#ChoosePT: The Opioid Epidemic and Older Adults

By Jimmy McKay, PT, DPT

Director of Communications

Opioids are meant to relieve pain. Some are available legally by prescription, like oxycodone (OxyContin), hydrocodone (Vicodin), codeine and morphine. Other illegal variations include heroin and fentanyl.

When taken for a short duration i.e acute pain, they are generally safe. Since they also produce a euphoric effect and are addictive, people who are taking them for a longer duration, inappropriately, or unnecessarily may become addicted. This is what you see in the local and national news coverage.

While much of the media focus remains with younger generations, it’s actually older adults who have seen a dramatic rise in the use of opioids. While opioid abuse declined in younger groups between 2002 and 2014, use nearly doubled for adults over the age of 50 according to the Substance Abuse and Mental Health Services Administration. Older adults are more likely to become addicted to opioids than younger Americans for two primary reasons. First, their bodies are less efficient at metabolizing these drugs. Second, their pain tends to be chronic so they remain on these drugs for longer periods of time.

How much of this use is medically necessary? A study in 2009 by Rosenbaum showed that while opioid use can be effective for short-term moderate to severe and chronic cancer pain, “their long-term use for chronic non-malignant pain remains controversial.” Another study published through the National Institutes of Health added that there is concern that the pendulum has swung from “undertreatment to overtreatment.”

Are we over-treating our older adults with opioid pain medication unnecessarily rather than using proven, non-pharmacological and non-invasive methods such as physical therapy and occupational therapy? Could a reliance on a pill rather than a preference for therapies that promote movement be the explanation of the dramatic rise in opioid use by our older adults?

STIGMAS UNDERMINE STRENGTHENING

There is a stigma in society that older adults after “a certain age” should be more careful about preventing injury. This stigma takes many forms but you may hear it take form as, “Sit down and be careful.”

This view brings with it a belief that older adults should move as little as possible to prevent such occurrences when the opposite is true. We know that things like sarcopenia, or the loss of up to 50 percent of muscle mass by adults over the age of 50 can leave adults at risk for devastating falls. Loss of strength, increase in body fat, loss of bone density, loss of balance, loss of cardio endurance, loss in range of motion are all risk factors as age increases and movement decreases.

For older adults over the age of 50, four out of five suffer from at least one chronic condition. When coupled with the mentality that exercise is something they should shy away from instead of something that should be embraced and increased, that one chronic condition can multiply.

Could this stigma be a reason that many older adults are receiving treatment in the form of opioids instead of evidence-based exercise?

FROM THE EXPERTS: WHEN PHYSICAL THERAPY MAKES MORE SENSE THAN PRESCRIPTION PAINKILLERS

The following points form the American Physical Therapy Association’s guidelines for when physicians should prescribe physical therapy rather than opioids:

• Side effects of exercise are few and far between when dosed properly. Compare that to the side effects of opioids: depression, overdose, withdrawal symptoms after use and addiction.

Essentially, think, “Is the juice worth the squeeze?”

• What’s the goal?

If the goal of using opioids is a return to function versus masking the pain, then physical therapy is the better option. Physical therapists can use interventions that involve movement to reduce pain while improving function. There is high-quality evidence supporting exercise as the intervention of choice for relieving pain in some of the most common conditions treated by physical therapists. Think low back pain, knee osteoarthritis, and fibromyalgia.

• Go low with opioids when they are a fit.

The Centers for Disease Control and Prevention’s recommendations include keeping the dose as low as possible when opioids are prescribed and combining it with non-pharmacological agents such as physical therapy.

• How long is too long?

Opioids can be effective in acute bouts of pain. Less than 90 days is generally considered acute by the CDC. If pain persists longer than this, CDC says to switch from low-dose opioids to non-opioid therapies as the preferred intervention, citing the “risks to the patient” as outweighing the benefits.

• Where to start after the pills?

It’s overwhelmingly more important for older adults to exercise with intensity. Without the guidance on what exercise to do, precisely how to do that exercise, and at what frequency to do it from a physical or occupational therapist, older adults could be increasing their risk of death far sooner than necessary.

EXERCISE IN OLDER ADULTS IS A FIGHT FOR LIFE ITSELF.

“If exercise could be packed into a pill, it would be the single most widely prescribed and beneficial medicine in the nation.” That was Dr. Robert Butler in 1980, who was the founding director of the National Institute on Aging. Decades later research has backed him up, time and time again.

So why do we look at the people most susceptible to loss of function and take away the very thing that could help them combat their decline in function?

Current views of pain and how it should be treated need to change across the healthcare spectrum as well as with the public. It is the responsibility of those who know the current evidence to share that with those populations who are at risk.