Best Practices: Managing Opioid Risks in Older Adults

Polypharmacy and slow metabolism of drugs create a high risk among older adults for substance use disorder, raising the odds of intentional and unintentional overdoses. However, screening, assessment, and treatment for substance use disorder occurs less often in younger adults.

Rates of overdose from opioids increased the most among people aged 65 years and older from 2021 to 2022 compared with among younger age groups. Meanwhile, recent data show less than half older adults with opioid use disorder (OUD) receive care for the condition.

"Nobody is immune to developing some kind of use disorder, so don't just assume that because someone's 80 years old that there's no way that they have a problem," said Sara Meyer, PharmD, a medication safety pharmacist at Novant Health in Winston-Salem, North Carolina. "You never know who's going to potentially have an issue."

Clinicians and health systems like Novant are spearheading efforts to best manage older adults who may need opioids because of conditions like chronic pain in an effort to reduce addiction and overdoses.

Older Adults Have Unique Needs

A major challenge of treating older adults is their high incidence of chronic pain and multiple complex chronic conditions. As a result, some of the non-opioid medications clinicians might otherwise prescribe, like nonsteroidal anti-inflammatory drugs, cannot be used, according to Caroline Goldzweig, MD, chief medical officer of the Cedars-Sinai Medical Network in Los Angeles.

"Before you know it, the only thing left is an opiate, so you can sometimes be between a rock and a hard place," she said.

But for adults older than 65 years, opioids can carry problematic side effects, including sedation, cognitive impairment, falls, and fractures.

With those factors in mind, part of a yearly checkup or wellness visit should include time to discuss how a patient is managing their chronic pain, according to Timothy Anderson, MD, an assistant professor of medicine at the University of Pittsburgh, Pittsburgh, and codirector of the Prescribing Wisely Lab, a research collaboration between that institution and Beth Israel Deaconess Medical Center in Boston.

When considering a prescription for pain medication, Anderson said he evaluates the potential worst, best, and average outcomes for a patient. Non-opioid options should always be considered first-line treatment. Patients and physicians often struggle with balancing an option that meets a patient's goals for pain relief but does not put them at a risk for adverse outcomes, he said.

Greater Risk

Older adults experience neurophysiologic effects different from younger people, said Benjamin Han, MD, a geriatrician and addiction medicine specialist at UC San Diego.

Seniors also absorb, metabolize, and excrete drugs differently, sometimes affected by decreased production of gastric acid, lean body mass, and renal function. Coupled with complications of other chronic conditions or medications, diagnosing problematic opioid use or OUD can be one of the most challenging experiences in geriatrics, Han said.

As a result, OUD is often underdiagnosed in these patients, he said. Single-item screening tools like the TAPS and OWLS can be used to assess if the benefits of an opioid outweigh a patient's risk for addiction.

Han finds medications like buprenorphine to be relatively safe and effective, along with nonpharmacologic interventions like physical therapy. He also advised clinicians to provide patients with opioid-overdose reversal agents.

"Naloxone is only used for reversing opioid withdrawal, but it is important to ensure that any patient at risk for an overdose, including being on chronic opioids, is provided naloxone and educated on preventing opioid overdoses," he said.

Steroid injections and medications that target specific pathways, such as neuropathic pain, can be helpful in primary care for these older patients, according to Pooja Lagisetty, MD, an internal medicine physician at Michigan Medicine and a research scientist at VA Ann Arbor Health Care, Ann Arbor, Michigan.

She often recommends to her patients online programs that help them maintain strength and mobility, as well as low-impact exercises like tai chi, for pain management.

"This will ensure a much more balanced, patient-centered conversation with whatever decisions you and your patient come to," Lagisetty said.

New Protocols for Pain Management in Older Adults

At the health system level, clinicians can use treatment agreements for patients taking opioids. At Novant, patients must attest they agree to take the medications only as prescribed and from a specified pharmacy. They promise not to seek opioids from other sources, to submit to random drug screenings, and to communicate regularly with their clinician about any health issues.

If a patient violates any part of this agreement, their clinician can stop the treatment. The system encourages clinicians to help patients find additional care for substance abuse disorder or pain management if it occurs.

Over the past 2 years, Novant also developed an AI prediction model, which generates a score for the risk a patient has in developing substance use disorder or experiencing an overdose within a year of initial opioid prescription. The model was validated by an internal team at the system but has not been independently certified.

If a patient has a high-risk score, their clinician considers additional risk mitigation strategies, such as seeing the patient more frequently or using an abuse deterrent formulation of an opioid. They also have the option of referring the patient to specialists in addiction medicine or neurology. Opioids are not necessarily withheld, according to Meyer. The tool is now used by clinicians during Medicare annual wellness visits.

And coming later this year are new protocols for pain management in patients aged 80 years and older. Clinicians will target a 50% dose reduction compared to what a younger patient might receive to account for physiologic differences.

"We know that especially with some opioids like morphine, they're not going to metabolize that the same way a young person with a young kidney will, so we're trying to set the clinician up to select a lower starting dose for patients that are older," Meyer said.

In 2017, the system implemented a program to reduce prescription of opioids to less than 350 morphine milligram equivalents (MME) per order following any kind of surgery. The health system compared numbers of prescriptions written among surgical colleagues and met with them to discuss alternative approaches. Novant said it continues to monitor the data and follow-up with surgeons who are not in alignment with the goal.

Between 2017 and 2019, patients switching to lower doses after surgeries rose by 20%.

Across the country at Cedars-Sinai Medical Network in Los Angeles, leadership in 2016 made the move to deprescribe opioids or lower doses of the drugs to less than 90 MME per day, in accordance with Centers for Disease Control and Prevention guidelines established that year. Patients were referred to their pain program for support and for non-opioid interventions. Pharmacists worked closely with clinicians on safely tapering these medications in patients taking high doses.

The program worked, according to Goldzweig at Cedars-Sinai. Goldzweig could only find two patients currently taking high-dose opioids in the system's database out of more than 7000 patients with Medicare Advantage insurance coverage.

"There will always be some patients who have no alternative than opioids, but we established some discipline with urine tox screens and pain agreements, and over time, we've been able to reduce the number of high-risk opioid prescriptions," she said.

Liz Seegert is a freelance journalist.