Substance abuse is increasing among the elderly

When Dr. Benjamin Han, a geriatrician and addiction medicine specialist, meets new patients at the University of California San Diego School of Medicine, he talks to them about common health issues that older adults face. : chronic diseases, functional capacity, drugs and their mode of action.

It also asks about their use of tobacco, alcohol, cannabis and other over-the-counter drugs. “Patients tend not to want to disclose this, but I put it in a health context,” Dr. Han said.

He tells them: “As you get older, there are physiological changes and your brain becomes much more sensitive. Your tolerance decreases as your body changes. It can put you in danger.

This is how he learns that someone complaining of insomnia may be using stimulants, possibly methamphetamine, to kick start the morning. Or that a patient who’s been on an opioid for chronic pain for a long time has had trouble with an extra prescription for, say, gabapentin.

When a 90-year-old patient, a woman fit enough to take the subway to her old hospital in New York City, began reporting dizziness and falls, it took Dr. Han a while to figure out why: she washed down her prescribed pills, an increasing number as she got older, with a glass of brandy.

He had older patients whose heart problems, liver disease and cognitive impairment were most likely exacerbated by substance use. Some overdosed. Despite his best efforts, some died.

Until a few years ago, even as the opioid epidemic raged, health care providers and researchers paid limited attention to drug use by older adults. concerns have focused on younger victims of working age who have been hardest hit.

But as baby boomers hit 65, the age at which they are typically eligible for Medicare, substance use disorders among the older population have risen sharply. “Cohorts have patterns of drug and alcohol use that they carry on throughout their lives,” said Keith Humphreys, a psychologist and addiction researcher at Stanford University School of Medicine.

Aging baby boomers “still do a lot more drugs than their parents did, and the field wasn’t ready for that.”

Evidence of a growing problem has been mounting. A study of opioid use disorder among people over 65 enrolled in traditional health insurance, for example, has tripled in just five years – to 15.7 cases per 1,000 in 2018 from 4.6 cases per 1,000 in 2013.

Tse-Chuan Yang, study co-author and a sociologist and demographer at the University of Albany, said the stigma of drug use can lead people to underreport it, so the true rate of the disease may be even higher.

Fatal overdoses have also exploded among the elderly. From 2002 to 2021, the rate of overdose deaths have quadrupled at 12 of 3 per 100,000, Dr. Humphreys and Chelsea Shover, a co-author, reported in JAMA Psychiatry in March, using data from the Centers for Disease Control and Prevention. These deaths were both intentional, such as suicides, and accidental, reflecting drug interactions and errors.

Most substance use disorders in older adults involve prescribed drugs, not illegal drugs. And since most Medicare beneficiaries take multiple medications, “it’s easy to get lost,” Dr. Humphreys said. “The more complicated the diet, the easier it is to make mistakes. And then you have an overdose.

So far, the numbers remain relatively low – 6,700 drug overdose deaths in 2021 among people aged 65 and over – but the rate of increase is alarming.

“In 1998, that’s what people would have said about overdose deaths in general – the absolute number was low,” Dr Humphreys said. “When you don’t respond, you end up in a painful state.” More than 100,000 Americans died of a drug overdose Last year.

Alcohol also plays a major role. Last year a study of substance use disordersbased on a federal survey, analyzed the drugs older Americans used, looking at differences between Medicare enrollees under age 65 (who may be eligible due to disability) and those age 65 and older.

Of the 2% of recipients over the age of 65 who reported a substance use disorder or addiction in the past year — representing more than 900,000 seniors nationwide — more 87% have abused alcohol. (Alcohol represented 11,616 deaths among the elderly in 2020, an increase of 18% over the previous year.)

Additionally, approximately 8.6% of disorders involved opioids, primarily prescription painkillers; 4.3% involved marijuana; and 2% involved non-opioid prescription drugs, including tranquilizers and anxiolytics. The categories overlap because “people often use multiple substances,” said William Parish, lead author and health economist at RTI International, a nonprofit research institute.

Although most people with substance use problems do not die from an overdose, the health consequences can be serious: injuries from falls and accidents, accelerated cognitive decline, cancers, heart and liver disease and renal failure.

“It’s especially heartbreaking to compare rates of suicidal ideation,” Dr. Parish said. Older Medicare beneficiaries with substance use disorders were more than three times more likely to report “severe psychological distress” than those without — 14% versus 4%. About 7% had suicidal thoughts, compared to 2% who did not report substance use disorders.

Yet very few of these seniors have had treatment in the past year — just 6%, compared to 17% of younger Medicare recipients — or even made an effort to seek treatment.

“With these addictions, it takes a lot to prepare someone for treatment,” Dr Parish said, noting that nearly half of those surveyed over the age of 65 said they lacked the motivation to start. .

But they also face more obstacles than young people. “We’re seeing higher rates of stigma issues, things like worrying about what their neighbors would think,” Dr Parish said. “We’re seeing more logistical hurdles,” he said, such as finding transportation, not knowing where to go for help, and not being able to afford treatment.

It can be “more challenging for older people trying to navigate the treatment system,” Dr. Parish said.

Unequal Medicare coverage also presents obstacles. Federal parity legislation, mandating the same coverage for mental health (including drug treatment) and physical health, ensures equal benefits in employers’ private insurance, state health scholarships, health markets of the Affordable Care Act and most Medicaid plans.

But that never included Medicare, said Deborah Steinberg, senior health policy attorney at the Legal Action Centera non-profit organization that strives to expand equitable coverage.

The defenders made some inroads. Medicare covers substance use testing and, since 2020, opioid treatment programs like methadone clinics. In January, following congressional action, it will cover treatment by a wider range of medical professionals and cover “intensive outpatient treatment,” which typically provides nine to 19 hours of weekly counseling and education. . Extended benefits of telehealthcaused by the pandemic, have also helped.

But more intensive treatment can be difficult to access, and residential treatment is not covered at all. Medicare Advantage plans, with their more limited provider networks and prior authorization requirements, are even more restrictive. “We’re seeing a lot more complaints from Medicare Advantage beneficiaries,” Ms. Steinberg said.

“In fact, we are making progress,” she added. “But people overdose and die because they don’t have access to treatment.” Their doctors, unaccustomed to diagnosing drug addiction in the elderly, may also overlook the risks.

In an age cohort whose youthful alcohol and drug use has sometimes provided amusing anecdotes (a common refrain: “If you remember the 60s, you weren’t there”), it may be difficult for people to recognize how vulnerable they have become. .

“That person may not be able to say, I’m addicted,” Dr. Humphreys said. “It’s a Rubicon that people don’t want to cross.”

A joke about the acid drop at Woodstock “makes me colorful”, he added. “Crush the OxyContin and the snort is not colored.”