Medication-assisted Treatment in An Aging Population

 

 

Patients prescribed medication-assisted treatments with buprenorphine, methadone, and naltrexone are getting older…as we all are. This is wonderful, because it means our patients are surviving, making it to old age. Methadone has been prescribed for the longest of the three, so we tend to see more older patients on it.

Aging in our patients can present specific challenges; research literature shows high rates of physical and psychological illness in opioid users in general, meaning as this population ages, we can expect to see even more co-occurring illnesses.

When looking for information about aging MAT patients, I was appalled to see a journal article define “older adult” as those fifty and above. I’ve always thought of “older” as being, well, older than me. I’m no longer pushing fifty – I’ve been pulling it behind me for nearly seven years, so I felt a little resentful on behalf of my patients.

Anyway, the article was titled “Older Adults Prescribed Methadone for Opiate Replacement Therapy: A Literature Review,” and the author said that the U.S. had 1.7 million people over age 50 in 2000 who needed substance abuse treatment. That number is expected to rise to 4.4 million by 2020. [1]

This article said the numbers of patients over 50 years old who are on MAT is expected to rise, and this group of patients has special needs. They say these patients tend to age more quickly (physiologically) due to past lifestyle.

I see that in my patients. Around 90% are smokers, and cigarettes cause a whole host of medical issues. Some patients have had poor dietary habits since childhood, from a combination of factors. Many patients haven’t had the time or energy for self-care, prior to entering recovery, and this takes a toll.

A New York study of older OTP patients on methadone [2] sampled 156 patients enrolled in OTPs. Twenty-nine percent were age 55 or older (45 patients) These patients, as compared with their younger counterparts, were significantly more likely to have been in treatment longer, less likely to be using heroin currently, but more likely to have an alcohol use disorder.

The older patients were less likely to be impulsive or hostile, but more likely to have chronic medical problems and more likely to be on medications for those problems. Older patients were more likely to be on more liberal take home schedules, due to less illicit drug use compared to younger patients. Despite having more chronic medical issues, older patients’ scores on life satisfaction scales weren’t different from younger patients.

Improving the health of our older OTP patients is a challenge, and I have a few suggestions to help.

Get them to a primary care provider. Some OTPs are fortunate enough to be able to offer primary care to their patients. That’s wonderful, but if, like me, you work at an OTP that can’t do that, patients will need to be referred. This should be easy, but it’s not, at least in some areas of this country My patients tell me when they call for an appointment as a new patient, they are told they can’t be accepted if they have a history of substance use disorder or treatment for chronic pain. They say they’ve called all the practices in the area and none will accept them.

Could this be exaggeration by patients? Maybe, but I’ve heard this over and over. Some patients say the receptionist who answers the phone takes their name and birthdate, then calls back to say they can’t be accepted. The patients think it’s because the prospective physician sees they have past histories of filling controlled substances on North Carolina’s prescription monitoring program. I hear the same things from patients with private insurance, Medicaid, and self-pay.

I’ve never heard any physician to admit to doing this, since it would unethical, and probably also a violation of the Americans With Disabilities Act.

Federally Qualified Health Centers (FQHCs) will take these patients. We have a center that does an excellent job with our patients; however, it’s an hour’s drive away. Some patients have difficulty getting transportation for that distance.

Medicaid patients should be assigned to a doctor or practice, and it’s printed on their Medicaid card.

Health maintenance can’t be neglected.  

Often a patient says something to the effect of, “I didn’t expect to live this long. I never thought of doing those things.” This is called a “sense of foreshortened future,” meaning the person senses he will not live to an old age and is destined to die young. It’s seen in people who have experienced trauma in their lives and can be a symptom of post-traumatic stress disorder (PTSD). But now here he is, over 50, and not accustomed to taking care of himself.

And yes, it also means that rite of passing age 50: the screening colonoscopy.

Our patients need routine PAP smears, mammograms, prostate exams, and vaccinations. They need their blood pressure and cholesterol profiles checked when appropriate. We need to encourage our patients to keep up with these simple measures.

After patients get into recovery, it takes time and effort to adjust thinking, and accept the idea that good self-care can extend the quality and length of life.

Opioid treatment programs, like all other medical practices, should keep an updated medication list and updated problem list.

That should be easy to accomplish, but at my OTP, our present software system has no provision to document this essential information. I’m left to figure it out with paper charts, which isn’t ideal, but workable. But I can only see that data if I’m in the office with the chart in front of me.

Methadone has interactions with many medications. The list is long, and difficult to remember, so I use a smart phone app that will tell me about drug interactions. There are many out there: Epocrates and Medscape are but a few. If you work in an OTP, get this phone app. It will save you time and effort.

See complicated patients more often.

This applies to older patients, but also to younger ones if they have a complicated medical history. Sometimes it’s hard to convince patients they need to see me if they are doing well. Particularly if they have their own doctor, and they are doing fine, why should they waste their time? Of course, I think it’s time well-spent, but I understand their thinking. I delay seeing my doctor too. Life is hectic and that’s never at the top of my list.

I’ve started “warning” new patients with more than a few medical issues that I will want them to see me every 3 months. We can flag this in our computer system, along with flagging when they will be due for a yearly physical.

I count diseases like heart disease, diabetes, COPD/emphysema/asthma, and other chronic conditions as complicating illnesses. There are dozens of others, and I also count chronic mental illnesses, even though they are treated by psychiatrists. Many of those medications can have interactions with methadone, making it prudent to see these patients more often.

More than anything else, keep talking to patients about quitting smoking. Smoking-related illness is the number one killer of people in recovery. It’s not easy, but keep encouraging and supporting them. My state has a quitline to help anyone wanting to quit at: https://www.quitnow.net/Program/This is sponsored by the American Cancer Society, for no cost to the patients.

In my next blog, I’ll talk about some of the most challenging co-occurring problems in my patients: deteriorating cognitive function and limited mobility.

  1.  Doukas et al., and published in Addiction and Preventive Medicine, February 10, 2017.
  2. Rajaratnam et al., Journal of Opioid Management, 2009 5(1), pp 27-37.

 

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