From the Guidelines
Combining a buprenorphine patch with Tylenol-codeine is not a suitable pain management regimen for an 87-year-old patient with bilateral shoulder osteoarthritis. This combination presents significant risks, particularly in elderly patients, due to overlapping opioid effects that increase the danger of respiratory depression, excessive sedation, and falls. For osteoarthritis pain in an elderly patient, a more appropriate approach would begin with non-opioid options like acetaminophen (up to 3000mg daily in divided doses) or topical NSAIDs such as diclofenac gel, as suggested by 1. If these prove insufficient, a low-dose oral NSAID with gastroprotection or a single, low-potency opioid might be considered, but not multiple opioids simultaneously, in line with the recommendations from 1. Physical therapy, activity modification, and assistive devices should form the foundation of treatment. The patient's age increases vulnerability to medication side effects, and polypharmacy with multiple opioids significantly raises the risk of adverse outcomes. A geriatric-specific approach emphasizing safety, function preservation, and minimizing medication burden would be more appropriate for managing this patient's osteoarthritis pain. Some key considerations for managing osteoarthritis pain include:
- Starting with non-opioid options like acetaminophen or topical NSAIDs
- Considering physical therapy and activity modification
- Avoiding multiple opioids simultaneously
- Minimizing medication burden and emphasizing safety
- Considering the patient's age and vulnerability to medication side effects, as highlighted in 1 and 1. Given the most recent and highest quality evidence from 1, it is clear that a non-opioid strategy is preferred for managing osteoarthritis pain, especially in elderly patients.
From the FDA Drug Label
CLINICAL PHARMACOLOGY: Mechanism of Action: Buprenorphine exerts its analgesic effect via high affinity binding to various subclasses of opiate receptors, particularly mu, in the central nervous system. The FDA drug label does not answer the question.
From the Research
Pain Management for Bilateral Shoulder Osteoarthritis
The management of pain for an 87-year-old patient with bilateral shoulder osteoarthritis can be complex and requires careful consideration of various treatment options.
- The use of buprenorphine patches and Tylenol (acetaminophen)-codeine as needed may be considered for managing chronic pain in this patient population 2.
- However, it is essential to weigh the benefits and risks of opioid therapy, such as buprenorphine, in elderly patients due to potential side effects and interactions with other medications.
- Acetaminophen is often recommended as a first-line treatment for osteoarthritis pain due to its relatively favorable safety profile 3, 2.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) may also be considered, but their use should be cautious in elderly patients due to potential gastrointestinal and renal side effects.
- Other treatment options, such as physical therapy, corticosteroid injections, and surgery, may also be considered depending on the severity of the patient's condition and their response to initial treatments 3, 4, 5, 6.
Considerations for Elderly Patients
When managing pain in elderly patients, it is crucial to consider their unique needs and potential comorbidities.
- Elderly patients may be more susceptible to side effects from medications, and their renal and hepatic function may be impaired, affecting drug metabolism and excretion.
- A multidisciplinary approach, including physiotherapy, occupational therapy, and psychology, may be beneficial in optimizing care for elderly patients with chronic pain 4.