Strategies for managing opioid use in elderly patients
In the wake of the Covid-19 pandemic, it’s easy for anyone to forget that there are other large-scale epidemics going on in the world. In the U.S. especially, the opioid crisis rages on despite being all but forgotten by the public. According to the CDC, drug overdose deaths were up a grim 30.9% year over year during 2020, with a significant portion of the 94,134 deaths caused by opioids.
Senior citizens are most at risk of misusing and abusing opioids, as they rely on this type of medication for treatment more than younger adults. A new USC survey found that one in 10 adults is at risk for an opioid overdose. However, physicians play an important role in reducing the risk of opioid misuse in this population – much of this risk can be avoided with better intervention and tracking.
With seniors especially vulnerable to the opioid epidemic, physicians can step up opioid tapering programs that have a proven track record of success while simultaneously instituting mitigation plans through strong, personal relationships and micro and macro metrics.
Opioid Tapering: Risks and Benefits
While sometimes debated, opioid tapering programs are a proven and effective resource for curbing abuse if the program is planned and managed holistically. A study from the Scandinavian Journal of Pain found that opioid tapering programs, when implemented holistically, had a success rate of 27.9%. Doctors must look carefully at all medications patients are taking to create an effective treatment regimen, particularly with seniors who are more likely to be taking one or several pain medications. In any tapering program drug interactions could be a problem: tapering an opioid and a Benzodiazepine, for example, must be done slowly and carefully, or the patient is at risk for discomfort, anxiety and depression as side effects. For elderly patients especially, following the Beers criteria, Benzodiazepine may not be the best choice anyway.
Improper weaning of medications can have negative consequences, especially in senior populations, which has led to the belief that tapering is ineffective and can lead to worse mental health outcomes. For example, one study in JAMA found that opioid tapering may be associated with an increased risk for overdose and mental health crises in patients prescribed long-term, high dose opioid therapy. However, co-morbidities, prior opioid use, and inefficient follow up with subjects could skew study results and may have been the case in this study, when analyzed more closely. Tapering programs, in reality, are used throughout the medical community successfully and many advocate for this type of approach, as long as they are managed and monitored carefully.
Strategies for curbing overuse
Doctors need to use innovative metrics to track opioid use in patients, utilizing both quantitative and qualitative methods to reduce misuse and overdose . Here are several metrics medical professionals can use to track and intervene with opioid use:
- Prescription Drug Monitoring Programs (PDMPs): With the exception of Missouri, 49 states, and the District of Columbia have implemented a state wide PDMPs which offer easy-to-access data resources to track opioids and other controlled substance use. PDMPs have online risk scores for each patients, and providers can use these scores to monitor use and potential abuse. If the risk score is high, patients might be using high dose opioids, or using a dangerous combination of medications, or showing aberrant behavior, signaling a sign of potential abuse. By streamlining medical data, prescription inputs and making this data available throughout a patient’s healthcare journey, doctors can better track how much a patient has been prescribed. For seniors, this is especially key, as many elderly patients visit only one doctor or pharmacist continuously and prescriptions become auto-refilled – this is a high-risk factor for misuse.
- Medication reconciliation: Providers do not do enough medication reconciliation, especially for elderly patients. These patients have pill bottles stacked up in their medicine cabinets from a host of past and present conditions, they may not understand what they’re taking, and this leads to unsafe opioid use. Doctors should frequently take the time to audit which medications seniors have at home and are taking to reduce negative side effects and interfere with potential opioid misuse.
- Pill counts: It’s encouraged to ask patients to bring in their pills and count the pills to make sure they are taking the right dosage. Also check refill levels: Are prescriptions being refilled every 30 days or 90 days? Adding this check and balance on the pharmacy system ensures patients, particularly seniors, are not being overprescribed medication, they don’t need or getting too much access to substances they could misuse.
- Drug screens: Effective in comparing what is being prescribed and what is present in the body, regular urine drug screens as part of initial and follow-up doctor visits are a helpful tactic in catching opioid abuse in early stages.
- Counseling: It is very important to educate people on medications and the danger of their use and unintentional overdose. Counseling is a key tenet of effective opioid tapering programs and is a useful tactic for curbing misuse with senior populations, who oftentimes don’t fully understand the complexities of their medications or the potential for abusing these medications.
Opioids should not be the first line treatment for pain- other meds and even over-the-counter drugs like Tylenol can be used and are much safer options, especially for older adults. When opioids are used, they need to be monitored very carefully both at the prescribing and reconciliation level. Clinicians must be aware that coordination of care is one of the key factors to combat opioid epidemic and stop overuse of more powerful and dangerous medications. Senior care providers who use these tactics and audit frequently ensure patients know all the benefits and risks of the medications they take. Healthcare workers are on the front lines of the opioid epidemic as well and taking a little extra time to reconcile medications and ask questions can make a big difference in curbing overuse.
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