New Report Highlights Opioid Misuse in the Elderly

When most of us think about the opioid crisis, we tend to think of young people or people in middle age who have been dealing with addiction for a long time. Seniors, we assume, have little interest in recreational drug use and are unlikely to misuse opioids prescribed for pain.

But according to a new report from the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality, that assumption is wrong. In fact, according to the report, the rate of opioid misuse in people over 65 nearly doubled between 2002 and 2014. Emergency room visits and inpatient stays also increased dramatically, as did the percentage of elderly persons receiving prescriptions for opioids.

Inpatient and Emergency Room Visits Soar

Between 2010 and 2015, the number of seniors needing inpatient care for an opioid-related issue increased 54 percent, from 80,500 hospitalizations in 2010 to 124,300 in 2015. The largest increase was in people 65 to 74 years of age (71.9 percent) followed by those 85 and older (42.6 percent). Hospitalizations increased the least (32.2 percent) in seniors age 75 to 84 years. During this same period, the number of non-opioid-related inpatient stays for people 65 and older decreased by 17 percent.

A similar trend was seen in the number of opioid-related emergency room visits, which doubled from 18,100 visits to 36,200 visits between 2010 and 2015. As was the case for inpatient stays, the most affected age group was persons 65 to 74 years old, for whom the rate of ER visits went up nearly 132 percent.

Worrisome Prescribing Practices

Chronic pain is a significant problem for the aging population, both here in the United States and across the globe. According to a 2015 study published in BMJ, over 50 percent of U.S. seniors suffer from persistent pain that interferes with daily life, as do the elderly in many other parts of the developed world. Chronic pain is associated with a number of health conditions that commonly occur in the elderly, including diabetes, heart, lung or kidney disease, Parkinson’s disease and, of course, arthritis.

But treating pain in the elderly is challenging, in large part because chronic health problems change the way seniors absorb and metabolize drugs. Problems with thinking, memory and balance are also more common as people age, which increase the danger of accidental overdose and falls. Thus, physicians are cautioned  to prescribe painkillers judiciously; to use nonpharmacologic therapies whenever possible; and to prescribe opioids as a last resort.  

Nonetheless, data shows that doctors are still prescribing opioids to elderly patients in copious amounts, often in doses that far exceed what’s recommended by the CDC. According to a 2017 report from the Office of the Inspector General, one in three Medicare Part D beneficiaries, or 14.4 million seniors, received at least one opioid prescription in 2016. More alarmingly, about 500,000 received “high” amounts of opioids, and about 90,000 were prescribed doses that put them at risk of serious harm, including addiction, overdose and death.

Additionally, about one in 10 beneficiaries, or 5 million seniors, received an opioid prescription for six months or more. Research shows that people who take opiate medications for longer periods of time are at higher risk for opioid misuse.  

Most Dangerous Drugs Prescribed in the Highest Amounts.

According to the OIG’s report, the largest number of opiate prescriptions written for seniors in 2016 were for Tramadol, a Schedule IV drug used to treat moderate to severe pain. Schedule IV drugs are thought to have a lower potential for abuse and fewer side effects than other opioids, although they may still be misused.

The second and third most commonly prescribed opioids were hydrocodone-acetaminophen combinations such as Norco and Vicodin,and oxycodone-acetaminophen combinations such as Percocet. Norco and Vicodin are Schedule III drugs, which have a slightly higher abuse potential than Schedule IV drugs. Percocet is a Schedule II drug, which is considered to have a higher potential for misuse. However, most of the prescriptions written for Percocet and Vicodin were for moderate doses (5 milligrams and between 7.5 and 15 milligrams respectively.)

Credit: sinirbilim.org

Interestingly, however, patients who received what the OIG report calls “high” and “extreme” amounts of opioids were also prescribed the most dangerous drugs, both in terms of their potential for abuse and the risk of significant and even deadly side effects. These included Schedule II controlled substances such as oxycodone, OxyContin, fentanyl and morphine. In one case from New Hampshire (where the number of opioid-related deaths is second highest in the nation) one Medicare Part D beneficiary received 134 prescriptions for opioids from one prescriber in 2016, including 13 months of OxyContin 80 mg, 13 months of OxyContin 60 mg, 13 months of OxyContin 40 mg, 14 months of oxycodone 30 mg, and 13 months of fentanyl patches.

A Delicate Balancing Act

Fortunately, examples of extreme prescribing practices, while alarming, are also rare. According to the OIG report, about 400 physicians were responsible for the vast majority of “suspicious” prescriptions and prescriptions that exceeded recommended amounts. Most of the other opioid prescriptions written for seniors, it would seem, were from caring physicians who are trying to balance patient comfort with safety concerns. And that, especially in the elderly, can be very hard to do. On one hand, undertreated chronic pain can result in limited mobility, increased disability, insomnia, depression and increased levels of psychological distress. On the other, overtreatment can lead to accidental injuries, chronic misuse, addiction and even death.

It’s a delicate balancing act made all the more difficult by an opioid crisis that shows no signs of letting up.