Skip to main content
Effective Health Care Program
Home » Products » Opioids Older Adults » Prevention, Diagnosis, and Management of Opioids, Opioid Misuse and Opioid Use Disorder in Older Adults

Prevention, Diagnosis, and Management of Opioids, Opioid Misuse and Opioid Use Disorder in Older Adults

Technical Brief Draft

Open for comment through Jun 12, 2020

These reports are available in PDF only (Draft Technical Brief [2 MB]; Draft Technical Brief Appendixes [1.14 MB]). For additional assistance, please contact us.

Structured Abstract

Background. Opioid-related harms are increasing among older adults. Until we better understand the factors contributing to this trend, we will be unable to design and implement effective interventions to optimally manage opioid use and its potential harms among older adults.

Objectives. To provide a framework for understanding how to reduce adverse outcomes of opioid use among older adults and to describe the evidence available for different factors associated with and interventions to reduce adverse outcomes related to opioid use in this population.

Approach. With input from a diverse panel of content experts and other stakeholders, we developed a conceptual framework and evidence map to characterize empirical studies of factors associated with opioid-related outcomes and interventions to reduce opioid-related harms in older adults. We identified relevant literature among older adults (age ≥60 years) for an evidence map by systematically searching PubMed, PsycINFO, and CINAHL for studies published in English between 2000 and August 30, 2019.

Findings. We identified 5402 citations, from which we identified 35 studies with multivariable models of factors associated with opioid-related adverse outcomes and 14 studies of interventions in older adults. Half (17/35) of the multivariable analysis studies evaluated factors associated with long-term opioid use. Prior or early postoperative opioid use, or greater amounts of prescribed opioids (high number of opioid prescriptions or higher opioid dose), were consistently  (100% agreement) and strongly (measure of association ≥2.0) associated with long-term opioid use. Back pain, depression, tobacco use, fibromyalgia, and concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs) also had consistent, but weaker, associations with long-term opioid use. Low income and benzodiazepine use were mostly associated (>75% agreement) with long-term opioid use. However, studies were mostly consistent that alcohol abuse and healthcare utilization were not associated with long-term opioid use. Gender, age among older adults, black race, and dementia were variably associated (<75% agreement) with long-term opioid use.

Six studies examined factors associated with opioid-related disorders. Alcohol misuse and gender were variably associated with opioid misuse (examined by 3 studies each).

All other evaluations of specific associated factors and outcomes of interest were evaluated by only one or two studies each. These included analyses of opioid use disorder, high-risk obtainment of prescription opioids, procuring multiple opioid prescribers, mental health outcomes, physical health outcomes, all-cause hospitalization, opioid-related hospitalization, nonopioid-specific hospitalization, emergency department visits, opioid overdose, all-cause death, opioid-related death, and nonopioid-related death.

The evidence on interventions directed at older adults is sparse. Of the 14 studies of opioid-related interventions in older adults, six examined screening tools to predict opioid-related harms, but none of these tools was tested in clinical practice to assess real-world results. Two studies found that prescription drug monitoring programs are associated with less opioid use in communities. Other studied interventions include multidisciplinary pain education for patients, an educational pamphlet for patients, provision of patient information and pain management training for clinicians, a bundle of educational modalities for clinicians, a nationally-mandated tamper-resistant opioid formulation, and motivational interview training for nursing students. Each intervention was evaluated by only a single observational study except for one of the clinician education studies which was evaluated by a randomized controlled trial.

Conclusions. The evidence base that is directly applicable to older adults who are prescribed opioids or have opioid-related disorders is limited. Fundamental research is necessary to determine which factors may predict opioid-related harms. Studies to date have identified numerous possible factors associated with long-term opioid use, but analyses of other opioid-related outcomes in older adults are relatively sparse. Research is also needed to identify interventions to reduce opioid prescribing where harms outweigh benefits, reduce opioid-related harms and disorders, and treat existing misuse or opioid use disorder among older adults.

Evidence Summary

Main Points

  • We developed a Conceptual Framework outlining the stages of care for older adults who require or use opioids, and factors that have an impact on management decisions and patient outcomes (see Figure). The framework prioritizes three potential targets to determine factors associated with and interventions for: 1) reducing opioid prescriptions where harms outweigh benefits, 2) preventing opioid misuse and opioid use disorder (OUD), and 3) reducing other opioid-related harms.
  • 35 studies assessed factors independently associated with opioid-related outcomes among older adults (≥60 years).
    • While the 35 studies reported multivariable analyses, none of the analyzed models was designed or evaluated as a screening or prediction tool.
    • 17 multivariable studies evaluated long-term opioid use, which may sometimes be a high-risk behavior, but is not necessarily evidence of problematic opioid use.
      • All 8 studies that looked at prior or early postoperative opioid use found mostly strong associations (e.g., relative risk [RR] >2.0) with long-term opioid use.
      • All 6 studies that examined greater amounts of prescribed opioids (higher number of opioid prescriptions or higher opioid dose) found mostly strong associations with long-term opioid use.
      • Other factors with consistent (100% agreement), but largely weak associations (e.g., RR <2.0, but statistically significant), included back pain, depression, tobacco use, fibromyalgia, and concomitant NSAID use.
      • Studies were mostly consistent (≥75% agreement) that having a low income and benzodiazepine use were each associated with long-term opioid use, but the associations were mostly weak.
      • In contrast, studies were mostly consistent that alcohol abuse and healthcare utilization were not associated with long-term opioid use.
      • Studies had variable findings (<75% agreement) regarding the associations with gender, age (within older adults), black race, and dementia.
    • Across 6 studies evaluating opioid-related disorders, including OUD and opioid misuse, 3 studies each had variable findings regarding the associations of alcohol misuse and of gender with opioid misuse.
    • All other evaluations of specific factors and outcomes of interest were evaluated by only one or two studies each. These included factors associated with opioid use disorder, high-risk obtainment of prescription opioids, procuring multiple opioid prescribers, mental health outcomes, physical health outcomes, all-cause hospitalization, opioid-related hospitalization, nonopioid-specific hospitalization, emergency department visits, opioid overdose, all-cause death, opioid-related death, and nonopioid-related death.
  • 14 studies addressed interventions related to opioid use and opioid-related disorders in older adults.
    • Only 1 study was a randomized trial. Each intervention was evaluated by only 1, or rarely, 2 studies.
    • The most-studied interventions were screening tools to predict opioid-related harms but none of these tools has been tested in clinical practice to assess real-world results.
    • 2 studies found that prescription drug monitoring programs have been associated with less opioid use (at the State level).
    • Other studied interventions include included multidisciplinary pain education for patients, an educational pamphlet for patients, provision of patient information and pain management training for clinicians, a bundle of educational modalities for clinicians, clinician education, a nationally-mandated tamper-resistant opioid formulation, and motivational interview training for nursing students. Each intervention was evaluated by only a single observational study except for one of the clinician education studies which was evaluated by a randomized controlled trial.
    • Among studies that had the goal of reducing overall opioid prescriptions or use, none specifically assessed “appropriate” reduction of opioid prescriptions or use (e.g., when the risks of opioid use outweigh the benefits).
  • Future research is needed to establish the strongest factors associated with important clinical outcomes related to opioid use in older adults and to identify interventions to improve primary prevention (reducing unnecessary opioid use), secondary prevention (reducing opioid-related harms), and treatment of existing opioid misuse or OUD.

Background and Purpose

Opioid-related hospitalizations, emergency department (ED) visits, and deaths are increasing among older adults even as rates of nonopioid-related hospitalizations and ED visits are decreasing. Older adults make up a growing share of the US population and are at a greater risk of opioid exposure due to higher incidences of pain and comorbidities that result in pain. Older adults are more likely than younger adults to experience adverse drug reactions and opioid misuse is an increasing source of opioid-related harms among older adults. To address these issues, we need a better understanding of the factors driving opioid-related harms in older adults and the evidence-based interventions to reduce those harms.

This Technical Brief provides a conceptual framework that diagrams the process of care to identify areas of risk and opportunities for intervention, and describes the relevant evidence base. The framework and evidence map will support the Agency for Healthcare Research and Quality (AHRQ) and other agencies’ development of an evidence-based research agenda to answer the most important questions regarding prevention, diagnosis, health outcomes, and management of opioid use, misuse, and opioid-related disorders among older adults.

Figure. Conceptual Framework

The figure shows a global conceptual framework. It encompasses all Guiding Questions and places an emphasis on the interest areas that were most amenable to an evidence map. These areas were Guiding Questions 2 and 3, which pertain to as risk factors for opioid-related harms among older adults and interventions to reduce the risk of opioid-related harms. The clinical care pathway events through which an older adults may progress are shown in blue rectangles with rounded corners. These are temporally ordered. The decision-making points that may lead to the events are depicted by arrows, and factors or predictors that may be contributing to many aspects of opioid use and misuse in older adults are shown in green ovals. The large shaded green box encompassing much of the figure indicates the broad influence of the factors on many parts of care management. Patient-, medication-, provider- and other factors are all included and represented in green ovals. Since older adults may initially engage in opioid use through either pain or recreational pathways, both are included and identified as red squares. Purple octagons represent risk factors that modify the relationship between one care pathway event (in blue boxes) and either another event or an outcome. Orange triangles with dashed arrows are used to show where interventions may be particularly appropriate along the care pathway. Finally, the purple rectangles at the bottom of the figure identify health outcomes.

 

Methods

We developed a Conceptual Framework based on existing frameworks and discussion with 15 Federal and nonfederal stakeholders (see Figure). The Conceptual Framework identifies key questions regarding factors potentially associated with opioid-related outcomes (featured in the octagons) and relevant interventions (featured in the triangles). Using the Conceptual Framework as a guide, we conducted a literature search of relevant studies published between January 2000 and August 30, 2019. The review was conducted in accordance with the AHRQ EPC Program Methods Guidance for Technical Briefs.

Results

The Conceptual Framework outlines the stages of care for older adults related to opioid use as well as the factors that impact management decisions and patient outcomes. These include assessment of pain, selection of pain treatment, choice of opioid regimen, assessment for opioid misuse or opioid use disorder (OUD), and management of misuse or OUD (featured in Rectangles B to F). Multiple potential patient, provider, health system, and societal factors (in the 8 ovals) may influence risks of adverse outcomes and the effect of interventions to reduce the adverse outcomes (Box O). The framework includes factors associated with interventions to 1) reduce opioid prescriptions where harms outweigh benefits 2) prevent opioid misuse and OUD and 3) reduce other opioid-related harms.

Regarding factors related to opioid use and harms in older adults (≥60 years), we focused on the 35 studies that reported multivariable analyses, to best identify independent factors associated with the outcomes of interest. Seventeen of these studies addressed long-term opioid use (categorized into Octagon R1). Eight studies that addressed opioid misuse or OUD (related to Octagon R2) examined two sets of outcomes: opioid misuse (6 studies) and having multiple opioid prescribers (2 studies). The 13 studies that addressed opioid-related harms (Octagon R3) had four sets of outcomes: mental or physical harms (4 studies), hospitalizations or ED visits (4 studies), opioid overdose (3 studies), and death (5 studies).

Seventeen multivariable models evaluated a large range of factors potentially associated with long-term opioid use among older adults. Eight studies that examined opioid use prior to surgery or injury (or early use after surgery) and 6 studies that examined greater amount of opioid use (more prescriptions or higher dose) were consistent (in full agreement) that these factors are associated with long-term opioid use, with mostly strong associations (e.g., RR ≥2.0).Other consistent associations, but with largely weak associations (RR <2.0, but statistically significant), were found with back pain (4 studies, 2 with strong associations), depression (10 studies, all weak associations), tobacco use (4 studies, 1 with a strong association), fibromyalgia (3 studies, all weak associations), and concomitant NSAID use (3 studies, all weak associations).

Studies were mostly consistent (≥75% agreement) that low income (5 of 6 studies) and benzodiazepine use (4 of 5 studies) were associated with long-term opioid use, but these associations were mostly weak. Studies were also mostly consistent that alcohol abuse (4 of 5 studies) and healthcare utilization (3 of 4 studies) were not associated with long-term opioid use; however, one of these studies found a strong association between “any hospitalization” and long-term use.

Factors with variable findings (<75% agreement) of association (evaluated by at least 3 studies) included gender (6 of 14 studies found weak associations with female gender; 2 found associations with male gender, one strong), “substance abuse” (8 of 12 studies found mostly weak associations), age among older adults (6 of 10 studies found mostly weak associations with younger age among older adults; 1 found a weak association with older age), black race (3 each, among 8 studies, found weak associations with increased and with decreased likelihood), and dementia (2 each, among 5 studies found associations with increased and with decreased likelihood).

Only 14 studies addressed interventions to appropriately reduce opioid prescriptions, reduce opioid-related harms, or identify or treat opioid-related disorders and only one was a randomized controlled trial. Seven studies evaluated interventions to reduce opioid prescribing (depicted in Triangle I1); although none specifically focused on or attempted to account for whether harms outweighed benefits. One of these interventions was also designed to prevent opioid misuse or OUD (Triangle I2) by minimizing activities that may lead to opioid misuse. Six additional studies evaluated screening tools to identify people at increased risk of opioid-related disorders (also Triangle I2). One study addressed an intervention to manage (and thus reduce) opioid misuse in older adults (Rectangle F and Triangle I3 in the Framework). No study specifically addressed reducing harms among older adults appropriately using opioids (Rectangle D). The studies provide some evidence that various screening tools and interventions may be effective to reduce opioid use, reduce the risk of opioid misuse, and manage opioid misuse among older adults. Two studies found that prescription drug monitoring programs were associated with less opioid use (at the State level), but, overall, there has been little replication of evaluations of interventions and none of the screening tools have been tested in routine clinical practice to assess the real-world results of their use.

Limitations

Our literature search does not include studies published prior to 2000 and did not include all potentially relevant literature databases. In accordance with guidance for AHRQ Technical Briefs, we did not fully assess each eligible study, including detailed assessments that would be required for evaluation of methodological quality, generalizability, and strength and conclusions of the evidence base.

Conclusions

The evidence base that is directly applicable to older adults who are prescribed or use opioids or who have opioid-related disorders is relatively sparse. Fundamental research is necessary to determine which factors may predict opioid-related harms. Studies to date suggest that the amount of prescribed opioids (or dose), prior or early use of opioids, musculoskeletal pain, and history of abuse of other substances are potentially important factors. Research is also needed to identify interventions to reduce opioid prescribing where harms outweigh benefits, reduce opioid-related harms and disorders, and treat existing misuse or OUD among older adults. Future research should emphasize the adaptation of existing interventions for use in older adults, but the development, validation, and evaluation of new interventions tailored to the needs of older adults will likely also be necessary to manage opioid misuse and OUD in older adults.