Full length articleA hidden aspect of the U.S. opioid crisis: Rise in first-time treatment admissions for older adults with opioid use disorder
Introduction
The opioid crisis has affected Americans from all walks of life. The rate of U.S. adults engaging in non-medical prescription opioid use has declined in recent years, yet the overall rate of illicit opioid use (including heroin and prescription opioids) and opioid use disorder (OUD) continues to rise (Jones, 2017). Older adults may have been overlooked as a potentially vulnerable population during this nation-wide tragedy. Although alcohol remains the most common substance use problem among older adults (Han et al., 2017a), illicit drug use is becoming more common in this population. The number of older adults seeking treatment for OUD is projected to increase (Cicero et al., 2012), and the magnitude of this trend has not been assessed in recent years. Since there is no consensus in the scientific literature regarding the definition of “older adults” (Carew and Comiskey, 2017), this term will be used here to refer to adults 55 and older because they are through their “mid-life” years and beginning to retire and experience age-related health problems (Petry, 2002).
Persons with OUD are often categorized as using either prescription opioids or heroin as their primary drug of choice. This is an artificial distinction, as prescription opioids and heroin both act on the μ-opioid receptor and are often co-used; however, classifying individuals by their drug of choice (e.g. prescription opioids or heroin) may also have value, as prescription opioid misuse is often an initial step toward heroin use (Jones et al., 2015; Compton et al., 2016; Mital et al., 2018). It is unclear how the opioid crisis has affected older adults compared to the larger population of persons with OUD, yet older adults might have unique risk factors that make them susceptible to opioid misuse and OUD.
Older adults have a higher rate of prescription opioid exposure than any other age group (Han et al., 2017b), and chronic opioid use for the purpose of pain relief can progress to physical dependence and/or the onset of OUD. Older adults at risk of developing OUD often engage the medical community, and a recent study reported that 40–50% of adults 50 and older who misused prescription opioids obtained those medications through physicians (Schepis et al., 2018). Likewise, as individuals age they are less likely to obtain prescription opioids illicitly (from ‘dealers’) and more likely to obtain prescription opioids via the medical community (Cicero et al., 2012).
Research examining trends in older adults using and seeking treatment for illicit drugs has generally found increased opioid use over relatively long periods of time. Between 1990 and 2010 illicit opioid use increased among older adults and this group was less likely than younger adults to perceive their drug use as problematic, and seek treatment (Wu and Blazer, 2011). Moreover, the proportion of older adults seeking treatment for heroin increased markedly between the mid 1990s and 2000s (Lofwall et al., 2008; Arndt et al., 2011). In general, the average age when individuals first seek treatment for OUD has increased since the 1960s (Carew and Comiskey, 2017), although in 2010 the average age of initiation of opioid use was still relatively low (23 years old) (Cicero et al., 2014).
Older adults are inherently more complicated to treat medically (Qato et al., 2008; Gerlach et al., 2017; Davis et al., 2017), and while it is well established that this growing population is often exposed to opioids for pain management, the longitudinal trends in older adults seeking treatment for OUD remains unclear. This information is necessary to help treatment facilities prepare for the unique needs of this population. The purpose of this report is to quantify trends in United States OUD admissions for older adults versus the rest of the OUD population (those under the age of 55) between 2004–2015. In addition, individuals were stratified by whether their primary substance of use at admission was heroin or prescription opioids. Associated demographics and routes of opioid administration over time were also evaluated.
Section snippets
Sample collection: the treatment episode data set (TEDS)
Data were collected from the Treatment Episode Data Set for Admissions (TEDS-A) between 2004–2015 (N = 22,160,542), a database of U.S. state certified substance abuse treatment systems maintained by the Center for Behavioral Health Statistics and Quality within the Substance Abuse and Mental Health Services Administration (Center for Behavioral Health Statistics and Quality, 2018). Each case in the TEDS-A represents a single treatment admission, and as such, the same individual could account
Trends in older adults seeking treatment for opioid use disorder
Joinpoint regression analysis identified two trends (joinpoint in 2013) in older adults presenting to treatment for primary OUD between 2004–2015. First-time OUD admissions among older adults increased 41.2% between 2004–2013 (p-trend = 0.046), with an AAPC of 8.0% (95% CI: 6.5%–9.7%), i.e. first-time admissions increased an average of 8% each year compared to the previous year. Subsequently, first-time OUD admissions increased 53.5% between 2013–2015 (p-trend = 0.009), with an AAPC of 24.7%
Discussion
Analysis of the TEDS-A database indicated a marked surge in older adults seeking first-time treatment for OUD between 2013–2015 (Fig. 1). While the U.S. population of adults 55 and older grew by 5.7% percent between 2013–2015 (United States Census Bureau, 2018), the proportion of older adults seeking treatment for OUD increased 53.5%, outpacing both population growth and the rest of the OUD treatment-seeking population (Fig. 1). Using 2012 as a baseline year, the proportion of older adults
Conclusions
Much of the media attention on the opioid crisis has focused on younger adults, however, a hidden consequence of the opioid crisis has been a sharp increase in older adults seeking treatment for OUD. This is a relatively understudied population that may be more susceptible to opioid misuse and OUD given ongoing comorbidities such as chronic pain and mental health conditions. In addition, typical OUD treatment options may not be optimized to treat this medically challenging population, making
Contributors statement
All authors contributed to the research design, data interpretation, and manuscript preparation. Author ASH performed all data analyses. All authors approved the final version of this manuscript.
Conflict of interest statement
Author DAT has received medication supplies from Indivior for an investigator initiated study, was site PI for a clinical trial sponsored by Alkermes, and is on a scientific advisory board for Alkermes. Author ECS has served as a consultant or served on advisory boards for Analgesic Solutions, Indivior, The Oak Group, Egalet Pharmaceuticals, Caron, Innocoll, and Pinney Associates, and has received research funding through his university from Alkermes. All opinions expressed and implied in this
Acknowledgements
The authors would like to thank Kathryn Van Eck and the BEAD Core at Johns Hopkins University for their assistance in planning the data analyses.
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