Silent epidemic: Seniors and addiction
America is experiencing an epidemic of heroin use and overdose deaths, often hitting young adults. But many people, sometimes much older, are at risk of abusing other types of drugs – the kind that come in prescription vials. Opioid pain medications – such as oxycodone, which is in OxyContin and Percocet; and fentanyl, which is administered through an adhesive patch – are prescribed for chronic conditions such as lower back pain, fibromyalgia, headache or arthritis. The fact is, however, that overdoses of these "respectable" drugs can be just as harmful as those from heroin sold on the street.
Addiction to prescription painkillers among seniors is growing, says Dr. Joseph Garbely, medical director of Caron Treatment Centers, which opened a 10-bed senior inpatient unit in Pennsylvania earlier this year. "The problem is certainly ubiquitous, and often missed, to be honest," Garbely says. "Caretakers oftentimes miss the signs and symptoms of a substance-use disorder. Doctors do too, and often aren't asking the questions when seniors are there for their monthly checkups."
Family members and caregivers are often the first to notice addiction-related changes, he says. Loved ones appear more anxious or depressed. They're injuring themselves and are confused at times, even disoriented. "[Relatives] don't know what's going on, but something is," he says. "And when they start looking, they're finding a problem."
Health care providers need to become more comfortable asking patients about substance use, Garbely says, and regularly screening to identify those at risk for substance abuse. It's important to ask about alcohol use, he adds, because of the enhanced effects of alcohol and opioids when combined. But seniors don't have to be drinkers to have problems with opioid drugs.
"Opioids were designed for acute pain, not chronic pain," Garbely says. "When we apply acute treatment strategies to chronic pain, that's when we get into trouble. Over time, there's a tolerance that occurs, so you need more and more for the required analgesic effect. Over time, you're getting into larger and larger doses of opioids. So there has to be a different strategy."
U.S. emergency departments saw a 78 percent rise in the number of visits among older adults with misuse of prescription or illicit drugs between 2006 and 2012, according to a new study presented in November at the annual meeting of the Gerontological Society of America. About 11 percent of that misuse was with opiate drugs, says Mary Carter, an associate professor at Towson University and author of the study. Emergency department and hospital charges involving opioid pain medications average about $25,275 per patient, Carter says.
Her study used a nationally representative sample with data from more than 71,000 cases involving older adults. Of those, 53 percent were ages 65 to 74. "Which means nearly half of the visits occurred among people ages 75 and older," Carter says. Yet older seniors are often ignored in the broader discussion about addiction, she says.
The rate of emergency department visits related to opioid misuse was much higher for older adults living in the South, the study found, which Carter says is consistent with regional differences in how these drugs are prescribed. "So this is about the prescribing patterns and the need for better state approaches to monitoring," she says.
Middle Age and Beyond
According to the Agency for Healthcare Research and Quality, hospitalizations for opioid overuse increased most sharply among Americans ages 45 to 85 and beyond, with rates rising more than fivefold between 1993 and 2012. Middle-aged adults between 45 and 54 have the highest death rates from opioid drug overdoses, according to the Centers for Disease Control and Prevention.
"We see the highest rates of overdose deaths in individuals who appear to be receiving legitimate prescriptions for chronic pain problems," says Dr. Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing and chief medical officer of the Phoenix House Foundation.
For younger adults, opioid addiction may have stemmed from a medical exposure, Kolodny says. "They liked the drug and used it recreationally and then got addicted," he says. But it becomes harder for them to maintain a sufficient supply. "Unless the doctor is a drug dealer, they really don't want to give a healthy-looking 25-year-old lots of pills," he says.
Older people in their 40s to 80s, on the other hand, are mostly becoming addicted through medical treatment for a chronic pain problem. "Some of them have very severe, intractable pain," Kolodny says. "They are able to find doctors to prescribe them all the opioids they might want."
People addicted to opioids really believe the drugs help their pain because they feel so awful – and anxious – if they don't take them. "They're feeling agonizing pain [and] if they take the opioid, the pain goes away," Kolodny says. "They believe the opioid is relieving their underlying pain problem. What's probably happening is that the opioid is treating their withdrawal pain."
Physical dependence can set in in as few as five days for someone taking several daily doses, Kolodny says. The longer they take these drugs, dependence grows stronger and tolerance increases. "As the doses get higher and higher, you tend to see people's functioning begin to decline," he says.
There's a place for high-dose opioids, Kolodny says – for instance, to ease suffering at the end of life. For other patients, he says, opioids can be appropriate for short-term use, such as when prescribed for a few days after major surgery. "But unfortunately, the bulk of our consumption in the United States is not for end-of-life care or short-term use," he says.
Painkillers and Accidents
Accidents can happen to seniors who aren't addicted. "Let's say you're prescribed an 80-milligram OxyContin tablet, which is not an uncommon dose," Kolodny says. "But if you're going to bed and you forget that you took your pill, so you accidentally take a second one – you're probably not going to wake up in the morning."
Falls are more likely for seniors on opioids, significantly raising their risk for potentially devastating fractures. "A common example of a drug-disease interaction would be someone with mild cognitive impairment," says Dr. Caleb Alexander, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness. When a person with this condition gets an opioid product, he says, it increases the risk for confusion, falls and other adverse events.
Because many seniors take several medications, the risk of harmful interactions increases, Alexander says. "An opioid could interact with a sleeping medicine that an older adult is on and increase the risk of sedation and respiratory depression," he says.
Something else to consider when it comes to older adults and quantities of opioids: "There's drug diversion at every level of the supply chain," Alexander says. "Grandma goes and gets a tooth pulled and gets 40 Vicodin but she only needed four – leaving 36 more Vicodin sitting in the bathroom cabinet."
Lower, Safer Doses
Kolodny says health providers can reduce overdose risk by prescribing lower-dose painkillers such as 5-milligram Vicodin or 10-mg Percocet tablets. "If they accidentally double their dose, it's not going to hurt them," he says.
An older adult with arthritis or spinal stenosis might take a low-dose opioid on an intermittent basis when pain is severe, Kolodny says. "So on good days, they're getting by with Tylenol or Advil, or Tylenol plus Advil," he says. "And on the really bad days, they take one or two Vicodin."
In November, the Johns Hopkins Bloomberg School of Public Health released a report on the prescription opioid epidemic that addresses prescribing guidelines, prescription drug-monitoring programs, overdose education, community-based prevention and more.
Medical schools and residencies need to better educate physicians, and that's starting to happen, Garbely says, with medical schools in Boston offering mandatory training around prescribing opioid analgesics.
To treat Caron addiction patients in the chronic pain track, he says the medical team slowly takes them off opioid painkillers and substitutes nonaddictive medications like Cymbalta (or generic duloxetine) or Neurontin (gabapentin). Non-drug treatments such as acupuncture, medical massage, hydrotherapy (soothing warm jets of water) and pool therapy, which allows gravity-free movement, all reduce pain. "We get people active again," Garbely says. "That helps more than you can imagine."
If you have a family member dealing with chronic pain, it helps to be mindful. "We all live busy lives, but if possible, go to the appointments with your mom or dad, stepmom or stepdad, and find out what's being prescribed," Garbely says. "Make sure you have an idea – maybe a list of what's being prescribed, and take it to your doctor and say, 'Is this OK?' Get curious, if you will."