A Systematic Review of the Evidence for the Efficacy of Opioids for Chronic Non-cancer Pain in Community-dwelling Older Adults

Michael David Cory O'Brien; Anne Pamela Frances Wand

Disclosures

Age Ageing. 2020;49(2):175-183. 

In This Article

Abstract and Introduction

Abstract

Introduction: the ageing global population and concomitant increase in the use of opioid analgesia have highlighted the need to evaluate the effectiveness of opioids for chronic pain in older people.

Methods: a systematic review of the evidence for the efficacy of opioids for chronic non-cancer pain in community-dwelling people aged 65 years or more was conducted using PRISMA guidelines. The databases MEDLINE, EMBASE, Pubmed and PsychINFO were searched. The quality of studies was assessed. Secondary aims were to assess correlates of opioid use and the decision-making processes of prescribers.

Results: seven studies were identified of low to high quality. The majority of older people experienced ongoing pain despite continuing opioid therapy. There were mixed results regarding benefits of opioids in terms of activities of daily living and social engagement. In nursing home residents, opioid use at baseline was associated with severe pain, severe impairment in activities of daily living and a diagnosis of depression. Fear of causing harm to older people was common amongst opioid prescribers, limiting prescription. Facilitators of opioid prescription included educational interventions and access to an evidence base for opioid use.

Conclusion: there is limited evidence supporting the use of long-term opioid use in older people for chronic non-cancer pain and a lack of trials in this age group. Age-specific guidelines are required addressing initial assessment, indications, monitoring and de-prescribing.

Introduction

Chronic pain is common in older people occurring in 45–85%.[1] With an ageing population, the management of chronic pain represents a major public health challenge. There is considerable associated morbidity, as inadequate treatment may result in reduced quality of life, social withdrawal, depression, sleep disturbance, cognitive impairment, disability and malnutrition.[1]

Opioid therapy is widely used to treat long-term cancer pain,[2] although the evidence for effectiveness for improving chronic pain and function is insufficient.[3] Despite this, the prescription of opioids for chronic pain has dramatically risen. In the USA, the number of opioid prescriptions supplied to older patients between 1996 and 2010 increased nine times.[4]

The adverse effects of opioid therapy are well known, including falls and fractures, cognitive impairment and gastrointestinal problems.[5] Additionally, there has been an increase in the prevalence of opioid overdose, abuse, addiction and diversion.[3] Other considerations in older people include the significant changes in the pharmacokinetics and pharmacodynamics, greater likelihood of polypharmacy—increasing the likelihood of drug interactions, and medical comorbidities contributing to drug–disease interactions.[6] These potential harms combined with the scale of use of opioids suggest the need for more targeted and evidence-based treatment of chronic pain in older people, yet specific guidelines are lacking.[7]

The purpose of this review was to investigate the evidence for the efficacy of opioids for chronic non-cancer pain in community-dwelling adults aged 65 years or more. Secondary aims were to evaluate correlates of opioid use and decision-making processes for opioid use by prescribers.

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