Navigating the Tightrope: Opioids and Fall Risk in Older Adults

The recent publication in JAMA Internal Medicine by Hopkins et al. (2024) spotlights a significant concern within healthcare, particularly in long-term care (LTC) and senior living communities: the increased risk of serious fall events associated with opioid analgesic use among older adults. As the aging population continues to grow, understanding and mitigating this risk becomes paramount for healthcare providers, LTC communities, and senior care pharmacists, to ensure the safety and well-being of their residents.

The Study’s Findings

The study, encompassing over 3.2 million individuals who initiated prescription opioid treatment, found a clear association between opioid exposure and an elevated risk of serious falls. This risk not only increased with age but was particularly pronounced within the first 28 days of starting opioid therapy. In a population already at high risk for falls and major injury associated with falls, these findings underscore the need for cautious opioid prescribing and vigilant monitoring, especially among older, frail LTC residents.

The Role of Senior Care Pharmacists

As a long-term care consultant pharmacist with a background in acute care clinical pharmacy, I’ve seen firsthand the life altering result—both positive and negative—associated with prescribing opioids for older adults. From prescribing doses that are too high for an individual’s comorbidities to inadequate pain control, there is a tightrope that healthcare teams face when addressing the specific medical needs of each resident.

Senior care pharmacists play a pivotal role in managing medication therapy within LTC and senior living communities. They are at the forefront of reducing the risk of polypharmacy, drug interactions, and adverse drug events. Their expertise is invaluable in ensuring that medications, particularly opioids, are used judiciously and appropriately. By conducting thorough medication reviews and assessments, pharmacists can help identify potential risks and intervene before adverse events occur.

Opioid Stewardship in LTC Communities

About 50% of all older adults report daily pain, and in the LTC setting, 45-80% of residents report chronic pain that negatively impacts their quality of life. Community staff, prescribers, and pharmacists are familiar with how to appropriately treat pain and are aware of what newer non-pharmacological approaches are available such as music therapy and massage.

Long-term care pharmacists review each new medication, including opioids, for appropriate dosing and for potential drug interactions that may lead to an adverse medication event, such as a fall. If a serious concern is identified, they will intervene, providing alternate therapy recommendations.

When new opioid therapy is initiated or when doses of opioids are increased, LTC community staff must be especially vigilant. This includes practicing principles of opioid stewardship, such as requiring prescribers to specify the diagnosis for use, expected results, and intended duration of therapy for each opioid prescribed. For “as needed” (PRN) opioids, clear documentation in the Medication Administration Record (MAR) by administering staff of the reason for each dose and the follow-up response is crucial. These measures not only enhance resident safety but also promote accountability and transparency in opioid prescribing.

Collaborative Efforts for Safer Opioid Use

Community leadership teams play a critical role in fostering a culture of safety and quality in medication management. One aspect of this is expecting their LTC pharmacy partner to provide trend reports on the use of opioids within the community, comparing these trends with peer institutions. Such data-driven insights enable leadership teams to make informed decisions and implement strategies aimed at reducing opioid-related risks.

The findings from Hopkins et al. (2024) highlight the complex interplay between opioid use and fall risk in older adults, particularly within LTC settings. By embracing a multidisciplinary approach involving senior care pharmacists, staff, community leadership, and healthcare providers, LTC communities can enhance their opioid stewardship practices and reduce fall risk among their residents. This collaborative effort is vital in safeguarding residents from the risks associated with opioid therapy while compassionately treating pain, ultimately contributing to higher standards of care and resident safety.

The American Society of Consultant Pharmacists has developed a comprehensive Opioid Stewardship Toolkit to help providers and pharmacists navigate the complexities of opioid use in older adults available at www.ascp.com/page/opioid.

Reference:

1. Davis, L. (2020). Pain Management and Opioid Free Treatment Order Sets: An Evolving Role for Pharmacists. The Senior Care Pharmacist, 35(10), 406-407. https://doi.org/10.4140/TCP.n.2020.406