Opioid deaths have risen to epidemic levels in the United States. Older adults are not exempt from opioid use and misuse. The Centers for Disease Control and Prevention (CDC) (2016) reports increases in drug overdoses and opioid deaths in the aging population, with a 7.7% increase in deaths related to opioid overdose in individuals over the age of 65 from 2013 to 2014.
An analysis of Medicare beneficiaries' prescription opioid use for the year 2016 revealed 1 in 3 Medicare Part D beneficiaries received a prescription for an opioid, and 500,000 beneficiaries received high doses of opioids. A review of prescribers revealed that approximately 400 prescribers had questionable prescribing practices, as they gave prescriptions for opioids beyond that of safe practice patterns, placing beneficiaries at considerable risk (Department of Health & Human Services, 2016).
Older adults often suffer from more pain than their younger counterparts due to joint and muscle issues, complications of disease, and age-associated debility. Common opioids used in treating pain in older adults include: morphine, oxycodone, hydrocodone, hydromorphone, codeine, fentanyl, tramadol, and buprenorphine.
The CDC has developed prescribing guidelines for the use of opioids in managing pain. Effective pain management can be achieved through complimentary modalities such as physical therapy, occupational therapy, and use of spiritual resources. The CDC guidelines are not intended for use with patients in active cancer treatment, hospice, or palliative care, but provide a guide for the safe and effective management of pain and reduced risk of opioid dependence and crisis.
The guidelines clearly state treatment with an opioid is not first-line treatment for pain. All nonpharmacological measures and nonopioid therapy should be considered first. Opioid therapy should be considered only when the anticipated benefits clearly outweigh the risks. Realistic goals for pain, function, and discontinuation of the opioid should be mutually established with the patient prior to the initiation of opioids. Patients should be started on immediate-release opioids first (not extended-release), and at the lowest dose with a slow titration up as necessary. Effectiveness and side effects should be evaluated and nonopioid treatments added. The recommended length of treatment is 3 to 5 days, with greater than 7 days of opioid treatment rare. Patients should be educated on the avoidance of all alcohol and should not concurrently be prescribed benzodiazepines, anxiolytic, or sedative medications to avoid opioid crisis (CDC, 2017).
Opioids require close monitoring and assessment of both kidney and liver function in older adults. Monitor for side effects that include: constipation, sedation and confusion, nausea and vomiting, respiratory depression, delirium, urinary retention, pruritis, hallucinations, dry mouth, opioid dependence and tolerance (Benyamin et al., 2008).
Nonopioid choices for the treatment and management of pain include acetaminophen, nonsteroidal preparations, lidocaine, and capsaicin patches. Use of heat, ice, positioning, compression, and elevation can be effective in reducing discomfort and present minimal risk to the patient. Explore what has worked for pain control in the past, and support patients in their personal choices for pain management.
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