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. Author manuscript; available in PMC: 2023 May 5.
Published in final edited form as: J Addict Nurs. 2022 Oct-Dec;33(4):218–232. doi: 10.1097/JAN.0000000000000488

Prescription Opioid Misuse in Older Adult Surgical Patients: Epidemiology, Prevention, and Clinical Implications

Chin Hwa Dahlem 1, Ty S Schepis 1,2, Sean Esteban McCabe 1,3,4,5, Aaron L Rank 6,7, Christian J Teter 1,8,9, Luisa Kcomt 1, Vita V McCabe 1,10,11, Terri Voepel-Lewis 1,12
PMCID: PMC10162467  NIHMSID: NIHMS1839598  PMID: 37140410

Abstract

The United States and many other developed nations are in the midst of an opioid crisis, with consequent pressure on prescribers to limit opioid prescribing and reduce prescription opioid misuse. This review addresses prescription opioid misuse for older adult surgical populations. We outline the epidemiology and risk factors for persistent opioid use and misuse in older adults undergoing surgery. We also address screening tools and prescription opioid misuse prevention among vulnerable older adult surgical patients (e.g., older adults with a history of an opioid use disorder), followed by clinical management and patient education recommendations. A significant plurality of older adults engaged in prescription opioid misuse obtain opioid medication for misuse from health providers. Thus, nurses can play a critical role in identifying those older adults at higher risk for misuse and deliver quality care while balancing the need for adequate pain management agains the risk for prescription opioid misuse.

Keywords: Older Adult, Analgesic Drugs, Prescription Opioid Misuse, Risk Factors, Screening, Prevention, Epidemiology, Surgical Populations

OVERVIEW

Opioid misuse in the United States (US) has been characterized by policymakers, researchers, and clinicians as an epidemic (Gottlieb & Woodcock, 2017; McCarthy, 2017). From 1999–2018, nearly 450,000 people have died from prescription and illicit opioid overdoses (Wide-ranging online data for epidemiologic research [WONDER], 2020). Despite recent decreases in opioid prescribing (Bohnert et al., 2018), one third of opioid overdose deaths in 2017 involved prescription opioids (Scholl et al., 2018). In fact, commentators have linked increases in opioid-related deaths to opioid overprescribing and prescription opioid misuse (Clark & Schumacher, 2017; Kanouse & Compton, 2015; Makary et al., 2017). Prescription opioid misuse is typically defined as use without a prescription or use of one’s own medication in ways not intended by the prescribing provider including taking more medication than instructed, or more frequently, for longer duration than prescribed (Schepis et al., 2019a).

PRESCRIPTION OPIOID USE

Older adults may be vulnerable to prescription opioid misuse given high prevalence rates of cancer (Bell et al., 2015; Kim & Park, 2018; Takano, 2017) and chronic pain (Fayaz et al., 2016; Maree et al., 2016; Meucci et al., 2015). Adults ≥ 65 years comprised 31% of all ambulatory surgical patients in 2010, trailing only the 45 to 64 age group (39%) (Hall et al., 2017). This age group is prescribed opioid analgesics at rates that are often highest among different age groups (Campbell et al., 2010; Paulozzi et al., 2015; Sites et al., 2014; Volkow et al., 2011). Indeed, a recent national study examining prescription fill rates from 2008–2018 revealed fill rates to be highest among older adults (≥ 65 years) compared to other age groups (Schieber et al., 2020). These high opioid prescription fill rates are concerning since this age group is also highly vulnerable to opioid-related adverse events, including motor vehicle accidents, cognitive impairment, accidental overdose, and respiratory depression (Dagenais-Beaule et al., 2019; Dublin et al., 2015; Kalapatapu & Sullivan, 2010; Maree et al., 2016; Monarrez-Espino et al., 2016; West & Dart, 2016).

Trends and Prevalence

Despite a relative dearth of research examining prescription opioid misuse among older adults (Maree et al., 2016), some studies suggest an increase in misuse from the early 2000s (Schepis & McCabe, 2016) through 2012 (West et al., 2015). Research using US nationally representative survey data found that both past-year and past-month prescription opioid misuse increased in older adults from 2002–03 to 2012–13 (Schepis & McCabe, 2016). Similarly, US Poison Control Center data indicated that opioid misuse (defined as inappropriate use for therapeutic reasons) and abuse (defined as inappropriate use for non-therapeutic reasons, such as euphoria) peaked in adults aged ≥ 60 years in early 2012 and 2013 (West et al., 2015). These trends in elder opioid misuse coincided with peak prescribing rates in the US (Jeffery et al., 2018; West & Dart, 2016).

Risk Factors for Prescription Opioid Misuse and Persistent Use

Most of what is known about misuse risk factors in older adults is derived from samples of adults aged ≥ 50 years. Notably, these risk factors appear to be consistent across age groups, with robust associations between prescription opioid misuse, psychologic comorbidity, and other substance use behaviors (Choi et al., 2017; Cochran et al., 2017; Mowbray & Quinn, 2015; Schepis et al., 2018a). Data from nationally representative surveys suggest that recent major depression, anxiety disorder, alcohol use, illicit drug use, and earlier initiation of alcohol use are associated with prescription opioid misuse in adults aged ≥ 50 years (Cochran et al., 2017; Mowbray & Quinn, 2015). More specifically, higher rates of past-year marijuana use (Choi et al., 2017) and prescription benzodiazepine or sedative-hypnotic misuse (Schepis et al., 2018a) have been associated with prescription opioid misuse. Perhaps most concerning are findings that past-year prescription opioid misuse was associated with an increased likelihood of past-year suicidal ideation, with the highest rates among those with both past-year opioid and benzodiazepine misuse (Schepis et al., 2019a).

Data on persistent prescription opioid use—often a precursor to misuse and opioid use disorder (Ling et al., 2011)—sheds additional light on potential risk factors. This work suggests: that females; those with a history of major depression or who currently use antidepressant medication; those who use a nonsteroidal anti-inflammatory drug (NSAID) medication; those who use prescription benzodiazepines; and those with a greater number of opioid prescriptions filled in the past-year and/or the three months post-hospitalization were at greater risk of persistent use (Daoust et al., 2018; Silva Almodovar & Nahata, 2019). Understanding risk factors of persistent opioid use is important as medical and pharmacy claims data indicate that more than 50% of adults who received opioid medication for greater than three months remained on opioids for years (Martin et al., 2011). Furthermore, the risk of developing opioid use disorder increases once patients take prescribed opioid medication greater than 90 days (National Academies of Sciences, Engineering, and Medicine, 2017).

In the perioperative environment, preoperative pain has been independently associated with preoperative opioid use in a large, cross-sectional study of adults (mean age of 53 years) presenting for a variety of major or minor surgeries (Hilliard et al., 2018). This study also found significant associations between prescribed preoperative opioid use and prescription opioid misuse and/or illicit drug use. Preoperative opioid use not only affects perioperative management and outcomes but also predicts persistent use and poorer surgical outcomes.

Additionally, in a large sample of older adults undergoing low-risk surgeries (e.g., cataract surgery, laparoscopic cholecystectomy, transurethral resection of the prostate, or varicose vein stripping), those prescribed opioids after surgery were 44% more likely to continue using opioids one-year postoperatively (Alam et al., 2012). Another study demonstrated that postoperative patients ≥ 50 years of age are most likely to engage in long-term use compared to younger cohorts (Sun et al., 2016). These data suggest that older adults, in particular, may be at risk for misuse. In addition to persistent use, preoperative opioid use and opioid use disorder have been associated with higher perioperative risks (e.g., acute respiratory failure, infection), longer length of hospital stays, and hospital readmissions (Cron et al., 2017; Gupta et al., 2018; Waljee et al., 2017).

Sources of Medication and Motives for Prescription Opioid Misuse

Physicians serve as the most common source of prescription opioids that are misused in older adults (Cochran et al., 2017; Schepis et al., 2018b). Nearly half (47.7%) of those aged ≥ 65 reported a physician source for prescription opioid misuse, which was the highest rate among all age cohorts (Schepis et al., 2018b). Additionally, adults ≥ 50 had higher rates than other age groups of obtaining opioids from multiple physicians (Mowbray & Quinn, 2015). In contrast, only 5–6% of adults aged ≥ 60 (Gold et al., 2016) and ≥ 65 (Cochran et al., 2017) have revealed multiple physician sources for their opioids. Overall, roughly 15% of adults aged ≥ 60 years obtain prescription opioids in high-risk ways, including use of multiple physicians or use of medication from another individual’s prescriptions (Gold et al., 2016). Thus, understanding the sources of prescription opioids that older adults use is critical to identifying their health risks. The use of such sources indicates higher risk for other substance use and use disorders (McCabe et al., 2018; Schepis et al., 2018b).

Mitigating Prescription Misuse and Persistent Use

Given the risks for persistent use and misuse, the Centers for Disease Control and Prevention (CDC) established opioid prescribing guidelines in order to minimize prolonged exposure to and risky prescription opioid practices. Other professional organizations including the American Society of Anesthesiologists, and American Society for Regional Anesthesia and Pain Medicine have similarly established pain management guidelines to ensure adequate pain management while mitigating the risk for opioid misuse. Each of these guidelines recommend that clinicians conduct comprehensive screenings for factors that place patients at risk for misuse. Such screenings include history of physical dependence or tolerance to opioids, prior or current opioid use disorder, and risk factors for prescription opioid misuse (American Society of Anesthesiologists Task Force on Acute Pain Management, 2012; Chou et al., 2016).

Preoperative Screening Tools for Opioid Misuse

Routine preoperative screening in older adults includes attention to factors that are known to heighten the risk for opioid use disorder and prescription opioid misuse. Many of the factors that predispose individuals to persisting opioid use and the transition to prescription opioid misuse have been collected in a set of screening tools to aid clinical decision making. Most tools are recommended for broad use in adults, although none, so far, are specific to older adult patients undergoing surgery. To date, one study has examined the Prescription Drug Use Questionnaire (PDUQ) on its ability to recognize prescription opioid misuse and opioid use disorder in adults aged ≥ 50 years with chronic pain (Beaudoin et al., 2016). This tool contains 31 items and takes approximately 20 minutes to complete, making its use more relevant to screening in a pain clinic setting than as a brief screening tool for surgical patients. Most of the general and opioid misuse-specific screening instruments available have been validated in populations of chronic pain patients on long-term opioid therapy, and the samples often include older adults (see Table 1). However, no studies have evaluated whether use of these screening tools reduce prescription opioid misuse, opioid use disorder, or opioid-related overdose (National Institutes of Health, 2014).

Table 1.

Screening Tools for Prescription Opioid Misuse

Name & Reference Description Setting/Population Benefits and Limitations Resources
Screening Tools for Prescription Opioid Misuse
SOAPP-R1 24-item self-report survey based on a 0–4 Likert scale that detects opioid misuse and predicts future aberrant medication-related behavior. Chronic pain patients on long-term opioids from pain clinics (n = 428) with mean age 51.4 (SD = 13.0) years. Cross-validated. Pros:

  • Scoring (18 or higher) identifies 80% of those who are at high-risk for prescription opioid misuse.

Cons:

  • Not a general screening tool.

  • Use only for chronic pain patients starting, with changes in, or restarting long-term opioid therapy.

 Permission to use: PainEDU@inflexxion.com
SOAPP-82 Briefer version of SOAAP-R, reduced from 24 to 8 items self-report. Chronic pain patients on long-term opioids from pain clinics (n = 127) with mean age 48.9 (SD = 8.4) years. Pros:

  • Brief.

  • Sensitivity of 0.46 and specificity of 0.90 were comparable with the full SOAPP-R.

Cons:

  • Scoring requires a computer algorithm and completed electronically.

  • Purchase through Inflexxion.

 To download and register to use:
https://www.painedu.org/opioid-risk-management-2/
Different formats and packages available: PainCAS Free, PainCas Premium, PainCAS Enterprise.
Opioid Risk Tool (ORT)3 6-item self-report survey to identify patients at high-risk for opioid misuse. Initial assessment. Chronic pain patients from pain clinic (n = 185). Mean age was grouped into 3 risk categories with mean age range of 41–50.9 years (SD = 9.2–14.9), range from 17–82. Pros:

  • Brief.

  • Complete and scored in less than five minutes.

  • Score of greater than eight considered high-risk of opioid abuse.

  • Distinguishes risk between high and low risk patients and between genders.

  • Should not be used as a tool to deny opioid therapy.

Cons:

  • Not validated in non-pain settings and older adults.

 More information and permission to use: http://www.lynnwebstermd.com/opioid-risk-tool/
Brief Risk Questionnaire4 12-item self-report to predict medication-aberrant related behavior Chronic pain patients (n = 257) 23%; (n = 59) of sample were 65 years or older. Pros:

  • Higher sensitivity than ORT and SOAPP, but lower specificity in terms of predicting who will not engage in drug related aberrant behavior.

Cons:

  • Time to complete not reported.

  • Not validated in non-pain settings.

 Permission to use and to download: http://tedjonesresearch.com/
Diagnosis, Intractability, Risk, Efficacy Tool (DIRE)5 7-item clinician-rated tool (each factor scored from 1–3) to predict efficacy of analgesia and monitor adherence to therapy. Chronic pain patients in primary care with mean age of 43.9 (SD = 10.7) years. Pros:

  • Score of less than 13 suggests patient is not suitable for long-term opioid therapy

  • Mean time to complete 102 seconds

Cons:

  • Clinician-administered.

  • Tested only in primary care.

  • Retrospective (based on case vignettes of patients with chronic pain).

 Permission to use: mbelgra1@fairview.org
Risk Screen for Patients Ongoing Opioid Therapy
Current Opioid Misuse Measure (COMM)6 17-item self-report measure to identify and monitor aberrant medication-related behaviors. Chronic pain patients on long-term opioids from pain clinics (n = 227) with mean age of 50.8 (SD = 12.4, range 21–89) years Pros:

  • Cutoff score of 9 yielded sensitivity of 0.77 and specificity of 0.68.

  • Less than 10 minutes to complete.

  • Helps clinicians to monitor adherence to treatment and opioid misuse for patients on long-term opioids.

Cons:

  • Over-identifies misuse.

  • Length is likely to limit utility as a universal screening tool.

 Permission to use: painEDU@inflexxion.com
Current Opioid Misuse Measure-9 (COMM-9)7 9-item self-report measure to identify and monitor aberrant medication-related behaviors. Briefer version of COMM. Chronic pain patients on long-term opioids from pain clinics. Pros:

  • Brief.

  • Specificity of 0.89 and sensitivity of 0.47.

Cons:

  • Scoring requires a computer algorithm.

  • Purchase through Inflexxion.

 To download and register to use: https://www.painedu.org/opioid-risk-management-2/
Different formats and packages available: PainCAS Free, PainCas Premium, PainCAS Enterprise.
Prescription Drug Use Questionnaire (PDUQ)8 31-item questionnaire to recognize substance use disorder. Chronic pain patients (n = 104) with mean age of 53 (range 25–65) years. Pros:

  • Comprehensive.

  • Tested in older adults.

  • Cutoff score of 10 or greater yields sensitivity of 0.67 and specificity of 0.60.

Cons:

  • Long – 20 minutes to complete.

 Instrument included in the Appendix of Compton et al.
General Screen for Drug Use
Single Question Screener9 Single-question screening test for drug use and drug use disorders. Primary care patients (n = 286) mean age 49 (SD = 12.3, range 21–86) years. Pros:

  • No scoring.

  • Sensitivity of 1.0 and specificity of 0.71.

Cons:

  • Does not assess measure of severity.

  • No diagnostics.

  • Will require additional screening to measure severity or as a diagnostic tool.

 Question: “How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons? -non-medical reasons – for instance because of the experience or feeling it caused?”
Drug Abuse Screening Test (DAST-10)10 10-item self- report to detect drug abuse or dependence disorders. Variety of populations: adolescents to adults from inpatient and outpatient settings, psychiatric patients, opioid users, female offenders. Pros:

  • 2 minutes to complete.

  • Provides severity of drug use.

  • Diagnostic with DSM-5 diagnosis of psychoactive drug dependence.

  • Cutoff scores of 0.5 to 0.75 yielded sensitivity between 0.41 and 0.95 and specificity between 0.68 and 0.99.

Cons:

  • Not specific for older adults.

 Copyright 1982 by Harvey A. Skinner. Permission to use: hskinner@yorku.ca
NMASSIST11 8-item self-report survey adapted from WHO’s Alcohol, Smoking and Substance Involvement Screening Test to detect psychoactive substance use and related problems. Primary care patients with mean age of 30.4 years. Pros:

  • Comprehensive assessment for broad range of substances, including opioids.

  • Valid for cross-cultural use.

  • Web-based interface available developed by NIDA.

  • Used with NIDA Quick Screen (1-item).

  • Risk stratification: low-risk or abstinent pattern of use, potential or actual risky pattern of use, dependent or at-risk of dependence.

Cons:

  • Clinician-administered.

  • Not tested on older adults.

 Download PDF information: https://www.drugabuse.gov/publications/resource-guide-screening-drug-use-in-general-medical-settings/nida-quick-screen
Accessible online and Permission to Use: https://www.drugabuse.gov/nmassist/
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Notes:

Abbreviations: SOAPP-R = Screener and Opioid Assessment for Patients with Pain-Revised; SOAPP-8 = Screener and Opioid Assessment for Patients with Pain-8; SD = standard deviation; COMM = Current Opioid Misuse Measure; COMM-9 = Current Opioid Misuse Measure-brief version; DAST-10 = Drug Abuse Screening Test; DSM-5 = Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition; NMASSIST = NIDA Modified Alcohol, Smoking and Substance Involvement Screening Test; WHO = World Health Organization; NIDA = National Institute on Drug Abuse

1

Butler, S. F., Fernandez, K., Benoit, C., Budman, S. H., & Jamison, R. N. (2008). Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). The Journal of Pain, 9(4), 360–372. doi: 10.1016/j.jpain.2007.11.014

2

Black, R. A., McCaffrey, S. A., Villapiano, A. J., Jamison, R. N., & Butler, S. F. (2018). Development and validation of an eight-item brief form of the SOAPP-R (SOAPP-8). Pain Medicine, 19(10), 1982–1987. doi: 10.1093/pm/pnx194. PMID: 29024987

3

Webster, L. R., & Webster, R. M. (2005). Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the Opioid Risk Tool. Pain Medicine, 6(6), 432–42. doi: 10.1111/j.1526-4637.2005.00072.x

4

Jones, T., Lookatch, S., & Moore, T. (2015). Validation of a new risk assessment tool: The Brief Risk Questionnaire. Journal of Opioid Management, 11(2), 171–83. doi: 10.5055/jom.2015.0266

5

Belgrade, M. J., Schamber, C. D., & Lindgren BR. (2016). The DIRE score: Predicting outcomes of opioid prescribing for chronic pain. The Journal of Pain, 7(9), 671–681. doi:10.1016/j.jpain.2006.03.001

6

Butler, S. F., Budman, S. H., Fernandez, K. C., Houle, B., Benoit, C., Katz, N., & Jamison, R. N. (2007). Development and validation of the Current Opioid Misuse Measure. Pain, 130 (1–2), 144–156. doi:10.1016/j.pain.2007.01.014

7

McCaffrey, S. A., Black, R. A., Villapiano, A. J., Jamison, R. N., & Butler, S. F. (2019). Development of a brief version of the Current Opioid Misuse Measure (COMM): The COMM-9. Pain Medicine, 20(1), 113–118. doi:10.1093/pm/pnx311

8

Compton, P. A., Wu, S. M., Schieffer, B., Pham, Q., & Naliboff, B. D. (2008). Introduction of a self-report version of the Prescription Drug Use Questionnaire and relationship to medication agreement noncompliance. Journal of Pain and Symptom Management, 36(4), 383–395. doi:10.1016/j.jpainsymman.2007.11.006

9

Smith, P. C., Schmidt, S. M., Allensworth-Davies, D., & Saitz, R. (2010). A single-question screening test for drug use in primary care. Archives of Internal Medicine, 170(13), 1155–1160. doi:10.1001/archinternmed.2010.140

10

Skinner, H. A. (1982). The drug abuse screening test. Addictive Behaviors, 7(4), 363–371. doi:10.1016/0306-4603(82)90005-3

A screening tool that detects prescription opioid misuse at two to four weeks post-surgery may be more useful for nurses. Unfortunately, the available screening tools predict prescription opioid misuse at five to six months and have not been validated to predict earlier signs of prescription opioid misuse.

A general screening tool available for clinicians is the National Institute of Drug Abuse (NIDA) Quick Screen that was adapted from the single question screener and explicitly asks for specific substance use and prescription opioid misuse. Similar to the single question screener, the NIDA–Modified Alcohol, Smoking, and Substance Involvement Screening Test (NM ASSIST) will need to be utilized for those with substance use on the Quick Screen tool. The NM ASSIST provides a comprehensive assessment for a wide range of substances, including opioids, is validated for cross-cultural populations, and has a web-based interface assessment to help guide clinicians (National Institute on Drug Abuse, 2015). This web-based interface could be added to an existing electronic health record system and be completed by patients prior to their surgeries; thus, improving the efficiency of clinic flow. As noted above, the screening tools for general substance use have often been tested in samples that include older adults, but none have been validated in a solely older adult sample.

Preoperative Opioid Weaning (for Enhanced Recovery after Surgery or Optimization)

Surgeons may consider delaying surgery for several months in order to optimize the patient’s fitness for surgery, and this optimization should include weaning of opioid doses and attention to other substance use (McAnally, 2017). Patients who have been taking opioids frequently or continuously for several weeks either pre- or postoperatively should be weaned carefully. A randomized controlled trial of preoperative opioid reduction among older adults undergoing total knee or total hip arthroplasty found that those who reduced their preoperative opioid doses by at least 50% had significantly better postoperative pain and functional measure scores, as compared to those with opioid use disorder (Nguyen et al., 2016). A large review of older patients undergoing posterior lumbar fusion, total knee arthroplasty, or total hip arthroplasty demonstrated that those with chronic opioid use who were able to wean and stop their opioid use for three months prior to surgery had a significant reduction in postoperative complications (e.g., emergency department visits, infection, hospital readmission) (Jain et al., 2019), though tapering of buprenorphine may not be indicated, especially in older adults receiving buprenorphine for opioid use disorder.

Postoperative Opioid Management

Early postoperative opioid use remains a risk factor for persistent use (and, thus, prescription opioid misuse) making this a modifiable factor to mitigate risk. Therefore, to prevent persistent opioid use and prescription opioid misuse, it is important to minimize overall opioid consumption and continuation. Prescribing less opioid volume is one strategy, but pain must be well-managed to avoid pain persistence or worsening and associated risks of activity avoidance and subsequent functional disability (Linton et al., 2018). A stepped approach to managing pain may minimize opioid consumption, wherein non- or low-risk treatments are initiated and others are progressively added if treatment or functional goals are unmet (Griffiths et al., 2014; National Academies of Sciences, Engineering, and Medicine, 2017). Given the potential for limited follow-up contact with specialists, coordination of care with the primary care physician or pain management specialist is important.

Multimodal treatment approaches should be used and individualized based on comorbid conditions, heightened risk factors, surgery type, and preoperative analgesic use (Cao et al., 2017). The use of multimodal analgesia, nerve blocks, non-opioid medication, and non-pharmacologic techniques has been shown to reduce morbidity and mortality in older patients undergoing orthopedic surgeries (McCartney & Nelligan, 2014; Nordquist & Halaszynski, 2014). For a list of non-opioid pharmacotherapy for the treatment of pain among older adults, refer to Table 2.

Table 2.

Non-Opioid Pharmacotherapy (Used as Monotherapy or as Part of Multimodal Analgesia) for the Treatment of Pain among Older Adults

Recommendations Pros & Cons
Acetaminophen (APAP) Generally recommended as 1st line treatment for mild to moderate pain; total daily exposure from all medications containing acetominophen must be taken into account; does not reduce inflammation Pros: more efficacious than placebo in reducing pain symptoms; relatively safe when used appropriately; lower risk of gastrointestinal, renal, or cardiovascular adverse events.
Cons: evidence that efficacy may not be as robust as oral NSAIDs for pain; overdose is a leading cause of hepatic toxicity and careful attention to dosing is essential; risk factors for hepatotoxicity include alcohol misuse and pre-existing hepatic insufficiency.
Gabapentinoid anticonvulsants (pregabalin and gabapentin) Recommended for neuropathic pain, in particular; pregabalin is a controlled substance (C-IV); gabapentin dose adjusted based upon renal function Pros: more efficacious than placebo.
Cons: potential for increased adverse effects (e.g., sedation, dizziness) among older adults; Creatinine clearance of < 60mL/min dose reduction needed; sedation or ataxia may be particularly problematic for older adults at risk of falls and injuries; pregabalin is only FDA indicated for treatment of neuropathic pain, and gabapentin is only indicated for the treatment of postherpetic neuralgia.
Topical Medications: NSAIDs (e.g., diclofenac) Lidocaine, Capsaicin, Menthol and menthol salicylate Recommended for localized pain, in particular; available over-the-counter or via prescription (usually based on concentration of active ingredient). Pros: more efficacious than placebo in reducing pain symptoms; lower systemic drug exposure; generally well-tolerated.
Cons: possibility of increased systemic exposure with prolonged use or following administration of large quantities.
Baclofen Recommended for pain associated with spasticity Pros: notably, baclofen was not listed in the AGS 2019 Beers Criteria as a medication to avoid (as were other skeletal muscle relaxants); no renal or hepatic dose adjustments required.
Cons: sedation may be particularly problematic for older adults at risk of falls and injuries; baclofen is not FDA indicated for the treatment of pain.
Medications commonly used to treat pain that require a careful risk/benefit analysis, given safety concerns that are particularly relevant among older adults and lack of an FDA indication for analgesia: systemic exposure NSAIDs (e.g., aspirin, ibuprofen), tricyclic antidepressants (e.g., amitriptyline), skeletal muscle relaxants (e.g., cyclobenzaprine), non-gabapentinoid anticonvulsants (e.g., carbamazepine), and corticosteroids (e.g., prednisone). Please refer to the 2019 AGS Beers Criteria for medications that are considered “potentially inappropriate” for older adults, including dangerous drug interactions and those medications that may necessitate a dose reduction among older adults. Serotonin-norepinephrine reuptake inhibitor medication may be considered, given its strong safety profile and evidence of superiority over placebo. Medications to AVOID for the treatment of pain among older adults: selective serotonin reuptake inhibitor as monotherapy (lack of efficacy) and benzodiazepines (risk profile >> benefit).
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Notes: Abbreviations: NSAIDs = Nonsteroidal anti-inflammatory drugs.

Table was adapted from the following four references:

1

By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 67(4), 674–694. doi:10.1111/jgs.15767

2

American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. (2009). Pharmacological management of persistent pain in older persons. Journal of the American Geriatrics Society, 57(8), 1331–1346. doi:10.1111/j.1532-5415.2009.02376.x

3

Makris, U. E., Abrams, R. C., Gurland, B., & Reid, M. C. (2014). Management of persistent pain in the older patient: A clinical review. JAMA, 312(8), 825–836. doi:10.1001/jama.2014.9405

4

Marcum, Z. A., Duncan, N. A, & Makris, U. E. (2016). Pharmacotherapies in geriatric chronic pain management. Clinical Medicine. Geriatrics, 32(4), 705–724. doi:10.1016/j.cger.2016.06.007

Postoperatively, non-opioids are recommended as the mainstay of pain management with opioid doses used sparingly. Older adults can use NSAIDs with the caveat that comorbid conditions (e.g., risk of internal bleeding due to gastroesophageal reflux disease, blood thinners) may preclude use or require dosing adjustments (Griffiths et al., 2014; McCartney & Nelligan, 2014). Administration of a histamine H2-receptor antagonist (e.g., famotidine, cimetidine, ranitidine) is recommended in conjunction with NSAID use (Medlock et al., 2013); proton pump inhibitors (PPIs) should be used more cautiously, given their risks related to surgery, such as Clostridium difficile infection (Savarino et al., 2017). Furthermore, recent evidence has shown that PPIs may worsen COVID-19 outcomes (Kow & Hasan, 2021; Li et al., 2020). Other adjuvants such as pregabalin may be particularly useful in patients with a neuropathic pain component (spine, total knee or total hip arthroplasty), however, side effects such as sedation demand caution and dose adjustments (White et al., 2012). Use of the lowest effective doses for all medications should be the norm in older adults given age-related changes in drug sensitivity and response (White et al., 2012).

Other Postoperative Risk Mitigation Strategies

Other postoperative risk mitigation strategies include use of prescription drug monitoring programs (PDMPs) (Fink et al., 2018), urine drug screening tests (Becker & Starrels, 2018), and provider-patient treatment contracts (Volkow & McLellan, 2016). The PDMP helps identify patients visiting multiple prescribers, which is a common indication of prescription opioid misuse, and can prompt providers to reduce opioid prescribing and consider an addiction medicine referral. For older adults and disabled adults enrolled in Medicare, presence of a state PDMP was associated with a reduction in prescribed opioid volume, versus similar states without a PDMP (Moyo et al., 2017). Thus, integrating PDMPs into electronic health record systems may improve use and access of PDMPs for healthcare providers. Importantly, identifying patients with multiple prescribers should prompt follow-up, since these patients will need careful opioid weaning and pain management rather than abrupt discontinuation.

Limited data suggest that adults who recalled a discussion of the risk of addiction at the time of receiving an opioid prescription were 60% less likely to keep leftovers for later use (Hero et al., 2016). Providing information about the importance of safe medication storage and disposal may also reduce the risk of later prescription opioid misuse by the older adult patient or by others in the family or community. Motivational interviewing is an intervention used in other forms of substance use to facilitate behavior change in patients who are ambivalent about making lifestyle changes that can improve their health. In older adults with chronic pain, motivational interviewing was found to reduce their risk of prescription opioid misuse at a one-month follow-up (Chang et al., 2015).

SPECIAL OPIOID-RELATED CONSIDERATIONS

Remission/Recovery from Substance Use Disorders

Special attention should be afforded to patients who are in remission/recovery from substance use disorders. Patients in remission/recovery will have varying attitudes towards opioid medication, which can include a strong desire to avoid opioid use. The role of the preoperative evaluation and subsequent referral to an addiction specialist cannot be understated. Not only would this type of thorough care help identify the challenges present given the proposed surgery, but it would allow for creation of a detailed plan upon which both provider and patient could agree. Patient participation in the plan of care and adequate coaching regarding pain control may alleviate unnecessary anxiety, satisfy safety concerns, address and respect the patient’s remission/recovery status, and improve overall satisfaction. To prevent relapse and support the patient in recovery, promising pathways such as the ComfortCare Perioperative Recovery Maintenance Program should be considered. The ComfortCare Program incorporates the principles of multimodal analgesia using an interdisciplinary team to guide the patient in recovery through the perioperative experience (Myers & Compton, 2018).

A growing number of patients receive maintenance therapy with methadone, naltrexone or buprenorphine. As such, a multidisciplinary plan that includes input from an addiction or pain specialist should include details regarding continuation versus transitioning to or from these medications perioperatively. It is beyond the scope of this review to provide detailed guidance about perioperative care for the patient on long-acting opioids such as buprenorphine or methadone. However, a recent review provides evidence-based and consensus guidance on how to manage patients taking buprenorphine at the time of surgery (Anderson et al., 2017). A significant role for the addiction or pain specialist exists in these situations as many options and opinions exist regarding treatment strategies, and any plan would need to be patient-specific, ideally by a care provider with relationship longevity.

Management of Opioid-Dependent Patients

Management of opioid dependent patients begins with preoperative administration of their daily maintenance or baseline opioid dose before induction of general, spinal, or regional anesthesia. Patients who utilize a transdermal fentanyl patch should continue to wear this into the operating room. Intravenous or oral doses of methadone and morphine may be used as both baseline and intraoperative analgesics for patients with heroin use disorders after ensuring adequate venous access, often necessitating central line placement (Mitra & Sinatra, 2004). Individuals on buprenorphine should have close and early consultation in the preoperative period with addiction medicine when available. Buprenorphine treatment should be continued, and a short-acting opioid should be titrated to desired analgesic effect. However, it is important to consider that higher doses of opioids will be necessary for competing with the buprenorphine (typically around a 25% increase) (Kampman & Jarvis, 2015). For more specific considerations, an excellent review of buprenorphine in perioperative pain management can be referenced (Coluzzi et al., 2017; Ward et al., 2018). Additionally, in a recent meta-analysis of studies examining pain medications for people with opioid use disorders, there is preliminary evidence to support the analgesic and antihyperalgesic effect of gabapentin, gamma-aminobutyric acid (GABA) agonists, and N-Methyl-D-aspartate (NMDA) antagonists (De Aquino et al., 2020).

Postoperatively, use of scheduled acetaminophen (at less than a cumulative dose of four grams per day with normal adult hepatic function) is suggested, with consideration of NSAID use for the first 48 hours at lower doses or as rescue/augmentation for suboptimal pain control later in the post-operative course, again with restricted duration of exposure and reevaluation, is recommended. Judicious use of opioids intraoperatively and immediately postoperatively with early weaning, as tolerated, should be employed. The use of multimodal medical therapy can greatly reduce overall opioid requirements and speed return home for patients whose pain control would otherwise become challenging (Nordquist & Halaszynski, 2014).

SUMMARY

Older adult prescription opioid misuse has increased in recent years (Schepis & McCabe, 2016), with health providers serving as the main source of opioid medication for misuse in older adults (Schepis et al., 2018b). Even in cases where older adults have not acknowledged prescription opioid misuse, the risk factors for prescription opioid misuse, including long-term opioid use (pre- or postoperatively), are pervasive in this population. Opioid use and persistent use (greater than 90 days) are highest among patients undergoing procedures common to older adults (Bedard et al., 2017; Hansen et al., 2017; Kim et al., 2018; Kim et al., 2017; Zarling et al., 2016). Furthermore, persistent opioid use is a risk factor for opioid use disorder, with the risk for opioid use disorder development increasing once patients have taken prescribed opioid medication for greater than 90 days (Ling et al., 2011; National Academies of Sciences, Engineering, and Medicine, 2017). The presence of preoperative opioid dependence or opioid use disorder complicates the clinical picture for postoperative pain management. Similarly, older adults with preoperative pain catastrophizing and non-opioid illicit substance use have greater difficulty weaning from opioid medication postoperatively.

Use of a brief screening checklist as well as the formal screening tools outlined in this review may help to identify a patient’s risk for medication-aberrant behaviors. To aid identification of those at elevated risk for prescription opioid misuse, we have provided a brief screening checklist in Table 3 that incorporates part of the NIDA Quick Screen. Incorporating well-established, multimodal analgesia treatments into the overall anesthetic plan may not only lessen opioid consumption, but also reduce opioid-related morbidity for older adult patients (McCartney & Nelligan, 2014; Nordquist & Halaszynski, 2014). In those prescribed opioid medication, limited data suggest that adults who recalled a discussion of the risk of addiction at the time of receiving an opioid prescription were 60% less likely to keep leftovers for later use (Hero et al., 2016). This reduces the risk of later prescription opioid misuse by the older adult patient or by others, such as friends or family members, given how common family sources of opioid medication for prescription opioid misuse are in younger individuals (McCabe et al., 2018; Schepis et al., 2019b). Additionally, motivational interviewing has been studied among older adults with chronic pain and was found to reduce their risk of prescription opioid misuse at one-month follow up (Chang et al., 2015). Finally, the management of older adult patients who are opioid dependent or in remission/recovery from substance use disorder require special attention; consultations with addiction medicine, pain management, and social services specialists are imperative. A core set of addiction and pain curricular elements have been recommended to be integrated in the nursing curricula to educate nurses across the lifespan (Compton & Blacher, 2020). Identifying older adults at risk for prescription opioid misuse and knowing how to care for older adults who are misusing prescription opioids and suffering from chronic pain and addiction throughout the perioperative period is critical to reducing the deleterious effects associated with the opioid crisis.

Table 3.

Identifying Older Adult Patients at High-Risk for Opioid Misuse – Check List.

Questions to ask in preoperative phase:

  • Hi, I’m __________, nice to meet you. If it’s okay with you, I’d like to ask you a few questions that will help me give you better medical care. The questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the substances we’ll talk about are prescribed by a doctor (like pain medications). But I will only record those if you have taken them for reasons or in doses other than prescribed. I’ll also ask you about illicit or illegal drug use—but only to better diagnose and treat you.

    (NIDA Quick Screen, https://www.drugabuse.gov/publications/resource-guide-screening-drug-use-in-general-medical-settings/nida-quick-screen)
    • Consideration of implementation of NIDA Quick Screen via tablet in pre-operative clinic setting or as part of patient intake at appointment for surgery scheduling.
  • Any history of substance use disorder, depression, trauma?
    • Increased risk if > 50 years of age, history of substance use disorder or tobacco use, benzodiazepine use, antidepressant use, or trauma.
Strongly consider in pre-operative evaluation if NIDA screen is moderate or high-risk:
  • Evaluation of prescription registry (via the Prescription Drug Monitoring Program)
    • Pre-op benzodiazepine use increase risk.
    • Check for multiple sources of prescriptions and locations.
  • Type of surgery?
    • Highest risk in total hip and knee arthroplasty, open cholecystectomy, thoracotomy and mastectomy.
    • Pre-operative counseling for joints, spine, and major surgeries, such as thoracotomy, cardiac or colon surgery to minimize pain catastrophizing, which is associated with the inability to wean opioids postoperatively.
    • Discussion preoperatively of proper storage, monitoring/gatekeeper and disposal.
    • Educate patients that 60% of patients receiving 90 days of continuous postoperative opioid therapy are at risk for developing substance use disorder.

  • Referral to addiction medicine for pre-operative consultation if screener positive with follow-up in post-operative phase and on discharge.

  • Single prescriber for opioids in post-operative phase with warm hand-offs if care is transferred.

GOAL: ask every patient, identify those at risk, verify and refer appropriately.
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Acknowledgements:

The authors would like to thank Sebastian Hoak for his assistance with a portion of the clinical literature search, and they would like to thank Kate Leary, Kathryn Lundquist, and Mahmoud Abdulkarim for their help with formatting, proofreading and editing the manuscript.

Funding Source:

This work was supported by the National Institutes of Health (NIH)/National Institute on Drug Abuse (NIDA) for grants R01DA042146 (Dr. Schepis, PI) and R01DA031160 (Dr. McCabe, PI). NIH/NIDA had no role in the development, writing or decision to submit the paper for publication. For the anchor author (Dr. Voepel-Lewis), work on this manuscript was supported by research grant R01DA044245. NIH/NIDA had no role in the development, writing or decision to submit the paper for publication.

Footnotes

Conflict of Interest: The authors declare no competing interests.

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