LAUSR

A focus on older adults and the use of opioid treatment for persistent pain is warranted given the high prevalence of pain and its impact in later life, as well as the substantial prevalence of opioid treatment in older adults. Almost half of all adults over age 65 daily experience persistent and debilitating pain due to multiple causes, including degenerative arthritis, spinal stenosis, and nerve damage (e.g. post-herpetic and diabetes). Persistent pain is associated with substantial disability in this age group, characterized by reducd mobility, activity avoidance, increased risk of falls, and psychosocial morbidity, including depression, anxiety, and social isolation. Pain relief constitutes one of the most commonly endorsed goals of older adults and a large body of evidence now demonstrates that advanced age is a risk factor for under-treatment of pain. Possibly in response to this finding, US providers are prescribing opioids to older adults in record numbers. One large study examined prescribing patterns from 1999 to 2010 in the US and found that almost one in ten older patients received an opioid prescription. In 2015, as many as 30% of Medicare Part D enrollees received an opioid prescription suggesting that opioid prescribing continues to increase in this age group. Parallel to the dramatic increase in medical prescriptions of opioids (POs), which has occurred over the past two decades in the US, non-medical and misuse of POs has also strongly increased. Although an increase in prescribing strong opioids has also taken place in most EU countries over the past 15 years, the total number of prescriptions and PO-related mortality rates remain far lower than in the US. The public health consequences of the opioid epidemic in the US have been profound to include record numbers of unintentional overdoses as well as overdose-related deaths (more than 165,000 over a 16 year period). In an effort to address the opioid epidemic, the Centers for Disease Control and Prevention (CDC) recently released a guideline for prescribing opioids for chronic pain. The recommendations focus on the treatment of patients with chronic non-cancer pain (hereafter referred to as persistent pain) as opposed to those receiving active cancer treatment or palliative/end-of-life care. The guideline presents recommendations to help providers: (1) determine when to initiate opioids and guidance regarding the selection and dosing of opioids; (2) establish whether treatment benefits are occurring and decide whether to continue opioid therapy; and (3) conduct risk assessments and address harm that occurs as a consequence of opioid use. In this editorial, we review elements of the CDC guidelines that we believe could have positive or negative consequences when providing care to older adults with persistent pain. We also speculate about the implications of implementing the guidelines from a geriatric medicine perspective. In the sections below, we examine several of the CDC guidelines, highlighting their positive and problematic elements. We also raise questions about what impact implementing the guidelines could have on the care of older adults with persistent pain (Table 1). Readers are strongly encouraged to review all 12 recommendations that are part of the guideline.