A better opioid policy shouldn't mean seniors suffer

Elizabeth Newman
Elizabeth Newman

In addition to the terrible tragedy of opioid addiction in the United States right now, long-term care providers have an additional challenge: Figuring out both how to make sure seniors retain access to pain medications and how to keep those medications from leading to addiction.

Part of that involves risk assessment. A recent study in Pain Medicine evaluated the Venebio Group's risk index tool, called the Venebio Opioid Advisor. It calculates a patient's likelihood of experiencing a potentially fatal overdose and gives individual guidance. Last year, the organization won a $1.5 million grant from the National Institutes of Health to evaluate the advisor. Change Healthcare, which encompasses what used to be McKesson Technology Solutions, also announced that an opioid tool as part of its new InterQual release.

But even the best risk assessment tool can't mitigate how managing opioids in the senior population has real and specific challenges. I personally knew an elder, who, approaching 90, didn't want to take pain medications because of her concern about constipation.

That's a common fear, according to Carla Perissinotto, M.D., an assistant clinical professor in the Division of Geriatrics, Department of Medicine.

“Constipation also ends up being one of the biggest challenges, and frankly many of my older adults don't want to be on opioids because of the fear of constipation,” she said in an interview with Kaiser Health News.

That fear may be mitigated by a good conversation, or a corollary prescription for a laxative, but what about pain prescriptions in the first place? This week Sens. Gillibrand and McCain announced legislation to address our opioid crisis that would limit the initial prescription amount for acute pain to seven days. That's reasonable, but I can't be the only person concerned that our much-needed focus on legislation, or even efforts to help people manage their addiction, may leave a lot of institutionalized seniors in pain.

For one, adults, old and young alike, respond with a wide variance to different types of pain, and opioids often allow seniors to either live independently or to exist without terrible suffering. I've written before about being a guinea pig in a study looking at whether video games can biologically lower levels of pain. For all our complaining about “obvious” studies, it has become increasingly clear that more research is need to understand who can benefit and who is harmed from opioids.

In fact, the Centers for Disease Control and Prevention also has said it wants to look at cost-benefit estimates around opioids, validate tools around identification of patient risk, and investigate risk identification and mitigation strategies. At the moment, the CDC urges caution, noting, “The balance between the benefits and the risks of long-term opioid therapy for chronic pain based on both clinical and contextual evidence is strong enough to support the issuance of category A recommendations in most cases.”

But it's a balancing act. Perissinotto, in her interview, said she “completely disagrees” with the assertion that there are no situations where opioids should be prescribed long-term.

“There are many illnesses in older adults that cannot be cured. And if you are trying to maintain someone's independence, there are very reasonable times where people may be on opiates. Osteoarthritis. Severe spinal stenosis. Some of those things do not have great treatments and there are times where opioids do have a positive effect on someone's relief of pain so that they can maintain their function,” she said.

I don't have an answer for what is a complicated problem, but I do know one thing: Our efforts to make opioids harder to obtain shouldn't mean we leave seniors in pain.

Follow Elizabeth @TigerELN.













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McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Emily Mongan.

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