Substance abuse is increasing among seniors
if dr Benjamin Han, a geriatrician and addiction medicine specialist, when he meets new patients at the University of California San Diego School of Medicine, he talks to them about the common health issues that older adults face: chronic conditions, functioning, 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 health context,” said Dr. Han.
He tells them, “As you age, there are physiological changes and your brain becomes a lot more sensitive. Your tolerance goes down as your body changes. It can put you at risk.”
He learns that someone who complains of insomnia may be using stimulants, possibly methamphetamine, to get them going in the morning. Or that a patient who has been taking an opioid for chronic pain for a long time has run into trouble with an additional prescription, say, gabapentin.
When a 90-year-old patient, a woman who was fit enough to ride the subway to her previous hospital in New York City, reported experiencing dizziness and falls, Dr. Han took a while to understand why: she was downing her prescribed pills, more and more as she got older, along with a shot of brandy.
He had elderly patients whose heart problems, liver disease, and cognitive impairment were most likely aggravated by substance use. Some have overdosed. Despite his best efforts, some have died.
Until a few years ago, when the opioid epidemic was raging, health care providers and researchers paid limited attention to drug use among older adults; Concerns focused on the younger, working-age victims, who were hardest hit.
However, since the baby boomer generation hit 65, the age at which they are typically eligible for Medicare, substance abuse disorders among the older population have risen sharply. “Cohorts have drug and alcohol use habits that they maintain throughout their lives,” said Keith Humphreys, psychologist and addiction researcher at Stanford University School of Medicine.
Older baby boomers “still use a lot more drugs than their parents did, and the industry wasn’t ready for that.”
Evidence of a growing problem is piling up. For example, a study of opioid use disorders in people over age 65 on traditional Medicare coverage showed a three-fold increase in just five years — to 15.7 cases per 1,000 in 2018 from 4.6 cases per 1,000 in the year 2013
Tse-Chuan Yang, co-author of the study and a sociologist and demographer at Albany University, said the stigma surrounding drug use can mean people underreport it, so the true incidence of the disorder may be even higher.
The number of fatal overdoses has also skyrocketed among the elderly. From 2002 to 2021, the rate of overdose deaths quadrupled from 3 per 100,000 to 12, Drs. Humphreys and Chelsea Shover, a co-author, in JAMA Psychiatry in March using data from the Centers for Disease Control and Prevention. These deaths were both premeditated, such as suicides, and accidental, resulting from drug interactions and errors.
Most substance use disorders in older people involve prescribed medications, not illicit drugs. And because most Medicare beneficiaries take multiple medications, “it’s easy to get confused,” said Dr. Humphreys. “The more complicated the cure, the easier it is to make mistakes. And then you overdose.”
The numbers remain comparatively low so far — 6,700 drug overdose deaths in 2021 among people aged 65 and over — but the rate of increase is alarming.
“That’s what people would have said in 1998 about overdose deaths in general – the absolute number was small,” said Dr. Humphreys. “If you don’t answer, you’ll get into a sorry state.” Last year, more than 100,000 Americans died from drug overdoses.
Alcohol also plays a big role. Last year, a study of substance use disorders based on a state survey analyzed what medications older Americans were using. It looked at the differences between Medicare enrollers under the age of 65 (who may be eligible because of disabilities) and those 65 and older.
Of the 2 percent of beneficiaries over the age of 65 who reported a substance disorder or addiction in the past year — that’s more than 900,000 seniors nationwide — more than 87 percent abused alcohol. (Alcohol was responsible for 11,616 deaths among seniors in 2020, an 18 percent increase from the previous year.)
In addition, about 8.6 percent of the disorders involved opioids, mostly prescription pain relievers; 4.3 percent was marijuana; and 2 percent involved non-opioid prescription drugs, including tranquilizers and anti-anxiety drugs. The categories overlap because “people often use multiple substances,” said William Parish, lead author and health economist at RTI International, a nonprofit research firm.
Although most people with substance use problems do not die from overdoses, the health consequences can be serious: injuries from falls and accidents, accelerated cognitive decline, cancer, heart and liver disease, and kidney failure.
“It’s particularly heartbreaking to compare the frequency of suicidal ideation,” said Dr. parish Older Medicare beneficiaries with substance use disorders were more than three times as likely to report “severe mental distress” as those without such disorders — 14 percent versus 4 percent. About 7 percent had suicidal thoughts, compared to 2 percent who reported no substance use disorders.
Yet very few of these seniors have received treatment in the past year — just 6 percent, compared with 17 percent of younger Medicare beneficiaries — or have even attempted treatment.
“With these addictions, it takes a lot to prepare someone for treatment,” said Dr. Parish, noting that nearly half of respondents over the age of 65 said they lacked the motivation to start treatment.
However, they also face greater hurdles than younger people. “We see a higher rate of stigma concerns, such as worrying about what their neighbors would think,” said Dr. parish “We’re seeing more logistical barriers,” he said, such as finding transportation, being unable to get help and being unable to afford care.
It may be “more difficult for older adults to navigate the treatment system,” said Dr. parish
Unequal Medicare coverage also poses obstacles. State parity legislation, which requires equal coverage for mental health (including addiction treatment) and physical health, guarantees equal benefits among private employer plans, state health exchanges, Affordable Care Act marketplaces, and most Medicaid -plans.
But Medicare was never included, said Deborah Steinberg, senior health policy advocate at the Legal Action Center, a nonprofit that works to expand equitable coverage.
Proponents have made some progress. Medicare covers substance use screening and, since 2020, opioid treatment programs such as methadone clinics. In January, following a decision by Congress, it will cover treatment by a wider range of health professionals and cover “intensive outpatient treatment,” which typically involves nine to 19 hours of weekly counseling and education. Expanded telehealth services triggered by the pandemic have also helped.
However, access to more intensive treatment can be difficult, and inpatient treatment is not covered at all. Medicare Advantage plans are even more restrictive, with their more restricted provider networks and prior approval requirements. “We’re seeing many more complaints from Medicare Advantage beneficiaries,” Ms. Steinberg said.
“We’re actually making progress,” she added. “But people overdose and die because they don’t have access to treatment.” Their doctors, unaccustomed to diagnosing substance abuse in the elderly, may also be overlooking the risks.
In an age cohort whose adolescent drinking and drug use has sometimes made for amusing anecdotes (a common refrain: “Anyone who remembered the ’60s wasn’t there”), it can be difficult for people to appreciate just how vulnerable they are became .
“That person may not be able to tell I’m addicted,” said Dr. Humphreys. “It’s a Rubicon that people don’t want to cross.”
A joke about throwing acid at Woodstock “makes me motley,” he added. “Crushing and snorting OxyContin isn’t colorful.”