Opioid Misuse in Older Adults
Substance use disorders affect people from all walks of life, but, when we hear about opioid abuse, we tend to think of teenagers or young adults. Unfortunately, opioid misuse in older adults is also a serious problem. It occurs most often when older adults misuse or abuse their own prescription medications, or when they intentionally take medications prescribed for other people. In a survey of adults ages 50 to 80 years, only half reported switching from an opioid to an over-the-counter (OTC) pain medicine as soon as possible (University of Michigan, 2018). About 1 in 20 admitted taking an opioid more often and in higher doses than prescribed. Most of the respondents said they kept leftover opioids in case they needed them later-a primary cause of prescription drug abuse and dependence (University of Michigan).
The Causes
Age-related physical and emotional changes appear to be reasons why older adults might misuse opioids. These changes may lead to boredom, depression, fear of aging, financial loss, health concerns, and chronic pain (Drug & Alcohol Rehab [DARA], 2019). Conditions and disease states that result in pain, such as arthritis, nerve damage, or cancer, are more common as people age. Older adults are also more likely to have mobility issues, sleep problems, and undergo painful surgical procedures, such as joint replacements (DARA; University of Michigan). They also may experience loneliness, social isolation, and anxiety from life events such as loss of employment or death of a spouse. Doctors often prescribe medications (e.g., benzodiazepines for anxiety and sleep disorders, opioids for pain) to improve quality of life. However, these medications can be the source of adverse effects and prescription drug misuse.
Signs and Symptoms
It can be very difficult to identify opioid use disorder in older adults. We are more familiar with identifying drug abuse in younger people when they are unable to fulfill work/family commitments. Older adults may have fewer commitments, making it harder to identify the signs of drug abuse. Some of the more noticeable symptoms of drug abuse in older adults are changes in appearance, behavior, or health that mimic symptoms that are commonly associated with aging, including: frequent falls and unexplained bruises; nausea/loss of appetite; sudden weight loss/gain; sleep disturbance; drowsiness/confusion; agitation; slurred speech; change in personality; deterioration in personal grooming; and loss of interest in activities they once enjoyed (Burke, 2018).
Safe Practice Recommendations. Know the physical and behavioral signs of prescription drug abuse. If you suspect an older patient is misusing a prescription medication, discuss your concerns and provide an opportunity for them to disclose any related concerns. Refer the patient to their doctor and/or a local substance abuse treatment program for evaluation and treatment. Be proactive and develop a local resource list that will be readily available.
It is critical to provide education to older patients or their caregivers when dispensing medications with abuse potential. Discuss the purpose and prescribed dose of each medication. When taking opioids for pain, encourage patients to switch to OTC medicines as soon as possible and discuss alternative treatments such as physical therapy, exercise, and acupuncture. Remind patients to avoid alcohol when taking opioids and teach them how to properly discard any leftover medications, including prescription drug disposal locations.
Give Thought to How "Thousand" and "Million" Are Expressed
When looking at wholesaler (AmerisourceBergen) listings for RETACRIT (epoetin alfa-epbx), a biosimilar to EPOGEN and PROCRIT (epoetin alfa), a pharmacist noticed that the strengths were listed differently. The Procrit vial containing 20,000 units was listed as "20K UN/ML," whereas the Retacrit vial containing 10,000 units was listed as "10M UN/ML." Although it is safest to avoid abbreviations for thousand, the failure to use a standard abbreviation adds to the risk of confusion. The letter M has often been used for millions (or MU for "million units"), and the letter K (kilo) is a popular abbreviation for thousand (as in a 10K race). However, M is the Roman numeral for 1,000, and it has been used at times, as it was here with Retacrit, to represent thousand. Although highly unlikely to be misunderstood in the case of epoetin, use of the abbreviation in another situation could potentially lead to a 1,000-fold error. We hope AmerisourceBergen avoids using these abbreviations or at least standardizes to K.
In healthcare, instead of using these abbreviations in computer listings, we believe that expressing large doses using words or numbers is safest. When deciding between words and numbers, consider that the words "million" and "thousand" carry nearly the same number of characters as its corresponding number but are less prone to confusion. This is because the words "million" and "thousand" exhibit different and more distinguishable characters, whereas 100,000/1,000,000 or 100000/1000000 are very similar, especially when commas are omitted or misplaced. As ISMP advisor Dr. John Senders, a human factors engineer and psychologist, points out, if all doses were written as a word, the occasional dropped or deformed character would still result in interpreting the correct meaning. For example, "one hundred thousand" would still be understood as 100,000; however, a dropped zero in 100,000 would change the number to 10,000. If doses in the thousands or millions are expressed as numbers (some situations may require numbers for dose calculations or electronic alerts), properly spaced commas (e.g., 5,000) are necessary to ensure understanding.
Enoxaparin Syringe Failures
The FDA and ISMP have received multiple reports from practitioners and manufacturers about enoxaparin prefilled syringe failures and inadvertent activation of the needle safety mechanism. The syringe manufacturers mentioned in the reports include Sanofi, which provides the brand, LOVENOX, and various generic product manufacturers (e.g., Fresenius Kabi, Winthrop, Amphastar Pharmaceuticals [IMS Limited], Sandoz, Teva [not manufacturing enoxaparin at this time]).
In 2018, 42 reports were submitted by manufacturers and practitioners to the FDA Adverse Event Reporting System (FAERS). Additional events of the same nature were reported to ISMP. Of the FAERS reports, all described problems with the syringe safety mechanism, such as: the syringe broke apart when engaging the safety mechanism (n = 22); the mechanism did not or was difficult to engage (n = 12); and the mechanism engaged too soon (n = 5). Three reports described problems with the safety mechanism but were not specific about the malfunction. Twenty-one events involved needlesticks (multiple cases in some reports), including one after the syringe had been used for a patient with human immunodeficiency virus (HIV). Three of the events were associated with underdoses; two involved missed doses; three involved embedded needles (e.g., x-ray showed an embedded needle in one patient's abdomen). The events involved both administration by healthcare professionals (n = 23) and patients (n = 19). The problems are not limited to a single-strength product. ISMP has asked FDA to look into the problem further.
Practitioners and patients handling these syringes should always point the needle end away from themselves and others, including the patient, until the moment of injection and after injection when activating the safety mechanism. Check with the company that supplies your enoxaparin, as some offer free educational materials and syringe disposal equipment for patients to support safe use.
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