Older adults (aged ≥65 years) make up a large portion of the population with chronic pain, and their presentation, diagnosis, and treatment tends to be more complicated because of age-related physiological changes and comorbidities. Guidelines on treating patients with severe back pain recommend opioids as an option for those who do not find adequate pain relief from acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). For older adult patients at higher risk for NSAID-related adverse effects, such as those who have gastrointestinal or cardiovascular disease, diabetes mellitus, or who are taking low-dose aspirin, opioids are recommended instead. Opioids may also be an appropriate option for patients with neuropathic pain who have not achieved adequate analgesia from maximum doses of first- and second-line antineuropathic agents. Still, opioids are not appropriate for all patients; rather, a differential diagnosis, consideration of other comorbidities, and the potential for opioid-related adverse effects and substance abuse are required to confirm the value of opioid treatment for each individual.

Article Opioids for Chronic Pain: New Evidence, New Strategies, Safe...

Tapentadol is a centrally acting analgesic with 2 mechanisms of action, μ-opioid receptor agonism and norepinephrine reuptake inhibition, that is available in an extended-release formulation for the management of chronic pain.It has bben recently published that tapentadol ER (100 - 250 mg bid) is effective for moderate to severe osteoarthritis pain, low back pain, and pain related to DPN and provides efficacy similar to that of oxycodone HCl CR (20 - 50 mg bid) for patients with osteoarthritis and low back pain. Due to a better adverse effects profile, tapentadol ER treatment has been associated with better gastrointestinal tolerability than oxycodone CR, which suggests that tapentadol ER may be a better option for the long-term management of chronic pain.

What´s your experience about this topic?

Article Efficacy of Tapentadol ER for Managing Moderate to Severe Chronic Pain

YES. and the best drug, in my experience is…ta da… methadone. It is best because it is long lasting and cheap. Of course, the patient has to have the type of pain amenable to opiods. anyhow, here is an anecdote of the efficacy potential. I was sent an elderly lady with severe osteoporosis. About every 6 months she had another vertebral collapse and she was essentially bed ridden as her doctor was afraid to give here more than tylenol and the occasional tylenol#3. I put her on methdone. I think 5 mg a day was all she needed and it transformed her life. She was able to be active, get out and shop, do all the stuff she wanted. About every 6 months she had a new collapse and she had to boost her dose for a couple of days but then she reverted back to her baseline. This went on for a couple of years before I was recalled to active duty for Desert Storm.

The only drawback to the drug, as far as I am concerned, is one has to get over the psychological issue that this is a drug for addicts. (this is a bigger issue for the family.). It is a hell of a lot better than risking all the side effects of chronic acteominophen use or NSAID use.

Very interesting article about opioid prescription in chronic pain patients.

http://www.dovepress.com/the-damage-done-by-the-war-on-opioids-the-pendulum-has-swung-too-far-peer-reviewed-article-JPR

IMPORTANCE:

Primary care clinicians find managing chronic pain challenging. Evidence of long-term efficacy of opioids for chronic pain is limited. Opioid use is associated with serious risks, including opioid use disorder and overdose.

OBJECTIVE:

To provide recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care.

PROCESS:

The Centers for Disease Control and Prevention (CDC) updated a 2014 systematic review on effectiveness and risks of opioids and conducted a supplemental review on benefits and harms, values and preferences, and costs. CDC used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to assess evidence type and determine the recommendation category.

EVIDENCE SYNTHESIS:

Evidence consisted of observational studies or randomized clinical trials with notable limitations, characterized as low quality using GRADE methodology. Meta-analysis was not attempted due to the limited number of studies, variability in study designs and clinical heterogeneity, and methodological shortcomings of studies. No study evaluated long-term (≥1 year) benefit of opioids for chronic pain. Opioids were associated with increased risks, including opioid use disorder, overdose, and death, with dose-dependent effects.

RECOMMENDATIONS:

There are 12 recommendations. Of primary importance, nonopioid therapy is preferred for treatment of chronic pain. Opioids should be used only when benefits for pain and function are expected to outweigh risks. Before starting opioids, clinicians should establish treatment goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks. When opioids are used, clinicians should prescribe the lowest effective dosage, carefully reassess benefits and risks when considering increasing dosage to 50 morphine milligram equivalents or more per day, and avoid concurrent opioids and benzodiazepines whenever possible. Clinicians should evaluate benefits and harms of continued opioid therapy with patients every 3 months or more frequently and review prescription drug monitoring program data, when available, for high-risk combinations or dosages. For patients with opioid use disorder, clinicians should offer or arrange evidence-based treatment, such as medication-assisted treatment with buprenorphine or methadone.

CONCLUSIONS AND RELEVANCE:

The guideline is intended to improve communication about benefits and risks of opioids for chronic pain, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy.

Summary for patients in

JAMA PATIENT PAGE. Opioids for Chronic Pain. [JAMA. 2016]

http://www.ncbi.nlm.nih.gov/pubmed/26977696