Feature

Opioids and the older-aged person.

December 3, 2019
By

Our ageing population presents challenges for doctors treating patients with opioids, including the opioid agonist therapy (OAT) agents, methadone and buprenorphine. Illnesses of older age, social and mental health issues, higher rates of chronic and acute injury and pain, overdose risk and more liberal attitudes towards alcohol, prescription medicines and illicit drugs – all can influence an older person’s risk and experience of illness, as well as a health care practitioner’s ability to deliver timely and appropriate care.

The respiratory, cardiovascular, musculoskeletal and other effects of opioids are exacerbated with advancing age and may be further complicated by other co-morbidities or other drug interactions.

Respiratory
The older aged population has a greater prevalence of sleep apnoea compared to the younger population and this is even greater among those taking chronic opioids for any reason. Any presentation of insomnia or ‘trouble sleeping’ and any unusual snoring should be investigated and depending on results, the patient may require CPAP, a sleep physician referral or other management. Take-home naloxone should be prescribed, and training in its use provided to these patients.

Cardiovascular
Prolonged QT interval is a serious side-effect of opioids, with which can lead to torsades de pointes (TdP). Whilst opioid-related prolonged QT usually occurs with higher risk opioids such as methadone or oxycodone, or with higher oral morphine equvalence doses of more than 150mg/day, it may also occur with other opioids or lower doses. Other risk factors include: advanced age, electrolyte abnormalities, heart disease (CCF or ischaemia) and other medications which increase QT (anti-arrhythmics, antidepressants, neuroleptics)

Musculoskeletal effects
People taking long-term opioids, including OAT, have a 1.5 times increased fracture risk due to a combination of factors, including hormonal changes contributing to osteopenia and osteoporosis, musculoskeletal condition weakening, myopathy, sedation, decreased alertness and confusion. All can be exacerbated in the older person.

Dangerous combinations
Combining opioids with alcohol, benzodiazepines or other opioids is well established to increase the risk of respiratory depression and accidental overdose. Similarly, the gabapentinoids, certain anti-psychotics and antidepressant drugs with opioids are combinations which should be avoided or closely monitored. Take-home naloxone should be provided.

Other opioid risks exacerbated in older age

  • Hyperalgesia – excess sensitivity to pain
  • Dental – increased risk of dental complications
  • Mental health – depression and suicidal ideation, age-related cognitive decline

Treatment of the older-aged person with opioids, whether for pain or for managing opioid  dependence, requires awareness, understanding and careful management of the multiple system effects and enhanced risk of these drugs in this cohort.

This is a summary of a brief presentation from a Victorian Opioid Management ECHO session.

The Victorian Opioid Management ECHO is a collaborative, multi-disciplinary community-of-practice, providing access to opioid education by a team of specialist addiction medicine specialists, psychiatrists, nurses, pharmacists and social workers. Weekly sessions consist of a brief presentation and case discussion, are delivered entirely by video-conferencing, can be accessed on virtually any device, and are open to all Victorian health practitioners. Taking part is free. Join us at echo.pabn.org.au

The Victorian Opioid Management ECHO is an initiative of the Pharmacotherapy Area Based Networks with St.Vincent’s Hospital, Melbourne.

The Pharmacotherapy Area-Based Networks (PABN) are a Victorian Government initiative to provide opioid pharmacotherapy support for primary care medical practitioners and pharmacists across the state of Victoria including metropolitan, regional and rural areas.

Each PABN provides connections between primary health care, hospitals and Alcohol and Other Drug (AOD) services to create a more cohesive and strengthened pharmacotherapy service system.

What is pharmacotherapy?

Pharmacotherapy is Medication Assisted Treatment of Opioid Dependence (MATOD). It includes treatments such as methadone and buprenorphine (Subutex®, Suboxone®). Pharmacotherapy is also known as Opioid Replacement Therapy (ORT), and Opioid Substitution Therapy (OST). In Victoria, most pharmacotherapy is provided via a community model, mainly via General Practitioner (GP) and pharmacist service providers. Additional services may be provided by nurse practitioners, community health organisations and specialist nurses and AOD workers.

Your local PABN provides local support

There are two metropolitan and three regional PABNs. Each PABN is structured to meet local need and includes highly qualified management and specialist teams such as GPs, Addiction Medicine Specialists (AMS), Clinical and AOD nurses, and pharmacists. These teams recognise the diverse needs of practitioners and patients, and provide innovative and flexible approaches to meeting local needs. See our About page and the contact details for your local PABN.

Victorian Opioid Management Extension for Community Healthcare Outcomes (ECHO) is a PABN program providing specialist no-cost opioid education for all Victorian health practitioners.