As we wrap up the holiday season, “Season’s Greetings” feels more like “Season’s Grievings” for some seniors. The holidays tend to bring back memories of good times, happier times when life was “good.” But sometimes what’s underlying a change in mood or behavior goes beyond the holiday blues – opioid use disorder may be the culprit.
Headline news is replete with the nation’s opioid crisis. While opioid use disorders are more commonly reported in younger populations, prevalence among the elderly is rapidly growing and poses unique risks in the geriatric population. (Psychiatric Times) Medicare beneficiaries (aged and disabled) had among the highest and most rapidly growing rates of opioid use disorder with 6 out of 1000 beneficiaries compared to 1 out of 1000 with commercial health insurance plans.
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), opioid use disorder is defined as two or more of the following within a 12-month period:
- Using larger amounts of opioids or over a longer period than was intended
- Persistent desire to cut down or unsuccessful efforts to control use
- Great deal of time spent obtaining, using or recovering from use
- Craving, or a strong desire or urge to use substances
- Failure to fulfill major role obligations at work, school or home due to recurrent opioid use
- Continued use despite recurrent or persistent social or interpersonal problems caused or exacerbated by opioid use
- Giving up or reducing social, occupational or recreational activities due to opioid use
- Recurrent opioid use in physically hazardous situations
- Continued opioid use despite physical or psychological problems caused or exacerbated by its use
- Tolerance (marked increase in amount; marked decrease in effect)
- Withdrawal syndrome as manifested by cessation of opioids or use of opioids (or a closely related substance) to relieve or avoid withdrawal symptoms.
The symptoms of opioid use disorder in seniors can be subtle and easily eclipsed by common demographic ailments such as depression or dementia. (Washington Post) Healthcare providers and staff should pay close attention to the following symptoms of opioid use disorder:
- Memory problems
- Changes in sleeping habits
- Unexplained bruises
- Irritability, sadness, depression
- Unexplained chronic pain
- Changes in eating habits
- Wanting to be alone often
- Failing to bathe or keep clean
- Losing touch with loved ones
- Lack of interest in usual activities
Older adults have several risk factors that make them more susceptible to misuse of opioid/prescription drugs.
- Over 40% of older adults have chronic pain that is often treated with opioids. In 2015, painkillers topped the list for the most commonly used prescription drugs. (AARP)
- Treatment for chronic conditions such as diabetes, hypertension, chronic pain/surgeries, sleep disorders and anxiety involve complex drug therapy that can require the use of multiple medications to manage. Pills are part of the daily routine.
- Social, emotional, physical and cognitive changes may lead seniors to turn to medication to cope.
Long-term health effects of opioid use among older adults need to be further studied, but it is currently known that opioid use among older adults may increase risk for falls, fractures, delirium and pneumonia. Moreover, older adults taking opioids are four to five times more likely to fall than those taking non-steroidal anti-inflammatory drugs. It becomes a vicious cycle; opioid use leads to falls, falls lead to pain, pain can lead to opioid use, and so on. (Washington Post) In addition, age-related physiological changes affect metabolism, weight and body fat, which impact how opioids affect seniors, increasing potential for misuse and abuse.
The unique characteristics of older adults demand more nuanced solutions. Historically, securing coverage for opioid use disorder was challenging for Medicare beneficiaries. Though Medicare paid for opioids, common drugs to treat opioid use disorder, such as Methadone, were not covered. This issue was compounded by limited access to drug treatment centers sensitive to the needs of seniors.
As one of the largest payers in healthcare services, Centers for Medicare and Medicaid Services (“CMS”) published the CMS Roadmap to Address the Opioid Epidemic in June of 2018. The key areas of CMS’ focus are:
- Prevention: Manage pain using safe and effective treatment options that rely less on prescription opioids
- Treatment: Expand access to treatment for opioid use disorder
- Data: Use data to target prevention efforts and to identify fraud and abuse
CMS has already achieved some successes with its new plan. For example, CMS coverage policies now ensure some form of medication-assisted treatment across all CMS programs, including Medicare, Medicaid and Exchanges. In 2017-2018, CMS sent out 24,000 letters to Medicare physicians to highlight those who were prescribing higher levels of opioids than their peers to incentivize safer prescribing practices. Additionally, in 2017 and 2018 CMS released data to show where Medicare opioid prescribing was high to help identify areas for additional intervention.
Although opioid use disorder is often highlighted in younger age groups, senior citizens are not immune to it. Chronic pain, depression and loss of autonomy can lead to opioid use to cope. With opioid use disorder on the rapid rise in our senior population, healthcare providers should be curious when signs of opioid use disorder occur, such as depression, lack of interest in activities or changes in appetite. These subtle signs can be overlooked or “chalked up” to age or the holiday blues. With more exposure of this issue and increased prevention, diagnosis and treatment options available, seniors challenged with opioid use disorder can get the help they need.