Opioids for Nursing Home Patients: What You Need to Know

When it comes to opioid addiction, the common scenario involves someone who is prescribed the medication to recover from a major surgery or car accident, only to get hooked. It’s less common to associate opioid addiction with the elderly, let alone a nursing home patient.

Yet, a recent study conducted by the Oregon State University College of Pharmacy, in conjunction with the University of Massachusetts Medical School, found that patients moved into a skilled nursing facility for short-term rehabilitation or long-term care are often prescribed a high-dose opioid to manage pain. Published in Pharmacoepidemiology and Drug Safety, the study found this pattern afflicts nearly 70 percent of elderly patients released in this fashion.

About the Study

Minimal research has been done to examine elderly patients and opioid addiction. To examine the nursing home population, researchers wanted to assess the frequency of opioid prescriptions given to elderly patients placed in a skilled nursing facility following their discharge.

To begin, researchers examined nearly 4,400 patients 65 years and older discharged to a short-term facility, rehabilitative care or residential facility following a hospital stay over the course of a year.

From analyzing this group, researchers found that not only were 70 percent of individuals given an opioid, but more than half were supplied with a high-dose medication – specifically 90mg of morphine or more, based on the Centers for Disease Control and Prevention’s standards.

Furthermore, researchers found that 61 percent of all patients receiving opioids with their discharge were age 65 and older. Among the patients prescribed an opioid, 68 percent were given oxycodone.

In general, the prescriptions were to help patients deal with acute pain following a procedure, but certain types of individuals were more likely to receive an opioid:

Yet, opioids affect patients 65 and older differently compared to younger demographics, including side effects. Medication interactions also have a higher likelihood, as patients in a skilled nursing setting often use multiple medications and patients may already be experiencing cognitive impairments. Researchers further found that for this population, a prescription related to pain management eventually evolves into dependency.

Following a short-term stay, patients are discharged back home, with little to no guidance about tapering off opioid usage. Meanwhile, for patients in nursing facilities, researchers noticed these individuals may be undertreated in regards to pain management.

Opioid Usage and the Elderly

A 2017 paper titled “Prevalence of Long-Term Opioid Use in Long-Stay Nursing Home Resident” pointed to the overall trend that opioid use has increased among older adults since 1999.

Examining Medicare Part D claims, researchers looked at prescriptions for short, medium and long-term stays. Specifically, over 30 percent of all long-term patients were prescribed an opioid and roughly 15 percent of patients were given a long-term prescription, with white female patients having the highest likelihood of receiving a prescription.

As one factor behind these levels, elderly patients have higher amounts of pain and therefore, are more likely to be treated with opioids to manage their condition.

On the other hand, hospitals and elder care facilities now report seeing more elderly patients arrive with opioid addiction. The patients tend to be living with another condition and during treatment, their addiction or dependency emerges. In turn, facilities have had to identify nonpharmacologic strategies for pain management.

As a third factor, opioid theft remains a problem in nursing homes, with workers and family members pilfering prescriptions – particularly if the individual lives with dementia or another cognitive impairment. Not only are these employees caring for some of the most vulnerable patients, but individuals who use these medications for pain management are not receiving their full dosage and may spend days in discomfort.

Complications

Along with the risk of addiction, elderly patients experience specific complications from long-term opioid use, even when directed and monitored by a medical professional:

Complications arise from age-related changes in metabolism, as well as cognitive impairment, osteoporosis, drug interactions, breathing difficulties and increasing frailty due to bone and muscle loss.

Specifically, older adults taking an opioid see fall risks four to five times greater than their peers taking an NSAID (nonsteroidal anti-inflammatory drug) for pain management.

The U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality also found that opioid-related hospitalizations for the elderly increased 34 percent and emergency visits 74 percent between 2010 and 2015.

On the other hand, the Agency for Healthcare Research and Quality notes that because many older adults live with reduced liver and kidney functioning or a cardiovascular condition, prescribing a non-opioid analgesic is not always an option. Also, not prescribing an opioid can negatively affect this population. Older adults recovering from surgery or living with pain:

• Have a higher likelihood of depression and falls
• May take longer to recover from a procedure
• May end up utilizing more healthcare resources

For these adults, an opioid not only helps with pain relief but provides a greater degree of independence and enables them to continue with therapy and other treatments.

For pain management in the elderly, doctors should ideally prescribe these medications at 25 to 50 percent of the dosage given to a typical adult, with an immediate release formula. Following, the patient’s dosage should be assessed every one to four weeks before increasing the amount.