Abstract

Tapering opioids is one of the most daunting dilemmas in clinical practice today. The decision to taper opioids is based on many factors, including a lack of efficacy, unacceptable risk, perioperative management, noncompliance, or patient preference. Tapering in the perioperative setting is quite common, though more complex in patients previously taking chronic opioid therapy. Outside of a medical emergency, opioid tapers are best managed in an outpatient setting, allowing for adjustments and more long-term nonopioid pain management, if necessary. No single strategy can be applied to all patients, and very few published guidelines are available for reference. Dose reductions and schedules are highly variable across available guidelines and literature. Dose reductions range from 10% to 50%, with a frequency ranging from daily reductions to every 2 weeks. Most guidelines address the concern of preventing physical withdrawal symptoms; however, few address the psychological ramifications of tapering. Individualized regimens and a willingness to adjust schedules and doses allows for improved patient comfort. The goal is to complete tapering without any symptoms of withdrawal; however, this is not always possible. Several available agents may help ameliorate these symptoms, including antihypertensives, antihistamines, antiemetics, antidepressants, anticonvulsants, and antipsychotics. Opioid tapering is rarely easy but should be a manageable process.

Abstract

The older adult population is one of the fastest growing age groups in the United States. As this population continues to expand, determining the safest way to provide pain management has become increasingly important. More than 50% of community-dwelling older adults experience pain on a daily basis, and up to 83% of those in assisted living facilities experience persistent pain. Pain is exceedingly challenging to treat safely and effectively in the elderly because of the physiologic changes that occur as people age. In addition, many nonnarcotic medications with analgesic properties are listed in both the 2012 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults and the Pharmacy Quality Alliance high-risk medications lists. An approach to the growing challenge of managing pain in the elderly that is gaining popularity among community-dwelling patients is the use of topical pain medications. The goal of this article is to review some of the available literature regarding the use of various topical analgesics alone or in combination, and to discuss their known or theoretical mechanisms of peripheral pain modulation. Commercially available or compounded topical pain medications may be used to replace or augment doses of oral medications in an effort to decrease the risk of adverse drug events for older adult patients. When prescribing topical pain medications physicians should consider the nature of the pain targeted, the type of analgesia expected from each ingredient, the potential for systemic absorption, and related side effects.

Abstract

Abstract

Abstract

Opioid-induced hyperalgesia (OIH) is a relatively new paradigm that has added to the already growing uncertainty surrounding long-term opioid treatment. OIH is the oversensitization to stimuli in the nervous system resulting from opioid exposure and subsequent neuroplastic changes. Because of its novelty and difficulty in identification, the true prevalence of OIH is unknown. Several mechanisms have been proposed for its development. These include changes in the N-methyl-D-aspartate system, descending pathway modulation, dynorphin activity, inflammatory changes mediated by cyclooxygenase, and increased sensitivity to excitatory neurochemicals. The clinical controversy regarding the management of OIH is due largely to the lack of guidance in diagnosis and lack of quality evidence to direct treatment. As a diagnosis of exclusion, several alternative causes of antianalgesia must be ruled out before OIH can be declared. Pharmacodynamic phenomena such as opioid tolerance share overlapping mechanisms with OIH and may present similarly. Pharmacokinetic changes such as drug-induced or disease-induced alterations to the cytochrome P450 or P-glycoprotein systems should also be excluded as causes of increased opioid demand that may be seen as OIH. Certain pharmacologic agents, such as N-methyl-D-aspartate receptor antagonists, alpha₂ receptor agonists, and cyclooxygenase inhibitors, have been identified as possible treatments to reverse the effects of OIH. Opioid rotation and dose reductions have also been used with some degree of success. Pharmacist involvement in the identification and management of OIH will be central to success because of the unique expertise they offer. The quality of these studies is limited by study design, small sample sizes, and lack of generalizability to chronic pain patients with long-standing opioid use.