Addressing Prescription Drug Addiction in Older Adults

WHEN THINKING ABOUT prescription drug addiction, one might understandably and automatically picture a young adult. Those 18 to 25 years of age “are the biggest abusers of prescription … opioid pain relievers, ADHD stimulants and anti-anxiety drugs,” according to the National Institute on Drug Abuse. However, research shows that there’s been a surge over the past decade in opioid misuse – which includes heroin as well as the powerful prescription pain narcotics like fentanyl fueling an overdose epidemic – in older adults.

In fact, between 2002 and 2014, opioid abuse nearly doubled in those 50 and older (from about 1 to 2 percent), while declining in younger age groups. And a report from the Agency for Healthcare Research and Quality released in September found that, among people 65 and older, opioid-related emergency room visits were up 74 percent from 2010 to 2015 and opioid-related inpatient stays were up 34 percent. (That compares to a 17 percent decrease in non-opioid related hospital stays and ER visits.) In 2015, there were 124,300 opioid-related hospital admissions of patients 65 and up in the U.S. “So it’s a big problem," says Dr. Arlene Bierman, director of AHRQ's Center for Evidence and Practice Improvement, who was involved in the research and is the corresponding author on the report.

To be sure, the report didn't breakdown what proportion of hospital admissions or emergency department visits related to abuse of the medications versus, for example, side effects that occurred when an older patient took opioids as prescribed. Bierman and other experts note that older adults often have chronic pain, along with multiple other chronic conditions, and opioids are frequently prescribed to treat that pain. Previous research finds in 2016 about 1 in 3 seniors enrolled in a Medicare prescription drug plan, or Part D, received prescription opioids and that “a substantial number received higher doses than recommended for prolonged periods of time, putting them at increased risk of misuse,” as noted in the AHRQ report.

But as with younger adults who struggle with addiction, the risks seniors face extend to other prescription drugs as well, including benzodiazepines, which are sometimes taken in combination with opioids. Prescribed for everything from anxiety to insomnia, older adults are often left on the medications – like Xanax, Klonopin, Valium – long-term; even though short-term use, if they’re to be used at all in seniors, is generally recommended. Older adults especially may have more difficulty metabolizing these drugs, or clearing them from their system, along with side effects such as dizziness and confusion. There’s also an increased risk for addiction when a person is on a medication for a longer period.

One recent study published in JAMA Internal Medicine found a third of older adults initially prescribed benzodiazepines by nonpsychiatric clinicians (like primary care providers, who prescribe the majority of these medications) went on to take them long term. “While treatment guidelines recommend only short-term prescribing, if any, these long-term patients were prescribed nearly 8 months’ worth of benzodiazepine,” the researchers note. Adds study lead author Dr. Lauren Gerlach, a geriatric psychiatrist and assistant professor of psychiatry at the University of Michigan: “At one year after patients were newly started on these medications, nearly 1 in 4 remained on the medications.”

That research didn’t chart addiction. But the higher number of medications older adults tend to take contributes to the risk individuals will become dependent on drugs like opioids or benzodiazepines, making it harder to stop them. And this can lead to addiction, which often goes undetected and undisclosed.

Although abuse of substances like heroin is a problem as well, experts say many overdose deaths in older adults involve prescription medications, and that misuse occurs gradually or without initial intent to abuse the drugs. “They’re not using these medications to get high or for risk-taking but they’re using them to manage their pain,” says Kenneth Leonard, director of the Clinical and Research Institute on Addictions at the University at Buffalo. But frequently medical and mental health professionals say despite increasing doses of pain medication, and because of an increased tolerance for opioids, for example, many take more of the medications, and still aren’t successful in managing their pain. “Sometimes they combine them with benzodiazepines that they are prescribed. And many of the deaths that we see involve a combination of opiates and benzodiazepines,” Leonard says.

Treatment and Prevention of Prescription Drug Addiction

“The standard of care in the field is to use some kind of medication to assist in the addiction treatment – and that’s largely buprenorphine or methadone,” Leonard says. “And there’s not any reason to think that those wouldn’t be appropriate for the older population.”

Other experts concur that what works for younger adults generally should for seniors as well.

“While substance abuse in older adults often goes unrecognized and therefore untreated, research indicates that currently available addiction treatment programs can be as effective for them as for younger adults,” the National Institute on Drug Abuse asserts.

Still, some adjustments in addressing addiction in older adults may help – where, for example, the issue often goes undiscussed by individuals, and family and even physicians don’t ask about it. Along those lines, experts suggest:

Encourage conversation. Often it’s incorrectly assumed that seniors don’t battle addiction to alcohol or drugs, which plagues many younger people. As a result, there’s a lack of discussion around the topic not only in many homes, but even in the doctor’s office, experts says – where frequently patients don’t disclose possible problems, and clinicians don’t inquire about them.

Seek out age-appropriate support groups. Although there are limited options for addiction treatment focused on older adults, some support groups are tailored to older individuals. These may provide a more comfortable atmosphere to share concerns and learn from generational peers.

Make sure other medical problems are treated as well. Many seniors have co-morbidities – or multiple medical problems at one time – with chronic pain often being one. So coming off a medication used to treat pain entirely may be difficult. However, experts suggest taking the lowest dose of opioids for the shortest period possible to be effective, and also considering non-drug alternatives to treat chronic pain; AHRQ did a systematic review of non-opioid strategies to deal with chronic pain, including things like exercise, yoga and tai chi. “I think that there’s a real benefit for starting first with non-drug treatment,” Bierman says.

Ask about having medications “de-prescribed.” As a geriatric psychiatrist, Gerlach spends a considerable amount of time with patients going over medications they’re taking and seeing what they might no longer need and could be taken off of – or that she could “de-prescribe,” Gerlach says. “It’s really important to periodically kind of reevaluate the medications that patients are on to figure out if there’s a way that patients can safely come off of these medications.”

Whatever the approach to prevention or treatment, experts emphasize, older adults and family shouldn’t overlook the risks of addiction with prescription medications (as with other substances like alcohol). Although some stigma still surrounds addiction that can make it more difficult to open up, clinicians say it’s critical to discuss any concerns about that or any adverse effects, or side effects, with a primary care provider.

By Michael O. Schroeder

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