The management of chronic pain in older adults is one of the most difficult to manage geriatric syndromes, as per my extensive experience working in the homes of older adults for almost 13 years. We can easily manage diabetes, reduce stroke risk by managing hypertension, improve function and quality of life by improving sleep and better manage urinary incontinence, and reducing the noxious effects of medications that cause older adults to seek medical attention. However, complaints of pain are still the most persistently mentioned issue when my residents complain about factors that affect their life. So, in applying the best evidence to help older adults manage their pain, we begin with assessment, then the implementation of non-drug interventions, and then the addition of pharmacologic therapies in a step-wise manner, always “starting low and going slow”. This is exemplified with the use of acetaminophen for mild pain, not to exceed 3 or 4gm per day, or 2gm if on warfarin. We can also use adjunctive treatments such as topical counterirritants or lidocaine patches, or even capsaicin, all with some benefit yet not complete relief. And then there are the NSAIDs, drugs which are replete in the literature to cause harm, in fact in numerous well-designed studies, are shown to be one of the leading causes of ER visits, hospitalizations and death in older adults, so we try to avoid their use, especially chronic use. So, as per the American Geriatrics Society Guidelines on managing pain, we may initiate a low-dose of an opiate if pain is still limiting and affecting quality of life, this would most likely be for moderate to severe pain. And based on my observation, most older adults respond well to a low-dose opiate, followed by slow titration, without significant harms. In fact, I can cite experiences with older adults, some just over 100 years old, who have been on opiates for several years, and do well in their continued journey, unmapped by most Americans.
But now we have guidance from AHRQ in their most recent analysis which states that there is no good evidence of beneficial effects of opiates in managing pain in older adults and that they may cause more harm than NSAIDs. I’m shocked! I searched the AHRQ document for references that included “elderly” or “older adults” in their title, and found five, yes, only five studies, of the 39 included in their analysis. Two of those studies were limited by the fact they used pharmacy claims databases; two others that studied the “initiation of opiates and associated risk of harms” and not long-term use; and one that showed harms yet did not speak to dose-related harms. Yet many speak to this “problem” of overuse and misuse of opiates in the older adult population. If you listen to this meme, you’ll likely believe it to be true.
A meme is a statement making a false claim, but as a result of being frequently repeated, many believe it to be true. Remember “WMDs”?
In one study the authors state that the incidence of GI bleeding from opiates is equal to that of NSAIDs. Hmm, well that’s interesting, because in no other studies can I find any evidence that opiates cause GI bleeding. None. This is the study that looked at low-income, Medicaid, beneficiaries’ prescription claims. Perhaps they did not include the use of OTC NSAIDs, which in my population may include up to 23% of older adults using opiates. Also, it does not take into account that a significant number of older adults may not even use the opiates but end up selling them and then using NSAIDs, as evidenced by numerous case reports throughout America of opiate diversion. So when is an opiate not an opiate? Answer: When it’s an NSAID.
Moving on to fracture risk: Yes, opiates are associated with an increase in fracture risk, but more so upon initiation of use or when the dose is too high. And what about the clinician that does not recognize opiate-induced hyperalgesia and continues dose escalation with subsequent worsening pain, of which there was no mention in any of these studies that that phenomenon was considered, most likely due to the lacking sensitivity of study design.
Lastly, I must emphasize that two of the five studies included in the AHRQ analysis of long-term treatment of pain concluded that harms from opiates were studied upon “initiation” of opiates, with one study showing harm greatest at 30-days, which is hardly long-term or chronic use.
General studies that may lack appropriate design, and do not take into account the person and associated risks versus benefits, may do nothing more than lead to ineffective treatment of pain in older adults and rendering their later years miserable and not living to their fullest potential.
Managing pain in the older adult needs to be in partnership, following a thoughtful approach knowing that older adults are at greater risk for harm from medications, and following the AGS guidelines since all of the necessary approaches are best summarized in their final guidelines. They were not “silent” on the potential for harm from opiates when they published these guidelines and these should remain the primary guidance in order to improve the quality of life of older adults suffering from life-altering chronic pain.