Opioid Management in Older Adults: Lessons Learned From a Geriatric Patient-Centered Medical Home
Background: The United States continues to confront an opioid crisis that also affects older adults. Best practices for prescription opioid management in older adults are challenging to implement in this population. We present our experience with a 1-year management of 48 high-risk older patients who received guideline-based best practices for chronic prescription opioid therapy at a US Department of Veterans Affairs (VA) patient aligned care team (PACT) patient-centered medical home.
Methods: The GeriPACT population at the Nashville Campus of the VA Tennessee Valley Healthcare System has an enrollment of 745 patients of whom 48 (6.5%) receive chronic prescription opioid therapy. The practice is supported by the VA Computerized Patients Record System, including the electronic patient portal, My health e Vet, and telemedicine capabilities. Data were collected by chart review and operations data.
Results: The mean (range) age of patients was 70.4 (66-93) years. Many patients had comorbid conditions, such as diabetes mellitus (35%), congestive heart failure (18.6%), and dementia (8.3%). More than half had an estimated glomerular filtration rates (eGFR) < 60 mL/min, indicating at least stage 3 chronic kidney disease, 41.7% used mental health services (41.7%), and 20.8% had a history of opioid use disorder. Most indications for chronic pain were for musculoskeletal pain (95.8%). The mean (range) morphine equivalent daily dose was 37 mg (10-109). More than half had been seen in the emergency department, and 20.8% had been hospitalized in the previous year for an opioid-related hospitalization, and 3% had expired. Over the year, dose reductions of benzodiazepines or narcotics was performed for 12.5% of patients, accidental overdoses occurred in 4.2%, and positive urine drug screens (UDSs) for cocaine and cannabinoid/tetrahydrocannabinol occurred in 10.4%. One patient was terminated from the program for multiple positive UDSs.
Conclusions: Guideline-based patient-centered medical home management of patients with chronic pain who were treated with opioids can be an effective model contributing to the health and well-being of older patients. Complex older patients on chronic opioid treatment are best managed by an interdisciplinary team.
Medication Reduction
Pharmacists routinely counseled patients regarding the appropriate timing of refills and made monthly calls to request refills of controlled drugs. Three patients agreed to opioid dose reduction due to improved clinical status. Two patients had 25% and 30% dose reductions, respectively, and 1 patient was able to be discontinue opioids. This was achieved through reduction of therapy and or substitution of alternative nonopioid pain medications. One patient was initiated on a slow benzodiazepine taper schedule after decades of benzodiazepine use in addition to engagement with a whole health coach and primary care mental health integration provider. Another patient was disenrolled from the clinic because of repeated nonadherence and positive UDSs for polysubstance use disorder.
Accidental Overdoses
There were 2 patients with accidental overdoses who survived, both on high morphine equivalent daily doses (MEDDs). One patient was admitted to the intensive care unit for increasing confusion after taking more than the prescribed opioids (120 mg MEDD) due to uncontrolled pain for 2 months following surgery. The second patient was taking 66 mg MEDD with multiple risk factors for respiratory depression (severe chronic obstructive pulmonary disease requiring oxygen, obstructive sleep apnea, and concomitant benzodiazepine use) who repeatedly refused tapering of opioids and benzodiazepines. He was found unresponsive in respiratory depression by home health staff. Both patients had naloxone kits in their home that were not administered.
Urine Drug Screening
There was an occasional negative opioid UDS attributed to patients on a low-dose opioid administered more than 24 hours before. Five patients (10.4%) had positive UDSs. Two patients were positive for cocaine, and because of chronic persistent pain and complex medical problems cared for in the clinic, counseled and continued on therapy with no repeat infractions. Two patients were positive for cannabinoids attributed to CBD oil products, which are legal in Tennessee. One patient had repeated positive UDSs for polysubstance abuse and was terminated from the clinic, preferring to use cannabinoids and other substances illegally. Meperidine, fentanyl, tramadol, and other synthetic opioids are not detected on a routine UDS.
Discussion
Primary care is critical in optimizing the prescribing and use of opioids in older adults. The patient-centered medical home can give health care providers the tools and support to provide evidence—based pain management for their older adult patients and to facilitate prescription and monitoring of appropriate opioid use to minimizing AEs and OUD risk. This includes a reliable health information technology monitoring system as part of a collaborative, person-centered care practice capable of managing frail older patients with multiple chronic conditions as well as social risk factors. GeriPACT was able to implement guideline—based evaluation and treatment of chronic pain patients through optimal management of opioids, risk reduction, and monitoring and management of AEs, misuse, and dose tapering using shared decision-making strategies when appropriate.
Complex older patients on chronic opioid treatment can do well and are best managed by an interdisciplinary team. Our panel had a high prevalence of chronic opioid patients and a high expected mortality based on the severity of comorbidities. Patients had frequent access to care with utilization of many support services. Patients received care for many chronic illnesses at the same time they received opioid therapy and generally were satisfied and adherent to their treatment plan. Published reports of the prevalence of coprescribing of benzodiazepines and opioids of 1.1 to 2.7% in the general population, may be lower than our veteran population.14 Despite the fact that nearly 20% of the population had a history of opioid misuse, only 1 patient was terminated from the clinic because of repeated episodes of polysubstance use disorder.
GeriPACT has the capability to be responsive to the changing needs of older chronic pain patients as a learning health system using continuous process improvement with frequent team meetings and interdisciplinary care.15 Our experience with chronic pain management demonstrates the feasibility and quality of guideline-based management and enhances our understanding of the intersection of care, chronic pain management, and opioid use disorder in older adults.
