Countermeasures Season 2 Episode 6 Podcast Transcript: Aging During the Opioid Crisis
[00:00:00] Maryann Mason We think of grandma baking cookies. But think about it now generationally, these grandmas wore miniskirts and listened to rock and roll and, you know, did recreational drugs. So that stereotype of grandma sitting in a rocking chair doing all those things prevents us from seeing them in their whole totality of how they’ve lived their lives and what social influence and some conditions are under. So sometimes it’s just stops people from asking, could this behavior be substance use related? It’s not even on the table for many people. I think that’s one of the big things. The other is stereotypes of what aging is like, where cognitive decline is expected. And so sometimes people will have that stereotype and not think, could this be due to miss substance misuse? And so they won’t investigate that alley.
[00:01:07] Narrator This is Countermeasures, brought to you by Emergent, maker of NARCAN® Nasal Spray. Join us as we explore the shifting complex world of the opioid crisis. Today, opioid overdose is a leading cause of accidental death for so many families, loved ones and friends behind these lives lost. This season, we’ll continue to explore some of the communities hit the hardest by the crisis. From prisons and construction sites to schools and elderly care. We will hear from changemakers offering a new way forward. When many of us think of the opioid crisis, we might not think of older adults. Stereotypes of what it means to age can prevent signs and symptoms of opioid misuse and dependency from being caught by medical professionals, friends and family and caregivers. However, older adults are a population that is deeply impacted by the opioid crisis and has historically been under addressed by education, harm reduction and treatment options. Maryann Mason is a sociologist and an associate professor of emergency medicine at Northwestern University. She’s been working in the area of substance and opioid misuse for ten years with a focus on older adults.
[00:02:27] Maryann Mason There has been an increase in opioid overdose deaths in older adults. Older adults are just like younger adults, but their rates are a little lower, but they have followed the curve of everybody else. So since 1999, which is the reference point, most of us use older adult overdose deaths have increased enormously over a thousand percent. There are certain periods during that 1999 to 2024 where the increase has been steeper. And about 2014, 2013 is when the increase started going steeply up and there have been permutations in the rates, but pretty much upwardly ever since. The major reasons for the increase are the same reasons really behind the overdose increase in general. It began with the overprescription of opioids by physicians, and then it morphed into illicit opioids like heroin. And then when the crack down came in that and it was harder to get heroin, fentanyl made its way into the drug supply and increase things. And now more recently, we have poly substance driving the increases. So people who are using opioids and stimulants and opioids and alcohol, those are the substances behind the increase. And just want to point out something really interesting about older adults. I’ve been looking closely at the most recent data. And overall in the United States, it looks like drug opioid drug overdoses are going down slightly from 2022 to three and then to 24. But that’s not the case for older adults. They’re continuing to climb for older adults.
[00:04:31] Narrator Mary Nguyen is a Doctor of Pharmacy graduate from the University of Waterloo outside of Toronto. She has worked as a pharmacist in a rural community in Ontario, where she saw the effects of the opioid crisis on older adults in the community. Like Maryann, she says that most people don’t think about the impact of the opioid crisis on older adults and that stereotypes of aging can prevent opioid misuse from being identified.
[00:04:57] Mary Nguyen It’s surprising how often older adults are affected, even though we don’t typically associate them with opioid misuse. You know, people rarely imagine someone like 80 year old Martha down the street struggling with addiction. But the opioid crisis really started in the 90s with OxyContin. And now that baby boomer generation who were highly prescribed opioids are older. So we’re really seeing that lasting effect. Now, to put it in perspective, one in six older adults have taken opioids. Opioid use disorder among this group tripled from 2013 to 2018. Older adults are actually the largest users of prescription opioids. So when you think about it that way, it’s not as surprising that opioid use disorder is prevalent in the population. Unfortunately, we see a lot of stigma in opioid use or misuse in this population, so it can prevent a lot of diagnosis and treatment.
[00:05:57] Narrator Mary found that the dangers of developing dependency were not fully understood by patients, especially if they were taking prescription opioids, and that many of these issues were exacerbated by the rural setting.
[00:06:09] Mary Nguyen The lack of resources, especially for comprehensive care and follow up, really makes it difficult to manage opioid dependency. You know, I’ve seen many of my patients struggle with dependency, whether or not they realize it, mostly because their long term use of opioids is often for legitimate reasons, like for chronic pain management. And they’re not always the most eager to explore safer options, especially when they think that opioids work the best for them. People also don’t realize how easily dependency can develop. You know, it can take as little as a couple of weeks. And then tolerance is a big issue as well. The longer you’re on opioids, the less effective they become, which leads to taking higher doses and a greater risk of dependency. Many assume that because a medication is prescribed, it’s safe. Especially if something they’ve been taking for a long time, they’re less likely to stop because they don’t think it’s an issue. You know, our health care system in Canada is quite strained. Doctors’ offices are overloaded. Sometimes they don’t have time to give proper education or ongoing check-ins for these patients who are on long term medications.
[00:07:25] Narrator In rural settings, especially, tools like naloxone can be crucial.
[00:07:32] Mary Nguyen It’s really important to reduce that stigma around naloxone. Many people hesitate to carry naloxone or take it when it’s offered because they think it implies that they’re an addict of some sort. I like to reframe it as a safety tool. It’s like having a fire extinguisher in your kitchen just in case of emergencies. It’s not that we think you’re abusing your medications, but if you were to accidentally take too much or if someone else were to get into your medications, it’s there as a safety net. And I think, you know, with the evolution of injectable naloxone to nasal naloxone kits, people are less hesitant to carry it because it’s a lot easier to use. Most people don’t want to carry around a needle and syringe and have to poke someone in an emergency.
[00:08:20] Narrator While one way older adults are affected by the opioid crisis is misuse of opioids that were prescribed to them. Some older adults may have a long history of using illicit drugs. The rise of fentanyl has put this population at greater risk.
[00:08:35] Maryann Mason Older adults, there’s kind of two types of opioid misuse. One, is early onset where people may have a 20, 30, 40, 50 year history of substance misuse. And then late onset, that happens in their older years and that’s mostly prescription oriented. So you kind of have to think about two distinct groups of people, older adults who are using. So the younger onset people, there could be a variety of reasons why they’re they’ve misuse and continue to misuse, including untreated pain, mental health issues, sort of cultural norms, generational cultural norms. And then for the older adults who initiate, it’s more likely to have to do with prescription abuse that builds dependency. The disparities are very stark. So among older adults, it’s the 55 to 64 year olds who are disproportionately affected and then men and then African-American men. And so while there is not a ton of definitive research on this, I think the general thought is that it’s a generational impact, meaning that it’s a group that’s likely had early onset use and maintain their use over decades. And so they’ve I mean, they’re survivors. Right. They’ve been able to survive with substance use for 30, 40, 50 years. But now we’re in a situation where the potency of the drug supply combined with their aging has put them at proportionate risk. So the older adults or the young old, as I like to call this group of African-American men, sort of have a generational legacy in that way, in that if you think back to the 1970s, there was a heroin epidemic. A lot of us don’t think that far back, but that was the population ensnared in that epidemic. And I think this population now, they’re older adults. They have continued to use and are ensnared in the new epidemic with greater risk.
[00:10:55] Narrator Jessica Liebster is a case manager at West Neighborhood House, a multi-service organization in Toronto that serves the community to address critical issues through personal and social change. A large portion of their programing is targeted at older adults in the community, some of whom have struggled with chronic opioid misuse. One of their programs includes volunteers going into the homes of seniors in the community who might be isolated.
[00:11:21] Jessica Liebster That program provides volunteer support to connect with participants, so sometimes they will get a weekly call if they would like to just chat and have a connection on a weekly basis. So through that, then we’re able to link up to other support services. So sometimes people don’t identify, they don’t want to ask for services that they think maybe are for other people, right? It’s like people are sometimes very proud or they don’t want to access charity because they don’t see themselves in that light. But we know that all of these social supports most people can benefit from, right? So but some people will then say, yeah, you know, I am kind of lonely. It would be nice to connect with a volunteer. But the volunteer then can identify all kinds of needs and supports. And when things deteriorate as they can, in terms of health or mental health or what have you, then the friendly visitor or the family connection volunteer can say, Hey, this person is struggling a bit and gets some advice or support on how they can refer them to other services. So that piece is, I think, really significant because it captures a lot of folks who wouldn’t necessarily see themselves as needing case management, but there is an element of identifying with some of the needs through that program.
[00:12:43] Narrator Like both Mary and Maryann, Jessica has seen the intersection of social isolation, poverty and substance misuse.
[00:12:53] Jessica Liebster Substance use, we’re maybe thinking of a younger population, so there’s less awareness and not always less awareness always leads to like less access to service as well as maybe somebody not identifying their own needs in that regard as they see themselves as different from other substance users that, you know, maybe are kind of sensationalized in the media or what have you. Right? So I think that ensuring that we’re kind of shining a light on substance use with older adults is really important. And I also think to like the older adult population within, you know, homeless or under housed folks is not really acknowledged. You know, we see lots of older adults who are unhoused, maybe living in shelter for a long time or living sleeping outside using substances. And so, you know, that piece, I think can also get missed because we’re looking at the impact of poverty, like severe poverty in addition to aging, in addition to substance use. So there’s some very specific needs there that, you know, require a bit of a nuanced perspective to respond to.
[00:14:13] Maryann Mason And then specific to the older adult, there’s lots of different things. But key to this group are things like income inequality. So people with lower income tend to have less opportunity for medical insurance to treat pain. And so there’s this idea that people self-medicate when they’re not able to get medical care. There’s also this idea, and it’s well documented, structural racism in the United States where African Americans were actually less likely to be treated for pain with opioids than other populations. And so, again, it leads one to think about the development of illicit views. So you think about those sort of legacy factors, the fact that people don’t have health care, that they’ve experienced lifetimes of racism, that they don’t have access to things like stable housing, which could help them manage these conditions. And the fact that employment and things like that is so racialized in the United States, you can kind of see how this happened.
[00:15:32] Narrator As a pharmacist, Mary saw the impact of the pandemic on older adults, which augments the social isolation that can contribute to substance use disorder.
[00:15:41] Mary Nguyen Covid-19 made things much harder during the pandemic. I saw a sharp rise in opioid abuse, with more patients starting medication assisted treatment increased and relapses, more naloxone requests and treatments for other substance use disorders like alcohol use. And I really do think it’s from that isolation increase in the stress and anxiety leading to this substance use. With health care services limited during lockdowns, it’s tough to get the support you need, right? And with the pandemic, it also led to shifts in the opioid prescription regulations in Ontario, because there weren’t as many in office visit and limiting the transmission risks of Covid. They provided at the Ontario government provided looser restrictions on opioid prescription transfers and longer dispensing intervals. But that inadvertently increased the risk of drug diversion. Across Canada, we saw increases in opioid related hospitalizations and fatal overdoses, especially from fentanyl. But from my experience, the elderly patients were the most impacted by opioid disorder because those were the ones often without a strong social support and a challenge that was further exacerbated by the pandemic.
[00:17:09] Narrator Mary has also seen that the health care profession has a ways to go when it comes to this issue, including in long-term care.
[00:17:17] Mary Nguyen You know, a lot of times when patients go to long term care homes, the health care they receive is often okay. Is there another problem we need to address? Let’s add on medication. It’s very rarely that a doctor goes in and like, hey, let’s see what we can take away. And it’s a practice that is starting to become more popular, especially as you see so many interactions between the different medications. And, you know, just because someone needed something at one point doesn’t mean they need to be on it forever. And as pharmacists specifically coming more into long term care homes, we are coming in and doing medication reviews to do prescribe to minimize the risks. A big thing with opioid use with the cognitive decline is the fall risk. You know, older adults, if they have a bad fall, I think 50 percent of patients who had a hip fracture aren’t able to return back to their normal independent living anymore after that. So I think it’s a big intervention that pharmacists can play.
[00:18:31] Narrator Lake Mary, Maryann believes that treatment is not curated to this population.
[00:18:37] Maryann Mason No, I don’t think there are services tailored to older adults out there for people, or at least in the quantity and the places where people need them. They’re, first of all, there, if you are talking about recovery and treatment, there are some things older adults may need that the general population doesn’t just because of how we age. So they might have transportation or mobility barriers, so they may need a different needs there. They may have hearing or vision issues that necessitate delivering supports and services. There’s been some work done looking at sort of the culture of recovery and how that works and the idea that sort of group therapy, talking about your things in in a group is not in alignment with what many older adults feel is comfortable for them. So there are adaptations that need to be made that way, but also medication assisted recovery, which we know is an effective treatment for opioid use disorder, is less often offered to older adults than younger adults. And so, you know, should that be something people are interested in, They’re not being asked.
[00:19:59] Narrator Maryann also believes that there is more work to be done to tailor current programs to the needs of older adults.
[00:20:06] Maryann Mason Older adults have come of age in a time where that wasn’t a thing. It wasn’t an option for them or that you had to go to specialized treatment. So many don’t know you can get substance use disorder treatment at your primary care physicians office. So there’s a couple of things there. One is the education of the older adult community about what’s now available. But to the education of providers to offering things. And then I guess three is how do we adapt things being offered to the needs of older adults? We have a long way to go. If you think about harm reduction, harm reduction are services that can help people who use drugs be safer and less risky. And there’s a whole menu of effective strategies people can use in harm reduction, anything from syringe distribution to test strips so you can test your drug supply to drug checking. All of those things are in the harm reduction menu or bucket. But there’s evidence showing that older adults are less often touched by harm reduction. And there’s again, a couple of theories about why they’re less often reach. But part of it has to do with stigma. And you think about this population generationally. There was this whole, I’m going to use a word we don’t use anymore, but this junkie label for people where there is a quite a bit of shame and personal failing associated with substance use. So people do not want to identify with that. Sometimes for older adults, they may have gone through a period of abstaining for a number of years and then have recently or more recently gone back to use. And so they really don’t want to go out to the mobile van and stand in line for services because they don’t want to self identify as someone who is using again. The other factors transportation and mobility. People aren’t in the places where they used to hang out and use drugs in their older days, so they’re they can’t be reached in those places and stuff. And so I think we’ve got a ton of work to do around strategies to reach this group with those this population, with those strategies.
[00:22:41] Narrator Older adults are a large, complex and diverse group, and opioid dependency looks different among different populations. However, stereotypes about aging and stigma surrounding opioid misuse can prevent older adults from seeking treatment or for dependency to be caught in the first place. In addition, harm reduction services and supports tailored to older adults are lacking. Increased interest and research into this area will help improve outcomes for everyone. Thank you for listening to this episode of Countermeasures. To learn more about what Emergent is doing to help address public health challenges like the opioid crisis, visit emergentbiosolutions.com. If this episode resonated with you, consider reading and reviewing Countermeasures on your preferred podcast platform.