Journal of Gerontological Nursing

Guest Editorial Free

The Opioid Epidemic and Persistent Pain Management in Older Adults

Keela Herr, PhD, RN, AGSF, FAAN; Paul Arnstein, RN, PhD, FAAN

Despite remarkable advances in health care that have extended life expectancy, most older adults live with persistent pain that is often undertreated. Severe persistent pain impairs physical, mental, and social functioning, robbing individuals of their vitality, independence, and quality of life. Effective management of pain is challenging for older adults due to age-related vulnerabilities, comorbidities, and socioeconomic resources that limit pain relief options.

Media, medical, and political attention to problems of pain have taken a back seat to an intense focus on the “opioid epidemic.” The spotlight on overprescribing, substance use disorders, and overdose deaths has rallied bipartisan support to rapidly develop regulations, guidelines, and resources to cut addiction and overdose death rates. President Obama has substantially increased funding at a level of $500 million in 2016 (Bloomberg, 2016) and a request to more than double that spending in 2017 (The White House, 2016). Although the comprehensive drug control program from the White House distinguishes problematic prescribing patterns, drug abuse, and illicit opioid agents, the media reports and many recently enacted state regulations do not distinguish legitimate from non-medical use of opioid drugs.

In their haste to halt overpre-scribing and illicit use, regulators, payers, and the media have not attended to protecting vulnerable populations, such as older adults, from the physical, mental, social, and financial consequences of undertreated pain. Nurses and other health care providers are challenged to provide safe, accessible, and cost-effective pain care to these older adults without contributing to the opioid epidemic. This is a daunting challenge given a limited strength of evidence regarding the safety, efficacy, and acceptability to older adults of pain-relieving interventions. We were motivated to develop this special issue to frame the issues and provide guidance to clinicians caring for older adults. Four important articles bring together experts in the field to provide current data and evidence, as well as recommendations for clinical application.

The first article by Chang and Compton (2016), “Opioid Misuse/ Abuse and Quality Persistent Pain Management in Older Adults,” provides an overview of the issues related to the public health crisis of opioid abuse/misuse, which too often leads to overdose deaths. Chang and Compton (2016) describe factors contributing to the opioid epidemic, the abusers, and what is known about the role of older adults in the epidemic. Lacking a system for safe use, a forgetful older adult may miss some or double-up on other doses, which is a concerning pattern. Also concerning is the growing prevalence of substance use disorders and overdoses among Baby Boomers, who are now transitioning from middle-age to older adulthood with risky drug-use behaviors.

In the second article by St. Marie and Arnstein (2016), “Quality Pain Care for Older Adults in an Era of Suspicion and Scrutiny,” the authors frame the impact of the response to the opioid epidemic on provider practices in managing pain while emphasizing the balance needed in addressing the harms of opioid drugs with safe and effective pain management. The role and duty of nurses to alleviate pain and suffering while protecting from harm and injury are highlighted, as is overcoming the barriers to care and scrutiny of practice when opioid drugs are deemed a safe and appropriate part of the pain treatment plan. St. Marie and Arnstein (2016) provide a framework for comprehensive assessment and use of multimodal pharmacological and nonpharmacological combination therapy to maximize effectiveness with the fewest side effects or toxicity risks. Building on concerns raised in the article by Chang and Compton (2016), the authors describe careful risk assessments needed before starting an opioid drug trial if that is deemed appropriate. Assessment of treatment expectations, physical/mental capabilities, and values provide a foundation for realistic goal setting, shared goal setting, treatment planning, ongoing monitoring, and refinement of therapy. The authors address an interprofessional approach to multimodal therapy, promoting self-care/self-management and appropriate screening and monitoring for risk for substance use or misuse. Strategies for overcoming the barriers to quality pain management are proposed (St. Marie & Arnstein, 2016).

The last two articles in this special issue focus on analgesic and complementary integrative approaches to managing persistent pain. “Complementary and Integrative Therapies for Persistent Pain Management in Older Adults: A Review” (Bruckenthal, Marino, & Snelling, 2016) focuses on evidence for effective nondrug pain treatments with recommendations for positioning in the treatment plan and increased emphasis on these treatments. Bruckenthal et al. (2016) emphasize holistic care that incorporates complementary and alternative therapies in the context of patient-centered self-management approaches for older adults.

This issue concludes with clinical guidance on decision making regarding the role of analgesic agents in “Pharmacological Approaches for the Management of Persistent Pain in Older Adults: What Nurses Need to Know.” Guerriero, Bolier, Van Cleave, and Reid (2016) present evidence-based pharmacological pain management strategies, including thoughtful discussion of the placement of opioid drugs within that framework and guidance on decision making regarding risk/benefit analysis when selecting analgesic agents. Addressing the role of nursing in pain assessments, addressing barriers to effective analgesic use, educating patients and family members, and establishing strategies to monitor treatment outcomes are highlighted.

It is our hope that the readers of the Journal of Gerontological Nursing will find this special issue valuable in understanding the complex issues surrounding the opioid epidemic and its impact on the use of opioid drugs to manage pain conditions in older adults. The issue has been designed to provide key evidence-based recommendations to guide clinicians in developing strategies for addressing persistent pain in older adults that are responsive to identifying risk, careful analysis, and documentation of assessment and treatment decisions and monitoring for desired outcomes to support or revise the treatment plan. Older adults with pain should not endure the consequences of a system focused on one epidemic to the exclusion of assuring quality pain care. Nurses are well positioned to participate as vital members of the interprofessional team, provide needed education and counseling, and influence the changes necessary to provide safe, effective pain control for older adults.

References

  • Bloomberg, A.W. (2016, March29). Obama confronts opiate abuse epidemic as death toll mounts. Retrieved from http://www.norwichbulletin.com/news/20160329/obama-confronts-opiate-abuse-epidemic-as-death-toll-mounts
  • Bruckenthal, P., Marino, M.A. & Snelling, L. (2016). Complementary and integrative therapies for persistent pain management in older adults: A review. Journal of Gerontological Nursing, 42(12), 40–48. doi:10.3982/00989134-20161110-08 [CrossRef]
  • Chang, Y.-P. & Compton, P. (2016). Opioid misuse/abuse and quality persistent pain management in older adults. Journal of Gerontological Nursing, 42(12), 21–30. doi:10.3982/00989134-20161110-06 [CrossRef]
  • Guerriero, F., Bolier, R., Van Cleave, J.H. & Reid, M.C. (2016). Pharmacological approaches for the management of persistent pain in older adults: What nurses need to know. Journal of Gerontological Nursing, 42(12), 49–57. doi:10.3982/00989134-20161110-09 [CrossRef]
  • St. Marie, B. & Arnstein, P. (2016). Quality pain care for older adults in an era of suspicion and scrutiny. Journal of Gerontological Nursing, 42(12), 31–39. doi:10.3982/00989134-20161110-07 [CrossRef]
  • The White House. (2016, February2). Obama asks for $1.1 billion to address opioid abuse in 2017. Retrieved from https://www.whitehouse.gov/the-press-office/2016/02/02/president-obama-proposes-11-billion-new-funding-address-prescription
Authors

Keela Herr, PhD, RN, AGSF, FAAN

Professor and Associate Dean

College of Nursing

University of Iowa

Iowa City, Iowa

Paul Arnstein, RN, PhD, FAAN

Clinical Nurse Specialist for Pain Relief

Massachusetts General Hospital

Boston, Massachusetts 

The authors have disclosed no potential conflicts of interest, financial or otherwise.

10.3928/00989134-20161110-01

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