Originating from the noble desire to ease the physical pain of our fellow human beings, the use of opioids has evolved into a catastrophic epidemic: billions of dollars in lost productivity; unprecedented health care costs; crime; the destruction of lives, families, and communities; and a death toll that far exceeds that seen in world wars. Every eleven minutes an American dies from an opioid overdose, according to the CDC statistic that 130 Americans die daily from opioid overdoses (CDC, 2018).
Prescriptions and sales of opioids in the United States have tripled since 1999 (Guy et al., 2017). While Americans account for less than 20 percent of the world’s population, they consume more than 80 percent of the world’s opioid supply and 99 percent of the hydrocodone supply (Manchikanti, 2007). Prescription opioids are the most significantly misused, doctor-prescribed substance, resulting in nearly 400,000 opioid-related deaths since 1999 (Scholl, Seth, Kariisa, Wilson, & Baldwin, 2019).
The enormity of this crisis has created greater need for treatment programs for the prescription- opioid-abusing population—ones presenting with novel challenges to recovery. Many patients struggling with opioid use disorder (OUD) began their troubled journey with a legitimate prescription for opioids; nearly 80 percent of heroin users reported using prescription opioids prior to heroin (Jones, 2013). Whether postsurgical or injury-related, pain is the common denominator for countless OUD patients.
Data collected through the research program at Foundations Recovery Network, the Addiction Services Division of Universal Health Services (UHS), reveals significant trends and characteristics among the OUD population that have important implications for treatment of these patients. The information presented in this article represents intake data collected on patients from across the country who completed treatment at one of their five facilities.
Intake data revealed that, when questioned about behaviors during the month prior to treatment, patients in their early fifties and older report the highest abuse frequency of prescription opioids, as well as the highest frequency of medical issues. Specifically, patients were asked the following two questions at intake:
We identified a strong correlation between increasing age and increasing prescription opioid use and medical issues. This finding raises significant implications for treating substance use disorder (SUD) patients in their fifties and beyond.
There are a number of possible reasons why patients in their early fifties and beyond report the highest frequency of abuse of prescription opioids. Firstly, as people age, the incidence of normally occurring chronic conditions increase, simply because with every passing year, our bodies are likely to be subjected to more external influences and the natural toll of aging slowly degenerates the body. Secondly, advanced age offers greater opportunities for past injury as well, simply by virtue of the greater number of past years in which injuries could have occurred. Thirdly, older adults are the fastest growing segment of the US population, with the population aged fifty or older estimated to increase 52 percent by 2020 compared to 1999–2001 estimates (Neve, Lemmens, & Drop, 1999; Colliver, Compton, Gfroerer, & Condon, 2006). Furthermore, the interest in treating older adults has also been increasing. A PubMed search of the term “older adults” yielded fifty-six articles in 1970, 2,519 in 1990 and 14,732 articles in 2013. Very little of the literature focuses on the problems or misuse of prescription medication (Rosen et al., 2013). Among adults aged fifty to fifty-nine, significant increases in the nonmedical use of prescriptions have been reported between 2002 and 2012, and between 2002 and 2012 illicit drug use in adults aged fifty to sixty-four has increased up to 7.2 percent (SAMHSA, 2013).
In a large, nationally representative sample, “bothersome pain” in the last month was reported by half of the community-dwelling older adult population of the US in 2011 (Patel, Guralnik, Dansie, & Turk, 2013). In this study, pain was strongly associated with decreased physical function with the inability to do some of the most fundamental tasks that underlie daily function was 70 to 80 percent more common in older adults with pain than in those without pain (Patel et al., 2013).
Substance use is often under-appreciated in the older adult population (Eden, Maslow, Le, & Blazer, 2012). In older Americans the most commonly abused substance is alcohol (Lin, Zhang, Leung, & Clark, 2011) and results from analyses of the Foundations Recovery Network data reveal that older adults are significantly more likely to abuse alcohol that their younger counterparts (Morse, Watson, MacMaster, & Bride, 2015). Even “socially normative” drinking has significant implications for the safety of patients who are taking prescribed pain medications. Adding any amount of alcohol to opioid-treated patients can depress the respiratory system and result in serious, permanent health problems and increase the likelihood of overdose and death.
Health care in the US has its underpinnings in the acute care model, originating when the population was significantly younger. As individuals and the population ages, however, chronic disease becomes the norm (Eden et al., 2012) and the experience of pain is more likely (Patel et al., 2013). The World Health Organization (WHO) reports a gap between the type of care needed and the type of care available for older adults, particularly those with mental health issues and SUDs (Kohn, Saxena, Levav, & Saraceno, 2003). The increasing rates of older Americans at risk for SUDs and the prevalence of pain reported in this population, multiplied by the sheer volume of the cohort, suggest that special attention should be given to developing and evaluating mental health and substance use treatment methods for this population (Morse et al., 2015).
Traditional substance use treatment has focused on a two-pronged approach that integrates SUD treatment with mental health disorder treatment as evidence developed in the 1980s by the Substance Abuse and Mental Health Services Administration (SAMHSA) and partner organizations demonstrates that these two conditions often co-occur. SAMHSA went on to write TIP 42: Substance Abuse Treatment for Persons with Co-Occurring Disorders (2013), their definitive guide which gives SUD treatment providers information on mental illness and SUDs and discusses terminology, assessment, treatment strategies, and models. Following that, the Dual Diagnosis Capability in Addiction Treatment assessment and toolkit was developed at Dartmouth University to assess and score the level of program readiness and integration in addressing both SUDs and mental health disorders.
While undoubtedly patients have presented at treatment with medical issues as well, it has not been a topic of significant conversation in the treatment provider industry. This raises the question of whether treatment providers need to begin focusing instead on a three-pronged approach: addressing the needs of addiction, mental health, and physical health in patients presenting for substance use treatment, especially patients aged fifty and older. Many programs address emergent medical issues, such as unmanaged hypertension or diabetes, but do not holistically plan for patients’ medical health during treatment and following discharge.
Higher rates of comorbidity, risks for worsening health related outcomes, and competing diagnostic symptoms in older adults prompts the need for special consideration during treatment planning, specifically for older adults presenting with co-occurring disorders (Wuthrich & Rapee, 2013). Further, engaging the older adult population in mental health treatment is challenging due their reticence in prioritizing treatment among multiple overwhelming life stressors including chronic health conditions and other cognitive, emotional, and/or social issues (Proctor, Hasche, Morrow-Howell, Shumway, & Snell, 2008).
With all of this in mind, crafting individualized treatment plans with a consideration towards age would allow for a greater attention to multiple aspects of this populations’ needs. Creating integrated systems that support comprehensive treatment plans for all patients and addressing their specific needs would include both mental health and medical health. In the same way that substance use and mental health programs address prevention (and relapse prevention), medical plans should address prevention in their aftercare plans. A program such as this would connect patients with primary care physicians not only during but also following treatment and these linkages would be assertive, akin to the linkages made to follow-up therapists. Communication is a key principle of the integrated systems both as communication between providers and education to patients. The primary care connection has special importance to the aging population as research reveals that older patients prefer to receive services from their primary care provider (Gum et al., 2006).
Pain and the experience of pain has played a significant role in the opioid epidemic. A brief review of the opioid epidemic reveals that the initial reemergence of wide-spread opioid use was in an attempt to mitigate and manage pain in patients. The Joint Commission on Accrediting Healthcare Organizations (JCAHO/Joint Commission) went so far as to promulgate the notion of pain as the fifth vital sign. Hospitals and medical teams began evaluating quality of care using a standard of pain management. Prior to the recent opioid use explosion, some insurance companies covered alternative, holistic, and/or complementary methods of pain management; however, prescription opioids since became the favored treatment and the sole focus of pain management.
Opioids alter the brain chemistry, eventually causing physical dependence and oftentimes addiction. Symptoms of both physical dependence and addiction include increasing tolerance and withdrawal upon cessation. There also are reports that patients begin to experience pain in other areas following chronic opioid treatment for pain—for example, patients who are on chronic opioid therapy for back pain may begin to experience and report neck pain, shoulder pain, knee pain, and headaches as well. Note that the site of opioid action is the brain, and while pain may be experienced in any part of the body, it is also registered in the brain.
Patients presenting for substance use treatment with pain issues often report pain that cannot be identified as having a specific, physical cause. A phenomenon known as “hyperalgesia” refers to when patients can experience initial relief at increased dosages, but it is only temporary. Patients with hyperalgesia become more pain sensitive and their pain is more diffuse, harder to pinpoint, and may move to different areas of the body (Lee, Silverman, Hansen, Patel, & Manchikanti, 2011). Medical and substance use treatment teams often dismiss this as “drug-seeking behavior,” but these patients’ experiences of pain are real, even if no physical cause of pain can be identified.
Take the following scenario: patients who have been receiving long-term opioid treatment for chronic pain have developed tolerance and hyperalgesia such that the pain is no longer managed with the treatment. Increasing doses have proven either ineffective or unsustainable. The prescribing providers must now support these patients in opioid cessation efforts as well as managing both the real pain associated with the initial injury and the experienced pain resulting from chronic use of opioid therapy. Very often in similar situations patients have not adequately understood the potential negative aspects or dependency issues associated with using an opioid over extended period of time. These patients may have significant difficulty with the initial period of opioid cessation, and not understand what is happening or why they are feeling so poor. This underscores the need for sufficient patient communication and education at initiation and throughout medication treatment.
There are a number of holistic-based or complementary treatments that have been effective in the management of pain and could support patients in transitioning to lower doses or replace medication management with opioids. While not studied in the same fashion as clinical pharmaceuticals, there is sufficient evidence and potential that these strategies should be considered in treating patients with chronic pain.
Dialectical behavioral therapy (DBT) is a well-established treatment known to help individuals with psychological and addictive disorders as it incorporates modalities designed to promote abstinence and to reduce the length and adverse impact of relapses (Dimeff & Linehan, 2008). Although DBT is not currently used in the United States as a standard form of pain management, studies have shown the implementation of these skills aiding in the de-escalation of perceived pain alongside concurrent mental health symptoms (Linton, 2010). DBT allows for increased participation in previously enjoyable activities, not only reducing pain but also working to accept that some pain may remain and regulating emotions around that. Due to the fact that brain circuitry is shared in emotional and physical distress, working to regulate one has shown to have a direct effect on the other.
Meditation techniques have long been used to support patients experiencing psychological pain. Interestingly, the brain does not differentiate between psychological and physical pain in terms of how we react to each at a physiological level; similar hormones and neurotransmitters respond regardless of the origination of pain. Mindfulness, body-scan techniques, and breathing exercises have all been deployed as effective pain-management adjuncts (Tartakovsky, 2018).
Other nontraditional therapeutic techniques have also been explored with pain management and strong positive results have been found. Studies have indicated that hypnotherapy consistently results in significantly decreased pain and was generally found to be more effective than nonhypnotic interventions such as attention, physical therapy, and education (Elkins, Jensen, & Patterson, 2007). Relaxation techniques such as guided imagery, where patients use their imagination to mentally picture a time, place, or person that allows them to feel relaxed, has demonstrated a reduction in circulating cortisol levels, eased stress and anxiety, improvement in physical functioning, and reduction of pain (Asmundson & Feldman, 2012). A study conducted by Morse and colleagues (2011) in substance-use-treatment-center patients reports a significant reduction of headaches (69 percent) and body aches (58 percent) in patients following use of an audio program combining tones and music with the principles of meditation.
Holistic treatments are known to play a role in healing both psychological and physical pain. A 2010 study showed that the integration of massage therapy into the acute-care setting creates overall positive results in patients’ ability to deal with the challenging physical and psychological aspects of their health conditions. The study demonstrated not only significant reduction in pain levels, but also the interrelatedness of pain, relaxation, sleep, emotions, recovery, and finally, the healing process (Adams, White, & Beckett, 2010). Acupuncture has also been proven to help with pain, specifically studies with patients experiencing chronic musculoskeletal, headache, and osteoarthritis pain (Vickers et al., 2018). These specific treatment effects of acupuncture were shown to persist over time, meaning that reductions in perceived pain were sustained beyond the treatment period (Mao & Kapur, 2010).
While not generally accepted by mainstream medicine, there are also reports of orthomolecular and nutritional solutions to pain. By inhibiting the breakdown of endorphins, the amino acid D-Phenylalanine may prolong the action of those natural painkillers. Similarly, D- or L-Phenylalanine, also known as DLPA, can take effect on the same day and its effects become more pronounced over time (Cheng & Cheng, 2017). Endorphins are part of the body’s natural pain management system and the primary ingredient in “runner’s high” chemistry.
There is great interest in the use of medical marijuana as well. Cannabidiol (CBD) oil has become the hot new product in states that have legalized marijuana products in reducing inflammation, which can be associated with localized pain (Thompson, 2018). Additionally, exploring ways to boost the body’s natural endorphins such as exercise, finding ways to connect with others, music therapy, and adventure therapies can create support patients in managing pain and reducing reliance on opioid medications.
As we continue to address the impact of our nation’s opioid crisis, treatment providers will need multiple options to support patients, especially older patients, in addressing pain. Substance use treatment patients exhibit greater use of pain medications as well as greater issues with medical problems in their fifties and beyond. These patients will need medical attention during treatment, linkages to medical care posttreatment, and methods and modalities to support reduced reliance on pharmacologic interventions to manage pain.