Opioid Prescribing in Older Adults

Opioid prescribing in older adults treats moderate to severe pain, breathlessness and cough in palliative care, and cancer pain, using lower starting doses and slower titration than in younger adults. Older people are more sensitive to respiratory depression, sedation, delirium, constipation and falls, and renal impairment prolongs the effect of morphine and codeine metabolites. Opioids are rarely first-line for chronic non-cancer pain.

Assessment. Define the pain type, function, kidney and liver function, cognition, swallowing, other sedatives and previous opioid exposure. Treat neuropathic pain with specific adjuvants rather than escalating opioid dose.

Laxatives. Prescribe a laxative with every opioid course: senna 7.5 to 15 mg orally at night with macrogol one sachet orally daily.

Step 1. Paracetamol 500 mg orally every 6 hours, maximum 3 g daily or 2 g daily if under 50 kg, frail, malnourished or with liver disease, before and alongside any opioid.

Opioid-naive start. Morphine immediate-release solution 2.5 mg orally every 4 hours as needed. Review after 24 to 48 hours and increase by 25% to 50%. Where oral morphine solution is the main strong opioid available, this remains the usual first choice.

Kidney impairment. In creatinine clearance under 30 mL/min lengthen the morphine interval to every 6 to 8 hours or change to oxycodone 2.5 mg orally every 6 hours, or to buprenorphine. Avoid codeine and pethidine.

Chronic stable pain. Buprenorphine transdermal patch 5 micrograms/hour, changed every 7 days, for people unable to swallow or with renal impairment; titrate after at least 3 days and no more than every 3 days. A 5 micrograms/hour patch is roughly equal to 12 mg of oral morphine daily.

Tramadol. 50 mg orally every 12 hours, increased cautiously, usual maximum 200 mg daily in older adults. Avoid in epilepsy, hyponatraemia and with SSRIs or serotonergic drugs. In creatinine clearance under 30 mL/min give no more often than every 12 hours.

Fentanyl patches. Not for opioid-naive people; use only after stable opioid dosing and at the equivalent dose.

Conversion. Oral morphine 10 mg equals oral oxycodone about 5 mg. Reduce the calculated dose by 25% to 50% on switching for incomplete cross-tolerance.

Respiratory depression. Naloxone 100 to 200 micrograms intravenously, repeated every 2 minutes, titrated to respiratory rate; effect lasts 30 to 90 minutes, so continue observation or give an infusion.

Special groups. In dementia use observed pain scales. In hepatic impairment lower the dose and lengthen intervals; morphine and oxycodone accumulate.

Monitoring. Record pain score, respiratory rate, sedation level, bowel function, nausea, cognition, falls and function at 24 to 48 hours and then each review. Stop increasing if sedation or respiratory rate under 10 breaths a minute appears.

Maximum dose. Set no fixed maximum, but review any dose that has doubled within a week.

Hepatic and renal. When creatinine clearance is under 30 mL/min lengthen intervals or halve the dose, and avoid long-term morphine.

Stopping. After more than 2 weeks of regular use reduce the dose by 10% to 25% every 1 to 2 weeks to avoid withdrawal.

Referral and escalation. Refer to palliative care or pain services when pain remains uncontrolled after two dose steps, for neuropathic or complex pain, when daily dose passes 50 mg oral morphine equivalent without clear benefit, or for suspected misuse.