Opioids and Older Adults

It’s not just young drug addicts who are dying of opiate use. A surprising number of people who would never describe themselves as drug dependent in fact are so. A surprising number of older people are addicted to opioids and the medical establishment may be implicated in the reasons why.

A recent study in JAMA, “Hospital Prescribing of Opioids to Medicare Beneficiaries” (Jena, 2016), concludes that of the patients who have never taken opioids before they were hospitalized, but were given a prescription for opioids when they were discharged from the hospital, as many as 42% filled a prescription for opioids 90 days after discharge. That means these patients were still wanting or needing the drugs three months after being released from the hospital.

There are, of course, good medical reasons for managing patient pain, even for using opioids to manage pain: orthopedic injuries, surgeries, chronic conditions requiring pain management. Research shows that failure to manage pain appropriately can interfere with rehabilitation regimes and have a negative effect on quality of life. On the other hand, opioids can lead to long term physical dependence. Should physicians be slower to prescribe these powerful drugs after hospitalization?

No one wants to be in pain if there is a remedy. This is true for people who are not hospitalized as well as for those who are. Older people may want very much to keep their pain at bay, and their sympathetic physicians prescribe medication to older patients who complain of pain from arthritis and cancer or other illnesses so common in later life. Sometimes, with the passage of time, people need more of the drug to manage pain, but the increase may have terrible consequences.

This problem has resulted from a lack of understanding of opiate use in the elderly. In 2009, the American Geriatric Society actually endorsed opioids, updating guidelines for pain management. The thought was that seniors would not become addicted. But physicians subsequently realized that there was no scientific basis for that idea, that the drug affects the brain, regardless of age. The guidelines are no longer in use; nonetheless opioid medications are frequently used to treat pain in the elderly. In the past 20 years, hospitalization among seniors because of opioid use has quintupled. The goal, according to Michael Barnett, assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health, is for physicians to prescribe safely and yet treat pain effectively.

The Wall Street Journal in its article, “Opioid Use Soars Among Middle Aged and Elderly” (April 23, 2017), reveals that the CDC (Centers for Disease Control and Prevention) reported that “Americans age 45 to 64 accounted for about 44% of deaths from overdoses in 2013 and 2014. And the proportion of adults 50 and older seeking treatment for opioid addiction has increased dramatically in recent decades.” In 2016, the CDC issued new guidelines for primary-care providers, who write 50% of the prescriptions for opioids. The new guidelines discourage use of opioids for chronic pain (other than for cancer patients and those at the end of life). For acute pain, following surgery or injury, the CDC urges doctors to prescribe the lowest effective dose in no greater quantity than needed for the duration of pain. However, a 2016 survey of the National Safety Council found that 99% of physicians prescribe opioids beyond the dosage limit recommended by the CDC.

And people don’t have to take much of the drug to get physically addicted. The U.S. News reported that even taking opioids for the first time can result in addiction. The senior medical advisor to the CDC was quoted as saying that the medical establishment overestimated the benefits of opioids and underestimated the risk. It doesn’t help that pharmaceutical companies aggressively marketed their opioids to physicians. Since 1995, when the FDA approved OxyContin, doctors have innocently prescribed OxyContin and other opioids (Vicodin, Percocet); the result has been addiction and overdose deaths.

Older patients should not blindly accept the prescription for opioid pain medication just because it was offered at discharge or because their doctor may recommend it. As people age, their risk for overdose increases. They often have long term intractable pain which requires medical management. But kidney and liver function slow with age which means the drugs remain in the body longer. Sometimes memory loss and confusion cause patients to take multiple doses of their medication. And many older patients take multiple medications.

There are alternatives and both doctors and patients should be open to trying options other than drugs for pain management, such as acupuncture, physical therapy, meditation, exercise, heat therapy, and others. Doctors need better education about opioid prescribing and use, and older patients need more counseling, treatment services, and social support as well as education. Few people anticipate problems such as physical addiction when their physician recommends a medication for pain. But patients need to understand the terrible risks.