Physicians grapple with prescribing opioids to seniors as addiction rates swell

It took a lot of convincing for John Evard to go to rehab. Seven days into his stay at the Las Vegas Recovery Center, the nausea and aching muscles of opioid withdrawal were finally beginning to fade.

"Any sweats?" a nurse asked him as she adjusted his blood pressure cuff. "Last night it was really bad, but not since I got up," replied Evard, 70, explaining that he'd awakened several times with his sheets drenched.

Even for him, it was hard to understand how he ended up 300 miles away from his home in Scottsdale, Ariz., at this bucolic facility in the suburbs of Vegas. "This is the absolute first time I ever had anything close to addiction," he said. He prefers to use the term "complex dependence" to describe his situation: "It was, shall we say, a big surprise when it happened to me."

As the nation grapples with a devastating opioid epidemic, concerns have primarily focused on young people buying drugs on the street. But America's elderly also have a problem. Over the past several decades, physicians have increasingly prescribed seniors pain medications to address chronic pain from arthritis, cancer, neurological diseases and other illnesses that become more common in later life.

[Also: Opioid-related hospital stays spike 64%, cost billions in ER, hospital care each year]

A recent study found that in 2011, 15 percent of seniors were prescribed an opioid when they were discharged from the hospital; three months later, 42 percent were still taking the pain medicine.

One in three Americans who have taken prescription opioids for at least two months say they became addicted to or physically dependent on the medications, according to a recent Washington Post-Kaiser Family Foundation poll. (KHN is an editorially independent program of the foundation.)

It's no surprise, then, that some seniors end up addicted.

Evard spent his life working as a corporate tax attorney. He's spry and white haired, with a contagious grin. A few years ago he and his wife retired to Arizona with their eyes on the golf course. The dream didn't last long. Just months later, a virus infected Evard's left ear. Overnight, he lost half his hearing and was left with chronic pain. In January, he had surgery to fix the problem.

"From the surgeon's standpoint, the operation was successful. The problem was, the pain didn't go down. It went up," he recalled.

[Also: Children, toddlers flood hospital emergency rooms due to opioid poisoning, study finds]

His doctors prescribed opioids, including Oxycontin. "They decreased the pain, particularly at first," said Evard. "As time went on they had less and less effect, and I had to take more and more."

As the doctors increased his dosage, Evard's once active life fell apart. He was confused, depressed, and still in pain. "I was effectively housebound. I couldn't play golf anymore. I couldn't go to social events with my friends or my wife."

He couldn't think of anything except the pills and when he could have the next one. He knew he was in trouble -- despite having taken them exactly as his doctor instructed.

"I was a rule-follower," he said. "And I still ended up, in a mess!"

In 2009, the American Geriatric Society came out strongly in favor of opioids, recommending that seniors with moderate to severe pain be considered for opioid therapy. The panel cited evidence that seniors were less likely than others to become addicted.

"You don't see people in this age group stealing a car to get their next dose," Dr. Bruce Ferrell, chairman of the panel that issued the Society's guidelines, told The New York Times at the time.

Mel Pohl, medical director of the Las Vegas Recovery Center, called that conclusion a "horrible misconception."

"There's no factual, scientific basis for that. The drug takes over in the brain. It doesn't matter how old the brain is."

[Also: Cigna asks medical practices to sign opioid pledge with goal of dropping usage by 25 percent]

The problem is that chronic pain is common as people age, and there aren't many good options to treat it. Even aspirin and ibuprofen carry bleeding risks. The 2009 AGS guidelines are no longer in use, but opioid medications remain a crucial tool to treat pain in older people. Most people are able to take opioids in small doses for short periods of time without a problem.

"We really don't use opioids necessarily as the first line of treatment because we understand what the risks are. But we also don't want to see our patients suffering needlessly if we can provide them with relief," said Dr. Sharon Brangman, past president of the AGS. The trick, she said, is to try non-pharmacological options such as acupuncture first and to use the smallest effective opioid dose possible, if necessary.

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Still, most of the seniors at the Las Vegas Recovery Center have taken the drugs as prescribed by a willing doctor trying to address their pain, said Pohl. That pattern sets them apart from many of the younger patients, many of whom start buying drugs on the black market after being turned away by physicians.

Nonetheless, in the past 20 years, the rate of hospitalization among seniors that is related to opioid overuse has quintupled. But relatively few of them end up in rehab. Pohl said that's due to a combination of factors.

"They've grown up in an era where drug addiction and alcoholism [were] evil, and I think that's internalized for some of the folks that I've seen," he said, so they don't seek help, particularly from an in-patient facility. Also, some rehabs not are equipped to deal with the complex medical problems common among older people.

Another problem are patients whose addictions have been misdiagnosed as dementia. "We'll have a family come [visit], three weeks into treatment, and it's like 'Oh my God, you're back! I haven't seen that glimmer in your eye in 20 years!'" said Pohl.

It took John Evard about a week to get over the vomiting and flu-like symptoms of detox, which can be particularly hard on older patients. He's speaking out now because he doesn't want other seniors to fall into the same trap.

"Don't just take the prescription because it's part of the checkout process from the hospital," he cautioned. "It's your body, take charge of it, and push for alternatives at all costs. And if you do go on, get off them as fast as you can."

KHN's coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Twitter: @HC_Finance