At Any Age, It Does Matter:
Substance Abuse and Older Adults (for Professionals)

Supplements

Opiate/Opioid Analgesics

An estimated 2 to 3 percent of noninstitutionalized older adults receive prescriptions for opioid analgesics.1 Opioids are undeniably effective for managing severe pain such as that occurring after surgery and serious trauma. It also is used to treat pain that occurs with some medical illnesses (e.g., gout, inflammatory bowel disease). This acute pain is usually short-lived and resolves within days to weeks at most.

Opioid analgesics are also used to treat cancer-related pain. This pain is experienced by nearly all patients with advanced disease and by one-third to one-half of patients in earlier stages. The use of opioid medications for these purposes is widely accepted in medical practice.2

Commonly Prescribed Opiate/Opioid Analgesics

Class Drug Brand Name Comments*
Opiates Methylmorphine Morphine Common ingredient of analgesics.
Codeine e.g., Tylenol III, Robitussin A-C Common ingredient of analgesics and antitussives. Can cause sedation and mild, dose-related impairment of psychomotor coordination.
Opioids (synthetic) Hydrocodone Lortab Can produce dose-related respiratory depression and irregular breathing if taken in large amounts.
Meperidine Demerol Contraindicated if patient is taking MAO inhibitors. Can produce psychomimetic effects and impair vision, attention, and motor coordination.
Oxycodone Percodan, Percocet, OxyContin Can produce substantial impairment of vision, attention, and motor coordination.
Propoxyphene Darvon Can produce sedation and mild, dose-related impairment of psychomotor coordination.
Pentazocine Talwin Age does not appear to increase sedative effects.

*Refer to product information insert for each drug as to its suitability for use in older adults.

Problems in Older Persons

In addition to the rapid development of tolerance and physiological dependence, other problems are associated with opioid prescriptions for older patients. Opioid dose requirements decrease with age. The onset of action is slowed by the decreased rate of gastrointestinal absorption of orally ingested narcotics. In addition, the duration of action is longer because of older patients’ decreased metabolism and liver functioning.

Older adults also have more adverse side effects because of changes in receptor sensitivity with age. The less potent opioids, codeine and propoxyphene (Darvon), cause sedation and mild, dose-related impairment of psychomotor performance.

The more potent opioids, oxycodone (Percodan and OxyContin) and intramuscular meperidine (Demerol), induce substantial impairment of vision, attention, and motor coordination. No apparent relation between age and sedation is observed in patients treated with morphine and pentazocine (Talwin).1,3

Long-Term Use

The prescribing of opioid analgesics for chronic nonmalignant pain is a controversial issue. Long-term treatment of chronic pain with opiates or opioids has not traditionally been accepted by either patients or physicians. However, a growing body of evidence suggests that prolonged opioid therapy may be both effective and feasible.

Convincing and persuasive testimony has been given by a number of clinicians and medical associations regarding the successful management of lengthy opioid treatment in patients with chronic nonmalignant pain.2 These advocates note that both acute and chronic pain in the United States is usually more undermedicated than overmedicated for a variety of patient- and provider-related reasons. One major reason is fear of addiction. In addition, patients may believe that stoicism is virtuous, that pain is an inevitable and intractable part of the illness or disease.

Some patients may think that prescribed medications are too costly, too complex to manage, or likely to have numerous and undesirable side effects. Clinicians also may underprescribe because of fear of sanctions.2

The disagreements among clinicians regarding management of long-term opioid therapy reflect different perspectives regarding the dangers and persistence of psychological dependence following physical addiction. They also reflect different opinions on the potential for psychosocial disintegration into an addictive, drug-abusing lifestyle. Many researchers point out that clinical populations can be successfully withdrawn from opiates and opioids without dire consequences.

One study found that only 4 of nearly 12,000 patients who were prescribed morphine for self-administration became addicted.4 Other practitioners argue that patients’ quality of life improves (e.g., less medical care utilization) if they are kept on opioids and manage pain without addiction.5,6 However, opioid analgesics are usually contraindicated if the patient has a history of alcoholism or another substance abuse or dependence disorder.

Withdrawal

Opioid withdrawal is accompanied by:

Although opioid withdrawal is uncomfortable, it is not life threatening or particularly dangerous compared with untreated withdrawal from benzodiazepines.

References

  1. Ray, W.A.; Thapa, P.B.; and Shorr, R.I. Medications and the older driver. Clinics in Geriatric Medicine 1993, 9(2):413-438.
  2. Portenoy, R.K. Therapeutic use of opioids: Prescribing and control issues. In: Cooper, J.R.; Czechowicz, D.J.; Molinari, S.P.; et al., eds. Impact of Prescription Drug Diversion Control Systems on Medical Practice and Patient Care. NIDA Research Monograph Series, Number 131. NIH Pub. No. 93-3507. Washington, DC: U.S. Government Printing Office, 1993, pp. 35-50.
  3. Solomon, K.; Manepalli, J.; Ireland, G.A.; and Mahon, G.M. Alcoholism and prescription drug abuse in the elderly: St. Louis University grand rounds. Journal of the American Geriatric Society 1993, 41(1):57-69.
  4. Chapman, C.R., and Hill, C.F. Prolonged morphine self-administration and addiction liability. Cancer 1989, 63:1636-1644.
  5. Finlayson, R.E.; Maruta, T.; Morse, R.M.; and Martin, M.A. Substance dependence and chronic pain: Experience with treatment and follow-up results. Pain 1986, 26(2):175-180.
  6. Finlayson, R.E.; Maruta, T.; Morse, R.M.; Swenson, W.M.; and Martin, M.A. Substance dependence and chronic pain: Profile of 50 patients treated in an alcohol and drug dependence unit. Pain 1986, 26(2):167-174.
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