September/October 2021

Medication Monitor: Prescription Drug Overdose in Older Adults
By Rene’ Wren, OTD, OTR, BCG
Today’s Geriatric Medicine
Vol. 14 No. 5 P. 8

Prescription drug overdose is more common among the older adult population than is generally known. As people age, they tend to take more medications, which can lead to adverse drug events or even unintentional drug overdose. Adults aged 65 and older are nearly seven times more likely to be admitted to the hospital due to adverse drug reactions than did younger adults.1

Moreover, due to issues such as chronic pain, older adults are often prescribed pain killers, including opioids. Older adults who use opioids, regardless of whether they are dependent, are 15 times more likely to overdose than their peers who do not use opioids.2 Not only do opioids confer a high risk of dependency but they also can interact negatively with other drugs. It’s imperative for health care providers to address this issue with health programs that can assist with medication management and provide education regarding risks and behaviors that may lead to prescription misuse and overdose associated with these drugs.

Theoretical Framework
When developing programs, the use of a theoretical framework can guide researchers to optimize planning of programs that will help to target these risks and behaviors in older adults. The use of a theoretical framework is likely to advance the health care community’s understanding of the problem, explain health behaviors, determine how to address them through a community-based program, and assist providers to successfully promote positive health practices.3,4 Application of the Health Belief Model (HBM) has been shown to influence health behaviors associated with beliefs and perceptions regarding medications.5 The HBM is a theory widely used to help develop interventions that positively influence a person’s health behaviors and promote change in their beliefs and perceptions surrounding the behavior.3

Developed in the 1950s by psychologists working for the US Public Health Service, the HBM attempts to understand why people don’t accept preventive measures for health care issues, such as screening for asymptomatic diseases. Later research applied the model to patients’ responses to symptoms and adherence to prescription regimens.6

The HBM is based on a person’s beliefs regarding health risks and whether a behavior is worth the risk to their health. The model was developed to study health behaviors and to explain why people do or don’t use available public health services related to prevention.7 This model is frequently used to help explain individuals’ health behaviors and develop insight into the underlying perceptions regarding the susceptibility of contracting a disease and the serious impact that disease might have on their health.6,8

Health Beliefs
At the center of the HBM is the idea that people’s beliefs and perspectives about a disease or condition influence their behaviors related to that disease. A person’s health actions are influenced by intrapersonal factors such as knowledge, attitudes, beliefs, experiences, skills, culture, and religion. These factors can persuade a person to engage in either positive or negative behaviors concerning a disease, as well as determine a person’s beliefs and perceptions of health risks and the consequences associated with the disease.3

An individual’s perception of a disease influences the seriousness of attitude they take toward a disease and thus their health behaviors, the less healthful of which could pose a real threat and increase their risk of developing the disease. To be motivated to avoid risks associated with a disease, individuals must believe that the benefits of changing disease-related health behaviors far outweigh the effort needed to overcome barriers to those behaviors.3

When it comes to prescription drugs, a person’s belief that “more medication is better” or that it’s acceptable to take someone else’s medicine can greatly influence attitudes toward following recommendations. On the other hand, addiction anxiety can contribute to medication nonadherence. With older adults, these seemingly disparate perceptions about medication management actually can combine to contribute to behaviors that can lead to prescription drug overdose.9 The challenge for health providers is to develop medication management and education interventions and programs that will help stop and prevent prescription drug overdose.

Perceived Benefits and Barriers to Medication Adherence
Perceived Benefits
In the HBM, it’s considered a perceived benefit when a person believes a new or changed health behavior brings value to their life by decreasing their chance of developing a disease or condition. Thus, to adopt new behaviors, individuals must feel that the behaviors add value to their health.3

However, some older adults think that if one pill is good for a condition, then two pills must be even better. This perception and behavior could place them at risk of drug overdose. With education about on side effects and the importance of taking medications as prescribed, older adults can make educated medication choices that will help prevent unintentional drug overdose. If older adults believe that taking medications as prescribed will prevent drug overdose, it’s more likely that they will take their medicines appropriately.

Perceived Barriers
Conversely, older adults may be reluctant to take prescription painkillers due to addiction anxiety and fear of dependency on opioids, which are commonly prescribed to them.10,11 This fear can lead to medication misuse. When older adults do not take a prescribed medication at the onset of their pain, they might be inclined to take more medication than was prescribed to lessen the pain—behavior that could lead to an accidental overdose. Education along with medication and pain management programs could lessen patients’ fear of addiction and alter their behaviors so that they take the medicines when their pain starts.

Perceived Susceptibility and Severity
According to the National Institute on Drug Abuse, 80% of older adults take at least one medication daily and 50% of those take four to five medications daily.10 As the number of medications increases, the risk of misuse rises. Older adults who believe they are more susceptible to drug overdose or adverse reactions if they misuse drugs are more likely to take their medications as prescribed. Medication education can help patients understand the seriousness of a misuse behavior and the importance of medication adherence. When they understand that medication misuse increases the risk for drug overdose, behavior toward medication adherence and management typically changes.

Cues to Action
One way of addressing risky health behaviors is application of “cues to action,” which are prompts or triggers that encourage people to change their health behaviors and positively influence the health decision-making process.3,6 Examples of cues to action are community educational materials, advice from peers or family, and physician follow-up calls.6

For older adults who are aware of the risk of drug overdose due to medication nonadherence or misuse, cues to action can help prevent adverse events. Behaviors such as taking medications as prescribed, only taking prescribed medications, making regular visits to the doctor, learning about side effects prior to starting a medication, and encouragement from family and friends can all be cues to action toward good medication management. Another cue to action is to utilize a pill sorter to avoid medication mistakes. These steps can help older adults manage pain, avoid prescription drug overdose, and stay healthy.

Summary
Prescription drug overdose is a significant problem among the older adult population. Using the HBM as a framework, health care providers and educators can develop appropriate medication management and educational intervention programs to avoid issues such as drug overdose.

— Rene’ Wren, OTD, OTR, BCG, is a core faculty member at the University of St. Augustine for Health Sciences in Dallas. Wren is American Occupational Therapy Association Board Certified in Gerontology. In addition to her role as instructor, she is a practicing occupational therapist of 20 years working primarily with the geriatric population in the skilled nursing facility and home health settings.

References
1. Adverse drug events in adults. Centers for Disease Control and Prevention website. https://www.cdc.gov/medicationsafety/adult_adversedrugevents.html. Updated October 11, 2017. Accessed March 23, 2021.

2. Larney S, Bohnert ASB, Ganoczy D, et al. Mortality among older adults with opioid use disorders in the Veteran’s Health Administration, 2000–2011. Drug Alcohol Depend. 2015;147:32-37.

3. Theory of reasoned action and theory of planned behavior. In: Hayden J. Introduction to Health Behavior Theory. 3rd ed. Burlington, MA: Jones & Bartlett Learning; 2019:36-58.

4. Herrmann A, Hall A, Proietto A. Using the Health Belief Model to explore why women decide for or against the removal of their ovaries to reduce their risk of developing cancer. BMC Womens Health. 2018;18(1):184.

5. Motavali ZS, Abedi H, Davaridolatabadi E. Self-medication and its effective modifiable factors among elderly referred health care centers in Shahr-e-Kord in 2015. Electron Physician. 2016;8(11):3205-3213.

6. Janevic MR, Connell CM. Individual theories. In: Hilliard ME, Riekert KA, Ockene JK, Pbert L, eds. The Handbook of Health Behavior Change. 5th ed. New York, NY: Springer Publishing; 2018:3-24.

7. Office of Behavioral and Social Sciences Research; Department of Health and Human Services; National Institutes of Health. Social and behavioral theories. https://obssr.od.nih.gov/wp-content/uploads/2016/05/Social-and-Behavioral-Theories.pdf. Accessed March 23, 2021.

8. The Health Belief Model. Rural Health Information Hub website. https://www.ruralhealthinfo.org/toolkits/health-promotion/2/theories-and-models/health-belief. Accessed March 23, 2021.

9. Benshoff JJ, Harrawood LK, Koch DS. Substance abuse and the elderly: unique issues and concerns. J Rehabil. 2003;69(2);43-48.

10. Misuse of prescription drugs research report. National Institute on Drug Abuse website. https://www.drugabuse.gov/publications/misuse-prescription-drugs/overview. Published June 2020. Accessed March 23, 2021.

11. Brown DA. Principles of pain management in the elderly. US Pharm. 2007;32(6):HS33-HS37.