When Dr. Benjamin Hahn, geriatrician and addiction medicine specialist, meets with new patients at the School of Medicine at the University of California, San Diego, he talks to them about common health problems older people face: chronic conditions, Functional ability, drugs and how they are working.
He also asks about the use of tobacco, alcohol, cannabis, and other nonprescription drugs. “Patients don’t want to disclose it, but I put it in the context of health,” Dr. Han said.
He tells them, “As you age, 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 may be using stimulants, possibly methamphetamines, to wake up in the morning. Or that a patient who has taken opioids for chronic pain for a long time has run into trouble because of additional prescriptions of gabapentin.
When a 90-year-old patient, who was fit enough to take the subway to her last hospital in New York City, began complaining of dizziness and falling, it took Dr. Han a moment to realize: The tablets, increasing in number as they age, are reduced with a shot of brandy.
He has older patients whose heart problems, liver disease, and cognitive impairment were most exacerbated by substance abuse. Some have overdosed. Despite their best efforts, some have died.
Until a few years ago, even as the opioid epidemic raged, health providers and researchers paid limited attention to drug use by older adults; Concerns focused on the young, working-age victims who were most affected.
But as baby boomers have turned 65, the age at which they typically qualify for Medicare, substance use disorders have risen sharply in the aging population. “Communities have drug and alcohol abuse habits that they carry over a lifetime,” said Keith Humphreys, a psychologist and addiction researcher at Stanford University School of Medicine.
Aging boomers “still use far more drugs than their parents, and the sector was not ready for that.”
Evidence of a growing problem is piling up. a study of opioid use disorder For example, people over age 65 enrolled in traditional Medicare saw a threefold increase in just five years—from 4.6 cases per 1,000 in 2013 to 15.7 cases per 1,000 in 2018.
Tse-Chuan Yang, a co-author of the study and a sociologist and demographer at the University of Albany, said the stigma of drug use may cause people to under-report it, so the true rate of the disorder may still be higher.
Fatal overdoses have also increased among seniors. rate from 2002 to 2021 Overdose deaths quadrupled From 3 to 12 per 100,000, Dr. Humphries and co-author Chelsea Shover reported in JAMA Psychiatry in March, using data from the Centers for Disease Control and Prevention. Those deaths were intentional and accidental, like suicides, reflecting drug interactions and errors.
Most substance use disorders in older people involve prescribed drugs, not illegal drugs. And since most Medicare beneficiaries take multiple drugs, “it’s easy to get confused,” Dr. Humphreys said. “The more complex the rule, the easier it is to make mistakes. And then you have overdose.
The numbers so far are comparatively small – 6,700 drug overdose deaths among people 65 and older are expected in 2021 – but the rate of increase is worrying.
“In 1998, that’s what people in general would have said about overdose deaths — the absolute number was small,” Dr. Humphreys said. “When you don’t respond, you end up in a sore spot.” over 100,000 Americans died of drug overdose Last year.
Alcohol also plays a major role. last year, a study of substance abuse disordersWhich drugs are older Americans using, based on a federal survey that looked at the difference between Medicare enrollees under age 65 (who may qualify because of a disability) and those age 65 and older? Were staying, it was analyzed.
Of the 2 percent of beneficiaries over age 65 who reported a substance use disorder or dependence in the past year—which equates to more than 900,000 seniors nationwide—more than 87 percent abused alcohol. (Alcohol counts 11,616 deaths among senior citizens in 2020, an 18 percent increase over the previous year.)
In addition, about 8.6 percent of the disorders involved opioids, mostly pain relievers; 4.3 percent involved marijuana; And 2 percent contained 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 institute.
Although most people with substance abuse problems do not die from an overdose, the health consequences can be severe: injuries from falls and accidents, accelerated cognitive decline, cancer, heart and liver disease, and kidney failure.
“Comparing rates of suicidal ideation is particularly heartbreaking,” Dr. Parish said. Older Medicare beneficiaries with substance use disorders were more than three times as likely to report “severe psychological distress” than those without such disorders — 14 percent versus 4 percent. About 7 percent had suicidal thoughts, while 2 percent did not report substance use disorders.
Yet very few of these seniors received treatment in the last year – only 6 percent, compared to 17 percent of young Medicare beneficiaries who received treatment – or even attempted to seek treatment.
“With these addictions, it takes a long time to prepare someone for treatment,” Dr. Parish said, noting that nearly half of respondents over the age of 65 said they lacked motivation to start. Is.
But they also face more obstacles than young people. “We see high rates of stigma concerns, worrying about what their neighbors will think,” Dr. Parish said. “We are seeing more logistical barriers, such as finding transportation, not knowing where to go for help, and being unable to afford care.
“Navigating the treatment system can be difficult for older adults,” said Dr. Parish said.
Uneven Medicare coverage also presents barriers. Federal parity laws mandate equal coverage for mental health (including addiction treatment) and physical health, guaranteeing equal benefits across private employer insurance, state health exchanges, Affordable Care Act marketplaces, and most Medicaid plans.
But it has never included Medicare, said senior health policy attorney Deborah Steinberg. Legal Action CenterA non-profit organization working to expand equal coverage.
Advocates have made some progress. Medicare covers substance use screening and opioid treatment programs like methadone clinics from 2020. In January, following congressional action, it will cover treatment by a wider range of health professionals and cover “intensive outpatient treatment,” which typically provides nine to 19 hours of weekly counseling and education. extended telehealth benefitsInspired by the pandemic, has 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 have received many more complaints from Medicare Advantage beneficiaries,” Ms. Steinberg said.
“We are actually making progress,” he said. “But people are taking overdoses and dying because of the lack of access to treatment.” Their doctors, who are not used to diagnosing substance abuse in older people, may also overlook the risks.
of an age group whose drinking and drug use in their youth have sometimes provided amusing anecdotes (a common saying: “If you can remember the ’60s, you weren’t there”) , it can be difficult for people to recognize how vulnerable they have become …
“The person may not be able to say, I’m addicted,” Dr. Humphreys said. “It’s a Rubicon that people don’t want to cross.”
He added, a joke about dropping acid on Woodstock “makes me coloured”. “Crushing OxyContin and sniffing it is not colorful.”