Opioids and Older Adults

Marilyn Grimes was 45 years old when she started taking opioids for pain. "I can actually remember saying to myself there's nothing that's addictive that I couldn't quit," she said.

By age 50, she had a problem she could not quit.

She was arrested at age 53 and sentenced to serve 10 years in Indiana for drug offenses. She lost her home and her plumbing business. "I ate those words," she said, "and lost everything."

Grimes' story is not unique. Since the 1990s, millions of people have been affected by the three waves of the opioid epidemic. Overdose death rates have persisted and soared in each wave, with the CDC reporting that the opioid epidemic has killed more than 900,000 people since 1999; 110,236 people died in 2022-2023 alone.

Little has been written about the opioid epidemic's effect on the people aged 55 and over. Data shows that opioid abuse killed 79,893 people in this cohort from 1999 to 2019. Of those victims, 79% were 55 to 64 years old and mostly men.

The numbers continue to increase. A JAMA Open Network study found "a notable increase" in rates of opioid overdose deaths for adults older than 55. Between 2000 and 2020, age-adjusted rates of drug overdose deaths among people aged 65 and over rose from 2.4 to 8.8 deaths per 100,000 people.

Further, the study found that Black men have accounted for a disproportional increase in overdose deaths for all adults since 2013. Overall, emergency room visits for opioid misuse rose 220% from 2006 to 2014, according to the study.

What accounts for these increases? Longer life expectancies, improved access to treatment and harm-reduction services and increased drug availability.

Structural racism and ageism also play a role, said Maryann Mason, an associate professor of Emergency Medicine at Northwestern University. "Living in low-resource communities, the experience and trauma of racism are things that would be associated with illicit drug use, so I feel like it's embedded in this," she said.

At the same time, she added, "we have this idea of grandmas baking cookies when in reality baby boomer grandmas are partying."

Medical personnel typically see two kinds of older patients: those who use opioids in a controlled setting to treat chronic pain and those with a history of regular drug abuse who are now aging along with an opioid use disorder, or OUD.

To treat either kind of patients, physicians, now often primary care physicians, must consider a myriad of conditions, such as kidney and pulmonary function, to determine what role opioid use is now playing in an aging person's body.

A primary motivator for opioid use is chronic pain, a condition, reports the CDC, that was most common in adults aged 65 and older. Chronic pain limits life and work activities, overall functionality and physical and mental health.

"Whether they are using prescription or nonmedical-use opioids, those comorbidities interact with opioids in a way that puts them [patients] at risk for an overdose at much lower rates," said Mason.

With advancing age, uncontrolled use of opioids can alter neurotransmitters in the brain and increase a person's potential for neurotoxicity, or brain damage caused by exposure to a toxic substance. According to a Psychiatrist.com study, if physicians use an opioid, they should introduce it at doses 30% to 50% of those given to younger patients.

A co-author of the study, Dr. Roopa Sethi of the University of Kansas Health Systems, found that opioids take a much greater toll on older adults than younger persons. Why? Because a younger person's body will metabolize opioids much slower than an aging person's body will metabolize.

"Typically, the organ systems become slower, so they tend to retain medications, drugs or illicit drugs longer," Sethi said. "Their liver metabolism decreases. Kidney function decreases, so these drugs are in their system hanging out for longer periods.

"As people age, they have more adipose tissue [fatty tissue], which means more fat and less water content in the body." As a result, Sethi said, opioids will stay longer in their system because they are released more slowly from those fatty tissues.

Because of this, older adults must be more cautious when using opioids. In addition, people with OUD or who use opioids for pain management must be aware that using opioids can complicate existing medical conditions affecting the kidneys, lungs or heart.

A good physician will screen for opioid use and the functionality of the person using opioids. Because of the press coverage of the opioid epidemic, aging patients may be afraid, reluctant or refuse to take opioids even when they are medically necessary.

The same is true of some physicians. Because training on the use of opioids is not universal, some physicians may not be confident about assessing an aging person who has OUD due to this lack of training and education. "I routinely hear that this is a population with a bias against prescribing opioids for them," said Mason.

After the FDA in 2017 adopted new regulations governing prescribing practices, some physicians felt pressured by various regulatory bodies, licensing boards, their institutions and even by insurance companies and pharmacists to stop prescribing opioids for pain treatment, said Dr. Ben Lai, a family medicine specialist at the Mayo Clinic in Rochester, Minnesota.

Opioids are critical to treating older adults with chronic conditions such as osteoarthritis, cancer and other chronic diseases. Without it, older patients who have long relied on opioids to manage chronic pain may suddenly find themselves rapidly tapering off or unable to fill their prescriptions.

As more and more physicians were becoming uncomfortable with prescribing opioids or with not being trained on pain management and safe use of opioids, "we had a kind of patient abandonment," said Lai.

What is safe use? Patients who take opioids for pain or chronic disease or even those for OUD must be evaluated for functionality and actual use, said Lai. Can that person walk with no trouble? How do they function in daily life? Do they have pain, and to what extent? What is their cognitive function? And what other medications do they use?

"While we often see our patients fleetingly," said Lai, "we must have a good patient-centered approach to their care, opioids or not."

Alternate pain treatments might include physical therapy, yoga, massage, or even exercise because, as Lai said, "motion is lotion" to an aging body.

People with OUD who depend on opioids and cannot manage their use may find their pain worse because opioids can sensitize nerve endings. Plus, as their bodies adapt to a medication, patients may need to take it more often to feel its effect. But increased use of opioids often comes with side effects like constipation, cognitive impairment, nausea and increased risk for overdose.

Despite the challenges she and others face with OUD, Marilyn Grimes reinvented herself out of opioid use disorder. Released from prison at age 57, she went on to earn a bachelor's degree in social work.

She now lives in Bloomington, Indiana, and manages Courage to Change Sober Living, a 12-step, low-barrier sober living environment for recovering addicts, helping others get back on their feet. She's found her way out, and now she's helping others find their way out too.