The explosion of opiate abuse and addiction in Maine cuts across all demographics, including age, race, gender, income, education and geography. But often overlooked in reports on the crisis are Maine’s older citizens, the rapidly growing population of people in their 50s, 60s and older, whose lives also have been affected by addiction to opiates, including prescription painkillers and heroin.
An October 2015 report by the Maine Office of Substance Abuse showed that older adults make up a significant percentage of emergency overdose cases. According to the report, of the 2,947 drug overdoses responded to by emergency medical providers in 2014, 494 cases, or 17 percent, involved individuals age 56 and older. Naloxone, the lifesaving medication that can reverse the lethal effects of an opiate overdose, was administered to 193 individuals 55 or older, or about 23 percent of total Naloxone administrations.
Despite the representation of older Mainers in these numbers, the report showed that people age 50 and older account for only about 4 percent of admissions to Maine opiate treatment programs.
Coming of age with drugs
Baby boomers, the generation born between 1946 and 1964, are at especially high risk for developing drug dependency and addiction, according to Lenard Kaye, director of the University of Maine Center on Aging. While reliable comparative data are hard to come by, Kaye said there are “disturbing trends” emerging nationally and in Maine. According to self-reported and professional surveys, he said, the incidence of opioid dependence in individuals age 55 and older has more than doubled over the past 10 years. As with the rise in drug abuse generally, the reasons are layered.
First, “the boomers have a lifetime history of being risk-takers,” Kaye said, a generational tendency that is playing out in high rates of alcohol consumption and recreational drug use well into maturity and beyond.
But not all drug-dependent baby boomers develop addiction through the intentional misuse of illicit and illegal opiates. In addition, Kaye said, “unlike their parents and grandparents, boomers have grown up in a society where the use of prescription drugs has increased dramatically,” as a routine element of health care. Americans have come to expect the quick fix of pharmaceuticals to provide immediate relief from pain, anxiety and other conditions, he said. And doctors, under pressure to see as many patients as possible during the clinical day, have obliged by prescribing ever more powerful drugs, including dangerously addictive painkillers, such as OxyContin, instead of proposing more complex alternatives.
Too often, Kaye said, doctors and other prescribers fail to teach patients how to safely use and then discontinue and dispose of these medications or to warn them about interactions with other drugs, the potential for theft and diversion for illicit use and the possibility of addiction. The result is a plethora of addictive drugs for individual use, bottles of unused and outdated medicines in home medicine cabinets and a flood of illicit prescription medications on the street.
“The responsibility is really on the physicians, who unfortunately continue prescribing these drugs at unprecedented rates,” Kaye said.
An ‘exponential’ increase in prescribing
In testimony presented late last month before the U.S. Senate Special Committee on Aging, which is chaired by U.S. Sen. Susan Collins of Maine, Dr. Steve Diaz, senior vice president and CEO of MaineGeneral Health in Augusta, said changes in clinical and regulatory standards are at least partially responsible for an “exponential” increase in the prescribing of opiates.
On the clinical front, Diaz said, a national initiative implemented in 1995 established pain as “the fifth vital sign,” that medical professionals should measure at every patient interaction, along with body temperature, pulse, respiratory rate and blood pressure. This initiative grew out of widespread recognition in the medical community that chronic and acute pain had for too long been undermanaged and that patients were suffering needlessly as a result. The initiative spurred a major increase in prescribing for pain that coincided with the development and easy availability of more effective and often more addictive drugs.
More recently, Diaz told the committee, a questionnaire developed for hospital patients by the federal Centers for Medicare and Medicaid Services includes questions aimed at determining how effectively medical providers managed pain during hospitalization. Hospitals get paid more by Medicare when Medicare patients respond favorably, leading some physicians to overmedicate for pain.
The combination of clinical pressure to eliminate pain using powerful new drugs and the financial incentive to keep hospitalized patients totally free of discomfort has proven disastrous, Diaz said. “The result is, we now give more opiates and have more addiction, diversion and overdoses,” he said. “This is increasingly a problem for the elderly.”
Diaz proposes a shift in chronic pain management strategies for all patients, including older adults, away from potent, addictive pharmaceuticals and toward a multidisciplinary approach that incorporates physical therapy, acupuncture, relaxation therapy and other elements, including cautious and informed prescribing of less dangerous drugs. Powerful opiates should be reserved for intractable pain associated with cancer and end-of-life conditions, he said.
For those already addicted to pain medicines and other opiates, Diaz said treatment must be de-stigmatized and made ready available through primary care offices, not reserved for specialized clinics and inpatient programs that may not meet the needs of Maine seniors.
“Alcohol is still the drug of choice for most older people,” said Pat Kimball, executive director of Wellspring, an established substance abuse treatment agency based in Bangor. But among all ages, the percentage of clients at Maine agencies being treated for opiate addiction is on the increase, she said.
While addiction to opiates and other substances can arise in any socioeconomic group, Kimball said it often is associated with childhood abuse or neglect, military service and other sources of physical and emotional trauma. Mental disorders such as depression, bipolar disease and other conditions also may be present.
For many, 180-day residential programs prove most effective, allowing clients to focus on their recovery and to separate from unhealthy relationships with people who may not be supportive of their goals. But others, including many older clients, chose an outpatient setting instead so they can maintain employment, family responsibilities and other obligations.
Ability to pay also is a deciding factor. Few clients have private insurance, many low-income adult Mainers do not qualify for Medicaid and Medicare and Medicaid coverage are subject to many conditions. Out-of-pocket costs for the residential program can be as much as $200 per day, but Kimball said costs for some clients can be offset through grant funding and donated gifts.
Treatment typically consists of therapeutic counseling, behavior modification strategies and developing tools for managing stress and adversity. For opiate dependency at any age, Kimball said, replacement therapy using medications such as methadone or Suboxone can mean the difference between success and failure.
“Methadone can be very effective for long-standing addictions,” Kimball said, but can require a lifetime commitment to daily clinic visits and other regulatory hurdles.
“Later-in-life addiction may respond well to Suboxone,” Kimball said, which can be managed on a month-to-month basis through a qualified primary care provider, making it more convenient and reducing stigma.
“Pride and stigma have a lot to do with why older people don’t seek treatment,” Kimball said. “Here they are, functioning members of their communities, holding down a job, taking care of their families, and all of a sudden they’re turning themselves over to an addiction treatment center.”
Kaye at the University of Maine Center on Aging said more must be done to change prescribing behaviors among physicians and to reduce the availability of illicit and illegal opiates. And, he said, it’s essential to bring more older Mainers into treatment, to help them manage their addiction, restore relationships with their families and reduce the likelihood of unlawful behavior.
“But because this population is less visible,” he said, “the problem of addiction in older people is easy to ignore and to just sweep under the rug.”
For more information about efforts in Maine to reduce the abuse of opiates and other drugs, visit the website of the Office of the Maine Attorney General at maine.gov/ag/initiatives/drugsummit2011.
For information about treatment services, contact the Maine Office of Substance Abuse and Mental Health Services at 207-287-2595 or visit the website at maine.gov/dhhs/samhs.