Key principles for opioid prescribing in older adults:
• Meperidine and codeine should be avoided since they both have dangerous metabolites that lead to more adverse effects than other opioids.
• Tapentadol and tramadol should be used with caution due to unique safety profiles and concern for serotonin syndrome for patients on multiple medications.
• Combination products that include acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution because of the increased susceptibility to NSAID side effects and the potential to exceed the maximum recommended daily dose of these non-opioid agents.
• They are at higher risk of medication-induced adverse reactions. Then, when prescribing opioids start at the lowest dose and titrate no faster than 4 times the selected opioids terminal half-life. E.g. short acting oxycodone immediate release is titrated no faster than every 2 days.
• For opioid-naïve patients, start with the lowest practical dose (E.g. half of a commercially available pill, e.g. 7.5 mg morphine or 2.5 mg oxycodone). For even lower doses, opioid elixirs can be used.
• Long-acting opioids should be initiated only after the patient has developed some opioid tolerance with the use of immediate release agents.

Common opioid-induced events in older adults are: constipation (30%), nausea (28%) dizziness (22%), and urinary retention, even if other side effects are possible. Adverse events prompt opioid discontinuation in 25% of cases.

Key differences in these adverse reactions:
• They risk for adverse reactions is due to the physiologic changes of aging, comorbidities such as cognitive impairment, kidney and/or liver dysfunction, and/or concomitant medications.
• Adverse reactions may present atypically. E.g. opioid-induced urinary retention can present as delirium and/or agitation in cognitively frail adults.
• They are at higher risk of falls and fractures when taking opioids. – they have a 38% increased likelihood of fractures compared to older patients not on opioids.
• Severe pain itself is strongly associated with developing delirium, and, in fact, patients who receive less than 10 mg of parenteral morphine sulfate equivalents per day are more likely to develop delirium than patients who receive higher daily opioid doses - while opioids increase delirium risk, so can untreated severe pain especially if it disturbs the natural sleep-wake cycle.
• Older age has been consistently associated with a decreased risk of aberrant opioid behaviors. Also, death from opioid overdose is less prevalent in older adults compared to younger adults.

They need proper opioid counseling, education, and anticipatory management of side effects to reduce the chance to miss doses, discontinue treatment, or refuse to take opioids in the future.

See reference for more information.

Adapted from Pruskowski J et al. Safety considerations when using opioids for older adults. Palliative Care Network of Wisconsin. Fast facts and concepts #357. Internet. Accessed on December 27, 2018.