When Dr. Benjamin Hahn, a geriatric and addiction medicine specialist, met with new patients at the University of California, San Diego School of Medicine, he talked with them about the typical health issues older adults face: chronic conditions, functional capacity, medications and how they work.
He also asks about their use of tobacco, alcohol, cannabis, and other non-prescription drugs. “Patients tend not to disclose this, but I put it in a healthy context,” said Dr. Hahn.
He tells them, “As you get older, physiological changes occur and your brain becomes more sensitive. Your tolerance decreases as your body changes. It can put you at risk.”
This is how he learns that someone complaining of insomnia is probably using stimulants, perhaps methamphetamine, to get the morning going. Or that a patient who had long taken an opioid for chronic pain had trouble with an additional prescription, for example, gabapentin.
When a 90-year-old patient, a woman fit enough to take the subway to the former hospital in New York City, began reporting dizziness and falls, it took Dr. Hahn some time to understand why: She washed down her prescribed pills, an increasing number with age. With a shot of brandy.
He had elderly patients whose heart problems, liver disease, and cognitive impairment were likely exacerbated by drug use. Some overdosed. Despite his best efforts, some died.
Until a few years ago, even with the raging opioid epidemic, health providers and researchers paid only limited attention to elderly drug use. Concerns have focused on younger, working-age victims who have been hit hardest.
But as baby boomers reach 65, the age at which they typically qualify for Medicare, substance use disorders among the older population have risen sharply. “Cohorts have habits around drug and alcohol use that persist throughout life,” said Keith Humphreys, a psychologist and addiction researcher at Stanford University School of Medicine.
Older Boomers “still used a lot more drugs than their parents did, and the field just wasn’t ready for that.”
Evidence is accumulating of a growing problem. study Opioid use disorder In people over 65 enrolled in traditional Medicare, for example, they showed a threefold increase in just five years — to 15.7 cases per 1,000 in 2018 from 4.6 cases per 1,000 in 2013.
Stigma around drug use may lead people not to report it, so the true rate of the disorder may be higher, said Tse-Chuan Yang, a study co-author and a sociologist and demographer at the University of Albany.
Fatal overdoses have also risen among the elderly. From 2002 to 2021, the rate Overdose deaths quadrupled to 12 out of 3 per 100,000, Dr. Humphreys and Chelsea Scheufer, co-authors, reported in JAMA Psychiatry in March, using data from the Centers for Disease Control and Prevention. These deaths were intentional, such as suicide, and accidental, reflecting drug interactions and errors.
Most substance use disorders among older adults involve prescription medications, not illegal drugs. And since most Medicare beneficiaries take multiple medications, “it’s easy to get overwhelmed,” said Dr. Humphreys. “The more complex the system, the easier it is to make mistakes. And then you have an overdose.”
The numbers are still relatively low so far — 6,700 drug overdose deaths in 2021 among people 65 or older — but the rate of increase is alarming.
“In 1998, that’s what people would say about overdose deaths in general — the absolute number was small,” said Dr. Humphreys. “When you don’t respond, you end up in a sad state.” More than 100,000 Americans He died from a drug overdose last year.
Alcohol also plays a major role. Last year, A.J Study of substance use disordersbased on a federal survey, analyzed the medications used by older Americans, looking at the differences between Medicare enrollees under age 65 (who may qualify due to disability) and those who are 65 or older.
Of the 2 percent of recipients over 65 who reported a substance use disorder or dependence in the past year — which amounts to more than 900,000 seniors nationally — more than 87 percent used alcohol. (Calculate alcohol 11,616 deaths among the elderly in 2020, an increase of 18 percent over the previous year.)
In addition, about 8.6 percent of the disorders involved opioids, most of which were prescription pain relievers. 4.3 percent from marijuana; and 2 percent for non-opioid prescription medications, including tranquilizers and anti-anxiety medications. 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 drug use problems do not die from overdoses, the health consequences can be severe: injuries from falls and accidents, accelerated cognitive decline, cancers, and heart, liver, and kidney failure.
“It is particularly distressing to compare rates of suicidal ideation,” said Dr. Parrish. Older Medicare beneficiaries with substance use disorders were more than three times as likely to report “serious psychological stress” as those without such disorders — 14 percent versus 4 percent. About 7 percent had suicidal thoughts, compared with 2 percent who did not report a drug disorder.
Yet very few of these seniors had treatment in the past year — just 6 percent, compared with 17 percent of younger Medicare recipients — or even made an effort to get treatment.
“With these addictions, it takes a lot to prepare someone for treatment,” said Dr. Parrish, noting that nearly half of respondents over the age of 65 said they lacked the motivation to start.
But they also face more barriers than young people. “We’re seeing higher rates of stigma concerns, things like worrying about what their neighbors might think of them,” said Dr. Parish. “We see more and more logistical barriers,” he said, such as finding transportation, not knowing where to go for help and not being able to afford care.
It can be “difficult for older adults to try to navigate a medication regimen,” said Dr. Parrish.
Unequal Medicare coverage also presents obstacles. Federal parity legislation, which mandates the same coverage for mental health (including addiction treatment) and physical health, ensures equal benefits in private employer insurance, state health exchanges, the Affordable Care Act markets and most Medicaid plans.
It never included Medicare, said Deborah Steinberg, the health department’s senior health policy attorney Legal Action Centrea nonprofit organization working to expand equitable coverage.
The Defenders made some inroads. Medicare covers drug abuse screening and, since 2020, opioid treatment programs such as methadone clinics. In January, after congressional action, it will cover treatment by a wide range of health professionals and cover “intensive outpatient treatment,” which typically provides nine to 19 hours of weekly counseling and education. expanded Benefits of telehealthSpurred on by the pandemic, it also helped.
But more intensive treatment can be difficult to access, and in-patient treatment is not included at all. Medicare Advantage plans, with their limited provider networks and pre-authorization requirements, are more restrictive. “We’ve seen many complaints from Medicare Advantage beneficiaries,” Ms. Steinberg said.
“We’re actually making progress,” she added. “But people overdoses and die because they don’t get treatment.” Their physicians, unfamiliar with diagnosing substance abuse in the elderly, may ignore the risks.
In an age group in which young people who drink and use drugs sometimes provide amusing anecdotes (a catchphrase: “If you remember the ’60s, you didn’t exist”), it can be difficult for people to recognize how vulnerable they are.
“That person may not be able to say I’m addicted,” said Dr. Humphreys. “It’s a Rubicon people don’t want to cross.”
He added that the joke about acid being thrown at Woodstock “makes me color”. “Crushing and snoring OxyContin is not colorful.”