The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. When letters are published, they are usually accompanied in the same issue by their responses or comments. The Committee screens out discourteous, inaccurate or libellous statements. The letters are sub-edited before publication. Authors are required to declare any conflicts of interest. The Committee's decision on publication is final.

Letter to the Editor

Editor, – I read the article on principles of prescribing for persistent non-cancer pain, anticipating I might get some insight into the management of non-cancer pain in the elderly (Aust Prescr 2013;36:113-5). Unfortunately I was disappointed. I have worked in a residential aged-care facility as a GP for the past nine years and the incidence of non-cancer chronic pain is high – possibly around 60% of our residents aged over 75 years are affected.

The practice I work in prescribes paracetamol up to the maximum advised dose (4000 mg/day) as baseline therapy. Some of our residents require additional pain management. We prescribe quite a lot of opioids, mostly commencing with buprenorphine patches. In a percentage of residents this is insufficient and we mostly use sustained-release oxycontin or even fentanyl patches.

The facility provides physiotherapy, hydrotherapy and occupational therapy but psychotherapy is not readily accessed.

We prefer not to use regular high dose codeine-containing analgesics as we believe there is a problem with metabolites accumulating. Also constipation seems to be a big problem with codeine.

My impression is that dependence and addiction is not a problem in the very elderly, possibly due to some age-related change to the nervous system.

I would be pleased to have some feedback.

John Vanlint
GP
Sinnamon Park
Qld

Author's comments

Milton Cohen, the author of the article, comments:

Thank you for your letter. I appreciate your disappointment as, due to space constraints, the article was limited to principles of prescribing rather than being a more comprehensive treatise on pharmacotherapy for patients with persistent non-cancer pain.

Your use of opioids for patients in residential aged care when paracetamol and physical measures have been insufficient reflects good quality use of those medicines, especially as you avoid the short-acting prodrugs such as codeine (which about 10% of Caucasians will not convert to morphine). I would however sound a word of caution about transdermal fentanyl, as the lowest dose patch (12 microgram per hour) is approximately equivalent to oral oxycodone 20 mg per day which would be a high dose in that age group.

Addiction is not an issue in the elderly, in contrast to altered cognitive function and constipation which are the main limiting factors. Dependence, as defined by a withdrawal syndrome if the dose is reduced too quickly, can be minimised by keeping doses low and reducing slowly.

For more information on practical pharmacotherapy for managing pain, may I refer you to the following articles:

Cohen ML, Wodak AD. Opioid prescribing in general practice: a proposed approach. Med Today 2012;13:24-32.

Katz B. Pain in older people: often unrecognised and undertreated. Med Today 2012;13:35-38.