In older adults with chronic non-cancer pain, short-term use of opioids reduces pain and physical disability but does not benefit mental health, and 25% discontinue due to adverse effects
- Correspondence to Carol Haigh
Department of Nursing, Manchester Metropolitan University, Elizabeth Gaskell Building, Hathersage Road, Manchester M13 0JA, UK;
Implications for nursing practice
■ Nurses are often hesitant to recommend opiate use for non-cancer pain.
■ People aged 65 and above are as likely to benefit from opioids as younger people.
■ In older people with no significant comorbidity, short-term use of opioids reduces pain and improves physical functioning.
■ 25% of patients stop using opioids because of adverse events, including constipation.
Implications for nursing research
■ Long-term safety, efficacy and abuse potential in older persons are yet to be determined.
■ Older age is associated with a lower likelihood of abuse and misuse of opioids.
There have been a number of previously published systematic reviews on short-term outcomes associated with opioid treatment from chronic non-cancerous pain. However, none of these reviews had focused upon older populations or had made any attempt to stratify the population by age. This review by Papaleontiou and colleagues addresses this omission, an important element for consideration as chronic non-cancer pain is very prevalent in later life.
This study is a systematic review of studies, published in English, that have investigated opioid medication as treatment for chronic non-cancer pain in older people. Studies were included if they reported efficacy, safety or abuse/misuse outcome data and evaluated one or more opioid medication, administered transdermally or orally. Studies were identified as including ‘older people’ if the mean age of the study population was 60 or above. A total of 43 articles were included in the final review. Study outcomes were abstracted independently by two investigators. A meta-analysis for pain and physical outcomes was performed.
The key finding of this study was arguably that ‘young-old’ patients (mean age 60–73), without significant comorbidities, could expect modest but favourable effects on pain and physical functioning from short-term opioid use. The review also reported that older age was associated with a lower likelihood of abuse and misuse behaviour. Three of the reported studies assessed the effect of age on adverse events suggesting that older patients (those >65) were more likely to report constipation, somnolence and vomiting. However, in the six studies reporting the effect of age, significant treatment effects in favour of opioid therapy for patients of 65 years and older were described for physical functioning, sleep and quality of life.
This is a well-constructed review on a very important topic. The methods used are generally appropriate although the limitation of the search strategy (only in English, no evidence of search grey literature) means that it is possible that other useful studies were omitted. In addition, the variety of different measurement tools used in the included studies means that the results presented, especially around quality of sleep, should be regarded with caution. Moreover, as the authors acknowledge, the prescribing patterns described in the included studies do not necessarily reflect prescribing patterns in practice. This would mean that some of the positive benefits reported may be an over estimation of the benefits of opioid therapy.
A further acknowledged limitation of the review was the overwhelming positive nature of results reported which may lead the reader to speculate about publication bias. However, the authors undertook a funnel plot with sample size plotted against effect size which eliminated this potential bias. This is a positive element of the study although this finding would have been strengthened had the relevant funnel plot been presented within the article.
Although only based upon four studies within the review, the finding that older age was negatively associated with abuse and misuse behaviour is an important message to send to clinicians. This review also goes someway to address concerns as to the appropriateness and effectiveness of opioid prescription for older peoples since the evidence presented suggests that older people without significant comorbidity are equally likely to benefit from opioid therapy as younger adults. This is clinically significant as Prowse noted the difficulties that are still faced by older people when attempting to achieve pain relief in the acute setting.1 Chodosh and colleagues highlighted similar problems for older people with chronic pain,2 and Chen and colleagues highlighted similar challenges, especially when confounding variables such as dementia are present.3
The message for nursing within this article is generally one that can be used to support the use of opioid pain management in older people by providing useful data to address professional concerns. The article also highlights which areas of concern in this issue would benefit from greater investigation.