Reducing controlled painkillers helped explain fewer falls in older people with spinal stenosis

Design

Secondary and mediation analysis of a randomised controlled trial (BOOST)

Population

435 older people with neurogenic claudication, UK

Primary outcome

Controlled pain medication use and mediators of falls

Effect

Controlled medication at 6 months OR 0.62 (0.40–0.96) vs best practice; reduction mediated part of 12-month fall reduction

Controlled pain medicines — opioids, and in the UK gabapentinoids — are commonly prescribed for neurogenic claudication and raise fall risk. The BOOST randomised trial had already shown that a physical and psychological group programme improved walking and reduced falls at 12 months in older people with neurogenic claudication. This secondary and mediation analysis of 435 participants asked whether medication change was part of the mechanism.

At baseline, 63% took some pain medicine and 34% at least one controlled drug. At six months, the programme was more effective than best-practice advice at reducing controlled medication (OR 0.62, 95% CI 0.40 to 0.96), though the difference narrowed by 12 months. Pain improved modestly. Among the factors mediating the 12-month fall reduction, reduction in controlled pain medication in the first six months stood out.

The lesson for geriatric practice is that an exercise-based programme with a psychological component can make deprescribing achievable, and the mediation analysis suggests that reducing these drugs contributes to falls prevention. In India, tramadol and pregabalin are widely prescribed for back and leg pain in older adults with little review.

• Review every opioid, tramadol and gabapentinoid in older people with spinal stenosis or claudication pain.
• Refer to a structured exercise and pain-coping programme as the route to reducing those drugs.
• Taper controlled pain medicines gradually with a written plan, rather than stopping abruptly.
• Ask about falls and near-misses at every review of pain medication.
• Revisit at 12 months, when the medication gains in BOOST had started to fade.

Why it matters

It suggests that reducing controlled pain drugs is part of how an exercise programme prevents falls, not a separate task.

Don't overread it

A secondary mediation analysis; the medication effect narrowed by 12 months and mediation does not prove causation.

The statistics, in plain English

An odds ratio of 0.62 means the odds of still taking a controlled pain drug at six months were about 40% lower with the programme. Mediation analysis estimates how much of a treatment's effect travels through a particular pathway; it depends on assumptions that cannot all be checked.

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