By Raj K. Kalapatapu, MD

People who are not involved in recovery or drug treatment often make the mistake of thinking that substance abuse is a problem concentrated in the younger generations. However, recent data from the National Survey of Drug Use and Health suggest that the number of older adults (50 and over) using substances addictively will increase in the next two decades. The number of older adults needing treatment for substance abuse is projected to increase from 2.8 million in 2002-06 to 5.7 million by 2020. T: Keith Richards Wants to Leave Behind the “Addict” Label

When you consider the size of the baby boomer generation, it’s clear that the projected number of older adults needing substance abuse treatment will have a significant impact on the healthcare workforce in the future. With aging, unique changes occur in one’s body, cognition, and social network. Such changes in an older adult with substance abuse problems may require new strategies in treatment, and treatment outcomes may not conform to the usual expectations.

INVISIBLE EPIDEMIC
One area of concern is the nonmedical use of prescription drugs, which has been called an “invisible epidemic.” For example, in the Florida Brief Intervention and Treatment for Elders (BRITE) Project, a state funded pilot program to screen and serve older adults at risk for misusing alcohol, prescription and over-the-counter medications, or illicit drugs, prescription substance misuse was the most prevalent problem. As the availability and accessibility of prescription drugs continue to increase, and as the baby boom cohort ages, it appears likely that the proportion of older adults using these drugs and experiencing substance abuse associated problems will also increase.

Cocaine abuse still remains a significant public health problem in the United States and is not limited to the younger population. For example, the Treatment Episode Data Set, which tracks federal- and state-funded substance abuse treatment admissions, shows a gradual overall increase in treatment admissions for older adults primarily abusing cocaine from 2005 (20,649 admissions) to 2007 (24,357 admissions). The patient may be a person who has abused cocaine since youth, someone who has formerly abused cocaine and has now relapsed in recovery, or someone who tried cocaine for the first time at age 55 and became immediately dependent on this highly addictive substance. Regardless of the history, an older adult struggling with cocaine addiction presents specific challenges – psychologically, cognitively and physically – for the healthcare workforce.

WHAT CAN HEALTH PROFESSIONALS DO?
First, we have to simply be aware of the presence and prevalence of substance abuse in older adults. When someone thinks of a person abusing a drug like cocaine or smoking crack, for example, a 75 year-old doesn’t immediately come to mind. Simply considering that an old lady with a walker or a white-haired grandfather sitting across from a health worker is not just using, but struggling with a serious addiction to cocaine or other substances is the first big step in opening an honest conversation about what treatment options are available to a senior citizen on Medicare.

Another step is to make sure that the older adult wishing to deal with his or her addiction issues should be firmly guided into a well-run detoxification/rehabilitation program or another type of medical/psychiatric treatment facility. Many of these patients have coexisting medical/psychiatric illnesses, and such additional problems can significantly add further stress and burden on the body and mind. For example, withdrawal from alcohol and benzodiazepines, such as Xanax or Valium, can lead to seizures, which can be devastating in a medically fragile senior. Therefore, engaging and motivating an older adult to go into substance abuse treatment should be reassuring, and not alarm the patient, but the medical/psychiatric safety concerns must be clearly outlined and understood by the senior.

Many older people are reluctant to enter any medical institutions, due to financial or distrust issues. They may insist that they can do it on their own; they may even try to change their history of the level of their substance abuse in order to stay out of a rehab or psychiatric hospital. This could be fatal to the patient.

Health professionals as well as friends and family must keep in mind that symptoms of substance abuse may be less evident in older adults. In the current system used to diagnose substance abuse, some of the criteria may not necessarily apply to older adults. For example, a retired adult with middle-aged children will naturally and justifiably be exempt from the diagnostic criterion of “a failure to fulfill major role obligations at work or home.” This can result in an under-diagnosis of substance abuse in older adults, who will lack the social network that might recognize a significant change in personality.

THE FUTURE
Clearly, substance abuse is not limited to the young. Whether the rise in older adults abusing substances is due simply to an increasing recognition of substance abuse in this population or to a true rise in geriatric substance abuse is a discussion for another place and time. What we do know is that older adults who abuse substances are a growing problem, and may overload a medical system already in crisis. Developing and applying effective interventions must be one of the goals that will have a direct and significant positive impact on the public health burden of not just the aging population, but on all generations.

HELP AVAILABLE
The Substance Treatment and Research Service (STARS) at Columbia University offers NIH-funded treatment studies for individuals dependent on cocaine, cannabis, alcohol, or opiates. These clinical trials are free of cost and provide both supportive counseling and medication for helping to achieve abstinence. STARS has two treatment sites, one in Midtown and the other located in upper Manhattan near the GW Bridge. Interested individuals should call 212-923-3031 to schedule an intake appointment.

Raj K. Kalapatapu, MD is a fellow in addiction psychiatry at Columbia University/New York State Psychiatric Institute. He is a board-certified psychiatrist, who has additional fellowship training in child/adolescent and geriatric psychiatry.