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[ARTICLE] Opioid Use in the Elderly
Filed Under: Medicine | Published: Feb 2, 2018 | Author: Uma Suryadevara, Richard Holbert, Robert Averbuch
Opioids reduce the perception of pain and produce a sense of well-being by binding to opioid receptors (mu, delta, and kappa) distributed in the brain, spinal cord, and other peripheral tissues. When deeper brain regions are stimulated by opioids, drowsiness and respiratory depression ensue. Opioids are classified by their origin, mechanism of action, or potency. Based on their origins in nature, opium, morphine, and codeine are opiates. Semi-synthetics include hydromorphone, hydrocodone, oxycodone, and heroin. Completely synthetic opioids are manmade and include fentanyl, methadone, pethidine, levorphanol, tramadol, and dextro­propoxyphene. Based on their potency, codeine, hydrocodone, and oxycodone are considered mild opioids; morphine, meperidine, hydromorphone, fentanyl, and methadone are classified as major opioids. All are opioid agonists with the exception of buprenorphine, which is a partial agonist/antagonist.

Opioids are also used for non-medicinal, recreational purposes. In the elderly, the line between use for physical and psychological well-being is often blurred, which complicates attempts to determine prevalence. Numbers vary for different countries and are based on different study results, further confounding the data. This variation in prescribing patterns could be a result of the inconsistent practice styles among physicians and a failure to adhere to the guidelines that aim at standardizing practice. The changing demographics of the elderly American population further influence the prevalence of substance use disorders.

The decision to prescribe opioids in the elderly requires careful consideration of the many pharmacokinetic changes associated with aging. Age-related changes include a decrease in hepatic blood flow and volume along with decreases in renal blood flow and the glomerular filtration rate. Depending on the opioid used, it is essential to estimate the creatinine clearance and hepatic function for appropriate dosing adjustments. Other age-related changes that may influence opioid levels include decreased rates of absorption and increased adipose tissue. Many comorbid medical conditions seen in the elderly can lower the serum albumin concentration, thereby increasing the free opioid concentration.

Additional risks include the potential for serious drug-drug interactions with opioids. The likelihood of such interactions is directly proportional to the number of medications prescribed and compounds the risk of serious adverse events such as respiratory suppression.

Non-opioid pharmacotherapy and non-pharmacological therapy are the preferred modalities of treatment for chronic pain. However, in the proper contexts, opioids can be a useful treatment option. They are most beneficial in the short term for acute injuries, including the management of pain postoperatively. Use should be time-limited, except in managing certain cancer-related pain syndromes and as a part of end-of-life care. Particularly in the elderly, appropriate precautions must be taken.

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