When Aging and Addiction Collide
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“We’ve gone from one extreme to the other,” she says. “Before the Joint Commission implemented the fifth vital sign, the only time we prescribed [opioid] pain medications was for cancer pain.”
Krantz (who herself has been recovering since 1981 from prescription drug addiction) notes that, after the advent of the fifth-vital-sign standard, pharmaceutical companies began advertising painkillers directly to consumers. And whereas patients who grew up during the Depression usually wait to see what treatments, if any, the doctor might advise, their baby-boom counterparts—armed with computer spreadsheets and Internet research—march into doctors offices asking for particular drugs.
“We started using more narcotics,” she says. “But we did that in a void” of medical education about the risks of addiction. At the national prescription drug summit in April, Krantz says, NIDA Director Nora Volkow pointed out that American medical students receive roughly 7 hours of instruction about addiction. So doctors don’t screen patients, particularly older patients, for risks of addiction.
“We didn’t have the education to ask the appropriate questions,” she says. “Our program alumni tell us that their doctors don’t ask, ‘Are you drinking? Do you have substance abuse issues in your family?’”
Older adults are more vulnerable to booze and drugs for a number of reasons: because of the way metabolism slows with age; because of coexisting medical conditions, such as high blood pressure, diabetes or psychological problems; because many older adults live in isolated situations without structure, which allows them to drink or use without anyone else noticing; and because of the ways alcohol and drugs can interact with medications used to manage those problems. All of which makes detox a trickier prospect than with a twenty- or thirty-something—especially if the patient has been using alcohol and drugs together.
“I wish they just came in on alcohol,” but it’s usually alcohol and benzos, alcohol and painkillers, Krantz says. Because of reduced metabolism, blood alcohol levels “are usually pretty high,” Krantz says. “And then you add, for example, hypertension to that, so when you go through withdrawal, what you can expect is the exact opposite—their seizure risk is up, heart arrhythmia is up, blood pressure is up.” Older patients experience greater and longer sleep disturbances, malnutrition, peripheral neuropathy, and other complications during withdrawal—problems that are best overseen by a trained staff, Krantz says.
Sharyn K., 67, is an example of how difficult it is for older people to metabolize drugs. After three surgeries left her with pain down her legs, she was prescribed dilaudid and fentanyl, two strong synthetic opioid painkillers. As Sharyn explains it, she thought she had quit drinking “the day before the first surgery” in 2009. “But I was so whacked out” on the painkillers “that I didn’t know I was still drinking vodka every night,” she says of her post-surgery experience. “And I was already on Valium and Xanax for anxiety.”
Though she took her medications as prescribed, she continued to drink and spent two years in a fog, falling twice and injuring her head. “I didn’t know where I was,” she says.
Depending on the level of physical dependence, even some addiction facilities apparently won’t take elderly people because of the complexities of detoxing them. Doris, a 73-year-old Atlanta grandmother and former nurse who had become addicted to methadone and fentanyl prescribed originally for arthritis and back pain, was refused admission by several local addiction facilities. She had climbed to more than 100 milligrams of methadone per day.
“Her dose was too high, and therefore a detox far too dangerous,” her daughter-in-law Elizabeth says. “Anything over 35 milligrams and they won’t touch her with a ten-foot pole.”