Opioid use disorder in older adults: More common than you might think

photo of a mature woman looking at a bottle of prescription pills

You've had a stressful few months: major surgery led to lingering pain worsened by vague anxiety, the unsettled sense you aren't quite back to normal. Your pain has subsided, but you've decided to ask your doctor for another refill of the opioid painkillers she prescribed after your operation. Just a little longer... just until the nerves shake out, you think.

Seems harmless enough, right? But staying on opioids to allay anxiety, rather than pain, is a slippery slope, Harvard experts say. It's also one of the most common ways well-meaning people slide into opioid addiction (formally called opioid use disorder), a problem responsible for about three-quarters of the nation's overdose deaths.

In contrast to drug addiction stereotypes, astounding numbers of people with opioid use disorder are older adults. Indeed, people over 60 are the largest users of prescription opioids in the United States — with women outpacing men, according to the CDC. And the toll is stunning: opioid use disorder in adults 65 and older more than tripled between 2013 and 2018, while opioid-related deaths among Americans 55 and older increased nearly 19-fold between 1999 and 2019, according to a 2022 study published in JAMA Network Open.

"One question to ask yourself is, 'If I didn't have pain, would I still have the desire to take these medications?' If the answer is yes, that raises some serious concern," says Dr. Christopher Gilligan, associate chief medical officer at Harvard-affiliated Brigham and Women's Hospital. "You may not realize you have an opioid problem."

Someone who continually seeks opioid refills, asks for higher doses, or tries to obtain prescriptions from multiple doctors is probably also in trouble. "If she comes up with excuses such as 'I lost it' or 'someone took it,' or asks me if I can help her get more, those are not good indicators," says Dr. Robert Jamison, a clinical psychologist and professor of anesthesia at Brigham and Women's Hospital Pain Management Center.

Who's more vulnerable?

A class of pain relievers also called narcotics or opiates, opioids include some familiar names. In addition to the illicit street drug heroin (often laced with fentanyl), prescription versions include morphine, hydrocodone, short-acting or long-acting oxycodone (OxyContin), tramadol, and hydromorphone (Dilaudid). They're typically prescribed to treat pain after surgery or injury, or extreme chronic pain from diabetic neuropathy, arthritis, or cancer.

While opioids carry indisputable dangers, "they're not necessarily a bad thing," Dr. Jamison says. "They're some of the best medications we have to manage postoperative pain," he says. "Quieting pain after surgery is really important, and opioids can do that."

However, certain factors can make someone susceptible to misusing opioids or becoming addicted. You're more at risk if you smoke cigarettes; have anxiety, depression, or another mood disorder; or have a family or personal history of abusing substances, including alcohol.

These scenarios can also make someone more vulnerable to opioid abuse:

Earlier drug use. Baby boomers who overdose on opioids often used drugs recreationally when they were younger and kept it up, according to the 2022 study in JAMA Network Open.

Quick discharge after surgery. Pandemic pressures and limitations imposed by health insurance companies have shortened hospital stays for many joint replacement patients, who may return home in significant pain and, in turn, may take more opioids than they would under close medical monitoring, Dr. Jamison says. (See "After joint surgery, less really is more.")

Longstanding use. People who take opioids for chronic pain conditions can develop tolerance, meaning the same dosage provides less relief. Then they might start taking more, Dr. Jamison says.

After joint surgery, less really is more

Joint replacement patients prescribed fewer doses of opioids after surgery don't require more refills than those whose prescriptions include a greater number of pills, a new study suggests.

Researchers evaluated national insurance data that included nearly 121,000 total joint replacements among adults up to age 75 whose surgeries took place from January 2015 to November 2019. None had previously used opioids. People who had knee replacement were far more likely (nearly 60%) than those who had hip replacement (26%) to refill their opioid prescription within 30 days. But patients whose initial prescriptions included fewer tablets weren't more likely to refill them than those whose prescriptions included more of the medication. The analysis was published online Nov. 6, 2022, by The Journal of Arthroplasty.

The study bolsters evidence indicating doctors can prescribe smaller amounts of opioids without sacrificing pain control or creating a need for urgent refills, says Dr. Christopher Gilligan, associate chief medical officer at Brigham and Women's Hospital. Smaller prescriptions lower the chances that patients will have leftover opioids in their homes after recovery — potentially tempting them or others to abuse the medication. "We're recognizing that prescribing excessive opioids after surgery inadvertently increases the problem of other people obtaining the medications, leading to misuse," says Dr. Gilligan.

Prevention strategies

Seeking treatment for opioid use disorder doesn't carry the stigma it once did. Treatment is common and reflects the understanding that opioid use disorder is just as much a disease as, say, diabetes or high blood pressure. Often, treatment blends behavioral therapies with medications such as buprenorphine (Butrans), naltrexone (Vivitrol), or a combination of buprenorphine and naloxone (Suboxone), which work by binding to the same pain receptors as opioids, easing cravings.

It's ideal, of course, to prevent opioid use from ever slipping into misuse. Dr. Gilligan and Dr. Jamison suggest these strategies:

Take opioids for the shortest possible time. Use them for only a few days or less — and at the lowest possible dose — before switching to non-opioid, over-the-counter pain relievers such as such as ibuprofen (Advil), acetaminophen (Tylenol), or naproxen (Aleve).

Tap a non-opioid option. You can turn down opioids if offered after a minor procedure, such as dental work, Dr. Gilligan says. For longer-lasting pain, certain medications used for other conditions can provide notable relief. These include the antidepressant duloxetine (Cymbalta), as well as the antiseizure drugs pregabalin (Lyrica) and gabapentin (Gralise, Horizant). "If you can achieve pain control with zero opioids, your risks are typically much lower," he says.

Try alternative approaches for pain relief. Comfort measures such as heat, ice, and massage "all make a difference," Dr. Jamison says. So too can complementary therapies, such as deep breathing, mindfulness meditation, and acupuncture. Cognitive behavioral therapy can also be "very helpful in coming off medications," he says.

Wean off opioids slowly — and with a doctor's guidance. Abruptly stopping opioids can trigger a temporary pain flare-up and bring on other withdrawal symptoms, such as nausea and sweating. "Continual monitoring and gradual tapering is helpful," Dr. Jamison says.

Discuss pain relief before you need it. If you're scheduled for surgery, ask your care team what types of pain measures are appropriate, including regional anesthesia that can block pain to a specific body area for hours to days. "Many different pathways can reduce opioid use after surgery while still delivering pain control," Dr. Gilligan says.