Unintended Consequences of Opioid Regulations in Older Adults With Multiple Chronic Conditions

Christine S. Ritchie, MD, MSPH; Sarah B. Garrett, PhD; Nicole Thompson, BA; Christine Miaskowski, RN, PhD, FAAN

Disclosures

Gerontologist. 2020;60(7):1343-1352. 

In This Article

Discussion and Implications

This qualitative study of older adults with both MCC and chronic pain revealed how national attention to the opioid epidemic and regulatory restrictions associated with opioid use have shaped the patient–clinician relationship and patients' concerns regarding their pain management.

Several interviewees described an erosion of the patient–clinician relationship and an undercutting of trust. In some instances, patients felt distrusted, stigmatized, or held in suspicion by their clinicians. These findings align with those seen in younger patients with chronic pain who, in focus groups, described feeling disrespected, stigmatized and distrusted (Antoniou et al., 2019; Upshur, Bacigalupe, & Luckmann, 2010). This underlying challenge of not having one's pain believed has threatened shared decision making and patient engagement for decades (Frantsve & Kerns, 2007; Werner & Malterud, 2003). Evidence suggests that these dynamics can in fact exacerbate patients' symptoms (Greville-Harris & Dieppe, 2015).

The lack of patient agency among older adults with chronic pain was illustrated in multiple instances where patients felt like they were given little say about how to optimally manage their pain. Some patients described a sense of abandonment when their clinicians would no longer care for them or no longer take into consideration their personal expertise with their pain experience and its management. These clinician–patient interactions diverge from the goal by U.S. health care toward greater patient-centeredness, namely: "providing care that is respectful of, and responsive to, individual patient preferences, needs and values" (Institute of Medicine, 2001). Numerous initiatives have sought to educate clinicians to invite and support patients' involvement in decisions about their treatment (Elwyn et al., 2012; Weston, 2001). However, several cases in our study reveal a failure of patient-centeredness in both the processes of care delivery (e.g., in communication, decision making, and the provision of acceptable options acceptable to the patient) and its outcomes (e.g., patient dissatisfaction and disempowerment, poor or no access to desired treatments). Efforts are needed to intentionally integrate shared decision making into pain management in older adults, with an emphasis on empathy and nonjudgment (Marchand et al., 2019).

Many patients described escalating anxiety and ambivalence about the use of opioids. This anxiety translated into worries about taking pain medications, being stigmatized or being discounted because of their use of opioids, and how to optimally manage their pain in the future. What is unclear from this study and others is the overall health impact of this type of chronic anxiety. Given the known association between anxiety and pain in the general population, this chronic anxiety may exacerbate an older adult's chronic pain symptoms (Asmundson & Katz, 2009; McWilliams, Cox, & Enns, 2003). However, how medication anxiety and stigma influence pain in older adults remains poorly understood.

The anxiety seen in older adults in this study appeared to be further complicated by, participants' conflation of addiction (a compulsive use of a substance despite associated harmful consequences) with physical dependence (chronic use of a tolerance-forming drug, in which abrupt or gradual drug withdrawal causes unpleasant physical symptoms; American Psychiatric Association, 2019; National Cancer Institute, 2019). Participants described fear of becoming addicted to opioids when they equated the experience of opioid withdrawal (due to physical dependence) with addiction. Such anxiety could lead patients to try to avoid analgesics altogether, even if such avoidance contributes to increased pain, reduced mobility, and more social isolation. Given the possible relationship between anxiety and pain, clinicians may be able to mitigate chronic anxiety about the future by anticipating and addressing worries related to future pain and its management.

Not all respondents indicated they experienced negative effects from the opioid epidemic or its policy responses. For a small number, the impact of these policies manifested as greater trust in and respect for their clinicians—even when the clinician prescribed lower doses of opioids than the patient had requested. This discovery is valuable, as these cases may serve as models for clinicians seeking to satisfy both public health needs and individual patients' needs. Research is needed on what clinician behaviors and care settings factors support these outcomes.

In response to the opioid epidemic, state and federal agencies have been racing to put into place policy and regulatory initiatives to curb opioid misuse, opioid overdoses, and opioid-related deaths. While substantial energy has gone into instituting and monitoring these outcomes, little attention has focused on the unintended consequences and harms these initiatives are having on older adults with MCC. This lack of attention to unintended or unanticipated consequences of these regulations on vulnerable populations has the potential to unleash continuous harm that contributes to substantial suffering, as predicted by Merton (1936) and others.

Older adults with MCC warrant their own focused consideration because many studies describe lower rates of opioid misuse among older adults than among young and middle-aged adults (Han, Sherman, & Palamar, 2019; Reid et al., 2010), and therefore a different potential burden–benefit ratio of opioid use. Lorenc and Oliver (2014) describe different types of harms that can occur as a result of a public health intervention: direct harms, psychological harms, equity harms, group and social harms, and opportunity harms. While our study participants did not describe direct harms such as functional decline from unaddressed pain, many described inadequately controlled pain, psychological harms related to increased anxiety or group and social harms related to labeling and stigmatizing. As the country seeks to address opioid misuse, it must systematically characterize and monitor these harms.

In light of the findings from this study, a number of actionable recommendations emerge:

  1. Navigating optimal pain management in the context of new state and federal regulations that restrict opioid use is challenging for patients and clinicians and can erode the patient–clinician relationship. Clinicians should engage in a detailed assessment of older adults' pain and seek to better understand the biological, psychological, and social components of their patients' pain. They should learn empathic communication skills and ways to optimize listening and understanding. In Upshur and colleagues' (2010) study, patients talked about the value of feeling listened to and trusted, and of having clinicians available to them in between visits to address any pain concerns. Clinicians may be helped by drawing on tools designed to support challenging conversations in other settings (Sager & Childers, 2019) and seek to preserve and strengthen the therapeutic alliance while engaging in straightforward dialogue regarding the benefits and risks of opioid use. Future research should investigate under what conditions these conversations regarding opioid treatment in older adults go particularly well versus poorly.

  2. Clinicians should seek to provide patients with more education about and promote better access to nonpharmacologic pain management interventions. While our participants sought out an array of nonpharmacologic treatments, they often felt thwarted by significant financial and other access barriers. Ensuring that a member of the clinician's interprofessional team is well-equipped to guide patients in their search for nonpharmacologic treatments will indicate support and nonabandonment to patients.

  3. Almost no research has systematically evaluated the prevalence, characteristics, and impact of chronic pain in older adults with MCC. Given the substantial increase in the aged population with MCC, longitudinal studies of chronic pain in these individuals are desperately needed. Additionally, more research is needed that focuses on how the opioid epidemic is influencing the management of specific pain conditions such as diabetic neuropathy.

  4. The National Institutes of Health Helping to End Addiction Long-term (HEAL) initiative—along with a number of other federal and state-based initiatives—will continue to research and address opioid use in the context of continued opioid misuse and overdoses. Rather than solely measure the impact of the HEAL initiative on traditional measures (e.g., Emergency Department visits and opioid-related outcomes), policy makers should evaluate the potentially harmful effects of these initiatives. A systematic approach to capture unintended harms associated with opioid regulations, such as increased anxiety and erosion of patient–clinician relationships, would inform real-time refinement of these interventions (Bonell, Jamal, Melendez-Torres, & Cummins, 2015).

This study is limited in its generalizability due to its size and location in the California Bay Area. Additionally, legislative changes related to opioid use continue to evolve. Therefore, the picture painted in this study may be more conservative than one from a study conducted even more recently, as the opioid epidemic continues to shape different aspects of older adults' care and health. Nevertheless, as far as we know, this study is the first qualitative investigation of community-dwelling older adults with both chronic pain and MCC. It represents a step forward in understanding the myriad effects of the opioid epidemic, as well as the various policy responses to it.

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