Opioids for persistent pain in older adults

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ABSTRACTOlder adults compose a large portion of patients with persistent pain. Opioid analgesics are widely used to treat acute and persistent pain in cancer and end-of-life care, but their use in other types of persistent pain in older adults is controversial. Clinicians and regulators must work together, balancing the legitimate medical need for opioids while acknowledging increasing opioid misuse and morbidity and mortality related to opioids.


  • Treatment of persistent pain in older adults presents several challenges.
  • Often, persistent pain is underrecognized and undertreated, impairing function and reducing quality of life.
  • A combination of pharmacologic and nonpharmacologic strategies is needed to address the multiple factors contributing to pain and manage it effectively.
  • The World Health Organization’s three-step ladder is valuable for treating persistent pain in older adults.
  • Although nonopioids are the first-line treatments for persistent pain, opioids are also important to provide safe and effective pain management in older adults.



The use of opioid analgesics is widely accepted for treating severe acute pain, cancer pain, and pain at the end of life.1 However, their long-term use for other types of persistent pain (Table 1) remains controversial. Clinicians and regulators need to work together to achieve a balanced approach to the use of opioids, recognizing the legitimate medical need for these medications for persistent pain while acknowledging their increasing misuse and the morbidity and mortality related to them. Finding this balance is particularly challenging in older patients.2


Persistent pain is a multifaceted manifestation of an unpleasant sensation that continues for a prolonged time and may or may not be related to a distinct disease process.3 (The term “persistent pain” is preferred as it does not have the negative connotations of “chronic pain.”4) “Older” has been defined as age 65 and older. As our population ages, especially to age 85 and older, more people will be living with persistent pain due to a variety of conditions.5

Persistent pain is more complicated in older than in younger patients. Many older people have more than one illness, making them more susceptible to adverse drug interactions such as altered pharmacokinetics and pharmacodynamics.6 Up to 40% of older outpatients report pain,7 and pain affects 70% to 80% of patients with advanced malignant disease.8 Pain is also prevalent in nonmalignant, progressive, life-limiting illnesses that are common in the geriatric population, affecting 41% to 77% of patients with advanced heart disease, 34% to 77% with advanced chronic obstructive pulmonary disease, and 47% to 50% with advanced renal disease.9

Pain is underrecognized in nursing home residents, who may have multiple somatic complaints and multiple causes of pain.10,11 From 27% to 83% of older adults in an institutionalized setting are affected by pain.12 Caregiver stress and attitudes towards pain may influence patients’ experiences with pain. This aspect should also be assessed and evaluated, if present.3

Pain in older adults is often undertreated, as evidenced by the findings of a study in which only one-third of older patients with persistent pain were receiving treatment that was consistent with current guidelines.13 Approximately 40% to 80% of older adults in the community with pain do not receive any treatment for it.14,15 Of those residing in institutions, 16% to 27% of older adults in pain do not receive any treatment for it.16,17 Inadequate treatment of persistent pain is associated with many adverse outcomes, including functional decline, falls, mood changes, decreased socialization, sleep and appetite difficulties, and increased healthcare utilization.18


Persistent pain is multifactorial and so requires an approach that addresses a variety of causes and includes both nonpharmacologic and pharmacologic strategies. Opioids are part of a multipronged approach to pain management.

To avoid adverse effects, opioids for persistent pain in an older adult should be prescribed at the lowest possible dose that provides adequate analgesia. Due to age-related changes, finding the best treatments may be a challenge, and understanding the pharmacokinetic implications in this population is key (Table 2).

Complete pain relief is uncommon and is not the goal when using opioids in older patients. Rather, treatment goals should focus on quality of life and function. Patients need to be continually educated about these goals and regularly reassessed during treatment.


Initial steps in managing pain should always include a detailed pain assessment, ideally by an interdisciplinary team.19,20 Physical therapy, cognitive behavioral therapy, and patient and caregiver education are some effective nonpharmacologic strategies.3 If nonpharmacologic treatments are ineffective, pharmacologic strategies should be used. Often, both nonpharmacologic and pharmacologic treatments work well for persistent pain.

The World Health Organization’s three-step ladder approach, originally developed for cancer pain, has subsequently been adopted for all types of pain.

  • Step 1 of the ladder is nonopioid analgesics, with or without adjuvant agents.
  • Step 2 if the pain persists or increases, is a weak opioid (eg, codeine, tramadol), with or without a nonopioid analgesic and with or without an adjuvant agent.
  • Step 3 is a strong opioid (eg, morphine, oxycodone, hydromorphone, fentanyl, or methadone), with or without nonopioid and adjuvant agents.

The European Association for Palliative Care recommendations state that there is no significant difference between morphine, oxycodone, and hydromorphone when given orally.21 Although this ladder has been modernized somewhat,22 it still provides a conceptual and practical guide.


Acetaminophen is first-line

Acetaminophen is the first-line drug for persistent pain, as it is effective and safe. It does not have the same gastrointestinal and renal side effects that nonsteroidal anti-inflammatory drugs (NSAIDs) do. It also has fewer drug interactions, and its clearance does not decline with age.23

However, older adults should not take more than 3 g of acetaminophen in 24 hours.24 It should be used with extreme caution, if at all, in patients who have hepatic insufficiency or chronic alcohol abuse or dependence.

Topical therapies

Topical NSAIDs allow local analgesia with less risk of systemic side effects than with oral NSAIDs, which have a limited role in the older population.

Capsaicin, which depletes substance P, has primarily been studied for neuropathic pain.

Lidocaine 5% topical patch has been found effective for postherpetic neuralgia; however, there is limited evidence for using it in other painful conditions, such as osteoarthritis and back pain.25


Duloxetine is a serotonin and norepinephrine reuptake inhibitor. Studies have found it effective in treating diabetic peripheral neuropathy, fibromyalgia, chronic low back pain, and osteoarthritis knee pain. However, except for the knee study, most of the patients enrolled were younger.

Antiepileptic medications. Gabapentin and pregabalin have been found to be effective in painful neuropathic conditions that commonly occur in older adults.25

Avoid oral NSAIDs

NSAIDs, both nonselective and cyclooxygenase 2-selective, should only rarely be considered for long-term use in older adults in view of increased risk of conditions such as congestive heart failure, acute kidney injury, and gastrointestinal bleeding.25 These adverse effects seem to be related to inhibition of prostaglandin, which plays a physiologic role in the gastrointestinal, renal, and cardiovascular systems.26 Oral NSAIDs should be used with extreme caution.

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