Understanding Chronic Pain Treatment Choices in Later Life

This guide is for clinicians and practice owners supporting older adults with chronic pain. It lays out a practical way to discuss function, non-drug care, medication risks and follow-up, including when frailty or cognitive impairment affects the plan.

Start with what pain changes in daily life

Older adults vary widely, from active people to those who are frail. The CDC's 2022 guideline says pain can worsen functional changes in frail older adults and contribute to declining health and independence. That makes function a useful anchor for a treatment conversation: what has become harder, and what would the person like to be able to do?

Pain may also have more than one source. Testimony by geriatrician Cheryl Phillips cited estimates that 45% to 80% of US nursing home residents have substantial undertreated pain, and noted that older people commonly have several sources of pain. For clinicians, that is a reason to make room in the visit to hear the person's account rather than treat a single symptom as the whole picture.

A clinic can make this discussion easier to carry forward by recording the person's pain concerns, functional changes and current treatment choices together. That creates a shared starting point for the next visit or for a conversation with a caregiver or another member of the care team.

Put non-drug options on the care menu

Clinical practice guidelines recommend noninvasive, nonpharmacological pain therapies. A study of community-dwelling older adults with a certified need of care found that most participants used active nonpharmacological interventions for chronic pain, and about half used active movement approaches. Its authors considered physiotherapy in the form of therapeutic exercise particularly appropriate for this vulnerable group.

These findings give clinicians concrete options to raise in a treatment discussion, including movement approaches and physiotherapy. They do not establish that one approach suits every person. Older adults may particularly benefit from physical, psychological and social strategies when medication changes could have a disproportionate negative impact on someone who is frail, according to authors of a BMC Geriatrics study.

Primary care clinicians interviewed in a study of older adult chronic pain prioritized multimodal, nonpharmacological care. They also identified practical barriers: comorbidities, short visits, insurance coverage restrictions and concerns about opioid misuse. A practice can make those barriers visible in its workflow by recording which options were discussed and whether time, coverage or other conditions affected access.

Review medication risks alongside possible benefit

Medication decisions can be complicated because both nonopioid drugs and opioids carry increased risks for older patients, the CDC's 2022 guideline says. For NSAIDs, that guideline advises the lowest effective dose for the shortest duration needed, with caution particularly for older adults and people with cardiovascular comorbidities, chronic renal failure or a history of gastrointestinal bleeding.

Cognitive impairment adds another consideration. The CDC says dementia can raise the risk of medication errors and make opioid-related confusion riskier. Older adults are also more likely to have multiple medical conditions and take medicines that may interact with opioids. A medication review can therefore include the full list of medicines and whether the person has help managing them.

The CDC also describes a caregiver's role in opioid therapy for older people with cognitive impairment. It lists monitoring cognition, assessing fall risk, and using exercise and bowel regimens to prevent constipation among interventions to address common opioid risks. For a practice, these are specific topics to include when planning follow-up with the patient and, where relevant, a caregiver.

Treat opioid decisions as a shared conversation

Older adults and primary care practitioners in one study agreed that opioids should be a last resort to improve quality of life. The same study found that conversations about deprescribing were often unsuccessful, with disagreement about long-term opioid risks and barriers to those discussions. Another study found that primary care practitioners tailored opioid reduction recommendations to their perception of harm and emphasized partnership with patients, while their approaches to starting conversations and reducing opioids varied.

One systematic review identified predictors and adverse outcomes associated with long-term opioid therapy in older adults. It also found that evidence on whether long-term opioid therapy is effective for pain in this population is absent. That is a limitation of the evidence clinicians can discuss when weighing long-term treatment.

In testimony before the U.S. Senate Special Committee on Aging, a law and health professor described added concerns including greater medication sensitivity with age, polypharmacy, medication hoarding or sharing, and comorbidities that can make opioid use disorder harder to identify. These concerns support a conversation that covers the person's goals, safety, current medicines and support needs, rather than focusing on the prescription alone. For an individual treatment decision, the patient or caregiver should discuss the options with the patient's doctor.

Plan for transitions and follow-up

Medication plans may change when an older adult moves between care settings. In a study of US older adults after hip fracture, most received pain medication, and multimodal regimens containing opioids were most common. Most people who received a gabapentinoid immediately after admission to a skilled nursing facility were also prescribed an opioid. The authors called for closer medication management in that setting.

For clinicians and practice owners, this is a practical handoff point: make the current pain medicines and the reason for each one easy to review when a patient transfers into or out of skilled nursing care. The study's findings concern older adults after hip fracture, so they should be understood in that context.

When a person is taking an opioid, follow-up can also make room for discussion of whether the current plan still fits. A study of primary care practitioners found that they differed in how they began opioid conversations and approached deprescribing, and that they wanted support from other health care team members when managing opioid use disorder in older adults. A practice takeaway is to identify who can join a difficult medication conversation and how the patient can be connected to additional support.

This page is general education only. It is not medical advice. Talk with your own doctor about your health.

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