Why are so many older people becoming hooked on painkillers?




Opioid addiction goes gray


Experts say doctors are insufficiently trained in how to prescribe opioids.


Could your doctor be prescribing too many pain pills?

The epidemic of opioid abuse sweeping the U.S. might seem like a distant phenomenon to the average middle-aged patient who is getting a joint replacement, visiting an emergency room or seeking help with persistent pain from a primary-care physician.

But according to the Centers for Disease Control and Prevention, Americans age 45 to 64 accounted for about 44% of deaths from overdoses in 2013 and 2014. And the proportion of adults 50 and older seeking treatment for opioid addiction has increased dramatically in recent decades.

While many deaths and overdoses are linked to illicit street drugs, the CDC reported in December that there is a continuing problem with prescription opioids, a class of narcotic painkillers that can be highly addictive and deadly when misused. Experts say many doctors are uninformed about the risks of opioids and are insufficiently trained in how to prescribe them.

Hair trigger

“Even one prescription can be a trigger for long-term use,” says Michael Barnett, assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health. “We have to figure out how to encourage safe prescribing without undertreating pain.”

Last year, the CDC issued new guidelines for primary-care providers, who write 50% of the prescriptions for opioids. The new regimen discourages use of opioids for chronic pain—defined as lasting more than three months—other than for cancer patients and those at the end of life. For acute pain, following surgery or injury, CDC says, “start low and go slow,” urging doctors to prescribe the lowest effective dose in no greater quantity than needed for the duration of pain severe enough to require a narcotic.

If an opioid is prescribed, CDC recommends faster-acting medication with a short duration of pain relief, rather than slower-acting, extended-release drugs with a longer duration.

The CDC released data recently showing that those who started out on long-acting drugs had the highest probabilities of long-term use. An unexpected finding was that the short-acting drug tramadol, considered less of a risk for abuse than other opioids, had the next-highest probability of long-term use. And 1 in 7 people who got any refill or second opioid prescription authorized were on the drugs a year later.

It can be a challenge to get doctors to change prescribing habits, as most were trained to treat pain aggressively. “The traditional approach was to give a prescription for 30 or even 90 days, but this has turned into a tremendous problem,” says Dr. Howard Marcus, an internal-medicine physician in Austin, Texas, and chairman of the Texas Physician Advisory Board for malpractice insurers the Doctors Co.

The insurer recently examined trends from 272 malpractice claims closed between 2007 and 2015 in which opioids resulted in patient harm, including errors in patient monitoring, insufficient warnings to patients about the risk of narcotic painkillers, and failing to assess patients for psychiatric issues or a history of drug abuse. Doctors also sometimes failed to communicate with one another about drugs prescribed to a patient and didn’t check to see whether patients were taking other drugs that could interact dangerously with opioids such as antianxiety medication or prescription sleep aids.

The Doctors Co. is now offering a course to help physicians apply the new CDC guidelines in their practice and help patients manage pain safely with other approaches including the over-the-counter painkiller Tylenol and physical therapy. “I have found patients are actually really happy to know they can take something else,” Marcus says.

Marcus advises patients to strictly follow instructions on opioid labels, never take an extra dose, avoid alcohol and inform the doctor of all medications they are taking. Patients should consider alternatives to opioids whenever possible, he suggests, such as controlling daytime pain after surgery with a non-opioid medication and using an opioid only at bedtime.

Harvard’s Dr. Barnett, who is also a hospitalist at Brigham and Women’s Hospital in Boston, says older patients “have the most to lose from getting the wrong opioid prescription or dose.” They are especially vulnerable to falls, fractures and respiratory arrest when using prescription narcotics—and often they are taking other medications that magnify the risks.

Rating prescribers

A study of a large sample of Medicare patients, co-written by Barnett, and published in February in the New England Journal of Medicine, found wide variations in the rates of opioid prescribing among doctors practicing in the same emergency department. Medicare patients who had not previously had the drugs and were treated by one of the “high-intensity” prescribers had higher rates of long-term use of opioids, likely because outpatient doctors continued providing previous prescriptions. The study suggests that for every 48 patients prescribed a new opioid in the ER who might not otherwise use the drugs, one will become a long-term user.

Patients should speak up about any concerns with an opioid prescription, even in an emergency setting, says Barnett. “It is OK to say, ‘I’ve heard these drugs have a lot of side effects, can I get something else or a lower dose?’ ”

A study of which medical specialists are prescribing medications to patients who die of prescription-drug abuse in San Diego County, published in the American Journal of Emergency Medicine in 2015, found that some doctors tended to prescribe more pills per bottle. Emergency-room doctors wrote about 5% of all prescriptions, giving patients an average of 23 pills per bottle. By contrast, surgeons wrote 7% of prescriptions for opioids, but gave an average of 123 pills per bottle.

Dr. Roneet Lev, lead author of the study and director of operations for the emergency department at Scripps Mercy Hospital in San Diego, says orthopedic surgeons prescribed 169 pills per bottle, the highest of any specialty.

Opioids are risky even if taken exactly as prescribed, Lev says. Of the 254 people whose records were used in the study, the majority were not following directions, and mixed with drugs, alcohol, or additional medications, but 16.5% died using the medication in the prescribed doses and intervals and weren’t combining their medication with other drugs or alcohol.

Emergency departments in San Diego and Imperial counties are participating in a safe-prescribing project led by Lev, with posters in emergency rooms warning that doctors there will only prescribe lesser amounts of medication and don’t prescribe long-acting pain medicines.

“Patients in pain can and should be able to obtain relief, and this often requires an opioid,” Lev says. “But when they are misused, unintentionally or otherwise, they can be a prescription for death.”

Laura Landro is a former Wall Street Journal assistant managing editor. Email her at