The Hidden Epidemic: Seniors and Opioid Addiction May 5, 2017 Gaylord National Resort, National Harbor, MD
The Opioid Epidemic: Understanding Trends in Drug Misuse among Older Adults Mary W. Carter, PhD Towson University ABA Senior Lawyers Division Spring Meeting 2017
An Overview for Today s Presentation History of Opioid Epidemic Current Trends of Opioid Misuse: All Ages Current Trends of Opioid Misuse: Older Adults Current Trends: Emergency Department and Hospital Use During my talk, 78 adults aged 18+ will die from an opioid overdose Every 23 minutes, an older adult is admitted to an emergency department with related drug misuse complications In Maryland, nearly 7% of all Emergency Department Visits related to Opioids occurs among adults aged 65 years or older.
Unprecedented growth 240+ million prescriptions were dispensed for opioids in 2014 more than one Rx for every adult aged 18+ In 2014, 28,647 or 61% of all drug-related deaths involved opioids. Each day, roughly 650,000+ opioid prescriptions are written Every 24 hours, 78 people die from an overdose Staggering annual costs $20 billion dollars in ED and hospital care $55 billion in related health and social costs Sources: HHS (2017). Opioids: The prescription drug and heroin overdose epidemic. Accessed 04/28/2017 from: https://www.hhs.gov/opioids/ ; Rudd et al. (2016). Increases in drug and opioid-involved overdose deaths United States, 2010 2015. MMWR, 65(50-51);1445 1452; Park & Blosh (2016). How the Epidemic of Drug Overdose [Image] Deaths Ripples Across America. The New York Times. Accessed on 04/28/29017 from: https://www.nytimes.com/interactive/2016/01/07/us/drug-overdose-deaths-in-the-us.html
A little history How many Opioid Related epidemics have there been in the US? Early 1800s Opium begins showing up in cough syrups and other preparations, widely available. Mid-1800s to Early 1900s increasing use and marketing of heroin and opium derived products Addiction increases, 1 in 3 addicts woman 1909 International meeting on Opium at the request of Pres. Teddy Roosevelt, followed by a 1911 international commission 1914 US sales prohibited without prescription Following WWII, epidemic Late 1940s to mid-1950s Following Vietnam War, epidemic Early 1970s to early 1980s the early stages of heroin epidemics are often hidden from society, and the epidemics are already full-blown by the time health and other agencies become aware Sources: Hughes &, Rieche (1995). Heroin epidemics revisited. Epidemiologic Reviews,May 1817(1):66-73; Karl M. Bowman, "Some Problems of Addiction," in Problems of Addiction and Habituation, ed. Paul H. Hoch and Joseph Zubin (New York: Grune & Stratton, 1958), p. 171. Old habits die hard: For the past 40 years we have been trying the mainly punitive approach; we have increased penalties, we have hounded the drug addict, and we have brought out the idea that any person who takes drugs is a most dangerous criminal and a menace to society. We have perpetuated the myth that addiction to opiates is the great cause of crimes of violence and of sex crimes.. Our whole dealing with the problem of drug addiction for the past 40 years has been a sorry mess. ~Dr. Bowman (1958)
A little more history the beginning of this epidemic: 1990s Long acting Opioids developed in 1990s New Concern: Unmanaged Pain, began to be referred to as the Fifth Vital Sign In response, call for increased use of opioids for pain Pharma companies minimized addictive properties, stressing efficacy and safety over adverse outcomes Pain Mills
We are now in the midst of the largest Human-Caused Epidemic Ever Drug Overdoses Per 100,000 Sources: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm; https://www.cdc.gov/nchs/products/databriefs/db190.htm
US Population Roughly 4.4% US Consumption of opioids has outpaced the rest of the world US oxycodone (e.g., Percocet) consumption Rate=81% The Rest of World Roughly 94.6% The US consumes nearly 100 percent of the world total for hydrocodone (e.g., Vicodin) [Source: Volkow (2014). America s Addiction to Opioids: Heroin and Prescription Drug Abuse. NIA/NIDA.
.Source: Accessed from: http://www.pbs.org/newshour/bb/drug-companies-helpeddrive-opioid-crisis/ 35,000,000,000 30,000,000,000 25,000,000,000 20,000,000,000 15,000,000,000 10,000,000,000 5,000,000,000 Annual Sales in Dollars: $50 Million to $30 Billion in 18 years 0 1996 $50 million 2002 $1.2 billion 2014 $30 billion
Up-Close: Mingo County, WV One pharmacy in a little town (Kermit, WV) with less than 400 people Located in Mingo County, population 33,000 people Received more than 9 million hydrocodone pills over two years. Eric Erye (2016). Drug Firms Make Millions By Sending Opioid Pills To W.Va. NPR Interview. Received a Pulitzer Prize for Investigative Reporting.
Maryland: Key Data Source Does not Track Older Adults MDHHS (2016) Drug- and Alcohol-Related Intoxication Deaths in Maryland, 2015. Office of Epidemiology and Planning, Baltimore City Health Department.
Despite lots of information, we still know very little about opioid addiction among older adults National prescription tracking data show that more than 40% of opioid Rx are written by [generalists] and most commonly for diseases of the musculoskeletal system Source: Okie (2010). NEJM, 363(21) One study found that 15% of hospital discharges resulted in a new prescription, with nearly 45% taking opioids 60 days later. Source: Jena & Goldman (2016). AMA Intern Med. 2016;176(7):990-997 Obstacles Few studies provide age-stratified results. Either: Studies do not include older adults, Studies lump older adults together with other age groups (50+) Because of earlier concerns of undertreating pain, research tended to downplay the risk of addiction in older adults (e.g., Guerriero, F. (2017). World Journal of Clinical Cases, 5(3), 73 81. ). Early recommendations suggested that older adults were less at risk of addiction (e.g., American Geriatric Society (2009). Pharmacological Management of Persistent Pain in Older Persons. [Note: these recommendations are no longer in use]
High Risk Opioid Use and Misuse Chronic Pain Chronic Use of Opioids Tolerance and Dosage Adjustments Dependence and Withdrawal symptoms Drug Misuse Early research focused on misuse of valid prescriptions only non-compliance Unintentional and intentional misuse High-Risk Misuse Strategies Obtained Rx from multiple doctors Stole prescriptions/pills Some other way (e.g., friends, street) Source: Gold et al. (2016). Journal of the American Geriatrics Society, 64(10).
Older Adults, Pain, and Opioids FAILURE TO RECOGNIZE BY HEALTH CARE PROVIDERS Misdiagnosis symptoms of misuse: dementia, depression, falls, insomnia Withdrawal symptoms mimic common complaints Gastrointestinal complaints, confusion Misinformation about addiction and older adults Older adults more apt to hide signs Misuse may be unintentional OLDER ADULTS ARE VULNERABLE Chronic Pain is common 50% community-dwelling older adults 75 to 95% of nursing home residents Multiple comorbidities and diagnoses Multiple doctors and care provided across multiple settings Multiple medications 80% take one Rx daily 20% take five or more Rx daily Higher rates of drug complications, e.g., infections Dosage changing target as adults age
Opioid Crisis: Growing Awareness of Drug Misuse among Older adults Steep Increase in Hospital Use Related to Opioid Misuse Aging Baby Boomers and Drug Misuse: Implications for Elder Drug Misuse 502% to 520% Increase among 65+ Source: Owens et al. (2014). Hospital Inpatient Utilization Related to Opioid Overuse Among Adults, 1993-2012. HCUP Statistical Brief. Frostenson (2017). The opioid epidemic s startling age divide. Vox, April 26, 2017, reporting of unpublished data, presented at the National Prescription Drug Abuse and Heroin Summit, by Jay Unick.
Hospital and ED Use and Costs Related to Drug Misuse among Older Adults Roughly 5% of all ED Visits by Older Adults involve drug misuse (both intentional and unintentional) 60% women 47% aged 75 years or older 21% rurally located From both high (21%) and low (27%) income groups 5% involved alcohol (much lower than other age groups) Nearly 21% of all drug misuse cases were identified through principal diagnosis Nearly 60% of those with a principal diagnosis of drug misuse were hospitalized Average Hospital Costs+ ED Costs per visit = $25,275 dollars. Annual Hospital + ED costs per year = $898.1 million dollars Carter (2015). Trends in Substance Misuse among Older Adults Treated in the Emergency Department. Presented at 68th Annual Scientific Meeting of the Gerontological Society of America. 450 Died 40,633 Hospitalized 71,309 Principal Diagnosis 345,595 Any Drug Misuse 64,991,127 Patient Visits
Maryland: Signs that Older Adults are Misusing Opioid Prescriptions Climbing ED Rates for Opioid-Related Visits Increase ED Use among Older Adults Climbing Faster than Younger Age Groups Data Source: HCUP Clinical Classifications Software (CCS) for ICD-9-CM. Healthcare Cost and Utilization Project (HCUP). 2006-2014. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp. Accessed April 30, 2017. Charts and Tables Prepared by Mary W. Carter (2017), Unpublished data.
Challenges in Opioid Use among Older Adults Untreated chronic pain has consequences Increased disability and reduced mobility Falls Depression, social isolation, and anxiety Poor Sleep Additional approaches: Massage Physical therapy Meditation Psychotherapy Yoga/Tai Chi Topical Chronic Pain may stem from multiple underlying conditions Many non-opioid drugs are contraindicated; fail to manage pain, but side affects with opioids are high (80%) Exhaust other options first Patient history (Prior addiction? Antipsychotic Use?) Low dosaging and frequent contact needed Patient education and consent needed Like most things in life, the middle of the road approach is warranted.