The Pendulum Has Swung Too Far

Treating Pain in Primary Care

Linda Brookes, MSc


February 22, 2019

In This Article

What Concerns in Older Patients Are Legitimate?

"Not many older people become addicted to opioids, and they are not the ones who are ending up on heroin down the road as a result," Fox asserts. Although opioid abuse is growing among older adults, according to a recent review,[29] marijuana is currently the most frequently used illicit substance in this age group; alcohol-use disorder remains the most prevalent substance-use disorder. However, hospitalizations of seniors for opioid-related issues have been increasing at a higher rate than hospitalizations for other causes, with a 54% rise between 2010 and 2015. A similar trend was seen in opioid-related emergency department visits. The prescription opioid-involved death rate has also been growing among seniors aged ≥ 65 years, rising by 10.5% between 2016 and 2017.[16]

From our results, it appears that you've got to treat about eight people to get one who experiences important pain relief. It would be wonderful if we had a way to pick that person out in advance.

Rates of intentional misuse of opioids (suicidal intent)[30] and unintentional misuse are also growing problems in the elderly.[31] Reid recalls a patient on oral opioids who wanted to try a fentanyl patch. "I did all the education about how to use it, and made the switch only after having explained how it would take 8-10 hours before she would feel the full effect of the medication and how you only put one patch on for 72 hours," he related. Next day, I got a call from the emergency department; she had appeared with three patches on and almost died." In older patients, it is preferable to prescribe this type of medication only when there is support, such as a spouse, an adult child, or a home caregiver, at home, Reid advised.

Which Patients Are Candidates for Opioids?

Evidence for the benefits of opioids in chronic pain is limited, and well-informed opinions vary. Recent reviews and meta-analyses all point to the lack of critical evidence and reach varying conclusions.[32,33,34,35,36,37,38,39]

Hsu suggests that there are "many patients with chronic pain who do benefit from daily use." Fox contends that opioids are not very beneficial for muscular pain but are helpful for skeletal or nerve pain. Busse, who was lead author of the most recently published meta-analysis, says that opioids are unlikely to be effective for most chronic pain patients, but that a subset does appear to benefit. "Because of the modest benefits, the risk for side effects, and the equivalence to alternatives with lower rates of harm, it does not make sense to look at opioids as first-line therapy for chronic pain," he says. "But for individuals in whom alternatives have failed, who have been given information on the risks and benefits, and who make an informed decision that they would like to try a course of opioids, I think that there is evidence to support that decision." However, it is not yet possible to predict which patients will benefit, he admits. "From our results, it appears that you've got to treat about eight people to get one who experiences important pain relief. It would be wonderful if we had a way to pick that person out in advance."

The Alternatives

Nonprescription options. "The real problem is that we do not have highly effective alternatives to narcotics," Hsu stresses. "NSAIDs have many side effects. Acetaminophen is ineffective for most. Topical lidocaine and diclofenac gel only help some areas. Long-acting duloxetine can help in only a small percentage of chronic pain patients."

Medical marijuana. Medical marijuana has generated interest as a possible agent to treat chronic pain in older individuals, although available data about its clinical effects are inconsistent.[40] It is also associated with a greater risk for adverse cognitive, cardiovascular, and gait and stability effects in older adults.[41]

Some US state regulators view medical cannabis as a rational substitute for prescription opioids.[42] A recent study reported that states with approved medical marijuana laws saw a 14% reduction in opioid prescribing among the Medicare Part D population compared with states with no such laws.[43] Over 30 states have now legalized medical marijuana, although its use remains illegal under federal law. And its approval without evidence of efficacy from randomized controlled trials has been criticized.[44,45,46]

"More studies with different designs from the ecological and correlation studies that have been the norm to date are needed to assess whether marijuana use can lessen opioid use," Reid asserts. He also points out that cost could be a barrier to its wider legal use. "Medical marijuana is actually quite expensive," he noted. "So for a senior who is on a fixed income, with medical marijuana costing about $150 per month, it's a no-brainer that they are going purchase medications on the street for $30-$40."

Nonpharmacologic interventions. Nonpharmacologic, noninvasive interventions, such as physical therapy and exercise, acupuncture, CBT, and mindfulness meditation, have all been studied. The conclusion of a 2018 comprehensive comparative effectiveness review was that they produce only slight to moderate improvements in function and pain for specific chronic pain conditions. For most patients, availability and coverage are problems.[47] "A multimodal approach is great for patients who are well resourced and have good information and decent health literacy. But it doesn't work so well for the others," Vega lamented.

Devices. According to the FDA, medical devices, including digital health technologies, are going to play a major role in confronting the opioid epidemic. The FDA's Innovation Challenge, launched in May 2018, aims to fast-track the development of medical devices. These could include products for opioid-sparing or -replacement therapies for chronic pain and devices to monitor the use and prevent diversion of prescription opioids.


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