Mitigating the Opioid Crisis Among Seniors During the COVID-19 Pandemic

The emergence of the coronavirus disease 2019 (COVID-19) pandemic was devastating, both to our health care systems and people alike. Although the disease can affect anyone, it has the greatest impact on our senior population.

The highest hospitalization and death rates are among those aged 65 years and older.^1,2 In addition, the pandemic is colliding with the nation’s ongoing opioid crisis, which has seen almost 450,000 lives lost between 1999 and 2018 due to drug misuse.³ More urgent care for seniors is needed during this collision of health crises.

Combined efforts to resolve the opioid crisis over the past few years have shown benefit, as the annual number of deaths due to the opioid crisis has been decreasing.⁴ Unfortunately, COVID-19 has stalled the progress.

The Overdose Mapping and Application Program (ODMAP) reported a 20% increase in national overdose submissions since the first reported case of COVID-19,⁵ whilst the American Medical Association’s September briefing highlighted that 42 states have reported an uptick in opioid-related mortality.⁶ In April and May, overdoses jumped 29% and 42% respectively.⁷

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The numbers are clear—COVID-19 has greatly exacerbated an already dire situation. No single entity is capable of resolving the opioid epidemic on its own. There needs to be a collaborative effort to fight the opioid crisis during and beyond the COVID-19 pandemic.

Historically, a major challenge in finding solutions for the opioid crisis has been about managing the balance between appropriate pain management and the avoidance of opioid misuse,⁸ especially among the senior population who are more prone to chronic pain.⁹ In 2018, Medicare recipients received an average of 5 opioid prescriptions per patient, and more than 350,000 of the recipients had prescription opioids dosed beyond an equivalent of 90 mg of morphine, the threshold recommendation by the Centers of Disease Control and Prevention (CDC) to avoid risk of overdose.¹⁰

Not only are high prescription rates and high doses an issue, but bodily changes due to aging make opioid use even more dangerous in the senior population.⁹ Effects of opioids can worsen health conditions in the elderly, such as delirium and immunosuppression, as well as put them at greater risk of death.¹¹

Respiratory depression is a potentially lethal complication of opioid treatment, and a major cause of opioid-induced death.¹¹ With COVID-19 in the picture, the likelihood of death is even greater in patients taking opioids.¹² The brutal effects of COVID-19 on the lungs may make breathing difficult even before opioid use. The combination of COVID-19 with opioid-induced respiratory depression, especially in an elderly patient, could be deadly.^13,14

Pain management providers are at the front lines of the opioid crisis, serving as the experts in balancing alleviation of suffering with reducing risk of addiction and overdose.¹⁵ However, with social distancing measures in place, it’s difficult for patients with chronic pain, such as seniors, to get the proper management. Shelter-in-place policies have limited in-person visits with health care providers (HCPs) and to pharmacies, creating a hurdle to medication adherence and increasing risks of suffering due to undertreatment, self-management, or possible misuse of opioids.^15,16

To ease the burden during the COVID-19 pandemic, government agencies such as the Drug Enforcement Agency (DEA) and the Center for Medicare and Medicaid Services (CMS) have temporarily eased some of the existing regulations. In-person visits are typically mandated for prescribing opioids. However, considering the circumstances, the DEA has allowed HCPs to use telehealth to assess patients prior to prescribing opioids.¹⁷

CMS agencies are waiving fees for Medicare patients, allowing them the access and convenience of pain medication management services such as telehealth, out-of-network pharmacies, and medication delivery services while also removing restrictions for some medicines, such as prior authorizations, to help ease the burden on HCPs trying to treat their patients.¹⁸

Similar to our approach in the fight against COVID-19, a collaborative, industry-wide effort is necessary to battle the opioid crisis during and beyond the pandemic. The entire health care industry plays a role in addressing this crisis together, with an aim to balance responsible opioid abuse risk mitigation with appropriate care.

Education and collaboration with health insurers, prescribing physicians, and other health care practitioners, as well as access to data, allows for more informed decision-making, and Humana’s efforts have shown this to work. Humana offers medication therapy management (MTM) services, allowing for pharmacists, physicians, and patients to work together in therapeutic management.

Humana has embedded pharmacists within primary care clinics to help facilitate this MTM service. An integrated care team is important to developing the right care approach for their patients—especially seniors, a population that often has complex health and prescription needs.

By working with pharmacists, physicians, and other clinicians to monitor drug interactions, we have observed a 44% decrease in members who are prescribed both opioids and benzodiazepines (referred to as double-threat therapy), decreasing the risk of opioid addiction and overdose. This collaborative effort has also resulted in a 52% decrease in the number of patients with high-dose opioids (opioid doses ≥ equivalent of 90 mg of morphine).

The need for education extends beyond the risks of double-threat therapy. Research from the American Society of Addiction Medicine estimates that 98% of providers are not trained to provide medication-assisted therapy (MAT) to patients addicted to opioids.¹⁹

Humana implemented new clinical strategies for MAT Adherence Outreach and Research, extending coverage of certain MAT drugs and educating providers on offering members a new alternative to tapering dosage or deprescribing medication(s).

These policy and formulary changes have proven that patients who use sublingual MAT had greater adherence and persistence to their therapy and were less likely to revert to opioid use. Recent data have shown that approximately 22% of Humana recipients at high risk of overdose (taking opioids dosed at ≥90 mg of morphine) have received naloxone, nearing its goal of 25%.

The resolution of the opioid crisis is one of the top health care challenges of our time and should be made an even higher priority due to the increased devastation caused by the COVID-19 pandemic. Although it may feel like individual actions aren’t making enough of an impact against an issue of this magnitude, all these efforts are synergistic.

Together, we can lead our industry and society to a better future while providing the help and support our communities need. What we do, or don’t do, affects policymakers, drug manufacturers, health insurers, prescribing physicians, pharmacists—and of course—seniors, their families, and the communities they are a part of.

About the Author

Scott Greenwell, PharmD, senior vice president and Humana Pharmacy Solutions president.

References

• https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html
• https://www.cdc.gov/mmwr/volumes/69/wr/mm6928e1.htm
• https://www.cdc.gov/drugoverdose/epidemic/index.html
• https://www.cdc.gov/drugoverdose/data/prescribing/overdose-death-maps.html
• http://odmap.org/Content/docs/news/2020/ODMAP-Report-May-2020.pdf
• https://www.ama-assn.org/system/files/2020-08/issue-brief-increases-in-opioid-related-overdose.pdf
• https://www.washingtonpost.com/health/2020/07/01/coronavirus-drug-overdose/
• Bonnie RJ, Schumacher MA, Clark JD, Kesselheim AS. Pain Management and Opioid Regulation: Continuing Public Health Challenges. Am J Public Health. 2019;109(1):31-34. doi:10.2105/AJPH.201304881
• Kress HG, Ahlbeck K, Aldington D, et al. Managing chronic pain in elderly patients requires a CHANGE of approach. Curr Med Res Opin. 2014;30(6):1153-1164. doi:10.1185/03007995.2014.887005
• https://oig.hhs.gov/oei/reports/oei-02-19-00390.pdf
• National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse; Phillips JK, Ford MA, Bonnie RJ, editors. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Washington (DC): National Academies Press (US); 2017 Jul 13. 2, Pain Management and the Intersection of Pain and Opioid Use Disorder. Available from: https://www.ncbi.nlm.nih.gov/books/NBK458655
• https://www.drugabuse.gov/about-nida/noras-blog/2020/04/covid-19-potential-implications-individuals-substance-use-disorders
• https://www.drugabuse.gov/about-nida/noras-blog/2020/04/covid-19-potential-implications-individuals-substance-use-disorders
• Leece P, Cavacuiti C, Macdonald EM, et al. Predictors of Opioid-Related Death During Methadone Therapy. J Subst Abuse Treat. 2015;57:30-35. doi:10.1016/j.jsat.2015.04.008
• Eccleston C, Blyth FM, Dear BF, et al. Managing patients with chronic pain during the COVID-19 outbreak: considerations for the rapid introduction of remotely supported (eHealth) pain management services. Pain. 2020;161(5):889-893. doi:10.1097/j.pain.0000000000001885
• Hayden JC, Parkin R. The challenges of COVID-19 for community pharmacists and opportunities for the future [published online ahead of print, 2020 May 21]. Ir J Psychol Med. 2020;1-6. doi:10.1017/ipm.2020.52
• https://www.deadiversion.usdoj.gov/coronavirus.html
• https://www.cms.gov/files/document/hpms-memo-covid-information-plans.pdf
• Rosenblatt RA, Andrilla CH, Catlin M, Larson EH. Geographic and specialty distribution of US physicians trained to treat opioid use disorder. Ann Fam Med. 2015;13(1):23-26. doi:10.1370/afm.1735