David J. Horn, MD, University of Arizona
TIPS ABOUT OPIOID THERAPY IN OLDER ADULTS
Pain is a complex form of suffering that arises from the interplay of tissue injury, pre-existing disease processes, mental health problems, functional impairment, and social isolation. More than half of older adults experience pain, and the majority of these individuals report pain in multiple sites. Musculoskeletal pain is most common, especially in the back, knees and shoulders. Persistent pain in older adults can lead to financial costs and increasing disability. Yet only about one third of older patients with persistent pain are receiving sufficient analgesia.
Opioids are potent analgesics. They were traditionally used in a limited fashion for temporary treatment of acute pain, especially after surgery. In the 1990s and early 2000s, many adults were started on chronic opioids for treatment of persistent pain. Opioids were started under the assumption that they were not addictive if used for "legitimate" pain. White patients tend to receive higher opioid doses than non-whites, perhaps due to clinician biases about non-white individuals.
We now know, however, that opioid analgesics have significant habit-forming potential, and Medicare data has shown increased opioid use in older adults. This increased use confers a higher risk for serious complications, including increased rates of falls, fractures, and hospitalizations, along with increased overall healthcare utilization.
Nonetheless, if non-opioid pharmacotherapy has not treated pain adequately, and non-pharmacologic interventions (e.g., physical therapy) have not been successful, escalating therapy to opioids may be a reasonable next step. Initiation of opioids requires an individualized discussion of risks and benefits with your patient. Electing to start opioid treatment may decrease pain; however, opioids also cause sedation, cognitive impairment, constipation, and dependence. It is also important to recognize that polypharmacy, sarcopenia, and decreased hepatic and renal function can all contribute to altered opioid metabolism in older adults, thereby enhancing opioid side effects and increasing risk.
It is important to use accurate language when discussing pain and pain medications with your patients. Definitions for health professionals are presented below, but must be presented to patients in easy-to-understand terms.
Categories of Pain Types
- Nociceptive Pain arises from tissue damage or injury that is detected by nociceptors in the body.
- Neuropathic Pain is caused by primary injury to or dysfunction of somatosensory nerves.
- Inflammatory Pain is due to activation and sensitization of nociceptive pain pathways, caused by the local release of inflammatory mediators.
- Mixed Pain is pain resulting from a combination of nociceptive, neuropathic and/or inflammatory processes.
- Total Pain is from a combination of the aforementioned biological factors, plus psychological and social factors.
- Malignant (Cancer) Pain can be nociceptive, neuropathic and/or inflammatory. It is caused by cancer lesions and/or procedures used to diagnose or treat cancer.
Categories of Pain Duration
- Acute pain arises suddenly from a specific cause, typically related to localized injury to a discrete tissue.
- Persistent pain lasts longer than expected after an inciting illness or injury, but it likely will resolve at some point. See the Elder Care sheet on Management of Persistent Pain for more information.
- Chronic pain, on the other hand, is typically long-lasting and not expected to resolve. It may not have an identifiable cause.
- Opioids are a class of drugs and medications related in physiologic effect to opium, a chemical found naturally in the opium poppy plant.
- Narcotic is a term defined by United States law that includes both opioids and cocaine, though in common usage narcotics refers to opioids.
Structured Approach When Considering Opioid Therapy:
When considering opioid therapy, a structured approach is recommended (Table 1) to minimize risk of opioid use disorder, optimize safe prescribing, and assure that patient/family goals of care are met. Opioids are best used in the setting of clear expectations and limits.
Table 1. Structured Approach to Initiating Opioid Therapy
1. Conduct a comprehensive pain history, including:
2. Assess risk for opioid use disorder
3. Check the prescription monitoring program (PMP)
4. Determine definite goals of care
5. Address risks, specifically:
6. Agree on monitoring plan as needed
7. Discuss what circumstances would lead you to discontinue opioid therapy
Non-Opioid Pain Management
It is important to consider the interventions in Table 2, both before and during opioid therapy.
Table 2. Non-Opioid Interventions for Treating Pain
References and Resources
- American Pain Society. Pain: Current Understanding of Assessment, Management, and Treatments.
- Daoust R, Paquest J, Moore L, et al Recent opioid use and fall-related injury among older patients with trauma. CMAJ. 2018 Apr 23;190:E500-E506.
- Makris U E, Abrams RC, Gurland B, Reid MC. Management of persistent pain in the older patient: a clinical review. JAMA. 2014; 312: 825-836.
- Patel KV, Guralnik JM, Dansie EJ, Turk DC. Prevalence and Impact of pain among older adults in the United States: Findings from the 2011 National Health and Aging Trends Study. Pain. 2013; 154:2649-57.
- Stewart C, Leveille SG, Shmerling RH, et al. Management of persistent pain in older adults: the MOBILIZE Boston Study. J Am Geriatr Soc 2012; 60:2081-2086.
- U.S. Department of Justice, Drug Enforcement Administration, Diversion Control Division. Part 1300, §1300.01 Definitions relating to controlled substances.