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.
This meta-analysis of opioid use in the elderly is limited by lack of robust data, particularly studies that include not just reduction of pain but improvement in function and quality of life. The concern regarding the "opioid epidemic" with deaths and addiction appears to have resulted in underprescribing by primary care doctors thereby further limiting the ability to assess improvement. Thoughtful, large scale prospective studies will be necessary to determine which patients and treatment options will be best.
I was excited to see this systematic review on opiates in non-cancer pain as I am seeing more and more opiate prescribing. Surprisingly there was very little research to include in the review and results were not really helpful. I wonder if all relevant research was included, as I am aware of papers looking at pain control in older adults that could have useful data but were not included in this review as they were not exclusively opiate focused.
This review highlights the paucity of evidence for the use of opioids in the elderly, a fact which is probably known by most physicians.