In another study involving older patients with restrictive back pain, the pain was frequently short-lived and episodic and did not increase with age.27 And in a population sample in Norway, the mean number of pain sites decreased slightly over 14 years in those older than 60 years, while increasing in those aged 44 to 60.28 Another study of patients with knee osteoarthritis identified factors that were protective against a decline in pain-related function: These included good mental health, self-efficacy, social support, and greater activity—but not younger age.29 The enormous heterogeneity in both the experience and the course of pain suggests that age-related pain progression is neither universal nor expected—and contradicts a purely biological paradigm in which pain inevitably worsens over time.
Stereotype #3: Stoicism leads to pain tolerance
Some patients believe that the inability to deal with pain is a sign of being soft or weak, and that a “tough it out” approach makes pain easier to tolerate.7 In one survey, older adults were more likely than their younger counterparts to express such stoicism, frequently agreeing with statements like, “I maintain my pride and keep a stiff upper lip when in pain,” “I go on as if nothing had happened …,” and “Pain is something that should be ignored.” 30
Unfortunately, some physicians reinforce such attitudes, telling older patients, in effect, that they’d better “get used to it.”10 And family and friends may make it worse. Patients taking opioids reported that it wasn’t unusual for those close to them to view their use of these analgesics as a sign of weakness.31
Does stoicism help? Probably not
Older adults seem less likely than younger adults to label a sensation as painful, suggesting a more stoic approach in general.30 While some research has found that nociception—the perception of pain in response to painful stimuli—decreases with advancing age,32 other studies have found the opposite.33 And population-based studies focusing on the consequences of pain indicate that it continues to have powerful negative effects, especially depression and insomnia, in older patients.
The degree of pain experienced is more strongly associated with depression in older patients compared with younger adults,34 and greater pain reduces the likelihood that depression will improve with treatment.35 Pain also continues to interfere with sleep. In one national sample, 25% of those with arthritis said they suffered from insomnia, roughly twice the prevalence of insomnia found in those without arthritis.36 In another study, individuals with arthritis were 3 times more likely to have sleep problems compared with individuals without arthritis37—an association independent of age. Being stoic about pain, it appears, does not diminish its consequences over time or help patients better tolerate it.
Stereotype #4: Prescription analgesics are highly addictive
Patients often think that prescription analgesics, especially opioids, are highly addictive or harmful—and older adults may refuse to take them for fear of becoming addicted.7 The stereotype is often shared by family and friends, as well as clinicians.
In one study, one-third of physicians said they hesitated to prescribe opioid medications to older adults because of the risk of addiction (a concern that no clinician with training in geriatrics shared).38 What’s more, 16% of the physicians estimated that about one in 4 older patients receiving chronic opioid therapy becomes addicted. The actual risk is far lower. (More on that below.) News reports of an epidemic of prescription opioid addictions and fatalities,39 including the assertion that opioids are replacing heroin as the primary drug of choice on the street,40 may reinforce such stereotypes.
How great is the risk of addiction? For older adults, it’s very low
While rates of aberrant opioid use vary widely depending on the context, one consistent theme is that older age is associated with decreased risk.41 In one retrospective cohort study of older patients who had recently been started on an opioid medication for the treatment of chronic pain, only 3% showed evidence of behaviors associated with abuse or misuse.42
What’s more, long-term opioid use among older patients with painful conditions is relatively uncommon, and prescription patterns suggest that most older adults discontinue opioids after one or 2 prescriptions.42-44 Decades of research have found that, although opioid medications can cause physiological dependence, addiction is rare in patients treated with them.45,46 (To learn more, see “Diagnosing and treating opioid dependence,” J Fam Pract. 2012;61: 588-597.)
Debunking myths: Implications for practice
Our findings—that pain is not a natural part of aging and often improves or remains stable over time, stoicism does not lead to acclimation, and pain medications are not highly addictive in older adults—make it clear that the stereotypes we identified are misconceptions of pain in later life. Debunking these stereotypes has several implications for clinical practice. We recommend the following: