Elderly Disproportionately Affected by New Limits on Opioid Painkillers
By Paula Span, New York Times
If you’ve come to rely on opioids for chronic pain, as a growing proportion of older adults has, you may have noticed that the drugs are becoming more difficult to get.
Something had to be done, surely: More than 165,000 people died from overdoses from 1999 to 2014.
But recent restrictions on access to these painkillers are likely to disproportionately affect the elderly — despite the fact that abuse and misuse of these painkillers have historically been lower among older patients than younger ones.
Older patients are simply more apt to have chronic pain. Some of their doctors are going to get an earful when they suggest different medications or nonpharmacological alternatives, as the Centers for Disease Control and Prevention recommended in new opioid guidelines in March.
Dr. Mary Lynn McPherson, a palliative care specialist and a professor at the University of Maryland School of Pharmacy, told me about a 78-year-old patient with “screaming pain from fibromyalgia” (which doesn’t respond to opioids anyway). McPherson urged her to undertake significant weight loss and begin regular aquatic therapy and stretching.
“Please, can’t you just give me Percocet?” she said. Her physician agreed to continue her prescription but, to the patient’s frustration, at a low dose.
“We do need to rein this in,” McPherson said of opioid use. Yet like many health care professionals, she’s worried about her patients’ suffering.
How do you balance the need to relieve pain against the possibility that potent, habituating drugs can also sabotage people’s health, particularly when older people are more vulnerable than the young to opioids’ side effects? “It’s this enormous conundrum,” she said.
For patients who want to get or refill prescriptions, “you have to jump through more hoops,” McPherson said.
Along with the CDC guidelines, which urge more careful monitoring, doctors face a wave of state laws restricting access. The Drug Enforcement Administration also reclassified certain opioid formulations in 2014, making them less readily available.
This represents a major swing of the medical pendulum. For years, doctors were warned against paying insufficient attention to pain. The Department of Veterans Affairs declared pain the “fifth vital sign” in 1999, and many hospitals and clinicians are evaluated in part on how well they treat it.
For many older people, chronic pain — lasting longer than three months or longer than the body’s tissues normally need to heal — becomes an everyday burden. Older patients are more apt than younger ones to hurt from musculoskeletal disorders like arthritis, from nerves damaged by diabetes or shingles, from cancer, from multiple causes all at once. They have more surgery.
Once, physicians actually struggled to induce older people to take opioids, which we used to call narcotics.
“Most older adults are phobic about these medications,” said Dr. Cary Reid, a geriatrician and palliative care specialist who directs the Translational Research Institute on Pain in Later Life at Weill Cornell Medical College. “You have to persuade them.”
Consider them persuaded. Last year, researchers at the University of California, San Francisco, published a study using two large national surveys of outpatient visits to examine analgesic drug use among older adults (average age: 75).
They found that from 1999 to 2010, the percentage of clinic visits involving any pain-relieving medication climbed to more than 19 percent from 13.6 percent. Opioid use drove much of that increase: The figure more than doubled, to 9 percent of visits from 4.1 percent.
In February, a Medicare administrator told the Senate Special Committee on Aging that in 2015, nearly 30 percent of those enrolled in Part D used an opioid prescription.
But the Medicare population is more likely to suffer these drugs’ ill effects, too, leaving physicians to ponder troubling trade-offs.
“Older adults don’t metabolize drugs as well as a 30- or 50-year-old, so the medication stays in a person’s system longer,” Reid said.
Opioids can bring on nausea and vomiting and often lead to constipation, which may then require additional medications, creating cycles of constipation and diarrhea. Long-term use can cause kidney and cardiac damage.
Opioids affect balance and are associated with higher risks of falls and fractures. They can impair thinking and memory.
Vexingly, the medications physicians might prescribe instead, including anti-inflammatories like ibuprofen or naproxen, also pose greater dangers for older patients: bleeding, elevated blood pressure, reduced kidney function.
Addiction and overdoses have historically been lower among older users, but public health experts have long wondered whether those patterns will change with the baby boomer cohort.
“The problem may grow worse with people who grew up in a culture where drugs were something to experiment with,” Reid said.
Experts worry, too, about diversion — relatives, neighbors or caregivers helping themselves to their elders’ medicines.
“It’s complicated terrain,” said Christine Ritchie, the lead author of the UCSF study and a past president of the American Academy of Hospice and Palliative Medicine. Nationally, opioid prescriptions have begun to decline, and some physicians have stopped prescribing them altogether.
As an older patient seeking pain relief, you’ll probably find that while you may continue using opioids, you’ll get more questions, hear more about alternatives — and take home fewer pills.
For example, doctors can no longer call in prescriptions with refills for certain formulations, notably Vicodin. Under the Drug Enforcement Administration’s tighter controls on such hydrocodone combinations, you have to take a paper prescription to a pharmacy, then return to your doctor for a new prescription every month, to allow closer monitoring. Those can be onerous requirements for older people in pain.
You’ll also find doctors talking about reasonable expectations. “You probably can’t make the pain a zero,” McPherson said. “We’re trying to make it tolerable.”
They’ll recommend a raft of nondrug therapies to manage pain, too: exercise, weight loss, cognitive behavioral therapy, mindfulness meditation, tai chi or yoga. Research has demonstrated that several of these approaches can reduce pain.
But not enough practitioners offer alternatives like cognitive behavioral therapy, and insurers (including Medicare) generally won’t pay for them. If the CDC wants doctors to advocate a “multimodal” approach to chronic pain (and it does), giving preference to nonpharmacological therapies, “we need a system that can deliver it and can pay for it,” Reid said.
In the interim, patients can seek out tai chi, yoga and mindfulness training at senior centers and YMCAs. Early studies have also shown that therapy sessions via the internet or videoconferencing can reduce pain.
Maybe future pain patients will look like Irene Cohen, 69, a homemaker in White Plains. She has had debilitating back and leg pain since she fell down a flight of subway steps when she was 20. In the decades since, with a desperation familiar to many, she has tried nearly every remedy, including two back operations.
At her lowest, Cohen couldn’t walk more than a block or two without unfolding her cane into a tripod seat that let her rest. “Pain just became part of me,” she said.
Over time, though, she has developed a combination of therapies that allow her to function. Acupuncture, chiropractic and hypnosis proved ineffective, but she finds a weekly massage essential.
She exercises faithfully and has worked up to a 15-minute walk on a slow treadmill, “which is a miracle.”
And when her pain flares anyway, she has a prescription for Vicodin, which she uses sparingly.
“She’s what we hope people will do,” said Reid, her physician. “She uses the drugs in a very smart way. She’s got a whole portfolio of things she can use. And despite the impairments pain has brought, she’s living a life.”
To Learn More:
CDC Urges Doctors to Render Prescription Painkillers a Last Resort (by Matthew Perrone, Associated Press)
Doctors Restricted From Prescribing Addiction Treatment (by Austin Frakt, New York Times)
U.S.: 5% of World Population; 80% of Opioid Consumption (by Steve Straehley, AllGov)
U.S. Doctors Prescribe Opiate Painkillers at Twice the Rate of any other Country…and 500,000 Veterans are Dependent (by Steve Straehley, AllGov)
FDA Panel Advises Limiting Prescription Refills for Addictive Painkillers (by Matt Bewig, AllGov)
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