Opioids in older people: benefits, harms and deprescribing

The evidence

The SPACE trial randomised 240 US veterans with moderate to severe chronic back pain or hip or knee osteoarthritis pain to opioids, or to non-opioid medicines starting with paracetamol or an anti-inflammatory. Pain-related function over 12 months did not differ (difference 0.1 on a 10-point scale, 95% CI −0.5 to 0.7). Pain intensity was better in the non-opioid group (difference 0.5, 95% CI 0.0 to 1.0), and medication-related symptoms were more common with opioids ²⁵.

In practice

Participants had an average age of 58 and 13% were women, so the trial says little directly about frail residents ²⁵.

The evidence

A meta-analysis of 96 randomised trials (26,169 participants, median age 58) found that opioids reduced pain by 0.69 cm on a 10 cm scale compared with placebo (95% CI 0.56 to 0.82), against a minimal important difference of 1 cm, with a small improvement in physical function and more vomiting. Compared with non-opioid alternatives, the benefit for pain and function may be similar, though that comparison rests on low- to moderate-quality evidence ²⁶.

The evidence

In 47 Norwegian nursing homes, 162 residents with advanced dementia and depression were randomised to active analgesic treatment, paracetamol or a buprenorphine patch, or to placebo for 13 weeks. Of those given buprenorphine, 52.3% were withdrawn because of adverse reactions, deterioration or death, against 12.2% of the placebo group. Buprenorphine did not significantly reduce pain or depression. Psychiatric and neurological adverse events were the most frequent ²⁸.

In practice

The trial was in people with depression as well as dementia, so it does not show that every resident will react this way. It does show why a new opioid in a resident with dementia needs close watching in the first days and weeks.

The evidence

A systematic review of 67 studies (11 randomised, 56 observational) of adults on long-term opioids for chronic pain rated 51 of them as poor quality. Among the fair-quality studies, all eight that reported pain, all five that reported function and all three that reported quality of life found improvement after dose reduction. The authors rated the overall evidence as very low quality ²⁹.

In practice

Opioids are reduced gradually by the prescriber, with the resident’s agreement, and the plan is reviewed as it goes. The TGA has noted that, where clinically appropriate and with patient consent, some patients may be safely tapered off prescription opioids ³⁰.