Guidance on opioids prescribing for the management of persistent non-cancer pain in older adults

Table 1 Management of opioid-related adverse effects in older adults

Adverse effect	Frequency	Management
Constipation	+++	Prescribe laxatives when starting opioids
		Consider oxycodone/naloxone preparation
Nausea	+++	Low doses and slow titration
		To treat with antiemetics
Sedation,	+	Careful review of medications (benzodiazepines, antidepressants, etc.)
mental confusion		Low doses and slow titration
Delirium	+	Careful review of medications (benzodiazepines, antidepressants, etc.)
		Low doses and slow titration
Falls,	+/-	To monitor walking instability and fall risk when initiating opioids
fractures		Careful review of medications
		To prefer long-acting opioids
Respiratory depression	Very rare	Low doses and slow titration
Immunosuppression	Rare	To consider in long-term therapy
Addiction	Very rare	Abuse history
		Use tools to assess risk
		Monitoring patient

Table 2 Before prescribing opioid treatment in older adults

Consider age-related physiological changes (creatinine clearance, hepatic function, serum albumen)

Assess polypharmacy (over-the-counter analgesics, benzodiazepines, antidepressants, antipsychotic drugs)

Consider multimorbidity

Use tools to assess risk of addiction

Share realistic treatment goals and make therapeutic plan

Consider exercise and psychological interventions

Table 3 When prescribing opioids in older adults

Beginning at the lowest possible dose and titrating upwards base on tolerability and efficacy

Longer dosing interval and regular monitoring are recommended

Switching to another opioid might be indicated in cases of unacceptable side effects of insufficient analgesia

The oral route may be the most convenient

Low-doses of strong opioids should be preferred to weak opioids because of its effectiveness and safety

Strong opioids generally recommended in frail old population are buprenorphine, hydromorphone and oxycodone (including oxycodone/naloxone formulation)

Controlled-release formulation and transdermal formulations are generally preferred (low risk of addiction and adverse effects)

Considering laxatives or oxycodone/naloxone to prevent constipation

Over-the-counter analgesics use should be avoided