When met Dr. Benjamin Han, a geriatrician and addiction medicine specialist, the new patients at the School of Medicine at the University of California, San Diego, he talked to them about common health issues facing the elderly: chronic conditions, ability available, drugs 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 it, but I put it in a health context,” said Dr. Han.
He told them, “As you get older, there are physiological changes and your brain becomes more sensitive. Your tolerance decreases as your body changes. This can put you at risk.”
That’s how he learned that someone complaining of insomnia may be using stimulants, possibly methamphetamines, to get through the morning. Or that a patient who had been taking opioids for chronic pain had a problem with an additional prescription for, say, gabapentin.
When a 90-year-old patient, a woman well enough to take the subway to her old hospital in New York City, began to report dizziness and falls, it took Dr. Here’s why: He washed down his prescription pills, increasing in number as he got older, with a shot of brandy.
He has elderly patients whose heart problems, liver disease and cognitive impairment are likely to be exacerbated by substance use. Some have overdosed. Despite his best efforts, some died.
Until a few years ago, even as the opioid epidemic raged, health providers and researchers paid limited attention to drug use by the elderly; concerns have focused on younger, working-age victims who have been hit the hardest.
But as baby boomers turned 65, the age at which they typically qualify for Medicare, substance use disorders among the elderly population rose sharply. “Groups have drug and alcohol use habits that they carry into life,” says Keith Humphreys, a psychologist and addiction researcher at Stanford University School of Medicine.
Aging boomers “are still using drugs more than their parents did, and the field is not ready for that.”
Evidence of a growing problem is piling up. A study of opioid use disorder among people over 65 enrolled in traditional Medicare, for example, showed 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, a co-author of the study and a sociologist and demographer at the University at Albany, said the stigma of drug use can lead people to underreport it, so the true rate of the disorder may be higher still.
Fatal overdoses have also increased among the elderly. From 2002 to 2021, the rate of the overdose death rate is four times higher to 12 from 3 per 100,000, Dr. Humphreys and Chelsea Shover, a co-author, reported in JAMA Psychiatry in March, using data from the Centers for Disease Control and Prevention. Those deaths are both intentional, such as suicides, and accidental, reflecting drug interactions and mistakes.
Most substance use disorders in older people involve prescription drugs, not illegal drugs. And because most Medicare beneficiaries take multiple medications, “it’s easy to get confused,” Dr. Humphreys. “The more complicated the regimen, the easier it is to make mistakes. Then you overdose.”
The numbers so far remain relatively low — 6,700 drug overdose deaths in 2021 among people 65 and older — but the rate of increase is alarming.
“In 1998, that’s what people would say about overdose deaths in general — the absolute number was small,” said Dr. Humphreys. “When you don’t respond, you end up in a sad state.” More than 100,000 Americans died of a drug overdose last year.
Alcohol also plays a big role. Last year, a study of substance use disordersbased on a federal survey, examined which drugs older Americans use, looking at differences between Medicare enrollees under 65 (who may qualify because of disabilities) and those 65 and older older.
Of the 2 percent of beneficiaries over 65 who reported a substance use disorder or dependence in the past year — which amounts to more than 900,000 seniors nationwide — more than 87 percent abused alcohol. (Alcohol is considered 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 substance use problems do not die from overdoses, the health consequences can be severe: injuries from falls and accidents, accelerated cognitive decline, cancers, heart and liver disease and kidney failure.
“It is particularly poignant to compare the rates of suicidal ideation,” said Dr. Parish. Elderly Medicare beneficiaries with substance use disorders were more than three times as likely to report “serious psychological distress” as those without such disorders — 14 percent versus 4 percent. About 7 percent had suicidal thoughts, compared to 2 percent who did not report substance disorders.
But very few of these older adults had undergone treatment in the past year — just 6 percent, compared with 17 percent of younger Medicare beneficiaries — or even made the effort to seek treatment.
“With these addictions, it takes a lot to prepare someone for treatment,” said Dr. Parish, noting that nearly half of respondents over 65 said they had no motivation to start.
But they also face more obstacles than younger people. “We see higher rates of stigma concerns, things like worrying about what their neighbors will think,” said Dr. Parish. “We’re seeing more logistical barriers,” she said, such as 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 treatment system,” says Dr. Parish.
Medicare’s uneven coverage also presents obstacles. Federal parity legislation, which mandates the same coverage for mental health (including addiction treatment) and physical health, guarantees equal benefits in private employer insurance, state health exchanges, marketplaces of Affordable Care Act and most Medicaid plans.
But it has not yet included Medicare, said Deborah Steinberg, senior health policy attorney at the Legal Action Centera nonprofit working to expand equal coverage.
The advocates made several admissions. Medicare covers substance use screening and, since 2020, opioid treatment programs like methadone clinics. 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. Expanded telehealth benefitsprompted by the pandemic, also helped.
But more intensive treatment can be difficult to access, and residential treatment is not covered by everyone. Medicare Advantage plans, with more limited provider networks and prior authorization requirements, are more restrictive. “We’re seeing more complaints from Medicare Advantage beneficiaries,” said Ms. Steinberg.
“We’re definitely making progress,” he added. “But people are overdosing and dying because of lack of access to treatment.” Their doctors, who are not used to diagnosing substance abuse in older people, may also miss the dangers.
In an age group where youth drinking and drug use sometimes provide amusing anecdotes (a common refrain: “If you remember the ’60s, you weren’t there”), it can be difficult for people to recognize how weak they have become. .
“That person may not be able to say, I’m addicted,” said Dr. Humphreys. “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.”