Study reveals aged care’s painkiller dependence

Michelle Wisbey

6/03/2024 4:28:03 PM

Opioid painkiller usage in Australian facilities is 30-fold higher than in other countries, with an expert GP calling on colleagues to ‘think outside the box’.

Older women taking medication with head in hands.
Around 178,000 Australians aged 65 and older are currently living in permanent residential care.

Almost three in four Australian aged care residents are prescribed a regular painkiller medication, compared to just one in 10 equivalent patients in Japan.
That is according to a new joint study from Monash University and Japan’s Institute for Health Economics and Policy, aimed at better understanding the pharmacological management of pain in residential aged care.
Published in Age and Ageing, researchers also found the use of opioid painkiller medicines in aged care facilities is 30-fold higher in Australia compared to Japan.
The study compared the painkiller usage of 550 residents from 12 residential homes in South Australia to 333 people in four homes in Tokyo.
These residents were all similar in age, sex, and degree of cognitive impairment, as well as being broadly representative of aged care residents in Australia and Tokyo.
It also included the expertise from three focus groups with Australian and Japanese healthcare professionals.
The study’s lead author Laura Dowd said the research highlights the differences in therapeutic goals, painkiller regulations, and treatment durations between the two countries.
‘Australia and Japan both have rapidly ageing populations but appear to have very different patterns of painkiller use,’ she said.
‘Australian participants described their therapeutic goal was to alleviate pain, and reported painkillers were often prescribed on a regular basis.
‘[Meanwhile], Japanese participants described their therapeutic goal was to minimise impacts of pain on daily activities and reported opioid painkillers were prescribed for short-term durations, corresponding to episodes of pain.’
The research found oral acetaminophen paracetamol, non-steroidal anti-inflammatory drugs, and opioids were the most popular medications used.
Professor Dimity Pond, a GP with a special interest in aged care, said the research indicates a need for Australia to ‘think outside the box’ when it comes to prescribing painkillers.
‘If the Japanese can manage their older population with fewer medications than we do, then we need to know their secret,’ she told newsGP.
‘We need to unpack why that works for them and if it’s a possible route that we could follow to really improve the quality of life for our older patients.
‘As a society, we tend to say, “I’ve got pain, so I’ve had to take a painkiller”, whereas other societies look at it differently.’
Previous studies have confirmed up to one third of all Australian aged care residents are prescribed opioid painkiller medications.
But while prescriptions are high, Professor Pond said many non-pharmacological management tools can also be used alongside, or instead of, painkillers.
‘It’s actually not rocket science, but it just takes a different approach from what we’re used to,’ she said.
‘In Japan, they’re looking at activities for those older people and I’ve seen some great examples of Japanese facilities where they do a lot of activities, then you’re not concentrating on how awful you feel.
‘For us to implement this, that means more funding, and we could probably do a bit more within current constraints, but the resources, particularly residential aged care but also the community, they need to be pumped up.
‘Being pain free might not be the goal – the goal might be a good quality of life, which would include going for a walk, sitting out in the garden, going for a wander through some bit of a nursing home.’
Currently, around 178,000 Australians aged 65 and older are living in permanent residential care, with the number of women almost double the number of men.

At the same time, 95% of all older people see a GP at least once a year, and the highest rates of Pharmaceutical Benefits Scheme (PBS) prescriptions are dispensed among those aged 85 and over.
Professor Pond said Australia as a culture needs to reframe the way it thinks of ageing and aged care.
‘We think, “you can have fun, but then you get old and decrepit and end up in residential aged care”, which is awful,’ she said.
‘You can have a reasonable quality of life as an older person and even with dementia, you can enjoy life.
‘We need to change our view and whatever it takes to make life better, we need to take steps towards getting there.’
Professor Pond’s advice to her fellow GPs treating patients within residential aged care is to ‘not write them off’.
‘It’s all about function and improving people’s function as they get older,’ she said.
‘We need to look at the outcomes of our painkillers, are they working? Are they overdoing it? Is everyone asleep? So, we need to actually titrate what we give against observable outcomes.
‘Patients may not be able to tell us what they’re feeling if they’ve got cognitive impairment, but we can observe their behaviour and see if they’re over-sedated.’
Researchers said further investigation is now needed to examine the differences in acute and chronic opioid prescribing between the two nations.
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Dr Natalie Jonker   7/03/2024 8:09:02 AM

To compare to Japan is ludicrous. I happened to have an open appendicectomy while living in Japan and was not charted any analgesia post op.
I was in agonising pain for days and can still tear up remembering it.

A.Prof Paresh Dawda   7/03/2024 8:27:11 AM

Interesting paper and potential host of multiple factors. Would be useful to compare prevalence of opioid use in other like countries as well as palliative care perspectives. We undertook a study of opioid stewardship with a pharmacist-GP model - .

Getafix   7/03/2024 8:44:39 AM

In many part s of Africa no painkillers are used for the elderly. Does this mean pain is better managed in Africa than in Australia ?

Dr Kristen Elizabeth Riley   7/03/2024 9:48:37 AM

This is a frustratingly simplistic account and conclusion to draw of a complex and multidimensional problem. Whether Australian GP prescribing should change or be compared negatively to the Japanese example requires a much deeper dive to avoid making potentially unhelpful recommendations. Prescribing opiates for suffering at the point of care is the very tip of this iceberg & I'm not convinced that Japanese use of NSAIDS is an appropriate alternative. As a lifestyle medicine physician attending RACFs, my thinking outside of the box could only reach so far when the resources were inadequate to provide the lifestyle measures I'd prescribe.

Dr Graham James Lovell   7/03/2024 11:39:04 AM

I agree to a point, but it’s really hard having worked in 17 facilities over 4 decades, when the REAL ISSUE is NOT having them arrive Narcotic and Benzo Dependent from Hospitals and the Community.
And surely I think the focus should be on the post retirement period of 20-30 years,
and NOT yet more “RACF Bashing “ , which is the popular focus, when statistics show life expectancy is <1year for men and just over 2 years on entering an RACF in Australia!

Dr Peter James Maguire   7/03/2024 11:53:28 AM

I agree with the other comments - this does need a reality check. In a perfect world, residential aged care facilities might resemble upmarket health resorts, with massage available, and lots of fun activities. That is patently not where we are currently.

In a perfect world, we would prescribe prn immediate release opioids as per guidelines, but if we do that the medication isn't given, so many of prescribe long acting opioids to ensure the patient gets some pain relief. Most of them can't take NSAIDs.
A significant proportion of RACF residents are effectively palliative. Why should we restrict opioids in palliative patients just because they have dementia, not cancer? If I'm admitted to an RACF in my last years with advanced dementia, please step up the morphine!

Dr Edward Peter Collinson   7/03/2024 12:11:23 PM

This is not comparing eggs with eggs. Japan has far less obesity than Australia. Analgesia is needed to allow patients to do more. When I'm 'over the hill' and in pain I hope no-one following this advice is looking after me.

Dr Matthew Piche   7/03/2024 12:47:12 PM

Let's all think outside the square.
Tell your nursing home patients to take some panadol, and go for a walk.

Dr Peter James Strickland   7/03/2024 1:52:49 PM

I feel really sorry for Natalie Jonker --a few days of analgesia post -op for abdo. surgery is mandatory anywhere, surely! As a person who is just on 80 yrs old I have chronic aches and pains in legs, arms etc every day, but the solution is without doubt is physical exercise every single day ---this can be done by walking on land or in the ocean etc, bicycling, gardening, going to the gym, playing some active sport (even veteran hockey, golf, swimming club etc) . The secret here is one must PUFF with that exercise, or it is nowhere as valuable. Puffing brings oxygen to all areas of the body that are ailing, heals things faster, and relieves pain to a large extent in 'oldies' and youngsters. My parents and siblings got early dementia, and probably because they were 'couch potatoes' throughout most of adulthood. The only downside to 'puffing' exercise' though can sometimes muscle and joint injuries in oldies from tripping and falls, but one recovers much faster if aerobically fit.

Dr Maureen Anne Fitzsimon   7/03/2024 9:35:44 PM

What does “ participant” mean? Is this the opinion of the patient, or the treating practitioner? Many practitioners could boast about rarely prescribing painkillers, while the residents suffer unnecessarily. I eventually resigned from aged care, after 4 decades, when the family of a resident who was bed bound, paralysed down one side, buzzing because of pain over 20 times per night, with 6 months to live, told me that I must not prescribe painkillers. The home didn’t want conflict.

Prof Joachim Peter Sturmberg   8/03/2024 11:30:17 AM

Totally agree, physical activity interventions are first line treatments.

Reality - nursing homes are not funded to provide rehabilitative care services - patients after hip replacement have to manage on their own to get going again or become bed-bound. A current patient of mine is not getting physio following his humerus fracture - now having a painful stiff shoulder and nurses having great difficulties providing personal care. The regulator's and the funding authority's priorities are all upside down - and utterly inconsistent with good care that achieves quality of life.

Another reality - there are hardly any physios employed at nursing homes, and physios are only paid to provide pain management: 3-5 min message to painful area/per resident per (irregular) visit. That's not working to the "full scope of practice" - or did I miss something?

A.Prof Christopher David Hogan   9/03/2024 11:16:21 AM

Comparisons are odious- according to Oscar Wilde especially when only comparing one factor.
As a long term provider of aged care & at an age when my contempories & relatives are consumers I can safely say that Australia is now poorly caring for our aged.
GPs are in short supply- especially in Aged Care- they cannot afford to work there
RACFs are under funded & it is hard to find a facility with enough nurses to be actively engaged in care rather than coping with the severe paperwork burden.
People residing in aged care facilities are lonely , families are busy , friends are dead or sick.
Shut downs of facilities due to infections happens so often.
So do we have a opiate problem or an aged care systems failure?