By Stuart Finkelstein, MD
HAWAIIAN GARDENS, CA– Do you know what the fastest growing US population is? Here’s a hint. This population is expected to double in the next twenty years. If your answer was adults over 65 years old you were correct. What age group do you think uses more psychoactive medications than any other group? That’s right, our seniors, and that’s possibly your Grandma or Grandpa or even your Mom or Dad who take prescription medication on a daily basis.
According to a recent report by the National Institute on Drug Abuse, as many as 1,800,000 Americans over the age of 65 may be dependent on Medicare-provided prescription drugs. The National Institute on Drug Abuse (NIDA) has released a report that suggests that older adults tend to use prescription medication three times more frequently than the general population and have the poorest compliance rates related to taking medications as directed.
Senior Substance Misuse & Nationwide Health Care Dilemma
Senior Substance Misuse & Nationwide Health Care Dilemma
Our senior citizens currently are at risk of addiction from regularly using benzodiazepines or a group of central nervous system depressants such as tranquilizers Xanax, Klonipian, Valium, Ativan, and Librum; along with sleeping medications like Ambien, Holician, Calmane, and Restoril; muscle relaxants such as Soma, Flexeril, and Robaxsin; and alcohol. In addition, opiates and analgesics for pain relief such as Vicadin, Codiene, Oxicotin, Ultram, Morphine, and duragesics are put our seniors at risk.
Causes of Misuse. Our older adults may have been misusing or abusing alcohol or drugs for years or now they may have problems of chronic pain, anxiety and insomnia or emotionally suffer from the loss of a spouse or other traumatic events creating feelings of grief or loneliness complicated by possibly financial or medical problems.
Discontinuation Difficulty. In general, seniors want to feel calmer and sleep better; however, many find it difficult to discontinue the use of their drugs and are unaware or ashamed to admit when they are become dependent. What’s worse is family members tend to ignore their drug problems because who could imagine their aging parent or grandparent was hooked on drugs? Maybe its depression or they are just getting sick. Could drugs have caused that accident or simple fall?
Accidents later in life often lead to complications that can become deadly or seriously hurt someone else if under the influence while driving. In fact, Ambien can cause both retrograde amnesia and antregrade amnesia when seniors will often eat in their sleep, sleep walk, drive their cars in their sleep and not remember they are doing it.
Easy Access. It’s easy for a senior to get a prescription. All they have to do is mention pain to get the drug they want. Did you know that older adults are prescribed higher doses of some medications for longer periods of time than younger adults even though there is a decrease in ability to metabolize medication latter in life? Unfortunately, it’s easy for seniors to get hooked on drugs from the high numbers of prescriptions they use. Family members may not understand that mood swings, depression, irritability, fatigue, insomnia, and inability to stay focused or involved in a conversation are not just signs of old age, but misuse or addiction.
Generational Influences. This Baby Boomer age group generation grew up in a time when “hard core” drugs were more widely accepted and were known to use a number of drugs at one time. They believe if a doctor prescribed the drugs they must be safe, and do not realize that these drugs cause dependency and interact with one another resulting in confusion. They may also believe they are immune to addiction and experience the misconception that mixing medications or doubling up on their medications are a fast fix to their health problems It’s also a fast way to an accidental overdose from combining sedatives and opiates with alcohol. Consequently, this fast fix mentality is leading to a nationwide health care dilemma.
Have you reached the age period of parenting your parents? If you have, you are about to face watching your loved ones suffer symptoms of aging complicated by solutions of mixing medications.
The Slippery Slope of Side Effects to Senility
The slippery slope to senility begins when you notice some common signs and symptoms of aging. The common signs and consequent physical side effects to watch for in your loved ones follow.
- Metabolism Decrease. As seniors mature their metabolism decreases. Decreases in metabolism cause declines in renal and hepatic functions which result in more accumulation of the chemicals in their body and for longer periods of time. What this really means is the drugs attain higher peak and last longer.
- Dehydration. They often become dehydrated either from decreasing their fluid intake due to congestive heart failure or renal failure, or even from use of diuretics. This results in higher peek levels and longer duration of drug concentration in the blood stream even though they have not increased their dose of medication.
Older adults require less sleep and they often cat nap during the day causing a pattern of insomnia and resulting anxiety. Regarding insomnia, pharmaceutical companies are now directly advertising to consumers. There are frequent ads on television, radio, and magazines for pharmacological sleep aids such as Ambien or Lunesta. These ads are often accompanied by a coupon for free trial pills and this is when the free slide to senility starts.
What if a medical provider refuses to give patients prescriptions for free medications? Often times our seniors will see other health care providers and the dilemma continues. One prescription for Ambien for 7 days is just enough time to get a senior dependant on the medication, and if they stop taking it, they will experience rebound insomnia and anxiety.
This situation is similar to seniors being placed on benzodiazepines in the 1980’s for anxiety, depression, insomnia, and then the discontinuation of these drugs resulted in insomnia and consequently justified their continued use. Stopping these medications could result in seizures and delirium.
- Chronic Pain. As seniors mature, arthritic pains may develop placing them on opiate analgesics for degenerative back disease, and their worn out hip and knees. In fact, 25-45% of older adults suffer from chronic pain conditions. However, discontinuation of opiate analgesics is often manifested by a well documented withdrawal syndrome which includes myalgias and arthralatgies, the same symptoms for which the patients have started to take medication in the first place. The opiates also affect their gastrointestinal track causing constipation and diaherra when the drug wears off. Now these patients are diagnosed as having irritable bowel syndrome and they actually have narcotic bowel syndrome.
- Neurological Diseases. Seniors may develop neurological diseases such as Parkinson’s disease, dementia, neuropathy and restless leg syndrome, and stroke which necessitate the need for treatment with psychoactive medication leading to possible misuse and interactions with other medications.
- Multiple Specialists. Seniors are often referred to multiple specialists and placed on additional medications that may completely inhibit the metabolism of their existing medications. This is called polypharmacy often causing the primary care physician to become unaware of all the medications their patients may be receiving.
- Polypharmacy. Polypharmacy can cause mixing medications as a solution to our senior’s mixed problems. Several medications will cause several physical effects. For example, opiates cause constipation, antihistamines cause urinary retention, opiate withdrawal cause diarrhea, and benzodiapenes withdrawal causes anxiety and insomnia and early alcohol withdrawal does the same thing causing anxiety, insomnia and tremors. Late alcohol withdrawal can cause tremors, seizures, and delirium hallucinations.
Side Effect Sequences
Senior Secrets. Seniors are often reluctant to give their physicians accurate substance abuse histories or doctors fail to ask the questions. How much do you drink? How often do you drink? If the patient is experiencing mild alcohol withdrawal he often goes to the doctor and complains of the symptoms of alcohol withdrawal with anxiety and insomnia and then are prescribed a benzodiapene for the anxiety and insomnia which will only over time make things worse if they continue to drink and use pills.
Misdiagnosis. Sometimes the side effects of a medication may generate a new diagnosis and further treatment with still more medication. For instance, if you look up in the physician desk reference you will see the number one side effect of Klonipin, Valium, and Lorazapan is depression. Now the doctors may misdiagnosis the patient not realizing the depression is caused by the pill, and will treat the depression as a primary disease and start him with an antidepressant such as Prozac. If the patient is currently taking codeine for his arthritic pain and he is given Prozac. The Prozac will inhibit the breakdown of metabolism of the codeine to its active metabolite which is morphine, and the patient will no longer get pain relief from the medication.
- Many elderly patients are treated with opiate narcotics which cause constipation when you first take them and diarrhea when they withdrawal. This patient is often diagnosed as having irritable bowel syndrome when they actually have narcotic bowel syndrome. The constipation can be so severe.
- Using over the counter antihistamines often found in cold and allergy medication can cause urinary retention and a patient will be diagnosed as having BHP. These patients may be treated with Proscar or Avadar which will decrease the already heavily declining testosterone levels. Long term opiate analgesics also have been associated with declining testosterone levels through the inhibition of hypothalamic pituitary axis.
- Episodic ailments such as cold and allergies will often require over the counter medication that can further complicate drug metabolism and impair mental gonadal status
- Chronic back pain is often treated with opiate analgesics that can lower a patient’s serum testosterone, never allowing the patient to regain his strength or muscle tone to recover from his initial injury.
- Patients are given opiates analgesics for back pain. When the medication wears off, the early withdrawal symptoms are often myalgias and arthralgies and then the patient gets diagnosed with fibromyalgia. Subsequently they are treated with more opiate analgesics at higher and higher doses until they become physically dependent and cannot discontinue the medication without going through opiate withdrawal syndrome which feels like a bad flu consisting of muscle aches, joint aches, runny nose, and sneezing, abdominal cramps and diaherra, severe anxiety and insomnia. All of this justifies continued use and supports the misdiagnosis.
Drug interactions and mixing medications as discussed often mimic medical and psychotic illnesses in the senior citizen. For instance, opiates analgesics and benzos have for a long time been associated with cognitive impairment. Use of opiates and benzos at bedtime can cause sleep disturbances and exasperated sleep apnea causing a further decline in patient’s cognitive ability.
Stop Time….Detoxify or Die
Senior drug addiction is something most seniors thought they would not have to overcome. Withdrawal symptoms are devastating and a safe and slow withdrawal is protocol with a board certified physician trained in addiction medicine who has specific experience with senior addiction issues and medical needs. Recognizing senior drug addiction is complicated. If you or someone you love is dealing with addiction, know detoxification is better than senility or death. It can be amazing to witness the cognitive improvement a patient will experience once you can assist him through the 3-5 hard days it takes to detoxify your grandmother or grandfather to get off this medication.
It is a shame that these seniors are rarely treated because the primary care physician rarely has the time or the training it takes to assist these patients through the detoxification process.
These patients do not seem to do well in psychiatric hospitals as they are not really depressed or anxious or senile and they resent the stamp of being in a psychiatric hospital because they are not crazy. And often times in psychiatric they are then placed on more psychoactive medication not less. May times these psychiatric hospitals are not licensed to provide detoxification services, but their patients are told to complain about their symptoms, (i.e. the depression or anxiety).
Remember, these patients are better treated by a Board Certified Addiction Medicine Specialist, ABAM, who can treat these patients in an ambulatory setting and in the comfort of their own homes. Unfortunately ABAM is a new specialty board and there are few specialists around. In addition, many HMO’s and third party payers do not recognize the specialty and refer patients to mental health specialists where they are quick often diagnosed as being bipolar patient and placed on more medications.
It’s time to stop the slippery slope of side effects to senility of your loved ones and contact a Board Certified Addiction Medicine Specialist.
(Dr. Stuart Finkelstein is an internal medicine and addiction specialists who is a member of the Society of Addiction Medicine. He is a member of the Medical Staff at Gardens Regional Hospital and Medical Center formerly doing business as Tri-City Regional Medical Center in Hawaiian Gardens.)