Older Adults_Bars-Geriatric Pain

FAST FACTS: Safety Precautions for Opioid Use

Older adults are at higher risk of medication-induced side effects also called Adverse Effects (AEs) from opioid use due to normal changes related to aging.  Having two or more diseases or medical conditions (also known as co-morbidities) make older adults more at risk for adverse effects. Co-morbidities, such as cognitive impairment, kidney and/or liver dysfunction, and the use of multiple medications can all impact opioid AEs. Side effects of common pain treatments can be a deterrent to good pain control --- especially with older adults who are physically vulnerable. It is extremely important to communicate with your healthcare provider to monitor opioid use and follow all safety precautions.

Key Principles

  • Opioids
    Because older adults are more sensitive to medication AEs, monitoring for and preventing issues is important.
  • When prescribing opioids to older adults, healthcare providers should start at a lower dose and adjust the dose based on patient’s response and reported AEs.
  • The following medications should be avoided in older adults due to increased adverse effects in this population: meperidine and codeine.
  • The following medications should be used with caution in older adults due to unique safety profiles and concerns for serotonin syndrome (increased nerve cell activity) in patients on multiple medications: tapentadol and tramadol.  
  • Combination medications that include acetaminophen (i.e., Tylenol) or non-steroidal anti-inflammatory drugs (NSAIDSs) (e.g., ibuprofen, naproxen, etc.) should be used with caution because of the increased susceptibility to NSAID AEs, such as issues with the gastrointestinal, cardiovascular, and kidney systems in older adults.
  • Because constipation is a common opioid-induced AE in older adults, when starting on an opioid treatment the patient should also be prescribed a routine laxative. The dose of laxative should be increased as the dose of opioid is increased.
  • Tolerance, the body's normal response to continued exposure to a medication resulting in a reduction of the AE over time, can develop to most of the AEs of opioids, except constipation.

Overview of Common Opioid Adverse Effects (AEs)

  • Common opioid-induced AEs in older adults include constipation, nausea, dizziness, and urinary retention.
  • Older adults are also at a higher risk of falls and fractures when taking opioids.
  • Opioids have also been shown to increase the risk of delirium, (an acutely disturbed state of mind, characterized by restlessness, illusions, and incoherent thought or speech) in older adults. However, pain is also a cause of delirium in some.
  • Prolonged AEs should be proactively treated with further medication management to counter medication-related AEs or reducing or eliminating opioid use.

What else you can do

  • Report all information about AEs to your Healthcare provider
  • Use a Pain Diary to note important information (such as AEs) useful to the provider


  1. Argoff C, Brenna J, Camilleri M, Davies A, Fudin J. Consensus Recommendations on Initiating Prescription Therapies for Opioid-Induced Constipation. Pain Medicine, Volume 16, Issue 12, December 2015, Pages 2324-2337.
  2. Safety Considerations when using opioids for older adults. Jennifer Pruskowski PharmD, Rollin Wright MD, Neal Sprissler PharmD, Mamta Bhatnagar MD. Palliative Care Network of Wisconsin, accessed 12/17/2020.

Used with permission of K. Herr, PI, Cancer Pain in Elders: Promoting EBP's in Hospices; NCI Grant R01CA115363; Adapted from AHRQ Grant RO1 HS 10482; M. Titler; PI; Revised 2/7/07.

Revised 3/2020

PDF Download