By Seema Gupta, MD, MSPH

Clinical Assistant Professor, Department of Family and Community Health, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV

Dr. Gupta reports no financial relationships relevant to this field of study.

SYNOPSIS: New and frequent opioid users 50-80 years of age who drove while on opioids increased their probability of an accident.

SOURCE: Monárrez-Espino J, Laflamme L, Rausch C, et al. New opioid analgesic use and the risk of injurious single-vehicle crashes in drivers aged 50-80 years: A population-based matched case-control study. Age Ageing 2016;45:628-634.

The treatment of pain in older adults presents unique challenges. Along with suffering from a number of chronic conditions for which multiple medications may be prescribed, the addition of another medication may place the patient at higher risk of drug-drug interactions. Existing morbidity, such as lower renal function, also may limit the choice of analgesics. Moreover, age-related changes, such as those in memory, cognition, and sensory functions, may deteriorate further with some analgesics, such as opioids, which can lower the ability of these patients to function independently. As the geriatric population in the United States grows, more older adults expect to lead an active life, which involves the ability to drive. As the nation endures an opioid epidemic in terms of addiction, morbidity, and mortality, optimizing drug therapy while adequately treating pain is an essential part of caring for an older patient. However, the potential impairment due to the use of opioids while driving remains an unsettled issue. Although some evidence-based literature reviews indicate opioids do not appear to be associated with intoxicated driving and are not associated with motor vehicle crashes, others have found an increased risk.1,2 Some have suggested that relieving pain actually could improve cognitive functions. However, most evidence is not direct, and there remains a need for high-quality studies to produce more persuasive empirical evidence.3

Monárrez-Espino et al conducted a population-based, matched, case-control study that included 4,445 Swedish drivers 50-80 years of age. These drivers had been involved in a single-car crash between 2005 and 2009 in which at least one person suffered an injury that required medical care. The 4,445 cases were matched 1:4 to 17,780 controls by sex, age, and residence. Study participants were considered new to opioid analgesics if they had received a prescription within one month before the crash. Regular or frequent users were those who received at least three prescriptions in the last six months, with at least one prescription within a month of the crash.

Researchers found that for the new opioid analgesic users, the risk was 100% higher compared with the risk in subjects of same age taking one or two non-opioid analgesics (adjusted odds ratio [OR], 2.0; 1.6-2.5). For the frequent opioid analgesic users, the risk was approximately 70% higher (OR, 1.7; 1.3-2.1) with three to four opioid dispensations, but no rising trend was observed with an increasing number of dispensations.

The authors asserted that the higher risk of crashing a motor vehicle associated with the new use of opioid analgesics possibly could be because of the lack of tolerance or adaptation to the pharmacological effects that could hinder driving abilities. However, the existing higher risk found in frequent users helped dismiss the notion that opioid-tolerant patients may not be at increased risk at all. Although some level of adaptation to the side effects may have developed in frequent opioid users, it is clear that the use of such medications while driving poses a safety risk.

COMMENTARY

According to the CDC, drug overdoses remained the leading cause of accidental death in the United States in 2015, increasing to 55,403 lethal overdoses, the equivalent of a Boeing-737 full of passengers crashing each day for the entire year.4 Opioid use and addiction continues driving this rise, with prescription and illicit opioids causing 33,091 deaths in 2015. The rising mortality rates from overdoses underscores the morbidity from the national opioid epidemic, which has yet to peak. Evidence suggests abuse and misuse behaviors may be negatively associated with older age, and opioids may play a role in treatment of chronic pain in this population. However, opioid use among the elderly is associated with poorer mental health function, which may produce other consequences, such as falls and motor vehicle crashes.5 Therefore, it is prudent to consider alternative treatment options and comorbid conditions as well as elderly patients’ ability to understand the importance of managing opioid therapy responsibly prior to providing such a prescription.6

When other options (non-pharmaceutical and pharmaceutical) already have been considered and a clinical decision is made to prescribe opioids, it may be reasonable to recommend that elderly patients consider refraining from driving when starting an opioid medication. For those already on maintenance opioid treatments, the study shines the light on the opportunity to take a case-by-case approach when considering the potential risk of an impaired driver while taking an opioid.

REFERENCES

  1. Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS. Can patients taking opioids drive safely? A structured evidence-based review. J Pain Palliat Care Pharmacother 2002;16:9-28.
  2. Rudisill TM, Zhu M, Kelley GA, et al. Medication use and the risk of motor vehicle collisions among licensed drivers: A systematic review. Accid Anal Prev 2016;96:255-270.
  3. Monárrez-Espino J, Möller J, Berg HY, et al. Analgesics and road traffic crashes in senior drivers: An epidemiological review and explorative meta-analysis on opioids. Accid Anal Prev 2013;57:157-164.
  4. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths — United States, 2010-2015. MMWR Morb Mortal Wkly Rep 2016;65:1445-1452.
  5. Papaleontiou M, Henderson CR Jr, Turner BJ, et al. Outcomes associated with opioid use in the treatment of chronic noncancer pain in older adults: A systematic review and meta-analysis. J Am Geriatr Soc 2010;58:1353-1369.
  6. Centers For Disease Control and Prevention, Public Health Service, US Department Of Health And Human Services. Guideline for prescribing opioids for chronic pain. J Pain Palliat Care Pharmacother 2016;30:138-140.