Lonely, older adults are nearly twice as likely to use opioids to ease pain and two-and-a-half times more likely to use sedatives and anti-anxiety medications, putting themselves at risk for drug dependency, impaired attention, falls and other accidents, and further cognitive impairment, according to a study by researchers at UC San Francisco.
The study found that just over half of 6,000 respondents in a nationally representative survey of seniors living independently were not lonely, while 40 percent were moderately lonely, and 7 percent were highly lonely.
The proportion of seniors in each group who had prescriptions for opioids and anti-anxiety medications and sedatives, which included drugs like Valium, Xanax, BuSpar and Ambien, correlated with their degree of loneliness, according to the study, which publishes in JAMA Internal Medicine on June 26, 2021.
“There’s a misconception that as we age, we become more withdrawn and less sociable,” said first author Ashwin Kotwal, MD, of the UCSF Division of Geriatrics and of the San Francisco VA Medical Center.
“In fact, older people are more socially active than other age groups and frequently play major roles in their communities. When older people are not socially active, we need to recognize that there’s a problem.”
The researchers used data from the National Social Life, Health and Aging Project, a population-based study of health and social factors, and checked each participant’s medications if they were used “on a regular schedule, like every day or every week.” The participants’ average age was 73; 46 percent were male, and 84 percent were white (7 percent were Black and 6 percent were Hispanic).
The researchers found that 6 percent of the non-lonely group used prescription opioids, versus 8 percent for the moderately lonely group and 11 percent for the highly lonely group. For anti-anxiety medications and sedatives – which includes anti-cholinergic drugs, like Valium, Unisom and tricyclic antidepressants, which have been associated with a higher risk for dementia – 9 percent of the non-lonely group used them, versus 13 percent for the moderately lonely group and 23 percent for the highly lonely group.
Similar patterns were found with antidepressants and NSAIDs, prescription and over-the-counter painkillers that may cause ulcers and bleeding in long-term use by older adults. The highly lonely group was also more likely to be on five or more medications – 58 percent versus 46 percent for the non-lonely participants.
Kotwal advocates for fewer prescriptions of psychotropic drugs for older adults who are lonely, and in its place “social prescribing” to local resources in the community. This can be done by “link workers,” based in primary care practices or within the community, with connections to amenities like senior centers, exercise classes, grief groups or volunteer programs.
He notes that the pandemic has taken the stigma out of loneliness, giving older adults an opportunity to discuss their feelings in clinic. Asking patients what might help can be a good first step to referring them to programs that might fit their needs.
“We don’t want to pathologize loneliness. Most people experience loneliness at some point in their lives, but when experiences of loneliness persist for many months or years, it can cause physiologic changes, such as a ramped-up stress response, sleep problems, and even heart disease,” said Kotwal. “And, a lack of social contact can erode our social skills, making it more difficult over time to connect with others and creating a vicious cycle.”
While physicians are well aware of the dangers of prescribing medications that should not be used in the long term, Kotwal noted that it “takes time and effort to de-prescribe,” and switching a drug that acts promptly with one that may take several weeks to have an effect may be very challenging to patients in distress.
In busy practices with complex patients, contraindications may not come to light until a patient is suddenly hospitalized, said Kotwal. “It’s only then that we might find out that a patient’s prescriptions include Valium and he’s been taking it for more than 20 years.”
A recent previous study, also led by Kotwal, found that in the last four years of life, 19 percent experienced social isolation, 18 percent were lonely and 5 percent experienced both social isolation and loneliness. Factors associated with loneliness included female gender, pain, incontinence and cognitive impairment.
The paper’s senior author is Alexander K. Smith, MD, of UCSF and San Francisco VA Medical Center. Co-authors are Michael Steinman, MD, also of UCSF and San Francisco VA Medical Center, and Irena Cenzer, PhD, of UCSF.
As the United States continues to battle an opioid epidemic, prescribing practices of providers and use of opioids by various subgroups of the population have come under significant scrutiny. It is well understood that prescription opioids place users at risk for not only physiologic and psychological dependence but also significant health consequences.
Opioid use in the geriatric population has become an increasingly concerning issue. Opioid prescriptions have quadrupled in the past decade, with no improvement in the prevalence of pain or disability.1,2 Furthermore, older adults and females are the most likely group to use opioids long-term.3 According to the Centers for Disease Control and Prevention (CDC), 17.4% of the US population, or 56,935,332 persons, filled at least 1 opioid prescription in 2017, and opioid prescribing was highest at 26.8% in the older age group (≥65 years).4
Chronic pain is one of the most common reasons for opioid prescriptions. Chronic pain contributes to a significant financial burden of $560 billion each year from costs of medical care, loss of productivity, and disability programs.5 In 2016, of 50,009,000 adults 18 years and older with chronic pain (defined as “pain on most days or every day in the past 6 months”) in the United States, 27.6%, or 11,808,000 persons, aged 65 to 84 years and 33.6%, or 1,766,000 persons, 85 years and older, had chronic pain; and 10.7%, or 4,578,000 persons, aged 65 to 84 years and 15.8%, or 830,000 persons, 85 years and older had high-impact chronic pain (defined as “chronic pain limiting life or work activities on most days or every day in the past 6 months”).6
Older adults with chronic pain are often unable to perform basic activities of daily living or maintain independent living and have less mobility, poor cognitive functioning, and a higher level of disability.7 Because chronic pain is highly prevalent and has negative consequences on older adults, it is extremely important to adequately manage chronic pain to prevent further disability.
However, the challenge is finding a balance between managing chronic pain with the goal to reduce disability and improve quality of life of older adults and mitigating the risks with opioid prescribing. Clearly, although opioids carry significant risks, they have and continue to occupy an important space in our treatment armamentarium, particularly in patients who may not tolerate alternatives or have medical comorbidities that make opioids a prime choice for pain management.
Quality of life in advanced decades can be significantly affected by persistent pain, and a rational approach to management does, at times, include opioids for patients who are appropriately selected and monitored.
It is imperative that prescribers, particularly those practicing primary care, where many of these patients receive their care, understand the appropriate indications for opioid therapy in older adults, potential complications, and alternative therapies that may be offered when opioids either are not indicated or place the patient at significant risk for harm.
Our intention herein is to generate a resource review that draws on other sources to heighten awareness of issues in older adults while providing guidance to enhance chronic pain management.
Most strong opioids, including buprenorphine, fentanyl, hydromorphone, morphine, and oxycodone, are often recommended equally in older adults to control pain. However, methadone is not included routinely as a first-line opioid medication in older adults because of a variety of potential complications, including prolongation of the corrected QT interval, high drug-drug interactions, and a long elimination half-life, producing greater toxicity.17,18
The physiologic changes of aging additionally complicate opioid therapy in older adults. From altered absorption in the gastrointestinal tract to changes in body composition and alterations in hepatic and renal metabolism, the response to opioids in geriatric patients is less predictable than in younger patients.18 In response to pharmacokinetic changes with aging, it has been recommended that dosing in older adults start at only 25% to 50% of what would be initiated in a younger adult and that the dosing intervals be extended.17 Therefore, treatment should begin with only 1 short-acting opioid titrated slowly to effect.
It is also important to note that altered response to opiates may significantly affect the adverse effect profile experienced by the older population. Common disease states in older adults play a significant role in producing these adverse effects if the wrong opioid is chosen. Renal insufficiency is not uncommon and requires the provider to be aware of potential metabolite accrual. Morphine should be avoided in the setting of significant renal impairment due to decreased excretion of morphine-6-glucoronide, with an ensuing risk of severe complication, including seizure. Hydromorphone and oxycodone are preferable but should be used with caution and in reduced dose.
Fentanyl and methadone are considered safe in renal failure.19
Similarly, prescribing opioids in the setting of liver failure is also complex. Because most opioids are metabolized in the liver, the risk of adverse effects is much higher. Common adverse effects of opioids that are exacerbated in liver disease include sedation, encephalopathy, and constipation. Because of reduced metabolism of these agents, reduced dosing is also recommended.19
One of the most obvious concerns is how opioids interact with other medications being taken.
Because geriatric patients tend to experience more medical comorbidities and, therefore, have a higher pill burden than younger adults, the potential for drug-drug interactions is increased. On average, nursing home patients are maintained on 7 daily medications, and the average older adult consumes 2 to 4 medications.9 Morphine and methadone are two opioids with multiple drug interactions due to their metabolism. Methadone, for example, may interact with both inducers and inhibitors of the cytochrome P450 enzymes. Because of its complex pharmacodynamics and pharmacokinetics, methadone is best prescribed and monitored by a provider experienced in its use, such as a pain or palliative medicine specialist. Oxycodone and hydromorphone are both less likely to instigate drug-drug interactions.17
Opioids that should be avoided altogether in older adults or used with extreme caution, because of the risk of adverse effects and potential medication reactions, include meperidine and tramadol. Tramadol should be avoided particularly in patients taking other serotonergic medications and in those in the setting of declining hepatic and renal function, in particular. Meperidine has a host of active metabolites, making it an undesirable option. Codeine should be used with caution, if used at all, understanding that up to 20% of the population lacks the ability to metabolize codeine to morphine, its active agent.13,20
The combination of benzodiazepines and opioids has been shown to be particularly deadly in all populations. The CDC guidelines specifically caution against this combination of depressant medications because a significantly higher number of “accidental” overdoses have occurred in patients taking both medications. This is particularly heightened in patients with contributing comorbidities: obesity, hypoventilation, obstructive sleep apnea, encephalopathy, and chronic obstructive pulmonary disease.10
Besides the complexities of prescribing opioids in comorbid states and the need to avoid medication interactions, opioids simply come with their own set of adverse effects; constipation, nausea, and dizziness are the most common (Table 2).21
Table 2Complications of Opioids
|Opioid-induced respiratory depression||Decreased respiratory rate||Naloxone|
|Sleepiness||Emergent medical intervention|
|Constipation||Decreased frequency of bowel movements||Stimulant laxatives|
|Hard bowel movements||Stool softeners|
|Decreased appetite||Peripheral mu receptor antagonists|
|Opioid endocrinopathy||Sexual dysfunction||Testosterone supplementation|
|Decreased testosterone levels (total and free)|
|Reduced bone mineral density|
|Hyperalgesia||Worsening pain||Rotation to N-methyl-d-aspartate receptor antagonist (methadone)|
|Sedation||Slow rate of dose increase|
|Opioid dose reduction or rotation|
|Time (tolerance often develops)|
|Psychosomatic stimulants (methylphenidate)|
|Nausea||Time (tolerance often develops)|
|Opioid dose reduction or rotation|
|Metoclopramide, prochlorperazine, ondansetron|
|Tolerance||Same dose of opioid does not improve pain as well||Increase dose|
Adapted from Chau DL, Walker V, Pai L, Cho LM. Opiates and elderly: use and side effects. Clin Interv Aging. 2008;3(2):273-278.From Prim Care Companion CNS Disord.,20 with permission.
Constipation is due to reduced peristaltic action due to opioid binding on bowel mu receptors. Therefore, treatment must include stimulant laxatives, such as senna. Because many older adult patients take limited fluids orally compared with younger adults, a softener is often required. Polyethylene glycol, which also encourages the ingestion of fluids, is a good choice. Occasionally a peripheral mu receptor antagonist may be required, such as methylnaltrexone, and there are now multiple novel agents that are Food and Drug Administration approved for this indication.21,22
Although opioids exhibit a host of adverse effects, it is important to note that alternative medications are not without risk.23 Examples include the gastrointestinal toxicity and renal impairment that may occur with the use of nonsteroidal anti-inflammatory drugs, and the concern for hepatotoxicity with acetaminophen.24
Tolerance and hyperalgesia are adverse effects of opioids that are not often discussed with patients.24 They may be difficult to distinguish on patient interview because both exhibit the same noted effect: diminished pain control with consistently consumed opioids. Although tolerance may improve with higher dosing, hyperalgesia (increased sensitivity to both painful and nonpainful stimuli) will not. In fact, the patient’s pain may worsen as dosing is increased.
Although tolerance is associated with mu receptors and their coupling to potassium channels, hyperalgesia is derived from activation of N-methyl-d-aspartate receptors in the central nervous system, primarily.25 In either case, alternative therapies should be explored.
For decades, it was commonly accepted that geriatric patients were at lower risk for addiction to opioids than younger patients. This may be at least partially due to the finding that opioid use disorder is underreported, underdetected, and undertreated.26 However, a growing body of evidence indicates that older adults are uniquely vulnerable to risk of abuse, and the prevalence of substance abuse disorder may be increasing.
Recall that “baby boomers” came of age in an era of increasing drug and alcohol use and acceptance in the United States. Although rates of abuse and misuse in older adults remain lower than those for younger adults, the issue remains troublesome, particularly as baby boomers age and we see a dramatic rise in our older population in the United States.26,27 The stigma commonly associated with substance use disorders in the United States may make providers less likely to screen older adults or refer them to addiction treatment.
reference link : https://www.mayoclinicproceedings.org/article/S0025-6196(20)30145-2/fulltext