When you think about the opioid crisis in the United States, what picture comes to mind? What does a person who is affected by this crisis look like? Maybe he is young, or maybe she is someone who uses illicit opioids like heroin. To be sure, illicit opioids are a significant problem. However, the opioid crisis affects older adults, too, and this vulnerable population has different needs.
Did you know that adults over 65 are hospitalized at nearly the same rate as younger adults for opioid-related stays? According to the Healthcare Cost and Utilization Project (HCUP), only adults 45-64 were hospitalized more frequently in 2016 than adults 65 or older1.
In addition, Medicare pays for more opioid-related hospital stays than every payer besides Medicaid. HCUP data show that Medicare pays for more than one in three of these stays. In some states, like Tennessee, Medicare pays for almost half of opioid-related stays, more than any other payer3.
CDC data also show how opioids affect older adults differently. Between 2016 and 2017, the rate of overdose deaths from all opioids in adults over age 25 increased. But the rate of prescription opioid overdose deaths increased by 10.5% for adults over age 65, while the rate for all other age groups decreased4.
Since prescription opioid safety is especially important for older adults, let’s look at prescribing patterns. In 2018, almost 30% of Medicare Part D beneficiaries received at least one prescription opioid5. Though this is a decrease from 2016 and 2017, it is still higher than other age groups. In 2017, about 17% of all Americans received at least one prescription opioid6.
Opioids also affect older adults differently. They are more sensitive than younger adults to the sedating effects of opioids. Opioids also increase fall risk, which is a significant concern in elderly patients even in the absence of opioids. Reduced liver and kidney function in older adults means that opioids are metabolized more slowly, which can lead to more severe adverse effects. Since older adults commonly have more chronic medical conditions, the risk of drug-drug and drug-disease interactions are increased as well.
Below are suggestions that align with the CDC’s opioid guidelines7, along with added commentary specific to older adults.
- Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Topical therapies can be effective for chronic pain, either in addition to or instead of opioids and are often available over the counter.
- Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients. An opioid treatment agreement can be helpful.
- Before starting and periodically during the continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. These harms can be especially dangerous in older adults.
- Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Older adults are particularly vulnerable to these risks.
- Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible. This drug interaction is especially dangerous to older adults. Caution should also be used when prescribing other sedating drugs such as muscle relaxants or hypnotics.
Medication taking behavior is also especially important for older adults. For those with cognitive impairment, dosing errors may be common. A pharmacist is a helpful resource to assist with packaging medications safely, and caretakers are key to preventing mistakes.
Even though older adults are not the first group you may think about when focusing on opioid safety, there is a great deal you can do to promote safe prescription opioid use. Along with the healthcare team, outpatient practices are uniquely positioned to address the specific needs of this population.
Need resources on opioid tapering, safe disposal, and patient education? Visit our website.
Merit-based Incentive Program Corresponding Measures
Quality Measures – Registry Only
|QUALITY ID||MEASURE NAME||MEASURE DESCRIPTION|
|468||Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)||Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment|
|412||Documentation of Signed Opioid Treatment Agreement||All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record|
|414||Evaluation or Interview for Risk of Opioid Misuse||All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record|
|408||Opioid Therapy Follow-up Evaluation||All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record|
Verify Opioid Treatment Agreement
For at least one unique patient for whom a Schedule II opioid was electronically prescribed by the MIPS eligible clinician using CEHRT during the performance period, if the total duration of the patient’s Schedule II opioid prescriptions is at least 30 cumulative days within a 6-month look-back period, the MIPS eligible clinician seeks to identify the existence of a signed opioid treatment agreement and incorporates it into the patient’s electronic health record using CEHRT.