Older adults are identified as one of the most vulnerable populations in the world needing improved pain control (International Association for the Study of Pain, 2019). With advancing age, individuals become more susceptible to developing persistent pain and other harmful effects of uncontrolled pain or its treatment. Older adults have substantially higher rates of severe and disabling pain than their younger counterparts, which has increased in recent decades (Nahin, Sayer, Stussman, & Feinberg, 2019). As professionals who care for older adults, we have seen how pain erodes the body, mind, spirit, and quality of life of so many and the importance of effective treatment.
In recent years, attention on the opioid crisis has led to practice and policy changes that impact the treatment of all patients with pain, including frail older adults. We present an overview of these actions, the effect on care of vulnerable older adults, and nursing's call for action.
With more than 100 million Americans with chronic pain and 20 million having daily pain severe enough to interfere with daily activities, opioid treatment has been considered a safe and effective treatment for some older adults (American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons, 2009). Subsequent public health data raised concerns about the potential misuse and abuse of opioids, resulting in dissemination of the 2016 Centers for Disease Control and Prevention (CDC) opioid prescribing guideline for primary care providers treating individuals with chronic pain who were not being actively treated for cancer or receiving palliative care (Dowell, Haegerich, & Chou, 2016).
Key provisions of the CDC guidelines can be summarized as follows:
- Nondrug and nonopioid medications are preferred pain treatments.
- Before initiating treatment, a comprehensive pain and risk assessment is needed.
- Goals of therapy are established, including pain reduction and functional improvement.
- Vigilant reassessment of treatment safety and effectiveness is performed every few months.
- When a treatment is unsafe, ineffective, or not adhered to, it should be tapered or stopped.
- Avoid drug interactions and monitor opioid-dispensing databases.
- Signs of addiction should be further evaluated and treated.
These are sound general guidelines that should be supported. However, these guidelines also included other specific recommendations related to dose and duration of opioid prescribing for acute and chronic pain that have been adopted as policy mandates by many states, health care organizations, pharmacies, and payers. These recommendations, not based on clinical research, have superseded clinical judgment and patient-centered approaches to treatment planning and can have unintended consequences that are harmful (Inouye, Brown, & Tinetti, 2018).
Many primary care practices, under pressure to implement these guidelines, started discharging patients with chronic pain who were taking opioids (O'Malley et al., 2017). Within 2 years, it was evident that opioid prescriptions were cut by more than one third (Bohnert, Guy, & Losby, 2018); however, opioid overdose deaths reached record high levels (Scholl, Seth, Kariisa, Wilson, & Baldwin, 2018). Further analyses revealed three waves of the opioid crisis, implicating prescription opioids (1999–2010), then heroin (2010–2012), and subsequently illicitly manufactured fentanyl as the primary causes of overdose deaths. The most recent data show 1.5% of overdose deaths involve a person 65 years or older, taking a prescribed opioid (Scholl et al., 2018).
In 2019, Medicare policies added requirements for prior authorizations and dose and duration limits of prescribed opioids. These requirements have resulted in denials, delays in dispensing, fewer pills than ordered being dispensed, and the requirement for repeated trips to prescribers and pharmacies for vulnerable older adults. Within a few months of that policy change, the U.S. Food and Drug Administration (2019) issued a warning against rapid tapers or abrupt cessation of opioids, given mounting evidence that this practice can result in harm or death. Rapid tapering destabilizes patients and precipitates severe withdrawal, pain/suffering, disability, and even death among chronic pain patients. Policies promoting this led to an international outcry that forced tapering is a humanitarian crisis (Darnall et al., 2019).
All this attention on opioids has taken the focus away from potential harm that can occur from nonopioid pain treatments. Estimates show that long-term nonsteroidal anti-inflammatory drug use carries a 5% risk of having major cardiovascular, gastrointestinal, or renal events, with an elevated risk of dying from these complications with each year of therapy (Solomon et al., 2017). Gabapentinoid and antidepressant agents have also been implicated in serious side effects and an increased risk of death (Coupland et al., 2011; Enke et al., 2018; Nelson & Spyker, 2017), with drug interactions a concern, especially for older adults (Cavalcante, Sprung, Schroeder, & Weingarten, 2017). In fact, the American Geriatrics Society Beers Criteria® Update Expert Panel (2019) warns against using any combination of three or more central nervous system depressants (e.g., antidepressants, antipsychotics, nonbenzodiazepine and benzodiazepine receptor agonists, hypnotics, antiepileptics, opioids) in older adults, particularly in those with multimorbidity (Boyd et al., 2019).
Amidst reports that patients with chronic pain are being treated as pariahs and drug seekers in a dismissive or adversarial tone, we need to advocate for patient-focused quality care. In older adults, this focused care requires the development of individualized pain treatment plans with shared goals of improving comfort, functioning, and avoiding treatment-related harm. Of particular concern are older adults with cognitive impairments, who have limited ability to engage in nondrug interventions and are at higher risk of harm from pain and its treatment. Additional barriers faced by older adults may include limited mobility, few socioeconomic resources, comorbidities involving major organ systems, and drug interactions. Nurses have a duty to balance concerns of helping without harming individuals experiencing pain and suffering.
Nurses are in a position to improve access and diminish disparities in care for individuals with pain through clinical practice, education, advocacy, and research (Table 1) (American Nurses Association, 2018). These actions include identifying and addressing patterns of under-prescribing, over-prescribing, or abandonment of patients with pain. Access to nonopioid and nondrug ways of managing pain should be made more accessible, while providing respectful, individualized care to all patients experiencing pain regardless of their personal characteristics, values, or beliefs. However, the science supporting nondrug approaches and resources to implement must also be in place to support evidence-based practice. It is too easy to become morally disengaged by blaming patients or others for the problem. Nurses need to preserve their professional and personal integrity by having the courage and resilience to speak up about the moral distress they feel and bear witness to when patients experience untreated pain. As the largest professional group in health care, nurses can unite to advocate for legislative and payer policies to assure parity in access to individualized treatment that is based on the clinical judgement that comes with knowing the patient.
Selected Resources to Support Quality Pain Management in Older Adults
Paul Arnstein, PhD, RN, FAAN
Clinical Nurse Specialist for Pain Relief
Massachusetts General Hospital
Keela Herr, PhD, RN, AGSF, FGSA,
Kelting Professor in Nursing
College of Nursing
University of Iowa
Iowa City, Iowa
- American Geriatrics Society Beers Criteria® Update Expert Panel. (2019). American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 67, 674–694. doi:10.1111/jgs.15767 [CrossRef]
- American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. (2009). Pharmacological management of persistent pain in older persons. Journal of the American Geriatrics Society, 57, 1331–1346. doi:10.1111/j.1532-5415.2009.02376.x [CrossRef]
- American Nurses Association. (2018). The ethical responsibility to manage pain and the suffering it causes. Retrieved from https://www.nursingworld.org/~495e9b/globalassets/docs/ana/ethics/theethicalresponsibilitytomanagepainandthesufferingitcauses2018.pdf
- Bohnert, A.S.B., Guy, G.P. Jr.. & Losby, J.L. (2018). Opioid prescribing in the United States before and after the Centers for Disease Control and Prevention's 2016 opioid guideline. Annals of Internal Medicine, 169, 367–375. doi:10.7326/M18-1243 [CrossRef]
- Boyd, C., Smith, C., Masoudi, F., Blaum, C.S., Dodson, J.A., Green, A.R. & Tinetti, M.E. (2019). Decision making for older adults with multiple chronic conditions: Executive summary for the American Geriatrics Society guiding principles on the care of older adults with multimorbidity. Journal of the American Geriatrics Society, 67, 665–673. doi:10.1111/jgs.15809 [CrossRef]
- Cavalcante, A.N., Sprung, J., Schroeder, D.R. & Weingarten, T.N. (2017). Multimodal analgesic therapy with gabapentin and its association with postoperative respiratory depression. Anesthesia and Analgesia, 125, 141–146. doi:10.1213/ANE.0000000000001719 [CrossRef]
- Coupland, C., Dhiman, P., Morriss, R., Arthur, A., Barton, G. & Hippisley-Cox, J. (2011). Antidepressant use and risk of adverse outcomes in older people: Population based cohort study. BMJ, 343, d4551. doi:10.1136/bmj.d4551 [CrossRef]
- Darnall, B.D., Juurlink, D., Kerns, R.D., Mackey, S., Van Dorsten, B., Humphreys, K. & Lovejoy, T. (2019). International stakeholder community of pain experts and leaders call for an urgent action on forced opioid tapering. Pain Medicine, 20, 429–433. doi:10.1093/pm/pny228 [CrossRef]
- Dowell, D., Haegerich, T.M. & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recommendations and Reports, 65, 1–49. doi:10.15585/mmwr.rr6501e1 [CrossRef]
- Enke, O., New, H.A., New, C.H., Mathieson, S., McLachlan, A.J., Latimer, J. & Lin, C.C. (2018). Anticonvulsants in the treatment of low back pain and lumbar radicular pain: A systematic review and meta-analysis. CMAJ, 190, E786–E793. doi:10.1503/cmaj.171333 [CrossRef]
- Inouye, S.K., Brown, C.J. & Tinetti, M.E. (2009). Medicare nonpayment, hospital falls, and unintended consequences. New England Journal of Medicine, 360, 2390–2393. doi:10.1056/NEJMp0900963 [CrossRef]
- International Association for the Study of Pain. (2019). Pain in older adults. Retrieved from https://s3.amazonaws.com/rdcms-iasp/files/production/public/2019GlobalYear/Pain%20in%20Older%20Adults.pdf
- Nahin, R.L., Sayer, B., Stussman, B.J. & Feinberg, T.M. (2019). Eighteen-year trends in the prevalence of, and health care use for, noncancer pain in the United States: Data from the Medical Expenditure Panel Survey. Journal of Pain. Advance online publication. doi:10.1016/j.jpain.2019.01.003 [CrossRef]
- Nelson, J.C. & Spyker, D.A. (2017). Morbidity and mortality associated with medications used in the treatment of depression: An analysis of cases reported to U.S. Poison Control Centers, 2000–2014. American Journal of Psychiatry, 174, 438–450. doi:10.1176/appi.ajp.2016.16050523 [CrossRef]
- O'Malley, A.S., Swankoski, K., Peikes, D., Crosson, J., Duda, N. & Heitkamp, S. (2017). Patient dismissal by primary care practices. JAMA Internal Medicine, 177, 1048–1050. doi:10.1001/jamainternmed.2017.1309 [CrossRef]
- Scholl, L., Seth, P., Kariisa, M., Wilson, N. & Baldwin, G. (2019, January4). Drug and opioid-involved overdose deaths—United States, 2013–2017. Retrieved from https://www.cdc.gov/mmwr/volumes/67/wr/mm675152e1.htm#T1_down
- Solomon, D.H., Husni, M.E., Libby, P.A., Yeomans, N.D., Lincoff, A.M., Lüscher, T.F. & Borer, J.S. (2017). The risk of major NSAID toxicity with celecoxib, ibuprofen, or naproxen: A secondary analysis of the PRECISION trial. American Journal of Medicine, 130, 1415–1422.e4. doi:10.1016/j.amjmed.2017.06.028 [CrossRef]
- U.S. Food and Drug Administration. (2019, April9). FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. Retrieved from https://www.fda.gov/drugs/drug-safety-and-availability/fda-identifies-harm-reported-sudden-discontinuationopioid-pain-medicines-and-requires-label-changes
Selected Resources to Support Quality Pain Management in Older Adults
|University of Iowa Csomay Center for Gerontological Excellence
Website with evidence-based tools and resources for providers, patients and caregivers to promote quality pain care (last updated 2019)
|International Association for the Study of Pain—Pain in Older Persons
Educational resources and webinars on pain in older adults (last updated 2019)
|The Hartford Institute for Geriatric Nursing
Resources and tools to support pain management in older adults (last updated 2012)