When Dr. Benjamin Han, a geriatrician and addiction medicine specialist, meets new patients at the University of California, San Diego School of Medicine, he talks to them about the common health problems that 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 want to disclose this, but I put it in a healthy context,” Dr. Han said.
He tells them, “As you get older, there are physiological changes and your brain becomes much more sensitive. Your tolerance decreases as your body changes. It can put you at risk.”
That’s how he learns that someone complaining of insomnia may be using stimulants, perhaps methamphetamines, to get going in the morning. Or that a patient who had been taking an opioid for chronic pain for a long time had problems with an additional prescription for, say, gabapentin.
When one 90-year-old patient, a woman fit enough to take the subway to her previous hospital in New York, began reporting dizziness and falls, it took Dr. Han a while to figure out why: She was washing down her prescription pills, increasing in number as she got older, with a shot of brandy.
He had older patients whose heart problems, liver disease and cognitive impairment were most likely made worse by drug use. Some have overdosed. Despite his best efforts, some died.
Until a few years ago, even as the opioid epidemic raged, health care providers and researchers paid limited attention to drug use by older adults; concerns focused on the younger, hard-working victims who were hardest hit.
But since baby boomers turned 65, the age at which they typically qualify for Medicare, substance use disorders among the older population have climbed steeply. “Cohorts have drug and alcohol habits that they carry through life,” said Keith Humphreys, a psychologist and addiction researcher at Stanford University School of Medicine.
Aging boomers “continue to use drugs far more than their parents, and the field wasn’t ready for that.”
Evidence of a growing problem was piling up. A study of opioid use disorder in people over 65 enrolled in traditional Medicare, for example, has shown 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.
Tse-Chuan Yang, co-author of the study and a sociologist and demographer at the University at Albany, said that the stigma of drug use can lead people to underreport it, so the true rate of the disorder may be even higher.
Fatal overdoses have also soared among the elderly. From 2002 to 2021, the rate of overdose deaths quadrupled to 12 from 3 per 100,000, Dr. Humphreys and Chelsea Shover, co-author, reported in JAMA Psychiatry in March, using data from the Centers for Disease Control and Prevention. These deaths were both intentional, such as suicides, and accidental, reflecting drug interactions and mistakes.
Most substance use disorders among the elderly involve prescription medications, not illegal drugs. And because most Medicare beneficiaries take multiple medications, “it’s easy to get confused,” Dr. Humphreys said. “The more complicated the regime, the easier it is to make mistakes. And then you have an overdose.”
The numbers so far remain relatively low — 6,700 overdose deaths in 2021 among people 65 and older — but the rate of increase is alarming.
“In 1998, this is what people would have said about overdose deaths in general – the absolute number was small,” Dr. Humphreys said. “When you don’t respond, you end up in a sad state.” More than 100,000 Americans died of overdoses last year
Alcohol also plays an important role. Last year, a study of substance use disordersbased on a federal survey, analyzed which drugs older Americans used, looking at the differences between Medicare enrollees under 65 (who may qualify because of disabilities) and those 65 and older.
Of the 2 percent of beneficiaries over 65 who reported substance use or dependence in the past year — which amounts to more than 900,000 seniors nationwide — more than 87 percent abused alcohol. (Alcohol calculated 11,616 deaths among the elderly in 2020, an 18 percent increase over the previous year.)
In addition, about 8.6 percent of disorders involved opioids, mostly prescription pain relievers; 4.3 percent involved marijuana; and 2 percent involved non-opioid prescription drugs, including tranquilizers and anti-anxiety medications. The categories overlap because “people often use multiple substances,” said William Parish, the lead author and a health economist at RTI International, a nonprofit research institute.
Although most people with drug problems do not die from an overdose, the health consequences can be severe: injuries from falls and accidents, accelerated cognitive decline, cancers, heart and liver disease, and kidney failure.
“It’s particularly heartbreaking to compare rates of suicidal ideation,” Dr Parish said. Older Medicare beneficiaries with substance use disorders were more than three times more likely to report “serious psychological distress” than 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 had undergone treatment in the past year — just 6 percent, compared with 17 percent of younger Medicare beneficiaries — or even made an effort to seek treatment.
“With these addictions, it takes a lot to prepare someone to enter treatment,” said Dr. Parish, noting that nearly half of respondents over the age of 65 said they lacked the motivation to begin.
But they also face more barriers than younger people. “We’re seeing higher rates of stigma concerns, things like worrying about what their neighbors will think,” Dr. Parish said. “We’re seeing more logistical barriers,” he said, like finding transportation, not knowing where to go for help and not being able to afford care.
It can be “more difficult for older adults to try to navigate the healthcare system,” Dr. Parish said.
Uneven Medicare coverage also presents obstacles. Federal equity legislation, requiring the same coverage for mental health (including addiction treatment) and physical health, guarantees equal benefits in private employer insurance, state health exchanges, Affordable Care Act marketplaces and most Medicaid plans.
But it never included Medicare, said Deborah Steinberg, senior health policy attorney at the Legal Action Centernonprofit working to expand equitable coverage.
Lawyers made some entries. Medicare covers substance abuse screening and, starting in 2020, opioid treatment programs like methadone clinics. In January, after 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. Expanded benefits of telehealthprompted by the pandemic, 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’re seeing a lot more complaints from Medicare Advantage beneficiaries,” Ms. Steinberg said.
“We’re actually making progress,” she added. “But people are overdosing and dying because of a lack of access to treatment.” Their doctors, unaccustomed to diagnosing substance abuse in the elderly, may also overlook the risks.
In an age cohort whose youthful drinking and drug use sometimes provided amusing anecdotes (a common refrain: “If you can remember the 60s, you weren’t there”), it can be hard for people to recognize how vulnerable they’ve become. .
“That person may not be able to say, I’m an addict,” Dr. Humphreys said. “It’s a Rubicon that people don’t want to cross.”
A joke about dropping acid at Woodstock “makes me colorful,” he added. “Crushing OxyContin and snorting it is not colorful.”