Opioid escalation in patients with cancer pain: the effect of age

Elderly people are commonly considered more susceptible to opioid effects. However, no data regarding the need for opioid escalation in patients already receiving opioids for the management of chronic pain are available. The purpose of this study was to evaluate the differences between younger and older patients during the crucial phase of opioid titration. One hundred consecutive patients with cancer pain requiring further opioid dose refinement were recruited for this cohort study. Pain intensity, dose of opioids, number of opioids used (need to switch), routes of administration used, and opioid-related symptoms were measured from admission until dose stabilization. Opioid escalation indexes (OEIs) were calculated. For the purpose of analysis, patients were divided into three age groups (<65, 65-74, 75 or over). Despite differences in opioid doses at admission (lower in older patients), no differences were found in routes, need to switch, OEI, or other parameters between younger and older patients. Similarly, adverse effects did not significantly differ between the three groups, although an overall distress score worsened in older patients during acute titration and then improved at stabilization time. These data contradict the assumption that older patients who already receive opioids are more susceptible than younger adults to opioid effects during opioid titration. Although the elderly require lower doses, opioid effects do not appear to vary with age in this population. However, the group of patients over 75 was relatively small and data should be interpreted with caution. Careful titration based on the individual response seems appropriate irrespective of age.