Prescription opioid exposures and adverse outcomes among older adults

Age-related Psychometric Dimensionality Using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition Opioid Use Disorder Diagnostic Criteria

OBJECTIVES

Age-related psychometric differences in Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) opioid use disorder (OUD) diagnostic criteria have been hypothesized, but not been tested. This study investigated DSM-5 OUD diagnostic criteria for age-related measurement noninvariance among younger adults (YAs) and middle/older adults (MOAs) with past 12-month nonmedical use of prescription opioids.

METHODS

People who participated in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions III and reported past 12-month nonmedical use of prescription opioids were included. YAs were 18-49 years old, and MOAs were 50+ years old. Item response theory, differential item functioning (DIF), and differential test functioning were used to assess for age-related measurement noninvariance.

RESULTS

One in 5 people met the DSM-5 OUD diagnostic criteria for OUD within the past 12 months, with the most endorsed criteria being tolerance (17.96%). DIF was identified for 3 criteria, including (1) taking opioids for longer or in larger doses than intended, (2) long periods spent obtaining/using/recovering from use, and (3) withdrawal. DIF was associated with the latent OUD severity needed to correctly endorse the criteria, with criteria being correctly endorsed at less severe levels of latent OUD for MOAs when compared with YAs. Differential test functioning analyses showed collectively the criteria had improved detection in MOAs when compared with YAs (P < 0.01).

CONCLUSIONS

These findings suggest that there may be age-related variations in the DSM-5 OUD diagnostic criteria's ability to detect latent OUD. Future research should identify contributing factors and the influence it has on the accuracy of age-specific surveillance estimations.

Polypharmacy and Healthcare Service Use Among Prescription Opioid Poisoning Cases Age 50

Objectives: To examine relationships between polypharmacy and level of healthcare service use among prescription opioid poisoning cases age 50 and older. Methods: Data came from the American Association of Poison Control Center's National Poison Data System, 2015-2020. We used multinomial logistic regression to examine the study questions. Results: Of the 77 946 cases with prescription opioid exposures, 64.5% were managed at a healthcare facility (HCF). Of HCF-managed cases, 41.2% were treated/evaluated and released and 21.3% and 37.5% were admitted for noncritical care and critical care, respectively. Medications for cardiovascular disease, benzodiazepines, other types of sedatives/hypnotics, antipsychotics, muscle relaxants, acetaminophen, and gabapentin were associated with increased risk of admission to both noncritical and critical care compared to treatment/evaluation and release. Acetaminophen use had the highest relative risk ratios (RRRs) for noncritical care (1.70, 95% CI = 1.51-1.91) and critical care (1.56, 95% CI = 1.39-1.76). Each additional medication/substance used was associated with 1.14 (95% CI = 1.11-1.17) and 1.19 (95% CI = 1.16-1.22) greater risk of noncritical and critical care admissions, respectively. Conclusions: Among older-adult poison control center cases for prescription opioid exposures, co-use of several commonly prescribed/used medicines was associated with increased risk of admissions to both noncritical and critical care units. Careful monitoring of medication use among older adults who use prescription opioids may reduce the risk of unintentional and intentional opioid poisoning.

Family history of substance use disorder and likelihood of prescription drug misuse in adults 50 and older

OBJECTIVE

Individuals who are family history positive (FHP) for substance use problems have increased risk for substance use, substance use disorders (SUDs), and psychopathology. Links between FHP status and prescription drug misuse (PDM) have not been well investigated; this study examined PDM in adults 50 and older by FHP status.

METHODS

Data were from the US NESARC-III (n = 14,667). Participants reported their opioid PDM, tranquilizer/sedative PDM, SUD, psychopathology, and family history status (i.e. first- and second-degree relatives with alcohol/substance use problems). Prevalence rates were estimated by FHP status, and logistic regressions compared FHP and family history negative (FHN) groups.

RESULTS

FHP status was associated with significantly higher rates of PDM (e.g. past-year opioid PDM, FHP: 3.8%, FHN: 1.5%) and SUD from PDM (e.g. past-year SUD, FHP: 1.2%, FHN: 0.2%); also, prevalence varied by family history density, with the highest rates in those with three or more relatives with substance use problems (e.g. past-year opioid PDM: 5.5%). Overall, 32.2% of FHP individuals with past-year PDM had past-year co-occurring SUD and psychopathology diagnoses, versus 11.0% of FHN individuals.

CONCLUSION

FHP status could inform treatment decisions in adults 50 and older with conditions for which prescription opioids or tranquilizer/sedatives are indicated.

TANGO: Development of Consumer Information Leaflets to Support TAperiNG of Opioids in Older Adults with Low Back Pain and Hip and Knee Osteoarthritis

INTRODUCTION

Globally, the rate of opioid prescription is high for chronic musculoskeletal conditions despite guidelines recommending against their use as their adverse effects outweigh their modest benefit. Deprescribing opioids is a complex process that can be hindered by multiple prescriber- and patient-related barriers. These include fear of the process of, or outcomes from, weaning medications, or a lack of ongoing support. Thus, involving patients, their carers, and healthcare professionals (HCPs) in the development of consumer materials that can educate and provide support for patients and HCPs over the deprescribing process is critical to ensure that the resources have high readability, usability, and acceptability to the population of interest.

OBJECTIVE

This study aimed to (1) develop two educational consumer leaflets to support opioid tapering in older people with low back pain (LBP) and hip or knee osteoarthritis (HoKOA), and (2) evaluate the perceived usability, acceptability, and credibility of the consumer leaflets from the perspective of consumers and HCPs.

DESIGN

This was an observational survey involving a consumer review panel and an HCP review panel.

PARTICIPANTS

30 consumers (and/or their carers) and 20 HCPs were included in the study. Consumers were people older than 65 years of age who were currently experiencing LBP or HoKOA, and with no HCP background. Carers were people who provided unpaid care, support, or assistance to an individual meeting the inclusion criteria for consumers. HCPs included physiotherapists (n = 9), pharmacists (n = 7), an orthopaedic surgeon (n = 1), a rheumatologist (n = 1), nurse practitioner (n = 1) and a general practitioner (n = 1), all with at least three years of clinical experience and who reported working closely with this target patient population within the last 12 months.

METHODS

Prototypes of two educational consumer leaflets (a brochure and a personal plan) were developed by a team of LBP, OA, and geriatric pharmacotherapy researchers and clinicians. The leaflet prototypes were evaluated by two separate chronological review panels involving (1) consumers and/or their carers, and (2) HCPs. Data collection for both panels occurred via an online survey. Outcomes were the perceived usability, acceptability, and credibility of the consumer leaflets. Feedback received from the consumer panel was used to refine the leaflets, before circulating the leaflets for further review by the HCP panel. Additional feedback from the HCP review panel was then used to refine the final versions of the consumer leaflets.

RESULTS

Both consumers and HCPs perceived the leaflets and personal plan to be usable, acceptable, and credible. Consumers rated the brochure against several categories, which scored between 53 and 97% positive responses. Similarly, the overall feedback provided by HCPs was 85-100% positive. The modified System Usability Scale scores obtained from HCPs was 55-95% positive, indicating excellent usability. Feedback for the personal plan from both HCPs and consumers was largely positive, with consumers providing the highest positive ratings (80-93%). While feedback for HCPs was also high, we did identify that prescribers were hesitant to provide the plan to patients frequently (no positive responses).

CONCLUSIONS

This study led to the development of a leaflet and personal plan to support the reduction of opioid use in older people with LBP or HoKOA. The development of the consumer leaflets incorporated feedback provided by HCPs and consumers to maximise clinical effectiveness and future intervention implementation.

The Association of Opioid Misuse and Suicidality among People with Disabilities

Background/Purpose: Past research has linked non-medical prescription opioid use (NMPOU) with suicide, though less focus has been placed among people with disabilities impacted by the opioid epidemic. This study examined the relationship of NMPOU and suicidality among people with and without disabilities while controlling for sociodemographic and other variables. Method: Using the 2019 National Survey on Drug Use and Health, weighted logistic regression analyses were conducted on a cross-sectional sample of 38,088 respondents 18 and older to examine the effect of opioid misuse and disability on serious thoughts of suicide, having a suicide plan, and making a suicide attempt. Results: Findings indicated opioid misuse was associated with 37% higher odds for having a suicide plan in the past year (OR = 1.37, p < .05). The main results indicated the people with disabilities had 30% higher odds for having a suicide plan (OR = 1.30, p < .05) and 73% higher odds for a suicide attempt in the past year (OR = 1.73, p < .001). Interaction analysis found that opioid misuse was associated with higher odds for having a suicide plan (OR = 1.89, p < .01), and having a suicide attempt among those with disabilities (OR = 2.57, p < .01). Conclusion: Results indicated that opioid misuse is a risk factor for suicide, and people with disabilities were at greater risk. Health workers can serve as a nexus point in effectively engaging at-risk people with disabilities in substance use and mental health prevention and recovery services.

Opioid poisoning cases aged 50+ in the 2015-2020 National Poisoning Data System: suspected suicides versus unintentional poisoning and other intentional misuse/abuse

High rates of opioid overdose and suicide among the 50+ age group call for an examination of suicidal intent in overdose incidents. Using 2015-2020 National Poison Data System opioid poisoning cases aged 50+ (n = 83 153), we examined the types of opioids and other substances associated with suspected suicides compared to intentional misuse/abuse without suicidal intent. During the six years, prescription opioid cases decreased, while illicit opioid cases increased. Among both types of opioid poisoning cases, the proportions of suspected suicides decreased and those of intentional misuse/abuse without suicidal intent increased. However, due to the large increase in illicit opioid cases, the number of suspected suicide cases involving illicit opioids increased. Multivariable analyses showed that among prescription opioids, acetaminophen with opioid (IRR = 1.17, 95% CI = 1.11-1.24) and tramadol (IRR = 1.12, 95% CI = 1.06-1.47) were associated with higher risk of suspected suicides than intentional misuse/abuse without suicidal intent. Among illicit opioid cases, fentanyl poisoning cases were associated with lower risk of suspected suicides (IRR = 0.40, 95% CI = 0.17-0.94). Of other medications, use of benzodiazepines and antipsychotics was consistently associated with higher risk of suspected suicides in both prescription and illicit opioid cases. Alcohol and cocaine were also associated with higher risk of suspected suicide. Along with continued reductions in opioid prescribing, more effective monitoring of individual patient misuse/abuse behaviors and suicide risk assessment are needed. Healthcare professionals should also review other prescription medications frequently co-prescribed with opioids that may have additive effects on suicidal behaviors among older adults.

Demographic and Clinical Correlates of Treatment Completion among Older Adults with Heroin and Prescription Opioid Use Disorders

In this study using 2015-2018 Treatment Episode Data Set-Discharge (TEDS-D) cases age 55+ for heroin (N = 101,524) or prescription opioids (PO; N = 25,510) as the primary substance, we examined treatment completion rates and correlates. We fit separate logistic regression models for heroin and PO cases with treatment completion status (completed vs. discontinued due to dropout/termination/other reasons) for each treatment setting (detoxification, residential rehabilitation, and outpatient) as the dependent variable. Results show that detoxification cases had the highest completion rates and outpatient cases had the lowest (14.8% for heroin and 24.0% for PO cases). A consistently significant correlate of treatment completion was legal system referral for heroin cases and having a bachelor's degree for PO cases. Medication-assisted therapy was associated with higher odds of completing residential treatment for both types of opioids but lower odds of completing detoxification and outpatient treatment. Treatment duration >30 days tended to have higher odds of completion. PO cases age 65+ had higher odds of completing residential treatment than cases age 55-64. Racial/ethnic minorities tended to have lower odds of outpatient treatment completion. Study findings underscore the importance of helping older adults complete treatment, especially those who are racial/ethnic minorities and receiving outpatient treatment.

Identifying Clinically Relevant Drug-Drug Interactions With Methadone and Buprenorphine: A Translational Approach to Signal Detection

Methadone and buprenorphine have pharmacologic properties that are concerning for a high risk of drug-drug interactions (DDIs). We performed high-throughput screening for clinically relevant DDIs with methadone or buprenorphine by combining pharmacoepidemiologic and pharmacokinetic approaches. We conducted pharmacoepidemiologic screening via a series of self-controlled case series studies (SCCS) in Optum claims data from 2000 to 2019. We included persons 18 years or older who experienced an outcome of interest during target drug treatment. Exposures were all overlapping medications (i.e., the candidate precipitants) during target drug treatment. Outcomes were opioid overdose, non-overdose adverse effects, and cardiac arrest. We used conditional Poisson regression to calculate rate ratios, accounting for multiple comparisons with semi-Bayes shrinkage. We explored the impact of key study design choices in analyses that varied the exposure definitions of the target drugs and the candidate precipitant drugs. Pharmacokinetic screening was conducted by incorporating published data on CYP enzyme metabolism into an equation-based static model. In SCCS analysis, 1,432 events were included from 248,069 new users of methadone or buprenorphine. In the primary analysis, statistically significant DDIs included gabapentinoids with either methadone or buprenorphine; baclofen with methadone; and benzodiazepines with methadone. In sensitivity analysis, additional statistically significant DDIs included methocarbamol, quetiapine, or simvastatin with methadone. Pharmacokinetic screening identified two moderate-to-strong potential DDIs (clonidine and fluconazole with buprenorphine). The combination of clonidine and buprenorphine was also associated with a significantly increased risk of opioid overdose in pharmacoepidemiologic screening. These DDI signals may be the most important targets for future confirmation studies.

Prescription Opioid Misuse in Older Adult Surgical Patients: Epidemiology, Prevention, and Clinical Implications

ABSTRACT

The United States and many other developed nations are in the midst of an opioid crisis, with consequent pressure on prescribers to limit opioid prescribing and reduce prescription opioid misuse. This review addresses prescription opioid misuse for older adult surgical populations. We outline the epidemiology and risk factors for persistent opioid use and misuse in older adults undergoing surgery. We also address screening tools and prescription opioid misuse prevention among vulnerable older adult surgical patients (e.g., older adults with a history of an opioid use disorder), followed by clinical management and patient education recommendations. A significant plurality of older adults engaged in prescription opioid misuse obtain opioid medication for misuse from health providers. Thus, nurses can play a critical role in identifying those older adults at a higher risk for misuse and deliver quality care while balancing the need for adequate pain management against the risk for prescription opioid misuse.

Differential patterns of opioid misuse between younger and older adults - a retrospective observational study using data from South Carolina's prescription drug monitoring program

Background: Most research on opioid misuse focuses on younger adults, yet opioid-related mortality has risen fastest among older Americans over age 55.Objectives: To assess whether there are differential patterns of opioid misuse over time between younger and older adults and whether South Carolina's mandatory Prescription Drug Monitoring Program (PDMP) affected opioid misuse differentially between the two groups.Methods: We used South Carolina's Reporting and Identification Prescription Tracking System from 2010 to 2018 to calculate an opioid misuse score for 193,073 patients (sex unknown) using days' supply, morphine milligram equivalents (MME), and the numbers of unique prescribers and dispensaries. Multivariable regression was used to assess differential opioid misuse patterns by age group over time and in response to implementation of South Carolina's mandatory PDMP in 2017.Results: We found that between 2011 and 2018, older adults received 57% (p < .01) more in total MME and 25.4 days more (p < .01) in supply, but received prescriptions from fewer doctors (-0.063 doctors, p < 01) and pharmacies (-0.11 pharmacies, p < 01) per year versus younger adults. However, older adults had lower odds of receiving a high misuse score (OR 0.88, p < .01). After the 2017 legislation, misuse scores fell among younger adults (OR 0.79, p < .01) relative to 2011, but not among older adults.Conclusion: Older adults may misuse opioids differently compared to younger adults. Assessment of policies to reduce opioid misuse should take into account subgroup differences that may be masked at the population level.

The role of age and opioid agonist treatment on substance use treatment completion in the United States

BACKGROUND

There is a large body of research indicating that substance use disorder treatment completion leads to higher rates of sustained recovery. However, not much is known about how age and opioid treatment programs (OTPs) OTPinteract to affect treatment completion. The purpose of this article is to better understand the pathway between age, OTP, and treatment completion.

METHODS

Data from the US 2017 Treatment Episodes Data Set was analyzed. Seemingly unrelated bivariate probit regression was used to determine whether OTP access mediates the relationship between age and treatment completion. We used propensity score matching to simulate the effects of a randomized control trial and to attenuate the likelihood of a Type 1 error.

RESULTS

Older adults have a higher likelihood than their younger counterparts of completing treatment regardless of OTP status in inpatient and outpatient settings. Those who received OTP in inpatient treatment had a 45% increased probability of completing treatment in detox settings and a 41% increased probability of completing treatment in inpatient settings. Older adults (age 50+) were more likely to receive OTP than their younger counterparts. There is a small but significant indirect effect of age on treatment completion in inpatient settings.

CONCLUSIONS

Older adults are more likely to receive OTP in both inpatient and outpatient settings. However, age does not appear to affect the probability of treatment completion when individuals receive OTP, except in inpatient settings. Implications are discussed.

Exposure reasons, other substance use, and medical outcomes of poison control center cases aged 50+ involving opioids, 2015-2020

CONTEXT

Rates of prescription opioid (PO) prescribing and filling remain high, and illicit opioid (IO) use has increased among late middle-aged and older adults. Research on PO and IO poisoning and their impacts among these age groups is needed.

METHODS

Data came from 2015 to 2020 poison control center cases aged 50+ (N = 83,135). We used χ2 tests to examine changes over the study period in the numbers of PO and IO cases, type of opioids used, exposure reasons, and medical outcomes. We fit multinomial logistic regression models to examine the associations of medical outcomes with exposure reasons and other medication/substance involvement.

RESULTS

Between 2015/2016 and 2020, the numbers and shares of PO-only cases steadily declined, but IO cases, with or without PO, nearly tripled, constituting almost 10% of all PCC opioid cases aged 50+ in 2020. The rates of intentional misuse/abuse increased among both PO-only and IO (with/without PO) cases during the study period, and the death rate among IO cases sharply increased in 2020. Compared to adverse reactions or other unintentional exposures, intentional misuse/abuse and suspected suicides were associated with significantly higher risks of serious outcomes (e.g., risk of death from intentional misuse/abuse: RRR = 22.11, 95% CI = 16.74-29.20 in PO-only cases and RRR = 6.95, 95% CI = 2.37-20.39 in IO cases with/without PO). The use of most other medications and substances was also significantly associated with serious outcomes.

DISCUSSION

Among older adults, medical outcomes in opioid poisoning cases have become more serious in recent years as intentional misuse/abuse became more common. Opioid use disorder treatment should be readily available and accessible, and alternatives to PO prescribing should be considered.

CONCLUSIONS

Among individuals aged 50+, PO poisoning cases decreased, but IO cases increased sharply from 2015 to 2020 with concomitant increases in intentional misuse/abuse and serious medical outcomes.

Discharge locations after hospitalizations involving opioid use disorder among medicare beneficiaries

BACKGROUND

Hospitalizations involving opioid use disorder (OUD) have been increasing among Medicare beneficiaries of all ages. With rising OUD-related acute care use comes the need to understand where post-acute care is provided and the capacities for OUD treatment in those settings. Our objective was to describe hospitalized Medicare beneficiaries with OUD, their post-acute care locations, and all-cause mortality and readmissions stratified by post-acute care location.

METHODS

We conducted a retrospective cohort study of acute hospitalizations using 2016-2018 Medicare Provider Analysis and Review (MedPAR) files linked to Medicare enrollment data and the Residential History File (RHF) for 100% of Medicare fee-for-service beneficiaries. The RHF which provides a person-level chronological history of health service utilization and locations of care was used to identify hospital discharge locations. We used ICD-10 codes for opioid dependence or "abuse" to identify OUD diagnoses from the MedPAR file. We conducted logistic regression to identify factors associated with discharge to an institutional setting versus home adjusting for demographics, comorbidities, and hospital stay characteristics.

RESULTS

Our analysis included 459,763 hospitalized patients with OUD. Of these, patients aged < 65 years and those dually enrolled in Medicaid comprised the majority (59.1%). OUD and opioid overdose were primary diagnoses in 14.3% and 6.2% of analyzed hospitalizations, respectively. We found that 70.3% of hospitalized patients with OUD were discharged home, 15.8% to a skilled nursing facility (SNF), 9.6% to a non-SNF institutional facility, 2.5% home with home health services, and 1.8% died in-hospital. Within 30 days of hospital discharge, rates of readmissions and mortality were 29.7% and 3.9%; respectively, with wide variation across post-acute locations. Factors associated with greater odds of discharge to institutional settings were older age, female sex, non-Hispanic White race and ethnicity, dual enrollment, longer hospital stay, more comorbidities, intensive care use, surgery, and primary diagnoses including opioid or other drug overdoses, fractures, and septicemia.

CONCLUSIONS

More than one-quarter (25.8%) of hospitalized Medicare beneficiaries with OUD received post-acute care in a setting other than home. High rates and wide variation in all-cause readmissions and mortality within 30 days post-discharge emphasize the need for improved post-acute care for people with OUD.

The iatrogenic opioid crisis: An example of 'institutional corruption of pharmaceuticals'?

RATIONALE

Prescribed opioids are major contributors to the international public health opioid crisis. Such widespread iatrogenic harms usually result from collective decision failures of healthcare organizations rather than solely of individual organizations or professionals. Findings from a system-wide safety analysis of the iatrogenic opioid crisis that includes roles of pertinent healthcare organizations may help avoid or mitigate similar future iatrogenic consequences. In this retrospective exploratory study, we report such an analysis.

METHODS

The study population encompassed the entire age spectrum and included those in whom opioids prescribed for chronic pain (unrelated to malignancy) were associated with death or morbidity. Root cause analysis, incorporating recent suggestions for improvement, was used to identify possible contributory factors from the literature. Based on their mandated roles and potential influences to prevent or mitigate the iatrogenic crisis, relevant organizations were grouped and stratified from most to least influential.

RESULTS

The analysis identified a chain of multiple interrelated causal factors within and between organizations. The most influential organizations were pharmaceutical, political, and drug regulatory; next: experts and their related societies, and publications. Less influential: accreditation, professional licensing and regulatory, academic and healthcare funding bodies. Collectively, their views and decisions influenced prescribing practices of frontline healthcare professionals and advocacy groups. Financial associations between pharmaceutical and most other organizations/groups were common. Ultimately, patients were adversely affected. There was a complex association with psychosocial variables.

LIMITATIONS

The analysis suggests associations not causality.

CONCLUSION

The iatrogenic crisis has multiple intricately linked roots. The major catalyst: pervasive pharma-linked financial conflicts of interest (CoIs) involving most other healthcare organizations. These extensive financial CoIs were likely triggers for a cascade of erroneous decisions and actions that adversely affected patients. The actions and decisions of pharma ranged from unethical to illegal. The iatrogenic opioid crisis may exemplify 'institutional corruption of pharmaceuticals'.

Opioid painkiller dependence in a sample of elderly medical inpatients

BACKGROUND

Over the past few years, there has been a growing concern about prescription opioid misuse and dependence in the elderly. Our study aimed to investigate the prevalence of previous and current prescription opioid dependence among elderly medical inpatients recruited from a large German hospital.

METHODS

This cross-sectional study analyzed a cohort of inpatients aged 65 years and older who were assessed with a structured clinical interview. Levels of past and current dependence on opioids benzodiazepines, hypnotics, and non-opioid analgesics were assessed.

RESULTS

Of 2108 elderly inpatients admitted to the hospital during a 6-month period, 400 fulfilled the inclusion criteria and agreed to participate to the survey. Among these 400 subjects, 43 (10.8%) presented with a dependence on opioid analgesics, including 41 with current dependence and 22 (51.2%) with a de novo condition. Addiction severity was considered mild in 65.1% of cases and severe in 11.6% of cases. Tilidine and oxycodone were the most typically reported molecules.

CONCLUSIONS

Further research is warranted, to better understand the possible risk factors of prescription drug misuse, abuse, and addiction in this vulnerable population. Clinicians should be updated and informed regarding both prescription medication misuse potential and safe prescribing practices in the elderly.

Predictors of Chronic Opioid Use: A Population-level Analysis of North Carolina Cancer Survivors Using Multi-Payer Claims

Background

No population-based studies have examined chronic opioid use among cancer survivors who are diverse with respect to diagnosis, age group, and insurance status.

Methods

We conducted a retrospective cohort study using North Carolina cancer registry data linked with claims from public and private insurance (2006-2016). We included adults with nonmetastatic cancer who had no prior chronic opioid use (n = 38 366). We used modified Poisson regression to assess the adjusted relative risk of chronic opioid use in survivorship (>90-day continuous supply of opioids in the 13-24 months following diagnosis) associated with patient characteristics.

Results

Only 3.0% of cancer survivors in our cohort used opioids chronically in survivorship. Predictors included younger age (adjusted risk ratio [aRR] 50-59 vs 60-69 = 1.23, 95% confidence interval [CI] = 1.05 to 1.43), baseline depression (aRR = 1.22, 95% CI = 1.06 to 1.41) or substance use (aRR = 1.43, 95% CI = 1.15 to 1.78) and Medicaid (aRR vs private = 1.93, 95% CI = 1.56 to 2.40). Survivors who used opioids intermittently (vs not at all) before diagnosis were twice as likely to use opioids chronically in survivorship (aRR = 2.62, 95% CI = 2.28 to 3.02). Those who used opioids chronically (vs intermittently or not at all) during active treatment had a nearly 17-fold increased likelihood of chronic use in survivorship (aRR = 16.65, 95% CI = 14.30 to 19.40).

Conclusions

Younger and low-income survivors, those with baseline depression or substance use, and those who require chronic opioid therapy during treatment are at increased risk for chronic opioid use in survivorship. Our findings point to opportunities to improve assessment of psychosocial histories and to engage patients in shared decision-making around long-term pain management, when chronic opioid therapy is required during treatment.

Prescription Pain Reliever Use and Misuse among Cannabis Users Aged 50+ Years

Objectives: To examine rates and correlates of dual cannabis and prescription pain reliever (PPNR) use and misuse among U.S. individuals aged 50+ who reported past-year cannabis use. Methods: Using the 2015-2018 National Survey of Drug Use and Health, we examined cannabis nonuse/use and PPNR nonuse/use/misuse among all 35,229 respondents, and then focused on 2,632 past-year cannabis users to examine the risk of PPNR use but no misuse and the risk of PPNR misuse, compared to PPNR nonuse. Results: More than one-half of older cannabis users used PPNR in the past year. Multinomial logistic regression results show that the risks of PPNR use/no misuse and PPNR misuse were higher among those who had more chronic medical conditions and a major depressive episode. The risk of PPNR use/no misuse was also associated with high frequency and medical cannabis use. The risk of PPNR misuse was also associated with younger cannabis initiation age and cannabis and other illicit drug use disorders. Conclusions: Correlates of dual cannabis and PPNR use/misuse among older adults are poor physical and mental health problems and problematic cannabis use. Clinical Implications: Older adults with cannabis and PPNR misuse need access to evidence-based treatment, including medication-assisted treatment when needed.

Factors influencing trends in opioid prescribing for older people: a scoping review

Aim:

The review aimed to identify factors influencing opioid prescribing as regular pain-management medication for older people.

Background:

Chronic pain occurs in 45%–85% of older people, but appears to be under-recognised and under-treated. However, strong opiate prescribing is more prevalent in older people, increasing at the fastest rate in this age group.

Methods:

This review included all study types, published 1990–2017, which focused on opioid prescribing for pain management among older adults. Arksey and O’Malley’s framework was used to scope the literature. PubMed, EBSCO Host, the UK Drug Database, and Google Scholar were searched. Data extraction, carried out by two researchers, included factors explaining opioid prescribing patterns and prescribing trends.

Findings:

A total of 613 papers were identified and 53 were included in the final review consisting of 35 research papers, 10 opinion pieces and 8 grey literature sources. Factors associated with prescribing patterns were categorised according to whether they were patient-related, prescriber-driven, or system-driven. Patient factors included age, gender, race, and cognition; prescriber factors included attitudes towards opioids and judgements about ‘normal’ pain; and policy/system factors related to the changing policy landscape over the last three decades, particularly in the USA.

Conclusions:

A large number of context-dependent factors appeared to influence opioid prescribing for chronic pain management in older adults, but the findings were inconsistent. There is a gap in the literature relating to the UK healthcare system; the prescriber and the patient perspective; and within the context of multi-morbidity and treatment burden.

Predictors of CNS-Active Medication Use and Polypharmacy Among Homebound Older Adults With Depression

OBJECTIVE

The authors assessed central nervous system (CNS) polypharmacy among low-income, racially diverse homebound older adults with depression (N=277) and its associations with the participants' ratings of depressive symptoms and pain.

METHODS

CNS-active and other psychotropic and analgesic medications intake was collected from patients' medication containers. Depressive symptoms were assessed with the 24-item Hamilton Depression Rating Scale, and pain intensity was measured on an 11-point numerical rating scale. Covariates were disability (World Health Organization Disability Assessment Schedule 2.0) and perceived social support (Multidimensional Scale of Perceived Social Support).

RESULTS

Of the patients, 16% engaged in CNS polypharmacy, taking three or more CNS-active medications. Of these, 69%, 69%, and 89% were using selective serotonin reuptake inhibitors, benzodiazepines, and opioids, respectively. Higher pain intensity ratings were associated with CNS polypharmacy. Benzodiazepine users were more likely than nonusers to use opioids.

CONCLUSIONS

Medication reviews and improved access to evidence-based psychotherapeutic treatments are needed for these older individuals with depression.

Prescription Drug Misuse: Taking a Lifespan Perspective

Prescription drug misuse (PDM), or medication use without a prescription or in ways not intended by the prescriber, is a notable public health concern, especially in the United States. Accumulating research has characterized PDM prevalence and processes, but age-based or lifespan changes in PDM are understudied. Given age-based differences in the medical or developmental concerns that often underlie PDM, it is likely that PDM varies by age. This review summarizes the literature on PDM across the lifespan, examining lifespan changes in prevalence, sources, motives and correlates for opioid, stimulant, and tranquilizer/sedative (or benzodiazepine) PDM. In all, prevalence rates, sources and motives vary considerably by age group, with fewer age-based differences in correlates or risk factors. PDM prevalence rates tend to decline with aging, with greater use of physician sources and greater endorsement of self-treatment motives in older groups. Recreational motives (such as to get high) tend to peak in young adulthood, with greater use of peer sources or purchases to obtain medication for PDM in younger groups. PDM co-occurs with other substance use and psychopathology, including suicidality, across age groups. The evidence for lifespan variation in PDM is strongest for opioid PDM, with a need for more research on tranquilizer/sedative and stimulant PDM. The current literature is limited by the few studies of lifespan changes in PDM within a single sample, a lack of longitudinal research, little research addressing PDM in the context of polysubstance use, and little research on minority groups, such as sexual and gender minorities.

Incidence of Opioid Overdose Among Patients Using ER/LA Opioid Analgesics Before and After Implementation of the Class-Wide Opioid Risk Evaluation and Mitigation Strategy

Introduction

The United States (US) Food and Drug Administration (FDA) required a Risk Evaluation and Mitigation Strategy (REMS) for extended-release and long-acting (ER/LA) opioid analgesics on 09 July 2012.

Methods

This study compared the incidence of opioid overdose before (July 2010-June 2012) and after (July 2013-September 2016) the initiation of the Risk Evaluation and Mitigation Strategy (REMS) for extended-release and long-acting (ER/LA) opioid analgesics. We identified patients with ≥1 ER/LA opioid dispensing in either time period in national data from the HealthCore Integrated Research Database^SM (HIRD) and in United States (US) Medicaid claims data from four states. We described each population, calculated the incidence rate (IR) of opioid overdose, and assessed crude and propensity score adjusted incidence rate ratios (IRR) comparing the overdose rate after vs before implementation of the REMS.

Results

A total of 121,229 commercially insured and 11,488 Medicaid patients were included in the analysis. Rates of overdose were substantially higher in Medicaid patients than in the commercially insured patients (IR 192.0, 95% confidence interval [CI] 162.60–225.18 versus 102.60, 95% CI 93.0–112.93 in the active period). The IRRs for opioid overdose were 1.01 (95% CI 0.87–1.17) in the commercially insured population and 0.70 (95% CI 0.52–0.93) in Medicaid.

Conclusion

This leveling off of overdose rates among commercially insured patients and decline among Medicaid patients is encouraging, but it is difficult to disentangle the specific impact of the REMS from many other ongoing initiatives with similar goals.

Age Differences in Non-Medical Prescription Opioid Use and Psychological Distress

Background/Purpose: Prescription opioid use has been recognized as an epidemic in the United States and globally. More research is needed to understand the association of opioids and mental health for older adults. This study examined age differences in the association of non-medical prescription opioid use (NMPOU) and psychological distress, with a focus on older adult populations. Methods: This study used the 2016 National Survey on Drug Use and Health (NSDUH), and included 37,842 adults aged 18 and older. Weighted multiple regression and logistic regression analyses were used to examine the association of NMPOU and psychological distress, measured by the Kessler Psychological Distress Scale (K6). Results: NMPOU was associated with higher psychological distress (b = 0.48, SE = 0.16, p < .01). For those 50 and older, NMPOU was associated with 224% increased odds of meeting the clinical threshold for having a serious mental illness (SMI; OR = 2.24, p < .01, 95% CI: 1.23, 4.09). Conclusions: Although the prevalence of NMPOU and psychological distress trended downward throughout the lifespan, the association of NMPOU on SMI was highest among the youngest and oldest adults. These findings highlight the need for services and supports that are tailored for older adult populations. Future research is needed to investigate vulnerabilities from life stage stressors specific to older adults, which may account for the disproportionate odds of opioid use on mental health pathology. Interprofessional collaboration is needed among geriatric professionals to provide effective mental health treatment for this at-risk population.

Social isolation proxy variables and prescription opioid and benzodiazepine misuse among older adults in the U.S.: A cross-sectional analysis of data from the National Survey on Drug Use and Health, 2015-2017

BACKGROUND

Prescription drug misuse in older adults is a growing public health problem. It is important to understand factors which predispose older adults to misuse prescription drugs, and social isolation may play an important role. In this study, we examined the association between social isolation proxy variables (living alone, being unmarried, and not attending religious services) and prescription opioid/benzodiazepine misuse in older adults.

METHODS

With pooled cross-sectional data from the National Survey on Drug Use and Health (2015-2017), we used multinomial multiple logistic regression models to analyze the association between each social isolation proxy variable and past-year prescription opioid/benzodiazepine misuse. We controlled for potentially confounding variables including sociodemographic, physical/mental health, and substance use variables.

RESULTS

Being unmarried was associated with approximately three times increased odds of combined opioid and benzodiazepine misuse (OR 2.98, 95% CI 1.75, 5.08), a finding that persisted after adjusting for multiple potential confounders. Further analysis showed this finding persisted for divorced/separated and never married individuals, but not widowed. Not attending religious services was also associated with prescription opioid/benzodiazepine misuse, but only in unadjusted analyses. There was no association between living alone and opioid/benzodiazepine misuse.

CONCLUSION

Increased odds of combined opioid and benzodiazepine prescription drug misuse was observed among unmarried older adults. Given the susceptibility of older adults to the harms of these medications, further exploration of the role of marital relationships and other forms of social connectedness in prescription drug misuse in this vulnerable population is indicated.

Trends in prior receipt of prescription opioid or adjuvant analgesics among patients with incident opioid use disorder or opioid-related overdose from 2006 to 2016

BACKGROUND

With increasing efforts to scrutinize and reduce opioid prescribing, limited data exist on the recent trend in receipt of prescription pain medications before diagnosis of opioid use disorder (OUD) or opioid-related overdose (OD).

METHODS

Using 2005-2016 Truven MarketScan Commercial Claims databases, we assessed trends in annual 1) incidence of OUD or OD and 2) prevalence of receipt of prescription opioids or four commonly-prescribed adjuvant analgesics among patients newly diagnosed with OUD/OD. Trends were examined in the overall sample and by 3 age groups, including youths (≤18 years), adults (19-64 years), and older adults (≥65 years).

RESULTS

The incidence of diagnosed OUD or OD increased more than 3-fold from 4.99 to 23.81 per 10,000 persons from 2006 to 2016, with the highest increase (14.18-fold) seen in older adults, followed by adults (3.53-fold), and youths (0.16-fold). Between 2006 and 2016, the proportion of patients with incident OUD/OD who received anticonvulsant adjuvant analgesics in the year before diagnosis increased (from 23.4% to 34.3% [P-trend = .005]) whereas the proportion receiving high-dose prescriptions opioids decreased (from 45.5% to 34.8% [P-trend =< .001]). A decreasing trend was observed in general for tricyclic antidepressants and serotonin and norepinephrine reuptake inhibitors.

DISCUSSION

In US commercially insured patients newly diagnosed with OUD/OD, receipt of high-dose opioid prescriptions preceding the diagnosis decreased over time, paralleled by increased use of anticonvulsants commonly prescribed for pain conditions. Further investigations are warranted to understand how prescribed and anticonvulsants contribute to the development of OUD/OD.

Factors Associated with Prescription Opioid Analgesic Use in the US Population, 2011-2014

OBJECTIVE

This study examined factors associated with prescription opioid analgesic use in the US population using data from a nationally representative sample. It focused on factors previously shown to be associated with opioid use disorder or overdose. Variations in the use of different strength opioid analgesics by demographic subgroup were also examined.

METHODS

Data came from respondents aged 16 years and older who participated in the National Health and Nutrition Examination Survey (2011-2014). Respondents were classified as opioid users if they reported using one or more prescription opioid analgesics in the past 30 days.

RESULTS

Opioid users reported poorer self-perceived health than those not currently using opioids. Compared with those not using opioids, opioid users were more likely to rate their health as being "fair" or "poor" (40.4% [95% confidence interval {CI} = 34.9%-46.2%] compared with 15.6% [95% CI = 14.3%-17.1%]), experienced more days of pain during the past 30 days (mean = 14.3 [95% CI = 12.9-15.8] days compared with 2.3 [95% CI = 2.0-2.7] days), and had depression (22.5% [95% CI = 17.3%-28.7%] compared with 7.1% [95% CI = 6.2%-8.0%]). Among those who reported using opioids during the past 30 days, 18.8% (95% CI = 14.4%-24.1%) reported using benzodiazepine medication during the same period and 5.2% (95% CI = 3.5%-7.7%) reported using an illicit drug during the past six months. When opioid strength was examined, a smaller percentage of adults aged 60 years and older used stronger-than-morphine opioids compared with adults aged 20-39 and 40-59 years.

CONCLUSIONS

Higher percentages of current opioid users than nonusers reported having many of the factors associated with opioid use disorder and overdose.

Mortality in older adults with frequent alcohol consumption and use of drugs with addiction potential - The Nord Trøndelag Health Study 2006-2008 (HUNT3), Norway, a population-based study

Background

The aim of this study was to investigate whether frequent drinking, use of drugs with addiction potential and the possible combination of frequent drinking and use of prescribed drugs with addiction potential were associated with all-cause mortality in older adults.

Methods

We used data from the Nord-Trøndelag Health Study (HUNT3 2006–08), a population-based study in Norway. A total of 11,545 (6,084 women) individuals 65 years and older at baseline participated. We assessed frequent drinking (≥ 4 days a week), occasional drinking (i.e. a few times a year), never drinking and non-drinking in the last year. Drugs with addiction potential were defined as at least one prescription of benzodiazepines, z-hypnotics or opioids during one year for a minimum of two consecutive years between 2005 and 2009. This information was drawn from the Norwegian Prescription Database. The main outcome was all-cause mortality with information drawn from the Norwegian Cause of Death Registry. Follow-up continued until death or latest at 31 December 2013. Logistic regression analyses were used to investigate all-cause mortality since date of study entry and exact age at time of death was unknown.

Results

The adjusted logistic regression analyses showed that frequent drinking was not associated with all-cause mortality compared to occasional drinking. Men who reported to be never drinkers and non-drinkers in the last year had higher odds of mortality compared to those who drank occasionally. Use of prescribed drugs with addiction potential was associated with increased mortality in men, but not in women. No association was found between the possible combination of frequent drinking and use of prescribed drugs with addiction potential and mortality.

Conclusion

Neither frequent drinking nor the possible combination of frequent drinking and use of prescribed drugs with addiction potential were associated with all-cause mortality in older women and men. Use of prescribed drugs with addiction potential was associated with higher odds of mortality in men. This finding should lead to more caution in prescribing drugs with addiction potential to this group.

Sources of opioid medication for misuse in older adults: results from a nationally representative survey

Despite increasing rates of prescription opioid (PO) misuse in adults 50 years of age and older, little research has investigated such misuse in this population. This work aimed to examine sources of misused opioid medication in adults 50 years and older, with comparisons to younger groups. Data were from the 2009 to 2014 National Survey on Drug Use and Health surveys. Prevalence rates of PO sources, misuse, and PO use disorder (POUD) symptoms were estimated. Design-based logistic regression investigated age-based differences in these factors and the association of sources with POUD symptoms and other concurrent substance use. Nearly half (47.7%) of adults 65 years and older used physician sources for past 30-day PO misuse, with the second highest rates in those 50 to 64 years old (39.2%). Conversely, use of theft (5.3%), purchases (8.5%), or friends/family (for free; 23.2%) to obtain opioids were least common in adults 65 years and older, with prevalence rates of these sources in those 50 years and older closer to those of younger groups. Across those 50 years and older, use of purchases, physician, or multiple sources were associated with elevated POUD symptom prevalence. Older adults, particularly those 65 years and older, use a different pattern of PO sources than adolescents or younger adults, and those using physician sources have elevated POUD symptoms. Physicians are a key avenue for older adults to obtain opioids for misuse, highlighting the potential role of clinicians in limiting such misuse.

Prevalence of Concurrent Prescription Opioid and Hazardous Alcohol Use Among Older Women: Results from a Cross-Sectional Study of Community Members

Concurrent use of prescription medications and alcohol is prevalent among older adults and impacts women more than men, however little is known about characteristics of older women who use both. The current analysis aims to evaluate those characteristics. Participants were recruited through HealthStreet, an outreach program. Community health workers (CHWs) assess health needs and concerns among community members. CHWs collect demographic, substance use, and other health data from participants. Female participants (≥ 50 years) interviewed November 2011-November 2017 were included and stratified into four groups: neither prescription opioid nor hazardous alcohol use (three or more drinks in a single day), hazardous alcohol use only, prescription opioid use only, and both prescription opioid and hazardous alcohol use. Chi square and ANOVA tests were used to compare these groups. Among the 2370 women (53% black; mean age 61 years), 70% reported neither prescription opioid nor hazardous alcohol use, 12% reported hazardous alcohol use only, 15% reported prescription opioid use only, and 3% reported use of both in the past 30 days. Concurrent prescription opioid and hazardous alcohol use were significantly associated with comorbid depression and anxiety (p < 0.0001); women who endorsed prescription opioid use only were significantly more likely to report a history of back pain, cancer, or diabetes compared to their counterparts (p < 0.0001). Nearly a third of women reported prescription opioid and/or hazardous alcohol use in the past 30 days. Because the risk and consequences of concomitant alcohol and opioid use increase with age, interventions tailored to women are needed.

Emergency Department Visits and Overnight Hospital Stays among Persons Aged 50 and Older Who Use and Misuse Opioids

Opioid misuse and adverse health outcomes are serious problems among the 50+ age group. Using data from the 2015-2016 National Survey of Drug Use and Health (N = 17,608 respondents aged 50+), we examined emergency department (ED) visits and hospitalizations among those who reported (1) no opioid use in the past year (61.4%); (2) opioid use but no misuse (36.0%); and (3) opioid misuse (2.6%). Compared to nonusers, those who reported use but no misuse or misuse had greater odds of any ED visit (AOR = 2.24, 95% CI = 2.05-2.47 and AOR = 1.99, 95% CI = 1.55-2.56, respectively) and hospitalization (AOR = 2.87, 95% CI = 2.48-3.32 and AOR = 2.57, 95% CI = 1.88-3.51, respectively); however, only those who used but did not misuse had more ED visits and longer hospital stays than nonusers. Those who misused opioids were younger, but they did not differ from those who used but did not misuse on ED visits and hospitalizations. Since those who misused had significantly higher rates of other substance use disorders and mental health problems than those who used but did not misuse, treatment of opioid misuse should also include help for these problems. Economically disadvantaged older adults suffering from chronic pain and opioid misuse also need assistance accessing effective pain treatment.

Predictors of Alcohol Use Disorders Among Baby Boomers Across the Life Course

Research suggests that baby boomers entering older adulthood may possess unique alcohol use patterns over time. Using the life course perspective as a guiding framework, this empirical study sought to examine correlates of alcohol use disorders among baby boomers by examining representative data from the National Survey on Drug Use and Health at two points in time, 1998 (N = 6,213) and 2010 (N = 5,880). Results from logistic regression analyses suggest that predictors of alcohol use disorders evolve over time as baby boomers continue to age. Risk factors for alcohol use disorders among baby boomers may include concurrent unprescribed pain reliever use, p < .01, while protective factors such as income, p < .01, and social supports, p = .01, may be of increased importance. Based on the findings of this study, practice implications and future research are discussed.

Opioid Administration and Prescribing in Older Adults in U.S. Emergency Departments (2005-2015)

INTRODUCTION

We assess trends in opioid administration and prescribing from 2005-2015 in older adults in United States (U.S.) emergency departments (ED).

METHODS

We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) survey from 2005 to 2015. ED visits for painful conditions were selected and stratified by age (18-64, 65-74, 75-84, ≥ 85 years). We analyzed trends in opioid administration in the ED and prescribing at discharge to encounters ≥ 65 and assessed predictors of use using survey-weighted chi-square tests and logistic regression. Trends in the use of five commonly prescribed opioids were also explored.

RESULTS

Opioid administration in the ED and prescribing at discharge for encounters with patients ≥ 65 years fell overall, but not significantly. By contrast, opioid administration in the ED and prescribing at discharge significantly declined for adult encounters 18-64 by 20% and 32%, respectively. A similar proportion of adult encounters ≥ 65 were administered opioids in the ED as 18-64, but adult encounters ≥ 85 had the lowest rates of administration. A smaller proportion of adult encounters ≥ 65 years with painful conditions were prescribed opioids at discharge compared to <65. However, this age-related disparity in prescribing narrowed over the study period. There were shifts in the specific types of opioids administered and prescribed in adult encounters ≥ 65 years over the study period, with the most notable being a 76% increase in hydromorphone administration comparing 2005-06 to 2014-15.

CONCLUSION

From 2005-15, 1 in 4 to 1 in 10 ED patients with painful conditions were administered or prescribed an opioid in U.S. EDs. Opioids prescribing increased from 2005-11 and then declined from 2012-15, more so among visits in the 18-64 age group compared to ≥ 65 years. Opioid administrating demonstrated a gradual rise and decline in all adult age groups. Age consistently appears to be an important consideration, where opioid prescribing declines with advancing age. Given the nationwide opioid crisis, ED providers should remain vigilant in limiting opioids, particularly in older adults who are at higher risk for adverse effects.

The Challenges of Treating Sciatica Pain in Older Adults

Sciatica is a debilitating condition affecting approximately 25 % of the population. Typically, the patient will complain of lower limb pain that is more severe than pain in the lower back, usually accompanied by numbness and motor weakness. Most international guidelines recommend pharmacological management for the pain relief of sciatica, including paracetamol, non-steroidal anti-inflammatory drugs, opioid analgesics, anticonvulsants, and corticosteroids, among others. However, the evidence for most of these pharmacological options is scarce, and the majority of clinical trials exclude older patients. There is overall very limited information on the efficacy, safety, and tolerability of these medicines in older patients with sciatica. This review presents a critical appraisal of the existing evidence for the pharmacological treatment of sciatica, with a special focus on the older adult. The age-related changes in the health of older patients, as well as their impact on the response to pharmacological treatment, including polypharmacy, drug interactions, and drug-disease interactions, is also discussed.

Opioid Prescribing Patterns and Costs in a Large Group of Patients in Colombia

The potential for development of tolerance and dependence and the risk of side effects of opioids make it necessary to monitor their prescribing patterns in order to decrease the morbidity and mortality associated with their continued use. The objective of this study was to determine prescription patterns of opioid medication in a group of patients through a cross-sectional study on a population database of 3.5 million people. Patients with three months of continuous opioid use were identified. Pharmacological, co-medication and cost variables were analyzed. We conducted a multivariate analysis. A total of 7,457 patients were included; 72.1% were women, the mean age was 65.1 years, and 3.8% had a diagnosis of cancer. 10.2% of the patients received opioids in combination therapy. The most prescribed opioids were codeine (57.7%), tramadol (30.9%), and hydrocodone (10.4%). The great majority of patients (91.8%) received pharmacological co-medication with antihypertensive agents (54.4%), statins (38.2%) and acetaminophen (35.4%). The use of other analgesics such as acetaminophen (OR: 1.45, 95% CI: 1.22 -1.75) or nonsteroidal anti-inflammatory drugs (OR: 1.98, 95% CI: 1.60 -2.44) was associated with increased risk of receiving opioids in combination therapy. Prescribing habits of weak agonists and short-acting opioids predominate, mainly in monotherapy and at lower than recommended doses.

Pharmacotherapy of Pain in the Older Population: The Place of Opioids

Pain is a common symptom in older people. It is possible that pain is underreported in older persons due to an incorrect belief that it is an inevitable part of aging. Opioid analgesics are potent medications, with confirmed efficacy for the treatment of moderate to severe pain. These drugs are commonly used in older persons. However, there is insufficient evidence regarding safety of opioids in older patients. One of the reasons for this is the lack of randomized, controlled clinical trials. People of advanced age often have comorbidites and use other prescription drugs, as well as over-the-counter (OTC) compounds, thus making them more suceptible to the risk of interactions with opioids. Significant pharmacokinetic and pharmacodynamic changes that occur with advancing age increase the risk of adverse effects of opioids. There are also some discrepancies between guidelines, which recommend the use of lower doses of opioids in older patients, and the findings in the literature which suggest that pain is often undertreated in this age group. It seems that there are significant variations in the tolerability of different opioid analgesics in older people. Morphine, fentanyl, oxycodone, and buprenorphine are still the preferred evidence-based choices for add-on opioid therapy for these patients. However, the safety and efficacy of other opioids in older patients, especially if comorbidities and polypharmacy are present, is still questionable. This review addresses the most important aspects of the use of opioids in older persons, focusing on pharmacokinetics, pharmacodynamics, adverse effects, and interactions.