Editor’s Note: Today’s post comes from contributing editor Michael Brownrigg. Michael recently received his PhD in US history from Northwestern University, where he studied the relationship between emotion, white masculinity, and capitalism to explain the emergence of an antinarcotic consensus in America at the turn of the twentieth century.
“The face of the nation’s opioid epidemic increasingly is gray and wrinkled,” wrote The Washington Post in 2018, “but that face often is overlooked in a crisis that frequently focuses on the young.” Since the early 2000s, medical experts have grown alarmed by the precipitous rise in opioid-related hospitalizations and deaths among the elderly and deeply concerned that the burgeoning crisis among the geriatric population was going unnoticed.
They pointed to several factors to explain the phenomenon but primarily blamed polypharmacy—the practice of prescribing patients multiple, often dozens of, medications—for the dramatic increase in addiction rates. “An increasing number of elderly patients nationwide are on multiple medications to treat chronic diseases,” one specialist claimed, “raising their chances of dangerous drug interactions and serious side effects. Often the drugs are prescribed by different specialists who don’t communicate with each other.” Older Americans are essentially being pharmaceuticalized, medicated to death, or, at the very least, subjected to extreme distress.
Overprescribing, as the Washington Post article noted, often results from a fractured medical community that impedes the type of collaboration and communication between practitioners necessary for providing integrated regimens tailored for specific patients. Instead of individualized care, elderly patients often receive standardized treatments, that emphasize the use of pharmaceuticals to alleviate chronic pain.
To better serve their patients, physicians need to listen more intently and more empathetically to fully understand the causes of their distress. In other words, they need to practice what Dr. Rita Charon, Professor of Medicine at Columbia University’s Irving Medical Center, has called “narrative medicine.”
By asking pointed questions about both mental and physical health, practitioners can prompt patients to explain their suffering and to situate their pain in narratives and stories that help foster more thoughtful patient-doctor relationships and, consequently, provide intimate and targeted care. Charon writes that:
“With narrative competence, physicians can reach and join their patients in illness, recognize their own personal journeys through medicine, acknowledge kinship with and duties toward other health care professionals, and inaugurate consequential discourse with the public about health care. By bridging the divides that separate physicians from patients, themselves, colleagues, and society, narrative medicine offers fresh opportunities for respectful, empathic, and nourishing medical care.”
Many physicians are untrained in the art of narrative medicine, so they rely instead on assumptions about treating the ailments that accompany old age—assumptions which often lead to pharmacological solutions. This over-reliance on pharmaceuticals is partly responsible for the rise in drug dependency and its accompanying negative side effects that can particularly effect the elderly like disorientation, falls, dangerously low blood pressure, and even respiratory failure. Due to the lack of coordination among practitioners and an inadequately collaborative doctor-patient relationship, medications—insufficiently monitored—are often the only therapeutic recourse. “There’s a tendency in medicine every time we start a medicine to never stop it,” explains one physician.
The predatory practices of pharmaceutical companies such as Purdue Pharma also contributed to the problem. In multiple lawsuits, Purdue was accused of targeting nursing homes with aggressive advertising campaigns that downplayed the addictive potential of OxyContin and other opiate analgesics. These lawsuits claimed that Purdue pursued such facilities because the company knew that Medicare would cover the cost of patient prescriptions, effectively turning elderly care centers into pill mills.
According to one news story, “Purdue told its sales staffers to ‘have a specific business plan in place’ for nursing homes and other long-term care facilities—‘maximizing demand’ for OxyContin and Ryzolt, Purdue’s brand of the narcotic-like pain reliever tramadol.” The report elaborated: “Purdue reminded its sales representatives that when it came to the elderly, the insurance was good and nursing homes [were] an ‘open formulary’ for drugs.”
Purdue even utilized “fake advocacy campaigns,” issuing brochures with titles like “Complexities of Caring for People in Pain,” which assured patients and nursing home staff that opioids were nonaddictive. A 2009 American Geriatric Society bulletin, which asserted that opioids were the safest and most efficacious agent for treating chronic pain, compounded the problems caused by the aggressive advertising campaigns of Big Pharma. The Bulletin’s claims were controversial and premised on the assumption that the elderly were unlikely to succumb to drug addiction.
In 2018, the United States Senate established a subcommittee to address the concerns of medical experts who warned of a geriatric opioid epidemic. The Senate Special Committee on Aging: Preventing and Treating Opioid Misuse Among Older Americans interviewed addiction and recovery specialists and proposed solutions to stop the rise in drug dependency among older Americans. Committee Chair Susan Collins (R–Maine) declared in her opening statement that “Many perceive the face of opioid addiction as young. This epidemic, however, intersects just as much with older adults, something that I think has not received the focus that it deserves.”
Senator Robert P. Casey (D–Pennsylvania), concurred: “Older Americans are among those unseen in this epidemic,” he stated. “In 2016, one in three people with a Medicare prescription drug plan received an opioid prescription. This puts baby boomers and our oldest generation at great risk.”
Collins became interested in the issue of elderly drug abuse after her home state’s Portland Press Herald published a devasting ten-part series that documented the opioid epidemic ravaging Maine. She cited statistics from the Centers for Disease Control indicating that people aged 55 and older who were treated for opioid overdoses increased by nearly a third between 2016 and 2017—an alarming increase not seen in other demographics.
“Regrettably,” Collins noted, “health care providers sometimes miss substance abuse among older adults, as the symptoms can be similar to depression or dementia.” She lamented the medical community’s reliance on psychoactive drugs while urging practitioners to consider nonmedicinal alternatives like physical therapy for pain alleviation. In 2016, Collins had championed the Comprehensive Addiction and Recovery Act and the 21st Century Cures Act to facilitate and encourage the promotion of more integrated models of medical care aimed at curtailing drug addiction.
William B Stauffer, a social worker specializing in drug and alcohol recovery and the Executive Director of the Pennsylvania Recovery Organizations Alliance, summarized the concerns of medical experts in his testimony for the Committee on Aging. He noted that opioid overdoses had killed 1,354 Americans ages 65 and older in 2016.
While acknowledging that older Americans accounted for only three percent of opioid-related deaths that year, he declared that “There is evidence that overdoses of older adult Americans are rising faster than other age groups in some regions of the country. There is also some sense that as the baby boomers age, these numbers will continue to climb nationwide. While alarming, this knowledge could allow us to take proactive measures to address the needs of our older adult citizens.”
According to Stauffer there were many reasons for this abrupt rise in addiction among the elderly. “Older adults are at high risk for medication misuse due to conditions like pain, sleep disorders and insomnia, and anxiety that commonly occur in this population,” he said. “They are more likely to receive prescriptions for psychoactive medications with misuse potential, such as opioid analgesics for pain and central nervous system depressants like benzodiazepines for sleep disorders and anxiety.”
Stauffer observed that “The combination of alcohol and medication misuse has been estimated to affect up to 19 percent of older Americans.” The dearth of funds available for recovery significantly exacerbated the problem, he pointed out, because while Medicare pays for opioid medications, Medicare does not pay for addiction recovery services and only rarely pays for medications to facilitate recovery like methadone.
Stauffer echoed concerns voiced by other specialists that “the needs of older adults who are experiencing a substance use condition get far too often missed or ignored.” Training physicians in techniques similar to narrative medicine, he suggested, might allow for a greater understanding about the causes of addiction while encouraging coordination between specialists to promote a more holistic healthcare approach:
“While substance use conditions have long been an issue for older adults, the topic receives scant attention in the literature and there is almost no training for medical professionals to identify and refer persons to care for a substance use condition to get the help that they need.”
Perhaps the major obstacle preventing older patients from receiving the required care, however, was their reluctance to disclose their substance abuse problems. Friends and family of elderly Americans, too, often recoiled from confronting the issue. Patients, Stauffer suggested, “face a triumvirate of stigma. The problem is unseen, often willfully, and underestimated, dependence on painkillers written off as merely a byproduct of old age.” He observed that “There may be a prevailing but mistaken sense that the older adult ‘has earned it’ or that it may be one of the few joys left—these views ignore the fundamental pain that underlies addiction at any life stage.”
Such “fundamental pain” includes the kind of emotional and psychological anguish engendered by feelings of loneliness, depression, and anxiety that are all too common among the elderly. Although chronic physical pain may initially trigger a reliance on opioids, existential despair or emotional pain could fuel a dependency that quickly grows into addiction. To slow the opioid epidemic among the geriatric population, physicians need to attend to the mental and physical health of their patients.
In the age of Covid-19, when precautionary measures have left isolated older Americans particularly vulnerable, a multifaceted, integrated healthcare approach to treating addiction and managing pain—both physical and mental—is all the more important.
“It’s Your Body. Take Charge of It.”
Retired Arizona tax attorney, John Evard’s story of opioid addiction and recovery serves as an example of the efficacy of the model of treatment proposed by Stauffer and recommended by Dr. Charon. Shortly after retiring, Evard, then 70, developed a viral infection in his left ear and sought surgery to restore his hearing. The operation caused him to suffer chronic pain, and doctors subsequently prescribed Evard numerous painkillers, including OxyContin. He quickly developed an emotionally and physically debilitating narcotic dependency after he required more pills to assuage the pain. “I was effectively housebound,” he recalled in an NPR interview. “I couldn’t play golf anymore. I couldn’t go to social events with my friends or my wife.”
After a stint in The Las Vegas Recovery Center where rehab activities included group therapy where he addressed his mental dependency on opioids, Evard became an advocate for drug reform. He speaks about the issue of addiction and the urgent need to find non-pharmaceutical solutions to assuage the various ailments that come with old age. “Don’t just take the prescription because it’s part of the checkout process from the hospital,” he counsels. “It’s your body. Take charge of it, and push for alternatives at all costs.”
Good advice that elderly Americans and their doctors should heed as they manage physical and mental health in old age.