Main Points

We developed a Conceptual Framework outlining the stages of care for older adults who require or use opioids, and factors impacting management decisions and patient outcomes. The framework prioritizes three potential targets to determine factors associated with and interventions for: (1) reducing opioid prescriptions where harms outweigh benefits, (2) preventing opioid misuse and opioid use disorder (OUD), and (3) reducing other opioid-related harms.

• The current literature on risk factors is mostly sparse, particularly for the most relevant patient-centered outcomes. The studies were not designed to evaluate predictive models or screening tools for clinical decision making. We found 41 studies that used multivariable analyses assessing factors independently associated with opioid-related outcomes among older adults (≥60 years).
  • 22 multivariable studies evaluated long-term opioid use, which is not specifically a high-risk behavior and may indicate continuing pain symptoms, but does increase exposure and, therefore, potential for opioid-related harms.
    • All 9 studies that looked at prior or early postoperative opioid use found mostly strong associations (e.g., relative risk [RR] >2.0) with long-term opioid use.
    • All 9 studies that examined greater amounts of prescribed opioids (higher number of opioid prescriptions or higher opioid dose) found mostly strong associations with long-term opioid use.
    • Other factors with consistent (100% agreement), but largely weak associations (e.g., RR <2.0, but statistically significant), included back pain, depression, concomitant NSAID use, and fibromyalgia.
    • Studies were mostly consistent (≥75% agreement) that concomitant benzodiazepine use, higher comorbidity score, (generally undefined) substance misuse, tobacco use, and having a low income were each associated with long-term opioid use, but the associations were mostly weak.
    • In contrast, studies were mostly consistent that alcohol “abuse” and healthcare utilization were not associated with long-term opioid use.
  • Across 6 studies evaluating opioid-related disorders, including OUD and opioid misuse, 3 studies each had variable findings regarding the associations of alcohol misuse and of gender with opioid misuse.
  • All other evaluations of specific factors and outcomes of interest were evaluated by only one or two studies each. These included factors associated with opioid use disorder, high-risk obtainment of prescription opioids, procuring multiple opioid prescribers, mental health outcomes, physical health outcomes, all-cause hospitalization, opioid-related hospitalization, nonopioid-specific hospitalization, emergency department visits, opioid overdose, all-cause death, opioid-related death, and nonopioid-related death.
• The literature on interventions specifically intended for or evaluated in older adults is sparse. 16 studies addressed interventions related to opioid use and opioid-related disorders in older adults. Only 2 studies were randomized controlled trials. Each intervention was evaluated by one, or in two instances, two studies.
  • The most-studied interventions were screening tools to predict opioid-related harms, but none of these tools has been tested in large, national populations of older adults to assess real-world results or clinical outcomes related to their use.
  • 2 studies found that prescription drug monitoring programs have been associated with less opioid use (at the State level) but did not address appropriate use.
  • Other studied interventions include included multidisciplinary pain education for patients, an educational pamphlet for patients, implementation of an opioid safety initiative, provision of patient information and pain management training for clinicians, a bundle of educational modalities for clinicians, clinician education, free prescription acetaminophen, a nationally-mandated tamper-resistant opioid formulation, and motivational interview training for nursing students.
  • Among studies that had the goal of reducing overall opioid prescriptions or use, none specifically assessed “appropriate” reduction of opioid prescriptions or use (e.g., when the risks of opioid use outweigh the benefits). Few evaluated patient-centered outcomes, including pain and functioning.
• Future research is needed of studies in older adults to establish factors associated with clinically-important, patient-centered opioid-related outcomes in older adults and to identify interventions to improve primary prevention (reducing unnecessary opioid use), secondary prevention (reducing opioid-related harms), and treatment of existing opioid misuse or OUD.