SAFE Glen Cove Coalition: Opioid Use Disorder and the Elderly

According to an article in the Psychiatric Times released earlier this year, while opioid use disorders are more common in younger patients, prevalence among the elderly is growing, and misuse poses unique risks in the geriatric population. From 1996 through 2010, the number of opioid prescriptions provided to older patients increased nine-fold. More alarming, 35% of patients aged older than 50 years with chronic pain reported misuse of their opioid prescriptions in the past 30 days.

The hospitalization rate for geriatric misuse of opioids has quintupled in the past 20 years alone. Given the scope of the problem, federal and state governments have begun to implement new guidelines in prescribing opioids, but tighter regulations may intrude on individualized patient care and the benefits of opioid therapy in some patients. Whether these new policies are the best strategies remains to be seen.

The article maintains that avoiding iatrogenic addictions- when a patient ends up abusing or becoming addicted to an opioid prescribed for a legitimate pain complaint- may be the first step in addressing the epidemic. Some situations are more straightforward.

The article provides two hypothetical scenarios in which most Doctors can distinguish inappropriate use of opioids: a 78-year-old in hospice care for terminal lung cancer; a 65-year-old who underwent major surgery that morning; or a 68-year-old with a history of depression, anxiety, and chronic pain, and a urine drug screen positive for cocaine, opioids, and benzodiazepines (prescribed). Contrast that with more complex, typical clinical scenarios in which the distinction can be a real challenge:

Mr. X is a 66-year-old under hospice care for liver cancer who also has a severe alcohol use disorder. Opioids were prescribed until his urine drug screen came back positive for marijuana and cocaine. Two days after opioid therapy was stopped, the patient was found dead due to a self-inflicted gunshot wound. Pain was determined to be a major contributing factor. This case highlights the importance of Doctors understanding the delicate balance between risks and benefits when prescribing opioids, and the unique role psychiatrists play in their use.

Obtaining a thorough history is the first step when making the decision to prescribe opioids to elderly patients. Screening for a history of opioid use disorder or other addictive disorders is critical, including nicotine use disorder and any family history of addiction. A complete psychosocial history, including current stressors, history of childhood abuse or neglect, legal problems, and interpersonal relationship stressors will help to identify high-risk opioid misusers. Comorbid depression and high levels of pain are additional risk factors for misuse of opioids in the elderly. Screening for cognitive deficits and other psychiatric disorders is imperative as research demonstrates depression and anxiety may increase the perception of pain and require a different approach to pain management altogether.

After a complete history and examination, if the decision is made to begin opioid therapy, a detailed list of all medical conditions, allergies, and medications—including over-the-counter and herbal remedies—must be obtained and regularly updated. Drug selection should be based on careful consideration of potency needs and individual patient characteristics. Before initiating therapy, realistic treatment goals should be set after careful consideration of pertinent risks and benefits.

Psychiatric Times is a medical trade publication written for an audience involved in the profession of psychiatry. For more information about the Psychiatric Times and their publications please visit www.psychiatrictimes.com.

The SAFE Glen Cove Coalition is conducting an opioid prevention awareness campaign entitled "Keeping Glen Cove SAFE" to educate and update the community regarding opioid use and its consequences. To learn more about the SAFE Glen Cove Coalition please follow us on www.facebook.com/safeglencovecoalition or visit SAFE’s website to learn more about the Opioid Epidemic at www.safeglencove.org.