title: Medication pain management in the elderly: unique and underutilized analgesic treatment options.
abstract: BACKGROUND
  By 2030, the US population of adults aged ≥65 years will increase by >80%, and these adults will account for nearly 20% of the US population. In this population, the decline of multiple physiologic processes and diseases collectively influence treatment options. Physiologic changes, drug-drug interactions resulting from polypharmacy, and drug-disease interactions combine to make elderly patients more sensitive to the adverse events (AEs) associated with medications, all of which must be considered in drug selection.
  
  
  OBJECTIVE
  This article focuses on select underutilized medication options for analgesia that may provide significant advantages in the elderly population above and beyond commonly prescribed conventional choices.
  
  
  METHODS
  We performed a complete review of the literature using the search terms pain management, elderly, opioids, NSAIDs, topical NSAIDs, levorphanol, buprenorphine transdermal, and tapentadol. Databases searched included PubMed, Google Scholar, Ovid, and Athens. Package inserts were utilized for approval dates, indications, and formulations available. We looked at reviews of agents to identify important studies for consideration that searches may have missed. Pharmacology and pharmacokinetic data were taken from randomized trials focusing in this area. Pivotal Phase III trials were utilized for discussion of clinical trial experience and to summarize efficacy and AEs. For purposes of validity, only peer-reviewed literature was included.
  
  
  RESULTS
  There were limited data that specifically outlined analgesic drug selection and highlighted safer alternatives for the elderly patient based on polypharmacy risks, end-organ deterioration, and/or drug choices that presented less risk. We focused on unique opioid alternatives: levorphanol, which offers several therapeutic advantages similar to methadone but without the pharmacokinetic and drug-interaction pitfalls associated with methadone; tapentadol, associated with significantly less gastrointestinal distress and constipation; and transdermal buprenorphine, an agonist/antagonist with less risk for the toxicities associated with conventional opioids and with compliance benefits. Topical NSAIDs are discussed as a viable therapeutic option. Specific attention to a more desirable tolerability profile, including avoidance of drug interactions, end-organ dysfunction, and gastrointestinal bleed with topical NSAID agents versus their oral counterparts is discussed, including the ability to achieve superior tissue levels for appropriately selected inflammatory conditions.
  
  
  CONCLUSIONS
  It is incumbent that providers consider these options as part of an analgesic armamentarium in an effort to maximize therapeutic benefit and minimize risks in the increasing elderly patient population.
authors.affiliation: Stratton Veterans Affairs Medical Center, Albany, New York. Electronic address: timothy.atkinson@va.gov.
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Atkinson
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Fudin
authors.forename: Abhinetri
authors.initials: A
authors.lastname: Pandula
authors.forename: Maira
authors.initials: M
authors.lastname: Mirza
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000375:Aging; D000700:Analgesics / Q000009:adverse effects / Q000493:pharmacokinetics / Q000627:therapeutic use*; D002986:Clinical Trials as Topic; D006801:Humans; D010146:Pain / Q000188:drug therapy*; D059408:Pain Management / Q000379:methods*
chemical_list: D000700:Analgesics
keywords: analgesia; buprenorphine transdermal; elderly; levorphanol; opioids; pain management; tapentadol; topical NSAIDs