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Summer 2008 | Vol 11 No 4

Q & A

Common questions about prescription pain medication

By Angela Pirisi

What proportion of older adults uses pain medication?

Although adults aged 65 and older make up approximately 13 per cent of the population in Canada, they consume 20 to 40 per cent of all prescription drugs and 25 per cent of all over-the-counter drugs, according to the Public Health Agency of Canada. A report by Partners Seeking Solutions with Seniors in Winnipeg, Manitoba, found that older adults fill an average of 15 prescriptions a year and often take up to 10 different medications at one time. About 60 per cent of community-dwelling older adults use pain medications regularly, according to Dr. David Lussier, director of the Geriatric Pain Clinic at the McGill University Health Centre in Montreal, Quebec. About five per cent use opioids [narcotic painkillers]. The most common pain medications used by older persons are non-opioid analgesics like acetaminophen.

What is the difference between medication use, misuse and abuse?

“Medication use has to be viewed on a continuum,” says Estela Torres, an older adult outreach counsellor with Richmond Addiction Services in British Columbia. “Use is taking medication for a specific purpose, usually with a time limit (for benzodiazepines; opioids and other classes may be long term). With misuse, medication is used beyond the intended recommended time period and to address other problems than it was prescribed for, such as using sleeping pills and tranquilizers as mood enhancers or painkillers as sedatives. If it continues, the body develops tolerance to the drug, which signals abuse.”

What prescription and non-prescription drugs carry greater risk of misuse and addiction?

Torres says that alcohol, benzodiazepines and nicotine tend to be the three most commonly abused substances in older seniors, while younger seniors tend to abuse illicit drugs more, such as crack, cocaine and marijuana. As the baby boomer generation ages, the number of cases among older people is expected to rise, given a more liberal attitude towards such drugs.

Older adults are much less likely to misuse opioids, says Dr. Roman Jovey, physician director of the Addiction and Concurrent Disorders Program at Credit Valley Hospital in Mississauga, Ontario. “Older patients are less likely to develop opioid tolerance but are more sensitive to opioid side-effects, such as constipation.”

What are common reasons for medication misuse and abuse among older adults?

Misuse is much more common than abuse, says Lussier. “Misuse is most often accidental, due to inadequate understanding of the proper dosing,” he says. Risk factors for misuse are taking several medications, lack of information on how to use the medications, functional impairments like decreased vision and cognitive deficits. As for abuse, “even though it is rare, pain medication abuse is possible in older adults, and is more frequent in those with a history of substance abuse,” says Lussier.

Depression, loneliness, chronic pain and boredom may also lie behind abuse, says Torres. Moreover, “some older adults were raised with the belief that pills offer solutions for everything and they look up to a doctor to fix things,” she adds.

What concurrent conditions may accompany pain?

“Many patients with chronic pain often have concurrent mental health conditions, such as anxiety or depression,” says Jovey. Impaired quality of life, secondary to the pain, may be evident as depression, anxiety, sleep disruption, appetite disturbance and weight loss, cognitive impairment and limitations in daily activity performance, according to the International Association for the Study of Pain.

Some older adults use alcohol to self-medicate, to nullify emotions or physical pain, explains Torres. Nurses and outreach workers should consider that medication misuse or abuse could signify that older adults are using pain medication to deal with these secondary problems. Effective pain management can help to treat these secondary symptoms, according to guidelines from the American Geriatrics Society. “Sometimes, treating pain will help depression, and treating depression can make pain treatment more effective,” says Jovey. “Some physicians like to treat both at once, and others treat one, then the other. I try to treat the pain first, then the depression.”

Why might some older adults be overprescribed or underprescribed?

For pain, older adults are much more likely to be underprescribed than overprescribed due to the common belief that pain is a normal part of aging, fear of addiction and side-effects and underreporting of pain by older adults. “Overprescribing is most often related to a physician’s lack of knowledge about pain management in older adults and the use of inappropriate medications,” says Lussier. “For example, if a person suffers from anxiety related to chronic pain, it is better to treat the pain than to prescribe benzodiazepines. Or if the person with chronic pain has depression, an antidepressant will be more useful than increasing opioid doses. Likewise, neuropathic pain will often require an adjuvant analgesic such as an anticonvulsant or antidepressant rather than increasing opioid doses.”

What does support for older adults with prescription medication misuse or abuse involve?

“You have to look at the whole picture to see if there is a problem,” says Torres, who does home visits. “Signs of benzodiazepine abuse include frequent falls, bruises, abdominal discomfort, disturbed sleep patterns, confusion and memory and cognitive impairment. Clues about alcohol abuse include money troubles, weight loss, tremors, diarrhea, vomiting, an unkempt appearance, a chaotic home setting and frequent admission to hospital for injury.”

“Young seniors may self-refer because of growing awareness,” says Torres. “For others, we refer them to a case manager. We use a two-pronged approach that includes psychosocial and medical components. The psychosocial part consists of support, education and exploring coping skills. The medical side, handled by a doctor on staff, includes a tapering schedule that involves reducing medications by very small amounts.”