Priority-Setting to Address the Geriatric Pharmacoparadox for Pain Management: A Nursing Home Stakeholder Delphi Study



Evidence to guide clinical decision making for pain management in nursing home residents is scant.


Our objective was to explore the extent of consensus among expert stakeholders regarding what analgesic issues should be prioritized for comparative-effectiveness studies of beneficial and adverse effects of analgesic regimens in nursing home residents.


Two stakeholder panels (nurses only and a mix of clinicians/researchers) were engaged (n = 83). During a three-round online modified Delphi process, participants rated and commented on the need for new evidence on nonopioid analgesic regimens and opioid regimens, short-term adverse effects, long-term adverse effects, comorbid conditions, and other factors in the nursing home setting (9-point scale; 1 = not essential to 9 = very essential to obtain new evidence). The quantitative data were analyzed to determine the existence of consensus using an approach from the RAND/UCLA Appropriateness Method User’s Manual. The qualitative data, consisting of participant explanations of their numeric ratings, were thematically analyzed by an experienced qualitative researcher.


For nursing home residents, evidence generation was deemed essential for opioids, gabapentin (alone or with serotonin norepinephrine reuptake inhibitors [SNRIs]), and nonsteroid anti-inflammatory drugs with SNRIs. Experts prioritized the following outcomes as essential: long-term adverse effects, including delirium, cognitive decline, and decline in activities of daily living (ADLs). Kidney disease and depression were deemed essential conditions to consider in studies of pain medications. Coprescribing analgesic regimens with benzodiazepines, sedating medications, serotonergic medications, and non-SNRI antidepressants were considered essential areas of study. Experts noted that additional study was essential in residents with moderate/severe cognitive impairment and limitations in ADLs.


Stakeholder priorities for more evidence reflect concerns related to treating medically complex residents with complex drug regimens and included long-term adverse effects, coprescribing, and sedating medications. Carefully conducted observational studies are needed to address the vast evidence gap for nursing home residents.

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Author information



Corresponding author

Correspondence to Kate L. Lapane.

Ethics declarations


This study was funded by a grant from the National Institute for Nursing Research (5R01NR016977; Principal Investigator: Kate L. Lapane) and supported by a grant from the National Institute on Aging (K24AG068300; Principal Investigator: Jennifer Tjia).

Conflicts of interest

Drs. Kate Lapane, Anne L. Hume, Bill Jesdale, Jayne Pawasauski, and Catherine Dubé have no conflicts of interest that are directly relevant to the content of this article. Dr. Jennifer Tjia is a consultant for CVS Health and Omnicare Long Term Care Pharmacy. Dr. Khodyakov is a leader of the ExpertLens team at RAND. ExpertLens was used to collect data for this study.

Availability of data and material

We are unable to share the data used to conduct this study per our institutional review board approval. The documents used to frame the panel questions are available from the authors on request.

Ethics Approval

This study was approved by the University of Massachusetts Medical School Institutional Review Board (protocol number H00011964) and the RAND Corporation.


Not applicable.


The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Author contributions

Drs. Lapane, Dubé, and Khodyakov had full access to all data in the study and are responsible for the data integrity and the accuracy of the data analysis. Study concept and design: Drs. Lapane, Dubé, Hume, Jesdale, Tjia, Pawasauskas, and Khodyakov. Acquisition of data: Drs. Hume, Lapane, Khodyakov, Tjia, and Pawasauskas. Interpretation of data: Drs. Lapane, Khodyakov, Tjia, Hume, Pawasauskas, and Dubé. Analysis: Drs. Khodyakov and Dubé. Preparation of manuscript: Drs. Lapane, Khodyakov, Hume, Pawasauskas, Tjia, and Dubé. Critical revision of manuscript for important intellectual content: Drs. Lapane, Jesdale, Hume, Tjia, Pawasauskas, Dubé, and Khodyakov. Obtained funding: Dr. Lapane. Study supervision: Dr. Lapane. The final manuscript was read and approved by all authors.

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Lapane, K.L., Dubé, C., Hume, A.L. et al. Priority-Setting to Address the Geriatric Pharmacoparadox for Pain Management: A Nursing Home Stakeholder Delphi Study. Drugs Aging 38, 327–340 (2021).

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