Opioids in senior living communities
Prescription opioids (e.g. oxycodone, hydrocodone and methadone) are used to treat moderate to severe pain and can provide effective pain management when prescribed and taken as directed. However, prescription opioids can also be misused, leading to addiction, death, drug diversion (transfer of a legally prescribed controlled substance from the individual for whom it was prescribed to another person for illicit use) and a host of other problems. For senior living communities, administering opioids to frail elderly residents may be associated with an array of unwanted symptoms, including increased falls due to confusion, drowsiness, hallucinations, nausea, postural hypotension, urinary retention and vertigo. The challenge is to make sure the risks of the drugs don’t outweigh the benefits.
Older adults living in long-term care settings experience a higher incidence of chronic pain than those living in the community and are prescribed opioids at approximately twice the rate. New research suggests that when hospital patients are moved to a long-term care facility, they are often given a prescription for a high-dose painkiller. The investigators found that seven out of 10 of these patients received an opioid prescription when they left the hospital, and most were for oxycodone (OxyContin). More than half of the prescriptions dispensed were high-dose – equivalent to 90 milligrams of morphine or higher – a threshold that the Centers for Disease Control and Prevention (CDC) advises doctors to “avoid” prescribing.
In response to CDC guidelines and the rising concern that pain may not be adequately treated for long-term care residents, the American Medical Directors Association (AMDA),3 which is the Society for Post-Acute and Long-Term Care Medicine, has two primary policies related to opioids in long-term care settings:
- Provide access to opioids when indicated to relieve suffering and improve or maintain function, and
- Promote opioid tapering, discontinuation and avoidance of opioids when the above goals are not achievable, to prevent adverse events, dependence and diversion.
Opioid stewardship strategies
According to the AMDA, specific opioid stewardship strategies in long-term care settings should include the following:
- First, long-term care practitioners who prescribe opioids should do so based on thoughtful interprofessional assessment that identifies:
- A clear indication for opioid use.
- Inadequate response to non-pharmacological treatments.
- Inadequate response to appropriate non-opioid pharmacologic treatments.
- Appropriate response that justifies risks and benefits of continued opioid use.
- Second, long-term care practitioners who manage residents who are prescribed opioids have a responsibility to minimize the risk of adverse events, dependency and diversion by:
- Never prescribing long-acting opioids for opioid naïve residents (those that are not accustomed to taking any opioid medications).
- Tapering opioids to the lowest dose necessary to maximize functional ability.
- Tapering and stopping opioids when risks outweigh benefits.
- Prescribing opioids at the time of discharge in a quantity that represents the minimal amount necessary to transition the resident to a follow-up appointment.
- Third, long-term care and hospice medical doctors, as part of the interprofessional team, have a responsibility to:
- Oversee policies and processes that guide appropriate prescribing and use of opioids.
- Participate in efforts to prevent opioid diversion.
- Provide ongoing education related to opioid prescribing, safety and monitoring.
If you have additional questions regarding opioid awareness, abuse or overdose treatment, call Risk Control Central at (800) 554-2642, ext. 5213, or email firstname.lastname@example.org.
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