Veteran nurse George Ates suffers from what is often considered the profession’s oldest malady: his feet hurt.
The Suisun City resident was long able to address that by switching out his shoes. But that stopped working in recent years. So he saw his doctor. He was eventually prescribed Norco, a combination of acetaminophen and the opioid hydrocodone.
Ates said he eventually crossed a dangerous threshold. “The way these medicines work, if you take them long enough, they will cause pain,” he said. “And to get through that pain, you wind up taking more.”
That led to an odyssey of ever-increasing doses, until each day Ates was taking 10 times what he had been originally prescribed. He was eventually switched to a fentanyl patch that would swiftly kill someone who hadn’t built up a high tolerance to opioids. He stopped working for several years and wound up in the emergency room twice while struggling with a brutal period of withdrawal.
On the surface, Ates appears to be another of the millions of Americans caught up in the nation’s epidemic of opioid drug use. But he will be 67 this fall – a seeming outlier to a phenomenon that has mostly swept up younger adults. Yet Ates’ struggles are actually commonplace at California’s hospitals.
According to data released earlier this year by the federal Agency for Health Care Research and Quality, California had the nation’s second-highest rate of patients over 65 seeking care at hospital emergency departments for opioid-related issues, such as falls or other accidents caused by the loss of fine motor skills associated with the drugs, or symptoms associated with withdrawal. In 2014, the rate was 110.4 per 100,000 of population. That’s second in the nation only to Arizona. In Massachusetts, where the rate of ER visits among residents between the ages of 25 and 44 for opioid issues comprised more than 1 percent of the state’s population, the rate among seniors was just 41 per 100,000.
“I’m seeing these types of patients daily,” said Aimee Moulin, an emergency medicine physician at UC Davis Medical Center and one of the supervisors of its medical residents. She added that the number has been rising in recent years.
Moulin, who is president-elect of the California chapter of the American College of Emergency Physicians, also believes the number of seniors coming into to the ER due to opioid dependency or addiction are being undercounted. She observed that many older ER patients who have such issues seek treatment at the ER for falls or traffic accidents, and that the focus on the physical injuries is pushing the root cause into the background. “Emergency rooms are notoriously bad for (recording) substance abuse diagnoses,” she said. And there’s also the struggle with admitting drug dependency – older Americans often view it as a severe stigma.
The Root Causes
Why are older Californians struggling with opioids? A study published last year in the Journal of the American Medical Association say many older patients are prescribed such medications to deal with managing pain after leaving the hospital for a joint replacement surgery, or for palliative care. About 1 million joint replacement surgeries occur each year in the U.S., according to data from the American Academy of Orthopaedic Surgeons, with those over the age of 50 most likely to go under the knife. Those numbers are growing each year. Of those who received an opioid prescription after discharge, the JAMA study concluded more than 42 percent still had a prescription in place 90 days after they left the hospital.
Sameer Awsare, an internist and associate executive director of The Permanente Medical Group (the physician arm of Kaiser Permanente) wasn’t specifically aware of the data on older Californians seeking care at the ER for opioid issues. Yet, he wasn’t surprised by the high rate of those seeking care. Research for an initiative The Permanente Medical Group undertook to reduce opioid prescribing concluded that orthopedic surgeons were the third-highest prescribers of the drugs in the entire Kaiser Permanente system.
The biggest prescribers in the Kaiser Permanente system: Family and internal medicine doctors. The reason is fairly straightforward, according to Awsare: “one out of three Americans have chronic pain,” he said. Awsare added that back in the 1990s, doctors were told to control their patients’ pain at whatever cost – bolstered by continuing medical education courses sponsored by pharmaceutical manufacturers (that practice has since stopped).
Internal research indicated that in 2009, opioid painkillers were the most frequently dispensed drug in the entire Kaiser Permanente system, topping prescriptions for diabetes and hypertension. Kaiser Permanente also did not subsidize many of those painkillers, meaning enrollees were bearing the entire cost out-of-pocket. The system began implementing reforms the following year, providing more specific training to doctors and pharmacists and alerting them through electronic medical records when potential prescribing issues arise. Kaiser Permanente has reduced overall opioid prescriptions by 40 percent since 2014.
Other providers are also making changes. Moulin said that UC Davis’ emergency department is adapting a program developed at Yale University where patients are given short-term prescriptions to buprenorphine (marketed as Suboxone) – another opioid that can be used to wean patients from stronger opioids. They are also sent to the appropriate provider for long-term treatment.
“The standard of care in the ER when you’re not being admitted is tell the patient to call AA and say ‘good luck to you.’” Moulin said.
Managing Older Patients A Challenge
Ates’ leave from work was actually a fortuitous event. When he left the now-closed Doctors Hospital San Pablo, he switched to his wife’s health insurance, which is Kaiser Permanente. His Permanente physician, Vallejo-based Paul Rubin, moved quickly to wean him off the fentanyl. But just stepping down his dosage from 100 to 75 micrograms led to what Ates described as the most hellish day of his life. “I thought I was going to die,” he said. That first hellish day was succeeded by many others. Ates didn’t eat or sleep for five days. He lost 40 pounds. That led to the first of his ER visits. Subsequent stepdowns led to extended bouts of nausea, and eventually a second ER visit for Ates after he went from a 50 microgram fentanyl patch to 25 micrograms.
Treating older patients can be a challenge aside from withdrawal. If they have been prescribed multiple medications, Moulin noted they often require a geriatrician to help them manage all the other medications while they’re being weaned off. But there is a shortage of geriatricians, which is among the lowest-paid specialties in medicine.
Ates himself has seen the consequences of not managing opioid-dependent patients well. He recalled one Doctors Hospital of San Pablo regular who also struggled with depression. One day her doctor cut her painkillers off entirely. She committed suicide almost immediately afterward.
“If a doctor is going to prescribe this pain medicine, they need to tell a patient that there has to be limits, that they can only take it for three weeks or a month,” he said, adding that the fentanyl patch he wore for two years should be against the law. “You can’t keep taking this stuff. It will kill you.”
Ates has now been off opioids for a year. He’s getting his master’s degree in nursing through an online program. And he’s just returned to work as a nurse at the state prison in Vacaville.
“I know myself, and I’m a pretty strong constitutional character,” he said. “In spite of that, I had to dig way down inside of myself to confront this.”
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