A Systematic Review of Opioid Use in LTC

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The opioid crisis remains a national priority in the United States. According to the Centers for Disease Control and Prevention (CDC), almost 400,000 Americans have died from opioid overdose since 1999, which averages to about 130 deaths a day.¹ The opioid epidemic affects all ethnic groups and a wide range of age groups, including older adults.¹ Significant resources have been mobilized to address misuse of opioids. Simmons-Duffin reported that the real cost of this opioid epidemic in the United States totaled $179 billion in 2018 alone, including overdose deaths accounting for $72.6 billion, health care costs accounting for $60.4 billion, lost productivity accounting for $26.5 billion, criminal justice accounting for $10.9 billion, and child and family assistance and education accounting for $9 billion.² In addition, more than $1 billion in grants have been awarded to study the problem.³ These efforts have yielded some positive results. From January 2017 to August 2018, opioid prescriptions dropped 21%, according to the US Department of Health and Human Services (HHS).³ Prescriptions for naloxone, the drug used to reverse opioid overdose, have increased by 264%. Medication-assisted treatment, meanwhile, has risen 16%.³

Weiss et al reported in 2018 that nearly 125,000 hospitalizations of older adults in the United States were opioid-related.⁴ An estimated 9 to 11 million older Americans were prescribed long-term opioid medications between 1997 and 2005.⁵ Although opioid prescriptions overall decreased 5% between 2014 and 2016, opioid prescriptions for chronic pain increased 55% in 2016.⁶ Huhn et al reported steady increases in older adults seeking treatment for opioid use disorder: a 41.2% increase between 2004 and 2013, and a 53.5% increase between  2013 and 2015.⁷ In 2017, the HHS Office of Inspector General reported that 460,000 Medicare Part D beneficiaries were prescribed an average morphine equivalent dose of greater than 120 mg per day for at least 3 months, which is equivalent to 12 tablets of Vicodin (10 mg) or 16 tablets of Percocet (5 mg) daily.³ Nearly one-third of nursing home (NH) residents received an opioid analgesic during the same period.⁸ The question of whether there is a problem with opioid use in long-term care (LTC) remains unanswered.⁸

In 2018, the Centers for Medicare & Medicaid Services (CMS) denied an opioid crisis; yet, the prevalence of opioid use in LTC facilities increased from 11.7% in 2003 to 30.2% in 2017.⁹ Since October 2017, CMS requires NHs to report opioid use in the Minimum Data Set (MDS) item N0410H.¹⁰ Although this added MDS item is not linked with Medicare reimbursement, care, or quality issues, it provides information to surveyors about opioid use in NHs.¹⁰  For opioid-related citations, surveyors can cite a NH for deficient pain management practices (F-Tag 697) and unnecessary drug use (F-Tag 757) such as prescribing morphine for anxiety and not pain or for no documented reason.¹¹ In 2015, 52,219 pain-management deficiencies were cited in NH inspections.¹² To our knowledge, no data specific to opioid citations in LTC have been reported thus far. 

Hunnicutt et al reported that among long-stay NH Medicare beneficiaries in 2012, 32.4% were prescribed opioids. Some 15.5% of them received long-term opioid prescriptions, and 10.4% received short-term opioid prescriptions.¹³ Recent studies have shown that fentanyl, oxycodone, and morphine are the leading opioids prescribed in NHs.^13-16

According to the CDC,  more than 4 million people are admitted to LTC facilities in the United States annually—NHs, skilled nursing facilities (SNFs), and assisted living facilities.¹ In 2016, there were 1,347,600 NH residents in the United States, occupying 15,600 licensed NHs, while approximately 1 million people resided in assisted living facilities.^1,17  

Reports of the prevalence of chronic pain in LTCs vary Lukas et al reported that 48.4% of LTC residents had pain, 12% had uncontrolled pain.¹⁸ An estimated 83.3% of NH residents have documented pain. However, Reinecke et al found that opioids alone were ineffective in treating chronic pain, particularly in reducing pain intensity.¹⁹ Thus, reducing the use of opioids in LTC has sparked renewed research interest, especially amid the current opioid crisis.^6,20

This systematic review of research of opioid use among older adults addresses the gaps in research and describes the extent and type of opioid use in LTC.

A review of relevant studies was conducted in June 2019 to identify gaps in research on opioid use among LTC residents. Medline/PubMed, CINAHL Plus with Full Text, PsycINFO, EMBASE, Cochrane, and Google Scholar were searched for pertinent studies. This search first yielded 25,408 journal articles when keywords such as “older adults,” “aged,” and “opioid use” were used. Using advanced search, the number decreased to 6659 after selecting articles with full text that were written in English between 2009 and 2019. The number was further reduced to 2153 when keywords such as “chronic pain” were added. Some 1538 duplicates were identified and excluded, leaving 615 articles for screening. 

Abstracts were assessed for eligibility and whether they addressed the topic of interest. After a final review of abstracts and titles that applied the inclusion and exclusion criteria, nine articles were retained. Reference lists used in the included studies (backward chaining) produced two more articles, bringing the total number of studies to 11.²¹ See Figure 1 for the flow diagram adapted from Preferred Reporting Items of Systematic Review and Meta-Analysis (PRISMA) by Moher et al.²²

Inclusion and Exclusion Criteria

Inclusion criteria for this systematic review were: (1) focused on opioid use; (2) participants were from LTC settings (NHs, SNFs, and assisted living, including residents receiving hospice/palliative care in LTC); (3) participants were primarily aged older than 65 years; (4) LTC residents with chronic pain; and (5) published in English. Hospice patients were included because LTC residents who met hospice eligibility criteria (ie, life expectancy less than 6 months as certified by the medical director and primary physician and eligible for Medicare Part A benefits) could also avail hospice services as an LTC care option.²³

The systematic review encompassed a 10-year period, from 2009 to 2019. No limitation was placed on the country of origin or location of the articles. Studies about other substances such as alcohol or barbiturates were excluded from the review.

Literature Search

Electronic databases used in the search were from nursing, medicine, and psychology databases. Keywords were “opioid use,” “opioid prescription,” “aged,” “older adults,” “chronic pain,” “nursing home,” and “long-term care facilities.”  

Process of Selecting the Articles

We used the PRISMA reporting system for the systematic review.A PRISMA flow diagram (Figure 1)²² illustrates the process of review and deselection of journal articles (N=25,408). After deleting for duplicates and irrelevant articles based on title and abstracts, there were 615 full-text articles examined for eligibility. Of the 615 articles searched, read, and reread, 604 were excluded, resulting in the evaluation of 11 articles for the systematic review.  

Sample

Of the 11 articles included in the systematic review, 10 were cross-sectional studies and one was a systematic review. Sample sizes ranged from 458 to 908,418 NH residents. More than half of the studies were conducted in the United States (six of 11), one study was from the Netherlands, one from Australia, one from Finland, and one from Denmark (which included the entire population of Finnish older adults). The systematic review included 16 countries.¹⁴

Prevalence of Opioid Prescriptions in LTC

The reported prevalence of opioid prescriptions in NHs varied from 20.7% to 69.2%.^16,24 One study reported a 2.2% increase in long-term opioids initiated within 30 days of admission to the facility between 2011 and 2013.²⁵ Another study indicated that among NH residents initiated with long-acting opioids (LAO), 39.3% of them were opioid-naïve (did not receive any opioid in the previous 60 days).¹⁴ On the other hand, among long-stay NH residents, 32.4% were prescribed any opioid, while 15.5% of them received opioid prescriptions long-term, and 10.4% were prescribed opioids short-term.¹³ Pimentel et al reported the majority of residents with LAO prescriptions during their NH stay were admitted from an acute care hospital.¹⁵ 

The opioid prescription rate differed with demographics. In the United States, 69.2% (n = 12,814) US nursing home residents received a prescription opioid as reported in the US NH MDS assessments and Medicare Part D enrollment in 2008.¹⁶ Sixty-five percent of US NH residents prescribed opioids were older adults receiving hospice/palliative care, most of whom had cancer.²⁶ Thirty-two percent of these residents were long-stay residents.¹³ In a study in Helsinki, Finland, the authors⁹ reported a 30% increase in opioid use in NH from 2007 to 2017, while 41% of NH residents used opioids in Denmark.²⁸ 

Frequently Prescribed Opioids in Older Adults in LTC

Six studies reported the fentanyl transdermal patch was the most frequently prescribed opioid in LTC.^{6,15,16,25,27,29} The trend was also evident in US NHs.^6,15,16,25 Oxycodone and morphine were the next most frequently prescribed opioids. In Australia,  a combination oxycodone and naloxone hydrochloride opioid was frequently prescribed (20.7%), followed by oxycodone alone.²⁴ 

Characteristics of LTC Patients Receiving Opioids

Non-Hispanic whites made up the largest group of LTC patients receiving opioids in the United States (80.6%-91.4%).^13,26 Among long-stay NH residents, women were prescribed opioids more often than men (34.1% vs 26.8%).¹³ Another study revealed that among US NH residents in 2011 prescribed LAOs during admission (N=22,253), 71.4% were women.¹⁵  

In one study, researchers reported that NH residents with an educational level below high school had higher rates of opioid use (55%). In another study, there was no significant difference in opioid use in terms of educational attainment.^14,16 NH residents were prescribed opioids for arthritis, osteoporosis, hip fracture, congestive heart failure, stroke, chronic obstructive pulmonary disease, and cancer.^13,14 A significant number of these older adults experienced chronic pain.^26,27 Pimentel et al reported an estimated 83.3% of NH residents have documented pain.¹⁵ This estimate was higher than the 48.4% of LTC residents with pain, 12% with uncontrolled pain, reported by  Lukas et al.¹⁸ Meanwhile, Fain et al stated that 16.7% of older adults with persistent pain did not receive prescription analgesics.¹⁶ Two research groups offered possible explanations, including failure to recognize pain or to document medication given.^26,30

The primary diagnoses among older adult NH residents receiving hospice/palliative care were neuropsychiatric conditions (38.75%), cardiac conditions (15.22%), and pulmonary conditions (14.19%), Hanlon et al reported.²⁶ Conversely, Hunnicutt et al reported that of the 64.5% of NH residents who use opioids in their study, 54.5% had a diagnosis of depression, and 25.8% had a diagnosis of anxiety.¹³

Consequences of Opioid Use in LTC

Frail, older NH residents with renal and hepatic insufficiency have a higher risk of adverse drug events, specifically with LAOs.¹⁴ Dosa et al suggested that opioid-naïve NH residents prescribed LAOs, such as transdermal fentanyl patch, during their NH stay had a higher risk of serious medication side effects.¹⁴

However, of the 11 articles reviewed, none studied the long-term effects of opioids among LTC residents. Four studies focused on the frequency of opioid prescribing, two on initiation of LAOs in NHs, and two on analgesic prescribing trends, including opioids.^{14-16,24,25,28} The rest reported on the prevalence of opioid use in LTC.

There is substantial evidence that opioid use is prevalent in most LTC facilities in the United States and in other countries, such as Finland and Denmark (Supplemental Table 1). Dosa et al reported a 39.3% LAO initiation rate among opioid-naïve NH residents, particularly those with advancing age and those diagnosed with Alzheimer disease or cognitive impairment.¹⁴ The LAOs prescribed were fentanyl, oxycodone, and morphine, all of which are strong opioid analgesics, and all of which were consistently reported as the most frequently prescribed opioids in NHs.^13-16 

Initiating LAOs in LTC has clinical implications. Opioids have an increased risk of adverse effects in older adults because aging is associated with physiologic changes that reduce drug metabolism and excretion.³¹ Morphine, for example, can cause hallucinations in some older adults.³² Other significant adverse effects of opioid use include respiratory depression, constipation, urinary retention, orthostatic hypotension, myoclonus, and nausea.³³ Aside from drug tolerance, euphoria, and excessive sedation, opioids predispose older adults to opioid use disorder and higher mortality risk.³⁴ Opioid use for chronic pain has been associated with increased risk for fractures in older adults.³⁵ In addition, opioids prescribed alongside other drugs can increase the risk of drug-drug interactions in older adults, which can lead to serious side effects.^34,36,37 

Caution should be used when prescribing both opioids and benzodiazepines due to their additive side effects and negative impact in older adults.³⁸ In one cohort study in North Carolina, the National Institute on Drug Abuse reported that adults age 50 and older who misused opioids and benzodiazepines had a 10 times higher likelihood of suicidal thoughts compared with those who did not.³⁸ In addition, opioid use with other medications contributes to polypharmacy (defined as the use of five or more medications),  which contributes to increased drug-drug interactions in older adults and falls.^39-41 Treatment outcomes of older adults using opioids for chronic pain remains uncertain.⁴²

Hunnicutt et al identified that among all long-stay residents in the US NHs from April 1, 2012 to June 30, 2012, 15.5% were prescribed opioids long-term.¹³ On the other hand, Dosa et al reported that 39.3% who were started with LAOs such as transdermal fentanyl were opioid-naive or first-time users, which was problematic given the Food and Drug Administration warning about the risks for adverse effects.¹⁴ Hunnicutt et al further reported that one of seven NH residents was prescribed a long-term opioid despite recent changes to CDC guidelines advising the need to reduce the use of LAOs to treat chronic pain in LTC facilities.¹³ 

A comparative study of all-cause deaths in NHs conducted by Allen et al found a 15% increased mortality rate among older adults considered opioid-naïve and newly prescribed opioids.⁴³ Moreover, opioid-related hospitalization rates and emergency department visits among adults aged 65 years and older increased 150% from 1993 to 2012.^4,44 West and Dart reported a significant increase in prescription opioid misuse among older adults that resulted in serious moderate or major medical outcomes and death.⁴⁵ Any misuse, abuse, or nonmedical use of opioids has consequential effects health, including death. More efforts are required in this area of pain management, particularly the consequences of opioid use in LTC. 

Addiction concerns are not a barrier to prescribing opioids for older adults in some settings.²⁹ This finding was congruent with the study by Griffioen et al, who reported patients’ reluctance to take opioids (83.3%), unknown pain level (79.2%), and pain of unknown origin (51.4%) as reasons for not taking opioids.⁴⁶ Fain et al reported two main factors for fewer analgesic (including opioid) prescriptions in US NHs: (1) resident factors that included being older, having advanced cognitive impairment, and being non-White (black or Asian); and (2) facility factors that included increased self-pay (which means private pay or residents paying on their own) and fewer staffing hours.¹⁶ Similarly, Chang et al found almost half of their participants (n=21) took fewer opioids than prescribed.⁴⁷ 

Research Gaps

Although opioid use among older adults is increasing, few researchers have studied its use in LTC. The LTC population is at high risk for negative consequences; investigating the consequences of opioid use in LTC residents warrants further research. Another research gap was the lack of international research. Although studies were conducted in the United States, Denmark, and Finland, additional international research is needed.

A systematic review of literature related to opioid use in LTC revealed substantial evidence of an increasing trend. LAOs such as fentanyl, oxycodone, and morphine were identified as the most frequently prescribed, yet LAO prescribing in older adults is not in accordance with the current CDC guidelines on opioid use for chronic pain. Furthermore, studies have shown the use of LAOs in LTC puts older adults at higher risk for serious drug effects, such as constipation, sedation, fractures, respiratory depression, increased hospitalizations, and death. Gaps in research warrant further study to elucidate the long-term effects of opioid use among older adults, particularly the use of LAOs, proper opioid monitoring, and robust opioid staff education in LTC facilities.

This synthesis of the literature research related to opioids in LTC residents offers contemporary insight into the state of science concerning this vulnerable population. As the aging population increases and more older adults experience pain that may affect their quality of life, a more expansive knowledge base is required to guide nursing practice. 

Authors: Armiel Suriaga, MSN-RN • Ruth M Tappen, EdD, RN, FAAN

Affiliations:
Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL

Disclosures:
The authors report no relevant financial relationships.

Correspondence:
Christine E. Lynn College of Nursing, Room 315
Florida Atlantic University
777 Glades Road
Boca Raton, Florida 33431
Phone: (561) 297-4949
Email: asuriaga2016@health.fau.edu