When Old Age and Addiction Collide

Hands across America

Carol Aronberg’s drunkalogue is common: she grew up outside New York City in a privileged family full of drinkers; both her parents were alcoholics, and her father was a mean drunk whose verbal abuse damaged her self-esteem. Still, she went to college, got married, had kids and started a successful business. And then, eight years ago, her mother died, and Carol’s drinking blossomed, and she expanded her repertoire to include drugs. Finally, after three overdoses on booze and benzodiazepines and a pharmacopeia of other pills (“the 'Cets,” she calls them—Percocet, Fioricet, the combinations of painkiller or sedative with acetaminophen), she checked into rehab. Now she has 18 months clean and sober.

Here's the biggest difference between Aronberg's story and that of most alcoholics: She was 69 years old when she became an addict.

Aronberg is part of what some analysts have described as an approaching tidal wave of addiction in America: older adults and members of the baby-boom generation now in their late 40s to their mid-60s, who develop addiction and get sober late in life.

Many of the growing number of older adults who need help can't get it because of the simple, shocking fact that Medicare does not pay for addiction treatment.

A report issued by the Substance Abuse and Mental Health Services Administration (SAMHSA) has warned that the aging of the baby-boom generation is leading to huge increases in levels of addiction among adults over 50—a fact that, SAMHSA says, will require double the availability of treatment services by 2020. And many of these people, having come of age in the drug-friendly culture of the 1960s and 1970s, have little hesitation about popping painkillers and other pills to deal with the physical and emotional stresses of aging.

“I call it ‘Pharmageddon,’” says Barbara Krantz, medical director of the Hanley Center, a nonprofit addiction treatment facility located in West Palm Beach, Fla. Hanley’s Center for Older Adult Recovery was the first treatment center to pioneer programs specifically designed to help elderly and baby-boom adults recover from addiction. Krantz says Hanley’s older-adult programs are always at full capacity with patients who come from the entire East, because so many older adults need treatment. “If you look at the SAMHSA data,” she says, “the prediction is that five million older adults will need treatment in 2020.” That’s twice the number requiring treatment in 2000.

Another SAMHSA study found that drug abuse (including prescription drug abuse) among adults 50-59 jumped from 2.7 percent of that population in 2002 to 5.8 in 2010, and that among those 55 to 59, the rate roughly doubled from 1.9 to 4.1 percent.

Aronberg traveled from her New Jersey home to spend 60 days at Hanley. She admits she was fortunate to have the resources to pay for private rehab services (at a cost of nearly $50,000). Not everyone is so lucky. Many older adults who need treatment are unable to get it due to the simple, shocking fact that Medicare does not pay for addiction treatment, says Neil Capretto, medical director of Gateway Rehabilitation in Pittsburgh, Pa. Capretto’s region has the highest concentration of elderly people outside the Florida retirement communities. “I’d take Medicare, but Medicare won’t take us,” Capretto says. “Medicare would recognize us if we were still hospital-based.” But many treatment facilities that offer “medically-monitored” detox are free-standing and independent of hospitals.

When Aronberg completed the 30-day program, she says, “I was no more ready to get out than the man in the moon,” and she re-upped for another month. She had arrived not just with her alcohol addiction but also with 30 bottles of prescription drugs—after her third OD, she says, “When they swept my house, you could have sold them on the street to pay your mortgage off. The doctors never told me to stop taking anything—they kept giving me more. My daughter went to the doctor and said, ‘My mom’s been taking too much,’ and he said, ‘That might be true, but it would be harder to get her off.’”

According to Krantz, at least half of patients like Aronberg arrive at Hanley with prescription drug problems, with painkillers being the primary drug of abuse, then sedative-hypnotics (usually benzos like Xanax and Ativan). And a common misconception doctors have about addiction in older people is that you can’t teach an old dog new tricks—that older folks just can’t recover from addiction or deal effectively in their later years with their underlying psychological problems and life-stresses.

It’s true that older folks are experiencing more stress. A 2011 “Stress in America” survey conducted by the American Psychological Association (APA) found that older adults are trying to cope with more life-stress than ever before. The results show stress is impacting health in particular among adults 50 and older who have to care for both parents and children, and also those who have been diagnosed with obesity and/or depression.

Loneliness and isolation can contribute to depression, and elderly people are increasingly vulnerable. A recent study at the University of California, San Francisco, found that while the number of older adults who say they feel lonely hasn’t changed much, the quality of health of lonely older adults has decreased: those who felt isolated said they had a harder time bathing, dressing, eating, and just getting around than those who felt connected to others. And loneliness can contribute to shame.

“Shame is the number one issue for older adults,” says Carol Colleran, an international certified alcohol and drug counselor, author of a sourcebook on aging and addiction, and pioneer of Hanley’s older-adult program in the 1990s. Retired from Hanley, Colleran is now helping to establish a brand-new program for those over 60 at Pine Grove Behavioral Health and Addiction Services, headquartered in Hattiesburg, Miss. “The reason for [their shame], I’ve realized, is that they grew up in a generation where alcoholism was not a disease—it was the town drunk, the man under the bridge. And to them, for a grandmother to be an alcoholic is a very shameful thing.”

Pine Grove is implementing secure, high-definition online videoconferencing as part of its intensive outpatient service to help the increasing numbers of older adults who reach out for help with addiction. According to population projections from the U.S. Department of Health and Human Services’ Administration on Aging, by 2030 nearly one in five U.S. residents will be 65 or older. “The nation is bracing for the impact of providing health care services to these 72 million adults,” the APA survey reports, “but what may be lacking is concern about the impact on caregivers.” The survey shows that these caregivers report higher levels of stress, poorer health and a greater tendency than the general population to use unhealthy behaviors—including drinking and drug-use—to relieve stress. Older adults usually report lower stress levels, but people with caregiving responsibilities say they have more stress and poorer physical health than the rest of us.

“Talk about stressors,” Krantz says: “Baby-boomers statistically come in with three to four times more emotional disorders. Anxiety, depression and chronic pain are the three stressors in their lives that are the most significant.” Hence the painkiller problems. Baby-boomers in particular, Krantz says, are interested in using chemicals to treat their stress—they comprise the generation of “the quick fix, better living through better chemistry.”

Add to this, she says, the freedom with which the medical community uses drugs to treat physical and emotional problems. Addiction specialists often point out that physicians began prescribing more painkillers after the adoption in 2001 of standards by the Joint Commission mandating the assessment of pain as the fifth vital sign.

“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.”

Doris’s family had to pay out of pocket for detox services at Emory University—and even then, Elizabeth says, Doris was so desperate for drugs that she threatened suicide, called in false prescriptions, and faked a middle-of-the-night injury at her assisted living facility to get sent to the emergency department, where, as a former nurse, she knew how to game the system for more painkillers. Doris has now successfully tapered down to 40 milligrams, Elizabeth says. The plan, she says, is to get Doris down to 10 milligrams once per day, with additional pain control provided through physical and psychological therapy.

“She is coherent now,” Elizabeth says. “Her handwriting has improved dramatically, she has lost weight since she’s no longer watching TV in bed all day long, and her overall mood is one of being with us instead of being obsessed about pain and pain pills.” She has also stopped falling so frequently—a situation diagnosed in detox as postural hypotension resulting from excessive opioid use, Elizabeth says.

Krantz says 40 percent of Hanley’s older adults enter treatment at the urging of family members who notice their loved one falling frequently or sustaining unexplained bruises. “Don’t just chalk it off to age,” she says. “You may see their hygiene declining, their memory loss increasing. They may isolate. They may have malnutrition. They may start to complain about sleep disturbances, or their other diseases may be getting worse. In these circumstances people need to start thinking about addiction.”

After Sharyn fell twice, her daughter saw she needed help and got her into rehab. “I was incoherent on the phone, and if she visited me, I was always sleeping,” Sharyn says. She stayed at Hanley for 113 days and went from there into an intensive outpatient program in North Carolina. Now she continues her recovery in 12-step programs. Since getting clean, she actually has less pain, and she can relate to her granddaughters, who initially were “very leery about seeing Nanny again because of the person I used to be.”

Carol Aronberg made it into detox after her daughter “rescued” her when she overdosed for the third time on alcohol and pills. Her daughter found out about Hanley from a cousin in Florida and arranged for Carol’s admission. She has been clean and sober since January 2011, and she and Sharyn both agree that the rehab program tailored for their generation made all the difference.

“It was important to me that I wasn’t sleeping next to an 18-year-old,” Sharyn says.

“You can’t be in a treatment program with all different age groups. We have different needs,” Aronberg says. “Our children are grown, we have grandchildren that are grown. Energy-wise, I might have fit in with the baby-boomers, but I needed to be with my own age group because of the quietness of the evenings. Fortunately I had the sense to realize that, if I’m going to be here, I’m going to get the best for me.”

Among her fellow patients in the program for older adults, Aronberg noticed that, despite their relative wealth, many of them had enormous fear of growing old and not being taken care of in their age. “That loneliness was a factor” that exacerbated their addiction, she says. “There was a lot of denial. Several people did relapse. There weren’t that many who had the same do-or-die attitude that I did.”

Aronberg is in the process of selling her business to concentrate on her own recovery. Like many women her age, she has spent a lifetime thinking of other people, and now she’s developing a new attitude. “Everybody has depended on me, and I’m done,” she says. “I’m not feeling guilty about it. I’m in a phenomenal new life—I’m happy, and I have a reason to live. Instead of looking at life like, ‘Why me?’ I don’t even think like that anymore. It’s like, ‘Thank you, thank you, thank you.’”

Jennifer Matesa is a frequent contributor to The Fix, and she writes about addiction and recovery issues on her blog, Guinevere Gets Sober. An author, educator, and public speaker, she is lecturing this summer to medical students about her family’s experience with addiction as part of a Scaife Foundation-funded program to educate doctors about addiction—one of only two such programs for medical students in the U.S.