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17 Articles in Volume 19, Issue #7
Analgesics of the Future: Inside the Potential of 3 Drug Delivery Systems
Balancing Pain Care - and Opioids - in the Aging Adult
Book Review: A Useful Guide for New Pain Practitioners
Correspondence: Opioid Tapering & Discontinuation
Effective Interventions for Post-Stroke Shoulder Subluxation and Pain
Family: Their Role and Impact on Pain Management
Introducing the "Phoenix Sign:" Improved Vascular Perfusion of the Dorsalis Pedis Artery after a Subanesthetic Dose of Lidocaine
Medication Management of Chronic Pain in Patients with Comorbid Cardiovascular Disease
Multisite Pain May Be Associated with Fractures in the Elderly
Reconciling the New HHS Opioid Tapering Guideline with CDC and State Policies
Research Insights: Impaired Motor Imagery in Chronic Pain Conditions
Tapentadol: A Real-World Look at Misuse, Abuse, and Diversion
Temporomandibular Disorders in Performance Artists (Part 2)
Thoracic Outlet Syndrome Presenting as an Acute Stroke Mimic
Untangling Chronic Pain and Hyperarousal with Heart Rate Variability: A Case Report
What topicals exist for post-herpetic neuralgia pain?
When to Keep Your License: Older Physicians and Boundary Issues

Balancing Pain Care - and Opioids - in the Aging Adult

Cary Reid, MD, PhD, explains why key opioid use trends among older adults should change the way you practice medicine.
Pages 43-46

Guest Commentary

It is hard not to pick up a newspaper without reading another story documenting the devastating consequences opioids have had on the health and lives of millions of Americans. Recent reports continue to paint a sobering picture. Of the more than 70,000 drug overdose deaths in 2017, over 47,000 (68%) were due to a prescription or an illicit opioid.1 In terms of its magnitude, many experts have compared the opioid crisis to the 1918 influenza pandemic which killed more than 650,000 US citizens,2 as well as the AIDs epidemic that has been responsible for over 700,000 deaths.3 Most of the news reporting and studies done to date have focused on young and middle-aged adults, while far fewer reports have examined the impact of this crisis in older adults, that is, those ages 65 and above. Gaining a full understanding of the effect of opioids in older adults is now needed for the many reasons discussed below.

Opioid Use Among Older Adults Matters

The number of older adults is rapidly growing — 20% of the US population will be 65 or older by the year 2050. In addition, older adults are far more likely than other age groups:

  • to experience chronic conditions (eg, osteoarthritis, cancer, neuropathies, osteoporotic-related fractures) where pain is the primary symptom
  • to sustain injuries requiring ER visits
  • to undergo surgery, which constitutes an important risk factor for persistent pain.

For example, up to 16% of individuals undergoing hernia repair surgery experience chronic pain following the procedure.4 All three of these outcomes serve as vehicles whereby older adults are exposed to myriad amounts of opioid medications for varying durations. Finally, several recent reports focused on older adults5-7 suggest sharp increases in misuse rates, as well as opioid-related hospitalizations and ER visits, further supporting the need to better characterize the prevalence rates and effects of opioids in this patient population.

Factors that may increase risk for adverse outcomes include the presence of frailty, polypharmacy, and multimorbidity, all of which are strongly associated with advancing age. Psychosocial stressors that could potentially lead to misuse and abuse of opioids in this age group include conditions that are common in this stage of life:

  • loss of a spouse, family members and/or friends
  • social isolation
  • financial strain
  • loss of purpose.

Furthermore, cognitive impairment rates are significant in this age group and may lead to difficulties using opioid medications as prescribed. Factors that likely mitigate opioid-related risk include the fact that deviant behaviors consistently decline with advancing age, while wellbeing and general satisfaction with life increase. Finally, multiple reports document that older adults remain skeptical of analgesic medications and endorse concerns about medication- related harm for themselves and others, which could serve to decrease risk.8-10

Older adults may face loss of family members, social isolation, financial strain, and loss of purpose - adding chronic pain to the mix requires specific healthcare intervention. (Image: iStock)

What is Known about Opioid Use in Later Life

The most recent prevalence data about opioid use in older adults come from two studies; one utilized 2015-2016 Part D Medical claims data, while the other used 2016 Medical Expenditure Panel Survey Household Component data.11,12 As recently as 2016, somewhere between 10 to 14 million older adults received at least one opioid prescription over a 12-month period, while as many as 3.6 to 5 million were identified as chronic users.11,12 In terms of adverse outcomes, one study documented a doubling of opioid misuse in older adults (defined as individuals 50 years of age and above) from 2002 through 2014.5 Overall rates of misuse, however, were considerably lower than the two other age groups (ie, 18 to 25 and 26 to 49) evaluated in the study.5

Another recent study documented a 54% increase in opioid-related hospital stays and a 100% increase in ER visits due to opioid use in older adults from 2010 through 2015.6 While this study did not provide comparative data for younger age groups, it did contrast rates of opioid-related hospitalization and ER visits with non-opioid causes. Hospitalizations and ER visits attributed to opioids made up far less than 1% of all hospitalizations and ER visits in this age group.

Finally, researchers recently analyzed Nationwide Emergency Department Sample data to investigate the prevalence of and factors associated with opioid-misuse related ER visits in older adults.7 This study documented a 220% increase in the rate of ER visits attributed to opioid misuse from 2006 through 2014. Factors associated with a greater likelihood of this outcome included number of chronic conditions, greater injury risk, and higher rates of alcohol abuse and dependence.7 While this rate increase is impressive, the total number of opioid-related events leading to ER visits was incredibly small (19,926) when compared to the corresponding number of ER visits attributed to non-opioid related causes (8,171,350) over the 9-year study. 

Collectively, these data tell us that a significant minority of older adults are prescribed opioid medications and that substantial increases have occurred in several salient outcomes, including rates of misuse, and opioid-related hospitalizations and ER visits. While these increases are particularly concerning from a service utilization standpoint, it is important to highlight that opioid-attributable causes continue to make up only a tiny fraction of all ER visits and hospitalizations.

What the Trends Mean for Researchers and Practitioners

The reasons underlying these increases remain unclear. Could these changes indicate a cohort effect with aging baby boomers moving into the older age category who possess different attitudes and beliefs about prescription medications to include opioids? Could the differences be due to increasing rates of polypharmacy, multimorbidity, and frailty, or an uptick in the number and magnitude of psychosocial stressors older adults experience, which could increase risk for opioid misuse? Alternatively, are clinicians simply doing a better job identifying these events because of a sensitization to the opioid crisis through social media and other sources? Worth noting, there is some evidence that a change in the number of diagnoses falling under the International Classification of Diseases allowed in patients’ discharge records (the mean number went from 3 in 1993 to 8 in 2012) may explain some of the observed differences.13 

From a research perspective, it will be important to determine whether the trends in opioid-related hospitalizations and ER visits and rates of misuse are continuing and to what degree. If they are, it will be important to determine the factors responsible for these temporal trends. Studies should also examine opioid prescribing trends by provider type. For example, to what extent are family physicians and other primary care physicians prescribing fewer opioid medications over time and are rates of opioid prescribing increasing among pain specialists? Given that many adults are now living well into their 80s and 90s, studies need to recruit across the full spectrum of older age and report outcomes for these subgroups, as risks for and the occurrence of specific outcomes are likely to vary greatly across the categories.

The clinical community also needs to ascertain factors that increase (and those that mitigate) opioid-related risk in older patients. These data can help clinicians make more informed decisions about whether to initiate an opioid trial in an older patient and whether to continue opioid therapy in long-term users. Finally, more research is needed to quantify the effects of state laws mandating dispensation of opioids, as well as drug prescription monitoring programs to include their possible salutary effects (eg, reduced rates of prescribing in individuals with known risk factors for opioid misuse), and to document possible unintended consequences (eg, long-term opioid users subjected to abrupt discontinuation of their opioid medication, difficulty accessing opioid medications among cancer and palliative care patients).

From a practice perspective, it is important that providers not lose sight of the fact that chronic pain is a common, morbid, and costly problem in older adults that deserves our full attention. We should not minimize the negative consequences of undertreated pain in the opioid epidemic era. The decision whether to initiate an opioid trial for the management of chronic non-cancer pain in an older patient remains vexing as does the decision to continue opioid therapy in long-term users. When deciding whether to initiate a trial in an older patient, efforts to reduce opioid-related risks are crucial given the increasing amount of data demonstrating opioid-related harms.

Risk Mitigation and Monitoring

Risk-mitigation strategies should be employed to include the use of screening tools, such as the Opioid Risk Tool,14 Screener and Opioid Assessment for Patients with Pain (SOAPP) for opioid naïve patients,15 and the Current Opioid Misuse Measure for patients on long-term therapy.16 These tools can help clinicians determine a patient’s risk of opioid misuse and guide their decisions regarding the extent of monitoring needed if an opioid trial is undertaken. Such monitoring should extend to the use of urine toxicology screens on a periodic basis.

Before older patients are prescribed an opioid medication, clinicians should be satisfied with arrangements for safe drug storage, given the risk for drug diversion. Beginning at the lowest possible dose and titrating upwards based on tolerability and efficacy is further recommended, given that age is associated with a greater incidence of treatment-related adverse effects. Careful surveillance (through frequent telephone contact or email) is mandatory after initiating an opioid trial to assess for evidence of efficacy and the occurrence of any negative side effects or toxicities. (See also fall risk and multisite pain risk in the elderly.)

How Does the CDC Guideline Fit Into Pain Care in the Aging Adult?

The 2016 CDC guideline17 on prescribing opioids for chronic pain was designed to help providers:

  • determine when to initiate opioids and provide guidance regarding the selection and dosing of opioids
  • establish whether treatment benefits are occurring and decide whether to continue opioid therapy
  • conduct risk assessments and address harm that occurs as a consequence of opioid use. 

While most of the recommendations appear reasonable for use in the care of older patients with chronic pain, several could lead to unintended consequences that warrant attention. For example, encouraging the use of non-opioid medications such as NSAIDs is likely to lead to negative health consequences via NSAID-related cardiovascular, gastrointestinal, and renal toxicities that are age-related. Encouraging the use of acetaminophen could likely lead to increased numbers of older patients with undertreated pain. Furthermore, strict implementation of the recommendation that patients must experience a clinically meaningful improvement in pain reduction and physical function enhancement (30% improvement for both outcomes) could lead to large numbers of older adults losing access to opioid medications. This is because many older adults have conditions (eg, advanced arthritis, spinal stenosis, post-stroke pain) where a meaningful improvement in function is unlikely to occur.  Furthermore, some patients may report that a 20% reduction in pain is a meaningful outcome for them.

Of note, the CDC’s recommendation to adopt a multimodal approach to managing pain is particularly appropriate in this age group and should be universally implemented. Clinicians should work to identify providers in their communities skilled in delivering non-pharmacologic modalities and encourage patients to try them (eg, movement- based therapies such as tai chi and yoga, psychological therapies such as mindfulness and acceptance and commitment therapy). Clinicians should encourage older patients to adopt and routinely use modalities they find helpful. Such an approach is likely to provide greater benefits and have the added advantage of lowering doses of analgesic medications and associated toxicities. 

The Bottom Line

Our overall challenge as clinicians is to balance the need to relieve chronic non-cancer pain and the consequences of inadequate treatment with the significant morbidity and mortality associated with opioid use over the past two decade. Achieving this balance in older patients is particularly challenging, but can be facilitated when clinicians start the process with a clear understanding of an older patient’s comorbidities, medication profile, cognitive and functional status, treatment goals and expectations, and resources, including their social and family supports.

Last updated on: December 9, 2019
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