Category Archives: Aging Policy

Seniors At the Crossroads of the Opioid Epidemic

For me, the term “opioid epidemic” evokes images of alienated young adults or demoralized people in economically depressed areas who are unable to make a decent living.  The facts are somewhat different.  According to the Office of the Inspector General of the U.S. Department of Health and Human Services, one third of the 43.6 million Medicare Part D beneficiaries were prescribed an opioid drug in 2016, with one in ten receiving opioid prescriptions on a regular basis.  In the same year, half a million Part D beneficiaries were prescribed excessive amounts of opioids over at least a three-month period, and around 400 Medicare Part D prescribers had engaged in questionable prescribing patterns which put their patients at risk.  Millions of people over sixty-five are users, misusers, diverters, and victims of the consequences of the growing availability of opioid medication.

Opioids are narcotic drugs that bind with opioid receptors in the body and brain to produce both pain relief and an experience of euphoria.  They include the illegal drug heroin and a number of prescription drugs such as oxycodone, codeine, morphine, and hydrocodone.  The opioid drugs are highly addicting and often misused because of the blissful high that many of the drugs produce.  Used improperly, opioid drugs present numerous hazards, including respiratory depression, confusion, fall and accident risk, somnolence, physical dependence, and death.  The National Institute on Drug Abuse relates that in 2015 more than 33,000 Americans died from both legal and illegal opioid overdose, and, in the same year, approximately two million persons in the U.S. had an opioid substance abuse disorder.  Michigan is among the states with the highest number of opioid prescriptions per 100 persons.

When considering normal age-related physical changes, the extensive use of opioids by older adults makes sense.  These physical changes are often accompanied by pain, as tissues stiffen, become more fibrous, function less efficiently, and wear down.  We seniors become more susceptible to acute and chronic illnesses, with more serious symptoms, and our recovery from trauma is slower and less robust.  The National Institutes of Health estimate that half of older persons living independently experience chronic pain, and 75 to 85 percent of the elderly in residential care are chronic pain sufferers.  The Gerontological Society of America asserts that pain in older adults is “often suboptimally assessed and treated”.

Pain is a complex and subjective experience, but very real to the sufferer.  It has physiological components and psychosocial components such as grief, depression, anxiety, emotional trauma, and stress, that can all intensify the experience of physical pain.   Treatment of these other components through various forms of psychotherapy, spiritual counseling, mindfulness practices, biofeedback, acupuncture or psychotropic medications can make chronic pain more tolerable and improve function and quality of life.  In addition, the underlying physical causes of pain can sometimes be ameliorated, as by losing weight to reduce stress on arthritic joints or strengthening back muscles to diminish strain on degenerating spinal discs.

It appears that we arrived at this crisis through a number of interacting forces, including well-meaning attempts by health care organizations to improve pain amelioration; an emphasis on patient satisfaction, including pain control, as an element in Medicare reimbursement; misleading representations of the safety of opioid drugs; and the enormous sums of money to be gained from the exploding sales of these preparations, which almost quadrupled from 1999 to 2014.

The federal government is addressing the problem in several ways, some of them at cross-purposes and with unintended consequences.  The Drug Enforcement Agency, which issues production quotas on the manufacture of many controlled substances, including virtually all of the opioid drugs, has imposed radical quota reductions of opioids in the last two years.   As a consequence, many hospitals are experiencing shortages in opioid supplies and are rationing their use for surgery and other procedures.  In addition, opioid users should not abruptly cease taking the drugs because of the physical dependence and withdrawal symptoms that ensue.

The Centers for Medicare and Medicaid Services (CMS) last month proposed regulations to establish limits on filling opioid prescriptions for Medicare beneficiaries.  Part D plans would have “hard formulary levels”, with a maximum strength of opioid allowed and a limit of a 7-day supply.  Comments of the proposal were due on March 5th, and the final regulation may differ as a result of stakeholder feedback.   At the end of February, bipartisan senators introduced federal legislation to limit to three days the initial supply of opioids and to increase recovery services for persons addicted to the drugs.  The long-term care industry is urging Congress to exempt their facilities from the three-day limit, asserting that their residents represent a very low risk for opioid abuse, while many of them experience severe, ongoing pain.

A year ago, the Centers for Disease Control (CDC) issued a thorough Guideline for Prescribing Opioids for Chronic Pain, based on research evidence, a panel of experts, and existing guidelines.  The document offers twelve recommendations, some of which apply to all persons and others that require individual decisions based on the patient’s situation.  The recommendations cover when to initiate opioids for chronic pain, collaboration with patients to discuss treatment goals and potential risks and benefits, dosages and duration of opioid therapy, ongoing monitoring of benefits and harms, mitigating risk in high-risk conditions (including advanced age), use of prescription drug monitoring programs,  potential drug interactions, and treatment of opioid use disorder.  The CDC recommendations are very consistent with the balanced approach advocated by The Gerontological Society of America in their 2016 monograph on treating older adults with chronic pain.   The CDC also provides online clinical tools for prescribers and pharmacists to assist with implementation of the Guideline.

In May, 2016, relatively minor stress on my arthritic neck resulted in severe, unremitting referred shoulder pain, which continued for a month.  I took ibuprofen and a turmeric anti-inflammatory extract, applied cold packs, and engaged in mindfulness practices.  Those treatments did little to reduce the pain, and, though I went to work, I was irritable, had trouble concentrating, accomplished relatively little, was unable to sleep, and gritted my teeth to get through the day.  Finally, in week five, the anti-inflammatory treatment started to work; the pain became intermittent, and it lessened in intensity.  By the end of week six it had diminished to a dull ache, which continues intermittently.  Had the severe pain lasted longer, I certainly would have sought stronger drugs.  The experience left me with great empathy for those with chronic pain, and how it reduces productivity, impairs relationships, contributes to depression and anxiety, and produces a very diminished quality of life.

Opioid-related deaths are clearly unacceptable, but so is reducing people to suffering.  If we want to be a humane society, we need better ways to help our citizens have meaningful and enjoyable lives even in the face of advanced age, dysfunction, disability, and the bleak misery that often accompanies these conditions.  Overly restrictive manufacturing quotas to limit opioid supply for diversion and misuse is punishing those with legitimate needs.  Even if prescribers act to transition patients from opioids to other pain management approaches, opioids must be tapered over many weeks or months to avoid aversive withdrawal symptoms and sometimes serious health consequences.  We need coordinated solutions that account for the needs of all parties affected.

As the CDC suggests in their Guideline, there is a need to individualize treatment, since so many factors affect both the experience of pain and the advisability of using opioids in any individual patient.  If we need physicians and other prescribers to spend more time with patients assessing pain, exploring the goals patients have for treatment, educating patients and families on proper use and risks, developing collaborative care plans, monitoring drug use and effectiveness, and devising opioid exit pathways, we need to provide reimbursement codes for these services, so that there is payment for the additional face time with patients.  Such incentives would be less costly than the social cost of opioid use disorders, which is reported by the National Institute on Drug Abuse to have been $78 billion in 2013.

We also need unbiased funding for more double-blind controlled trials on promising alternatives to opioid drugs such as hypnosis, use of placebos, biofeedback, virtual reality distraction, Comfort Talk, turmeric extracts, and cannabinoid drugs, so that we can amass the evidence necessary to establish confidence and expertise in using them.  If we have learned anything from the opioid crisis it is that, as a country, we cannot allow the potential profits to manufacturers to establish health care practice.  We must fund research and establish treatment protocols that primarily benefit the individual patient and our society.

Sue Sweeney, Assistant Professor, Aging Studies Program, Madonna University

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Medicaid: Long Term Care Security

As a gerontologist and a member of the Baby Boom generation, I think about what the state of long term care may be in seven years when I join the older-old, those above age 75.  Most of us would prefer to remain in our own homes as long as possible, but ultimately many of us will need more supervised care in a residential setting.  Most people don’t realize what various types of long term care cost, and many have not accumulated enough retirement savings to pay for all of the long term care they will need, especially given the extended lifespan that is now possible.  In addition, there are a lot of misperceptions about the scope of long term care benefits available through Medicare.

logo-genworth-desktopGenworth Financial Insurance Company conducts an annual survey of long term care costs in the United States.  In 2016, the national median annual cost of homemaker services in an individual’s private home came to $45,756.  The median annual cost of assisted living was $43, 536, and the median annual cost of a semi-private room in a nursing home was $82,128.  The median annual 2016 costs in Michigan were generally somewhat higher than the national median.  Genworth is predicting a 34% increase in costs in ten years, and an 80% increase in twenty years.

Americans are not great retirement savers compared with other nations, but there are reasons for that omission.  For the middle classes especially, wages have been stagnant since the 1970s, while the cost of living has increased.  The cost of a college education is more than eight times gregg-chicken-eggs-raw-eggs-eggshell-128885eater than it was in the 1970s, while the Consumer Price Index rose approximately four times  higher during the same period.  Pensions, which guaranteed retirement income for life, have virtually disappeared.  As a consequence, workers have lost one source of retirement income, since the pension replacements, the 401(k) or 403(b) plans, result primarily from employee savings, rather than employer contributions.  Finally, the economic downturn, which began earlier in Michigan than in much of the rest of the country, eroded the savings of many unemployed mature workers.

Our family story is no different; we experienced layoffs in the 2000s, which used up our retirement savings, up to then.  I paid off my student loans two years ago, and my husband just paid off his this year. We’re still paying on Parent PLUS loans for our son’s college education.  We expect to keep working as long as possible, and we’re also working hard to stay healthy so that we can do so.  But health is a result of past exposure and lifestyle, as well as present health practices, and we don’t know what lies ahead.

We do know that we can’t count on Medicare to cover our long term care expenses; it wasn’t designed for that.  Medicare will pay for skilled care, such as rehabilitation services, at home or in a nursing home,  for a limited period of time.  It will also pay for hospice care.  It does not pay for  assistance with managing personal care or housekeeping or ongoing nursing support in any setting, except for the brief period in which skilled care is also needed.  Each of us will have to manage those care expenses out of our retirement savings.  But when we live longer than expected, or health care expenses are greater than anticipated, or when both spouses require custodial care, then income and retirement assets often prove insufficient, and people rely on Medicaid to pay for their care.

Medicaid pays for the health care costs of qualifying poor people of all ages.  Low income older adults most often have Medicare coverage, and Medicaid helps them pay for the considerable out-of-pocket premiums, deductibles and coinsurance costs that Medicare does not cover, estimated to average between $1,700 to $3,000 per year.  Those costs can escalate quickly with surgery or expensive long term medications.  It also helps the low income elders receive care at home, rather than a nursing home, if they are lucky enough to qualify for a Medicaid waiver program.  The Medicaid waiver program allows for case management, in-home services, and community-based services for low income ill or disabled persons who would otherwise require nursing home placement.  In Michigan it’s called the MI Choice Waiver Program, and it’s about one third less costly than nursing home care.

But most areas have long waiting lists for Medicaid waiver services, and rural areas generally do not have sufficient supply of community-based services to keep people in their homes.  At a cost of more than $82,000 a year, most people needing custodial care in a nursing home will run out of personal savings and assets in a relatively brief period of time.  At that point more than half of nursing home residents apply for assistance from Medicaid.  Because of Medicaid older adults worry less at night about where they may end up when the money runs out.

A fixed cap on federal Medicaid payments to states could remove that sense of security.  With increasing health care costs, increasing numbers of older adults, lengthening lifespans, and a stagnant economy, states will have to reduce Medicaid spending considerably.  What will we do with ill, disabled, and poor older people who no longer receive payment for their nursing home bills?

It is these thoughts that keep me exercising most days of the week, meditating daily, and keeping up my license and professional credentials.   However, these are just stop gap measures, and I don’t feel nearly as secure.

Sue Sweeney, Assistant Professor, Aging Studies Program, Madonna University

2015 White House Conference on Aging

logo-WHCOA2015This is the year for the decennial White House Conference on Aging.  However, the Older Americans Act, which traditionally has outlined the Conference process, has not been reauthorized and the President’s budget has not been approved.  As a result, there are very little structure and no additional funds for the 2015 Conference.

nora-super-140Ms. Nora Super is the Executive Director of the Conference.  Her background includes more than twenty years experience in aging policy and community outreach.  The four themes that have emerged from community input, so far, are Retirement Security, Healthy Aging, Long-Term Services and Supports, and Elder Justice.  There is a blog for the Conference at  http://www.whitehouseconferenceonaging.gov/blog/   A number of regional forums are also scheduled.  The closest one to SE Michigan is the conference in Cleveland, OH on April 27th.

The Administration is using social and electronic media as much as possible to receive grass roots input and conduct informational meetings.  Everyone can participate by going to the web site and signing up to receive notices of events, such as webinars, and opportunities to participate.  You can also provide your thoughts and/or a story about your experience with aging or aging services, such as Medicare, Social Security, or in-home services, by submitting them through the following link:  http://www.whitehouseconferenceonaging.gov/submissions/register.aspx

Here’s the contact information if you have specific questions:

White House Conference on Aging
200 Independence Avenue SW, Suite 637D
Hubert H. Humphrey Building
Washington, DC  20201
(202) 619-3636
info@whaging.gov
www.whitehouseconferenceonaging.gov

Aging touches everyone.  I encourage you to participate in this opportunity for civic engagement at a time when our society includes the greatest proportion of older adults in history.

Sue Sweeney, Chair, Department of Aging Studies, Madonna University

Affordable Care Act Across the Generations

ACALogoThe Affordable Care Act is a very complex piece of legislation that is changing the health care landscape.  Jim Luke and I are offering a presentation on some of the significant provisions of the Act on November 12, 2014 from 10 am to 11:30 am for the Michigan Intergenerational Network.  The Villa of Redford is hosting the event at Villa at Redford, Village of Redford, 25340 Six Mile Road, Redford Township, MI 48240.

 

Do the Old Gain at the Expense of the Young?

This past July, Lansing Community College economics professor Jim Luke gave a presentation sponsored by the Michigan Intergenerational Network on our Country’s intergenerational transfer programs:  Social Security and Medicare.  You can view his PowerPoint slides and read his blog post on the topic at www.econproph.com.  The point that impacted me the most is the fact that intergenerational transfer programs are inevitable, because the very young and the very old cannot possibly generate the resources necessary to support their well being.  When societies lack formal intergenerational transfer programs, the task of supporting the two ends of the lifespan usually falls to the family.  However, that arrangement allows many children and old people to lack support because of death, social changes, economic instability, acrimony within families, mental illness, war or other hazards.

MoneyA form of social insurance is more reliable and benefits the society as a whole, due to the economic stability provided by predictable income, and therefore predictable cash infusion into the economy.  In other words, our intergenerational transfer programs are not perks that old people receive to the detriment of the young.  They’re an organized way of addressing a universal social problem, and the current solution provides additional advantage to everyone in the society.   Indeed, we need to preserve them so that the economically productive group that is contributing now to Social Security and Medicare will ultimately receive the same benefit that they are providing to their elders.  Breaking the intergenerational compact, that would be an injustice to the young!  Sue Sweeney, Chair, Gerontology Department, Madonna University

Retirement Security

We know that the “three-legged stool” of retirement security has largely become a “two-legged stool” over the last several decades.   The “legs” of pension, Social Security benefits, and personal savings, have been reduced to personal savings and Social Security benefits for many.  Company and public pensions (defined benefit programs) are on the wane, while 401(k) or 403(b) plans (defined contribution programs) have become much more common.     While companies often contribute to defined contribution plans up to a given percent of income, the bulk of the contributions come from the employees, and represent personal savings in a tax deferred instrument. Thus the demise of the “third leg” of the retirement security foundation.

According to the Bureau of Labor Statistics, Monthly Labor Review of December 2012, pension coverage of private industry workers has declined from 35% in the last 1990s to 18% in 2011.  Of those who are covered by a pension plan, 1 out of 5 of them participate in frozen plans.  That is, new employees of their companies are not permitted to participate.  Only 10% of private industry companies offer a pension plan, and 48% of those are larger organizations with at least 500 employees. ( But 52% of U.S. workers are employed by firms with less than 500 employees.)  Among private industry employers, there is great variation in the existence of a pension program by industry sector .  Utilities and banking related industries far exceed any other industry sector in the frequency of including a pension among employee benefits.

The National Institute on Retirement Security is a non-profit research and education organization formed by member organizations who are concerned with retirement plans and policies. The Institute recently conducted a poll to assess the attitudes of American adults toward retirement security.  The poll was administered to 800 individuals aged 25 or older through telephone interviews held between December 3 and December 22, 2012.  The findings were released in a report, Pensions and Retirement Security 2013:  A Roadmap for Policy Makers.

The report reveals that 85% of those polled expressed anxiety about their prospects for a decent retirement income, and nearly as many feel that federal elected officials fail to understand their struggles to save toward retirement.  These attitudes are not limited to Baby Boomers (those born 1946-64).  Millennials  (those born after 1976) also express concerns, and 90% of them believe lawmakers need to make improvement of the retirement system a higher priority.  Sue Sweeney, Chair, Gerontology Department, Madonna University