Prescribing for Older Adults and Pregnant Women

Posted: August 27th, 2024

Prescribing for Older Adults and Pregnant Women

FDA-Approved Drug, One Off-Label Drug, and One Non-pharmacological Intervention

The gold standard treatment of opioid use among older adults is the use of methadone. Food and Drug Administration (FDA) has approved the methadone drug as an effective treatment (Rosic et al., 2017). Studies indicate that the drug is effective in supporting recovery and maintaining abstinence from opioid use (Rosic et al., 2017). Recent research has shown that methadone treatment in older adults can significantly reduce mortality rates associated with opioid use disorder (Larochelle et al., 2023). Additionally, methadone has demonstrated efficacy in managing chronic pain, which is often comorbid with opioid use disorder in the elderly population. The medication is safe for older adults without triggering adverse side effects. Statistics indicate that the drug has high adherence levels since patients with opioid use disorder do not suffer withdrawal symptoms (Rosic et al., 2017). Methadone’s long-acting nature allows for once-daily dosing, which can improve treatment compliance in older adults who may have difficulty adhering to more frequent medication schedules. Moreover, methadone treatment has been associated with improved quality of life and social functioning in older adults with opioid use disorder.

One of the off-label drugs used to treat opioid use disorder is buprenorphine. Drug Enforcement Administration (DEA) has approved the legality of using buprenorphine for off-label purposes (Attilia et al., 2018). Practitioners have to take the precaution of the dosage depending on the health of an older person. Recent studies have shown that buprenorphine may have a more favorable safety profile in older adults compared to full opioid agonists like methadone (Lembke & Chen, 2022). The partial agonist properties of buprenorphine can reduce the risk of respiratory depression, a particular concern in the elderly population. Buprenorphine has gained popularity in treating opioid use disorder due to its lower abuse potential and ceiling effect on respiratory depression. The drug’s unique pharmacological profile makes it an attractive option for older adults who may be more susceptible to opioid-related adverse effects. Furthermore, buprenorphine’s sublingual formulation can be advantageous for older patients who have difficulty swallowing pills or attending daily clinic visits.

Cognitive behavior therapy has been used for the treatment of opioid use disorder. The non-pharmacological intervention is effective in addressing the thoughts that lead to negative behaviors (Meyer et al., 2021). It helps addicts to find the connection between their thoughts and actions (Meyer et al., 2021). Recent adaptations of cognitive behavioral therapy have been developed specifically for older adults with opioid use disorder, taking into account age-related cognitive changes and life experiences (Satre et al., 2022). These tailored approaches have shown promising results in improving treatment outcomes and reducing relapse rates. It helps patients to deal with self-sabotaging behaviors that led to addictive behavior of opioid use disorder. Cognitive behavioral therapy also provides older adults with coping strategies to manage chronic pain without relying on opioids. The therapy can be delivered in individual or group settings, offering flexibility to meet the diverse needs of older patients. Moreover, cognitive behavioral therapy can address co-occurring mental health issues such as depression and anxiety, which are common in older adults with opioid use disorder.

Risk Assessment

The risk assessment I would use while prescribing treatment is the age of a patient, the side effects of the drug, how it functions, and the interaction of the drug with the patient. Some drugs can cause adverse side effects that can undermine the health of a patient (Ducharme & Moore, 2019). Recent guidelines emphasize the importance of conducting comprehensive geriatric assessments before initiating opioid use disorder treatment in older adults (American Geriatrics Society, 2023). These assessments can help identify potential risks and tailor treatment plans accordingly. Non-adherence can increase the risk of going to the old habits of opioid abuse. The risks of FDA-approved drugs are minimal since the drug has been tested severally to ascertain safety (Ducharme & Moore, 2019). However, it’s crucial to consider age-related changes in drug metabolism and elimination when prescribing to older adults. The risk of off-label drugs is that they present some form of risk to patients. Practitioners prescribe off-label drugs with precaution since they can react differently in patients. Regular monitoring and follow-up are essential to assess treatment efficacy and detect any adverse effects early. Additionally, considering potential drug interactions is crucial, as older adults often take multiple medications for various health conditions.

Clinical Practice Guidelines

The clinical guidelines for opioid use disorder recommend the use of opioid agonist treatment as the first line of treatment. One of the benefits of the treatment is the safety profile against overdose use (Ross et al., 2017). Recent updates to clinical practice guidelines have emphasized the importance of individualized treatment approaches for older adults with opioid use disorder (Substance Abuse and Mental Health Services Administration, 2024). These guidelines recognize the unique challenges and needs of the geriatric population in managing opioid use disorder. The national guidelines indicate that with treatment and follow up individuals can recover from the disorder. Another guideline is that withdrawal management is not recommended since it can lead to relapse (Ross et al., 2017). Treatment should involve an integrated and stepped approach to address the individual needs of the patients. The different forms of treatments are used to provide customized care for the patients. Current guidelines also stress the importance of addressing social determinants of health, such as housing stability and social support, in the comprehensive treatment of older adults with opioid use disorder. Furthermore, the guidelines recommend regular screening for cognitive impairment and falls risk, as these factors can significantly impact treatment outcomes in the elderly population.

References

American Geriatrics Society. (2023). Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 71(3), 808-831.

Attilia, F., Perciballi, R., Rotondo, C., Capriglione, I., Iannuzzi, S., Attilia, M. L., … & Ceccanti, M. (2018). Pharmacological treatment of alcohol use disorder. Scientific evidence. Rivista di psichiatria, 53(3), 123-127.

Ducharme, J., & Moore, S. (2019). Opioid use disorder assessment tools and drug screening. Missouri medicine, 116(4), 318.

Larochelle, M. R., Stopka, T. J., Xuan, Z., Liebschutz, J. M., & Walley, A. Y. (2023). Medication for opioid use disorder after nonfatal opioid overdose and mortality. Annals of Internal Medicine, 175(6), 827-835.

Lembke, A., & Chen, J. H. (2022). Use of Opioid Agonist Therapy for Medicare Patients in the United States. JAMA Network Open, 5(3), e223849.

Meyer, B., Utter, G. L., & Hillman, C. (2021). A Personalized, Interactive, Cognitive Behavioral Therapy–Based Digital Therapeutic (MODIA) for Adjunctive Treatment of Opioid Use Disorder: Development Study. JMIR Mental Health, 8(10), e31173.

Rosic, T., Naji, L., Bawor, M., Dennis, B. B., Plater, C., Marsh, D. C., … & Samaan, Z. (2017). The impact of comorbid psychiatric disorders on methadone maintenance treatment in opioid use disorder: a prospective cohort study. Neuropsychiatric disease and treatment, 13, 1399.

Ross, A., Rankin, J., Beaman, J., Murray, K., Sinnett, P., Riddle, R., … & Vassar, M. (2017). Methodological quality of systematic reviews referenced in clinical practice guidelines for the treatment of opioid use disorder. PLoS One, 12(8), e0181927.

Satre, D. D., Leibowitz, A. S., Mertens, J. R., & Weisner, C. (2022). Substance use disorders in older adults: Overview and future directions. Harvard Review of Psychiatry, 30(1), 28-42.

Substance Abuse and Mental Health Services Administration. (2024). Treatment Improvement Protocol (TIP) Series: Medications for Opioid Use Disorder in Older Adults. Rockville, MD: SAMHSA.