From the Guidelines
For chronic pain management in the elderly, oral opiates are generally preferred over transdermal fentanyl patches due to the higher risk of overdose associated with extended-release/long-acting (ER/LA) opioids, as stated in the CDC guideline for prescribing opioids for chronic pain - United States, 2016 1. When managing chronic pain in the elderly, it is crucial to consider the potential risks and benefits of different opioid formulations. The CDC guideline recommends prescribing immediate-release opioids instead of ER/LA opioids, such as transdermal fentanyl, when starting opioid therapy for chronic pain 1. This recommendation is based on a fair-quality study showing a higher risk for overdose among patients initiating treatment with ER/LA opioids than among those initiating treatment with immediate-release opioids.
Some key points to consider when choosing between oral opiates and transdermal fentanyl patches for chronic pain management in the elderly include:
- Oral opiates, such as oxycodone or hydrocodone combinations, may be better for patients with variable pain patterns, those who need dose flexibility, or patients with cognitive impairment who might forget about wearing a patch.
- Transdermal fentanyl patches are only appropriate for opioid-tolerant patients and should be initiated at low doses with careful titration.
- When using either approach in the elderly, start with reduced doses (25-50% of standard adult doses), monitor closely for side effects like respiratory depression, confusion, and falls, and implement a bowel regimen to prevent constipation.
- Regular reassessment of pain control, function, and side effects is essential, with the goal of using the lowest effective dose for the shortest necessary duration.
It is also worth noting that the ESMO clinical practice guidelines for the management of cancer pain in adult patients recommend oral morphine as the opioid of first choice for moderate to severe cancer pain, with oxycodone or hydromorphone as effective alternatives 1. However, the guidelines also suggest that transdermal fentanyl can be useful in patients with stable opioid requirements, nausea, vomiting, problems with swallowing, constipation, and poor compliance. Ultimately, the choice of opioid should be individualized based on the patient's specific needs and medical history.
From the FDA Drug Label
Initial doses should be reduced in elderly or debilitated patients Fentanyl transdermal system should be used with caution in elderly, cachectic or debilitated patients as they may have altered pharmacokinetics due to poor fat stores, muscle wasting, or altered clearance Data from intravenous studies with fentanyl suggest that the elderly patients may have reduced clearance and a prolonged half-life Moreover elderly patients may be more sensitive to the active substance than younger patients.
The recommended approach for chronic pain management in the elderly is to use the lowest effective dose and monitor patients closely.
- Fentanyl transdermal system should be used with caution in elderly patients due to potential altered pharmacokinetics and increased sensitivity to the active substance.
- Initial doses should be reduced in elderly or debilitated patients.
- Oral opioids may be considered as an alternative for chronic pain management in the elderly, but the choice between fentanyl transdermal system and oral opioids should be based on individual patient needs and medical status 2.
From the Research
Comparison of Fentanyl Patch and Oral Opiates for Chronic Pain Management in the Elderly
- The use of opioids in chronic pain management for the elderly is a complex issue, with various factors to consider, including overall efficacy, side-effect profile, onset of action, drug interactions, abuse potential, and practical issues such as cost and availability 3.
- Fentanyl patches are a transdermal formulation of opioids, which can be effective in managing chronic pain in the elderly, with low toxicity and good tolerability profiles, especially at low doses 3.
- Oral opiates are also commonly used for chronic pain management in the elderly, but may have a higher risk of adverse events, such as respiratory depression, compared to transdermal formulations like fentanyl patches 3.
- The choice between fentanyl patches and oral opiates for chronic pain management in the elderly should be based on individual patient needs and considerations, including safety, tolerability, and efficacy 3, 4, 5.
- A multimodal treatment approach, including pharmacologic and nonpharmacologic strategies, is recommended for managing chronic pain in older adults 4, 5.
- Age-related physiologic changes, comorbidities, and polypharmacy should be taken into account when selecting a treatment plan for chronic pain management in the elderly 4, 6, 5.
- Slow dose titration and careful monitoring can help reduce the risk of adverse events and improve treatment outcomes for elderly patients using opioids for chronic pain management 3, 5.