Are Opiates Safe for Older Adults?
As the percentage of older individuals in the U.S. population grows dramatically in the coming decades, the problem of how to address the chronic pain that is so common in this age group looms as a significant challenge. Opioid medications represent one possible response in the battle against pain in older adults, but their unwanted side effects—as well as the paucity of data on the efficacy and addictive potential of these drugs in older populations—must be addressed before their benefits and drawbacks become clear, an MGH expert warns.
Meanwhile, opioid use is rising. A study of U.S. government data collected between 2000 and 2010 published online Sept. 13, 2013 in the journal Medical Care found that while prescriptions for non-opioid painkillers had remained stable, prescriptions for opioids had nearly doubled,
“Estimates by the U.S. Bureau of Statistics suggest that by 2030, there will be 72 million people in their 60s and older in the U.S—a growth of 20 percent from 2000,” says David Borsook, MD, PhD, a neurologist and neurobiologist who is director of the Pain and Imaging Neuroscience Group in the Department of Psychiatry at MGH. “Given the estimates that peak pain prevalence for men is reported to occur be-tween the ages of 65 and 70, with 27 percent of individuals reporting pain, and peak pain prevalence for women occurs around age 80, with 30 percent reporting pain, finding appropriate pain-treatment caregivers and treat-ments for this age group presents a huge challenge.”
WHAT YOU CAN DO
If you are using an opioid medication and experience these warning signs of medication overdose, check with your physician:
- Blue fingernails, toenails, or lips
- Stumbling while walking
- Dizziness
- Confusion
- Slurred speech
- Slow respiration and/or heartbeat
- Pale or clammy skin
- Excessive drowsiness
- Difficulty waking from sleep
The situation is complicated by the fact that there are few evidence-based guidelines to help physicians decide when opioids are right for an older patient, Dr. Borsook says: “Current data suggest that the medica-tions are clearly appropriate for treatment of such problems as short-term acute pain, metastatic cancer, or end-of-life pain, where the treatment benefits usually outweigh the potential for addiction. But treatment of chron-ic pain in older individuals must take into account the long-term effects of drugs on their aging minds and bodies, along with other factors that might call for special care. Ideally, not only should we provide treatment at the best possible current standards of care, but we need to develop better drugs and gather better data on opioid use in older people before we can be confident in our ability to address chronic pain in this population. Until then, we have to be thoughtful about how we prescribe opioids.”
Defining opioids
Opioid medications are opium-like compounds predominantly derived from opium poppies, although some forms of the drug may be manufactured as a synthetic. The drugs, which are also known as narcotics, take advantage of opioid receptors in the brain that respond to the action of opioids produced naturally in the body. By binding to these receptors, opioid drugs reduce the intensity of pain signals reaching the brain, triggering sedation and pain relief. Examples of common opioid medications are oxycodone (e.g., OxyContin, Percocet, Percodan), hydrocodone (e.g., Vicodin), morphine (e.g., Kadian, Avinza), and codeine.
“With regular use over time, as individuals become accustomed to opioid medications, they frequently require larger doses to achieve the same effect, and physical dependency—along with withdrawal symptoms such as craving, anxiety, insomnia, and agitation—become a concern,” Dr. Borsook says. “With younger patients, guidelines are in place to try to mitigate against opioid abuse, but the standards for the elderly are much less clearly defined. We need to develop consensus treatment parameters specifically for this age group and preferably through well-controlled studies.”
Challenges of age
Caring for older individuals with pain can be significantly more difficult than caring for younger patients. Among the many treatment challenges of the older age group are the greater likelihood that they:
- Are undergoing age-associated changes that might increase the incidence or severity of opioid side effects or accidental overdose, such as constipation, decreased renal and respiratory function, dizziness, and cognitive problems
- Eliminate drugs more slowly from their systems than younger individuals do
- May have multiple medical conditions with conflicting treatment demands
- May be taking one or more other medications for various medical conditions, some of which might interact negatively with opioids
- May have undergone a recent surgery, for which other pain medications have been prescribed
- May suffer from depression, anxiety, feelings of loneliness, and other psychological issues that might com-plicate opioid usage or lead to addiction
- May be more reluctant than younger people to complain about pain or request pain treatment
“In cases where older individuals do consult a physician about pain, a further problem is that many patients also have high expectations, and ideally want pain medication that will allow them to enjoy an active life-style despite their health limitations,” Dr. Borsook says. “The physician or caregiver has to strike a balance between what the patient wants and an appropriate medical response. It’s important that older patients be educated about the risks inherent in opioid use, so that together the physician and patient can make the best treatment decisions.”
Seek specialized care
Pain treatment available to older people is often less than satisfactory, Dr. Borsook says. Many older people live in institutions where care may not be optimal. Aging patients may be treated by multiple health care providers, who may fail to share information about pain medications they are prescribing. Elderly patients who suffer from cognitive dysfunction including Alzheimer’s disease (AD) may have difficulty communicating with their caregivers. In many instances, appropriate medical evaluation of pain is lacking.
“I advise older patients who are coping with chronic pain to visit special pain clinics or consult geriatricians and other specialists who focus on pain treatment in older people,” Dr. Borsook says. “These professionals are more apt to understand the best practices of pain treatment in the elderly, to know the full range of treatment options and how to match them to individual patients, and to carefully monitor pain treatment.”
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