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.