Gently Euthanizing the Elderly

It is well-known the elderly are at higher risk for medication adverse effects.  It is, likewise, recognized opiates are one of the most dangerous prescription medications in use.  Therefore, the prudent thing to do would be avoid opiate use in the elderly – and, certainly, not be irresponsible regarding multiple, concurrent prescriptions for opiates.

However, as this 20% random sample of Medicare beneficiaries demonstrates, an estimated 5.2M Americans covered by this insurance source received opiates – with approximately 85% of this cohort aged greater than 55.  Most patients who received opiates filled more than one prescription – including a full 7% who received >4 prescriptions, from >4 different providers.  This last group received a mean number 15 opiate prescriptions in a single calendar year.  Unsurprisingly, increased opiate prescriptions were associated with increased subsequent hospitalizations.  While there is no mortality data in this report, I don’t think it’s a stretch to speculate the illness-adjusted outcomes would be much poorer.

The use of opiates for pain control for acute and chronic illness is a necessary evil, particularly in the elderly.  This study, given its limitations, cannot precisely elucidate whether the opiates provided represented irresponsible prescribing – but it supports much of what we anecdotally observe regarding the fragmented healthcare process.  Whether the magnitude of the problem is as great as these authors seem to suggest, there should be no argument we have plenty of room for improvement in treating some of our most vulnerable patients.

“Opioid prescribing by multiple providers in Medicare: retrospective observational study of insurance claims”
http://www.bmj.com/content/348/bmj.g1393