While the article Pharmacological management of non-cancer pain in frail older people1 accurately summarises the current literature and clinical guidelines, it provides little help to GPs struggling to provide appropriate pain management for frail older people. The bottom line is that the drugs recommended for use have very little benefit. We have seen a huge increase in the prescription of gabapentinoids by GPs attempting to avoid prescribing opioids, but there is little evidence of their effectiveness, and the associated adverse effects are significant. Doses of gabapentinoids tend to be subtherapeutic.
The advice to refer to geriatricians and pain specialists is fine in theory, but aside from issues of access, there are no magic bullets, and patients generally return to a drug not recommended in the guidelines.
It is little wonder that GPs resort to low-dose opioids, particularly in nursing home settings, where mobility and function are more likely to be limited, and the priority is the relief of suffering. In the absence of better alternatives, I do not think GPs are prescribing inappropriately in this setting.
Peter Maguire
General practitioner, WA Country Health, Narrogin, WA
