Dr. Veronica Nuzzolo presents Opioid Prescribing Policy Changes and the Impact on Chronic Pain Patients. Hosted by Middlesex District Attorney Marian Ryan, Eastern Middlesex Opioid Task Force Meeting (December, 2019).
In the early 1990’s when it was determined that Americans were under-treated for pain, pharmaceutical companies began producing stronger and longer-acting medications. More than 191 million opioid prescriptions were dispensed to American Patients in 2017. Recent data from the Center of Disease Control and Prevention suggests that illegally manufactured fentanyl, its analogs, and heroin are responsible for well over half of all overdose deaths. The most common drugs involved in prescription opioid overdose deaths include: Oxycodone, Oxycontin, and Vicodin. Noteworthy is that many who died from prescribed opioid medications were not the medically approved patient. In addition, most deaths involve multiple substances that are used in combination, often including alcohol. Research futher indicates that approximately 65 percent of adults in the United States have used alcohol. Furthermore, almost 6 percent of adults used both alcohol and drugs, representing approximately 12.6 million adults in the U.S. population.
While the opioid epidemic/crisis draws the spotlight, Benzodiazepines come second in terms of dependence and overdose risk. Benzodiazepines are involved in more than 30 percent of opioid-related overdoses, according to the NIDA. Because both types of drugs suppress breathing, taking them together is dangerous. CNS depressants such as Benzodiazepines are central nervous system depressants used to sedate, induce sleep, prevent seizures, and relieve anxiety. Examples include alprazolam (Xanax®), diazepam (Valium®), lorazepam (Ativan®), and clonazepam (Klonopin®).
A study encompassing adults ages 65 and older in the U.S., Australia and Ontario, Canada, found the use of benzodiazepines remains inappropriately high, particularly among adults ages 85 and older. The number one pharmacological combination for overdose deaths in older adults continues to be benzodiazepines mixed with alcohol.
An estimated 1 in 4 older adults may be adversely affected by combining alcohol and medication especially opioids and CNS depressants. Disorientation, balance problems, daytime drowsiness and increased risk of injuries – like falls – are also opioid/benzodiazepine side effects. The very problems older adults hope to avoid, such as mental confusion or hip fractures may become more likely when substances are combined. Under-treatment of pain in older persons may also have negative consequences such as depression and sleep disorders. There has been a reported increase in suicide among people who have inappropriate pain management.
In the midst of this opioid epidemic guidelines are changing how Doctors prescribe medications. Pain patients are left to wonder how these new guidelines will impact their daily lives if their physicians decide to stop prescribing. The latest scrutiny on physicians may negatively impact chronic and severe pain patients. Abruptly stopping medication or a “rapid” taper from a medication may lead to physical withdrawal and increase risk factors, specifically, the potential to misuse other prescription medications such as benzodiazepine or illicit substances. Older adults may require additional help to gradually come off of opioids. De-prescribing involves stopping or decreasing medications. The de-prescribing process should include a tapering schedule that is patient centered and appropriate for the individual involved.
OxyContin was developed and prescribed liberally to treat chronic pain and cancer pain, and this medication thrived on the market for several years with little attention to issues of diversion. Balance Is Imperative: While physicians are being encouraged to practice patient centered care, the reality is that they are often practicing prescription policy care driven by National, State, and Insurance Policies, as well as Hospital and Practice policies. Physicians need to continue to address chronic and severe pain patients who would have trouble functioning without their medications with individualized Patient Centered Care.
The challenge: Safe prescribing for those who need opioids for pain, while avoiding overuse or potential misuse.
Substance Use Disorder (SUD) and Opioid Use Disorder (OUD) are under-identified, often ignored, unrecognized, misdiagnosed, and under treated in older adults. Physicians have historically received little-to-no training in SUD’s, OUD’s, and pain management. However, this has been changing as a result of the opioid crisis.
With the aging baby boomer population today’s current medical system is “ill-prepared” for wave of older adults with SUD’s/OUD’s. Whereas Gerontologists are in short supply, there is limited research and understanding regarding opioid use, misuse, or active disease among the elderly population. Dependence and active disease can be mistaken for depression, or dementia in elderly persons, which explains why the prevalence of these disorders in the elderly is underestimated. Risks and benefits of long-term opioid use are poorly understood, particularly among older adults. Increased surveillance of the safety of long-term opioid use is needed in community practice settings.
When discussing pain and opioid use in older adults “Patient Centered Care” approaches should be at the center of all conversations regarding the risks/benefits of opioids. It is imperative for healthcare professionals and care givers to recognize the differences in use and potential misuse of medications. Providing compassionate care is to understand that use and potential misuse and dependence in the elderly is often associated with clinical, social, and psychological consequences. Continued patient centered care and medication risk/benefit education is imperative. As long as medications are being taken as prescribed, opioids may have positive benefits for older persons with chronic pain.
Opioid Policy Changes has become stigmatizing for patients whom opioid painkillers are necessary when medically appropriate. bandoning pain patients out of fear of regulatory reprisal may place a patient’s health and well-being at risk. Physicians and Pharmacies have responsibilities under the Americans with Disabilities Act not to discriminate on the basis of a patient’s condition, including chronic pain, or a perceived condition, as when a person with pain is erroneously regarded as a person with opioid use disorder when there is no clinical basis for that perception.
Remember, the goal is to decrease pain, increase functionality, and improve overall quality of life!
Bierman, Arlene, M.D., M.S. director, Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, Md.; Anita Everett, M.D., chief medical officer, Substance Abuse and Mental Health Services Administration, Rockville, Md.; September 2018, Agency for Healthcare Research and Quality Reports
Center for Disease Control and Prevention, https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm, retrieved 2019.
Center for Disease Control and Prevention, https://www.cdc.gov/drugoverdose/opioids/prescribed.html, retrieved 2019.
National Institute on alcohol abuse and alcoholism, https://www.niaaa.nih.gov/research/nesarc-iii, retrieved 2019.
Greenfield, Brooks, Gordon, Green, Kropp, McHugh, Lincoln, Hien, & Miele, (2007)
Martina, C. (2016), https://today.mims.com/the-elderly-are-suffering-in-silence—survey, Loneliness in the general population: prevalence, determinants and relations to mental health BMC Psychiatry. 2017; 17: 97, published online 2017 Mar 20. doi: 10.1186/s12888-017-1262-x
National Institute on Drug Abuse (NIDA), (2019), https://www.drugabuse.gov/September/October 2018 Harvard Review of Psychiatry
Substance Abuse and the Elderly in a Primary Care Setting, Brauner, M, (2014), SAMHSA, (2012), Doweiko, (2014); Bartels & Blow (2011)