Publications

BACKGROUND AND OBJECTIVE

There has been concern over rising use of prescription opioids in young and middle-aged adults. Much less is known about opioid prescribing in older adults, for whom clinical recommendations and the balance of risks and benefits differ from younger adults. We evaluated changes in use of opioids and other analgesics in a national sample of clinic visits made by older adults between 1999 and 2010.

DESIGN, SETTING, AND SUBJECTS

Observational study of adults aged 65 and older from the 1999-2010 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, serial cross-sectional surveys of outpatient visits in the United States.

METHODS

Medication use was assessed at each study visit and included medications in use prior to the visit and medications newly prescribed at the visit. Results were adjusted for survey weights and design factors to provide nationally representative estimates.

RESULTS

Mean age was 75 ± 7 years, and 45% of visits occurred in primary care settings. Between 1999-2000 and 2009-2010, the percent of clinic visits at which an opioid was used rose from 4.1% to 9.0% (P < 0.001). Although use of all major opioid classes increased, the largest contributor to increased use was hydrocodone-containing combination opioids, which rose from 1.1% to 3.5% of visits over the study period (P < 0.001). Growth in opioid use was observed across a wide range of patient and clinic characteristics, including in visits for musculoskeletal problems (10.7% of visits in 1999-2000 to 17.0% in 2009-2010, P < 0.001) and in visits for other reasons (2.8% to 7.3%, P < 0.001).

CONCLUSIONS

Opioid use by older adults visiting clinics more than doubled between 1999 and 2010, and occurred across a wide range of patient characteristics and clinic settings.

In the European Union, more than 400,000 individuals are homeless on any one night and more than 600,000 are homeless in the USA. The causes of homelessness are an interaction between individual and structural factors. Individual factors include poverty, family problems, and mental health and substance misuse problems. The availability of low-cost housing is thought to be the most important structural determinant for homelessness. Homeless people have higher rates of premature mortality than the rest of the population, especially from suicide and unintentional injuries, and an increased prevalence of a range of infectious diseases, mental disorders, and substance misuse. High rates of non-communicable diseases have also been described with evidence of accelerated ageing. Although engagement with health services and adherence to treatments is often compromised, homeless people typically attend the emergency department more often than non-homeless people. We discuss several recommendations to improve the surveillance of morbidity and mortality in homeless people. Programmes focused on high-risk groups, such as individuals leaving prisons, psychiatric hospitals, and the child welfare system, and the introduction of national and state-wide plans that target homeless people are likely to improve outcomes.