Opioids in Older Adults: Indications, Prescribing, Complications, and Alternative Therapies for Primary Care

doi:10.1016/j.mayocp.2020.02.002

Mayo Clinic Proceedings

Volume 95, Issue 4, April 2020, Pages 793-800

https://doi.org/10.1016/j.mayocp.2020.02.002 Get rights and content

Abstract

The fact that opioids are valuable tools for the management of pain has been known and used for thousands of years. Currently, millions of Americans are treated annually with opioids, and many of these patients are elderly. Opioids present risks to geriatric patients, some of which are unique to the population, and providers should have a good grasp of those risks. An understanding of how to select appropriate medications for the management of pain and of the myriad of alternatives available for pain management is vital to the care of older patients. This article presents a review, for primary care providers, of issues unique to opioid management in older adults.

Section snippets

Indications

For thousands of years, opioids have been the mainstay of management of acute, severe, and terminal pain. Indications for opioid therapy are well established for patients with these conditions, but the utility of opioids in chronic, non–cancer-related disease states is less established.⁸ Although pharmaceutical developments have increased the availability of nonopioid options in recent decades, many geriatric patients have comorbidities that preclude the use of many other classes of medications

Appropriate Prescribing

In March 2016, the CDC published guidelines for opioid prescribing.¹⁰ As the most evidence-based opioid guidelines to date, these recommendations contain 12 points concerning opioid prescribing to adults. Although specific dose limits for long-term use are discussed, the focus is on appropriate selection, screening, and monitoring of patients using opioids long-term. The guidelines were specifically intended to inform primary care providers who provide long-term opioid therapy to patients.

Complications

Most strong opioids, including buprenorphine, fentanyl, hydromorphone, morphine, and oxycodone, are often recommended equally in older adults to control pain. However, methadone is not included routinely as a first-line opioid medication in older adults because of a variety of potential complications, including prolongation of the corrected QT interval, high drug-drug interactions, and a long elimination half-life, producing greater toxicity.¹⁷^,¹⁸

The physiologic changes of aging additionally

Alternative Therapies

The treatment of pain, including chronic pain, is multifaceted and should involve a multidisciplinary approach. Nonopioid medication options include the following:

•
Scheduled acetaminophen should be considered first-line treatment for acute and chronic pain, paying attention to safe daily doses.²⁸ Although there is limited evidence for the efficacy of acetaminophen in the treatment of chronic pain conditions, the lower adverse effect profile and the potential of acetaminophen contributing to an

Conclusion

Opioids remain some of the most potent pain relievers known. However, the current climate of opioid prescribing in the United States, given the opioid crisis, is driving many providers to either severely limit the opioids they prescribe or cease prescribing them altogether. Although there is excellent evidence for caution, particularly in the geriatric population, it is also important for primary care providers to understand not only appropriate indications for prescribing but also how to

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Burden of Chronic and Heavy Opioid Use Among Elderly Community Dwellers in the U.S.
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Opioid overprescribing may fuel the opioid epidemic and increase the risk of complications of opioid misuse. This study examined trends and determinants of chronic and heavy opioid use among elderly community dwellers in the U.S.
Medicare Current Beneficiary Surveys data from 2006 to 2019 were used. Common opioid medications were identified in the prescription medication files (n=47,264). Chronic users were defined as those receiving 6 or more opioid prescriptions within a year or on medication for 3 or more months, and heavy users were those having an average daily dose of 90 or more morphine milligram equivalents or 3,780 morphine milligram equivalents or more per continuous treatment episode.
One in 6 elderly community dwellers ever used opioids during the study period. Chronic users were more likely to be women than men (68.9% vs 31.1%, p<0.001). Of all survey participants, 4.3% were chronic users, and 2.8% were heavy users. Among ever users, 27.7% were chronic users, and 18.1% were heavy users. The rate of opioid use rose from 12.1% in 2006, peaked at 22.8% in 2013, and decreased to 11.7% in 2019. Chronic use was 5.1%, 10.7%, and 7.6%, respectively. Heavy use was 5.5%, 10.7%, and 7.6%, respectively. However, for chronic and heavy users, there was no significant difference in the median opioid dosage and opioid duration between males and females.
Among elderly Medicare beneficiaries, opioid prescriptions have been decreasing since 2013. However, a substantial number of elderly people were chronic and heavy users, calling for better opioid management among them.
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Poor pain management remains a major barrier to high-quality care for patients facing serious illness. Palliative care clinicians have the ability to provide safe and effective pain control for the majority of patients through the appropriate dosing and titration of opioids. This chapter aims to outline basic principles of how to assess pain and considerations of which opioid to start and at what dose.
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Accidental overdose has been described in individuals taking both opioids and benzodiazepines, and this risk is even higher in individuals with certain medical comorbidities (eg, COPD, OSA).7 Older adults also tend to misuse multiple medications (eg, opioids, benzodiazepines, hypnotics, muscle relaxants).27,35 This in turn increases the risks of serious health consequences including death.
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Potential complications associated with methadone use include prolongation of the corrected QT interval, high drug-drug interactions via the cytochrome P450 (CYP)-3A4 enzyme, and a long elimination half-life, especially in older adults producing greater toxicity. Buprenorphine is, in theory, a better option for older adults: it does not cause prolonged QTc, nor requires dose adjustment in renal failure.72 It may also be a safer option than methadone for individuals with severe cardiac or respiratory illnesses.
Substance Use and Misuse Among Older Adults
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Substance use and abuse among older adults is an increasingly important area of focus due to evolving trends of increased substance use within this group. This chapter provides an overview of the social, cultural and biological factors pertaining to older adult substance use and its shifting nature stemming from cohort and cultural changes. Alcohol is the most frequently abused drug in older adults and thus has a strong focus in the chapter, but other substances including marijuana and opioids that are on the rise in this population are also discussed. The chapter also provides an overview of empirically supported intervention approaches for older adult substance abuse and discusses new and emerging intervention possibilities that can be leveraged to provide needed support for older individuals with a substance abuse problem.
Demographic and clinical factors associated with variations in opioid administration using conscious sedation during HDR brachytherapy for cervical cancer
2021, Brachytherapy
Citation Excerpt :
Physiologic changes of aging can result in decreased administration of opioids for elderly patients during conscious sedation. One way these physiologic changes can contribute to decreased opioid need is due to decreased hepatic metabolism and increased half-life, although this effect is more pronounced for oxycodone and buprenorphine than fentanyl (due to different metabolic pathways) (29,30). In addition, renal function declines with age, resulting in decreased clearance of opioid substrates with age.
PURPOSE/OBJECTIVES To examine patient characteristics that predispose to higher opioid administration during tandem and ovoid (T&O) high-dose rate (HDR) brachytherapy.
METHODS A single-institution retrospective review was performed on patients who underwent brachytherapy for cervical cancer. Patients were included if they received at least one fraction of HDR T&O brachytherapy with analgesia administration recorded in the Medication Administration Record. Fentanyl dose was dichotomized as “low” (mean <125 μg per fraction), or “high” (mean ≥ 125 μg per fraction). Descriptive statistics and multiple logistic regression analysis were performed comparing mean opioid dose per fraction with demographic and clinical information.
RESULTS From July 2014 through May 2020, 113 patients underwent 531 T&O HDR brachytherapy fractions with oral benzodiazepine and intravenous opioid fentanyl for conscious sedation. The median opioid dose per fraction was 100 μg fentanyl (range 0–250 μg). Using multiple logistic regression analysis, younger age (OR 1.071, p = 0.002) and higher BMI (OR 1.091, p = 0.019) were associated with increased opioid administration during brachytherapy. Black women received less opioid during brachytherapy when compared to White women (OR 0.296, p = 0.047). FIGO stage, ECOG score, smoking status, prior narcotic use, prior illicit drug use, parity, prior cervical procedure, Smit sleeve placement, and distance to treatment center were not associated with high opioid dose.
CONCLUSION Cervical cancer patients who are younger or have higher BMI receive more narcotic analgesia during HDR brachytherapy whereas Black women received less narcotic analgesia, irrespective of age and BMI. This underscores the immediate need to address how pain is assessed and managed during brachytherapy.

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: Potential Competing Interests: The authors report no competing interests.

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Concise review for cliniciansOpioids in Older Adults: Indications, Prescribing, Complications, and Alternative Therapies for Primary Care

Abstract

Section snippets

Indications

Appropriate Prescribing

Complications

Alternative Therapies

Conclusion

Mayo Clin Proc

J Pain

Pain

J Pain Symptom Manage

Mayo Clin Proc

Clin Geriatr Med

Br J Anaesth

Drug Alcohol Depend

Mayo Clin Proc

Increases in the use of prescription opioids and the lack of improvement in disability metrics among users

Reg Anes Pain Med

Characteristics of initial prescription episodes and likelihood of long term opioid use—United States, 2006-2015

MMWR Morb Mortal Wkly Rep

2018 Annual Surveillance Report of Drug-Related Risks and Outcomes

Prevalence of chronic pain and high-impact chronic pain among adults—United States, 2016

MMWR Morb Mortal Wkly Rep

Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain

J Pain

Opioids and the management of severe pain in older adults: consensus statement of an international expert panel with focus on the six clinically most often used World Health Organization step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone)

Pain Pract

CDC Guideline for prescribing opioids for chronic pain—United States, 2016

MMWR Recomm Rep

Inappropriate use of CDC guidelines for prescribing opioids D-120.932. AMA website

No shortcuts to safer opioid prescribing

N Engl J Med

Basic opioid pharmacology: an update

Br J Pain

Opioids and the treatment of chronic pain: controversies, current status, and future directions

Exp Clin Psychopharmacol

Concise review for clinicians
Opioids in Older Adults: Indications, Prescribing, Complications, and Alternative Therapies for Primary Care