A Guide to Addiction Among the Elderly
The term “elderly” is ambiguous, and it casts up different perceptions for different people. Although the earliest wave of baby boomers (born in 1946 – 1964) may be classified as elderly, the term “elderly” is often reserved for individuals born before 1946. In terms of age, in 2015, baby boomers range in age from 51-69 years of age.
The baby boomer group and those born before 1946 make up a considerable part of the population. Today, there are over 43.1 million Americans in the 65-plus age group (approximately 13.7 percent of the general population). By 2040, the government estimates this number will increase to 79.7 million. For purposes of this article, the discussion will differentiate between baby boomers and individuals born before 1946 where relevant.
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), the following facts illuminate the problem of substance abuse in older populations:
- Among Americans aged 60 and older, substance abuse, specifically alcohol and prescription drug abuse, is one of the fasting growing health care issues today.
- Alcohol and prescription medication abuse affects an estimated 17 percent of older Americans.
- Despite the prevalence of the problem, substance abuse disorders in older Americans are largely undertreated, underdiagnosed, and underestimated.
- Scholarly literature on geriatric medicine and elderly drug abuse first appeared in 1964 but has been slow to gain momentum as a major research topic.
The most common drugs baby boomers abuse are marijuana, heroin and other illegal opioids, cocaine and other illicit stimulants, and hallucinogens, such as LSD.
Source: NIH Senior Health
SAMHSA characterizes the problem of substance abuse among the elderly as largely invisible. However, treatment is particularly risky when it comes to this population. Research shows that older persons who abuse alcohol or prescription drugs are more likely to report feeling lonely and being more dissatisfied with life compared to non-substance-abusing peers. Among older women who drink, research shows they are more likely to experience depression, have a spouse with a drinking problem, and be injured during falls. Further, substance abuse undermines an older person’s ability to be self-supportive and independent.
Substance abuse among the elderly presents numerous additional hazards and complications, including:
- Dangerous biomedical interactions between the intoxicating substance and the older person’s physical state
- Increasing the risk of injury, sickness, and financial decline
- In the case of alcohol abuse, accelerating the normal physical decline associated with ageing
- The substance abuse going unchecked and therefore worsening over time (As life expectancy rates increase in this population, that means older people will be sickly longer if they do not recover.)
The foregoing facts and insights speak to the importance of recognizing and treating substance abuse in older populations. Although American society generally defers to the elderly and seeks to protect their privacy, this attitude can raise a barrier to treatment for substance abuse and contribute to the problem of under-detection. Educating the public on the realities of senior drug abuse is an important first step to overcoming misconceptions that impede delivering treatment to this population in need.
Senior Prescription Medication Abuse
Americans aged 65-69 take an average of nearly 14 prescriptions each year. Among those aged 80-84, the number of medications increases to 18 prescriptions per year.
According to the Center for Applied Research Solutions, among elderly persons who seek medical services, 12-15 percent suffer from prescription drug abuse. In fact, prescription drug abuse is second only to alcohol abuse in Americans over age 65. It is important to note that the number of prescriptions seniors take increases their risk of potential abuse. Further, prescription drug abuse is a fast growing problem in the US overall, but it affects the elderly in particular. One-third of all prescription medications are for seniors aged 65 and older. It is clear that the elderly, who are susceptible to chronic pains associated with aging, have considerable access to prescription medications.
However, many seniors may not be receiving adequate warnings about the abuse potential of these medications because doctors and other health care providers are underestimating the likelihood of abuse. It is important to note that while some seniors intentionally abuse medications, not all abuse begins this way. Medications, such as prescription painkillers, can be dependency-forming. The path to abuse is rather slippery, which makes proper education and vigilance all the more necessary.
This discussion begs the question: What type of prescription medications are seniors abusing? The most common types of prescription pills to which seniors are exposed are opiates/opioids, antidepressants, stimulants, and benzodiazepines.
Opiates and opioids are a class of drugs naturally derived from, or synthetically based on, the opium in the poppy plant. Some of the most popular brands include Vicodin and OxyContin. A great danger of these drugs is that they are as addiction-forming as street drugs such as heroin, although their legality masks this fact for many prescribed users.
Among the elderly, depression is one of the most common mental health disorders. Depression can occur organically or be a side effect of taking other medications. Recognizing the prevalence of suicide in the aged population can directly help older persons and their loved ones to understand that depression can cause substance abuse. Of important note, older individuals make up 18 percent of all suicide cases in America. Although abuse of antidepressants may not be a cause for concern (they are usually not addiction-forming), it is important to note that depression can co-occur with substance abuse. Specialized psychiatric treatment is always necessary for diagnostic purposes and medication management.
The main effect of stimulants is to enhance activity in the brain. Most often, stimulants are used to treat sleep disorders like narcolepsy and attention deficit hyperactivity disorder (ADHD). ADHD is generally associated with younger populations, but research published in the British Journal of Psychiatry revealed that approximately 3 percent of older adults suffer from ADHD. Although stimulants such as Adderall have a legitimate medical use, these medications are dependency-forming and can lead to addiction.
Benzodiazepines and barbiturates (sedatives) are generally used to treat sleep disorders and anxiety. They work by depressing the central nervous system and are dependency-forming. According to the National Sleep Foundation, aging is associated with increased trouble sleeping, which cannot be met simply with sleeping less, as research shows sleep needs do not diminish with age. For this reason, older individuals are particularly likely to be prescribed sedatives, which can expose them to a risk of abuse.
Older Americans take different types of prescription simultaneously, a practice known as polypharmacy. It is well-noted that the more drugs a person takes, the greater the risk of dangerous drug interactions. Add to this equation that aging bodies most often have increased sensitivity to medications. Further, when older persons misuse a drug, there are only increased potential health hazards.
For the foregoing reasons, older persons and their loved ones should take special precautions to lessen the likelihood of an adverse drug event (ADE). Simple measures that can be taken include:
Inquire with the prescribing physician if the drug’s clinical trials included older subjects.
Ask the prescribing doctor to review and explain the Beers Criteria, a classification system developed in 1991 that lists, by name and class, the medications that are known to be potentially harmful to the elderly.
Ensure that the attending doctor is provided with a full and accurate history of all drug intake of both licit and illicit drugs.
Carefully review the instructions for use of each drug prescribed and follow them to the letter, while making sure to immediately report any adverse side effects to the attending physician.
Safe polypharmacy practices can help prevent older persons from accidentally developing dependency on drugs. Again, some elderly persons mistakenly stray into addiction, which is entirely preventable. For those older persons who intentionally abuse drugs, a drug treatment intervention is necessary to detox and receive structured rehab services, including psychotherapy, to uncover the root causes of the addiction.
Illicit Drug Abuse
It is important to note that in addition to prescription medications, older persons do abuse illegal drugs. While there is a dearth of research on this topic, recent surveys on adults 50 years of age and older reveal that illicit drug abuse is on this rise in this demographic.
According to Dr. Barbara Kranz, baby boomers (more so than those persons born before 1946) have gone back to taking drugs, such as cocaine, marijuana, and heroin. Dr. Kranz attributes this type of illicit drug abuse to the generational mindset of baby boomers. As Dr. Kranz notes, baby boomers have always been a target audience for product marketing and bought into the idea of “better living through better chemistry.”
In fact, Dr. Kranz noted that in her general medical practice, baby boomer patients, compared to older patients, tend to research drugs on the Internet and request certain branded drugs. While Dr. Kranz advised that she does not take issue with patients having a say in their care, she does see some potential danger in it. For instance, according to her experience, Dr. Kranz has found that baby boomers tend to be intolerant to discomfort and believe that a medical “fix” is, or should, be available. Such thinking can lead to prescription-seeking without evaluating non-medical alternatives. Obtaining a prescription may turn out to the best course of action in any given case, but it needn’t always be the first port of call.
Relevant to the inquiry of prescription pill abuse among the elderly, Psychiatric Times notes the difference between “early-onset” and “late-onset” abusers. Early-onset individuals began their substance abuse before age 65, whereas late-onset individuals began after that pivotal age. Among older alcohol abusers, it is estimated that two-thirds were early-onset (i.e., began before age 65). Irrespective of the type of substance abused, early-onset individuals tend to have more medical and psychiatric problems compared to late-onset individuals. Regarding late-onset substance abusers, the prevailing interpretation is that this group turned to intoxicating substances in response to life stressors associated with ageing (e.g., death of a companion, retirement, social isolation, and changes in lifestyle and living circumstances). An understanding of when the substance abuse began is relevant to treatment.
Not surprisingly, the lack of attention given to addiction in the elderly has resulted in a general deficit in research into evidence-based treatments for this demographic. For this reason, traditional treatment methodologies are generally applied to older clients; however, older persons often present with different needs compared to younger clients. The best practice is generally for addiction specialists to use existing methodologies but to account for the specific age-related needs of the older person.
Should an intervention be warranted, heightened sensitivity will likely be necessary to overcome any resistance to younger generations, such as children and grandchildren, assuming the role of interventionist, which may be seen by the older adult as authoritarian and out of generational sequence. It is important, as in any intervention, to frame it in terms of creating options, rather than demanding rehab. It’s helpful to choose an interventionist with experience in geriatric interventions.
The first phase of treatment will likely be a detoxification. In view of the biomedical sensitivities associated with age, an older person going through a detox may experience serious withdrawal symptoms. For this reason, a medically supervised detox is particularly warranted. The process of “going cold-turkey” or doing an “at-home detox” can be dangerous at any age, but it is especially risky for an older person. It is important to further note that certain drugs, such as opiates, are associated with more dangerous withdrawal symptoms than other drugs. In the case of a senior detoxing from opiate dependence, it is imperative to seek medical counsel.
Psychoeducation about the ill effects of incorrectly taking lawful or illicit drugs can be particularly helpful in older patients. This type of education is especially important for those persons who combine alcohol and medications, as such combinations can be lethal at any age, let alone in older demographics.
Psychotherapy is one of the cornerstones of primary treatment for substance abuse. Attitudes toward psychotherapy may be generational. For instance, a baby boomer may be more agreeable to psychotherapy than a person born before 1946 because of the popularization of “talk therapy” in the baby boomer generation. However, during rehab, resistance to psychotherapy can be discussed during sessions, to help familiarize older generations with the process and set them at ease about it. In the case of group therapy, older patients may be best grouped with peers rather than joined a mixed age group. Ultimately, such decisions will need to be made by the older patient in rehab and his treatment team.
The invisibility of the problem of substance abuse among the elderly is dissolving as research and patient feedback draw attention to this issue. Although fear of the stigma associated with drug abuse may have prevented older generations from seeking treatment, the times have changed. The alarming rates of addiction to prescription painkillers in America, across all age groups, has helped to awaken the public to the need to respond to this epidemic. In the face of this epidemic, the best individual response a person can make is to seek treatment.
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