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Under Treatment of Pain: A Prescription for Opioid Misuse Among the Elderly?

Levi-Minzi M A, et al.

Journal: Pain Med. 2013; 14:1719-1729. 49 references.
Reprint: Maria A. Levi-Minzi, MA, Center for Applied Research on Substance Use & Health Disparities, Nova Southeastern University, 2 NE 40th Street, Suite 404, Miami, Fl. 33137, USA Email: 
Faculty Disclosure: Abstracted by N Walea, who has nothing to disclose.

Editor's Note:
This is an interesting study with a misleading title-it seems that opioid misusers don’t fit the usual perception of grandma and grandpa in the selected population with all drug abusers, 30% homeless in the past month, “77.3 % had ever been arrested; 50% had ever been admitted to drug treatment and 10.2% reported having sold prescription medication in the past 90 days” and 30% were receiving drugs from dealers or family members. It seems to me that a more stable population would be a better indicator of opioid underuse in chronic pain patients.The title belies sound advice to screen your patients, enter into “contracts” (now called agreements for legal reasons), do urine testing and set goals.

Class: Legal aspects of opioids

In elderly persons in various settings, it has been estimated that 45-85% experience chronic, noncancer pain but less than half are treated effectively by their general practitioners. For the elderly specifically, studies report that over 40% experience daily pain with only one fourth receiving any analgesic. The cause of this undertreatment of noncancer pain in older adults has been attributed to both provider and patient factors.In this study, individuals aged > 60 (only opioid prescription misusers [N = 88]) were interviewed in research field offices or senior/community centers in South Florida. The main survey instrument was the Global Appraisal of Individual Needs (GAIN) and a subset of elderly (N = 30) who reported substantial prescription drug misuse were selected for in-depth interviews. Mental distress was measured by the General Mental Distress Scale (GMDS). The mean age was 63.3 years; 75% were male; 36.4% were African American/Caribbean; 37.5% were White; 20.5% were Hispanic/Latino; and 5.6% listed “other race/ethnicity.” Forty-two percent had more than a high school education. The majority of participants (73.3%) had health insurance; 46.6% had an income over $1,000 per month; 61.4% had disability or social security as the income source; 28.4 % reported being homeless in past 90 days; 77.3 % had ever been arrested; 50% had ever been admitted to drug treatment and 10.2% reported having sold prescription medication in the past 90 days.In the past three months, the drugs of abuse/misuse were: alcohol (63.6%), benzodiazepines (48.9%), powder cocaine and/or crack (35.2%), marijuana (30.7%), heroin (14.8%), prescription antidepressants (10.2%) and prescription antipsychotics (13.6%). The primary opioids of abuse were oxycodone (38.6%), tramadol (20.5%), and hydrocodone (15.9%). Sources of diversion for prescription medications varied with regular doctor as most popular source (52.3%), 29.5% listed a dealer, sharing and trading 29.5%, 8% listed family, and pharmacy was 1.1%.Whites, Hispanics and those of “other” ethnicity had significantly lower odds of getting their primary opioid from their regular doctor as compared with the African American/Caribbean group. Individuals had nearly five times higher odds of obtaining their primary opioid from a dealer if they had ever been arrested. Disability or social security income individuals had significantly lower odds of using a dealer but those who said they had been homeless in the past three months had over three times higher odds of having a dealer as their source. Veterans had nearly four times higher odds of acquiring their primary opioid via a regular doctor and were significantly less likely to obtain medication through sharing or trading with others. Individuals with insurance had over three times higher odds of using a regular doctor and had lower odds of using a dealer or sharing. Individuals reporting recent physical problems had lower odds of using a dealer while those reporting recent primary opioid misused for pain had over 12 times higher odds of using a regular doctor to obtain their opioid and significantly lower odds of using a dealer. None of the mental health variables were significant.The three themes that emerged from the in-depth interview were: the misuse of prescribed medications to manage pain; reluctance of physicians to prescribe high dose/potency pain medications; and participants need to purchase pain medication from other sources due to lack of legitimate prescriptions or insurance. The results reflect a group of elderly individuals (many with substance abuse histories) that are being undertreated for their pain. Doctors seem to be cautious about the types of medication prescribed which could be due to recent local crackdowns on physicians prescribing medications or concerns that patients may develop dependence on prescription opioids.

Important Points:

The study findings suggest that the group of elderly often misuse their own prescriptions for pain. There is a need to educate professionals, who are prescribing, on substance abuse identification; perhaps utilize treatment contracts or urine testing to facilitate the process of prescribing appropriately while identifying abuse for treatment referrals. Physicians can work with their patients to clearly identify therapeutic goals, and discuss safe and responsible use for long-term opioid therapy. Screening tools and medication agreements are valuable tools to use as part of ongoing pain management.

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