Opioid Addiction in Older People: Is MAT (Medication-Assisted Treatment) Helpful?

National Center for Health Statistics survey showed that between 2015 and 2018, adults over age 60 reported using prescription opioids in the last 30 days, more than any other age group.

Key takeaways:
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    The most significant use of prescription opioids is among adults older than 60 years old.
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    In 2020, 5.7 million adults over age 50 sought addiction treatment.
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    Billions of U.S. dollars are being allocated to address opioid addiction, clinically known as opioid use disorder (OUD).
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    Rates of OUD in older adults have been increasing and tripled from 2013 to 2018.
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    Observational studies demonstrate positive results using medication-assisted treatment (MAT) for OUD in older adults.

Opioids

Opioids are a class of drugs that offer analgesia or pain relief. They are made to have the same effects as the opium poppy plant. When referring to opioids, the phrases opiates, narcotics, or painkillers are frequently used. One illegal drug that comes from opium is heroin. Prescription opioids can be natural, like morphine, semi-synthetic such as tramadol, hydrocodone, oxycodone, or synthetic, as in fentanyl.

Here are some statistics:

In 2018, two out of three drug overdose deaths were due to opioids.

In 2019, 9.7 million people misused prescription pain relievers.

From 2016 to 2019, the U.S. government allocated nine billion dollars toward the problem.

Opioid misuseThe use of prescription opioids in any way other than as directed by a prescriber; the use of any opioid in a manner, situation, amount, or frequency that can cause harm to self or others.
Opioid toleranceAlteration of the body’s responsiveness to opioids such that higher doses are required to produce the same effect achieved during initial use.
Opioid dependenceWhen a person using opioids begins to experience a reduced response to medication, requiring more opioids to experience the same effect.
Opioid Use Disorder (Opioid addiction)A mental health condition where attempts to cut down or control use are unsuccessful, or when use results in social problems and a failure to fulfill obligations at work, school, and home. OUD occurs after opioid tolerance and dependence develop, making it physically challenging to stop opioid use and increasing the risk of withdrawal.

The scope of OUD in older adults

Medicare data from 201 to 2018 suggests that OUD has tripled in people over the age of 60.

Almost three times as many older adults – tallying 5.7 million people – entered treatment for a substance use disorder in 2020 compared to 2000. The need for treatment in this cohort will rise among retirees partly because baby boomers came of age in a time of more liberal drug and alcohol use. Therefore, their experience with substances is more significant than previous generations, so their attitudes toward use may be more relaxed.

What is MAT?

Medication-Assisted Treatment (MAT) is the use of medications with behavioral therapies in the treatment of substance use disorders. The medications used to treat OUD are:

  • Methadone
  • Buprenorphine
  • Naltrexone
  • Buprenorphine and Naloxone (Suboxone)

The specifics of how each drug works are beyond the article's scope, but basically, they bind to the same receptors as opioids, weakening or completely blocking euphoria and other narcotic effects. The results include a decreased craving (the intense desire to use opiates) and a much lower risk of overdose.

MAT is controversial and not offered as often as it could be – particularly for older people – due to the concern of substituting an opioid-based medication for an opioid of abuse. MAT in any setting is best if offered with behavioral health counseling.

Methadone

Methadone has been used the longest and remains the most inexpensive MAT medication.

Observational studies in older patients on methadone suggest:

  • Less opioid use
  • Better treatment retention rates
  • Improved addiction severity scores
  • Fewer socioeconomic concerns

Buprenorphine

Buprenorphine is safer to use in older adults because of fewer drug-drug interactions and side effects. Success rates in MAT using methadone or buprenorphine are similar.

Naltrexone

Naltrexone is less popular because it requires complete detoxification before initiating therapy. However, it is an effective and safe option.

Naloxone

Naloxone is best known as Narcan, the emergency-use medication given in the community for opioid overdose. It is also combined with buprenorphine as Suboxone and used in MAT.

From an MD: Special consideration for older adults

Starting MAT in older adults is guided by research done in younger populations. High-quality research (double-blind, random, controlled trials) focused on MAT outcomes in elders isn’t available. Nevertheless, experts endorse MAT use in older populations.

Many patients who’ve become dependent on opioids were given them as prescriptions for pain control. Neal Guffey Jr., MD, has treated adults with buprenorphine for years.

“It is common that you have people with opioid dependence who were first prescribed opioids for legitimate conditions. The 2016 CDC guidelines for limiting the number of opioid milligrams prescribed for chronic pain proved problematic for these individuals when prescribers immediately started cutting them down or stopped them completely. This led to withdrawal, pain crises, and drug-seeking by illegitimate means.”

Regarding MAT and Suboxone in older people, he states “We have found it is a safe and cost-effective way to treat both opiate use disorder and chronic pain. You must carefully consider an older patient’s medical history and other medicines, and not everyone will be a candidate.”

He also said, “I treated a gentleman in his early 70s with stage three chronic kidney disease. He had been taking 7.5 mg of Lortab (hydrocodone/acetaminophen) five to six times a day for chronic pain. We started Suboxone at a lower dose and increased it more slowly than in someone younger, however, we were able to transition him to Suboxone with incredibly good results. For him, it proved an easier and safer regimen that was also more affordable.”

The liver, not the kidneys, metabolizes Buprenorphine. “Patients that have any kind of renal disease should be dosed with MAT medications in conjunction with a nephrologist. That said, I’ve had both dialysis and renal transplant patients on buprenorphine, and they did fine,” explained Dr. Guffey.

Opioid use disorder has shown to be as much of a problem in older adults as in younger people. The importance of addressing the issue of opioid overdoses reflects in the billions of grant dollars being dedicated to prevention and treatment by the U.S. government. Medication-assisted treatment offers many proven options to combat OUD. Initiating it in older patients takes special consideration. The use of MAT to treat OUD in later life requires more research to confirm best practices, but available evidence points to the method as safe and effective.

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