Opioids And Older Adults: Addressing Both The Epidemic And Undertreated Pain

Today, federal and state governments, as well as hospitals and clinics, are struggling with the country's devastating opioid epidemic. With prescription pain medication abuse a driving factor, the focus has mostly been on younger and middle-aged people and restricting drug access. However, millions of older people experience chronic, even debilitating pain and desperately need relief. We must take a balanced approach so that older adults can continue to make contributions to their communities and families and continue to live well as they age.

Older adults and prescription drug problems
In recent years, the health care system, led by the Veterans Administration in 1999, began to treat pain as the "fifth vital sign." Needed painkiller prescriptions increased. The unintended result? An explosion of opioid addictions and overdoses, with an intergenerational ripple effect on grandparents, parents, young children and our overall society.

Older adults are not immune to the problems of abuse and addiction, and signs point to a growing problem. One study, presented at the American Academy of Addiction Psychiatry's (AAAP) 23rd Annual Meeting, reported that approximately one in five individuals aged 65 years and older take analgesics, including opioids, several times per week and that rates of abuse or addiction in those with chronic pain is 18 percent. The efforts underway to help clinicians recognize patients with drug problems and appropriately prescribe opioids must include a focus on our Medicare patients, in addition to younger adults.

Chronic pain should not be a constant companion simply because we age.
While concerns about addiction are warranted, we must also ensure adequate pain management in older people. Almost half of all adults over age 65 routinely live with pain, part of a larger and important public health challenge. Chronic pain in older adults comes from a variety of (and often multiple) sources--degenerative arthritis, nerve damage (from fibromyalgia, shingles and diabetes) and cancers.

Still, undertreatment remains a significant problem. We know that severity of pain is subjective, and can be particularly hard to diagnose and manage in the elderly. This health disparity must be addressed, just as variations in pain treatment based on race and ethnicity found in recent research from the University of Pennsylvania require similar attention.

Treating pain is a critical aspect of good health care, and sometimes opioids are the best option. A review of studies showed that short-term use of opioids in older non-cancer patients can be safe and effective, and the risk of abuse is negatively associated with age. Tightened restrictions on opioid use may present difficulties for the nearly 30 percent of those enrolled in Medicare Part D in 2015 who had at least one opioid prescription, as described by The New York Times' Paula Span.

Beyond opioids: drug and non-drug alternatives
Fortunately, opioids are not the only pain treatment options, and in fact, they should often be avoided in older adults. With aging, metabolism slows and side effects such as nausea, vomiting, constipation and falls are more frequent. Further, despite common expectations, opioids do not always work and may instead exacerbate the pain. Clinicians need to be conservative as long-term opioid use in general can be dangerous, and experts find that opioids may not be effective in terms of restoring activity and function.

In many cases, alternative therapies should be considered first. Physical therapy may be an important initial step, along with massage therapy. Clinicians in the community are also examining other evidence-based non-drug approaches to pain, including exercise, tai chi/yoga, cognitive behavioral therapy, and meditation. There are several places to access supervised programs at local senior centers, churches, Ys, on television and in online classes. Some older people may be able to eschew opiates all together, with combinations of non-opioid drug and non-drug alternatives, and manage their pain to tolerable levels. Currently, grantees of The John A. Hartford Foundation are developing standards and resources to limit opioid overuse during and after surgery and in the emergency room.

Moving to action
The opioid epidemic remains a national crisis, one that requires actions at all levels. The solutions must take the special needs of older people into account. The FDA, CDC and other groups have offered responses, for example, placing limits on various opiate formulations, constraining how clinicians can call in opiate refills, and providing a clearer sense of who will benefit from opioids and who should not receive them. These efforts should include a focus on older adults. At the same time, we need an approach that avoids unintentionally exacerbating the undertreatment of pain in elders. We need action that includes:

  • Further development, testing and prescription of pharmaceutical and non-pharmaceutical alternatives to opioids;
  • Clinical support necessary to help older people take on and manage drug and non-drug options for their pain; and
  • A commitment to more research into opioid use and its efficacy for chronic pain management.

For older people already addicted to opioids, we also need to create greater access to treatment services and social supports that can help them break their addictions and find new ways to take control of their pain and their lives. Together we can both stem the opioid epidemic and ensure that older adults get the pain management they need.

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