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Management of Drug-Drug Interactions: Considerations for Special Populations—Focus on Opioid Use in the Elderly and Long Term Care
Tom Lynch, PharmD, BCPS
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Participation Faculty: Improving Outcomes With Opioid Use: Focus on Drug-Drug Interactions

Management of Drug-Drug Interactions: Considerations for Special Populations—Focus on Opioid Use in the Elderly and Long Term Care

Tom Lynch, PharmD, BCPS
Identify all medications, with a focus on medications that alter CYP450 activity. Before initiating opioid treatment, the pain management team must know all the prescriptions the elderly patient or long term care resident is taking. A thorough assessment of all medications should be conducted and effort should be made to reduce the number of medications if possible. Specifically, the team should ascertain whether any CYP450-interacting medications are required by the patient. If a CYP450-dependent DDI is anticipated, then they should consider an opioid that is not metabolized by the CYP450 system (morphine, hydromorphone, or oxymorphone). An alternative for the nonanalgesic drug may also be selected. However, it may not be ideal to change long-term, regular medications that require maintenance at particular therapeutic levels for a given patient. Individualization of patient care is key.

Consider route of administration. Each route of administration has its own considerations. The pharmacokinetics, costs, and patient’s preference need to be discussed prior to administration. Elderly patients susceptible to nausea and vomiting, such as those undergoing oncologic treatment, may not be able to take oral medications and thus may require an alternate route of administration; this may impact the choice of opioid. The route of administration of an opioid can also affect drug interactions. A drug that does not undergo first-pass metabolism through the liver (ie, is not taken orally) may have less potential for CYP450 interaction. Thus, routes including intravenous, rectal, and buccal administration may have less potential for interaction and resulting adverse effects than oral administration.

Avoid errors. Prescribing an opioid with a potentially interacting drug may be due to a medical error, which may occur for the same reason as many other medical errors: incomplete communication. Patient transitions from acute to long-term care or hospital to outpatient care are fraught with risk of incomplete communication among providers. Future use of universal electronic medical record (EMR) systems may decrease errors of incomplete communication. These systems, which contain a patient’s complete prescription list and medical and drug history, can provide prompts that alert clinicians to interaction potentials when they enter a new prescription.36 Currently, however, few elderly and long-term care patients can be expected to have their entire history in an EMR. In the absence of a lifelong medical record, prescribers should obtain the input of a patient advocate (family caregiver, nurse care coordinator, etc) with knowledge of all of the patient’s current prescriptions as well as the patient’s complete medical and drug history.

Follow-up. Finally, patients should be closely monitored after initiating any new drug in the medical regimen. In all situations with opioids, the care team should monitor the patient closely to assess the effects of the pain medication, the ongoing effects of previous medications, and any changes in effects that may reflect interactions. Regardless of whether interactions are anticipated, close monitoring is essential with the powerful opioid drug class and these particularly vulnerable populations. With many opioid preparations available, prescribers need not settle for inadequate pain relief or severe adverse effects; however, they should expect dosage adjustments and possible changes of agent or route of administration.

Conclusion

Prescribing an opioid to an elderly patient or a long term care resident with multiple medical conditions and multiple medications can be complicated. Also, other factors, such as communication problems, poor adherence, inappropriate prescription, and poor continuity of care, may impact opioid therapy. Treatment guidelines for pain management often focus on the central and gastrointestinal adverse effects of opioid therapy. Clinicians should also take into account the potential for CYP450 interactions when initiating opioid therapy. Knowledge of the patient’s medical history and current prescriptions can help guide the pain management team in the selection of treatment, to help minimize the risk of DDIs and provide these patients with the pain relief they require.

Author Affiliation: Department of Family and Community Medicine, Eastern Virginia Medical School, Norfolk, VA.
Funding Source: This supplement has been supported by funding from Endo Pharmaceuticals.
Author Disclosure: Dr Lynch reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this supplement.
Authorship Information: Concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content.
Address correspondence to: Tom Lynch, PharmD, BCPS, Associate Professor, Eastern Virginia Medical School, 651 Colley Ave, Room 323, Norfolk, VA 23507. E-mail: lyncht@evms.edu.

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