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