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

Project Summary Title and Description

Prevention, Diagnosis, and Management of Opioids, Opioid Misuse, and Opioid Use Disorder in Older Adults
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. Although considerable research has been done in younger or mixed-age populations, the degree to which it is directly applicable to older adults is uncertain. 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 May 6, 2020. Findings. We identified 5,933 citations, from which we identified 41 studies with multivariable models of factors associated with opioid-related outcomes and 16 studies of interventions in older adults. More than half (22/41) of the multivariable analysis studies evaluated factors associated with long-term opioid use (which, though not a harm per se, may increase the risk of harms if not appropriately managed). 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, concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs), and fibromyalgia also had consistent, but weaker, associations with long-term opioid use. Several factors were mostly associated (>75% agreement) with long-term opioid use, including benzodiazepine use, comorbidity scores, (generally undefined) substance misuse, tobacco use, and low income. 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, dementia, rural/nonurban residence, prescription of long-acting opioids, unmarried status, and use of muscle relaxants were variably associated (<75% agreement) with long-term opioid use. Six studies examined factors associated with opioid-related disorders, although only one study evaluated factors associated with opioid use disorder. Alcohol misuse and gender were variably associated with opioid misuse (examined by three studies each). All other evaluations of specific pairs of associated factors and outcomes of interest were evaluated by only one or two studies each. These included analyses of factors associated with 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 16 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, implementation of an opioid safety initiative, provision of patient information and pain management training for clinicians, a bundle of educational modalities for clinicians, free prescription acetaminophen, a nationally mandated tamper- resistant opioid formulation, and motivational interview training for nursing students. Few intervention studies evaluated pain or other patient-centered outcomes such as disability and functioning. 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 clinically important, patient-centered, opioid-related outcomes. Studies to date have identified numerous possible factors associated with long-term opioid use (whether appropriate or not), 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 (including screening tools), reduce opioid-related harms and disorders, and treat existing misuse or opioid use disorder among older adults.
Brown Evidence-based Practice Center
Authors of Report
Andrew R. Zullo, Pharm.D., Ph.D. Kristin J. Danko, Ph.D. Patience Moyo, Ph.D. Gaelen P. Adam, M.L.I.S., M.P.H. Melissa Riester, Pharm.D. Hannah J. Kimmel, M.P.H. Orestis A. Panagiotou, M.D., Ph.D. Francesca L. Beaudoin, M.D., Ph.D. Daniel Carr, M.D. Ethan M. Balk, M.D., M.P.H.
Methodology description
Systematic Review
The report for this systematic review can be found at: Data entered prospectively, with additional data entered retrospectively: Study Data can be found in the following downloadable documents: 1) Opioids in Older Adults.xlsx belongs to key questions 1, 2, and 3. This is an evidence map. Link: 2) MVA data.v10.xlsx belongs to key question 2. This document contains results Link: 3) Intervention studies.docx belongs to key question 3. This document contains results Link: Please note that copying and pasting any of the AmazonAWS urls into your browser will enable you to immediately download that document to your computer.
Funding Source
AHRQ Contract No. HHSA 290-2015-00002-I

Key Questions

1. 1. What are the most important factors driving the increase in opioid-related hospitalizations and ED visits for older adults and what interventions are needed to reduce the risk of opioid-related adverse events, opioid misuse, and OUD in older adults without compromising pain control or quality of life?
2. 2. Among older patients taking opioids, what factors are most strongly associated with harms from opioids (adverse events, misuse, or opioid use disorder)?
3. 3. What interventions have been studied to help providers to: a) reduce opioid prescription where harms outweigh benefits in older adults without compromising pain control or quality of life (e.g., shared decision-making)? b) reduce the risk of adverse events, misuse or opioid use disorder in older adults for whom opioids are appropriate? c) identify and treat opioid misuse or opioid use disorder in older adults?

Associated Extraction Forms


Associated Studies (each link opens a new tab)

Title Authors Year
Long-term pattern of opioid prescriptions after femoral shaft fractures. Al Dabbagh Z, Jansson KA, Stiller CO, Montgomery S, Weiss RJ 2016 May
Long-term analgesic use after low-risk surgery: a retrospective cohort study. Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM 2012 Mar 12
Impact of Prescribing on New Persistent Opioid Use After Cardiothoracic Surgery. Brescia AA, Waljee JF, Hu HM, Englesbe MJ, Brummett CM, Lagisetty PA, Lagisetty KH 2019 Oct
Narcotic Use and Total Knee Arthroplasty. Cancienne JM, Patel KJ, Browne JA, Werner BC 2018 Jan
Patterns of Potential Opioid Misuse and Subsequent Adverse Outcomes in Medicare, 2008 to 2012. Carey CM, Jena AB, Barnett ML 2018 Jun 19
Increasing Rates of Opioid Misuse Among Older Adults Visiting Emergency Departments. Carter MW, Yang BK, Davenport M, Kabel A 2019 Jan
Association between Nonmedical Marijuana and Pain Reliever Uses among Individuals Aged 50. Choi NG, DiNitto DM, Marti CN, Choi BY 2017 Sep-Oct
Emergency Department Visits and Overnight Hospital Stays among Persons Aged 50 and Older Who Use and Misuse Opioids. Choi BY, DiNitto DM, Marti CN, Choi NG 2019 Jan-Mar
Risk Factors for Symptoms of Prescription Opioid Misuse: Do Older Adults Differ from Younger Adult Patients? Cochran G, Rosen D, McCarthy RM, Engel RJ 2017 Aug-Oct
Changing Trends in Opioid Use Among Patients With Rheumatoid Arthritis in the United States. Curtis JR, Xie F, Smith C, Saag KG, Chen L, Beukelman T, Mannion M, Yun H, Kertesz S 2017 Sep
Incidence and Risk Factors of Long-term Opioid Use in Elderly Trauma Patients. Daoust R, Paquet J, Moore L, Gosselin S, Gelinas C, Rouleau DM, Berube M, Morris J 2018 Dec
Preoperative opioid use and postoperative pain associated with surgical readmissions. Dasinger EA, Graham LA, Wahl TS, Richman JS, Baker SJ, Hawn MT, Hernandez-Boussard T, Rosen AK, Mull HJ, Copeland LA, Whittle JC, Burns EA, Morris MS 2019 Nov
High-Risk Obtainment of Prescription Drugs by Older Adults in New Jersey: The Role of Prescription Opioids. Gold SL, Powell KG, Eversman MH, Peterson NA, Borys S, Hallcom DK 2016 Oct
Correlation of Opioid Mortality with Prescriptions and Social Determinants: A Cross-sectional Study of Medicare Enrollees. Grigoras CA, Karanika S, Velmahos E, Alevizakos M, Flokas ME, Kaspiris-Rousellis C, Evaggelidis IN, Artelaris P, Siettos CI, Mylonakis E 2018 Jan
Risk for Prolonged Opioid Use Following Total Knee Arthroplasty in Veterans. Hadlandsmyth K, Vander Weg MW, McCoy KD, Mosher HJ, Vaughan-Sarrazin MS, Lund BC 2018 Jan
Long-term use of opioids for nonmalignant pain among community-dwelling persons with and without Alzheimer disease in Finland: a nationwide register-based study. Hamina A, Taipale H, Tanskanen A, Tolppanen AM, Karttunen N, Pylkkanen L, Tiihonen J, Hartikainen S 2017 Feb
Association of Long-term Opioid Therapy With Functional Status, Adverse Outcomes, and Mortality Among Patients With Polyneuropathy. Hoffman EM, Watson JC, St Sauver J, Staff NP, Klein CJ 2017 Jul 1
Risk factors for persistent and new chronic opioid use in patients undergoing total hip arthroplasty: a retrospective cohort study. Inacio MC, Hansen C, Pratt NL, Graves SE, Roughead EE 2016 Apr 29
Preoperative Chronic Opioid Therapy: A Risk Factor for Complications, Readmission, Continued Opioid Use and Increased Costs After One- and Two-Level Posterior Lumbar Fusion. Jain N, Phillips FM, Weaver T, Khan SN 2018 Oct 1
Opioid Prescribing for Opioid-Naive Patients in Emergency Departments and Other Settings: Characteristics of Prescriptions and Association With Long-Term Use. Jeffery MM, Hooten WM, Hess EP, Meara ER, Ross JS, Henk HJ, Borgundvaag B, Shah ND, Bellolio MF 2018 Mar
Opioid prescribing by multiple providers in Medicare: retrospective observational study of insurance claims. Jena AB, Goldman D, Weaver L, Karaca-Mandic P 2014 Feb 19
Concomitant use of benzodiazepines and opioids in community-dwelling older people with or without Alzheimer's disease-A nationwide register-based study in Finland. Karttunen N, Taipale H, Hamina A, Tanskanen A, Tiihonen J, Tolppanen AM, Hartikainen S 2019 Feb
Trends in Opioid Prescriptions Among Part D Medicare Recipients From 2007 to 2012. Kuo YF, Raji MA, Chen NW, Hasan H, Goodwin JS 2016 Feb
Predictors of persistent prescription opioid analgesic use among people without cancer in Australia. Lalic S, Gisev N, Bell JS, Korhonen MJ, Ilomaki J 2018 Jun
Opioids in hip fracture patients: an analysis of mortality and post hospital opioid use. Lindestrand AG, Christiansen ML, Jantzen C, van der Mark S, Andersen SE 2015 Jul
Evaluation of Machine-Learning Algorithms for Predicting Opioid Overdose Risk Among Medicare Beneficiaries With Opioid Prescriptions. Lo-Ciganic WH, Huang JL, Zhang HH, Weiss JC, Wu Y, Kwoh CK, Donohue JM, Cochran G, Gordon AJ, Malone DC, Kuza CC, Gellad WF 2019 Mar 1
Opioid Use after Radical Prostatectomy: Nationwide, Population Based Study in Sweden. Loeb S, Cazzaniga W, Robinson D, Garmo H, Stattin P 2020 Jan
Short- and Long-term Opioid Use in Patients with Oral and Oropharynx Cancer. McDermott JD, Eguchi M, Stokes WA, Amini A, Hararah M, Ding D, Valentine A, Bradley CJ, Karam SD 2019 Mar
Characteristics associated with transition from opioid initiation to chronic opioid use among opioid-naive older adults. Musich S, Wang SS, Slindee L, Kraemer S, Yeh CS 2019 Mar - Apr
Patient Factors Associated With Prolonged Postoperative Opioid Use After Total Knee Arthroplasty. Namba RS, Singh A, Paxton EW, Inacio MCS 2018 Aug
Persistent Opioid Use Among the Elderly After Lung Resection: A SEER-Medicare Study. Nelson DB, Niu J, Mitchell KG, Sepesi B, Hofstetter WL, Antonoff MB, Giordano SH, Mehran RJ, Rice DC 2020 Jan
Risk factors associated with opioid medication misuse in community-dwelling older adults with chronic pain. Park J, Lavin R 2010 Oct
Risk factors for postoperative opioid use after elective shoulder arthroplasty. Rao AG, Chan PH, Prentice HA, Paxton EW, Navarro RA, Dillon MT, Singh A 2018 Nov
New persistent opioid use among older patients following surgery: A Medicare claims analysis. Santosa KB, Hu HM, Brummett CM, Olsen MA, Englesbe MJ, Williams EA, Waljee JF 2020 Apr
Prescription opioid and benzodiazepine misuse is associated with suicidal ideation in older adults. Schepis TS, Simoni-Wastila L, McCabe SE 2019 Jan
Long-Term Opioid Therapy in Older Cancer Survivors: A Retrospective Cohort Study. Shah R, Chou LN, Kuo YF, Raji MA 2019 May
Opioid dispensing and overlap in veterans with non-cancer pain eligible for Medicare Part D. Suda KJ, Smith BM, Bailey L, Gellad WF, Huo Z, Burk M, Cunningham F, Stroupe KT 2017 May - Jun
Incident opioid use and risk of hip fracture among persons with Alzheimer disease: a nationwide matched cohort study. Taipale H, Hamina A, Karttunen N, Koponen M, Tanskanen A, Tiihonen J, Hartikainen S, Tolppanen AM 2019 Feb
Incident opioid drug use and adverse respiratory outcomes among older adults with COPD. Vozoris NT, Wang X, Fischer HD, Bell CM, O'Donnell DE, Austin PC, Stephenson AL, Gill SS, Rochon PA 2016 Sep
Association of Tramadol With All-Cause Mortality Among Patients With Osteoarthritis. Zeng C, Dubreuil M, LaRochelle MR, Lu N, Wei J, Choi HK, Lei G, Zhang Y 2019 Mar 12
Polydrug epidemiology: Benzodiazepine prescribing and the drug overdose epidemic in the United States. Zoorob MJ 2018 May
Prevalence and Detection of Prescription Opioid Misuse and Prescription Opioid Use Disorder Among Emergency Department Patients 50 Years of Age and Older: Performance of the Prescription Drug Use Questionnaire, Patient Version. Beaudoin FL, Merchant RC, Clark MA 2016 Aug
Motivational interviewing training with standardized patient simulation for prescription opioid abuse among older adults. Chang YP, Cassalia J, Warunek M, Scherer Y 2019 Oct
Impact of an Opioid Safety Initiative on Patients Undergoing Total Knee Arthroplasty: A Time Series Analysis. Chen Q, Hsia HL, Overman R, Bryan W, Pepin M, Mariano ER, Mudumbai SC, Buchheit T, Krishnamoorthy V, Good CB, Brookhart MA, Raghunathan K 2019 Aug
The Severity of Dependence Scale detects medication misuse and dependence among hospitalized older patients. Cheng S, Siddiqui TG, Gossop M, Kristoffersen ES, Lundqvist C 2019 Jun 24
Longitudinal treatment outcomes for geriatric patients with chronic non-cancer pain at an interdisciplinary pain rehabilitation program. Darchuk KM, Townsend CO, Rome JD, Bruce BK, Hooten WM 2010 Sep
Screening for alcohol and substance use for older people in geriatric hospital and community health settings. Draper B, Ridley N, Johnco C, Withall A, Sim W, Freeman M, Contini E, Lintzeris N 2015 Jan
Multidisciplinary intervention decreases the use of opioid medication discharge packs from 2 urban EDs. Gugelmann H, Shofer FS, Meisel ZF, Perrone J 2013 Sep
Prescription Opioid Use and Misuse Among Older Adult Rhode Island Hospital Emergency Department Patients. Henderson AW, Babu KM, Merchant RC, Beaudoin FL 2015 Mar 3
Impact of prescription drug monitoring programs (PDMPs) on opioid utilization among Medicare beneficiaries in 10 US States. Moyo P, Simoni-Wastila L, Griffin BA, Onukwugha E, Harrington D, Alexander GC, Palumbo F 2017 Oct
Factor structure of pain medication questionnaire in community-dwelling older adults with chronic pain. Park J, Clement R, Lavin R 2011 Jul-Aug
Educational intervention for physicians to address the risk of opioid abuse. Pasquale MK, Sheer RL, Mardekian J, Masters ET, Patel NC, Hurwitch AR, Weber JJ, Jorga A, Roland CL 2017 Sep/Oct
Opioid information pamphlet increases postoperative opioid disposal rates: a before versus after quality improvement study. Rose P, Sakai J, Argue R, Froehlich K, Tang R 2016 Jan
Person-level changes in oxycodone use after the introduction of a tamper-resistant formulation in Australia. Schaffer AL, Buckley NA, Degenhardt L, Larance B, Cairns R, Dobbins TA, Pearson SA 2018 Mar 26
Screen of drug use: Diagnostic accuracy for opioid use disorder. Tiet QQ, Leyva YE, Moos RH 2019 May 1
A cluster randomized trial to measure the impact on nonsteroidal anti-inflammatory drug and proton pump inhibitor prescribing in Italy of distributing cost-free paracetamol to osteoarthritic patients. Vicentini M, Mancuso P, Giorgi Rossi P, Di Pede S, Pellati M, Gandolfi A, Zoboli D, Ricco D, Busani C, Ferretti A 2019 Dec 6
Prescription Drug Monitoring Programs Produce a Limited Impact on Painkiller Prescribing in Medicare Part D. Yarbrough CR 2018 Apr

Downloadable Data Content

  • XLSX Project Data