid peptides produced in the heart through the respective receptors.…”

The Effects of Opioids on Cognition in Older Adults With Cancer and Chronic Noncancer Pain: A Systematic Review

“…Opioids are used to manage moderate to severe pain (11) and can be used with older adults when they have pain despite other treatments (2,12). Short-term opioid use has some benefit in older adults with chronic non-cancer pain (13,14).…”