A Painful Setback: Misinterpretation of Analgesic Safety in Older Adults May Inadvertently Worsen Pain Care

Observational findings by Solomon et al¹ of safety events associated with opioid and nonsteroidal anti-inflammatory drugs (NSAIDs) have made headline news and are now at risk of misinterpretation and potentially worsening overall pain care for older adults. The studies have significant limitations that may preclude the implications investigators and journal editors hope to convey. While propensity scores were used to methodologically adjust for the limitations of Medicare and pharmacy claims data, sizeable confounders, including the severity of pain experienced by subjects, the type of medications used (including over-the-counter analgesics), and more importantly, the dose and duration of medication use could not be accounted for.¹ Despite these shortcomings, the results have received considerable attention. The general public and medical communities have been quick to caution against the use of opioids and analgesics in older adults. Alarmist headlines with phrases such as “Narcotic Painkillers” and “Hazards in Elderly” were found in national headlines^2–4 and medical Web sites^5–7 immediately after results were released.

With the continued prevalence of inadequate pain care in many health care settings, despite over a decade of heightened awareness and initiatives by regulatory bodies,^8–10 study limitations must be emphasized. Clinicians who are overly concerned that analgesic risks might outweigh benefits may now withhold medications and inadvertently setback any advances made to improve pain management. An example of this is in the emergency department (ED), where Web site headlines for the largest emergency medicine specialty organization, the American College of Emergency Physicians, have warned against the use of opioids in elderly patients.⁷ Older adults with acute pain have poorer reduction of their pain when compared with younger counterparts and concurrently receive less opioids and more NSAIDs when in the ED.⁹ While such findings may be misconstrued as beneficial by Solomon et al,¹ older adults with acute pain in the ED nonetheless have decreased reduction of their pain. This scenario will only worsen if clinicians incorrectly conclude that opioids are not safe and that NSAIDs are safer—a causal association not demonstrated by the article by Solomon et al,¹ as investigators themselves point out.

Although the article by Solomon et al¹ was well intentioned and could have better advocated a balanced approach in understanding the risks and benefits of all analgesic treatments, the findings are now obscured by misinterpretations by the general public and medical community. Pain care in older adults must continue to be aggressively addressed. Any excuses to not treat pain in elderly patients cannot be tolerated.