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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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The Freedom of the Road

Yellow car with blurred backgroundDriving is regarded almost as a right by those of us in Michigan.  We like our independence and the freedom of the road. But driving requires complex skills such as fine and gross motor coordination, sensory acuity, the ability to judge distances and speeds, quick reaction time, joint flexibility, concentration, and sound judgement.  To some degree, normal aging diminishes all of these skills. Add to that the health conditions that often accompany aging, and older drivers can be an accident waiting to happen. 

Older drivers travel fewer miles but have more accidents per mile than younger drivers, However, according to The Highway Loss Data Institute, a 2014 study revealed their vehicle crash involvement rates declined between 1997 and 2012, while the number of older drivers increased significantly by during that period.  The Institute also reports that, relative to younger drivers, crash rates and fatal crash rates begin increasing by about age 70.  Physical fragility increases from middle age onward, which largely accounts for the greater involvement in fatal crashes by older people.  

States vary greatly in their licensing provisions for older drivers.  Some require more frequent renewals and/or renewal in person and/or a vision care provider’s statement of visual acuity and/or a medical review following driving incidents.  Individual assessment of driving ability is necessary because each person ages uniquely, and blanket measures or an arbitrary age cutoff to limit or prohibit driving among older adults would penalize some who retain skills longer, and miss others who lose skills sooner. 

Our attachment to our personal vehicles has also contributed to mass transit systems that are not widespread or robust, leaving those who cannot drive with few options for transportation.  Keeping track of bus schedules and figuring out bus routes can be complex and confusing for older adults who have always driven their own car.  Mobility limitations may require curb-to-curb or door-to-door service, and these services are less available even than fixed route bus lines, especially when crossing community or county borders.  When my father became blind, he tried taking the bus, which stopped only three blocks from his home.  He found the waiting, inclement weather, uncertain schedules, and unpredictable responses from drivers and passengers to be more than he could tolerate.  He resorted to taxi rides, an expensive alternative.  

Many older adults self-limit their driving when they observe that they are not as able as they once were.  They stop driving at night if their night vision is poor, or they don’t drive in bad weather, because they know their reflexes are slower than in the past.  They may cease driving on the expressway because it requires rapid processing of a great deal of information.  They may turn off the radio or ask not to have conversation in the car, because it distracts from attention to the road.  Some no longer make left turns, which require judging both distance and speed in order to safely execute, and go past the desired street then make three right turns to take the direction they want. These measures may be sufficient to assure safety.

However, some older adults lack the insight to objectively observe their driving performance or ignore the signs because they are afraid of giving up their keys.  In those cases, either a driving mishap brings the problem to light or friends and family members muster the courage to address the issue earlier.  It’s more helpful to have a number of conversations over time, preferably before there is a concern about safety.  When the topic of driving arises in some other context, family members can use the opportunity to ask whether the older adult feels comfortable about his or her driving ability, and whether they have thought about the possibility that they may not be able to drive at some point in the future.  Their verbal and nonverbal answers will give you an idea of their attitudes and emotions around the subject.

There are a number of helpful websites and publications to inform older drivers about how to drive more safely and to coach families and friends on conducting conversations on driving.  The Hartford provides several publications that offer guidance on family conversations, driving evaluations, and driving and dementia.  The National Highway Traffic Safety Administration (NHTSA) offers resources to assist with self-evaluation and regulation of driving as well as family discussions, as do the AAA and the National Institute on AgingAARP has an online seminar called “We Need to Talk” to walk family members through the conversation process.

When older drivers are resistant to family concerns, the older adult’s physician may be of assistance in evaluating the physical and cognitive conditions that can impede safe driving, as well as offering advice for improving safety.  There are materials available to assist doctors with this task.  A helpful example is a joint online effort of the NHTSA and the American Medical Association, entitled “Physician’s Guide to Assessing and Counseling Older Drivers”, which the physician can submit for continuing medical education credit.  Michigan Department of State provides an online form, “Physician’s Statement of Examination”, which can be used to document to officials the medical interview and examination.

Driver rehabilitation is a recommendation that the physician may make.  This could include strengthening muscles, stretching exercises, improving vision with corrective lenses or surgery, and referral to a driver rehabilitation specialist, usually an occupational therapist.  This professional conducts a clinical and functional driving evaluation, assesses the vehicle for possible modifications and equipment, and recommends measure to improve safety.  Alternatively, the specialist may provide concrete documentation of unsafe driving.

Michigan has no requirement for accelerated driving license renewal, special terms of renewal or additional testing.  There is a form, OC-88, Request for Driver Evaluation, that anyone can submit who observes unsafe driving.  The person submitting the OC-88 must provide the driver’s identifying information, as much as known, the reason for the evaluation, and the requestor’s information.  The requestor’s identity will be “kept confidential to the extent permitted by Michigan and Federal law”.  The State will then require the driver in question to participate in a formal evaluation to determine whether they perform safely enough to retain their license.

Clearly whether older adults should continue to drive is a complex question with no pat answers.  In our culture, which greatly values youth and independence, older people find it highly challenging to maintain self-esteem in the face of increasing dependence.  Quality of life, and even longevity, are intimately related to opportunities for activity and social interaction and to retaining a sense of purpose.  In addition, many of us continue to work or to make contributions to society in other important ways.  We need to be sensitive and sensible in our approach to limiting or curtailing driving access, to the benefit of everyone involved.

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

National Healthcare Decisions Day – April 16, 2015

Refusal of TreatmentApril 16th this year is National Healthcare Decisions Day (NHDD), which is a day to think about and prepare or update your advanced directives for healthcare.  It’s a great gift to your family and friends to let them know your wishes in case of health crises in which you may not be able to speak for yourself.  It’s comforting to you to know that you’ve discussed the circumstances and interventions that would fit with your values and desires for your future.  It reduces family discord to have a designated patient advocate who has a written document with your decisions about treatment.  It’s also hard to think about and talk about such frightening eventualities.

There is a website about NHDD that helps make it easier to undertake those conversations and to execute the relevant documents.   It lists a number of websites in which to find state-specific advanced directives forms.  It also has links to many sites that help facilitate family conversations about health crises and each person’s wishes, including some card games and a phone app to store advanced directives for yourself and loved ones.

commlaw-aging-v-blackThe American Bar Association’s Commission on Law and Aging also has a number of helpful resources on preparing advanced directives and serving as a patient advocate.  There’s a guide to completing a universal health care power of attorney form, a guide to making medical decisions for another, and a toolkit that invites you to think about the various factors involved in coming to a decision about your possible care if you were faced with a serious medical condition.

Try not to put it off again this year.  My colleagues in the senior ER are begging us all to help them to help us and our families go through such harrowing experiences in a way that honors the person at risk and helps us all have greater peace of mind.

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

March is National Nutrition Month

yellowpeppersAs we get older, we have to be mindful of what we eat.  With slowing metabolism, it’s easier to gain weight, and with less efficient digestion, we have to be sure we’re getting all the right nutrients packed into our diets.  To help prevent illness we want to include a lot of fiber, phytonutrients, and antioxidants.  Keeping up the normal flora in the gut is increasingly demonstrated to be a benefit to optimal functioning.  Preventing or minimizing bone loss required mineral supplementation.  Aging well requires more education and care than when we were younger.  You can’t retire from managing your own well-being!

ncoa-logoThe National Council on Aging has developed an infographic with helpful links, to help remind older adults of important nutrition habits to cultivate.  They also have produced several YouTube videos on eating well in later life.  I know I can use all the help I can get to stay healthy and able to function optimally.  Pass it on!

6 Ways to Eat WellSue Sweeney, Chair, Department of Aging Studies, 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

What “Ego Integrity” Looks Like

Erik Erikson

You have probably encountered Erik Erikson’s theory of psychosocial development, in which he posits eight epigenetic stages.  In each stage a developmental crisis must be positively resolved for optimal further growth to occur.  The final crisis occurs in late life, in which a person faces mortality and examines his or her life.  This life review can result in either ego integrity, a sense of appreciation for one’s life as lived, or in despair, a sense of regret and disappointment over the outcomes of one’s life.

In teaching adult development, I’ve found it much easier to convey the experience of despair.  Students seem to understand that a person could look back over her lifetime and conclude that she had not accomplished enough, had made bad choices, or harmed others unnecessarily.  Getting across the experience of ego integrity has been less successful.  Feeling a sense of satisfaction seems a pale accomplishment in contrast to the wrenching feeling of despair.  Then I read a brief essay in the New York Times online edition by neurologist and author Oliver Sacks.

Oliver Sacks

Among other writings, Dr. Sacks has written numerous very readable books about how people experience and adapt to unusual neurological phenomena and pathologies.  He is 81 and describes himself as robust.  However, he recently learned that he has metastatic and terminal cancer from a rare tumor he’d thought had been cured nine years ago.  The article, entitled, “My Own Life”, contains what I consider an eloquent representation of ego integrity.  It contains  a deeply genuine expression of expansiveness, individuality, and aliveness in the face of impending death.  He ends his essay with this observation, “Above all, I have been a sentient being, a thinking animal, on this beautiful planet, and that in itself has been an enormous privilege and adventure.”

I urge you to read his moving essay.  To me it contains inspiration that each of us may reach the end of our lives  with a measure of authenticity, clarity, and gratitude.  It also conveys a sense of celebration of a life well-lived.  That’s the kind of ego integrity I hope to accomplish and wish for all of us!

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

National Council on Aging Funding for Outreach for SNAP

ncoa-logoIn the January 13th issue of the National Council on Aging‘s NCOA Week e-publication, they announced grant proposals for $25,000 or $50,000 to increase enrollment of older adults who are eligible for the federal  Supplemental Nutrition Assistance Program (SNAP).  The details of the RFP will be available next week.  As stated in the e-publication, “NCOA soon will be seeking proposals from community-based organizations for Senior SNAP Enrollment Initiative grants in two competitive categories ($25,000 and $50,000). The Request for Proposals will be released on or around Jan. 20. Optional Letters of Intent are due Feb. 13, and applications are due March 6.”

FoodNutrSvcesLogoA 2012 presentation by Lura Barber of the National Center for Benefits Outreach and Enrollment of NCOA is available online.  Called SNAP and Older Adults, the presentation points out that only one out of three eligible older adults are enrolled in SNAP, and provides basic information about SNAP organizational structure, eligibility, application process, and techniques to reach out to older adults who qualify.