A TGB READER STORY: The Stairs
Scheduling Old Age

Old People and the Opioid Problem

On the day after my 12-hour Whipple surgery in June 2017, as I lay barely conscious in a hospital bed, a doctor put something in the middle of my back that I later learned delivered fentanyl to my body to control post-surgical pain.

It stayed there for three days and because of that, I know exactly how people become addicted. When the doctors busted me down to Tylenol along with some other over-the-counter pain killer, I yearned for, lusted after fentanyl.

The OTC drugs cut the pain to a tolerable level but oh my god, did I miss the feel-good part of fentanyl. I wanted to keep feeling that way. Forever.

Now, the United States is caught up in “the opioid crisis” and I am not here to doubt it. People are dying from opioid overdoses by the tens of thousands a year. According to the U.S. National Institute on Drug Abuse (NIDA) (emphasis is mine),

”More than 70,200 Americans died from drug overdoses in 2017, including illicit drugs and prescription opioids - a 2-fold increase in a decade...

“Drug overdose deaths involving prescription opioids rose from 3,442 in 1999 to 17,029 in 2017.”

When counting all opioid deaths, young people die in much larger numbers than old people. But two age groups in one category - prescription opioids - are just about even according to the U.S. Centers for Disease Control (CDC). They report that in 2017, deaths numbered 1,100 for people 24 and younger, and 1,055 for people 65 and older.

In an effort to combat these terrible numbers, the medical community, reports the Washington Post, is conducting

”...a sweeping change in chronic pain management — the tapering of millions of patients who have been relying, in many case for years, on high doses of opioids.

“With close to 70,000 people in the U.S. dying every year from drug overdoses, and prescription opioids blamed for helping ignite this national catastrophe, the medical community has grown wary about the use of these painkillers.”

I have personally seen the difference in prescriptions related to my cancer. When I left the hospital after that surgery in 2017, I was handed a bottle of oxycodone (or oxycontin – I don't recall which) to take home with me for pain control.

As it turned out, I didn't need it and I later recycled the pills at a drug take-back day in my community.

In the past few months, I have had trouble with severe joint and body pains and opioids were never mentioned. It was suggested, instead, that I take certain over-the-counter pain pills three times a day.

When normal dosages were ineffective, the doctor didn't offer a prescription pain killer. He told me to double up on what I was taking. That worked fairly well, but nothing like fentanyl. When the pains subsided a good deal after a couple of months, I cut back to the normal dosage which I need now only once a day most of the time.

But I wonder if I might have been able to skip the weeks of all-day, all-night pain with an opioid. Here's a short video from the Washington Post story about one man's pain predicament:

This is happening to elders and others with chronic pain all over the U.S. The Washington Post explains further:

”Hank Skinner has been tapered gradually over the course of the year. The situation is worse for people forced to cut back their medication too quickly.

“Even medical experts who advocate a major reduction in the use of opioids for chronic pain have warned that rapid, involuntary tapering could harm patients who are dependent on these drugs.

“There is little doubt among medical experts that opioids have been prescribed at unsound and dangerous levels, particularly in their misuse for chronic pain. But at this point there’s no easy way to dial those dosages back.

“Long-term use of opioids creates dependency. Tapering can cause extreme pain from drug withdrawal, regardless of the underlying ailment.”

So the medical system's cutback on opioid prescriptions appears to be a case of throwing out the elders with the bath water.

Let's be clear about this: very few elders are taking fentanyl or other opioids recreationally. Old people did not cause the opioid crisis.

Lots of old people have lots of pain. Cutting their opioid drugs or recommending over-the-counter drugs instead, is causing them harm, they are suffering as one TGB reader, Elizabeth Rogers has been telling us here for quite awhile and she's angry about it. From last Saturday's comments:

”...ongoing physical pain is a significant challenge,” she writes. “Thanks mostly to 20-somethings who overdosed on illicit opioids used recreationally, our omniscient government cracked down--on chronic pain patients, many of whom are 60+, and their physicians.

“DEA raids on doctors' offices haven't done much to reduce overdoses among 20-somethings from heroin and fentanyl, but they have without question had an impact on patients who have used prescribed pain medications responsibly for years.”

Last year, WebMD reported on a study of opioid use from the Agency for Healthcare Research and Quality (AHRQ):

”...millions of older Americans are now filling prescriptions for many different opioid medications at the same time, while hundreds of thousands are winding up in the hospital with opioid-related complications...

“AHRQ's second report found that nearly 20 percent of seniors filled at least one opioid prescription between 2015 and 2016, equal to about 10 million seniors. And more than 7 percent - or about 4 million seniors - filled prescriptions for four or more opioids, which was characterized as 'frequent' use.”

I'm no physician but yes, I would guess that that number of opioid prescriptions at once is a bit over the top.

My point, if I've be too verbose for it to come through, is that it is wrong, as always, to lump all people together. It is younger people who most often abuse drugs (and we as a country need to be helping them). But old people should not be caused to suffer pain when there is a remedy; their lives are harmed by being denied them.

The secondary issue is that I have no idea what to suggest on how to correct this. I have no suggestions and no advice for Elizabeth Rogers or anyone else to restore needed drugs for elders who suffer with chronic pain.



Comments

Yes, I used a generic Vicodin when working. My last day I took 4 to keep my pneumonia under control. My last day before retirement was February 28, 2019. I stopped the next day entirely. I had taken these pills since about 2009. No problems. They are a tool, not an escape to me. Yes, we elders DO get lumped in with the addicts. Recreational use to me was about 50 years ago and included speed, LSD, and weed. Times change, and alcohol became my release. Now I use opioids only as needed. By the way, the military still supplies opioids as prescribed at no cost at military hospitals and pharmacies. I guess to sum it all up, why are the elderly punished for the mistakes of the young?

Excellent post. Growing up, I believed that doctors were gods. I am now aware of how falibie they are and how we need to be informed to ensure that we can advocate on our own behalf when we think our doctor is making a mistake.

May I suggest that doctors be allowed to treat their patients. Admittedly many doctors were pushed to overprescribe opiods by sales pitches from Pharma. However there are better ways to correct this. Better medical education, crack down on abusers with better awareness of patterns, or offer alternnatives that are not pablum like get more exercise.

I am old and decided to wean myself off drugs because the handwriting was on the wall and I did not want to fight the system. Although I had always used only half of the prescribed dosage, It was a long and painful process. I've watched other people who have never taken more than prescribed be tapered too fast and live in agony. The underlying cause of pain is never addressed. We continue to live in pain and lose function and joy.

We should not be scapegoated.

Good essay Ronnie.

The opioid crisis is so multi-faceted. For instance, we know there is a crisis by the number of deaths but so many news releases emphasize the number of opioid prescriptions filled for old people. 1) Filling a prescription is not the same as taking the medication. I had a prescription filled that turned out to be for 50 tablets of opioid; however, I took exactly 3 of them, comprising my life-time consumption and that was 10 years ago. Husband had a similar experience 2 years ago when he took 7 tablets comprising his life-time consumption. 2) Younger family members/friends/casual workers have been known to steal the pills from old people who suffer from cognitive impairment.

Another facet of the crisis is reflected in today's headline, "Military veterans are at the epidemic’s forefront, a new study says", which is a whole different thing that Bernie Fleming mentioned, above.

Great post as usual, Ronnie. And I agree with the comment about the insurance companies thinking they should be telling the doctors how to practice medicine (how the hell did that stupid idea that an MBA equals—or is even greater than!—an MD get started anyway, for crying out loud?! I bet Harvard Business School was at least one of the instigator, them with their policy of telling 23 year olds that they will and should be the masters of the universe, sigh). And for those who are lucky enough that they get some relief from natural stuff like marijuana, that’s great but for those of us who are allergic to it and can no longer get the medication (in my case darvocet which was taken completely off the market and 6 (six!) MDs told me it shouldn’t have been since it was a perfectly good drug) that helped us, we’re out of luck ( and in pain all the time); what a way to spend one’s old age, huh?

Good post!

I've only recently 'outed' myself as an opioid user. My pain is chronic, severe and complex and nothing else works - or is affordable. I can continue to work only bec I can control pain.

I laugh: I've never been "high" - tho' of the generation that got high on pot; I didn't. I've been drunk only twice and not falling-down-acting-stupid-Kavanaugh drunk! I've written testimony to the FDA, contacted the writers of the Wash. Post article and many other reporters who never return my calls or emails, and wrote to two Senators and a member of Congress who want to outlaw opioids sending my FDA testimony. Only one Senator responded w/ a generic letter .. that I was not a constituent so .. buh-bye.

My primary care doctor and pharmacist monitor my 'scripts closely. I am restricted in use and have even cut myself back as Jill notes (tho' I've not weaned off bec I couldn't function bec of pain) bec I fear the outlawing of the drugs or huge curtailment a cousin has experienced in FL.

Yes, chronic pain patients who have found no other way to manage are being thrown out w/ those who have abused the drugs. Oddly, no one is outlawing alcohol tho' many use it in the same way they use drugs. No one is outlawing nicotine (outside of vaping) tho' smoking causes many deaths and second and third hand smoke is making many of us sick.

With no voting representation in Congress as a DC resident, I have no help and no one to advocate for me.

It is stunning that it's all or nothing with these v. other drugs like nicotine, and like alcohol.

I want to live and work and to do so effectively and cannot without the help of medication.

Thanks, Ronni, for opening this up wider.

Great post and writing. You make everything so clear.

What's funny is how the government makes such a huge deal out of opioid use but does nothing to stop the flow of heroin on the streets.
In my neighborhood people shoot up openly on the streets and have no fear about dealing on the corner.
Excellent post!

The four-different-types might in some cases represent, say, four surgeries or injuries within that time period, with short-term pain relief being prescribed by four different doctors, each of whom default to a somewhat-different opioid for pain relief - or, alternatively, might be someone trying to figure out which level/type of medication works best for them out of the various options available (my insurance has had fits before because of dosage level changes [for non-opioid medications] being less than a month apart; guess what? It does not take a full month with some medications to figure out that a particular dosage is too much or too little! And they don't let you just get 3 days or a week's worth of a new medication to try out and then adjust, aggravatingly; it's a full month or nothing, which can be incredibly wasteful and expensive).

If the four different medications are simultaneous prescriptions and refilled, though, then yes, I'd smell a rat...

But the "easy" way out of just banning them all and leaving many people in unnecessary and extreme pain: not an acceptable answer.

This is one of my greatest fears -- that someday if I'm in great pain I will not be able to get the drugs needed to control it. My pain threshold is so low that I sometimes describe it as "I take aspirin for hangnails." Honestly I think I fear pain more than death. And now the abuse and excesses of others has increased the likelihood that old people with chronic or severe pain will be denied the drugs to control it, even though the drugs exist.

I agree, Susan; I too fear pain more than death. And I agree with you that the abuse & excesses of others [I'm thinking you're maybe referring to patients or addicts here?] has led to this problem; but I think there's a lot of blame to go around, namely the insurance companies who seem to have decided that they're better at deciding who's addicted to a drug than the patient's own doctor...no wonder more & more doctors are retiring early and fewer & fewer people are even deciding to work in the medical field in the first place; I know it'd bother me to work my butt off for years becoming an MD (or a PA or an RN, LVN, CNA, whatever) and then some ins. company CEO thinks they know better than me...what nonsense!

It's gratifying to see that others share this problem--not the pain, of course, but the restrictions on effective treatment for it. I am indeed angry for all the reasons noted above but mostly because I think the government has NO business practicing medicine. Last I heard, DEA agents weren't required to attend medical school! I'm a lifelong left-of-centrist politically, but this situation is a major case of government overreach.

I considered long and hard before "outing" myself as taking a low dose of an opiate-based medication (Tylenol #3), legally prescribed and responsibly used. There's a HUGE difference between a 20-something who downs a handful of pills at a party--often washed down with alcohol--and an older person with painful medical conditions who takes prescribed medication in compliance with today's MANY rules and restrictions. I have been compelled to sign a punitive "pain management contract" and submit to urine testing. I live in fear of being arbitrarily cut off or involuntarily tapered. These are the "Golden Years"?

Without question, overdoses are tragic, especially when they involve young people, but that's only one side of a multi-faceted story. It's true that until about 5-7 years ago some unscrupulous doctors overprescribed, and pill mills operated openly in some states. Those days are long gone. In my state opiate-based medications are now closely monitored and restricted. Twenty-eight days means 28 days. A refill, IF approved by all parties involved, cannot be picked up until Day #29. I cannot imagine anyone being able to obtain 3-4 Rx's for opiate-based meds these days! The statewide computerized drug monitoring system would catch it; the person likely would be labeled a "drug seeker" and denied all further pain medication in perpetuity!

Yet, restricting meds for people in pain, many of whom are elders, has not resulted in a significant drop in overdoses among teens and 20-somethings. Business has never been better for fentanyl labs in China and local illicit drug dealers. Teens can probably score an opioid at their high school more readily than many elders can obtain a legal prescription for needed pain medication.

I don't have "the" answer--the issue is nuanced and complex. I do know, however, that serious pain has stolen much of the joy from what remains of my life. I have tried many "alternatives" with very limited success (I cannot tolerate NSAIDs, unfortunately, and plain Tylenol is ineffective). I guess all I can hope for is that some degree of balance will return to the system and that my physician will be able to practice without fear of losing her license or being raided by the DEA for doing her job.

Hello, I have not had any problems getting my oncologist to prescribe opiods. Having stage 4 cancer I guess makes it okay as I am likely to die within a few years anyway. But, having seen the damage that opiods can do within the family, I have been very leery, and am waiting until I absolutely need to take them... maybe the last year or so when the cancer spreads into the rest of my bones.

What I have seen in my family is a person taking opiods needs a larger and larger dose over time to get the same pain relief. Add alcohol to the high dose, and the euphoric feeling is increased. Taking away the opiods leaves the person totally in pain as the body no longer can manage pain naturally.

I also take Tylenol with codeine #3 at a low dose for arthritis pain. I do not increase the dose. NSAiDs and aspirin gave me acid reflux and stomach problems (gone since I quit them). I also had asthma caused by acid reflux (was quite surprising when an allergist pronounced this). The asthma is also gone now, since I do not take NSAIDs or aspirin. My doctor is reasonable and just said not to take aspirin and NSAIDs anymore.

I think part of the problem with opiate abuse (or with underprescribing for people in real pain) is that doctors do not have time to sit with each person and get to know their real needs and situation (“slow medicine”). So medicine follows whatever the trend is (give more opiates! No, limit them-they are bad!!), rather than looking at individual needs. Also, elders are overlooked, in general, when it comes to thinking these things through.

I have several family members who are on strict pain plans as Elizabeth describes above (her description was accurate). One person got hit by a Google bus while in a crosswalk (I know, it’s a San Francisco thing, but they are huge buses made to transport Google workers), but needs to work to support a family.
Anyhow, all have legitimate reasons. The pain plans are very strict with drug testing (they even test for marijuana use), not allowing the person to go over the prescribed amount etc. They also require that the opiates be stored carefully in a locked box and that only the recipient has the key (in case of burglary or young relatives stealing, I suppose).

Maybe other states do not have these restrictions, and tragic deaths from opiates should not be happening, but there is a trend and a backlash that is currently harming people in pain. And, by the way, is there any harm in a person in the last months of their life becoming dependent on a pain killing drug that increases their quality of life?

I follow @ThomadKleinMD on Twitter. Long-to-short, apparently CDC is intimidating health providers into torturing people in pain by denying the pain med of choice of the ages with puritanical policies and not addressing addiction.

Yes, intimidation of physicians is a popular tactic in our quasi-police-state. One thing I neglected to mention in my earlier post is that physical dependence on a medication in and of itself is NOT addiction. There is ample supportive research. IMO, the inability or unwillingness of officials and regulators to separate dependence from addiction definitely has contributed to the current overreaction to the "opioid crisis".

Most people can develop physical tolerance/dependence if a drug is used over a period of time. Yet, among pain patients using medication responsibly, as prescribed, addiction is rare. People in their 70s and 80s are not the ones keeping heroin/fentanyl dealers in business. Although some elders may combine high dosage opiate meds with alcohol and other drugs, based on what I read and hear, I do not think that is a common practice.

No question, addiction is life-destroying and can be tragic. Pursuit of a drug-induced high can take precedence over all other aspects of life. Health, families, jobs, homes and financial security can be lost--as can life itself. This is one side of the story and usually the only one we hear today.

However, responsible use of medication is life-affirming for those living with chronic pain. It enables us to continue functioning, albeit at a reduced level. It can help elders continue to live independently and prevent or delay the need for long term care. To me, that makes major sense not only on a humanitarian level but also from the standpoint of cost-effectiveness.

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