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Opioids in older adults

Drug-class library

Opioids in older adults are the clearest case in this whole subject where both errors are real and both do damage. Untreated severe pain is not a safe alternative to opioid therapy, and neither is a taper imposed on someone who did not agree to it.

Before you read on

Never stop or change a prescribed medication without speaking to your own prescriber. Several of the classes described on this site rebound, or cause a withdrawal syndrome, when they are stopped abruptly, and some have to be reduced gradually over weeks or months under supervision. Nothing here is advice about your own medication, and nothing here is a reason to change anything on your own.

The framing this site uses, and why

Stewardship here does not mean zero. It means that a person on an opioid is either being helped by it or being reconsidered, that the reconsideration happens with them, and that nobody is left in withdrawal or in untreated pain because a number on a chart looked wrong to someone who never met them.

That is not a soft position. It is the position of the regulator. The CDC’s 2022 Clinical Practice Guideline for Prescribing Opioids for Pain — which replaced the 2016 guideline — is unusually direct about what went wrong with its predecessor.

What the CDC said about the misapplication of its own guideline

The 2022 guideline states that policies “purportedly drawn from” the 2016 guideline went well beyond its recommendations, including “rapid opioid tapers and abrupt discontinuation without collaboration with patients, rigid application of opioid dosage thresholds… and patient dismissal and abandonment,” and that these actions “have contributed to patient harm, including untreated and undertreated pain, serious withdrawal symptoms, worsening pain outcomes, psychological distress, overdose, and suicidal ideation and behavior.”

What changed in 2022

  • Scope widened from chronic pain only to acute (under one month), subacute (one to three months) and chronic (over three months) pain, and the audience widened beyond physicians.
  • Recommendations on tapering were substantially expanded.
  • Hard dosage thresholds were removed from the recommendation statements — deliberately, “to discourage the misapplication of opioid pain medication dosage thresholds as inflexible standards.” Dosage material moved to implementation considerations.
  • Exclusions stated explicitly: the guideline does not apply to sickle cell disease pain, cancer-related pain, palliative care or end-of-life care.

On not stopping abruptly

The recommendation itself: “Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages.”

And the reasoning: “Unless there is a life-threatening issue such as warning signs of an imminent overdose, the benefits of rapidly tapering or abruptly discontinuing opioids are unlikely to outweigh the substantial risks of these practices.”

Current FDA-approved opioid labeling says the same thing in the highlights section: do not rapidly reduce or abruptly discontinue in a physically dependent patient, “because rapid reduction or abrupt discontinuation of opioid analgesics has resulted in serious withdrawal symptoms, uncontrolled pain, and suicide.” The label adds that abrupt discontinuation “has also been associated with attempts to find other sources of opioid analgesics, which may be confused with drug-seeking.”

What the tapering-harm studies found

Three large observational studies, all of which state their own causal limits.

  • Among 113,618 US adults prescribed a stable mean of 50 morphine milligram equivalents per day or more for twelve months, mean age 57.7, tapering was associated with adjusted incidence rate ratios of 1.68 (95% CI 1.53 to 1.85) for overdose and 2.28 (95% CI 1.96 to 2.65) for mental health crisis. Speed mattered: each 10% increase in maximum monthly dose-reduction velocity raised those ratios further. The authors state that “interpretation is limited by the observational study design.”
  • A follow-up by the same group, using an exposure-crossover design in which each patient serves as their own control, found the elevated risk persisted 12 to 24 months after taper initiation — adjusted incidence rate ratios 1.57 (95% CI 1.42 to 1.74) for overdose or withdrawal and 1.52 (95% CI 1.35 to 1.71) for mental health crisis. This is a follow-up, not an independent replication.
  • Among 1,394,102 Veterans Health Administration patients with an outpatient opioid prescription, hazard ratios for death from overdose or suicide after stopping rose with how long the person had been treated: 1.67 at 30 days or less, 2.80 at 31 to 90 days, 3.95 at 91 to 400 days, and 6.77 beyond 400 days. The authors write that “the associations observed cannot be assumed to be causal.” Notably, death rates rose after both starting and stopping.

What the risks of continuing are, in older adults specifically

  • Fracture. Among 12,436 opioid initiators with arthritis, mean age 81, versus 4,874 NSAID initiators, the hazard ratio for hip, humerus, ulna or wrist fracture was 4.9 (95% CI 3.5 to 6.9). The differential between short-acting and long-acting agents was apparent only in the first two weeks after starting.
  • Comparative safety. In propensity-matched Medicare cohorts, mean age 80, opioids versus non-selective NSAIDs showed a fracture hazard ratio of 4.47 (95% CI 3.12 to 6.41) and all-cause mortality hazard ratio 1.87 (95% CI 1.39 to 2.53). These are observational comparisons in frail 80-year-olds and residual confounding by indication is the obvious alternative explanation — sicker people get opioids.
  • Delirium. A systematic review of prospective studies found opioids associated with 2.5-fold increased odds of delirium in older adults at risk. The same authors add the necessary counterweight: untreated severe pain can itself trigger delirium.
  • Co-prescribing with benzodiazepines. Among 71,248 Medicare Part D beneficiaries filling an opioid prescription, mean age 66.5, 29.0% were concurrently using a benzodiazepine and 68.4% of those had more than 180 days of overlap. Hazard ratio for opioid-related overdose versus opioid alone was 5.05 (95% CI 3.68 to 6.93) in the first 90 days, falling to 1.87 (95% CI 1.25 to 2.80) for days 91 to 180. Benzodiazepines.

What the evidence does and does not show

Sedating medications impair gait, balance and reaction time, and their labels say so. That part is not in doubt. What has not been shown is that a deprescribing program reduces fall rates — the trials that tested it were small, short, and mostly measured a medication count rather than a fracture. Those are two different questions, and absence of evidence from underpowered trials is not evidence that the drugs do not cause falls. What the evidence actually shows about deprescribing and falls.

When a reduction goes well

It can. A systematic review of 67 studies — 11 randomized trials and 56 observational — found that among 40 studies examining patient outcomes after dose reduction, improvement was reported in pain severity, function and quality of life. The essential qualifier, which must travel with that finding: overall evidence quality was rated very low, with study quality good in only 3 studies, fair in 13 and poor in 51.

The 2022 CDC guideline puts the same point clinically: “after slow, voluntary reduction of long-term opioid dosages, patients might experience improvements in function, quality of life, anxiety, and mood without worsening pain or with decreased pain levels.” Note the two adjectives — slow, and voluntary.

When patient and clinician disagree

The guideline addresses this directly, and its language is the model this site follows: “When patients and clinicians are unable to arrive at a consensus on the assessment of benefits and risks, clinicians should acknowledge this discordance, express empathy, and seek to implement treatment changes in a patient-centered manner while avoiding patient abandonment… Patient agreement and interest in tapering is likely to be a key component of successful tapers.”

Rate, where a reduction is agreed

Two authoritative sources give different figures, and both are correct for the population they describe. Do not blend them.

  • CDC 2022, for patients on opioids for a year or longer: “Tapers of approximately 10% per month or slower are likely to be better tolerated than more rapid tapers.” For shorter durations, a decrease of about 10% of the original dose per week or slower until roughly 30% of the original dose is reached. It adds that “at times, tapers might have to be paused and restarted again when the patient is ready.”
  • FDA-approved opioid labeling: “initiate the taper by a small enough increment (e.g., no greater than 10% to 25% of the total daily dose) to avoid withdrawal symptoms, and proceed with dose-lowering at an interval of every 2 to 4 weeks,” with the note that patients treated for briefer periods may tolerate a faster taper.

Both documents say the same thing about individualization. FDA: “There are no standard opioid tapering schedules that are suitable for all patients. Good clinical practice dictates a patient-specific plan to taper the dose of the opioid gradually.” And: “It is important to ensure ongoing care of the patient and to agree on an appropriate tapering schedule and follow-up plan so that patient and provider goals and expectations are clear and realistic.”

Common questions

Does DWARAA think older adults should not take opioids?

No. DWARAA takes no position on any individual’s prescription and does not prescribe or deprescribe anything. The position on the evidence is that risk in this class concentrates at initiation and at abrupt stopping rather than in stable treatment, and that a reduction agreed with the patient is a different intervention, with different outcomes, from one imposed on them. Tapering principles.

Is it dangerous to stop an opioid?

Stopping abruptly can be. The CDC guideline says opioid therapy should not be discontinued abruptly absent a life-threatening issue, and FDA-approved labeling warns that rapid reduction or abrupt discontinuation has resulted in serious withdrawal symptoms, uncontrolled pain and suicide. This is precisely why no one should change an opioid dose without their own prescriber. What the trials measure.

What about someone who cannot tell you they are in pain?

That is one of the most consequential situations in long-term care, because untreated pain presents as agitation and agitation gets treated with something sedating. A cluster randomized trial of 352 nursing home residents with dementia found a stepwise pain-treatment protocol reduced agitation by an average of 17% over eight weeks. Pain in residents who cannot tell you.

Back to the drug-class library.

References

  1. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recommendations and Reports. 2022;71(3):1–95. PMID 36327391 · DOI 10.15585/mmwr.rr7103a1.
  2. Agnoli A, Xing G, Tancredi DJ, Magnan E, Jerant A, Fenton JJ. Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids. JAMA. 2021;326(5):411–419. PMID 34342618 · DOI 10.1001/jama.2021.11013.
  3. Fenton JJ, Magnan E, Tseregounis IE, Xing G, Agnoli AL, Tancredi DJ. Long-term Risk of Overdose or Mental Health Crisis After Opioid Dose Tapering. JAMA Network Open. 2022;5(6):e2216726. PMID 35696163 · DOI 10.1001/jamanetworkopen.2022.16726. Same research group as Agnoli 2021 — a follow-up, not an independent replication.
  4. Oliva EM, Bowe T, Manhapra A, et al. Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. BMJ. 2020;368:m283. PMID 32131996 · DOI 10.1136/bmj.m283.
  5. Miller M, Stürmer T, Azrael D, Levin R, Solomon DH. Opioid analgesics and the risk of fractures in older adults with arthritis. Journal of the American Geriatrics Society. 2011;59(3):430–438. PMID 21391934 · DOI 10.1111/j.1532-5415.2011.03318.x.
  6. Solomon DH, Rassen JA, Glynn RJ, Lee J, Levin R, Schneeweiss S. The comparative safety of analgesics in older adults with arthritis. Archives of Internal Medicine. 2010;170(22):1968–1976. PMID 21149752 · DOI 10.1001/archinternmed.2010.391.
  7. Clegg A, Young JB. Which medications to avoid in people at risk of delirium: a systematic review. Age and Ageing. 2011;40(1):23–29. PMID 21068014 · DOI 10.1093/ageing/afq140.
  8. Hernandez I, He M, Brooks MM, Zhang Y. Exposure-Response Association Between Concurrent Opioid and Benzodiazepine Use and Risk of Opioid-Related Overdose in Medicare Part D Beneficiaries. JAMA Network Open. 2018;1(2):e180919. PMID 30646080 · DOI 10.1001/jamanetworkopen.2018.0919.
  9. Frank JW, Lovejoy TI, Becker WC, et al. Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review. Annals of Internal Medicine. 2017;167(3):181–191. PMID 28715848 · DOI 10.7326/M17-0598.
  10. Darnall BD, Ziadni MS, Stieg RL, Mackey IG, Kao MC, Flood P. Patient-Centered Prescription Opioid Tapering in Community Outpatients With Chronic Pain. JAMA Internal Medicine. 2018;178(5):707–708. PMID 29459978 · DOI 10.1001/jamainternmed.2017.8709. Research letter, not a randomized trial.
  11. U.S. Department of Health and Human Services. HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. October 28, 2019. hhs.gov. 2019. https://nida.nih.gov/nidamed-medical-health-professionals/opioid-crisis-pain-management/hhs-guide-clinicians-appropriate-dosage-reduction-or-discontinuation-long-term-opioid.
  12. Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ. 2011;343:d4065. PMID 21765198 · DOI 10.1136/bmj.d4065.
  13. Lee J, Negm A, Peters R, Wong EKC, Holbrook A. Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: a systematic review and meta-analysis. BMJ Open. 2021;11(2):e035978. PMID 33568364 · DOI 10.1136/bmjopen-2019-035978.
  14. Dyer SM, Kwok WS, Suen J, et al. Interventions for preventing falls in older people in care facilities. Cochrane Database of Systematic Reviews. 2025;8(8):CD016064. PMID 40832852 · DOI 10.1002/14651858.CD016064.

Bibliographic records on this page were retrieved from PubMed. Every reference links to its DOI or PubMed record.

Written and medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, founder and medical director of DWARAA. Last reviewed . This page is educational. DWARAA does not prescribe, deprescribe, diagnose or treat.