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Older adults and medical opioid use
Older adults are one of the largest demographic of Americans prescribed opioids for pain management. Approximately 50% of older adults experience daily pain and it is estimated that 10 million seniors fill at least one opioid prescription a year. A recent study found that a nearly nine-fold increase in opioid prescriptions from office-based medical visits by older adults occurred between 1995 and 2010.
Other research tracking prescribing in hospitals noted that one-third of older adults hospitalized for non-surgical conditions were prescribed opioids, suggesting that these medications were being prescribed to older adults who may not need them. Even more concerning is that, compared to the community setting, opioid use may be even higher in nursing homes, with one study finding one in seven nursing home residents receive long-term opioid prescriptions.
Older adults and nonmedical opioid use
These dramatic increases in medical opioid use have been paralleled by rises in nonmedical use (also called misuse). Nonmedical use is defined as taking a prescription opioid that was not prescribed to the user or in ways the prescriber did not intend (e.g., using in higher doses, improper ingestion method). Opioids can cause euphoria, mood elevation, pain relief, and extreme relaxation, making them prone to misuse.
Nonmedical use of opioids among older adults has been steadily rising for approximately two decades. A recent federal report showed that opioid misuse among older adults has nearly doubled since 2002. Even heroin has become a concern, with one study noting significant increases in the number of older adults seeking treatment for heroin addiction.
Vulnerability of older adults
This rise in opioid use and misuse is concerning because older adults are more vulnerable to the adverse effects of opioids than younger age groups. Older adults experience a variety of age-related changes that affect opioid absorption, distribution, metabolism, and elimination. For example, age-associated decline in kidney and liver functioning can compromise their ability to metabolize and eliminate opioids.
In addition to pharmacokinetic changes, older adults are prone to enhanced sensitivity to opioids (i.e., more pronounced effects at equivalent doses used in younger adults), which can cause over-sedation and accidents. Older adults are also at elevated risk due to social problems (financial difficulties, social isolation), psychological issues (depression, loss of memory), and physical ailments (lack of mobility, general ill health). Clinicians should keep in mind that these co-occurring issues can make screening for opioid use difficult, and older persons are less likely to admit misuse than younger age groups due to stigma.
Aging also carries an increasing risk of painful medical conditions, and the vast majority of older persons report having recently experienced some sort of pain. This may lead to the development or continuation of nonmedical use of opioids for pain relief because of their short-term analgesic effects. Additionally, older adults often take multiple medications, increasing their risk for adverse events stemming from drug reactions and interactions involving opioids. These unique risk factors place older adults at high risk for opioid-related hospitalizations and overdose deaths.
Opioid-related consequences among older adults
The prevalence of opioid-related emergency room visits, inpatient hospitalizations, and overdoses among older adults are not only high, but rising fast. From 2005 to 2011, for example, there was a 121% increase for older adults in the rate of prescription opioid-related emergency room visits. Additionally, recent CDC data show that the sharpest increase in opioid-related overdoses occurred in adults aged 55-64. And regarding opioid-related inpatient hospitalizations, the largest increases over the past decade were among patients age 65+ (85% increase).
Recent estimates have opioid-related hospitalizations costing the United States $15 billion annually, while overdoses due to opioids cost over $21 billion. The societal costs associated with these outcomes are also significant and impact workplaces, communities, individuals, and healthcare systems.
Unique challenges faced by older adults
The gold standard for treating opioid use disorders is pharmacotherapy and involves the use of medications such as methadone, buprenorphine, and naltrexone. The problem is that the majority of older adults are covered by Medicare and securing coverage for these medications through the prescription drug benefit (known as part D) has been challenging.
The first roadblock is that Medicare Part D does not cover methadone to treat opioid use disorder in an outpatient setting, even when a doctor is willing to prescribe. Medicare Part D may help to cover the cost of buprenorphine, but that’s only if the patient can find a buprenorphine-waivered prescriber who participates in Medicare, accepts the assignment, and deems the prescription medically necessary. This can be particularly difficult for older adults in rural areas. Even if the patient is able to meet these requirements, the cost of the medication is usually only covered in part.
Beyond Medicare coverage, stigma is a major barrier to treatment for older adults. While stigma is not unique to older adults, it can be pronounced among this age group. Because of this, older adults are more reluctant to seek treatment or admit their opioid misuse to others.
With this in mind, providers should know that older adults are known to respond more to a supportive, non-confrontational approach than more assertive styles of assessment and intervention. Clinicians should speak to older adults about their opioid use not with the intent of identifying an “abuser,” but within the context of a global assessment and with the goal of overall health promotion.
The fact that interventions are rarely tailored to the specific needs of older adults is also problematic. Screening tools used to identify opioid misuse among older adults are often not designed specifically for this age group. As a result, these instruments often fail to identify opioid misuse among older clients.
Additionally, programs that treat opioid use disorder are rarely designed specifically for clients of an older age. In fact, it is estimated that only 18% of treatment programs in the United States are designed with older adults in mind. It is also uncommon for support groups like Narcotics Anonymous to be tailored to this age group, which can limit their benefit for older adults. Modifications to traditional support groups, such as slowing the pace of the meeting to reflect cognitive changes in aging, might be needed in order for older adults to benefit and feel welcomed.
Fortunately, there is reason for optimism. Congress is currently considering allowing Medicare to cover methadone treatment. Legislation has been introduced and a federal commission on the opioid epidemic has recommended this be done. If this bill is passed, more older adults who need methadone would have access to it, which could help lower opioid-related hospitalizations and deaths.
As far as lowering stigma among older adults, research shows that self-stigma can be reduced through therapeutic interventions such as group-based acceptance and commitment therapy, while social stigma can be reduced through motivational interviewing and communicating positive stories of people with substance use disorders. Clinicians would also do well to familiarize themselves with “elder-friendly” treatment programs and self-help groups to which they can refer their older adult clients. As a group at high risk, older adults deserve specialized attention and interventions that take their unique needs into account.
