Analgesics
| Type | Recommendation |
|---|---|
| When to deprescribe | |
| CBR |
We suggest deprescribing be offered to older people taking opioid or non-opioid analgesics with:
|
| Ongoing treatment | |
| CBR |
If deprescribing is unsuccessful despite multiple attempts, we suggest maintaining the lowest effective dose; however, we suggest reassessing the need for long-term therapy at least annually. We suggest appropriate non-pharmacological therapies and/or safer alternatives be considered and offered. |
| GPS |
For older people using opioid analgesics to manage cancer-related pain in the palliative stage, healthcare providers should consider seeking input from palliative care providers (ungraded good practice statement). ---- proposed for deletion (although the Guideline Development Group reached consensus (>75% agreement), qualitative feedback indicated that this GPS may not be feasible in certain settings, such as residential aged care facilities. As a result, it is proposed for deletion from the final version of the guidelines.) |
| How to deprescribe | |
| CBR |
Non-opioids (excluding paracetamol) We suggest individualising the tapering schedule and adjusting it according to the individual's response to establish the lowest effective dose if therapy continuation becomes necessary. In general, we suggest reducing the non-opioid analgesic dose gradually every 2-4 weeks. Once completely ceased, we suggest switching to on-demand or intermittent use of non-opioid analgesics at the lowest effective dose. Non-opioid (paracetamol) We suggest tapering may not be needed for paracetamol. However, tapering may be required to establish the lowest effective dose if therapy continuation becomes necessary. |
| GPS |
Opioids (ungraded good practice statements) For people taking opioids for < 12 months, we suggest gradually reducing by 5-10% of the morphine equivalent dose or 10-25% of the opioid dose every week. If symptoms recur, return to the previously tolerated dose until symptoms resolve and plan for a more gradual taper For people taking opioids for 12 months or more, We suggest gradually reducing by 5-10% of the morphine equivalent dose or 10-25% of the opioid dose every month. If symptoms recur, return to the previously tolerated dose until symptoms resolve and plan for a more gradual taper. We suggest advising people of the increased susceptibility to opioid overdose or opioid poisoning during dose tapering due to a change in opioid tolerance, and that extra caution is required, especially if returning to doses prior to deprescribing. |
| GPS |
Opioids and non-opioids Healthcare providers should consider offering non-pharmacological interventions (e.g. pain management services, walking programs), referrals to relevant allied health professionals, and psychological support as part of the management plan, as appropriate (ungraded good practice statement). |
| Monitoring | |
| CBR |
We suggest closely monitoring for pain, functional status, and quality of life every two weeks until at least four weeks after the medicine is fully ceased if practical. After this initial period, we suggest monthly monitoring for at least three months, followed by monitoring every six months thereafter to maintain therapeutic relationships with the individuals. This should be tailored based on individual factors such as their preferences, responses and tolerance to deprescribing. If in-person visits are impractical, we suggest advising people to report symptoms as needed. |
| GPS | Healthcare providers should use validated assessment tools to evaluate changes in pain severity, functional status, and quality of life (ungraded good practice statement). |
CBR, consensus-based recommendation; GPS, good practice statement
Chronic pain affects approximately one in five (20%) Australians aged 65 to 74 [569]. The most common cause of chronic pain-related hospitalisations is musculoskeletal and connective tissue disorders (e.g. osteoarthritis and lower back pain), accounting for 40% of admissions [569].
Non-pharmacological interventions for pain management encompass a range of psychological and physical techniques. For some people, non-pharmacological approaches can be as effective as standalone treatments for mild pain, or used in conjunction with pharmacological therapies to enhance pain relief in cases of moderate to severe pain. A 2024 systematic review and meta-analysis of 25 trials found that non-pharmacological interventions significantly reduced pain intensity, pain interference, depressive symptoms, and catastrophising beliefs while improving physical health [570]. In particular, older people who incorporated psychological approaches and physical activity had a small but statistically significant effect on improving pain interference.
Non-opioids
For mild to moderate nociceptive pain, paracetamol and NSAIDs are often recommended as first-line pharmacological treatments in people without contraindications [571]. NSAIDs are particularly effective for pain with an inflammatory component but may be unsuitable for people with renal impairment, cardiovascular disease, or gastrointestinal complications.
Opioids
For severe pain, opioids may be indicated, either alone or in combination with other analgesics such as paracetamol and NSAIDs. A multimodal analgesic approach reduces individual drug dosages, thereby minimising side effects [571]. Opioids are primarily used for severe acute pain or chronic cancer pain [571], with limited evidence supporting their long-term use (≥ 12 weeks) for chronic non-malignant pain in older people due to poor efficacy and an unfavourable side effect profile [572]. It is essential to clearly communicate the risks and benefits to individuals prior to any changes in therapy, enabling informed consent and shared decision-making. Regular monitoring is crucial, and clinical practice guidelines recommend planning for deprescribing at the time of opioid initiation [573].
Refer to the narrative evidence summary, the GRADE Summary of Findings table in the guidelines, and the Technical Report for a complete presentation of the deprescribing evidence based on the GRADE framework (including other factors considered in developing the recommendations).
Common side effects related to opioids include nausea, vomiting, constipation, orthostatic hypotension, and dizziness [177]. Opioids also contribute to anticholinergic burden which is associated with cognitive impairment, sedation, and respiratory depression in older people [177]. Opioids may increase the risk of falls, fall injuries, and fractures [574] as well as the risk of infection due to their potential immunosuppressive effects [575]. Older people typically require lower opioid doses, with dose requirements decreasing progressively with age [177]. However, tolerance can develop, leading to escalating doses. Long-term high-dose opioid use can exacerbate pain through nociceptive sensitisation [576]. Deprescribing may be appropriate when the risks of harm with continuation outweigh the benefits and in people where opioids offer little benefit in pain relief or improving function or those experiencing recurrent falls caused by opioid-induced sedation, orthostatic hypotension and dizziness [577]. If pain related to an acute injury has resolved or chronic pain is well managed by other non-pharmacological measures, it may be appropriate to offer deprescribing to individuals to minimise the potential substantial harm related to long-term opioid use. Individual’s goals of care, values and preferences are important considerations in the shared decision-making process. If opioids are used for the management of complex and/or refractory pain, cancer-related pain or chronic cancer-survivor pain, referral for specialist input is necessary (e.g. pain and/or palliative care specialists if relevant).
Opioids
Discontinuing opioids is complex and requires clinical expertise and patient engagement. Motivational interviewing is recommended at each visit to encourage patient participation. Educating patients about the risks of long-term opioid use enhances their readiness for discontinuation. Several online resources, such as the NPS MedicineWise Lowering Your Opioid Dose consumer guide, can aid in patient education [578].
Before tapering, healthcare providers and patients should collaboratively develop a discontinuation plan, outlining goals, tapering steps, and review intervals. Ideally, opioid discontinuation should be accompanied by non-opioid medications and non-pharmacological therapies (e.g. acupuncture, massage, physiotherapy, osteopathy) where relevant. A 2019 meta-analysis found that mind-body therapies provided moderate pain relief and reduced opioid use, although the overall evidence remains limited [579].
Opioid substitution for tapering is generally not encouraged, except in cases where transdermal formulations necessitate gradual withdrawal. Two tapering strategies are commonly recommended [177, 580, 581]:
- Fast tapering (for use < 1 year): Reduce the opioid dose by 10-25% per week
- Slow tapering (for use >1 year): Reduce the opioid dose by 10-25% per month
For individuals using both immediate-release and extended-release opioids, deprescribing long-acting opioids first is generally recommended. If tapering leads to withdrawal symptoms or worsening pain, a temporary pause is advised to reassess goals and consider adjunct non-opioid analgesics. Referral to a pain or addiction specialist may be necessary [580].
Opioid withdrawal may present with nausea, vomiting, sweating, diarrhoea, anxiety, myalgia, and irritability [177, 580]. Routine pharmacological management to prevent withdrawal symptoms is generally not recommended but rather, attempting slower tapering strategies to reduce the risk of adverse drug withdrawal events. However, for individuals with severe symptoms, clonidine (0.1-0.2 mg every six hours) may be considered [580], with careful monitoring for bradycardia and hypotension [571, 581].
Withdrawal-associated hyperalgesia (increased sensitivity to pain) may occur but is usually temporary [581]. If withdrawal-associated hyperalgesia occurs during opioid tapering, individuals should be reassured that the heightened pain is likely short-lived and that, over time, reducing or stopping opioids often leads to improved pain management and overall well-being.
There is also an increased susceptibility to opioid-related harms (e.g. opioid overdose or poisoning) during dose tapering due to a change in opioid tolerance or increased sensitivity [582]. Therefore, extra caution is required, especially if returning to doses prior to deprescribing.
Non-opioids
Please refer to the antiepileptics section for antiepileptics used for neuropathic pain. For other non-opioids analgesics, tapering is generally not required; however, some people may prefer gradual tapering such as reducing the dose evert two to four weeks or at an even slower rate. The approach to deprescribe should be individualised with the speed of tapering be guided by the individuals. Tapering may also be helpful to establish the lowest effective dose if therapy continuation becomes necessary.
We identified one RCT related to tramadol deprescribing [583] from the systematic review and meta-analysis [583].
Overall, the current evidence is derived from a single RCT focused on tramadol and is of very low certainty due to methodological limitations, including a small sample size and short follow-up duration. A significantly higher proportion of participants in the discontinuation group reported insufficient pain relief compared to those who continued tramadol but adverse drug events were more frequently reported in the tramadol group. This highlights a trade-off between pain control and treatment-related harms. Deprescribing may still be appropriate in people who are at higher risk of adverse effects, especially when alternative non-opioid strategies are available or pain is well-controlled. However, the evidence is inadequate to inform evidence-based recommendations. There is also a lack of evidence on deprescribing non-opioid analgesics such as paracetamol. If deprescribing is considered appropriate, it may be appropriate to closely monitor for changes in pain, functional status, and quality of life.
Key study characteristics and results
Kawai 2022 conducted an RCT that included patients with chronic knee osteoarthritis pain for at least three months [583]. Prior to the four-week double-blind period comparing tramadol discontinuation and continuation, all participants entered an open-label, tramadol dose-escalation period of one to three weeks (100 to 300 mg daily). Eligible participants were randomised to continue tramadol or switched to a placebo for four weeks (double-blind period). Eligible participants were those with 1) an improvement in Numeric Rating Scale (NRS) for pain of ≥ 2 points dose escalation period compared to baseline, 2) a difference of ≤ 2 points between the minimum and maximum NRS value in the three days prior to randomisation, and 3) dose compliance rate of ≥70%. Concomitant use of NSAIDs (for osteoarthritis), aspirin (as antithrombotic medicine), and prochlorperazine (as an antiemetic) were permitted as long as the dose was kept the same as pre-trial. Rescue analgesics were not permitted. Four weeks after randomisation, there were considerably more participants in the placebo group who reported inadequate analgesic coverage compared with the tramadol group (25/81 vs. 12/78; OR 2.46, 95% CI 1.13, 5.33). However, adverse drug events were more frequent in the tramadol group than placebo (20/78 vs. 11/81; OR 0.46, 95% CI 0.20, 1.03), with the most common complaints being nausea, vomiting, constipation, somnolence, and dizziness.
The method of deprescribing was not described in the study, but it appears to have involved abrupt discontinuation by using a placebo [583].