Are opioid medications good for chronic pain in older adults?

Chronic pain is common among older adults. Sometimes it is severe and other medicines “don’t work”. A narcotic pain reliever is then often tried. Is this good or bad? More than 10% of older adults have had a prescription for an opioid in the past year. Almost 25% of long-term users of opioids are older adults. Are these numbers cause for alarm?

Many people are afraid of “narcotics”. Almost all healthcare providers have bad stories about patients on narcotics. One patient of mine fell off a ladder and developed chronic pain. He started taking an opioid pain reliever so that he could keep on working. But the opioid turned out to be a two-edged sword for him. He asked for opioids more frequently. Ultimately, he switched physicians to find one who “understands my pain”. A warning sign was that he became careless about narcotics and “popped” pills. He ended up dying from an accidental overdose.

“Don’t you understand, I’m in PAIN”

Opioids are strong pain relievers that “work” when other painkillers don’t. They are essential for severe acute or cancer-related pain. But their use for chronic pain is more controversial. Pain relief decreases over time and potential harm increases. That’s because pain receptors in the body adjust to the presence of opioids. This leads to the need for a larger dose to have the same effect. The progressive need for higher doses is a warning sign. In the worst case, the body becomes dependent on the drug to avoid withdrawal symptoms.

Addiction is when a person physically and psychologically craves a drug. Drug seeking becomes the central focus as a person’s life falls apart. This is uncommon among seniors. Although opioids are commonly prescribed to seniors, few become long-term users. Even fewer become addicted. Some patients worry about becoming “high” and  getting “hooked” after one dose. This is also uncommon.

Should opioids be prescribed for older adults with chronic pain?

My answer is a cautious sometimes. They can be beneficial if used sparingly. Problems are less likely if patients and caregivers are concerned about the risks. Some patients desire as much pain relief as possible. These patients may tend to have medication, tobacco, alcohol, or drug dependency. Opioids are a much higher risk among these patients.

Follow these guidelines to control risks:

  • Avoid opioids if there is a history suggesting tobacco, alcohol, or drug problems.
  • Start opioids only after other pain relief medications have been tried.
  • Establish clear and realistic pain control goals.
  • Have one healthcare provider and one pharmacy provide guidance and oversee prescriptions.
  • Be aware that extra paperwork is required.
  • Be careful to secure narcotics in a safe place away from family members and others.
  • Start at a low dosage and increase slowly if needed.
  • Always adjust dosage gradually and with supervision, even when decreasing.
  • Check carefully for drug interactions. Alcohol and medicines for anxiety or insomnia are particularly problematic.

Bottom line

The word “narcotic” makes patients worry. For that reason, medical professionals prefer to use the term “opioid”. That’s ironic because opioid comes from the word “opium”. I’ve provided some general comments about their use. This is not meant to provide advice for any specific patient.

I suspect my experience is the same as most other clinicians. Older adults with chronic pain are often prescribed opioid pain relievers. Proceed with caution. Most patients have benefited but fewer use opioids over extended periods of time. For some, there’s a temptation to increase the dose when pain is not well controlled. But decreased efficacy is also a warning sign of potential harm. Long-acting and stronger opioid medications are particularly high risk. They increase the likelihood of chronic drug dependency, and emotional and physical frailty.

Attached is a good CDC summary about opioids for chronic pain.

Warmest Aloha,


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PS: I say it over and over again: There’s no one more important than the caregiver in the daily life of a frail person.

Attachment PDF: CDC Guidelines for Prescribing Opioids for Chronic Pain

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