Step 1: Recognition
The prevalence of chronic pain combined with age-related vulnerability can lead to adverse effects, including addiction. Being familiar with the warning signs is critical.
“Within the industry, we see many older individuals who demonstrate an elevated rate of pain disorders, which, in turn, yields considerable opioid prescribing and dispensing. Oftentimes, long-term care residents are relatively frail and demonstrate age-related vulnerability to adverse health outcomes, including developing dependence to addictive medications. The profound adverse effects that opioids can impart, particularly in those who are abusing medications by using them outside the oversight of their healthcare providers, make it critical to be familiar with the signs of opioid addiction and abuse,” said Kishore “Josh” Bose, PharmD, BCGP, Manager of Clinical Services at PharMerica.
There are both physical and behavioral signs of opioid abuse and addiction:
- Physical: When observing for physical signs of opioid abuse, consider the notable effects seen when individuals are exposed to high levels of opioids: decreased respiratory rate, small pupils (miosis), and drowsiness or non-responsiveness. When these effects are observed in an individual prescribed opioids, it may be a sign that their current regimen is unsafe, or that they are consuming opioid medications beyond their prescribed course of therapy. Long-term opioid abuse may present in physical signs and symptoms, such as change in appetite (loss or increase), change in weight (loss or increase), change in physical appearance due to behavioral changes, and intense flu-like symptoms (nausea, sweating, myalgia) indicative of withdrawal.
- Behavioral: Behavioral signs of opioid abuse include changes in personality, changes or lack of interest in activities, isolation or withdrawal, moodiness or irritability, and loss of interest in hygiene or physical appearance.
"A key aspect of opioid medications is that they may lead to tolerance, or the need for higher doses to achieve the same effects over time. The potential for abuse and addiction are associated with the amount and duration of opioid therapy.."
Kishore “Josh” Bose, PharmD, BCGP
Manager of Clinical Services
PharMerica
Clinically, an important scenario to recognize is when someone receiving opioid therapy states their pain is not adequately relieved, especially if it previously was. This could suggest a number of things: the resident’s pain is worsening and they need to be reassessed, the resident is developing a tolerance to their prescribed medication and their treatment plan needs to be adjusted, or, unfortunately, that medication is being diverted and the resident is not receiving their full prescribed dose(s) (e.g., in the instance that a staff member with OUD is diverting medication intended for the resident).
It is also important to be alert to factors that increase an individual’s relative risk for developing opioid abuse and addiction. Risk factors include a personal or family history of substance abuse (including alcohol), untreated psychiatric disorders, social isolation/loneliness (often accompanied by depression), and polypharmacy, particularly the concomitant use of other addictive and CNS-depressing medications (e.g., benzodiazepines).
Even those taking opioids as prescribed are still at some risk for OUD. Bose noted, “A key aspect of opioid medications is that they may lead to tolerance, or the need for higher doses to achieve the same effects over time. The potential for abuse and addiction are associated with the amount and duration of opioid therapy. Therefore, a well-accepted clinical approach is to use the lowest adequate dose for the least necessary time to appropriately manage a resident’s pain.”
There are some tools that help assess risk and make a diagnosis of OUD. For instance, the DSM-5 has criteria for diagnosis of OUD. Russell said, “If someone has two to three of the criteria, they are considered to have mild OUD.” She added that dose reduction or weaning patients off opioids should be considered on admission.