Friday, November 5, 2010

Help Promote Safe Opioid Use in Elderly Patients

OpioidsPain is a pervasive complaint among elderly patients and it can be challenging for healthcare providers to treat both safely and effectively. Opioids are often a recommended option for acute or chronic pain in this population and the vast majority of elderly patients will be compliant with the prescribed therapeutic regimen; but they (and their family caregivers) must be educated on safe opioid use. There are implications here for all healthcare providers who may prescribe opioids, whether in community medicine, dentistry, emergency care, hospice or palliative care, and other settings.

Prior surveys have found that undertreated pain or inadequate pain relief for both acute and chronic conditions are common in older patients. A newly-reported large-scale study in the Annals of Internal Medicine notes this situation worsens as persons approach later years of life [Smith et al. 2010]. In the report, unrelieved pain of at least moderate severity was experienced by a quarter of persons (26%) during the last two years of life and this increased to affect nearly half of them (46%) during the last month of life, regardless of the cause of death (eg, cancer, heart disease, frailty, or other). Earlier reports suggested that 70% of patients with cancer have significant pain, yet fewer than half of them receive adequate pain relief [discussed in blogpost here].

Some guidelines, such as those from the American Geriatrics Society, recommend opioid analgesics as a first choice for moderate to severe pain in the elderly [see blogpost here]. Indeed, a recent report indicated that 30% of patients aged 65 to 74 years and 25% of those 75 or older are prescribed opioid therapy for such pain [discussed here]. However, even though pain is more prevalent in the elderly, opioids are prescribed less frequently for these patients than in younger persons.

Certainly, there are considerable concerns about adverse events associated with opioid analgesics in the elderly, along with the usual fears of abuse, diversion, addiction, and overdose. However, it might be speculated that much of the undertreatment of pain in the elderly stems from doubts about their ability to safely manage and use opioid medications at home. Consequently, when opioids are deemed necessary for these patients, weaker opioids might be prescribed, in smaller than optimal doses, and for inadequate periods of time; albeit, further research is needed to confirm such practice.

The U.S. FDA has taken a special interest in examining pain medication use in elderly patients as part of their “Safe Use Initiative” [access website here]. The aim of this program, launched in November 2009, is reducing preventable drug-related adverse events. One of the apprehensions raised at FDA meetings has been the risk of multiple medication use by elderly patients, particularly involving analgesics. Along with that, it has been acknowledged that many prescribers are concerned about misuse/abuse of opioid medications in older patients, which is much less common than in younger adults; however, there is less information about how often older adults abuse substances and which individuals are at greatest risk. Typically, unless there are specific deterrents (eg, medication cost, access problems, adverse reactions, etc.) older patients tend to be more compliant with medication regimens than younger adults. However, in older patients there also may be comorbidities and cognitive declines that could incur special safety concerns when it comes to their keeping track of and properly taking opioid medications.

Opioid Safety Strategies in the Elderly
Assuming that an appropriate decision to prescribe an opioid analgesic for the patient has been made (which is a separate topic), opioid safety further relies on patients taking responsibility for safe use, storage, and disposal at home. This is no easy matter because persons rarely know what such safety entails and, in the case of elderly patients, responsibility also often rests with their caregivers — family or friends who help to look after them.

Educating patients and their caregivers on medication safety begins at the point-of-care — granted, it takes extra time that may be uncompensated by insurance, and available research suggests it is often neglected [Tarn et al. 2006]. However, special counseling whenever an opioid is prescribed can prevent many potential safety problems (and increase practitioner comfort levels for prescribing more adequate opioid medication). To the extent possible, the patient’s caregivers also should be included in a presentation of the following points, which are adapted from the Opioids911-Safety education program [see:]:
  1. First, all patients should be advised at the point-of-care about prescribed medication names, doses, and dosing regimens. As part of Informed Consent, elderly patients should be cautioned about potential opioid adverse effects, including signs/symptoms of opioid overmedication and overdose.

  2. Ideally, caregivers will be able to help ensure that the patient is using the opioid medication properly, and they will be educated on monitoring the patient’s response to any new opioid medication or following a change of dose, and how to watch for signs of overmedication or overdose, along with what to do in an emergency.

  3. Since polypharmacy is the rule rather the exception in older adults, it is important to take into account all other medications (Rx and OTC) and other substances that the patient is taking and to advise them to notify you of any changes. (Opioid-drug interactions were previously discussed in a blogpost [here]).

  4. Medication cost may be a safety factor in the elderly, as they may skip opioid doses to conserve precious medication but then overuse the drug if the pain gets out of control. Or, they may try to spit individual tablets or patches to extend their supply, which can be overtly hazardous. Medication costs rarely enter into the prescriber-patient interaction but such discussions could be critical for safety.

  5. Elderly patients may have special needs, such as difficulty swallowing medications. They need specific instructions and appropriate cautions on taking the particular opioid medication; for example, whether it can be opened (capsule) or crushed to sprinkle on food. The proper application of opioid patches and precautions (eg, avoid heat, etc.) must be carefully explained; there have been deaths due to accidental patch misuse [discussed here].

  6. Elderly patients may be trusting of the few guests who come into their homes. However, they need to be cautioned about safeguarding opioids from ALL visitors, including their friends, relatives, adult children, and grandchildren. Ask where they will store their medications and stress that a locked box, drawer, or cabinet is the safest place — even though this may seem inconvenient. (A trustworthy caregiver also should know the location and have the key or lock combination.)

  7. Along with that, there should be a discussion about not sharing opioid medication with anyone, including elderly friends and relatives who may have similar pain conditions and opioid prescriptions of their own. Patients should be informed of the dangers and also that sharing is illegal, which in itself may be enough to deter law-abiding older persons.

  8. Advise elderly patients to wear any reading glasses they may have when sorting or consuming their medications, so they can clearly see labels and amounts. And, for the same reasons they should never take medications in a darkened room.

  9. Older adults often have diminished manual dexterity, so they should be advised not to handle or open medicine containers near a sink or toilet where the contents might fall in and be ruined.

  10. Many elderly patients enjoy an evening cocktail, beer, or wine, and they are not about to change that habit unless they are specifically warned against it while taking opioid medications.

  11. When starting or changing an opioid regimen driving skills may be impaired, and many elderly patients have diminished reflexes and alertness to begin with; so, they must be cautioned against driving (or operating any potentially hazardous machinery or devices) until effects of the opioids are known.

  12. Older patients who may be forgetful, at least sometimes, plus taking multiple medications, must be advised to carefully keep track of opioid amounts and times taken each day, such as by using an organizer tray, a daily medication log, or other means. Ask the patient and/or caregiver how they keep track of meds.

  13. Frugal older patients often hoard leftover medicines, including opioids, for “future use.” Inform patients about the possible hazards of doing this and instruct them on how to safely discard their unused opioids. (The current recommendation is to flush opioids down the toilet or deliver them to “take-back programs” when available.)

  14. If they will be traveling, patients should be advised to carry their opioid medications with them at ALL times; including, never leaving them in a car or hotel room. For travel out of the country, the opioid prescriber should provide a letter indicating that the opioid (specifying name, amount, and dose) was legitimately prescribed for the patient, else there could be problems at security checkpoints.
More details regarding the above points, plus others, can be reviewed at Also, a one-page instructional handout for patients and caregivers can be accessed and downloaded [here], along with other helpful resources.

The list of important safety points to cover is admittedly extensive; however, neglecting them as has been so often done in the past could set the stage for a misadventure. And, it is essential that elderly patients (and their caregivers) are counseled on opioid safety whether they are being prescribed a handful of weak opioids for acute pain or a long-term supply of strong opioids for a chronic pain condition; the risks are essentially the same and under certain circumstances one pill, tablet, or patch may be fatal to an adult, child, or even a household pet. Busy healthcare providers often overlook that harsh reality, sometimes assuming the pharmacist or information sheets that come with the prescription will provide necessary counseling and education — yet, research [eg, here] shows that this is rarely the case.

> Smith AK, Cenzer IS, Knight SJ, et al. The Epidemiology of Pain During the Last 2 Years of Life. Ann Intern Med. 2010(Nov):153;563-569 [
abstract here].
> Tarn DM, Heritage J, Paterniti DA, et al. Physician communication when prescribing new medications. Arch Intern Med. 2006;166(17):1855-1862 [