Unintended Consequences of Opioid Regulations in Older Adults With Multiple Chronic Conditions

Christine S. Ritchie, MD, MSPH; Sarah B. Garrett, PhD; Nicole Thompson, BA; Christine Miaskowski, RN, PhD, FAAN

Disclosures

Gerontologist. 2020;60(7):1343-1352. 

In This Article

Abstract and Introduction

Abstract

Background and Objectives: The opioid epidemic has led to substantive regulatory and policy changes. Little is known about how these changes have impacted older adults, especially those with chronic pain and multiple chronic conditions (MCC). We sought to understand the experiences of older adults with chronic pain and MCC in the context of the opioid epidemic and policy responses to it.

Research Design and Methods: Purposive sampling of older adults in a West Coast metropolitan area. Semistructured in-depth interviews lasting 45–120 min were digitally recorded and transcribed. Responses were analyzed using the constant comparative method. Participants were 25 adults aged 65 years and greater with three or more self-reported medical conditions and pain lasting for more than 6 months.

Results: Respondents' accounts revealed numerous unintended consequences of the opioid epidemic and its policy responses. We identified four main themes: changes to the patient–clinician relationship; lack of patient agency and access in pain management; patient ambivalence and anxiety about existing opioid treatment/use; and patient concerns about future use.

Discussion and Implications: Older adults have high rates of chronic pain and MCC that may reduce their pain management options. The opioid epidemic and policies addressing it have the potential to negatively affect patient–clinician relationships and patients' pain self-management. Clinicians may be able to mitigate these unintended consequences by actively conveying respect to the patient, empowering patients in their pain self-management activities, and proactively addressing worries and fears patients may own related to their current and future pain management regimens.

Introduction

Chronic pain occurs in over 18 million older adults in the United States (Patel, Guralnik, Dansie, & Turk, 2013). In a nationally representative sample of older adults, the overall prevalence of bothersome pain in the previous month was 52.9% (Patel et al., 2013). In a cross-sectional, Internet-based survey conducted in a nationally representative sample of U.S. residents, chronic pain lasting 6 months or longer was present in over 33% of adults ≥65 years of age (Johannes, Le, Zhou, Johnston, & Dworkin, 2010). Older adults are particularly vulnerable to severe and persistent pain, especially those with chronic musculoskeletal disorders, degenerative spine disorders, and/or osteoarthritis (Bicket & Mao, 2015).

Among Medicare beneficiaries, over two-thirds have ≥2 chronic conditions and 24% have ≥4 chronic conditions. The likelihood of having a higher number of conditions increases with age. Older adults with multiple chronic conditions (MCC) experience challenges with complex or conflicting treatment regimens, where treatment of one condition exacerbates the management of another condition. They are often prescribed a larger number of medications that cumulatively increase their experience of adverse events and decrease treatment adherence (Blozik, van den Bussche, Gurtner, Schäfer, & Scherer, 2013).

Chronic pain is more common among older adults with MCC (Agborsangaya, Lau, Lahtinen, Cooke, & Johnson, 2012). Chronic pain can serve as a barrier to self-management behaviors and can be more difficult to treat, because common conditions such as high blood pressure, coronary artery disease, upper gastrointestinal bleeding, acute kidney injury, and heart failure can be precipitated or exacerbated by many over-the-counter analgesics such as ibuprofen or naproxen (Butchart, Kerr, Heisler, Piette, & Krein, 2009; Griffin, Yared, & Ray, 2000; Kim et al., 2016). Older adults are often prescribed opioids because comorbid conditions limit analgesic choices. While some evidence exists to suggest that older adults can benefit from opioid use (Papaleontiou et al., 2010), some studies report high rates of adverse effects, such as falls and fractures (Krebs et al., 2016; Solomon et al., 2010).

The management of chronic pain in older adults over the past three decades has reflected the overall zeitgeist of pain management in many ways. In the 1990s, pain was designated as the fifth vital sign. Health systems and practices established guidelines to insure that pain was assessed and treated—often with opioid analgesics. Findings from small studies suggested that opioid addiction was a rare event and that most patients prescribed opioids would not experience adverse effects. Over the next 20 years, sales of prescription opioids quadrupled. Opioid use rates also increased, but to a lesser degree, in older adults (Steinman, Komaiko, Fung, & Ritchie, 2015).

As opioid use grew, increasing numbers of studies reported opioid-related overdose deaths and a rise in opioid use disorder, although these rates were lower in older adults than in those 50 and younger (National Academies of Sciences, Engineering and Medicine, 2017). In 2017, over 70,000 Americans died from drug overdoses—a twofold increase in 10 years (National Institute on Drug Abuse, 2019).

In response to the growing number of opioid-related deaths and suggestions of an increase in the number of individuals with an opioid use disorder, in 2016, the Centers for Disease Control (CDC) published guidelines that recommended restraint in opioid use (Dowell, Haegerich, & Chou, 2016). In 2017, the Acting Health and Human Services Secretary declared a public health emergency due to the increased rates of opioid-related drug overdoses (U.S. Department of Health and Human Services, 2017). In 2018, President Trump signed the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (United States House of Representatives, 2018). Subsequently, the Centers for Medicare and Medicaid Services endorsed widespread restrictions on opioid dosing for chronic pain management, establishing a ceiling of 90-mg morphine-equivalent units for opioid prescriptions under the Part D Medicare program starting in 2019.

The CDC designed its recommendations as nonmandatory guidance. However, many health care systems, individual clinicians, practices, legislators, pharmacy chains, and insurers took aspects of these guidelines and translated them into more across-the-board restrictions on opioid dosing. Today, in over 50% of U.S. states, patients in acute pain from surgery or an injury may not, by law, fill an opioid prescription for more than 3–7 days, regardless of the severity of their surgery or injury. Most of these restrictions do not take into account age, comorbidity, or other age-related considerations that might influence what other pain management options older patients may have.

While the ensuing hardships associated with opioid restrictions are being felt by a wide array of persons with chronic pain, older adults with chronic pain and MCC have the potential to suffer disproportionately from these restrictions for the following reasons: (a) nonopioid analgesics have a higher risk for adverse events in older adults with age- or disease-related declines in kidney or liver function; (b) the use of nonpharmacologic therapies may be too costly for this largely fixed-income population; and (c) limited mobility may be a significant barrier to access both pharmacologic and nonpharmacologic treatments. Inquiry into to the "iatrogenic" consequences of public health interventions may be particularly valuable in this setting (Lorenc & Oliver, 2014; Magasin & Gehlen, 1999; Merton, 1936).

As policy swings toward greater restrictions on prescription opioids, certain unintended consequences have already been documented, including increased use of illicit substances and increased suicide rates among opioid users (Health Professionals for Patients in Pain, 2019; Lagisetty et al., 2019). However, none of these studies focused on older adults or those with MCC. It is unclear what unintended consequences are seen in older adults with MCC. Therefore, our study sought to better understand the unintended consequences of the opioid epidemic and subsequent opioid regulations on the experiences of older adults with chronic pain and multiple chronic conditions, as these conditions may exacerbate older adults' pain and limit their pain management options.

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