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RESEARCHERS say the relatively high use of transdermal opioid patches as first-line therapy for patients in aged care facilities raises safety concerns, but a pain management expert has welcomed their findings as an indication that previously neglected pain in elderly groups is being addressed.
A cross-sectional cohort study, published in the MJA this week, found that opioid patches were dispensed to 11.3% of 5297 residents living in 60 residential aged care facilities in the 5 years to 2013. Buprenorphine patches were administered to 8.7% of residents, while fentanyl patches were administered to 2.6%. (1)
About a third of residents (34%) receiving transdermal fentanyl and about half (49%) of those administered buprenorphine were opioid naive in the 4 weeks before initiation, the researchers found.
”Given the difficulties with the dose titration of transdermal buprenorphine preparations and concerns about the safety of fentanyl in opioid-naive patients, the use of transdermal preparations in older patients should be limited to opioid-tolerant patients with stable opioid requirements”, they wrote.
Although the authors said their findings raised some safety concerns, they said about 90% of opioid-naive patients were started on transdermal opioids at the lowest possible dose. “It appears that the ‘start low, go slow’ adage is being followed,” they said.
Dr Malcolm Hogg, head of pain management services at Royal Melbourne Hospital, welcomed the research focus on pain management in this often neglected population.
“We don’t know enough regarding pain in the older person, but we do know that it’s of higher frequency”, he said, adding that musculoskeletal pain appeared to account for much of this pain burden.
He said the findings might reflect a “changing appreciation” of the advantages of transdermal opioid therapy in older patients, particularly those with chronic musculoskeletal pain.
The patches resulted in improved compliance and a lowered risk of constipation, and this method of delivery was thought to be safer in the older patient with renal impairment and may be preferred in those at risk of confusion, Dr Hogg said.
The multidimensional assessment of a patient’s pain in the aged care environment — where input was sought from nursing staff and family members— might also be a factor in improved recognition and management of pain in this population, particularly if there was cognitive impairment, he said. With input from others and the use of appropriate pain assessment tools, a trial of an opioid might be initiated, and the assessment of response would determine if the opioid was maintained.
Dr Hogg also pointed to the relatively low proportion of patients who were started on transdermal fentanyl as first-line therapy, with opioid-naive patients representing just one-third of the 2.6% of patients initiated on fentanyl patches. “This would seem to me to be a positive result.”
Professor Andrew McLachlan, program director of the NHMRC Centre for Research Excellence in Medicines and Ageing, said the study was a powerful insight into the “real world” impact of medicine use on patient care.
However, he said, comparing the initiation of transdermal opioid patches with guideline recommendations didn’t tell the full story.
“In order to make a judgement about safety and appropriateness, we also need to know a little more about the clinical picture”, he said. “For example, we know other research has shown that people in aged care facilities, and particularly frail older people, often have poorly managed pain, and this contributes to other health and quality-of-life issues.”
Professor McLachlan said there could also be complicating factors in this population, such as swallowing difficulties, that play into the decision to use transdermal therapy.
“There is certainly also convenience — which may be a good or bad thing — in the application of a transdermal patch that will last several days and afford good pain relief over that period.”
However, Professor McLachlan said this had to be balanced against the potential risks associated with this therapy.
“There are two broad discussions here. One is the optimal management of pain in people who are very vulnerable both to the effects of the pain and the impact on their quality of life, but also to the possible unwanted or harmful effects that some of the stronger, pain-relieving medicines might have”, he said.
Dr Hogg, who is the immediate past president of the Australian Pain Society, said the society was in the process of updating its “Pain in residential aged care facilities” guidelines, first issued in 2005. (2)
He said the updated guidelines would have an increased emphasis on complementary approaches to pain management, such as yoga, tai chi and relaxation programs, and multimodal drug therapy, where a neuromodulation drug is used in combination with an opioid, if required.
The revision is expected to be released in mid 2016.
(Photo: Ocskay Mark / shutterstock)
Were transdermal Buprenorphine or Fentanyl patches actually trialled on this population (ie, nursing home patients, often over 80 years old, often with dementia) ? If not, it is interesting that they are used so much.