Opioids and the Elderly: How to Address Addiction Risk in Your Practice

The number of adults 50 and older with substance abuse disorders is expected to double by 2020. “We need to consider that recreational drug users of the ‘60s are still practicing the same behaviors of today,” said Ann Eshenaur Spolarich, RDH, PhD, in her recent presentation at the American Dental Association’s 2016 Meeting in Denver, CO.

Below are important pharmacological considerations in the elderly as well as tips to appropriately manage patients currently using medications/substances with a high risk of abuse, according to Dr. Spolarich.

Important pharmacologic principles to consider in the geriatric population

In the elderly, many typical drug doses act at overdose levels, and starting at a lower dose is appropriate, Dr. Spolarich advised. A decline in kidney and liver function occurs, meaning metabolism and excretion of many dental medications decreases. Elderly patients are therefore prone to greater sedation and increased psychomotor impairment.

Many drug classes increase the risk for falls in the elderly, including antihypertensives, sedative hypnotics, benzodiazepines, opiates, and antidepressants.

The elderly tend to use many prescription drugs, usually filled at different pharmacies. This increases the likelihood of drug interactions.

When in doubt, Dr. Spolarich advises, refer to the Beers Criteria, which is a document listing medications that should be avoided in elderly adults.

Benzodiazepines

Benzodiazepines are commonly prescribed for anxiety. Dentists need to be aware that a common benzodiazepine, diazepam, has an active metabolite and sticks around in elderly patients longer.

If a patient takes a benzodiazepine and an opiate, Dr. Spolarich recommended to reduce the dose of the opiate by at least a third when the benzodiazepine is added, and to counsel the patient to avoid any alcohol while on benzodiazepines.

Long term benzodiazepine use can worsen COPD, GERD, and increase fall risk. Possible side effects include fatigue, drowsiness, xerostomia, and additive effects with other CNS depressants.

Opiates

Dentists must realize that not all pain is the same, and will not respond to the same medications. If a patient’s pain is unresolved or continues to worsen despite dose escalation, there is the possibility of disease progression, diversion, or pseudo-addiction.

The current practice among dentists is to prescribe a 3-day supply of opiates, a sufficient amount for many dental procedures.

Alcohol

Alcohol and tobacco cause more medical problems than all other drugs combined.

Forty percent of older adults drink alcohol, and use tends to increase with age.

As the physiology of the body changes, alcohol is metabolized differently. The elderly tend to have decreased total body water and lean body mass, leading to a higher concentration of alcohol in the blood. Alcohol is metabolized slower and stays in the body longer. Side effects secondary to alcohol are more likely to occur with increasing age.

Dr. Spolarich mentioned that the alcohol limits recommended by the National Institute on Alcohol Abuse and Alcoholism may not apply to elderly. Age-appropriate alcohol limits have not been established for the elderly.

Chronic alcoholism in elderly adults can lead to biological brain disorders, systemic health problems, and increases risk of certain cancers. It can also lead to poor oral hygiene from neglect, enlarged parotid glands, increased bleeding if liver failure is present, fungal infections, glossitis, and angular cheilitis.

Common drug interactions with alcohol include NSAIDs, acetaminophen, and antihistamines.

Tobacco/nicotine

A history of lifetime smoking reduces life expectancy by approximately 13-15 years, contributes significantly to heart disease and stroke, COPD, cancer, the development of dementia and Alzheimer’s, and can increase the risk of developing cataracts.

Of note, cessation aids have not been tested in older adults, and this can pose a challenge to healthcare providers.

Conclusion

Every patient 60 and over should be screened for alcohol and drug abuse as part of their regular exam. The warning signs of abuse are easily confused with concurrent/chronic conditions. Therefore, it is vital to be actively involved in your patient’s care and always be prepared with resources specifically for geriatric patients.

Mary Lenefsky, PharmD, is a consultant pharmacist and medical writer who specializes in the creation of medical education content for pharmacists, nurses, physicians, and other healthcare providers. She received her Doctor of Pharmacy Degree from the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences. She then completed two years of post-graduate residency training at Northwestern Memorial Hospital, specializing in the care of the critically ill.