Start Low & Go Slow: Increasing Opioid Safety Among Seniors

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In a letter published in August 2016, U.S. Surgeon General Vivek Murthy wrote to the nation’s physicians outlining the state of the opioid epidemic, stating, Since 1999, opioid overdose deaths have quadrupled and opioid prescriptions have increased markedly…[yet] the amount of pain reported by Americans has not changed.”

While the epidemic has received national attention due to the scale and scope of the problem, the impact of opioids on the Medicare population is often less discussed. According to Dr. Michael Crooks, the technical lead for pharmacy interventions at Alliant Quality, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Georgia and North Carolina, many of the national challenges — like illicit abuse, addiction and heroin substitution — are less common in senior populations. However, he says the attention has helped open doors” to discussions about opioid safety among Medicare beneficiaries, and the role of clinicians.

Prescribing high or long-acting doses of opioids are the primary causes of harm for seniors,” said Crooks. Many seniors can overdose from doses that are normal for younger adults.”

Further, prescribing long-acting or extended-release opioids to seniors with pain is dangerous because many seniors may not clear the medication from their bodies as fast as younger people. Crooks suggests that physicians limit the use of these long-acting pills— especially for seniors with acute pain— and that when prescribing opioids, physicians should always start with the lowest effective dose and closely monitor patients’ pain and medication use before considering an increase.

Prescribing high or long-acting doses of opioids are the primary causes of harm for seniors.” 

Another challenge is that many seniors and their clinicians often have an incomplete understanding of all of the medications that have been prescribed by multiple clinicians.

Seniors tend to use a larger number of medications, which increases the likelihood of confusion; drug-to-drug and drug-to-disease interactions; additive side-effects; and unpredictable responses to medications,” said Crooks.

He encourages patients to bring all of their medicines to medical appointments and for clinicians to review them thoroughly.

But even with these strategies in place, overdoses can still happen. Fortunately, Naloxone, an opioid reversal agent available through most community pharmacies, can help save lives. The recent Centers for Disease Control and Prevention’s (CDC) Guideline for Prescribing Opioids for Chronic Pain recommends expanding the availability of Naloxone and co-prescribing it with an opioid for at-risk populations.

To help support opioid safety in Georgia and North Carolina, Alliant Quality is in the planning stages of a project that will combine direct-to-patient and direct-to-prescriber outreach to encourage the use of My Meds bags with information on specific opioid medication safety concerns.

Participating patients will receive a My Meds bag, including a flyer explaining the benefit of comprehensively reviewing all medications with their prescribers. The bag will also contain information to help seniors identify opioid medications and the additive effects of other medications and alcohol. Participating prescribers, on the other hand, will receive a sample of the My Meds bags and patient materials, tips on performing medication reviews and incorporating them into clinic workflow, and resources to inform safe opioid prescribing, including calculating Morphine Milligram Equivalents.

For more information about the project or opioid safety, contact Michael Crooks or Adrienne Mims at Alliant Quality.