Pharmacotherapy of Pain in the Older Population: The Place of Opioids

Opioids in geriatric units in 14 Belgian hospitals: prevalence, dosage and associated factors

Introduction: Adverse effects of opioids are common among older individuals, and undertreatment as well as overuse can be an issue. Epidemiological data on opioid use in older individuals are available, but scarce in hospitalized patients.Aims: The aim of this study is to examine the one-day prevalence of opioid use among older inpatients and identify the factors associated with both opioid use and dosage.Materials and methods: One-day cross-sectional study with data collected from geriatric units across 14 Belgian hospitals. The primary focus of the study is to assess the prevalence of opioid use and dosage, along with identifying associated factors. To achieve this, a multiple binary logistic regression model was fitted for opioid use, and a multiple linear regression model for opioid dose.Results: Opioids were used in 24.4% of 784 patients, of which 57.9% was treated with tramadol, 13.2% with oxycodone or morphine and 28.9% with transdermal buprenorphine or fentanyl. The odds for opioid use were 4.2 times higher in patients in orthogeriatric units compared to other patients (OR=4.2, 95% CI=2.50-7.05). The prevalence of opioid use was 34% higher in patients without dementia compared to patients with dementia (OR=0.66, 95% CI=0.46-0.95). The overall mean daily dosage was 14.07mg subcutaneous morphine equivalent. After adjustment for age, gender and dementia, dosage was only associated with type of opioid: the estimated mean opioid dose was 70% lower with tramadol (mean ratio=0,30,95% CI=0,23-0,39) and 67% lower with oxycodone and morphine (mean ratio=0,33, 95% CI=0,22-0,48) compared to transdermal buprenorphine and transdermal fentanyl.Conclusions: One in four patients received opioid treatment. It is not clear whether this reflects under- or overtreatment, but these results can serve as a benchmark for geriatric units to guide future pain management practices. The utilization of transdermal fentanyl and buprenorphine, resulting in higher doses of morphine equivalent, poses significant risks for side effects.

Factors Influencing the Self-Management Stages of Older Patients With Chronic Pain: A Cross-Sectional Study

PURPOSE

To investigate the current status and related influencing factors of self-management stages in older patients with chronic pain.

DESIGN

A cross-sectional study.

METHODS

A total of 326 older patients with chronic pain were selected as the study subjects in five city districts from December 2022 to June 2023. We used a general information survey form, a numerical rating scale, a pain stages of change questionnaire, a health literacy assessment instrument for patients with chronic pain, and a psychological inflexibility in pain scale to collect relevant information from participants. Univariate analysis and multiple ordinal logistic regression analysis were conducted to identify the relevant influencing factors of the self-management stages.

RESULTS

The self-management stages of older patients with chronic pain were as follows: precontemplation stage (n = 52; 16.0%), contemplation stage (n = 103; 31.6%), action stage (n = 62; 19.0%), and maintenance stage (n = 109; 33.4%). Regression results showed that average monthly household income, smoking history, pain duration, health literacy, and psychological inflexibility were the influencing factors for the self-management stages of older patients with chronic pain.

CONCLUSIONS

In this study, the self-management stages of older patients with chronic pain still needed to be improved. Suitable personalized pain self-management strategies should be developed based on identified factors affecting patients to improve their self-management stages.

CLINICAL IMPLICATIONS

Nursing professionals can use research survey findings to identify patients at low levels of self-management stage and develop personalized intervention strategies based on various influencing factors. For example, nurses can provide practical smoking cessation guidance to assist older chronic pain patients in improving their lifestyle. Nurses can also seek support from family members to collectively offer better medical care and nursing services for the patient if financially feasible. Secondly, as our study has demonstrated, patients' health literacy and psychological flexibility were poor. Nurses can utilize available clinical resources to offer educational materials, such as portable handbooks and online videos, covering pain-related knowledge, managing pain medication, and coping strategies like massage and exercise. Combining this approach with mental health education, such as relaxation therapy, can help patients better understand their pain and actively participate in their self-management. In addition, nursing staff should pay more attention to the self-management stages of older chronic pain patients, and the assessment of self-management stages can be included in clinical pain management for patients. Regular assessment will help track more patients needing attention and make timely adjustments to their pain management plans.

Role of primary care in opioid prescribing for older head and neck cancer survivors

BACKGROUND

Older head and neck cancer (HNC) survivors have concerning rates of potentially unsafe opioid prescribing. Identifying the specialties of opioid prescribers for HNC survivors is critical for targeting the settings for opioid safety interventions. This study hypothesized that oncology and surgery providers are primarily responsible for opioid prescriptions in the year after treatment but that primary care providers (PCPs) are increasingly involved in prescribing over time.

METHODS

Using linked Surveillance, Epidemiology, and End Results-Medicare data, a retrospective analysis was conducted of adults aged >65 years diagnosed between 2014 and 2017 with stage I-III HNC and who had ≥6 months of treatment-free follow-up through 2019. Starting at treatment completion, opioid fills were assigned to a prescriber specialty: oncology, surgery, primary care, pain management, or other. Prescriber patterns were summarized for each year of follow-up. Multinomial logistic regression models captured the likelihood of opioids being prescribed by each specialty.

RESULTS

Among 5135 HNC survivors, 2547 (50%) had ≥1 opioid fill (median, 2.1-year follow-up). PCPs prescribed 47% of all fills (42%-55% each year). PCPs prescribed opioids to 45% of survivors with ≥1 opioid fill, which was a greater share than other specialties. PCPs prescribed longer supplies of opioids (median, 20 days/fill; median, 30 days/year) than oncologists or surgeons. The likelihood of an opioid being prescribed by an oncology provider was four times lower than that of it being prescribed by a PCP.

CONCLUSIONS

PCP involvement in opioid prescribing remains high throughout HNC survivorship. Interventions to improve the safety of opioid prescribing should target primary care, as is typical for opioid reduction efforts in the noncancer population.

Opioid metabolism and drug-drug interaction in cancer

Concomitant use of multiple drugs in most patients with cancer may result in drug-drug interactions (DDIs), potentially causing serious adverse effects. These patients often experience unrelieved cancer-related pain (CRP) during and after cancer treatment, which can lead to a reduced quality of life. Opioids can be used as part of a multimodal pain management strategy when non-opioid analgesics are not providing adequate pain relief, not tolerated, or are contraindicated. However, due to their narrow therapeutic window, opioids are more susceptible to adverse events when a DDI occurs. Clinically relevant DDIs with opioids are usually pharmacokinetic, mainly occurring via metabolism by cytochrome P450 (CYP). This article aims to provide an overview of potential DDIs with opioids often used in the treatment of moderate-to-severe CRP and commonly used anticancer drugs such as chemotherapeutics, tyrosine kinase inhibitors (TKIs), or biologics. A DDI-checker tool was used to contextualize the tool-informed DDI assessment outcomes with clinical implications and practice. The findings were compared to observations from a literature search conducted in Embase and PubMed to identify clinical evidence for these potential DDIs. The limited results mainly included case studies and retrospective reviews. Some potential DDIs on the DDI-checker were aligned with literature findings, while others were contradictory. In conclusion, while DDI-checkers are useful tools in identifying potential DDIs, it is necessary to incorporate literature verification and comprehensive clinical assessment of the patient before implementing tool-informed decisions in clinical practice.

Short-Term Opioid Treatment of Acute Locomotor Pain in Older Adults: Comparison of Effectiveness and Safety between Tramadol and Oxycodone: A Randomized Trial

INTRODUCTION

We conducted a head-to-head comparison of step 2 (tramadol) and step 3 (oxycodone) of the WHO pain ladder in older adults with moderate to severe acute locomotor pain.

MATERIALS AND METHODS

Multi-center prospective randomized study. Patients were 70 years or older, admitted to the acute geriatric ward of three hospitals, suffering from acute moderate to severe locomotor pain, and opioid-naive. Patients were randomized into two treatment groups: tramadol versus oxycodone. The Consort reporting guidelines were used.

RESULTS

Forty-nine patients were included. Mean numeric rating scale (NRS) decreased significantly between day 0 and 2 of the inclusion in both groups. A sustained significant decrease in mean NRS was seen at day 7 in both groups. Nausea was significantly more prevalent in the tramadol group, with a trend towards a higher prevalence of delirium and falls and three serious adverse events in the same group.

CONCLUSIONS

Opioid therapy may be considered as a short-term effective treatment for moderate to severe acute locomotor pain in older adults. Oxycodone may possibly be preferred for safety reasons. These results can have implications for geriatric practice, showing that opioids for treatment of acute moderate to severe locomotor pain in older patients are effective and safe if carefully monitored for side effects. Opioid therapy may be considered as a short-term treatment for moderate to severe acute locomotor pain in older adults, if carefully monitored for (side) effects, while oxycodone may possibly be preferred for safety reasons. These results can have implications for daily practice in geriatric, orthopedic, and orthogeriatric wards, as well as in terminal care, more precisely for the treatment of moderate to severe acute locomotor pain in older adults.

Hydrocodone, Oxycodone, and Morphine Metabolism and Drug-Drug Interactions

Awareness of drug interactions involving opioids is critical for patient treatment as they are common therapeutics used in numerous care settings, including both chronic and disease-related pain. Not only do opioids have narrow therapeutic indexes and are extensively used, but they have the potential to cause severe toxicity. Opioids are the classical pain treatment for patients who suffer from moderate to severe pain. More importantly, opioids are often prescribed in combination with multiple other drugs, especially in patient populations who typically are prescribed a large drug regimen. This review focuses on the current knowledge of common opioid drug-drug interactions (DDIs), focusing specifically on hydrocodone, oxycodone, and morphine DDIs. The DDIs covered in this review include pharmacokinetic DDI arising from enzyme inhibition or induction, primarily due to inhibition of cytochrome p450 enzymes (CYPs). However, opioids such as morphine are metabolized by uridine-5'-diphosphoglucuronosyltransferases (UGTs), principally UGT2B7, and glucuronidation is another important pathway for opioid-drug interactions. This review also covers several pharmacodynamic DDI studies as well as the basics of CYP and UGT metabolism, including detailed opioid metabolism and the potential involvement of metabolizing enzyme gene variation in DDI. Based upon the current literature, further studies are needed to fully investigate and describe the DDI potential with opioids in pain and related disease settings to improve clinical outcomes for patients. SIGNIFICANCE STATEMENT: A review of the literature focusing on drug-drug interactions involving opioids is important because they can be toxic and potentially lethal, occurring through pharmacodynamic interactions as well as pharmacokinetic interactions occurring through inhibition or induction of drug metabolism.

Age-dependent decrease in inhibitory drive on the excitatory superficial spinal dorsal horn neurons

The excitatory and inhibitory interneurons of superficial laminae I-II of the spinal dorsal horn (SDH) receive and process pain-related information from the primary afferents and transmit it to the brain via the projection neurons. Thus, the interaction between excitatory and inhibitory SDH interneurons is crucial in determining the output from the spinal cord network. Disruption of this interaction in pathological conditions leads to increased SDH output to the higher brain centers, which could underlie pathological pain. Here, we examined whether the changes in the intrinsic SDH connectivity also occur with age, possibly underlying age-related increase in pain sensitivity. Using Vgat;tdTomato transgenic mouse line, we compared the spontaneous inhibitory postsynaptic currents (sIPSCs) in inhibitory tdTomato+ and excitatory tdTomato- interneurons between adult (3-5 m.o.) and aged (12-13 m.o.) mice. We demonstrate that in adult mice, the amplitude and frequency of the sIPSCs on the excitatory interneurons were significantly higher than on inhibitory interneurons. These differences were annulled in aged mice. Further, we show that in aged mice, excitatory neurons receive less inhibition than in adult mice. This could lead to overall disinhibition of the SDH network, which might underlie increased pain perception among the aged population.

Over the Counter Pain Medications Used by Adults: A Need for Pharmacist Intervention

BACKGROUND

The safety of pharmacotherapy for geriatric patients is an essential aspect of the demographic perspective in view of the increasing size of this population. Non-opioid analgesics (NOAs) are among the most popular and often overused over-the-counter medications (OTC). The reasons for drug abuse are common in the geriatric population: musculoskeletal disorders, colds, inflammation and pain of various origins. The popularity of self-medication and the ability to easily access OTC drugs outside the pharmacy creates the danger of their misuse and the incidence of adverse drug reactions (ADRs). The survey included 142 respondents aged 50-90 years. The relationship between the prevalence of ADRs and the NOAs used, age, presence of chronic diseases, and place of purchasing and obtaining information about the mentioned drugs were evaluated. The results of the observations were statistically analyzed using Statistica 13.3. The most commonly used NOAs among the elderly included paracetamol, acetylsalicylic acid (ASA) and ibuprofen. Patients consumed the medications for intractable headaches, toothaches, fevers, colds and joint disorders. Respondents indicated the pharmacy as the main location for purchasing medications, and the physician as the source of information for selecting the therapy. ADRs were reported most frequently to the physician, and less frequently to the pharmacist and nurse. More than one-third of respondents indicated that the physician during the consultation did not take a medical history and did not ask about concomitant diseases. It is necessary to extend pharmaceutical care to geriatric patients that includes advice on adverse drug reactions, especially drug interactions. Due to the popularity of self-medication, and the availability of NOAs, long-term measures should be taken to increase the role of pharmacists in providing effective, safe health care to seniors. We are targeting pharmacists with this survey to draw attention to the problem of the prevalence of selling NOAs to geriatric patients. Pharmacists should educate seniors about the possibility of ADRs and approach patients with polypragmasy and polypharmacy with caution. Pharmaceutical care is an essential aspect in the treatment of geriatric patients, which can contribute to better results in their existing treatment and increase the safety of medication intake. Therefore, it is important to improve the development of pharmaceutical care in Poland in order to enhance patient outcomes.

Equity Reporting in Systematic Reviews of Opioid Treatment of Chronic Non-Cancer Pain with Patient-Reported Outcomes

Chronic non-cancer pain can affect a patient's social life, ability to work, and overall quality of life (QoL). Opioid therapy is often prescribed as therapeutic treatment in chronic pain. Systematic reviews (SRs)-the pinnacle of research quality-are often used in guideline development; however, pain may differ across cultures and communities. Thus, examination of equity reporting in such SR is necessary. This study examines reporting using the PROGRESS (Place of resident, Race, Occupation, Gender, Religion, Education, Socioeconomic status, Social capital)-Plus framework to examine equity within SRs with patient reported outcomes of chronic, non-cancer pain. A systematic search for SRs was conducted, which were evaluated for PROGRESS-Plus items and study characteristics were extracted. Among the 46 included SRs, seven did not include any PROGRESS-Plus items. The most commonly reported items were age, included within 34 SRs, followed by gender (30/46), and duration of pain (14/46). All other items were reported in five or less studies. Our investigation revealed a deficiency in SR's reporting of equity measures for opioid treatment of chronic non-cancer pain. Given the need to address healthcare disparities among minorities, implementing the PROGRESS-Plus framework may influence QoL and patient-centered care.

Pain management for people with dementia: a cross-setting systematic review and meta-ethnography

Background

Pain management for people with dementia is challenging. There is limited understanding on the experiences of pain management from people with dementia, but also from those who support them. This study synthesised the qualitative evidence to explore the perspectives of people with dementia, their family, friends, carers and healthcare professionals to pain management.

Methods

A systematic literature review was undertaken of published and unpublished literature databases (to 01 November 2021). All qualitative research studies reporting the perspectives of people with dementia, their family, friends, carers and healthcare professionals to managing pain were included. Eligible studies were appraised using the Critical Appraisal Skills Programme (CASP) qualitative appraisal tool. A meta-ethnography analysis approach was adopted, with findings assessed against the GRADE-CERQual framework.

Results

Of the 3994 citations screened, 33 studies were eligible. Seven themes were identified from the data. There was moderate evidence from six studies indicating inequity of pain management for people with dementia. There was moderate evidence from 22 studies regarding anxieties on cascading pain information. There was moderate evidence from nine studies that familiarisation of the person with pain, their preferences, routines and behaviours were key factors to better pain management. Consistently, carers and healthcare professionals had a low opinion of the management of pain for people with dementia, with tensions over the 'best' treatment options to offer. This was associated with poor training and understanding on how pain 'should' be managed.

Conclusion

The findings highlight the challenges faced by people with dementia and pain, and those who support them. Improvements in education for people who support these individuals would be valuable across health and social care pathways. Supporting family members and relatives on pain experiences and treatment options could improve awareness to improve quality of life for people with dementia and pain and those who support them.

Opioid-Free Anesthesia: The Pros and Cons

Appropriate perioperative pain control is essential to aid in patients' recovery after surgery; however, acute postsurgical pain remains poorly treated and there continues to be an overreliance on opiates. Perioperative pain control starts in the operating room, and opiate-free anesthesia (OFA), where no opiates are used intraoperatively, has been proposed as a feasible strategy to further minimize opiates in the perioperative period. In this article, we address the potential benefits and shortcomings of OFA, while exploring tools available to accomplish multimodal anesthesia and ideally OFA, and the evidence behind the techniques proposed.

Attitudes and Beliefs of College Students towards Pain Management Modalities: Theory of Planned Behavior Approach

Background

Chronic pain exhibits a burdening onset and duration in young adults. It is critical to understand appropriate pain management decision-making.

Objective

To investigate the associations of attitudes and beliefs of college students with their intention and behavior toward pain management modalities using the Theory of Planned Behavior (TPB).

Methods

In this cross-sectional online survey study, we recruited college students (age≥18 years) at West Virginia University, Morgantown, West Virginia, United States. We examined four pain management modalities: Over-the-Counter (OTC) pain medications, prescription pain medications (RX), mindfulness therapy, and yoga/exercise. Likert scales were used to assess TPB constructs (attitude, Subjective Norm [SN], Perceived Behavior Control [PBC], intention, and behavior). We analyzed the associations of the TPB constructs with both intention and behavior toward pain management modalities using multiple linear regression.

Results

Of the 364 returned surveys, 227 were completed and analyzed. Attitude was found to be significantly associated with the intention to use all pain management modalities, while PBC was significantly associated with the intentions to use RX, mindfulness, and yoga/exercise (RX: β = 0.38; 95%CI= 0.28, 0.84; p=<0.001, mindfulness: β=0.27; 95%CI=0.07, 0.76; p=0.019, and Yoga/exercise: β=0.35; 95%CI=0.25, 0.85; p=<0.001). Furthermore, the intention to use pain management modalities consistently predicted all behaviors (OTC: β=0.49; 95%CI=0.32, 0.76; p=<0.001, RX: β=0.47; 95%CI=0.17, 0.58; p=<0.001, Mindfulness: β=0.62; 95%CI=0.40, 0.72; p=<0.001, Yoga/Exercise: β=0.59; 95%CI=0.42, 0.84; p=<0.001).

Conclusion

College students' attitude and PBC were the top predictors of intention to choose pain management modalities, and intention predicted behavior. Research with robust study design is needed to confirm our study findings.

Age-related changes in peripheral nociceptor function

Pain and pain management in the elderly population is a significant social and medical problem. Pain sensation is a complex phenomenon that typically involves activation of peripheral pain-sensing neurons (nociceptors) which send signals to the spinal cord and brain that are interpreted as pain, an unpleasant sensory experience. In this work, young (4-5 months) and aged (26-27 months) Fischer 344 x Brown Norway (F344xBN) rats were examined for nociceptor sensitivity to activation by thermal (cold and heat) and mechanical stimulation following treatment with inflammatory mediators and activators of transient receptor potential (TRP) channels. Unlike other senses that decrease in sensitivity with age, sensitivity of hindpaw nociceptors to thermal and mechanical stimulation was not different between young and aged F344xBN rats. Intraplantar injection of bradykinin (BK) produced greater thermal and mechanical allodynia in aged versus young rats, whereas only mechanical allodynia was greater in aged rats following injection of prostaglandin E₂ (PGE₂). Intraplantar injection of TRP channel activators, capsaicin (TRPV1), mustard oil (TRPA1) and menthol (TRPM8) each resulted in greater mechanical allodynia in aged versus young rats and capsaicin-induced heat allodynia was also greater in aged rats. A treatment-induced allodynia that was greater in young rats was never observed. The anti-allodynic effects of intraplantar injection of kappa and delta opioid receptor agonists, salvinorin-A and D-Pen²,D-Pen⁵]enkephalin (DPDPE), respectively, were greater in aged than young rats, whereas mu opioid receptor agonists, [D-Ala2, N-MePhe4, Gly-ol]-enkephalin (DAMGO) and morphine, were not effective in aged rats. Consistent with these observations, in primary cultures of peripheral sensory neurons, inhibition of cAMP signaling in response to delta and kappa receptor agonists was greater in cultures derived from aged rats. By contrast, mu receptor agonists did not inhibit cAMP signaling in aged rats. Thus, age-related changes in nociceptors generally favor increased pain signaling in aged versus young rats, suggesting that changes in nociceptor sensitivity may play a role in the increased incidence of pain in the elderly population. These results also suggest that development of peripherally-restricted kappa or delta opioid receptor agonists may provide safer and effective pain relief for the elderly.

Nanobiosensors for detection of opioids: A review of latest advancements

Opioids are generally used as analgesics in pain treatment. Like many drugs, they have side effects when overdosing and causeaddiction problems.Illegal drug use and misuse are becoming a major concern for authorities worldwide; thus, it is critical to have precise procedures for detecting them in confiscated samples, biological fluids, and wastewaters. Routine blood and urine tests are insufficient for highly selective determinations and can cause cross-reactivities. For this purpose, nanomaterial-based biosensors are great tools to determine opioid intakes, continuously monitoring the drugs with high sensitivity and selectivity even at very low sample volumes.Nanobiosensors generally comprise a signal transducer nanostructure in which a biological recognition molecule is immobilized onto its surface. Lately, nanobiosensors have been extensively utilized for the molecular detection of opioids. The usage of novel nanomaterials in biosensing has impressed biosensing studies. Nanomaterials with a large surface area have been used to develop nanobiosensors with shorter reaction times and higher sensitivity than conventional biosensors. Colorimetric and fluorescence sensing methods are two kinds of optical sensor systems based on nanomaterials. Noble metal nanoparticles (NPs), such as silver and gold, are the most frequently applied nanomaterials in colorimetric techniques, owing to their unique optical feature of surface plasmon resonance. Despite the progress of an extensive spectrum of nanobiosensors over the last two decades, the future purpose of low-cost, high-throughput, multiplexed clinical diagnostic lab-on-a-chip instruments has yet to be fulfilled. In this review, a concise overview of opioids (such as tramadol and buprenorphine, oxycodone and fentanyl, methadone and morphine) is provided as well as information on their classification, mechanism of action, routine tests, and new opioid sensing technologies based on various NPs. In order to highlight the trend of nanostructure development in biosensor applications for opioids, recent literature examples with the nanomaterial type, target molecules, and limits of detection are discussed.

Age-Induced Changes in µ-Opioid Receptor Signaling in the Midbrain Periaqueductal Gray of Male and Female Rats

Opioids have decreased analgesic potency (but not efficacy) in aged rodents compared with adults; however, the neural mechanisms underlying this attenuated response are not yet known. The present study investigated the impact of advanced age and biological sex on opioid signaling in the ventrolateral periaqueductal gray (vlPAG) in the presence of chronic inflammatory pain. Assays measuring µ-opioid receptor (MOR) radioligand binding, GTPγS binding, receptor phosphorylation, cAMP inhibition, and regulator of G-protein signaling (RGS) protein expression were performed on vlPAG tissue from adult (2-3 months) and aged (16-18 months) male and female rats. Persistent inflammatory pain was induced by intraplantar injection of complete Freund's adjuvant (CFA). Adult males exhibited the highest MOR binding potential (BP) and highest G-protein activation (activation efficiency ratio) in comparison to aged males and females (adult and aged). No impact of advanced age or sex on MOR phosphorylation state was observed. DAMGO-induced cAMP inhibition was highest in the vlPAG of adult males compared with aged males and females (adult and aged). vlPAG levels of RGS4 and RGS9-2, critical for terminating G-protein signaling, were assessed using RNAscope. Adult rats (both males and females) exhibited lower levels of vlPAG RGS4 and RGS9-2 mRNA expression compared with aged males and females. The observed age-related reductions in vlPAG MOR BP, G-protein activation efficiency, and cAMP inhibition, along with the observed age-related increases in RGS4 and RGS9-2 vlPAG expression, provide potential mechanisms whereby the potency of opioids is decreased in the aged population.SIGNIFICANCE STATEMENT Opioids have decreased analgesic potency (but not efficacy) in aged rodents compared with adults; however, the neural mechanisms underlying this attenuated response are not yet known. In the present study, we observed age-related reductions in ventrolateral periaqueductal gray (vlPAG) µ-opioid receptor (MOR) binding potential (BP), G-protein activation efficiency, and cAMP inhibition, along with the observed age-related increases in regulator of G-protein signaling (RGS)4 and RGS9-2 vlPAG expression, providing potential mechanisms whereby the potency of opioids is decreased in the aged population. These coordinated decreases in opioid receptor signaling may explain the previously reported reduced potency of opioids to produce pain relief in females and aged rats.

Better Executive Functions Are Associated With More Efficient Cognitive Pain Modulation in Older Adults: An fMRI Study

Growing evidence suggests that aging is associated with less efficient endogenous pain modulation as demonstrated by reduced conditioned pain modulation, and that these changes may be mediated by differences in frontal functioning. Yet, little is known about potential age-related changes in cognitive pain modulation, such as distraction from pain. In a first session, 30 healthy young (19-35 years) and 30 healthy older (59-82 years) adults completed a battery of neuropsychological tests. In a second session, we acquired functional brain images while participants completed a working memory task with two levels of cognitive load (high vs. low) and concurrently received individually adjusted heat stimuli (warm vs. painful). In both age groups, completing the high load task was associated with a significant reduction in the perceived intensity and unpleasantness of painful stimuli and a reduction in activation of brain regions involved in pain processing. Group comparisons revealed that young adults showed a stronger de-activation of brain regions involved in pain processing during the high load vs. the low load task, such as the right insula, right mid cingulate cortex and left supramarginal gyrus, compared to older adults. Older adults, on the other hand, showed an increased activation in the anterior cingulate cortex during the high load vs. low load task, when compared to young adults. Covariate analyses indicated that executive functions significantly predicted neural pain modulation in older adults: Better executive functions were associated with a more pronounced de-activation of the insula, thalamus and primary somatosensory cortex and increased activation of prefrontal regions during the high vs. low load task. These findings suggest that cognitive pain modulation is altered in older age and that the preservation of executive functions may have beneficial effects on the efficacy of distraction from pain.

Population Pharmacokinetic Model for Tramadol and O-desmethyltramadol in Older Patients

BACKGROUND AND OBJECTIVES

Tramadol is commonly prescribed to manage chronic pain in older patients. However, there is a gap in the literature describing the pharmacokinetic parameters for tramadol and its active metabolite (O-desmethyltramadol [ODT]) in this population. The objective of this study was to develop and evaluate a population pharmacokinetic model for tramadol and ODT in older patients.

METHODS

Twenty-one patients who received an extended-release oral tramadol dose (25-100 mg) were recruited. Tramadol and ODT concentrations were determined using a validated liquid chromatography/tandem mass spectrometry method. A population pharmacokinetic model was developed using non-linear mixed-effects modelling. The performance of the model was assessed by visual predictive check.

RESULTS

A two-compartment, first-order absorption model with linear elimination best described the tramadol concentration data. The absorption rate constant was 2.96/h (between-subject variability [BSV] 37.8%), apparent volume of distribution for the central compartment (V₁/F) was 0.373 l (73.8%), apparent volume of distribution for the peripheral compartment (V₂/F) was 0.379 l (97.4%), inter-compartmental clearance (Q) was 0.0426 l/h (2.19%) and apparent clearance (CL/F) was 0.00604 l/h (6.61%). The apparent rate of metabolism of tramadol to ODT (k_t) was 0.0492 l/h (78.5%) and apparent clearance for ODT (CL_m) was 0.143 l/h (21.6%). Identification of Seniors at Risk score (ISAR) and creatinine clearance (CrCL) were the only covariates included in the final model, where a higher value for the ISAR increased the maximum concentration (C_max) of tramadol and reduced the BSV in Q from 4.71 to 2.19%. A higher value of CrCL reduced tramadol C_max and half-life (T_1/2) and reduced the BSV in V₂/F (from 148 to 97.4%) and in CL/F (from 78.9 to 6.61%).

CONCLUSION

Exposure to tramadol increased with increased frailty and reduced CrCL. Prescribers should consider patients frailty status and CrCL to minimise the risk of tramadol toxicity in such cohort of patients.

Safety of opioid prescribing among older cancer survivors

BACKGROUND

Cancer survivors receive more long-term opioid therapy (LTOT) than people without cancer, but the safety of LTOT prescribing is unknown.

METHODS

Opioid-naive adults aged ≥66 years who had been diagnosed in 2008-2015 with breast, lung, head and neck, or colorectal cancer were identified with data from Surveillance, Epidemiology, and End Results cancer registries linked with Medicare claims. Survivors with 1 or more LTOT episodes (≥90 consecutive days) occurring ≥1 year after their cancer diagnosis and before censoring at hospice entry, another cancer diagnosis, 6 months before death, or December 2016 were included. The safety of prescribing during the first 90 days of the first LTOT episode was measured during follow-up. As a positive safety indicator, the proportion of survivors with concurrent nonopioid pain management was measured. Indicators of less safe prescribing were the proportion of survivors with a high average daily opioid dose (≥90 morphine milligram equivalents) and the proportion of survivors with concurrent benzodiazepine dispensing. Multivariable logistic regression analyses were conducted to identify clinical predictors of each safety outcome.

RESULTS

In all, 3628 cancer survivors received LTOT during follow-up (median duration, 4.9 months; interquartile range, 3.5-8.0 months). Seventy-two percent of the survivors received multimodal pain management concurrently with LTOT. Eight percent of the survivors had high-dose opioid prescriptions; 25% of the survivors received benzodiazepines during LTOT. Multivariable analyses identified variations in safety measures by multiple clinical factors, although none were consistently significant across outcomes.

CONCLUSIONS

To improve safe LTOT prescribing for survivors, efforts should focus on increasing multimodal pain management and reducing inappropriate benzodiazepine prescribing. Different clinical predictors of each outcome suggest different drivers of safe prescribing.

Chronic Pain in the Elderly: Mechanisms and Distinctive Features

Background: Chronic pain is a major issue affecting more than 50% of the older population and up to 80% of nursing homes residents. Research on pain in the elderly focuses mainly on the development of clinical tools to assess pain in patients with dementia and cognitive impairment or on the efficacy and tolerability of medications. In this review, we searched for evidence of specific pain mechanisms or modifications in pain signals processing either at the cellular level or in the central nervous system. Methods: Narrative review. Results: Investigation on pain sensitivity led to conflicting results, with some studies indicating a modest decrease in age-related pain sensitivity, while other researchers found a reduced pain threshold for pressure stimuli. Areas of the brain involved in pain perception and analgesia are susceptible to pathological changes such as gliosis and neuronal death and the effectiveness of descending pain inhibitory mechanisms, particularly their endogenous opioid component, also appears to deteriorate with advancing age. Hyperalgesia is more common at older age and recovery from peripheral nerve injury appears to be delayed. In addition, peripheral nociceptors may contribute minimally to pain sensation at either acute or chronic time points in aged populations. Conclusions: Elderly subjects appear to be more susceptible to prolonged pain development, and medications acting on peripheral sensitization are less efficient. Pathologic changes in the central nervous system are responsible for different pain processing and response to treatment. Specific guidelines focusing on specific pathophysiological changes in the elderly are needed to ensure adequate treatment of chronic pain conditions.

Population pharmacokinetic model of subcutaneous fentanyl in older acute care patients

PURPOSE

Subcutaneous fentanyl injection is commonly prescribed to manage acute pain in older patients; however, there is a gap in the literature describing the pharmacokinetic parameters for this route of administration in this population. The aim of this study was to develop and evaluate a population pharmacokinetic model for subcutaneous fentanyl injection in older patients.

METHODS

Twenty-one patients who received subcutaneous fentanyl injections (50 to 75 μg) were recruited. Fentanyl concentrations were determined using a validated liquid chromatography/tandem mass spectrometry method. A population pharmacokinetic model was developed using non-linear mixed-effects modelling. A base model was selected based on the Akaike information criterion. Age, sex, body weight, number of previous fentanyl doses, number of prescribed medications, creatinine clearance, Charlson Comorbidity Index, Identification of Seniors at Risk score and concurrent use of CYP3A4 inhibitors were covariates considered for inclusion. A p value of < 0.05 was considered statistically significant for inclusion of covariates in the final model by stepwise addition. The simulation performance of the model was assessed by visual predictive check.

RESULTS

A one-compartment, first-order absorption with lag time and linear elimination model was the best to fit to the fentanyl concentration data. The absorption rate constant was 0.136 h^-1 (between subject variability (BSV), 46%), lag time 0.66 h (BSV 51%), apparent volume of distribution 6.28 L (BSV 30%), and apparent clearance 16.3 L.h^-1 (BSV 54%). The Charlson Comorbidity Index was the only covariate included in the final model, where a higher value of the index increased fentanyl exposure and C_max.

CONCLUSION

This is the first report of subcutaneous fentanyl population pharmacokinetic model to evaluate fentanyl pharmacokinetic in older patients. The between subject variability in clearance and subcutaneous absorption rate was relatively high, and some patients recorded high fentanyl concentrations in the context of their titration to effect.

Optimized Tibial Nerve Stimulation Partially Reduces Visceral Hypersensitivity in Rats Mediated via Autonomic and Opioid Mechanisms

OBJECTIVES

The aim of this study was to investigate the therapeutic effect and possible mechanisms of tibial nerve stimulation (TNS) on visceral hypersensitivity in rats.

MATERIALS AND METHODS

1) The effects of TNS with five sets of parameters on visceral sensitivity in normal rats were evaluated by the assessment of abdominal electromyogram (EMG) and abdominal withdrawal reflex (AWR). 2) The effects and mechanisms of TNS with a special set of parameters (14 Hz, 330 μsec, and 40% motor threshold) were evaluated in acute visceral hypersensitivity rats induced by restraint stress and colonic hypersensitized rats induced by acetic acid during the neonatal stage assessed by the EMG, AWR, and the spectral analysis of heart rate variability derived from the electrocardiogram.

RESULTS

1) In normal rats, TNS did not show any effect on the visceromotor reflex. 2) In rats with restraint stress-induced hypersensitivity, TNS with the special set of parameters reduced AWR scores and EMG responses to rectal distention at a pressure of 20-60 mmHg (p < 0.05, vs. baseline for both AWR and EMG). Concurrently, TNS increased vagal activity and decreased sympathetic activity (p < 0.03 for both). 3) Similar effects were noted on the EMG (p < 0.05, vs. baseline) and AWR (p < 0.05 vs. baseline) with acute and chronic TNS in rats with chronic colonic hypersensitivity and the effects were blocked by naloxone.

CONCLUSIONS

TNS with parameters of 14 Hz, 330 μsec, and 40% motor threshold is effective in improving visceral hypersensitivity in rodent models of colonic hypersensitivity via the modulation of autonomic and opioid mechanisms.

Advanced age attenuates the antihyperalgesic effect of morphine and decreases μ-opioid receptor expression and binding in the rat midbrain periaqueductal gray in male and female rats

The present study investigated the impact of advanced age on morphine modulation of persistent inflammatory pain in male and female rats. The impact of age, sex, and pain on μ-opioid receptor (MOR) expression and binding in the ventrolateral periaqueductal gray (vlPAG) was also examined using immunohistochemistry and receptor autoradiography. Intraplantar administration of complete Freund's adjuvant induced comparable levels of edema and hyperalgesia in adult (2-3 mos) and aged (16-18 mos) male and female rats. Morphine potency was highest in adult males, with a greater than two-fold increase in morphine EC50 observed in adult versus aged males (3.83 mg/kg vs. 10.16 mg/kg). Adult and aged female rats also exhibited significantly higher EC50 values (7.76 mg/kg and 8.74 mg/kg, respectively) than adult males. The upward shift in EC50 from adult to aged males was paralleled by a reduction in vlPAG MOR expression and binding. The observed age-related reductions in morphine potency and vlPAG MOR expression and binding have significant implications in pain management in the aged population.

Factors influencing trends in opioid prescribing for older people: a scoping review

Aim:

The review aimed to identify factors influencing opioid prescribing as regular pain-management medication for older people.

Background:

Chronic pain occurs in 45%–85% of older people, but appears to be under-recognised and under-treated. However, strong opiate prescribing is more prevalent in older people, increasing at the fastest rate in this age group.

Methods:

This review included all study types, published 1990–2017, which focused on opioid prescribing for pain management among older adults. Arksey and O’Malley’s framework was used to scope the literature. PubMed, EBSCO Host, the UK Drug Database, and Google Scholar were searched. Data extraction, carried out by two researchers, included factors explaining opioid prescribing patterns and prescribing trends.

Findings:

A total of 613 papers were identified and 53 were included in the final review consisting of 35 research papers, 10 opinion pieces and 8 grey literature sources. Factors associated with prescribing patterns were categorised according to whether they were patient-related, prescriber-driven, or system-driven. Patient factors included age, gender, race, and cognition; prescriber factors included attitudes towards opioids and judgements about ‘normal’ pain; and policy/system factors related to the changing policy landscape over the last three decades, particularly in the USA.

Conclusions:

A large number of context-dependent factors appeared to influence opioid prescribing for chronic pain management in older adults, but the findings were inconsistent. There is a gap in the literature relating to the UK healthcare system; the prescriber and the patient perspective; and within the context of multi-morbidity and treatment burden.

Should we treat pain in the elderly palliative care cancer patients differently?

Opioids are considered the cornerstone of pain management in palliative care. Available data suggest that older patients use different analgesics and lower opioid doses compared to younger patients. However, it has not been elucidated yet whether such dosing is associated with worse pain levels or shorter survival in the palliative care setting. We evaluated the relationship among pain scores, quality of life, opioid dose, and survival in palliative care cancer patients in a hospice setting. A total of 137 palliative care cancer patients were analyzed prospectively. We divided patients into two groups using the age of 65 as a cut-off value. Younger patients exhibited significantly higher pain ratings (5.14 vs. 3.59, p=0.01), although older patients used almost 20 mg less oral morphine equivalent (OME) on arrival (p=0.36) and 55 mg OME/day less during the last week (p=0.03). There were no differences in survival between the two groups (17.36 vs. 17.58 days). The elderly patients also used nonsteroidal analgesics less often and paracetamol more often. Hence, using lower opioid doses in older palliative care cancer patients does not result in worse pain rating, and could be a plausible approach for pain management in this patient group.

Sacral nerve stimulation with optimized parameters improves visceral hypersensitivity in rats mediated via the autonomic pathway

The purpose of this study was to determine effects and mechanisms of sacral nerve stimulation (SNS) on visceral hypersensitivity in rodent models of colonic hypersensitivity. SNS was performed with different sets of parameters for 30 min in six regular rats. Visceral sensitivity was assessed by the measurement of electromyogram and abdominal withdrawal reflex before and after SNS. Real/sham SNS with optimized parameters was performed in 8 restraint stress-induced visceral hypersensitivity rats and 10 neonatal acetic acid-treated colonic hypersensitivity rats; acute effect of SNS was assessed by comparing electromyogram and heart rate variability. Neonatal acetic acid-treated rats were treated by SNS (n = 10) or sham-SNS (n = 10) daily for seven days for the assessment of the chronic effect of SNS. (1) When the stimulation amplitude was reduced from 90% of motor threshold to 65% or 40% motor threshold, SNS with certain parameters showed an inhibitory effect on abdominal withdrawal reflex. The best stimulation parameters for SNS were “14 Hz, 330 µs, and 40% motor threshold.” (2) SNS significantly reduced visceral hypersensitivity and improved autonomic function in restraint stress-induced rats. The inhibitory effect was blocked by naloxone. (3)Acute and chronic SNS significantly reduced visceral hypersensitivity and improved autonomic function in acetic acid-treated rats. SNS with reduced stimulation strength may be used to treat colonic hypersensitivity and the best stimulation parameters seem to be “14 Hz, 330 µs and 40% motor threshold”. SNS with optimized parameters improved visceral hypersensitivity in rodent models of colonic hypersensitivity mediated via the autonomic and opioid mechanisms.

The Effects of Opioids on Cognition in Older Adults With Cancer and Chronic Noncancer Pain: A Systematic Review

CONTEXT

Opioids are prescribed to manage moderate-to-severe pain and can be used with older adults; however, they may lead to several adverse effects, including cognitive impairment.

OBJECTIVES

To identify, appraise, and synthesize evidence on the impact of opioids on cognition in older adults with cancer/chronic noncancer pain, and screening tools/neuropsychological assessments used to detect opioid-induced cognitive impairment.

METHODS

A systematic literature review following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (international prospective register of systematic reviews registration: CRD42018092943). MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Library, and Web of Science were searched up to December 2018. Randomized controlled trials, quasi-experimental studies, and observational studies of adults aged 65 years and older with cancer/chronic noncancer pain taking opioids were included. A narrative synthesis was conducted.

RESULTS

From 4036 records, 10 met inclusion criteria. Five studies used one screening tool, and five studies used a range of neuropsychological assessments; assessing 14 cognitive domains. Most studies demonstrated no effect of opioid use on cognitive domains, whereas four studies showed mixed effects. In particular, attention, language, orientation, psychomotor function, and verbal working/delayed episodic memory were worsened. Changes to cognitive function were predominantly observed in studies with higher mean doses of opioids (120-190.7mg oral morphine equivalent daily dose).

CONCLUSION

Both improvements and impairments to cognition were observed in studies with higher mean opioid doses. In clinical practice, a brief screening tool assessing attention, language, orientation, psychomotor function, and verbal working/delayed episodic memory may be beneficial to detect worsening cognition in older adults with chronic pain using opioids.

Intranasal Fentanyl versus Subcutaneous Fentanyl for Pain Management in Prehospital Patients with Acute Pain: A Retrospective Analysis

Objective: Retrospective analysis evaluating and comparing the feasibility, effectiveness and safety of intranasal fentanyl (INF) and subcutaneous fentanyl (SCF) for pain management of patients with acute severe pain in a rural/suburban Emergency Medical Services (EMS) system. Methods: Pre- and post-pain management data of all patients (aged ≥14 years) who were transported to the emergency department (January 2015-August 2017) were extracted from EMS and online medical control center records, and compared for groups receiving INF or SCF. Kaplan-Meier analysis and the log-rank test were used to describe and compare the percentage of patients in both groups who experienced relief according to their clinically significant pain relief score. Subgroup analysis was performed by patient age (<70 years, ≥70 years). Results: 94.6% (SCF = 94.8%; INF = 94.4%) of patients successfully received fentanyl and 82.7% (SCF = 81.2%; INF = 84.0%) had complete data and were included in the analysis. No difference was observed in time to administration or in the effectiveness of INF and SCF, and neither route of administration resulted in major adverse events that required intervention by paramedics. Upon subgroup analysis, INF patients ≥70 years were more likely to experience relief compared to those <70 years. Conclusion: This retrospective analysis of prehospital patients in the Chaudière-Appalaches EMS system demonstrates that both IN and SC are feasible, effective and safe routes for administering fentanyl. The observed effects of INF were found to be greater among patients ≥70 years. Further research is required to compare these routes with more conventional methods of pain management.

Geriatric Pharmacology: An Update

An aging worldwide population demands that anesthesiologists consider geriatrics a unique subset of patients requiring customization of practice. This article reviews the current literature investigating physiologic changes of the elderly that affect pharmacokinetics and pharmacodynamics. Changes in drug absorption, distribution, metabolism, and excretion are discussed as well as the ultimate effects of medications. Implications for practice regarding specific anesthetic and analgesic drugs are addressed. Despite the immense body of research that contributes to understanding of geriatric pharmacology, elderly patients often are excluded from rigorous research trials, and further scientific investigation to inform best practices for this group of patients is needed.

Expert consensus on the management of breakthrough cancer pain in older patients. A Delphi study

OBJECTIVES

We aimed to generate expert-based recommendations on the management of breakthrough cancer pain (BTcP) in older patients with cancer.

MATERIAL AND METHODS

A two-round multidisciplinary Delphi study. Specialists rated their agreement with a set of statements using a nine-point Likert scale (one = totally disagree and nine = totally agree). Statements were classified as appropriate (median ranged from seven to nine), irrelevant (median ranged from four to six) or inappropriate (median ranged from one to three). Consensus was established when at least two thirds of the panel scored within any of the ranges.

RESULTS

A total of 64 specialists from pain units (44.4%), palliative care units (25.4%), medical oncology (19.1%), geriatric medicine (7.9%) and others (3.2%), participated in two consultation rounds. Specialists agreed that effective coordination between the different specialties and levels of care is essential for proper management of BTcP. Most participants (81.3%) supported the assessment of frailty and resolved (96.8%) that frailty status is a better indicator of patient needs than biological age. Participants agreed (75.8%) in the application of the Davies algorithm for diagnosis of BTcP in older patients. A strong consensus was achieved regarding which pharmacological treatment (transmucosal fentanyl) and dosing method (start low and go slow) are the most suitable for the older population. No agreement was reached on how interventionist techniques should be integrated into the therapeutic strategy for BTcP.

CONCLUSIONS

The present Delphi has generated a set of recommendations that will help healthcare professionals in the management of BTcP in older patients.

Trends in Opioid Use Among Older Survivors of Colorectal, Lung, and Breast Cancers

PURPOSE

Cancer survivors may be at increased risk for opioid-related harms. Trends in opioid use over time since diagnosis are unknown.

METHODS

Using data from SEER and Medicare, we conducted multilevel logistic regression analyses to compare chronic opioid use (≥ 90 consecutive days) among opioid-naïve survivors of colorectal, lung, and breast cancers diagnosed from 2008 to 2013 and matched with noncancer controls. Among cases and controls with chronic use, we compared rates of high-dose opioid use (average ≥ 90 morphine milligram equivalents daily).

RESULTS

We included 46,789 survivors and 138,136 noncancer controls. In the first year after the index date (survivor's diagnosis date), chronic use among colorectal and lung cancer survivors exceeded chronic use among controls (colorectal cancer: odds ratio, 1.34; 95% CI, 1.22 to 1.47; lung cancer: odds ratio, 2.55; 95% CI, 2.34 to 2.77). Differences in chronic use between survivors and controls declined each year after the index date. Chronic use among breast cancer survivors was less than that of controls each year after the index date. Survivors with chronic use were more likely to have a high daily dose than controls with chronic use in the first 3 to 5 years.

CONCLUSION

Among three large populations of older cancer survivors, chronic opioid use varied by cancer. However, by 6 years after diagnosis, survivors were no longer more likely to be chronic users than controls. Strategies for appropriate pain management during and after cancer treatment should take into account the risks associated with chronic high-dose opioid use.

Loss of Sfrp2 contributes to the neurological disorders related with morphine withdrawal via Wnt/β-catenin signaling

Morphine administration is a medical problem characterized by compulsive opioid use that causes terrible negative consequences. The exact mechanisms of morphine-induced dependence and morphine withdrawal symptoms remain unclear. Recent studies have revealed that the upregulation of Wnt/β-catenin signaling plays important roles in morphine exposure and morphine withdrawal. Secreted frizzled-related protein 2 (Sfrp2) can prevent the activation of Wnt/β-catenin signaling by competing with the Frizzled receptor for Wnt ligands. We conducted this study aimed to evaluate the effect of iatrogenic trauma induced by stereotactic surgery and the protective effect of stereotaxic Sfrp2 injection on morphine withdrawal symptoms in Male Sprague Dawley (SD) rats. Many techniques including western blot analysis and immunoprecipitation were used. Anxiety-related behaviors, morphine withdrawal syndrome, and dendritic spines were also examined in male SD rats after morphine treatment and stereotaxic injection of Sfrp2. Western blot results suggested that Wnt signaling was activated in the nucleus accumbens of SD rats suffering from morphine withdrawal and that Sfrp2 attenuated the overexpression of Wnt signaling. Similarly, the withdrawal-like symptoms of morphine dependent rats were abrogated by intracerebral Sfrp2 injection. The iatrogenic trauma induced by stereotactic surgery showed no influence on the Wnt signaling and withdrawal-like symptoms. Moreover, the results of Golgi-cox staining and DiI staining indicated that the damage on proximal spine density caused by morphine treatment was restored by intracerebral Sfrp2 injection. Together, the data presented here indicated that Sfrp2 abrogated the neurological disorders and loss of proximal spine related with morphine withdrawal via Wnt/β-catenin signaling.

General practitioners' prescriptions of benzodiazepines, Z-hypnotics and opioid analgesics for elderly patients during direct and indirect contacts. A cross-sectional, observational study

OBJECTIVE

To describe Norwegian general practitioners' (GPs') prescription patterns of benzodiazepines, Z-hypnotics and opioid analgesics (BZO-drugs) to elderly (≥70 years) patients.

DESIGN, SUBJECTS AND SETTING

Cross sectional, observational study. Contact- and prescription data from 148 Norwegian GPs, issued for elderly patients during eight months in 2008. GP-patient contacts were categorized as direct contacts (DC: face-to-face consultations) or indirect contacts (IC: via third party, phone or mail). Explanatory variables were characteristics linked to the GPs, patients, and practices. During analyses, GPs' number of listed patients, share of which for elderly patients, and total number of patient consultations during the period (proxy for practice activity), were categorized in quintiles (Q1-5) by number of GPs.

MAIN OUTCOME MEASURES

Number of BZO-drug prescriptions and quantities issued during direct- and indirect GP-patient contacts.

RESULTS

In total, 62% of BZO-prescriptions were issued during ICs. Of all prescriptions, 66% were large quantum packages (50 tablets or more), 62% out of which were prescribed during ICs. During the study period, 50% of the patients received repeat prescriptions. Prescribing during ICs was associated with low over all practice activity (Q1) and many (Q5) older patients on the GP's lists.

CONCLUSION

GPs' BZO-drug prescribing to elderly occur more frequently during ICs than within DCs, and are more commonly issued as large quantity packages. This indicates that regular- or long-term use among elderly is common, contrasting with previous and current national guidelines, which recommend regular clinical assessments and short time or intermittent use of BZO-drugs. Key Points GPs frequently prescribe benzodiazepines, Z-hypnotics and opioid (BZO) drugs for elderly people. BZO-drugs are frequently issued during indirect GP-patient contacts and in relatively large quantities, indicating regular or long-term use. GPs' BZO-drug prescribing patterns contrast with national guidelines recommending clinical assessment and short time or intermittent use of BZO-drugs.