Analgesic use by ageing and elderly patients with chronic non-malignant pain: a qualitative study
Int J Clin Pharm
Analgesic use by ageing and elderly patients with chronic non-malignant pain: a qualitative study
Mary-Claire Kennedy 0 1 2
Grainne Cousins 0 1 2
Martin C. Henman 0 1 2
0 School of Pharmacy, Royal College of Surgeons in Ireland , St. Stephens Green, Dublin , Ireland
1 School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin , Dublin , Ireland
2 School of Healthcare , Baines Wing , University of Leeds , Leeds LS29JT , UK
Background Analgesics are used in the management of chronic non-malignant pain (CNMP), a condition which is highly prevalent among older adults. CNMP may not only be physically distressing but also complicated by psychosocial and economic factors. An individual's perception and use of analgesics may be influenced by a range of factors such as perceptions of risk or benefits, ability to purchase medication or access to non-pharmacological therapies or specialist care. Objective The aim of this study was to describe the perceptions and experiences of analgesics by ageing and elderly individuals with CNMP and identify factors that influence their use. Setting Telephone interviews with 28 members of Chronic Pain Ireland aged C50. Method In-depth semi-structured interviews; audio-recorded, transcribed verbatim, and thematically analysed. Main outcome measure Experiences and perceptions of ageing and elderly individuals with CNMP taking analgesics. Results A combination of factors specific to the patient and arising from outside influences informed perceptions and experiences of analgesics. Pain severity, perceived efficacy of analgesics, occurrence of adverse-effects and concerns about addiction/dependence were identified as internal factors influencing medication use. External factors included views of family members, access to specialised care and the individual's interaction with healthcare professionals (HCPs). Conclusion Individuals with
Ageing; Analgesics; Chronic treatment; Health behavior; Ireland; Medication; Pain; Qualitativce research
CNMP regard analgesics as an important method for
managing pain and are relied upon when other interventions
are difficult to access. HCPs in primary care, who are the main
point of contact for patients, need to take into account the
various factors that may influence analgesic use when
consulting with this patient group.
Impacts on practice
While analgesics are an important method of pain
control, patients attempt to offset use through
nonpharmacological management strategies, but limited access to
physical and psychological interventions contributes to
increased reliance on analgesics for pain management.
Primary care physicians must be offered opportunities
to engage in continuing professional education on the
subject of analgesia as new therapies are licensed and
concerns about existing medications emerge.
Patients have concerns about long-term use of strong
opioids which is perceived to be inherently linked with
addiction. Before starting treatment, these concerns
should be discussed with patients who need strong
Chronic non-malignant pain (CNMP) is defined as pain that
exists beyond 3 months or the expected timeframe for
]. It is prevalent among ageing and elderly
patients due to the development and progression of chronic
degenerative conditions [
]. The burden of CNMP is
certain to increase in future years with our globally ageing
Analgesics such as non-opioids [e.g. paracetamol and
non-steroidal anti-inflammatories (NSAIDs)] or opioids are
commonly used to manage CNMP. A recent European
survey suggested that two-thirds of individuals with CNMP
were taking some form of analgesic [
]. Depending on
the nature of the pain condition adjuvants may be used,
examples include anticonvulsants, antidepressants and
muscle relaxants . In common with all medications,
optimal outcomes are achieved when analgesics and
adjuvants are taken as prescribed, the clinician having
considered the risks and benefits of the medication for that
patient. Elderly patients are at increased risk of harmful
outcomes from medications due to physiological changes
that alter pharmacokinetics and pharmacodynamics in
addition to multi-morbidities and polypharmacy [
These challenges limit the range of pharmacotherapeutic
options available to the clinician.
The pattern and extent of analgesic use is also
influenced by the patient’s perceived need for, efficacy of, and
concerns about the medication, some of these concerns
particular to older patients [
]. Stoicism of elderly
patients may lead to an increased tolerance towards painful
conditions and a tendency to take analgesics less frequently
or at a lower dose than prescribed . Additional factors
affecting use of analgesics by patients with CNMP have
been described in the literature including addiction
concerns, unfavourable scrutiny, adverse effects, tolerance,
withdrawal and mistrust in the prescriber [
these issues, there is a steady increase in the use of
prescription opioids in several countries including the USA,
UK, Germany, Australia and Canada [
]. In recent
years, there has also been an increase in the prescribing of
gabapentin and pregabalin with a simultaneous rise in
reports of misuse of these medications [
few studies have considered attitudes of patients towards
these adjuvants, particularly in light of this emerging
information on misuse of these agents.
The NICE Medicines Adherence guideline (2009)
details recommendations for the involvement of patients in
decisions about prescription medications [
guideline references Horne’s model of adherence as a framework
to consider the various factors that may affect the manner
in which patients take their medications [
]. The model,
which builds upon the self-regulatory model of illness,
describes internal factors including beliefs about disease
and medications, the perception of the role of medications
in disease management, and the patient’s ability to take
]. External factors include the sources
from which patients gain information about medications
including healthcare professionals (HCPs), family, friends
and media, the financial implications of medication use and
the influence of regional or national health policy [
Using this framework to consider the factors affecting
medication use by patients with CNMP is of particular
relevance to HCPs seeking to implement NICE
Aim of the study
This study aimed to examine the experiences of ageing and
elderly individuals with CNMP with analgesics, and to
describe the factors that influence the way these
medications are used by this group.
Ethical approval was granted by the Health Sciences
Research Ethics Committee, Trinity College Dublin
Semi-structured telephone interviews were conducted with
members of Chronic Pain Ireland (CPI), a patient support
organisation with approximately 300 members. An e-mail
invitation was sent to all members and an advertisement
was placed both on the CPI’s Facebook and Twitter
pages and in the quarterly newsletter. Individuals aged
[=50 years were eligible to partake in this study.
Individuals of this age are classified as ‘ageing’, as they may
have retired, are no longer of child-bearing potential and
will be considered elderly within a number of years [
is important that economic, social and healthcare policy
planners are aware of the needs of this group before
reaching old age. For these reasons, longitudinal studies on
ageing conducted internationally have included individuals
aged 50 and older [
Individuals could not take part in the study if they had a
terminal illness or had been diagnosed with dementia or
any other memory impairment. Any member of the CPI
who volunteered to participate and were eligible for
inclusion were sent an interview invitation. Participants
were allowed at least 5 days between signing the consent
form and conducting the interview.
A pragmatic approach was adopted to this study with the
focus on identifying themes rooted within the data to
capture participants viewpoints [
]. Data was managed
using the framework method and analysed through applied
thematic analysis, which can be viewed as a methodology
in its own right [
]. An interview guide was developed
by the research team, questions were constructed by
reviewing the literature and professional experience. The
guide was piloted with a qualitative researcher who
recommended revisions based on their experience with
semistructured interviews. The interview guide is outlined in
‘‘Appendix 1’’, it includes probing statements that were
used to obtain some detailed information or to follow up on
points of interest. All interviews were conducted by
telephone by MCK who had training and experience in
qualitative interviews. Interviews were recorded using the
Audacity software package and a portable recording
device. The research team monitored the thematic content
as the interviews progressed, as no new themes emerged at
the 24th interview, data saturation had been reached and
only the interviews that had already been arranged were
completed . Transcripts were reviewed by participants
and were then transferred to NVivo Version 10. A
member of the research team (MH) reviewed a sample of
the transcripts to ensure that coding and thematic analysis
Twenty-eight interviews were conducted over 6 months
(May–October 2013). Twenty-seven transcripts were
retained for analysis as 1 participant did not wish to
proceed with the study after reviewing the transcript.
Interviews were an average of 36 min. Nine men and 18 women
participated in the study and were aged 50–70 years.
‘‘Appendix 2’’ details the age ranges, pain conditions and
current classes of pain medications of participants.
The Horne Model applied after completing thematic
analysis allowed for the identification of internal factors
affecting analgesic use which included pain severity and
the perceived efficacy of analgesics, concerns and negative
experiences with medications and engagement in
self-education or use of non-pharmacological interventions.
External factors included influences of family and friends,
access to specialised care and interaction with HCPs [
Pain severity and analgesic efficacy
Pain affected participants in different ways; some had
limited ability to undertake daily activities such a washing
and dressing, while others were limited only when they
sought to participate in additional activities such as
walking distances or driving. All participants contrasted
previous activity levels with current abilities to
contextualise pain severity or to describe disease progression.
That is the other thing; my stamina isn’t nearly what
it was. I could do a full day’s work and do three
meetings back to back whereas if I can do one
expedition out of the house now in one day it is about
as much as I can manage. (P28, female, chronic back
Participants discussed their perception of the risks and
benefits of analgesics by describing the efficacy of the
medication in delivering pain relief relative to the negative
effects of the medication. Embedded within these
discussions regarding efficacy weighed against risk was a sense
of acceptance of the unremitting nature of the condition
and the necessity to take analgesics continuously. All
participants indicated that analgesics were an important
aspect of their approach to pain management, enabling
them to undertake daily activities. In cases where
medications provided effective analgesia, participants described
the importance of adherence to the prescribed regimen as
pain may recur upon omission of a dose:
If I happen to forget taking them or maybe went off
by mistake, and I wouldn’t have taken them, I’d
know that evening that it would be much, much more
painful. (P8, male, peripheral neuropathic pain)
My perception of it is that it’s essential for the
maintenance of my health and wellbeing. It also
assists in maintaining my relationship with my wife,
my children and my grandchildren. (P13, male,
However, this is contrasted with negative perceptions of
analgesics voiced by a number of participants who viewed
them as perpetuating a negative cycle of use which they are
unable to stop:
…it is a terrible vicious circle that you get into, you
are taking the medication, you know it is not going to
cure it and at the same time you keep taking it in the
hope of just bringing it down a few levels [pause] … I
think if I was dealing with somebody else, I would be
telling them for God’s sake [sic] come off that
medication, and here I am. I am caught up in it. (P18,
female, chronic neuropathic pain)
Adverse effects were described for NSAIDs, opioids and
adjuvants however, those arising from opioids appeared to
cause most distress. Participants appeared to be aware of
the adverse gastrointestinal (GIT) effects of NSAIDs,
however, no one discussed the potential adverse
cardiovascular effects. One participant described the
development of a stomach ulcer which she stated was caused by
I have osteoarthritis, a pain in my back, then
eventually I got a stomach ulcer from taking Difene
[diclofenac]. They say that it may have been stress
but it may have been Difene (P27, female, arthritic
Adjuvants including pregabalin, gabapentin,
amitriptyline and duloxetine were described as causing adverse
effects among participants which in some necessitated
stopping the medication:
The other side effect … is that I am overweight, and
that is because of the increased appetite or things like
that things, cravings for sweet foods because of
medication, again that is to do with side effects. (P9,
female, rheumatic condition)
I was told to try amitriptyline … now that [pause]
even the smallest amount of that would have me
asleep for 24 h so I decided not to. (P10, female,
The adverse effects of strong opioids which caused
greatest distress were GIT upset and sedation. For some
participants, these adverse effects necessitated
discontinuation of the medication, even if this medication was
effective in providing pain relief. One participant also
described the sense of detachment associated with opioids
as impacting on her ability to function on a daily basis:
That would have been the main reason I would have
taken a break from them. I found that I was too
sedated [pause] not so much sedated more that I felt
maybe a detached, like feeling like the world was
going on around me. Even the children were saying
that my favourite hobby was sleeping! (P26, female,
Addiction and tolerance
The potential for substance dependence with opioids is
widely known and participants often voiced such concerns
during the interviews. Notably none of the participants
taking adjuvants such as pregabalin and gabapentin
expressed similar concerns about these medications. There
were, however, differing degrees of concern about the
potential for developing addiction or tolerance to opioids:
What I have learned is the opiates are only [pause] I
understand people take them for a long time but there
should be something that stops you, because you
eventually reach the stage where you need more and
more to get the same effect. (P23, male, chronic neck
Addiction would be of a concern for me and with the
family here and you’re concerned about things like
this. And they are very much aware of what they do.
And they’re concerned that I might be dependent too
much on them. (P16, male, central neuropathic pain)
Participants discussed the long-term health implications
and potential problems of taking analgesics. While there
was a sense acceptance among participants that analgesic
use will continue indefinitely with a likely increase in the
quantity and dose of medication, this raised concerns about
the impact of medication on their future physical health,
tolerance to the medication and lack of treatment options:
It was going to relieve me of my pain, but really the
end result would be that it would damage my system.
(P24, female, peripheral neuropathic pain)
I was speaking to a colleague at work about the very
same thing, we were sitting on night duty talking
about it and she said, now you might die younger, but
at least you won’t be in as much pain. [Laughter]
(P21, male, chronic back pain)
Self-education and non-pharmacological interventions
Participants referenced access to and use of patient support
groups and have incorporated strategies discussed in
workshops and meetings into their every-day routine.
Several participants who had attended a pain management
programme outlined the improvements the programme had
made to management of their condition:
Now one thing I was doing which was wrong, I was
watching the clock and saying, oh I can take another
tramadol, you know what I mean, I’d say every 4 h.
[pause] With the pain programme I stopped doing
that. (P14, female, arthritic pain)
Participants also discussed their use of physiotherapy,
hydrotherapy, acupuncture, pilates, yoga, cognitive
behavioural therapy and transcutaneous electrical stimulation
(TENS). Some were using one or more of these
interventions to minimise or offset the need for an analgesic:
I’d normally start with one [tramadol tablets] and
hope it works, but I do usually end up having to take
a second one [tramadol tablets] and I kind of, try and
use heat or a TENS machine or something else rather
than take anymore (P7, female, chronic head/pelvic
Several participants described accessing information on
the internet and highlighted the contribution of this
information towards their personal appraisal of their medication
regimen or their consultation with the prescribing
If I go to somebody and they prescribe something, the
first thing I do is go to the internet and look it up.
And, what tends to be on the internet…is quite a lot
of negative stuff. And again you’re starting off with a
negative base… (P3, male, chronic back pain)
Third party influences
Participants have developed an understanding or
perception of their condition through personal experience and
interaction with family members, friends and other
patients. Family members were universally concerned
about the pain experienced by participants and were
perceived to be more accepting or encouraging of analgesic
use than others. The support received from family members
appears to dispel some of the reservations participants may
have about taking analgesics. This is in stark contrast to
the sense of stigmatisation and misunderstanding that
individuals perceived with the general public.
Probably my family would be different because
they’ve actually seen me and seen me in pain and
they would be very much inclined to say look you
know you’re going to end up taking it, why don’t you
just take it now instead of in 4 h time when you’re
much worse. They would try to encourage me to take
it much more. (P7, female, chronic head/pelvic pain)
I suppose what I would find about the community in
general is that nobody understands the word
chronic… So when people see you and you are
looking well and tanned… you must be better. (P18,
female, chronic neuropathic pain)
All participants discussed the care received from their
GP, with the majority speaking positively about this
experience. Participants considered the clinical
knowledge and the personal experience of interacting with their
GP as the most important topics when discussing GP
care. While some participants were satisfied with the
management received, some did express the opinion that
GPs had not received adequate specialised training on
The GPs, there is a real need for more training and
up-skilling in the area, with me they just don’t know
what to do anymore and they haven’t known what to
do for a good while really. (P12, female, pelvic pain)
Despite the perceived limitations of GP’s clinical
knowledge of CNMP, participants spoke warmly of these
relationships. They understood that GPs wished to help and
often independently and proactively researched the
condition to aid their patient. Several participants reported that
they also relied on the GP to ensure that the care received
from the various HCPs was harmonised in primary care:
My doctor… she is excellent… and she kept going
until she got a diagnosis, and she is proactive in
looking up new medication and trying to get it right,
you know, get it sorted, and as I said I always get her
to check what the hospital say. (P2, male, chronic
Participants referred to the financial and geographical
restrictions affecting access to specialised care. Financial
barriers related primarily to the inequity of the current
public–private structure of the Irish healthcare system.
Health insurance or private payments enabled patients to
bypass public waiting lists, gaining faster access to
consultant level care, however this placed considerable
financial burden on most participants. The cost of healthcare,
particularly medications and private specialist care, was a
major concern particularly for those seeking healthcare
privately. This is contrasted with difficulties associated
with access to similar services in the public system.
Participants appear to factor in the cost of management of their
condition as a contributory barrier to effective
The way I have sort of gone paying, not that I can
afford it, but paying you will get in somewhere much
quicker anyway and you sort of have to weigh up
things. (P1, female, rheumatic condition)
Participants were asked to comment on their experience
of interdisciplinary co-operation in the management of
their condition. While participants tended to praise the care
received in primary care, and acknowledged the expertise
of specialists, the connectivity of these domains clearly
remains an issue:
I know there were doctors who were writing out
things but no one was paying any attention to what
the other fella [sic][meaning: man] was doing. (P23,
male, chronic head/ neck pain)
This study highlights the multiple complex factors that can
influence the use of analgesics by ageing and elderly
individuals with CNMP. These factors can be mapped onto
those identified within Horne’s model of adherence, this
framework is of particular importance to clinicians seeking
to optimise analgesic use among patients with CNMP in
accordance with the NICE Medicines Adherence guideline
Ability to undertake daily activities or engage in social
or leisure pursuits appears to be an implicit measure
employed by patients to establish the efficacy of the
analgesic regimen [
]. However, these perceived benefits of
both analgesics and adjuvants are balanced with the risks
associated with the medications. There is extensive
literature on the clinical complexities of prescribing medications
for ageing and elderly patients and it would appear that this
group were somewhat aware of these potential problems
citing specific issues such as adverse effects and drug
interactions. Adverse effects appear to be the most
significant influence on analgesic use or non-adherence to the
prescribed regimen. This finding is similar to that of
quantitative studies of opioid and NSAID adherence which
have indicated that adverse effects such as GIT effects or
sedation contribute to cessation of these medications
]. Addiction or dependence arising from the use of
strong opioids did not appear to concern participants to the
same extent as other adverse outcomes. Although concerns
were vocalised by a few participants, this was balanced
with an acceptance of the role of strong opioids in pain
management and the potential that these medications might
be used on a long-term basis. This is at odds with numerous
studies with both patients and physicians which detail
concerns about opioid related aberrant behaviours and the
development of dependence or tolerance [
11, 12, 34–38
In addition, the potential for misuse of adjuvants was not
addressed by any participant. It is probable that this is due
to widespread public knowledge of the negative aspects of
strong opioids which is not associated with other drug
classes at present.
External factors can exert effects on the management of
the patient with CNMP. HCPs and social support networks
can influence the patient’s approach to coping with the
]. Positive interactions with these networks
can reduce stigma and encourage acceptance of both the
chronic pain condition and the necessity for long-term use
of analgesics and perhaps help to minimise stoicism of this
patient group reported in the literature [
particularly those responsible for prescribing medications,
contribute to a patient’s understanding and acceptance of
analgesics. A positive patient-physician relationship has
been demonstrated to reduce patient concerns and negative
perceptions of medication [
]. This study has
highlighted the supportive relationships between the
participants with their GPs and is contrary to that of similar
qualitative studies in which patients with CNMP have
described the feeling of being a burden to the GP or viewed
as a drug seeker by HCPs [
]. The shared decision
making with GPs described by participants is further
evidence of this supportive relationship. This is associated
with enhanced adherence to the medication regimen, with
patients also reporting a greater reduction in pain than
those managed through the paternalistic model .
Several participants in this study described a concern
that GPs lack sufficient knowledge on CNMP to provide
effective management in primary care. This concern is
echoed in empirical studies which have highlighted
insufficient focus on pain education within undergraduate
medicine curricula leading to a lack of confidence when
managing patients with CNMP [
]. Engagement with
clinicians is further hampered by ineffective
communication and co-ordination between primary care and specialists
as well as the difficulties in accessing specialist care. The
financial and geographical barriers to access were
referenced by all patients receiving care through the public
system, of particular significance to ageing and elderly
patients, the majority of whom are dependent on public
]. Furthermore, negative experiences in
specialist care or suboptimal analgesia achieved by clinical
interventions in this setting may cause the patient to return
to primary care seeking further interventions. This desire to
establish relationship continuity with a HCP has been
reported to be of high importance to older patients and
those with chronic conditions [
]. This study suggests that
a HCP with specialised clinical knowledge of CNMP, who
is easy to access and possesses good knowledge of the
patient’s medical history would be best placed to
co-ordinate and optimise management.
Patients are becoming an increasingly empowered group
with access to information independent of HCPs, mainly
via the internet [
]. Participants discussed their efforts to
self-educate together with incorporating
non-pharmacological interventions which supplemented or offset
analgesic use. These measures indicate a willingness to
selfmanage the condition, a behaviour associated with positive
health outcomes for CNMP including fewer GP and
hospital visits and improved health behaviours [
Previous studies have highlighted variability in the extent to
which older patients are prepared to participate in
selfmanagement . In essence, a willingness to self-manage
the condition may be an effort to self-regulate use of
analgesics, particularly those medications that patients
view in a negative light such as opioids; this theory of
selfregulating use of strong opioids has recently been reported
by Paterson et al. [
]. It should be considered that
engaging in self-management behaviours with a view to
offsetting medication use, as identified in this study, is a
potential barrier to optimising pain relief for the patient.
There are several limitations to this study. Participants
were members of CPI and self-selected into the study
which demonstrates a degree of self-empowerment and
interest in their condition. Such self-empowerment may not
be representative of the general ageing and elderly
population with CNMP [
]. Interviews were conducted by
telephone as this is an inexpensive, efficient method for
interviewing a relatively large number of participants
]. Telephone interviews also allowed individuals to
participate from a location which they could arrange to suit
their physical needs. The main disadvantage is the loss of
nonverbal cues gained from face-to-face interaction and the
opportunity to use visible aids during the discussion.
Finally, analysis of qualitative data may introduce bias into
the study as the researcher may approach the topic with
pre-formed opinions and ideas. We have sought to address
this through extensive documentation, auditing and
recording of recruitment and analytical strategies allowing
external parties to review the reflexivity of the research
This study described the factors affecting the use of
analgesics by ageing and elderly adults with CNMP. Internal
factors including efficacy of the analgesic together with the
perceived risks of the medication are specific to the patient
and influence the nature and extent of analgesic use.
External factors, such as poor access to pain specialists,
physiotherapists or other allied healthcare professionals,
affect the quality of management of the condition.
Awareness of these factors is of value to HCPs when
seeking to optimise analgesic use within this patient group.
Acknowledgments We thank the members of Chronic Pain Ireland
who agreed to take part in interviews for this project.
Funding This research was funded by the Health Research Board
(HRB) in Ireland under Grant No. PhD/2007/16.
Conflicts of interest The authors declared no potential conflicts of
interest with respect to the research, authorship, and/or publication of
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Introduction and information for
Demographic information and background
on pain condition
Impact of pain and pain medications
Statements/questions in interview guide
Describes the aims and objectives of the study
Can you tell me what is the cause of your chronic pain?
Duration of pain?
Impact of pain on activities of daily living?
Would you be able to name the painkillers that you take for your pain? (Prompt frequency)
Can you describe when you take prescribed pain medications (triggers)?
Are there certain times when you take more painkillers than others?
Do you get satisfactory pain relief from the prescribed pain medications you are currently taking?
Have you ever avoided taking prescribed painkillers? (Prompts-no perceived
benefit/cost/sideeffects/overuse) (if necessary follow-up)
Do you ever increase/reduce the number of tablets you take or avoid taking medication?
Participant Gender Age
Strong opioid, selective NSAID (oral), weak opioid, paracetamol/weak
opioid, non-selective NSAID (topical), muscle relaxant
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