番茄社区

Older people with chronic pain expressed views about opioid use that often sharply differed from those of primary care doctors, an interview-based study indicated.

When asked about the risks associated with long-term opioid use, patients were mainly concerned about becoming addicted, whereas physicians were more worried about acute adverse events such as falling, according to Timothy S. Anderson, MD, MAS, of the University of Pittsburgh, and colleagues.

And while doctors in the study generally agreed that tapering opioid doses is often warranted, both they and the patients said conversations about "deprescribing" were difficult and often unsuccessful, the researchers reported in .

There were substantial areas of agreement, however, between patients and the physicians: Regarding opioids as a treatment of last resort is OK, the goal of pain therapy is to improve patients' comfort and functional ability, and trust is paramount in the patient-doctor relationship.

But more could and should be done to kick-start discussions about deprescribing, Anderson and colleagues concluded.

"Safely reducing opioid use among older adults with chronic pain is likely to require the development of materials to foster more informed conversations on the benefits and harms of opioids as well as payment and policy interventions to support the time and teams needed for deprescribing opioids," the group wrote.

Greatest Prevalence of Opioid Use

Impetus for the new study could be said to have originated with the so-called opioid epidemic of the early 2010s, which led public health officials to begin urging doctors to show more restraint in prescribing opioids. Evidence that opioids such as oxycodone were helpful in chronic pain was scant, and in 2016, the CDC issued guidelines that warned against the practice, while still embracing these medications for cancer pain and in acute painful conditions such as trauma and surgery.

Those guidelines, however, ignited a firestorm of controversy. Patients complained that their doctors were now treating them like abusers, refusing to renew their prescriptions. 番茄社区 articles about opioids began to be flooded with comments from patients who accused the CDC of disregarding their needs and lived experience. In 2022, the CDC updated the guideline, softening the language although the original principles (explore alternatives first, minimize doses, balance risks and benefits) remained the same.

The new study focused on older adults because it is this population -- not the younger people typically pictured in the popular press -- that has the greatest prevalence of prescription opioid use. Anderson and colleagues pointed out that in 2019, 15% of Americans ages 65 and older had received an opioid prescription and 5% had been using the drugs chronically.

"Older adult populations face a unique set of risks, with a lower frequency of misuse but heightened risks of medication-related harms related to polypharmacy and multimorbidity," the researchers noted. Yet, they added, these medications "may also provide substantial benefits to older adults with chronic pain and multimorbidity, particularly promoting physical functioning, which may be vital to achieving other chronic disease goals and emotional well-being."

Thus the question is how to achieve an optimal balance between benefits and risks in older people with chronic pain. This involves shared decision-making, which in turn requires open discussion between patients and their physicians -- the type of discussion that, it appears, is too rare and too often unsuccessful.

Study Details

Anderson's group recruited 18 primary care doctors and 29 patients who had received opioid prescriptions at Beth Israel Deaconess Medical Center in Boston, conducting semi-structured interviews with them from September 2022 to April 2023. Physicians were asked about their interactions with patients when prescribing opioids and when suggesting lowering the doses; topics for patients included their experiences with opioids and previous discussions they had with their doctors.

Most of the doctors were internal medicine physicians, but otherwise they ran the gamut in terms of age, duration of practice, and patient load. Patients were mostly in their late 60s to mid-70s; two-thirds were women, and one-third were Black. Some 80% had been in pain for more than 5 years; 90% said they had back or neck pain, almost 80% reported joint pain, and only 17% had pain from cancer.

Just over 60% said they had been taking opioids for 5 years or more, and another 27% put the duration at 2-5 years. The median current dose was 21.3 morphine milligram equivalents. About half were using oxycodone, 31% were on tramadol, and 24% took another type of opioid.

Current pain intensity, rated on the 10-point Pain, Enjoyment of Life, and General Activity (PEG) scale, averaged 6.8 (higher scores represent greater intensity or interference). Ratings for its interference with life enjoyment and daily activities were similar. Importantly, asked how these ratings might change if they stopped taking opioids, patients estimated increases averaging 1.1 to 1.9 points.

Consequently, it was not surprising that both patients and physicians said in the interviews that "apprehension" about what would ensue with deprescribing was a barrier to successful tapering. Patients with higher pain intensity ratings were, the investigators found, the least enthusiastic about attempting a taper.

Anderson and colleagues reported few numerical results, mainly outlining general themes. However, one set of quantitative findings did appear in their paper. Patients were asked to rate their willingness to consider deprescribing under different scenarios. For example, if they experienced a fall or their memory was clearly suffering, roughly 75% said they would think favorably about dosage reductions. But if deprescribing was merely endorsed in an official guideline, only about 35% would find that motivating.

For their part, physicians cited several barriers to deprescribing. Obviously, patient reluctance was a big one. But they also said that such discussions with patients were time-consuming and difficult to fit into the time allotted in a patient visit, during which patients often have more pressing problems. Physicians also complained about the lack of reliable alternatives for patients with chronic pain (most patients in the study were also taking acetaminophen, and many were on other non-opioid medications as well).

Another area of general agreement between physicians and patients was that when tapering had been discussed, it seldom went anywhere. One doctor confessed to not having tapered "very successfully" or to stopping prescriptions "very often." Meanwhile, one patient offered the perspective that "my doctor has always kind of brought it up, [but] I don't feel that I have any problem as far as the medication is concerned."

Anderson and colleagues argued that the time-based barriers could be addressed. "In a promising development, in 2023," they wrote, "Medicare released new for managing chronic pain, which has the potential to spur the greater time spent on developing a long-term care relationship needed to support safe and patient-centered pain management, including conversations on opioid prescribing and deprescribing."

The researchers also suggested development of educational materials geared toward older people on opioids. They pointed to such efforts now underway in and the Netherlands, suggesting that perhaps they could be adapted for use in the U.S.

Comment