Aging and Opioids: 
Important Considerations in Drug Selection

by Phil Walls, RPh
Chief Clinical Officer

Approximately 10,000 baby boomers will turn 65 every day until about the year 2030, according to the U.S. Census Bureau, and last year about one-fifth of all employed workers were age 55 or older. In addition to the challenges this aging workforce may pose for employers, this patient population may also have a significant impact on the number and types of workers’ compensation claims.

Increasing Challenges for Managing Injured Seniors

Opioids will most certainly be used to treat pain in many of these cases, and yet this patient population may exhibit impaired hepatic and renal function, thus decreasing the body’s ability to metabolize or clear these drugs from the patient’s system. Therefore, to offset this decreased clearance, it is recommended that doses of most opioids be reduced, less frequent dosing be used, and creatinine clearance be monitored (an indicator of renal function). Unfortunately, all too often the data indicates that these guidelines are not followed for this population. Therefore, an alternative may be the use of an opioid known as buprenorphine.

Buprenorphine as a Treatment for Neuropathic Pain

senior hands pillsBuprenorphine is often thought of primarily for its use in detox. However, it is actually a superior agent for treatment of neuropathic pain, and its metabolism and clearance in the elderly is not delayed by impaired hepatic and renal function. Another factor to consider in the elderly injured patient is the respiratory depression caused by opioids, which is magnified in a patient with pre-existing pulmonary conditions or other drug therapy that depresses respiration. Careful dosing of opioids must be followed when treating these patients, and once again, buprenorphine appears to be a more suitable choice. Lastly, one must consider the impact of opioids on the immune system. Immunosenescence is the gradual decline in the immune system associated with aging, and the impact may be deadly in the presence of infectious diseases, autoimmune diseases, cancer, vaccination and inappropriate opioid therapy. Again, buprenorphine may be recommended but opioids like morphine and fentanyl are not.

What Does This Mean for You?

  • Your myMatrixx clinical pharmacist will monitor and identify seniors who are at risk from opioid therapy
  • Engage your pharmacist to conduct a review of these patients’ drug therapy
  • Initiate changes in therapy well in advance of a Medicare Set-Aside (MSA)! Remember, the Centers for Medicare and Medicaid Services (CMS) does not allow for clinical considerations as described above over the life expectancy of the patient. Therefore, it is imperative that appropriate changes are made well in advance of the MSA, and in the case of opioids, this includes weaning first; if that is not possible, switch to a more appropriate agent.