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.