Senate Special Committee on Aging Issues Testimony From St. Joseph Hospital
"Thank you, Chairman Collins and Ranking Member Casey. My name is
"As you know, the opioid epidemic claims the lives of almost 120 Americans every day and more than one a day in my state of
"I see patients every day who are impacted by this crisis, including many who are older. While the effects of the opioid epidemic on seniors are in large part similar to the effects on the population as a whole, the epidemic does present some unique challenges for older Americans. It seems likely that most seniors who are currently on opioid medications were prescribed them for pain as opposed to younger people who may be more likely to have started with so-called "recreational use." As we know, most people who are now addicted did start on prescription opioids however those opioids were not necessarily prescribed for them but very often obtained through illicit channels.
"In addition to being at risk for crime such as having their medications stolen and diverted by caretakers, family members and others, we are seeing many cases in which people who have become dependent on these medications seem to be tapered off them too quickly with little offered in the way of alternative pain management. One of the difficulties we have in treating pain is that the entire class of NSAIDs, nonsteroidal anti-inflammatory drugs which include ibuprofen and naproxen, cannot be used in patients with compromised kidney function or certain other medical problems that are common in older people. Acetaminophen can be used for the most part, and while its power is often underappreciated, it is usually not enough for truly severe pain. Nevertheless, there is a range of pain tolerance among people and a fair amount of variability in how well medications like acetaminophen and the NSAIDs will work.
"Prescribing is further complicated by comorbidities, which are more common the longer a person lives, and by interactions with other medications a person may be taking, including anti-anxiety medications (such as the benzodiazepines) and nausea medications. Another problem with prescribing these medications in this age group is the likelihood of magnified effects or undesirable side effects. People in this age group are more susceptible than younger people to confusion, drowsiness, hypoventilation, respiratory arrest, falls (and fractures), constipation and bowel blockage, so the dose must be reduced to a point where it can be hard to break pills into small enough pieces.
"One interesting impact of all the publicity about the epidemic and the potential for harm these medications have is that, for example, those in the field of oncology are hearing more often that patients even with terminal cancer are reluctant to be started on opioid pain medication because they fear becoming addicts. This is something we all had heard before but never as much as we are hearing it from patients now.
"I was interested and appalled to see some of the data in the HHS OIG data brief of
"Regarding the prescription monitoring website, we do have new software in line with what other states have but problems remain. One interesting challenge is that the program is designed only to show pills that were dispensed. Some practitioners feel it would be helpful to know when pharmacists deny attempts to fill opioid prescriptions. While we do have new software, we don't have the most easy to use product from the vendor that now services almost every state. Furthermore, hospitals and other employers have not opted for the ability to link the prescription monitoring site into their electronic records. Where I work, we now use Epic and I have seen that PMP date can flow right into the Epic system. Also, in spite of legislation enacted by
"Patient perception of pain is a real challenge, particularly among those who have been on opioids for long periods of time for chronic pain because they are used to the status quo and fear that nothing will work as well for their pain. Barring exceptions for cancer, end-of-life care, hospice or palliative care, people in
"I am happy to say that there are a lot more resources for recovery than there were just a year ago. I know the limits for prescribing Suboxone have been increased and now PAs and nurse practitioners can prescribe as well. We still need more people to become prescribers of Suboxone however, especially primary care clinicians who in many cases already have these patients in their practice, but the patients may not have divulged their drug problem yet or the practitioners may not realize how easy it would be to help their patients with their drug problems. In addition, there are emergency departments around the country, including at least one in
"In my community, thanks to the effort of the Community Health Leadership Board and others, leading practitioners came together and reviewed their own prescribing practices and agreed upon new guidelines. In addition, a psychiatrist brought forth an idea for a social detox center to that same group and it has become a reality, providing a place in
"Nevertheless, serious barriers remain, including lack of insurance coverage. While some of the services are available to people with no insurance, many programs are not available to them and the gold standard of medication assisted therapy, Suboxone, is not adequately covered by some insurance plans and is a barrier for those with no insurance, particularly in states like my own that not only have been blocking Medicaid expansion but have been reluctant to release funds for Suboxone for patients with no insurance. I want to personally thank
"Also, as you know, there's a great deal of overlap between substance abuse and psychiatric illness and holding psychiatric patients in emergency departments for extended periods for lack of a proper care setting is only getting worse. This is not only bad for their wellness and recovery, it sometimes causes patients who come to us for detox to have to wait long periods of time when they could have been seen fairly quickly and transported to the detox facility. The psychiatric boarding problem has adverse effects on everyone's care.
"Another thing that has improved or will improve things is the change in wording of patient satisfaction surveys and federal programs. While there was a strong feeling the old language created a perverse incentive and even pushed practitioners to prescribe more pain medication, the new language, is less likely to have such an effect as long as people answer the question honestly and don't seek to exact retribution for what they perceive as pain management that was not specifically what they had in mind. I want to thank the
Summary / Call to Action:
"While we now have more tools than ever to address the opioid crisis, much remains to be done, particularly in the areas of removing barriers to inpatient residential treatment and medication assisted therapy. To this end, anything that would increase coverage for these people for these services is essential.
"Also, given the overlap between psychiatric illness and substance abuse problems, it is imperative to address the shortage of psychiatric services which causes psychiatric patients to board in the emergency department. This is virtually an everyday problem at my hospital and hospitals across the country.
"I would like to see passage of the Opioid Crisis Response Act of 2018 (S. 2680) which essentially includes all the provisions of S. 2610, the Preventing Overdoses While in Emergency Departments Act of 2018, and S. 2516, the Alternatives to Opioids (ALTO) in the Emergency Department Act."
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