America's Senior Addiction Problem
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Despite the prominence of prescription pill abuse in American society and extensive coverage by the media, there is a little dark dirty secret that is being ignored and forgotten: prescription drug dependence and alcohol abuse among the elderly population is rapidly growing in America. It has been swept under the rug or simply not recognized due to the population affected, The Fix is investigating this issue by conducting an interview with two people on the frontlines of elder addiction.
Dr. Damon Raskin, Medical Director at Fireside Convalescent Hospital and Good Shepherd Nursing Home, has extensive firsthand experience taking care of elderly patients. Beyond his work with the elderly, Dr. Raskin has become a true expert in the field of addiction treatment. By joining forces with Cliffside Malibu rehab, he has had the opportunity to help hundreds of clients successfully complete comprehensive detox and begin down the path of recovery. By combining his two specialties, Dr. Raskin has become one of the foremost voices in the battle to raise awareness about elder drug and alcohol abuse, and other addiction issues.
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Having worked with Dr. Raskin in efforts to help her husband, Ruth Dent has faced the issues of prescription drug abuse and alcoholism on a painfully intimate level. A former dentist with a successful career with the Veterans Administration, Dr. Dent fell into a downward spiral upon retirement. Although he overcame his dependence on prescription painkillers, Dr. Dent remains in the depths of alcohol abuse. With courage and fortitude, Ruth Dent reveals the story that has derailed her life and hijacked the so-called happiness of her golden years.
Dr. Raskin, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), over the last twenty years the rate of hospital admissions for conditions related to prescription medications and illicit drug use rose by 96% among people between the ages of 65 to 84; for people 85 and older, admissions grew 87%.
I would imagine that few people, even the readers of The Fix, have a lot of experience with the problem and the resulting challenges of elder addiction and drug abuse. Can you provide us with an initial orientation beyond the statistics?
Dr. Damon Raskin: Yes, I can. The reason we are even speaking today is because elder addiction is something that remains quite unrecognized. We need to get out the message that this is a problem not only with young people and the well-covered prescription drug abuse epidemic, but also with old people as well.
No one is immune to the problem: not a poor population or a rich population, not a young population or an older population. It really affects everyone across every strata of our society. What happens, however, is the older patients are not seen as often and their problems are not as apparent, and that is for a variety of reasons. For example, a lot of older people are retired so they are not going to be missing work or causing problems at the office. In addition, when there’s less work to do and they don’t have a job, when they literally don’t have to show up at an office or anywhere else, they have more time on their hands and this often leads to boredom and depression. Such difficulties lead to the co-morbid problems of mental health issues and drug abuse that can quickly evolve into drug addiction. That’s a big part of it.
The other thing is that families and even medical providers will excuse older patients for memory problems and other health-related problems like falls or dizziness that are obvious signs of drug abuse issues. In older people, we will attribute those problems to signs of age or other health problems or issues with other medications and not take into account the big contribution of drinking and drug abuse. With young people, we don’t expect to see them falling down in the middle of the street and we don’t expect them to have sudden bouts of dizziness or fatigue. With older patients, we use age as an excuse for symptoms that we normally recognize with younger people as signs of drug or alcohol abuse.
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Mrs. Dent, I know that you have dealt with this challenge of elder addiction on a firsthand basis with your husband, Dr. Robert Dent. I truly respect the strength you are displaying by stepping forward and speaking about Dr. Dent’s difficulties with prescription opioid addiction in order to raise awareness. Can you provide us with a basic picture of what you have experienced and how it brought you to this place of courage?
Ruth Dent: What I first experienced was that when Dr. Dent lost his job, he suddenly had little or no purpose in life, and then he really, really went awry. I’m not sure whether his problems are all alcohol-related or a combination of both alcohol and depression. I’m really concerned to find an answer because they seem to be quite intertwined.
What I do know is that, number one, when Dr. Dent drinks, he turns very mean and, number two, his memory is badly damaged when he drinks alcohol. In terms of the prescription painkillers, he willingly checked himself into detox for seven days and they got him off the drugs. Afterwards, he spent five solid weeks at a rehab and walked out saying that the pills were behind him and that he did not have a drinking problem. He said he could continue to drink if he wanted to drink.
Is it true that older adults are more likely to have more than one substance abuse problem? I know a recent study found that the demographic most likely to binge drink are adults over 65. Does that mean that an older person who is abusing pills probably also has an alcohol dependency, as was the case with Dr. Dent?
Dr. Raskin: Sure and it is quite common. I do see combinations quite frequently and most of them are quite dangerous. Older patients commonly abuse benzodiazepines like Valium and Xanax. They seem to be commonly taken in combination with other substances like alcohol or prescription opiates. A major problem, as we get older, is that we seem to be less able to handle our alcohol. For older people, less alcohol causes greater intoxication while complicating secondary medical conditions. When you combine alcohol with prescription drugs, you have an addictive or synergistic effect in terms of debility and morbidity and, ultimately, mortality.
I recently interviewed David Sheff, and we discussed the lack of addiction awareness training for medical professionals and care providers in America. Would you say that there is a general failure by doctors to catch elderly substance abuse because it can look like dementia, frailty, or other age-related disorders? For example, do doctors fail to inquire about a patient’s drinking patterns before prescribing medication, potentially leading to accidental overdose and even death? What training do medical providers need to properly address the issue of elder addiction?
Dr. Damon Raskin: I agree with everything you said and the answer is no—in terms of doctors being trained to handle these problems and a general lack of addiction awareness. Doctors simply aren’t as good as I would like to see them be, in terms of screening. As general practitioners, the burden is on us to screen all our patients whether they are young, middle-aged or older. If the general screening tests raise red flags, then we should do further interventions as needed.
As I mentioned at the start of this interview, this is a very under-recognized condition. I think this contributes to the dual-nature of the problem. One, it is under-recognized, and two, poor screening by doctors leads to many older patients with drug and alcohol problems never being properly diagnosed.
Ruth Dent: To add to that answer, what I have noticed with my husband is that it is extremely important for me to go with him when he sees his doctors and for me to be there to tell the truth. If my husband is asked any questions about his drinking, he literally lies to the doctors. He never seems to tell anyone the whole truth.
Dr. Damon Raskin: That is a very common thing because most patients who are unwilling to get help or ask for help are in a state of denial. They won’t be truthful or upfront with a doctor and that puts a doctor at a real disadvantage. You can do all the screening you want, but if you don’t get honest answers, you’re not going to get a correct diagnosis.
When it comes to elder drug and alcohol abuse, family members often avoid intervening because they figure the person is old and should be allowed to take their comfort. After all those years of work and sweat, they’ve earned it. Is this a challenge that you have experienced firsthand when confronting this problem? What can be done to raise awareness and avoid such kindly misconceptions?
Dr. Damon Raskin: I have experienced the scenario before where we excuse our older relatives or family friends by saying, “They earned it.” The important thing to combat this perspective is education about how excessive abuse or dependence on alcohol or drugs can make the lives of older patients much worse, leading to a downward spiral.
That doesn’t mean that older patients can’t have a drink, that’s not the point. Rather, we are talking about alcohol and drug abuse and dependence that leads to falls and hip fractures, liver disease and early death. While we are saying let them be comfortable and have a good time, these negative outcomes are far from comforting. It can be a slow and painful way to live.
Mrs. Dent, when the signs of Dr. Dent’s addiction first arose, you thought his memory loss and lack of coordination were age-related problems. Are the signs of addiction often mistaken for age-related problems in the elderly population? How can such mistakes be avoided when they seem so easy to make? Should there be a checklist provided in regards to the specific warning signs or red flags in regards to drug and alcohol abuse in this population?
Ruth Dent: That’s a toughie. What I have seen with my husband is a lot of falling, a lot of bruising. He’ll get up the next morning and I’ll ask him what happened, and he’ll say that he doesn’t remember. We’ve had some serious, serious falls. I believe he has severely hurt himself only because he was always drunk.
Dr. Damon Raskin: I think what’s really needed is getting the family educated about the red flags and the warning signs. A little more education can go a long way and prevent a lot of needless suffering.
As a certified prosthodontist, Dr. Dent worked for a VA hospital, helping veterans regain their smiles. Dental work involves the use of prescription painkillers like Vicodin, Percocet, and OxyContin, and Dr. Dent fell victim to temptation, becoming addicted to the tools of his trade. As his prescription drug abuse worsened, he was fired from his job with the VA. Dr. Dent was able to continue getting drugs, however, from young doctors and pharmacists at the VA. In the modern version of the Hippocratic Oath, a medical professional takes an oath that says, “May I always act so as to preserve the finest traditions of my calling.” Do you believe Dr. Dent violated his oath? Do you think the younger doctors and pharmacists at the VA who continued to give him prescription drugs violated their oaths?
Ruth Dent: As far as Dr. Dent’s professional life, I truly believe he did not violate his oath and his performance was professional throughout his career. As far as medical people and addiction, the problem is that the drugs are available. Doctors and dentists can write prescriptions and that can quickly become a problem. I believe Dr. Dent started out, years and years ago, with back pain and taking medications for the back pain. I think he continued to take those meds and when they stopped working all that well, he took more meds.
As far as the VA doctors, yes, they definitely violated their oaths. As an older gentleman who was respected, Dr. Dent was able to get his way with these young people. He would tell them that I would like a script for this and this, and they were writing the scripts. They basically gave him whatever he requested. They kind of didn’t argue with him because of his age, and so on and so forth.
Since then, we have called the VA hospital, and we have talked to the doctors and the druggists and let them know he no longer needs the drops they were prescribing to him and that they had become a problem. We were able to clean that up, but the damage had been done. In all reality, they should have been turned in for giving Dr. Dent all of those scripts that he didn’t need in the first place, but that doesn’t make what my husband did right.
Dr. Raskin, there have been reports across the country of armed drug addicts robbing nursing homes, elderly nursing rehab centers and assisted living facilities and demanding prescription drugs and narcotics. From the perspective of these drug abusers, such places are easy pickings on account of limited security and a plethora of on-site prescription medication. Have you heard about this growing problem, and what do you think can be done to stop it?
Dr. Damon Raskin: I actually have not heard about this growing problem. I am involved with several nursing homes and assisted living centers, and it has not been a problem in this area. It must be more of the exception because addicts tend to steal from family members or from their friends or they go doctor shopping. I’m sure it happens, and a way to address the problem would be greater security, but that does not seem like a cost-effective option.
A better way to deal with this problem would be to have pharmacies send smaller quantities to places where such incidents have occurred. As opposed to a month’s worth of morphine, send only a week at a time. By having less available, there would be less of a threat. At the same time, all of these places should have security systems in place with such drugs locked away in a safe.
We discussed how the challenges presented by age-related memory loss, often an early sign of dementia or Alzheimer’s disease, misled Mrs. Dent into thinking her husband’s drug abuse actually was something else entirely. Without question, dementia is a serious problem as the elderly population continues to grow and the baby boomer generation takes over the nursing homes. With advances in geriatric medicine keeping people alive longer, by 2030, there will be about 72.1 million older persons, more than twice the population number in 2000. Dementia results in such problems as unintended doctor shopping, multiple repeat prescriptions filled, and an inability to remember what drug has been taken and when. Such prescribing trends by doctors lead to elderly drug abuse and addiction problems. How can such concerns be prevented and the overall issue of the growing elderly population be handled in relation to the threat of drug abuse and addiction?
Dr. Damon Raskin: As physicians in California, we have access to a service where you go online and find out if a patient is getting controlled substances from multiple places. It’s called the CURES System and other states have it as well. The problem is to educate doctors about the system and get them to actually use it. If it’s used, you can know if a patient has been doctor shopping for controlled substances. It seems obvious to make sure that patients are not getting controlled substances from multiple providers if you are prescribing such drugs. If they are, you have to take action to both protect them and yourself.
Like Mrs. Dent said, I think it’s great when a patient having memory issues brings a family member with them to any consultation or office visit. Such a responsible party can make sure the practitioner is receiving the information they need. You can’t prescribe the right treatment if you don’t know what’s really going on. Another thing is to have a current list of the medications being taken by the patient in their wallet that is updated regularly. When given to the medical provider, such a list can be an invaluable resource.
Ruth Dent: When it’s time to set up medication, my husband would just yell at me in the beginning and insist that he could do it on his own. Even though he’s setting out his meds, he’s not necessarily taking them. I would realize that he often skipped two or three days without saying a thing. Unless I literally set it out and shoved it down his throat, he wouldn’t take them as prescribed.
The other concern was what if I wasn’t here to set out my husband’s meds and making sure that he takes them. I think many people out there are doing what he was doing. Any person out there taking any kind of heavy-duty medication needs someone to help them by setting them out, making sure they are being taken when they are supposed to be taken, and then dispose of them when it’s over. Dr. Dent will just take the drugs helter-skelter, but he often wouldn’t listen. What do you do about people like that who just won’t comply with you when you are trying to help them?
From retirement age on, older Americans drink more and more than any other age group. Many attribute this problem to loneliness and depression with the alcohol being a form of self-medication. How do you think this almost endemic hurdle can be overcome?
Ruth Dent: When the time of retirement came for my husband, he was taken completely off guard. He has not set anything up as far as retirement was concerned and he didn’t prepare himself accordingly. Yes, he loved to play golf, but that simply wasn’t enough. I don’t feel like my life changed when he retired, but his life changed drastically. Suddenly my husband would stay up till two, three, four o’clock in the morning and drink by himself, then sleep till two, three, four o’clock in the afternoon. He had no life.
Dr. Damon Raskin: That’s absolutely right, and these are the common reasons I see older people involved with alcohol abuse or drug dependence. It’s so often a form of self-medication to help with the feelings of depression and loneliness brought on by retirement. One of the things I commonly will do for these patients is address the underlying depression separately from the recovery from drugs and alcohol. Whether it’s anti-depressant medications or with psychotherapy or both, it’s an integral part of helping to prevent relapse is to address their mood disorder and get it under control.
There seem to be a limited number of drug and alcohol treatment options available to the elderly. There is a good argument to be made that rehab is a young man’s game. What can be done to expand the treatment options for older Americans? How can rehabs become more accommodating to the elderly?
Dr. Damon Raskin: As far as I’m concerned, I see older patients in the rehab centers that I work at, specifically at Cliffside Malibu. What often happens is that if the older patients get to a facility and all they see are young people, they may not feel like they can relate. They may not feel like they belong in that group, bringing on a greater sense of isolation. Certain rehabs have special programs for elderly patients and more should follow suit. Group therapy sessions that bring older patients together and address their specific issues might make them feel more included.
Ruth Dent: When Dr. Dent went into a rehab program, he was adamant that we go to a facility that would accept his Blue Cross/Blue Shield insurance and Medicare. Such an insistence landed him at a place that was three hours away from where we lived. While he was there, even though the treatment was covered, we were paying out well over $1,500 a week for his room and board. In addition, when he was in the rehab program, the doctors there kept writing him new scripts for new drugs and filling in his old scripts with a pharmacy out there that proved to be very expensive. It was hard to believe how much out-of-pocket money it cost for all of those prescriptions written for Dr. Dent while he was in rehab.
Mrs. Dent, in 12-step programs, there is a genuine consensus that you can carry the message but you can’t carry the addict (Ruth Dent quietly says, “Amen.”). This is particularly true if an addict is unwilling to take the first step and admit the addict has a problem. In Al-Anon, it is written that, “Detachment is neither kind nor unkind. It does not imply judgment or condemnation of the person or situation from which we are detaching. It is simply a means that allows us to separate ourselves from the adverse effects that another person’s alcoholism can have upon our lives.” How do you “detach” yourself from your husband’s ongoing struggles? Is there a point when you decide that enough is enough?
Ruth Dent: What Al-Anon teaches you is to detach with love. I do try to detach with love and I do try not to judge because Al-Anon tells you that it is a disease. If a person had cancer, you wouldn’t talk poorly about them and you shouldn’t be unkind to a person who is addicted to alcohol. It is an addiction and it’s also a disease— a serious, serious disease.
My problem is that I’d like to see Dr. Dent want to do something about this problem. I keep saying to him, “When I can see you start to help yourself, I will be happy to help you.” He will not agree to go to any additional counseling, yet the previous counselor he saw said he would work with him on his alcohol problem and the abuse of his medications if he’s willing to do the work. But my husband has said no; he won’t go and he refuses to even discuss it.
When does it finally reach the point where enough is enough? I think that point has been reached. My husband doesn’t have a life. We don’t have a life together, we don’t sleep in the same bedroom. When he drinks, he just becomes mean and nasty, and I just walk away. I literally had locks put on our bedroom door just to protect myself. It’s no longer our bedroom door. He sleeps in another room. Now, it’s my bedroom door and I often have to lock it. (Mrs. Dent takes a deep breath) Enough is getting to be enough. I wish he would try to help himself and try to work through some of this. I wish it would end.
I am so sorry.
Ruth Dent: Well, it surely isn’t your fault. Al-Anon teaches you that I didn’t cause it and I can’t cure it. But then what am I supposed to do?
The Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Substance Abuse Treatment (CSAT) released a guide on treatment protocols for older adults in 1998. Unfortunately, like many of their releases, the protocols have been largely ignored or forgotten by medical providers and the overall drug and alcohol treatment industry.
SAMHSA's mandate proposed the inclusion of the following six program features in the treatment industry:
1. Age-specific group treatment that is non-confrontational and aims to build or rebuild the patient's self-esteem.
2. A focus on coping with depression, loneliness, and loss.
3. A focus on rebuilding or establishing a social support network.
4. A pace and content of treatment appropriate for the older person.
5. Staff members who are interested and experienced in working with older adults.
6. Linkages with medical services and other supportive services.
SAMHSA also promotes the inclusion of the following protective factors specifically designed to help recovering older adults manage their addiction and cope with other issues in their lives:
1. Access to resources, such as housing and health care.
2. Availability of support networks and social bonds.
3. Involvement in community activities.
4. Supportive relationships.
5. Education (for example, instruction in the wise use of medications) and skills.
6. Sense of purpose and identity.
7. Ability to live independently.