Introduction
Given the widespread use and unfortunate misuse of opioids in the United States, the appropriate management of chronic non-cancer pain (CNCP) has been extensively debated in recent years. It is estimated that nearly 50% of older adults have CNCP, and approximately 5% to 10% of them chronically use opioids to manage pain.1 Older adults tend to have more persistent or severe pain and are more susceptible to the side effects and drug interactions associated with opioids than younger adults with similar CNCP.2 Therefore, it is imperative that the benefits are optimized and the risks are minimized when it comes to opioid use for CNCP in older adults.
The use of pharmacogenomics (PGx) testing is effective in optimizing the benefits of certain drugs, such as antidepressants, clopidogrel, and warfarin.3 PGx testing minimizes the risks associated with the opioid codeine, and could be used to balance the benefit-risk profile of not only codeine, but all opioids that are metabolized by CYP2D6. 3 This article describes a simulated patient case modeled after numerous encounters in our practice involving the clinical application of PGx for CNCP opioid optimization. We also provide examples of PGx-based recommendations to optimize treatment. This case serves as instructional guidance for clinicians only; medical decision-making will vary based on each individual patient case. Additionally, this case provides context about the clinical utility of PGx to guide opioid analgesic drug selection and demonstrates the impact of genetic variations and concomitant medications on drug interactions and phenoconversion.