Prescribing Opioids to Seniors: A Balancing Act

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Dr. Carla Perissinotto ImageNational conversation about the opioid epidemic has focused mostly on young people who buy drugs illegally on the street. But the real scrutiny of opioids has also inevitably changed the way physicians are prescribing medications to the elderly.

Over the past decade, a growing number of seniors have been prescribed opioids including hydrocodone, codeine and oxycodone. A recent study found that in 2011, 15 percent of seniors were prescribed an opioid when they were discharged from the hospital.

As concern grows about a national opioid epidemic, however, some seniors now find it harder to get medications they need from doctors and pharmacies. Some medical practices refuse to accept patients already taking an opioid for pain.

Beyond the obvious dangers of addiction, opioids can pose serious risks for seniors. But opioids can also be a critical tool in treating debilitating pain that leaves seniors immobilized and homebound.

Carla Perissinoto, a geriatrician at the University of California San Francisco, says prescribing opioids to seniors is often about helping them maintain their independence and the delicate balancing act of prescribing opioids.

The following questions were asked of Dr. Perissinoto:

Q: How do you decide whether to prescribe an opioid to an older adult?

One of the tenets in geriatrics with prescribing any medication is the idea that you start low and go slow. For someone who is older, there’s a different biology of aging with medications that take longer to metabolize. They affect people differently. For someone who’s younger, you may be able to start at a dose, for example, of 10 milligrams. In an older adult you often have to start at 2.5.

But how I decide really depends on what are this person’s goals? How is the pain affecting their life? What have I tried and what is not indicated for them? 

Ultimately, my goal with using opioids when I have to is, “Can I relieve this person’s pain well enough so that they can maintain their function?” Because ultimately in older adults, their function and ability to live independently is one of the greatest predictors of health. I have patients who unless they take their opioid really cannot get out of bed. And if that small dose of opioid is going to help them get out of bed and move around their house and cook for themselves, then that is absolutely something worth doing. Their biggest risk is going to be if they stop moving and [decline more]. That’s going to have a bigger consequence on their health than prescribing an opioid at a reasonable dose and with close supervision.

Q: What are some of the risks of prescribing opioids to seniors?

As with any person taking opioids, there are real side effects of becoming addicted. Constipation also ends up being one of the biggest challenges, and frankly many of my older adults don’t want to be on opioids because of the fear of constipation. The other thing is, of course, that opioids can be sedating and so they can put people at risk for falls and an increased risk of confusion.

What’s interesting though is that there are some people with dementia who at times appear to be more confused or delirious. And it turns out it can be from uncontrolled pain. So this is where it’s so tricky for geriatricians to figure out, are we giving enough pain medication or not enough? And how do we figure out that balance? And it’s a very close relationship you need to have with the patient to really figure out, “Am I doing the right thing?”

Q: What are some of the other tools you have available to treat pain for seniors?

There are some topical agents that work for some people. Understandably, many patients don’t like taking that many pills, and so the idea of being able to put something on the joint or on the skin is really fantastic. There are other modalities that I think work for people, for example massage. Some people get benefit from acupuncture and chiropractic care.

The challenge is that many of the additional therapies, even some topical therapies, are not covered by insurance. And that actually brings up an interesting point in how we prescribe, in that there are times that I would prefer to prescribe something topical and it’s not covered by insurance, but yet the opioids are. So it also limits you as a physician in terms of “What am I able to prescribe? What can I do for this person that is covered by insurance?” So unfortunately that is one of the unspoken things — that how things are paid for still makes a big difference.

Q: How do seniors fit in with the larger national conversation about opioids?

I do not want to undermine the national efforts which are very real in terms of the serious consequences of opioids. At the same time, for many older adults, these are very reasonable treatment modalities.

What I’m seeing from the national perspective is that because of this real concern about opiate overuse, many patients are being discriminated against. I have patients who are on opioids, they’re on low doses, they’re very stable. There’s no evidence of abuse. And if I’m out of town and they are out of medications, no one wants to refill them. And that actually puts someone at risk for withdrawal. And what happens is someone then comes to the office and requests an opioid refill for something they’ve been on, and they’re labeled as drug seeking.

It’s very sad. And I think that the challenge is how do we keep this national dialogue going so that we educate providers to prescribe safely? How do we educate patients to know how to look for signs of withdrawal and look for signs of overdose? So that we’re not discriminating against people with chronic illness and chronic pain who really do need these medications to function when other therapies have failed.

Q: Are you seeing patients come into your practice for the first time who are taking too many opioids?

I absolutely have received or have started taking care of people that are frankly incorrectly dosed on too many variations of opioids, and it can be risky. And it’s really hard when someone is on them to really try to take someone off and taper down. But it’s something that can be done if there’s significant trust.

I think that part of it is education of providers in terms of safe opioid prescribing. Because of the national concern over opioid use, we’ve swung away where it’s never prescribed … and I think as a result our physicians in training aren’t being taught how to prescribe correctly.

Q: Some people say there are no situations in which opioids should be prescribed long-term. What would you say to them?

I completely disagree. Palliation, which is the relief of symptoms, is something that is incredibly important with older adults. There are many illnesses in older adults that cannot be cured. And if you are trying to maintain someone’s independence, there are very reasonable times where people may be on opiates; osteoarthritis or severe spinal stenosis. Some of those things do not have great treatments and there are times where opioids do have a positive effect on someone’s relief of pain so that they can maintain their function.

I think that unless you have lived [with] pain yourself, it’s very easy to judge and very easy to assume that someone can just get over it. And I hear this time and time again from some of my patients who were being judged … : “I’d like for that person to walk in my shoes and see what it’s like to live with pain and maybe they would think differently.”

Why Computer Hackers Invade Health-Care Providers

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Male Hacker Using ComputersLast year the dizzying news of a computer hack at MedStar Health, one of the largest medical providers in the Baltimore/Washington area, forced the organization to shut down most of its online operations. 

The exact nature of the attack was suspected as ransomware and MedStar is just one of the the victims in a string of cyberattacks that have hit the health-care industry hard. Here’s what you need to know about how health-care providers became a digital battleground.

Why would cybercriminals go after the health-care industry?

The health-care sector has a lot of information that could be valuable to criminals and that makes them a juicy target.

First, they often have a bunch of personal information that could be used for traditional financial fraud — things like your name, social security number, and payment information. But they also have health insurance information, which can be sold for even more on online black markets because it can be used to commit medical fraud — things like obtaining free medical care or purchasing expensive medical equipment — that often isn’t caught quite as quickly as credit card or bank account fraud.

A particularly aggressive cybercriminal could even find a way to leverage compromising medical information guarded by health-care providers into a blackmail scheme — although that has not become a major avenue for attack yet, according to Ben Johnson, co-founder and chief security strategist at cybersecurity Carbon Black.

However, several U.S. hospitals have also now been hit with ransomware, a type of malicious software that basically lets an attacker hold a computer hostage. Once ransomware gets in a system, it starts quietly using hard-to-break encryption to lock up the information stored there — making information inaccessible to the legitimate user. After the software has finished locking things up, it typically pops up with a message demanding a payoff in a difficult-to-track digital currency like bitcoin in exchange for the digital key needed to get back into the data.

This is a particular type of nightmare scenario for health-care providers because more and more of them rely on electronic medical records to keep things up and running.

“Health care is a bit unique in that up-time is really important,” said Johnson, which means providers may be more likely than other targets to pay quickly so they can get back to work.

Just how vulnerable is the health-care sector to cyberattacks?

Things are not looking good.

According to cybersecurity firm TrendMicro, health care was the sector that was hit hardest by data breaches from 2010 through 2015. Not all of those breaches involved hacks — two-thirds were actually due to the loss or theft of things like laptops, smartphones, or thumb drives — but it still demonstrates a major problem with the way the industry approaches keeping data safe.

“It’s a big environment with a lot of different pieces — and not a lot of investment in cybersecurity,” said Johnson.

Part of the problem is that hospitals and doctors’ offices often need to oversee a mishmash of different types of equipment running different types of software — and they cannot always apply standard security practices, like regular updates, without risking instability because it might break the connections between systems, according to Jay Radcliffe, a senior security consultant at cybersecurity company Rapid7.

The FBI actually warned health-care providers that they needed to increase their digital defenses in April of 2014. “The healthcare industry is not as resilient to cyber intrusions compared to the financial and retail sectors, therefore the possibility of increased cyber intrusions is likely,” said a private notice the FBI distributed to the sector.

In 2015, several big health insurers suffered major breaches. One hack at Anthem, the nation’s second-largest health insurer, left information on up to 80 million people exposed. Another at Premera exposed data on 11 million people, including medical information in some cases.

Also last year a ransomware attack hit Hollywood Presbyterian Hospital in California. Staff was forced to resort to paper record-keeping for a week and divert patients to other hospitals. The hospital eventually paid the attackers roughly $17,000 to get access back to their data.  Two other hospitals in Southern California were also reportedly hit with similar ransomware — as was a Kentucky hospital, which declared an “internal state of emergency” after the attack.

And to make matters worse, the health-care providers are also having to grapple with the problem of securing connected medical devices: A hacked pacemaker or drug pump could have potentially life-threatening consequences for patients, and even other types of networked devices could end up helping a cybercriminal find a furtive way to get access to a hospital’s computer systems.

“That can be the weak spot in your network — and in a lot of cases, a hospital might not even realize it was connected,” said Radcliffe.

What is the health-care sector doing to fix this problem?

The industry has its own groups dedicated to helping coordinate how it responds to cybersecurity threats, including the National Health Information Sharing and Analysis Center, or NHISAC, which was founded in 2010. These sort of efforts are useful because they can help industries work together to help stem the spread of a particular type of threat early.

And there is at least one bright side to all the breaches and hacks in the health-care sector: “They are really waking up to the fact that they are a huge target,” said Johnson.

But, unfortunately, that awareness is just part of the problem. Even once an organization has committed the funds to build up their digital defenses, it can be difficult to plot the best path forward, according to Johnson, because it takes time to figure out which tools to put in place and whom to hire.

The latter part can be difficult for health-care providers because there’s a shortage of security professionals across all industries.

“I’ve literally talked to health-care organizations that have 300 open security positions, and are struggling to fill even a handful of them,” said Johnson.

“It’s going to continue being a rough period of time,” he said.

Common Traits of Financial Fraud Victims

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Man with credit card on phone“I am an older male and married. I’m also a war veteran who values wealth accumulation as a significant measure of success in life. Although I’m idealogically conservative, I’m willing to take risks and am open to unsolicited telephone and email pitches.” 

This is the demographic profile of Americans who are most likely to become victims of financial fraud, according to a new survey by the AARP Fraud Watch Network.

“While previous surveys in this area have developed a demographic picture of investment fraud victims — usually older, financially literate males who are more educated and have higher incomes — our goal with this survey was to learn about why people fall prey and how it can be avoided,” says Doug Shadel, Ph.D., lead researcher for the AARP Fraud Watch Network. “Meanwhile, today’s sophisticated technology makes it significantly easier for scammers to reach large numbers of investors.”

The Fraud Watch Network survey, conducted in August and September 2016, included interviews with more than 200 known victims of investment fraud and 800 interviews with members of the general investing public.

According to Shadel, “what emerges from this study is a well-rounded profile of the kinds of mindsets, behaviors and demographic characteristics that are correlated to falling prey to investment fraud.”

The financial fraud universe

The world of financial abuse and identity theft is a vast one. Sometimes the thieves manufacture alluring Ponzi schemes. Other popular scams involve fake IRS phone calls, emails from oversees ‘royalty,’ or tactics that are closer to home — an appeal on behalf of a family member with an eye on their loved one’s nest egg.

The amount of thievery taking place in America varies as well. Many studies estimate the money lost to elder financial abuse alone at $2.9 billion. A 2016 study by True Link Financial, a San Francisco-based company that provides tools and services for seniors, and adults with disabilities, found that number to be a gross understatement.

The True Link Financial research revealed that seniors lose $36.5 billion each year to elder financial abuse with approximately 37 percent of seniors affected by financial abuse in any five-year period. Here is a breakdown of the problem:

        • Financial exploitation: $17 billion is lost annually to financial exploitation, defined as when misleading or confusing language is used — often combined with social pressure and tactics that take advantage of cognitive decline and memory loss — to obtain a senior’s consent to take his or her money.
        • Criminal fraud: $13 billion is lost annually to explicitly illegal activity, such as the grandparent scam, the Nigerian prince phishing scam, or identity theft.
        • Caregiver abuse: Nearly $7 billion is lost annually to deceit or theft enabled by a trusting relationship — typically a family member but sometimes a paid helper, friend, lawyer, accountant or financial manager.

A perfect storm for fraud

AARP’s survey notes that economic forces have converged to make the current environment ideal for investment swindlers to practice their craft.

“The decline in traditional pensions has prompted millions of relatively inexperienced Americans to take on the job of investing their own money in a fast-moving and complex market,” says Shadel. 

The AARP survey found stark differences between the past investment fraud victims and regular investors in three areas:

        1. Psychological Mindset: More victims reported preferring unregulated investments, valuing wealth accumulation as a measure of success in life, being open to sales pitches, being willing to take risks, and describing themselves as ideologically conservative.
        2. Behavioral Characteristics: Victims reported that they more frequently receive targeted phone calls and emails from brokers, they make five or more investment decisions each year, and more of them respond to remote sales pitches — those delivered via telephone, email or television commercials.
        3. Demographics: Somewhat replicating the previous industry studies, higher percentages of victims were found to be of older age, male, married and military veterans.

To further educate yourself, one suggestion is to take the AARP Fraud Watch Network’s online quiz. There you can learn whether or not you possess the characteristics that may predict likely fraud victimization.

According to AARP, “Investors who score high on the quiz are urged to apply a new level of caution if they receive unsolicited investment overtures.” Also investors should adhere to the following investor protection tips:

        • Do:  Invest only with registered advisors and investments.
        • Don’t:  Make an investment decision based solely on a TV ad, a telemarketing call or an email.
        • Do:  Put yourself on the Do Not Call list.
        • Do:  Get a telephone call blocking system to screen out potential scammers.
        • Do:  Limit the amount of personal information you give to salespersons until you verify their credentials.
        • Don’t:  Make an investment decision when you are under stress.  For example, when you’ve recently experienced a stressful life event such as the loss of a job, an illness or death of a loved one.

Friendly fire

According to the True Link Financial study, risk and vulnerability can play an equal role in putting consumers in the greedy hands of financial criminals. “People often assume that those perceived as most vulnerable — widows, the very old, people with severe memory loss — are at greatest risk. In fact, risk equals vulnerability plus exposure. Seniors who are young, urban, and college-educated lose more money than those who are not.”

Unfortunately, those who are friendly and welcoming to others, including strangers, are most at risk. “Seniors described as extremely friendly lose four times as much to elder financial abuse, perhaps because they are approachable and may give strangers the benefit of the doubt.”