Issues, resources for covering opioid use among older adults

By Alan Cassels

We have an opioid crisis in the United States. Every day in this country there are 45 deaths and 30 emergency room visits due to the effects of these powerful painkillers, which include hydrocodone (Vicodin), oxycodone (such as OxyContin or Percocet), morphine (Kadian or Avinza), codeine, and related drugs, according to the CDC.

The use of such  drugs has increased by 300 percent in the last decade. In the second quarter of 2015, there were nearly 60 million outpatient prescriptions dispensed for the 13 leading opioid drugs, according to data from IMS Health Inc.

The Centers for Disease Control and Prevention (CDC) reported 18,893 overdose deaths in 2014 from licit and illicit use of opioids, a 14-percent increase from the previous year, emphasizing the public health risks of these drugs.

Poor and inappropriate prescribing among elderly people, especially instances of polypharmacy (the prescribing of multiple drugs) contributes to the risk of adverse drug reactions (ADRs).

While there are tools to try to prevent inappropriate prescribing in the elderly (such as the Beers Criteria and a Canadian tool called the Inappropriate Prescribing in the Elderly Tool (IPET), the prescribing of opioids in the elderly is a unique problem.

While it is widely believed that easy access to opioid medications comes from doctors being too liberal with their prescribing pad, the truth is more complex. The reality is that a range of painkillers are available, and Americans suffer from pain for a wide spectrum of reasons. Older patients are often offered opioids for their pain even if it might not be the best choice. The risk of becoming dependent on these drugs is well-known, yet there are few effective mechanisms to control their use.

For journalists assigned to cover prescription drugs or health issues among the elderly, here are some helpful basics about different types of pain medication, opioid prescribing to the elderly and what is driving the growth.

The use of opioids in the elderly merits special attention for several reasons:

• Drug to drug interactions: Older people typically have more chronic conditions and often their health needs necessitates multiple medications. As a physicians add more medications the chance for the patient to have a drug-to-drug interaction increases. Sometimes these interactions can be fatal.
• Slower metabolism: Older people are more likely to process drugs more slowly than younger people, so it takes longer for a drug to work its way through their system. In addition, because the elderly also are less likely to be active, and in some cases are bedridden, the active ingredients in many drugs can accumulate more rapidly in older people and that leads to more problems. An additional aggravating factor: the elderly often are prescribed much higher doses of opioids than are necessary to control their pain.
• Effects on functioning: Because of the above, as well as some genuine medical problems, older adults are more likely to experience side effects that include drowsiness, dizziness, falls, slower reaction times and more difficulty driving safely while taking opioids.
• Intolerability of other forms of pain relief: When choosing an opioid, the best evidence suggests a systematic and graduated approach, such as following the World Health Organization’s Analgesic Ladder (Medscape registration required). This suggests that physicians should start with non-opioid drugs and only gradually move the patient to weaker opioids or nonsteroidal anti-inflammatory drugs (NSAIDs). Keep in mind, though, that ne reason physicians are more apt to prescribe opioids to elderly patients is the fact that many older people cannot tolerate NSAIDs (stomach bleeding and interactions with other drugs are a side effect).

These above concerns often can mean a big potential problem with prescribing opioids for non-cancer-related pain in older people. Clinicians need to be especially aware of patients with dementia or cognitive difficulties and be trained to recognize pain in those unable to communicate.

Here are some comparative notes on the main opioid medications:

• Codeine: A weaker opioid that converts to morphine in the liver. Can lessen milder pain, but doesn’t work for all people.
• Morphine: Much more potent than codeine, but requires a user to have adequate kidney function so it won’t accumulate as easily. Should be used very cautiously in the elderly since many of them have reduced kidney function.
• Hydromorphone: Much more potent than morphine, so should only be used in very small doses. Considered a better choice for patients with impaired kidney function.
• Oxycodone: Is considered one of the better drugs for older adults, but is twice as potent as morphine.
• Fentanyl: For patients who can’t take opioids orally, this drug comes in a patch that releases the drug through the skin.
• Meperidine: Not recommended for older adults. Both the American Pain Society and the Institute for Safe Medication Practice do not recommend meperidine’s use by the elderly.
• Combination products: Codeine or oxycodone often are mixed with drugs like acetaminophen, ASA (aspirin) or ibuprofen. Physicians have to be careful with the amount of these additional products as they can case stomach bleeding, which can be fatal.

Data sources and Additional Reading

• Prescribing opioids in older adults: A guide to switching and choosing among them. Geriatrics and Aging, January/February. 2009 is a good primer on the issues.
• Adverse event reports: A source such as QuaterWatch, operated by the Institute for Safe Medication Practices, analyzes reports made to the FDA and provides important context.
• International comparisons on the use of opioids: A report from the Pain and Policy Studies Group at the University of Wisconsin-Madison, is a thorough source of data on global opioid use.
• Geriatrics and Aging: Guide to prescribing opioids in older adults. This report looks at use of opioid medications and challenge of using them in the older adult population.
• Centers for Disease Control, Deaths from Prescription Opioid Overdose. Has up-to-date data on overdose deaths related to opioids.
• Solving the problem of overprescribed opioids: Article from The Fix web site, January 28, 2013.
• Consumer Reports guide, Figuring Out Which Pain Reliever to Take, April, 2011, (covers non-opioid medications).
• New Standard of Care for Prescribing Opioids (from Medscape Nurses) July, 2015, contains links to more than a dozen federal and state guidelines on the prescribing of pain medications.
• U.S. Senate Committee on Finance report, Examination of links between pharmaceutical companies and the promotion of misleading information about narcotic painkillers. Unravels the complex ties between patient groups focused on pain and pharmaceutical manufacturers making pain medications.

Some issues to pursue

• What is driving the utilization of these drugs in the elderly?
• How have new prescribing restrictions (such as those imposed by the Drug Enforcement Administration on the hydrocodone-acetaminophen combination) affected patients, drug utilization and costs?
• How are rules around pain medication prescribing affected (or failed to affect) rates of adverse events among elderly opioid users?
• What is the role of the pharmaceutical industry in promoting (or preventing) rational use of opioids?
• What is continuing to drive the prescribing of opioid prescriptions? Which programs across the U.S. (and in other countries) are effective in curbing or reducing the health impact of these drugs?

Independent experts on opioids

• Dr. Andrew Kolodny, chief medical officer, executive director and co-founder of Physicians for Responsible Opioid Prescribing (PROP). Contact Jean Chu-Hsu, MA, his executive assistant, at (347) 396-0371, or via email at jchuhsu@phoenixhouse.org.
• Dr. Jane C. Ballantyne, professor of education and research in the Department of Anesthesiology and Pain Medicine at the University of Washington. Email is Jcb12@uw.edu.
• Dr. Irfan Dhalla, University of Toronto dhallai@smh.ca; (416) 864-6060, ext. 7113.
• Dr. David Juurlink, Sunnybrook Health Sciences Centre, Toronto. Email is dnj@ices.on.ca; (416) 480-4055, ext. 3039.