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. 2025 Jun 4;42(4):cmaf056.
doi: 10.1093/fampra/cmaf056.

Impact of eliciting treatment priorities on analgesic prescribing in older patients with high levels of polypharmacy

Caroline McCarthy  1 , Barbara Clyne  2 , Susan M Smith  3 , Fiona Boland  4 , Emma Wallace  5 , Michelle Flood  6 , Frank Moriarty  6
Affiliations

Impact of eliciting treatment priorities on analgesic prescribing in older patients with high levels of polypharmacy

Caroline McCarthy et al. Fam Pract. .

Abstract

Background: Multimorbidity guidelines recommend tailoring care to patients' priorities. The Supporting Prescribing in Multimorbidity in Primary Care (SPPiRE) trial focused on optimizing medicines use in older adults with significant polypharmacy and tailoring prescribing and deprescribing to individual priorities. This study aimed to compare self-reported and general practitioner (GP)-recorded patient priorities and examine the impact of prioritizing pain on analgesic prescribing.

Methods: This secondary cohort analysis of the SPPIRE trial and process evaluation assessed baseline participant-identified priorities and intervention group GP-recorded priorities during medication reviews with agreement assessed using Cohen's kappa. Analgesic prescribing patterns and daily morphine milligram equivalents changes during the study period were summarized. The impact of pain (self-reported, GP-recorded, and severe or extreme pain on the baseline EQ5D) on opioid intensification was analysed using multi-level models accounting for GP practice clustering and intervention effects.

Results: A total of 403 patients (mean age 76.5 years) were included; 178 (44.2%) reported pain as a priority at baseline. Agreement between self-reported and GP-recorded pain was poor (kappa 0.118, P = 0.05). Most analgesic prescriptions decreased during the study, except for potent opioids, which increased in both trial arms. All three pain variables were associated with increased odds of opioid intensification at follow-up.

Conclusion: In this older population of patients with significant polypharmacy, identifying pain as a priority was associated with an increased likelihood of opioid intensification, despite guidelines advising against their use for chronic pain. This study highlights the challenges faced by GPs treating pain in older adults with multimorbidity.

Plain language summary

Guidelines for managing patients with multiple health conditions recommend focusing on what matters most to patients. The Supporting Prescribing in Multimorbidity in Primary Care (SPPiRE) trial aimed to improve medication use in older adults prescribed ≥ 15 medicines by aligning prescribing decisions with individual patient priorities. This study analysed data from the SPPiRE trial to assess how often patients and general practitioners (GPs) agreed on treatment priorities and how prioritizing pain affected painkiller prescribing. This study included data on 403 older adults (average age 76.5 years), 178 of whom self-reported pain as a priority for treatment when returning postal questionnaires at the start of study. Overall, agreement between patients and GPs on treatment priorities was poor. When assessing changes in painkiller prescribing in all patients (those who had a medication review and those who did not) prescriptions for most painkillers reduced during the study period, but prescriptions for stronger opioids increased. When GPs recorded pain as a treatment priority during the medication review, patients were 2.73 times more likely to have their opioid prescribing intensified compared to patients whose pain was not recorded as a priority in their medication review. This is despite clinical practice guidelines advising not to use opioids to treat chronic pain.

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Conflict of interest statement

The authors have no conflicts of interest to disclose.

Figures

Figure 1.
Figure 1.
Multi-level logistic regression exploring the effect of self-reported pain, GP-recorded pain, or severe or extreme pain on the EQ5D-5L (compared to no pain) on opioid intensification. Models including both trial arms (n = 403) account for any potential effect of the intervention. All models adjust for clustering within GP practices, while adjusted models additionally control for age, gender, and the number of medicines at baseline.
Figure 2.
Figure 2.
Marginal predicted probability of opioid intensification by pain and allocation group. The reference group is patients in the control group with no self-reported pain. Predictions are adjusted for clustering within GP practices, age, gender, and number of medications. Error bars represent 95% confidence intervals.
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