Journal of Gerontological Nursing

Feature Article 

Opioid Misuse/Abuse and Quality Persistent Pain Management in Older Adults

Yu-Ping Chang, PhD, RN, FGSA; Peggy Compton, PhD, RN, FAAN

Abstract

The United States is amid an epidemic of prescription opioid drug abuse, bringing with it not only high rates of overdose, but growing rates of heroin abuse and addiction. Liberal opioid drug prescribing on the part of well-meaning clinicians has in part fueled this epidemic, being correlated to opioid death and addiction treatment admission rates. Misuse and abuse of prescription opioid drugs is greatest among young adults (ages 18 to 25); however, the fastest growing age group for opioid drug misuse/abuse is older (ages 50 to 64). Prescription opioid drug use issues may emerge in the context of persistent pain, and risk factors for misuse/abuse and overdose in older patients with pain require further description. In keeping with national initiatives to combat prescription opioid drug abuse and overdose, current clinical guidelines reflect an “opioid-sparing” approach. To the degree that these guidelines improve persistent pain and opioid drug misuse/abuse outcomes, significant public health benefits will be accrued. Efforts to reduce both require action and are national priorities. [Journal of Gerontological Nursing, 42(12), 21–30.]

Abstract

The United States is amid an epidemic of prescription opioid drug abuse, bringing with it not only high rates of overdose, but growing rates of heroin abuse and addiction. Liberal opioid drug prescribing on the part of well-meaning clinicians has in part fueled this epidemic, being correlated to opioid death and addiction treatment admission rates. Misuse and abuse of prescription opioid drugs is greatest among young adults (ages 18 to 25); however, the fastest growing age group for opioid drug misuse/abuse is older (ages 50 to 64). Prescription opioid drug use issues may emerge in the context of persistent pain, and risk factors for misuse/abuse and overdose in older patients with pain require further description. In keeping with national initiatives to combat prescription opioid drug abuse and overdose, current clinical guidelines reflect an “opioid-sparing” approach. To the degree that these guidelines improve persistent pain and opioid drug misuse/abuse outcomes, significant public health benefits will be accrued. Efforts to reduce both require action and are national priorities. [Journal of Gerontological Nursing, 42(12), 21–30.]

The United States is in the midst of a growing and dangerous epidemic of prescription opioid drug abuse. It was estimated that 4.3 million individuals age 12 or older were current nonmedical users of prescription opioid drugs in 2014 (Center for Behavioral Health Statistics and Quality [CBHSQ], 2015) with health consequences evident in increasing numbers of emergency department (ED) visits (Frank, Binswanger, Calcaterra, Brenner, & Levy, 2015), treatment admissions (Ling, Mooney, & Hillhouse, 2011), and overdose deaths (Centers for Disease Control and Prevention [CDC] & National Center for Health Statistics [NCHS], 2015; Rudd, Aleshire, Zibbell, & Gladden, 2016). Although many individuals benefit from using prescription opioid agents for pain management, improper use of prescription opioid drugs is common. Approximately 50.5% of individuals who misused prescription opioid drugs obtained them from a friend or relative for free, and 22.1% obtained them from a physician (CBHSQ, 2015). In 2016, the CDC reported that 78 individuals in the United States die from an opioid overdose daily, a number that has approximately quadrupled since 1999. There were more than 28,000 deaths related to opioid (i.e., opioid analgesics and heroin) overdose in 2014, more than any year on record, and approximately one half of these involved a prescription opioid (CDC & NCHS, 2015). Reflecting the national significance of this public health crisis, President Obama referred to “helping people who are battling prescription drug abuse” in the first paragraph of his 2016 State of the Union address (The White House, 2016). The purpose of the current article is to evaluate the existing approach and guidelines for opioid drug use and misuse, describe issues related to opioid misuse and abuse in older adults, and propose improvements to the current published guidelines. Table 1 provides definitions of the terms used throughout the article.


Definitions of Terminology

Table 1:

Definitions of Terminology

Of increasing concern, the rapid rise of heroin use and overdose in the United States has been tied to prescription opioid drug abuse related to its high availability and relatively low cost; 45% of individuals who use heroin are also addicted to prescription opioid analgesics (CDC & NCHS, 2015). A recent analysis of the annual National Survey on Drug Use and Health showed that the 12-month heroin use incidence rate was 19 times higher in individuals who reported prior prescription opioid drug abuse than among those who did not report abuse (0.39% versus 0.02%) (Muhuri, Gfroerer, & Davies, 2013). Further, the rate of recent prescription opioid drug abuse was approximately twice as high in those who reported prior heroin use than those who did not report prior use (2.8% versus 1.6%). Approximately 80% of heroin initiates reported previous prescription opioid drug abuse, whereas only 1% of recent prescription opioid abuse initiates reported prior use of heroin. However, despite its strength as a risk factor for initiating heroin use, only a small subset (3.6%) of individuals who had abused prescription opioid drugs started using heroin within 5 years (Muhuri et al., 2013), suggesting that prescription opioid abuse is only one factor in the pathway to heroin abuse (Compton, Jones, & Baldwin, 2016). Individuals who abuse prescription opioid drugs who transition to heroin use tend to be frequent users of multiple substances (i.e., polysubstance use) (Jones, Logan, Gladden, & Bohm, 2015). More studies are needed to better identify characteristics of individuals who transition from prescription opioid drugs and then transition to heroin use, including demographic characteristics, concurrent use of other drugs, and involvement of injection drugs (Jones et al., 2015).

The costs associated with prescription opioid drug misuse and abuse represent a substantial and growing economic burden in the United States. Best estimates from one decade ago show total expenses related to opioid drug abuse to the United States to be approximately $54 billion (Oderda, Lake, Rüdell, Roland, & Masters, 2015), of which 78% was related to lost productivity, 15% to criminal justice costs, 4% to drug abuse treatment, and 3% to medical complications (Hansen, Oster, Edelsberg, Woody, & Sullivan, 2011). A subsequent analysis found the total U.S. societal costs of prescription opioid drug abuse were somewhat higher ($55.7 billion in 2007), but with health care expenses accounting for a much larger percentage of the total (45%) (Birnbaum et al., 2011). Recent estimates from the CDC (2011) suggest that nonmedical use of prescription opioid drugs costs health insurers up to $72.5 billion annually in direct health care costs. Additional costs associated with prescription opioid drug abuse range from workplace drug screening tests, state prescription monitoring programs, and law enforcement efforts to identify and prosecute physicians prescribing for profit (CDC, 2011). High rates in the prevalence of prescription opioid misuse and abuse suggest continued societal burden in the future.

Role of Opioid Drug Prescribing in the Abuse Epidemic

This public health crisis has been attributed to the large supply of opioid drugs being prescribed in communities, making them more readily available than ever before. The quantity of prescription opioid agents sold to pharmacies, hospitals, and doctors' offices was four times greater in 2010 than in 1999 and, in 2012, clinicians wrote an estimated 259 million prescriptions for opioid analgesics (CDC, 2013), resulting in Americans consuming approximately 70% of the global opioid supply (Berterame et al., 2016). Including those used to treat surgical, trauma, end-of-life, and chronic pain, the CDC (2011) reported that enough prescription opioid drugs were prescribed in 2010 to medicate every American adult around-the-clock for 1 month.

In addition, opioid drug prescriptions are being written for higher doses such that the therapeutic dose of prescription opioid drug per person increased 347% between 1997 and 2006 (CDC, 2011). Further, prescriptions for persistent pain for extended periods of time and extended release/long-acting formulations might contribute to higher prevalence of non-medical use, including misuse, abuse, and opioid use disorders. In fact, a strong relationship exists among the increased rates of prescription opioid drug sales, opioid drug–related deaths, and opioid drug addiction treatment admissions (Figure). In a study of more than 2 million patients prescribed opioid agents, the risk of death from opioid drug overdose does not substantially increase until the dose exceeds 200 morphine milligram equivalents (unless the patient receives benzodiazepine agents, which increase the overdose risk 10-fold) (Dasgupta et al., 2016).


Rates of prescription painkiller sales, deaths, and substance abuse treatment admissions (1999–2010).
Reprinted from the Centers for Disease Control and Prevention. (2011). Prescription painkiller overdoses in the US. Retrieved from http://www.cdc.gov/vitalsigns/PainkillerOverdoses/index.html

Figure.

Rates of prescription painkiller sales, deaths, and substance abuse treatment admissions (1999–2010).

Reprinted from the Centers for Disease Control and Prevention. (2011). Prescription painkiller overdoses in the US. Retrieved from http://www.cdc.gov/vitalsigns/PainkillerOverdoses/index.html

Who Abuses Prescription Opioid Drugs?

Overall rates of prescription opioid drug misuse remained stable between 2013 and 2014, with 13.6% of individuals older than 12 reporting non-medical use over their lifetime; however, indicators of more recent use find the rates of past year misuse dropping from 4.2% to 3.9%, and past month use from 1.7% to 1.6% during the same time period. Men misuse prescription opioid drugs at a higher frequency than women (15.9% versus 11.5%). The highest rates of misuse are in individuals between the ages of 18 and 25; notably, the only age group in which prescription opioid drug misuse has risen over the past year are those individuals between the ages of 50 and 64 (CBHSQ, 2015).

Less is known about those who meet diagnostic criteria for an opioid drug use disorder (i.e., addiction). It appears that 0.7% of Americans are addicted to prescription opioid drugs, with rates of addiction higher in males and in those ages 18 to 25. Although national data describing rates of prescription opioid drug addiction among older adults are not available, it is important to note that rates of illicit substance dependence in general has doubled in individuals ages 55 to 64 between 2013 and 2014 (CBHSQ, 2015). A recent survey showed that the largest age group of individuals receiving methadone treatment in New York City comprises individuals older than 60, and that the percentage of individuals between ages 50 and 59 has risen more than four-fold from 7.8% in 1996 to 35.9% in 2012 (Han et al., 2015).

Opioid drug overdose is a possibility in all patients using opioid drugs in a non-prescribed manner. Known risk factors potentiating opioid drug–induced respiratory depression include underlying respiratory disorders and sleep apnea, as well as concurrent central nervous system depressant drug use (e.g., alcohol, benzodiazepine agents). The CDC reports that more men than women die of overdoses from prescription opioid drugs, and that middle-aged adults have the highest overdose rates. White and American Indian or Alaska Native individuals are more likely to experience overdose than individuals of other ethnicities, and individuals living in rural communities are almost twice as likely to overdose on prescription opioid drugs as individuals in big cities (CDC, 2011). Although linked to high-dose, chronic opioid drug therapy, recent data suggest that more than one half of opioid drug overdoses in Washington State between 2006 and 2010 were in patients on relatively low prescribed doses and with acute or intermittent opioid drug use (Fulton-Kehoe et al., 2015).

Opioid Misuse and Abuse in Patients with Persistent Pain

A subpopulation of patients with persistent pain who are prescribed opioid drugs do not adhere to their medication regimen and engage in behaviors reflecting misuse and/or abuse (Larance, Degenhardt, Lintzeris, Winstock, & Mattick, 2011). The literature indicates that the prevalence of prescription opioid drug misuse in individuals with persistent pain ranges from 21% to 29% across health settings, and the rate of addiction is approximately 8% to 10% (Vowles et al., 2015). Using criteria for opioid abuse and dependence from the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders, Boscarino et al. (2010) found that 26% of patients with persistent pain receiving chronic opioid drug therapy in primary care or pain specialty treatment clinics (N = 705) reported a current opioid drug use disorder and 36% had a lifetime opioid drug use disorder.

Most studies investigating prescription opioid drug misuse in patients with pain have focused on adolescents, young, or middle-aged adults. Risk factors for opioid drug abuse, misuse, and other aberrant drug-related behaviors in patients with persistent pain receiving prescription opioid drugs have been well-documented, with a history of alcohol and illicit drug abuse being the most consistent predictor of current prescription opioid drug abuse, regardless of age (Jamison & Edwards, 2013; Sehgal, Manchikanti, & Smith, 2012). Other important risk factors for opioid drug abuse include: pain-related functional limitations; current cigarette smoking; a family history of substance abuse; history of a mood disorder (e.g., current depression); history of child sexual abuse or child neglect; involvement in the legal system; and significant psychosocial stressors (Boscarino et al., 2010; Jamison & Edwards, 2013; Liebschutz et al., 2010; Sehgal et al., 2012). Recent work by Alford et al. (2016) suggests that a significant amount of illicit substance use in primary care patients is to self-medicate pain.

Among female patients with persistent pain, those with more emotional issues (i.e., pain caused by psychological problems) and affective distress were found to be at increased risk for opioid drug misuse, whereas among males, those with legal problems tended to have a heightened risk of misuse of prescription opioid drugs (Jamison, Butler, Budman, Edwards, & Wasan, 2010). Other studies have suggested that cravings for opioid drugs and catastrophic thinking are significantly associated with prescription opioid drug misuse in patients with persistent pain (Martel, Wasan, Jamison, & Edwards, 2013).

Prescription Opioid Drug Misuse in Older Adults

In a geriatric sample, higher levels of pain intensity and depression and lower levels of physical disability were associated with increased opioid drug misuse (Lavin & Park, 2010). Similar risk factors were found in a recent study indicating that older adults with a moderate level of depression and more pain interference in functionality had a greater risk of opioid drug misuse defined as taking more than prescribed (Chang, 2016). Levi-Minzi, Surratt, Kurtz, and Buttram (2013) found that approximately 34% of older adult participants reported substantial prescription opioid drug misuse, supporting the finding of Chang (2016) that 35% of patients with persistent pain age 50 or older reported misusing their prescription opioid drugs in the past 30 days. Reflecting the national data, patients with persistent pain ages 50 to 64 were more likely to misuse their prescription opioid drugs compared to their older counterparts. In fact, more than 40% of participants aged 50 to 64 in the study by Chang (2016) reported prescription opioid drug misuse, which is slightly higher than the general persistent pain population (Boscarino et al., 2010; Vowles et al., 2015). Furthermore, middle-aged and older adults who reported alcohol use or illicit drug use were more likely to develop opioid drug misuse (Chang, 2016). Middle-aged patients with persistent pain, ages 50 to 64, reflect the Baby Boomer generation; as this cohort ages, the prevalence of persistent pain will rise, with concern that increased opioid drug prescription is likely to follow.

Individuals who abuse opioid drugs, particularly those who are middle-aged adults and older, often experience co-occurring mental health, persistent pain, and other substance use problems, and are likely to be high users of hospital and community-based care services. A recent study examined 2014–2015 Medicaid claims data in western New York in individuals with opioid drug abuse (Chang, Casucci, Xue, & Hewner, 2016). Not only did investigators find that individuals who abused opioid drugs had significantly higher use across three types of health care services (i.e., ED, outpatient, and inpatient) than those without opioid drug abuse, but older individuals who abused opioid drugs had significantly higher use across different types of health care services. Higher ED use was correlated with gender, mental health comorbidities, smoking, other substance use disorders, and persistent pain (Chang et al., 2016). Furthermore, among adults 50 or older who abuse opioid drugs, approximately one half (48.5%) had at least one type of mental health comorbidity, approximately 20% had persistent pain, 44.4% reported tobacco use, and approximately 3% reported other types of substance use disorder. These results suggest that older adults with opioid drug abuse have higher health care needs due to the complexity of their co-morbid chronic conditions.

The aging process and its effect on body composition and pharmacokinetic processes (e.g., altered drug absorption and decreased renal excretion) put older adults at higher risk for opioid drug toxicity (Makris, Abrams, Gurland, & Reid, 2014). Among adults 50 or older who visited the ED for prescription drug toxicity, pain relievers were most commonly involved (43.5%), with opioid pain relievers being the most frequent type mentioned (Substance Abuse and Mental Health Services Administration [SAMHSA], 2010). Misuse or abuse of opioid drugs in this population results in accidents, mood changes, and cognitive decline (Ballantyne, 2012; Mailis-Gagnon et al., 2012), in addition to overdose and death (CDC, 2013). Furthermore, between 1993 and 2012, the rate of hospital stays involving opioid drug overuse, including opioid drug dependence, abuse, poisoning, and adverse effects, was highest for adults 45 and older (8.9% to 9.1% average annual percent change) (SAMHSA, 2010).

Some studies have investigated reasons that older adults with persistent pain give for taking more prescription opioid drugs than prescribed. Such reasons include accidental misuse (i.e., due to forgetfulness and/or confusion caused by multiple medication regimens); seeking immediate relief for poorly controlled pain; experiencing increased pain intensity due to poor activity pacing; wanting to be free of pain when spending time with family members and grandchildren; and experiencing negative emotions that intensify perceptions of pain (Chang, Compton, Almeter, & Fox, 2015). Community-dwelling older adults reported depleting their prescription opioid drugs because of overuse and then buying opioid drugs on the street or from other sources, or using over-the-counter analgesic agents to get through the interval before their next medical appointment (Chang et al., 2015).

Efforts to Curb the Epidemic

Government and public health organizations, responsible for monitoring and treating drug abuse in the United States, such as the Office on National Drug Control Policy (ONDCP), Department of Health and Humans Services (USDHHS), and SAMHSA, have been actively engaged in curbing the rising tide of prescription opioid drug abuse and mortality. In contrast to the prior administration's emphasis on interdiction and criminalization approaches to substance abuse in general, in 2010, President Obama took a strong stance against prescription opioid drug abuse, emphasizing the need for inter-departmental collaboration among government, law enforcement, health care, and regulatory agencies. In a move away from the “War on Drugs” perspective, current efforts reflect a disease orientation to addiction with a focus on treatment and prevention.

At the forefront of the response has been the ONDCP, which exists to develop guidelines, priorities, and goals for the United States drug abuse initiatives. In the 2015 National Drug Control Strategy, President Obama emphasized the Administration's commitment to confronting the prescription drug misuse and heroin epidemic (The White House, 2015). A total of $27.6 billion was requested by the President in fiscal year 2016 to support these efforts to reduce drug use and its consequences; this request represents an increase of more than $1.2 billion (4.7%) over the enacted 2015 level of $26.3 billion. Key funding priorities include addressing the current opioid drug overdose epidemic by increasing overdose prevention (primarily via naloxone administration) and enhancing state prescription drug monitoring programs (PDMPs). The expansion of medication-assisted treatment (MAT) (methadone or buprenorphine) programs, both in the community and criminal justice system, is another significant goal. In addition, funding will be targeted toward the development of drug-free communities, as well as activities to address domestic and international organized crime associated with illicit opioid drug trafficking (The White House, 2015).

Concurrent with the White House efforts, the USDHHS has also been engaged in strategies to decrease prescription opioid drug misuse and abuse. The recently updated Opioid Overdose Toolkit (SAMHSA, 2016) is aimed at medical personnel and laypersons, and includes educational materials regarding preventing opioid drug overdoses, highlighting the use of naloxone. In March 2015, the Secretary of the USDHHS announced the Secretary's Opioid Initiative, which aims to reduce addiction and mortality related to opioid drug abuse. The Secretary's efforts focus on following three priority areas to address opioid drug and heroin overdose and death: (a) providing training and educational resources to health care providers; (b) increasing use of naloxone; and (c) expanding the use of MAT (USDHHS, 2015) (Table 2).


Three Priority Areas of the Secretary of the USDHHS Opioid Initiative

Table 2:

Three Priority Areas of the Secretary of the USDHHS Opioid Initiative

The U.S. Food and Drug Administration (FDA) has been engaged in efforts to identify and mitigate the abuse of extended-release or long-acting prescription opioid drugs. In 2007, the FDA Amendments Act granted the FDA authority to create a risk evaluation and mitigation strategy (REMS), which, similar to the RADARS® initiative of Purdue Pharma L.P., enables the federal government to require manufacturers to develop effective methods to monitor the diversion/misuse of various opioid drugs (monitoring 77 products overall via four separate methods of monitoring) (FDA, 2015). Under this act, and recently updated, the FDA required safety labeling changes and post-market studies to detect misuse, abuse, addiction, and overdose. Recognizing that training was lacking, included in the REMS is a requirement that the manufacturers of all new extended-release or long-acting opioid drugs provide training and information for opioid drug prescribers (FDA, 2012).

Perhaps of most significance to the prescription opioid drug abuse crisis, this administration passed the Affordable Care Act in 2013, increasing access to health insurance coverage for those in substance abuse treatment, such that patients receive the same coverage as they would for any other chronic disease (The White House, 2014). It is estimated that by 2020, 62.2 million individuals will receive increased coverage for substance abuse treatment, 32.1 million of whom will be receiving such coverage for the first time (The White House, 2014).

Potential Impact on Effective Pain Management

Although public health data support aggressive and wide-ranging responses to the prescription opioid drug abuse crisis, there is concern among the pain community that these efforts will have a chilling effect on the provision of opioid drugs for patients with persistent pain and result in ineffectively managed pain (Reuben et al., 2015). This is not an unfounded concern in that unchecked prescribing practices bear some degree of responsibility for the crisis; therefore, these initiatives make it incumbent upon providers to be more thoughtful and discriminating in their opioid drug prescribing practices (Compton & Weaver, 2015). Consistent across recently published guidelines on responsible opioid drug prescribing is an “opioid-sparing” approach in the management of persistent pain (Dowell, Haegerich, & Chou, 2016), thus it is likely that access to opioid drugs will become limited at the level of the provider. Exemplified in the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain (Table 3) is an informed partnership between the patient and health care professional, opioid drug prescribing practices with respect to dose and regimen, and initial and ongoing assessment of benefits versus harms associated with opioid drug therapy (Dowell et al., 2016). Recommended within the guidelines is the use of multi-modal non-opioid pain management strategies (e.g., behavioral therapy, acupuncture, acceptance therapy, organized exercise), provision of naloxone, and careful screening for risk of misuse and abuse.


2016 Centers for Disease Control and Prevention Guideline for Prescribing Opioid Drugs for Chronic Pain

Table 3:

2016 Centers for Disease Control and Prevention Guideline for Prescribing Opioid Drugs for Chronic Pain

Critics of the CDC Guideline are concerned that they are too prescriptive (especially with respect to limits on dosage and duration) for a disease and symptom with much subjective and individual variability. Management of persistent pain should be based on quality of life and function as opposed to milligrams of opioid. In addition, there is concern that the current health care and insurer environments are not resourced or prepared to provide the non-medication types of interventions that would be required of opioid drug–sparing approaches. Finally, and perhaps most concerning, is that the CDC recommendations are based on little scientific evidence of efficacy, not only with respect to addiction and overdose, but for the benefits of long-term opioid drug therapy in general (Chou et al., 2015). Concerns have been expressed that the CDC guidelines were not developed by representatives of professional organizations and experts in geriatrics/pain management. Furthermore, there is limited evidence regarding the long-term effect of nonpharmacological intervention on pain management (Reuben et al., 2015). Albeit imperfect, the CDC guidelines will likely bring benefits beyond any associated with opioid drug sparing. Medication development efforts directed toward new classes of non-opioid analgesics will be stimulated. To minimize opioid drug use in patients with persistent pain, alternative effective non-opioid interventions will need to be offered, forcing payors and providers to introduce and integrate behavioral and complementary therapies into pain care (Interagency Pain Research Coordinating Committee, 2016).

The guidelines recommend screening all patients with persistent pain for risk of misuse and abuse prior to and during opioid drug therapy; such screening could serve as case identification for initiation of treatment for opioid drug use disorder. The guidelines recommend the prescription of naloxone as an overdose prevention strategy, which, if adopted, would likely save lives. The notable lack of evidence supporting the guidelines presents a ready research roadmap for the NIH and other scientific foundations (Interagency Pain Research Coordinating Committee, 2016). For example, what types of approaches and/or in what combination can improve pain management and function, and what types of patients with persistent pain can benefit the most from these approaches (NIH, 2016). Patients with persistent pain with occurring chronic conditions such as substance abuse or mental health problems would benefit from an integrated approach that also includes behavioral health treatments. Perhaps most importantly, the guidelines being released amid the prescription opioid drug abuse epidemic provide an unparalleled opportunity to educate pain clinicians about the components of good pain care (opioid drugs are only one) and ways to assess for, prevent, and manage opioid drug abuse or use disorders.

Conclusion

Prescription opioid drug abuse and misuse may emerge in the context of persistent pain management. Risk factors for misuse, abuse, and overdose in patients with persistent pain have been well-described; the losses associated with persistent pain in combination with those associated with aging may put older patients at higher risk for untoward outcomes. Understanding how older adults take their prescription opioid drugs will increase the awareness of misuse and abuse among this population, caregivers, and health care providers, as well as better identify and treat opioid drug use disorders.

Several national efforts are focused on combatting prescription opioid drug abuse and overdose, including efforts to dispose of unused medications, expand access to MAT, and inform providers of prescribing patterns through PDMPs and REMS. In keeping with national efforts to limit opioid drug prescriptions, current clinical guidelines have adopted a clear opioid-sparing approach. To the degree that adoption of these guidelines improves persistent pain outcomes and the management of opioid drug misuse, abuse, and use disorders, significant public health benefits are accrued. Because prescriptive recommendations on dose and duration of opioid drug therapy are not based on strong evidence (Chou et al., 2015; Reuben et al., 2015), clinicians are cautioned to base dosing decisions on functional outcomes as opposed to strict guidelines. Absent from these guidelines is the extent of the need for and the design of prevention and treatment efforts tailored for the older adult population.

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Definitions of Terminology

TermDefinition
Prescription opioid use disorder (POUD)The clinical diagnosis of a problematic pattern of substance use behaviors leading to clinical impairment or distress, including the inability to control use, consequences related to use, and failure to meet major responsibilities at work, school, or home. POUDs are categorized as mild, moderate, or severe to indicate the level of severity, and are both preventable and treatable.
MisuseUse of a prescribed medication for nonmedical use, or for reasons other than prescribed (i.e., altering dosing, route of administration, or combining substances). Misuse may or may not reflect POUD.
AbuseMisuse with consequences (mild to moderate POUD). Potentially harmful consequences include accidents or injuries, blackouts, legal problems, and risky sexual behaviors.
AddictionA chronic, relapsing, and progressive disease leading to significant impairment in all life domains (moderate to severe POUD).
Aberrant drug-use behaviorTaking a medication in a manner that is outside the boundaries of the prescribed treatment plan, such as using multiple pharmacies and prescribers, repeatedly losing medication, or requesting early refills. The presence of these behaviors may or may not reflect POUD.

Three Priority Areas of the Secretary of the USDHHS Opioid Initiative

1.Providing training and educational resources: Providing updated prescriber guidelines to assist health professionals in making informed prescribing decisions and address the over-prescribing of opioid drugs.
• Teaching medical professionals how and when to prescribe opioid drugs by working with lawmakers on bipartisan
legislation requiring specific training for safe opioid drug prescribing and establishing new opioid prescribing guidelines for chronic pain
• Supporting data sharing for safe prescribing by facilitating prescription drug monitoring programs (PDMPs) and health information technology integration and further adoption of electronic prescribing practices
• Increasing investments in state-level prevention interventions, including PDMPs, to track opioid drug prescribing and support appropriate pain management
2.Increasing use of naloxone: Continuing to support the development and distribution of the life-saving drug to help reduce the number of deaths associated with prescription opioid drug and heroin overdose.
• Supporting the development, review, and approval of new naloxone products and delivery options
• Promoting state use of Substance Abuse Block Grant funds to purchase naloxone
• Implementing the Prescription Drug Overdose grant program for states to purchase naloxone and train first responders on its use
3.Expanding the use of medication-assisted treatment (MAT): MAT is a comprehensive way to address the needs of individuals that combines the use of medication with counseling and behavioral therapies to treat substance use disorders.
• Launching a grant program in fiscal year 2015 to improve access to MAT services through education, training, and purchase of MAT medications for treatment of prescription opioid drug and heroin addiction
• Exploring bipartisan policy changes to increase use of buprenorphine and develop the training to assist prescribing

2016 Centers for Disease Control and Prevention Guideline for Prescribing Opioid Drugs for Chronic Pain

Determine when to initiate or continue opioid drugs for chronic pain
  1. Assessment prior to opioid prescription—Are opioid drugs indicated?
  2. Establish treatment goals with patient.
  3. Discuss risks, benefits, and expectations with respect to opioid drug therapy.
Opioid selection, dosage, duration, follow up, and discontinuation
  4. Begin with immediate-release (not long-acting) opioid drug formulations.
  5. Prescribe lowest effective dosage.
  6. For acute pain, prescribe in small quantities.
  7. Evaluate benefits of opioid drug therapy within 1 to 4 weeks of initiation and regularly (at least every 3 months) thereafter.
Assess risk and address harms associated with opioid drug use
  8. Evaluate risk factors for opioid drug–related harms (e.g., overdose, abuse) when initiating and at regular intervals during ongoing opioid drug therapy.
  9. Review state prescription drug monitoring programs when initiating and at regular intervals during ongoing opioid drug therapy.
  10. Use urine drug testing when initiating and at regular intervals during ongoing opioid drug therapy.
  11. Avoid concurrent prescription with benzodiazepine agents.
  12. Offer and arrange evidence-based treatment (usually medication-assisted treatment) for patients with opioid drug use disorder.
Authors

Dr. Chang is Associate Dean for Research and Scholarship and Associate Professor, School of Nursing, The State University of New York, Buffalo, New York; and Dr. Compton is Associate Dean for Research, Evaluation and Graduate Programs Interim Chair, Department of Advanced Nursing Practice, School of Nursing and Health Studies, Georgetown University, Washington, DC.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Yu-Ping Chang, PhD, RN, FGSA, Associate Dean for Research and Scholarship and Associate Professor, School of Nursing, The State University of New York at Buffalo, 3435 Main Street Wende Hall 101C, Buffalo, NY 14214; e-mail: yc73@buffalo.edu.

Received: July 31, 2016
Accepted: October 27, 2016

10.3928/00989134-20161110-06

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