Addiction issues have rarely been seen as a priority in palliative care. Yet unmanaged substance use can make the diagnosis and treatment of pain and psychiatric symptoms difficult, if not impossible—managing substance use aims to relieve or prevent such symptoms stemming from drug use. The major societal problem posed by opioid use disorders and overdose highlight that those around the patient need to be protected from the diversion of medications intended for the patient. This article should clarify how definitional, assessment, and management issues will prove helpful to patients, their caregivers, and the professionals charged with their comfort.
addiction, pain, palliative care, older adults, substance use disorders
Had an issue of Generations Journal focusing on Death and Dying appeared just a decade or two ago, an article on Addiction Among Older Adults—if included at all—might have been included solely as a nod to completeness and seen as somewhat esoteric. But across this time, the prescribing of opioids and other controlled substances to treat chronic pain has risen dramatically. Simultaneously, illicit opioids such as fentanyl have become more abundant and dangerous. Further, the psychiatric consequences of the COVID-19 pandemic have led many adults of all ages to increase their use of alcohol and controlled substances. We are amid a confluence of public health crises, which, perhaps not surprisingly, among our older population has been referred to as the “silent epidemic” (Wu & Blazer, 2011).
The article might have seemed esoteric because it is known that 85% of addictions manifest by age 35 (Cicero et al., 2012). An older person without a history of substance use disorder (SUD) or mental illness who develops a painful or life-threatening medical condition is unlikely to show signs of addiction for the first time in the context of such an illness. But, increasing percentages of older Americans have a history of SUD in the remote or recent past, and the management of any medical condition, even those generally thought of as unrelated to drug and alcohol use (e.g., hypertension) is more difficult in the context of such untreated addictions.
Furthermore, such older adults’ medications may be sought after by younger drug users in their family who are at risk for addiction, overdose, and death. Thus, addiction in older people and its interface with treatment for painful and even non-painful medical conditions needs to be understood, with subsequent management strategies directed at reducing risks and mitigating harm.
Why Bother Treating Late-Life Addiction?
For readers who might wonder “Why bother?” treating late-life addiction, we have wrestled with this question in the past, and our rationale is consistent with palliative care goals. Our colleagues ask this question, sometimes in the form of, “Why hound Mr. Smith about his drinking now? He won’t get sober and anyway, it’s all he has left.”
Such nihilism is not only misplaced but also harbors a fundamental misconception about addiction— that it is more about pleasure (getting high, drinking and feeling momentarily calmer, etc.) than it is about suffering. Addiction makes people suffer. The high or euphoria from alcohol and drug use becomes increasingly fleeting as people use for longer and longer periods of time, and instead they spend the lion’s share of their time withdrawing, miserable, obsessed with drug procurement, often struggling with self-loathing because they are unable to stop or limit use.
‘End-of-life care is focused on relieving suffering—including suffering that strikes caregivers as self-inflicted.’
End-of-life care is focused on relieving suffering—including suffering that strikes caregivers as self-inflicted. Moreover, treating suffering is thought to help remove barriers to better psychiatric diagnosis and care, and importantly, to accomplishing end-of-life goals—particularly rapprochement with family members, making amends, and moving beyond what is sometimes a lifetime of ill will. It is remarkable how much the goals of recovery and those of end-of-life care overlap.
That is why we bother. That is why patients and families should be encouraged to acknowledge and wrestle with these issues. It is not too late for growth, and the pride that can come from gaining a modicum of control over a lifelong problem. Addiction, as we will show in this article, should not be confused with normal physiological occurrences that accompany an opioid exposure, and misplaced fears of addiction that are partly based on such confusion should not be allowed to linger and hinder aggressive pain and symptom management. Likewise, when true addiction appears, it is easy to see why we should bother.
Scope of Problem and Trends
In the early 1960s, 50% of individuals addicted to narcotics were no longer active drug users by age 32, and more than 99% were no longer users by age 67 (Winick, 1962). Thus, the belief, widely held until recently, that problematic substance use would diminish and vanish with age was not surprising. However, as the Baby Boomer cohort ages, the extent of alcohol and medication misuse is predicted to significantly increase (potentially doubling from levels found in 2006) (Colliver et al., 2006) due to the combined effect of the growing population of older adults and cohort-related differences in lifestyles and attitudes (Patterson & Jeste, 1999).
The use of illicit drugs and nonmedical prescription opioids have increased significantly in the general population over the last two decades (Manchikanti & Singh, 2008), with the highest prevalence occurring among younger adult men (Substance Abuse and Mental Health Services Administration [SAMHSA], 2013). However, alarming trends are emerging among older adults. Recently, among adults in the United States ages 50 or older, nearly 5 million, or a little more than 5% of that age group, report using illicit drugs in the past year (SAMHSA, 2011a).
Marijuana and prescription drugs are the most commonly misused drugs among adults ages 60 or older. The increasing problematic use of prescription medications among older adults has been accompanied by a similar rise in associated emergency-room visits (SAMHSA, 2011b), primarily for prescription opioids and benzodiazepines. Although family and friends remain the most frequent sources of diverted prescription medications, (SAMHSA, 2013; Cicero et al., 2012) the source among older adults in substance-treatment settings (>60%) relative to younger adults (~30%) (Cicero et al., 2012) is more likely to be prescriptions from healthcare professionals.
Because opioids have been and continue to be prescribed for chronic pain, we need to be mindful of the prevalence of pain in the Baby Boomer generation. A 2018 report by the Centers for Disease Control and Prevention (CDC) estimates that nearly 28% of individuals ages 45–84 experience chronic pain, and between 10.7% and 12% are struggling with high-impact chronic pain, which limits life or work activities on most days for at least six months (CDC, 2018).
Although opioid pain medications are now used less often to manage chronic pain, there is reason to believe that the decrease does not necessarily result in risk reductions. A recent study concludes that medical opioid tapering is significantly associated with increased risk of overdose and mental health crisis (Agnoli et al., 2021). Perhaps not surprisingly, recent data suggests that problematic prescription opioid misuse is common among older adults (70% or more) and occurs more frequently than in younger adults (Cicero, 2012; Morasco & Dobscha, 2008). To the extent that chronic pain and substance use are comorbid or mutually exacerbating problems, older adults appear to represent a particularly vulnerable population.
What Is, and Is Not, Addiction
As a first step in discussing how addiction presents clinically in older adults, it is important to clarify what addiction is and is not. Addiction is not represented by physiological dependence or tolerance, which are expected developments that may occur with continuous exposure. Dependence refers to symptoms of withdrawal that a person may experience when abruptly discontinuing use of a psychoactive medication. In the pain management setting, if a patient runs out of their opioid analgesics before they can get a refill from their doctor, they might suffer some symptoms of withdrawal, which could include a flu-like syndrome, nervousness, excessive yawning, and goose bumps. The most important implications of dependence are that patient must take their medication as directed so they last between visits, and medication discontinuation must be undertaken as a gradual taper.
Tolerance refers to the need to increase the drug to maintain the desired effect, such as pain relief. People also can develop tolerance to some side effects, meaning that these side effects may be reduced over time. With opioid analgesics this could mean, for example, that sedation and respiratory depression (reduced breathing), might decrease with continued use. Note that tolerance is less likely to develop for constipation. The development of tolerance is highly variable in people with pain, and requests for higher doses need to be evaluated carefully. But the need for some adjustment in dose over time is, by itself, not a sign that the patient is becoming addicted. It is also important to note that tolerance fades after opioid discontinuation. If an individual returns to opioid use after a period of discontinuation, the last dose to which he or she were accustomed could be lethal.
If an individual returns to opioid use after a period of discontinuation, the last dose to which he or she were accustomed could be lethal.
In contrast to physical dependence and tolerance, addiction is marked by the so-called 4Cs: Craving, Compulsive use, loss of Control, and Continued use despite harm (Jovey, 2012). Think about how these four features distinguish addiction from withdrawal and tolerance (though the latter can be present in SUD). This definition also appropriately emphasizes that addiction is, fundamentally, a psychological, neurological, and behavioral syndrome. Addiction is the result of a complex interaction between certain types of drugs and genetic, psychological, and stress vulnerabilities in the person. Aberrant behaviors such as unprescribed dose escalation and subsequent requests for early prescription renewal should not be assumed to be a sign of addiction, and the treating professional should rule out (and address) other factors, among them: new or worsening conditions, poorly treated pain, self-medication of anxiety or depression, diversion by family members.
Addiction is a progressive, relapsing-remitting disease that has an ebb and flow, with periods of exacerbation or relapse and relatively inactive periods between—all of which may be impacted by life stressors and other medical conditions. In the medical setting, addiction issues will be identified by the 4 Cs described above and identified by a growing set of aberrant behaviors noted over time. Specifically, clinicians should watch for signs of social withdrawal and worsening medical conditions, which might indicate an exacerbation of substance use. Next, we look at ways to assess potentially problematic drug-related behaviors.
Even if the treating professional is mainly seeking to find more useful ways to have a discussion with the patient about substance use, they may want to consider reviewing several well-established assessment tools, if only to be aware of their content as a preliminary guide to risk factors. Having said that, there is a relative lack of instruments designed and validated for assessing SUD in older adults. Assessment tools utilized in younger populations likely have some utility, but caution should be applied in interpreting responses to certain items.
For example, many screeners and tools include items that assess legal consequences of substance use that are less common in older adults, while at the same time they may lack items related to accruing medical issues and loss of social networks, which may be more relevant. A commonly used set of questions for assessing problematic alcohol and drug use, referred to by the acronym CAGE, asks whether a patient has attempted to Cut down, been Annoyed by people asking about use, felt Guilty about use, and if he or she ever have and Eye-opener (alcohol or drug use first thing in the morning; Ewing, 1984).
It may also be helpful to consider problematic substance use by older adults in terms of “early-onset” versus “late-onset.” Early-onset users are more prevalent and have a longer history, with continued use even as they age. Late-onset users, which represent less than 10% of this population (Taylor & Grossberg, 2012), are those who develop the behavior when they are older (possibly in the context of medical exposures).
Many screening tools are designed to be relatively brief and contain items on personal and family addiction history as well as other history-related risk factors, such as pre-adolescent sexual abuse, age, and psychological problems. Clinicians may want to learn more about the Brief Intervention and Treatment for Elders (BRITE; Schonfeld, 2012), which is a more age-appropriate version of Screening, Brief Intervention, and Referral to Treatment (SBIRT; Center for Substance Abuse Treatment, 1999). These two approaches have in common that they are easy for healthcare providers to learn and implement, and they provide a bridge to treatment.
The Opioid Risk Tool (ORT) (Webster & Webster, 2005) is an example of a brief questionnaire designed to assess a patient’s risk for developing problematic use of opioid pain medication. Also with pain medications, it may be helpful to consider four domains for assessing pain outcomes with an eye toward identifying addiction or misuse behaviors: pain relief, functional outcomes, side effects, and drug-related behaviors. As a mnemonic, these domains have been labeled the “Four A’s” (Analgesia, Activities of daily living, Adverse effects, and Aberrant drug-related behaviors) (Passik, 2004). Whichever tool the clinician chooses, to encourage openness, it is advised that they present the screening process to the patient with the assurance that there are no answers that will negatively impact care.
As noted above, perhaps more important than the screening instruments is the content areas with which clinicians can be familiar in preparation for conversations with patients. Also important is the need to be aware of how drug and alcohol use can be highly stigmatized, interfering with patient-provider communication. In an effort not to shame or anger patients, clinicians often avoid asking about drug use. Or there may be an expectation that patients will not answer truthfully. But, obtaining a detailed history of duration, frequency, and effects of alcohol and drug use is vital. Adopting a nonjudgmental position and communicating in an empathetic and truthful manner is the best strategy when taking patients’ substance-use histories (Savage, Kirsh, & Passik, 2008).
In anticipating patient defensiveness, it can be helpful for clinicians to mention that patients often misrepresent their drug use for logical reasons, such as stigmatization, mistrust of the clinician, or concerns regarding fears of under-treatment. Acknowledging stigma directly and how it can interfere with communication can help put patients at ease. Clinicians should not attach value statements to substance use. A statement from a clinician to a patient such as, “I know you would never do anything bad, but I have to ask you these questions,” discourages openness. Rather, one should explain that to keep the patient as comfortable as possible, prevent withdrawal, maintain access to sufficient medication for pain and symptom control, and decrease the risk of relapse, an accurate account of drug use is essential.
Urine Drug Testing
In older people being treated with controlled substances, urine drug test (UDT) results may indicate a variety of issues not limited to drug misuse by patients. In our clinical experience, UDT results sometimes gave the first indication of problems in the elder-abuse spectrum. We have seen, for example, older patients who tested negative for a prescribed medication and upon review with the patient, it was found that family members were stealing the medication and threatening the patient with violence if they did not continue to complain of pain to their physician to obtain medications for their continued diversion. We also have seen multiple instances when a patient in their 70s or 80s, well-known to their physician and believed to have no history of SUD, tested positive for cocaine (false positive was ruled out). Of course, unexpected positive results for alcohol and unprescribed opioids and benzodiazepines are not uncommon.
Clinicians must deter diversion of pain and other medications to those outside of the patient’s care.
In all cases, the appropriate response by the treating professional is to use unexpected UDT results as an opportunity to better understand the patient and improve their care (Rzetelny et al., 2016). A new aspect of the patient’s history could be revealed, or there may be additional prescribers in the picture that were unknown to the clinician. Given the widely held myth that older adults do not intentionally misuse medications or illicit substances, and data showing the opposite, there is a need for monitoring in older populations.
The goal of treatment is to improve the patient’s quality of life and potentially extend their life. Depending upon the patient and their circumstances, this may involve total abstinence. However, it may just as equally involve harm reduction. Harm reduction is a concept that follows a wealth of research showing the best outcomes are achieved not by total abstinence but by gaining partial control over harmful drug behaviors, or at least making them less lethal. There are multiple examples of medical and behavioral treatments for opioid and other addictions, but their appropriate fit to the management of a person at the end of life can be poor, and their application demands flexibility.
For example, buprenorphine has gained wide acceptance for treating opioid use disorder, but its use may be complicated by worsening cancer pain in some patients. Recently, however, buprenorphine has been used successfully to treat cancer pain in patients at risk of opioid use disorder (Powell et al., 2021). As another example, for a palliative-care patient with a long history of alcohol use disorder, meetings at a 12-step program that may have been beneficial in the past could now be impossible. However, there may still be utility in creating an opportunity for the “sponsor” to visit with the patient, as some of the goals of 12-step programs overlap with those at the end of life, such as making amends, forgiveness, and re-establishing family relationships. (For an overview of therapies for opioid, alcohol, and other forms of SUD in older adults, see SAMHSA TIP 26: Treating Substance Use Disorder in Older Adults.)
Regardless of the specific problem or treatment choice, several points are worth bearing in mind. It is useful to try to differentiate individuals who can be managed in the primary healthcare setting, co-managed, or referred to specialty treatment. In all cases, members of the treating community need to be on the same page, for example, hospice or hospital staff, primary and specialty providers, etc. Also, one needs to consider if at any point it becomes necessary to restrict who can visit a patient in hospital or even hospice settings. We have seen multiple occasions when friends and even family members sneak illicit drugs into such settings to give to the patient, on one such occasion resulting in the patient’s death. Such experiences stand as reminder to attempt to coordinate treatment efforts with the family and help them to understand the importance of treating SUD.
While the treatment of SUD in the older person with serious illness may require flexibility, patience, and harm reduction rather than total abstinence, one dimension demanding strict adherence is to deter diversion of pain and other medications to those outside of the patient’s care. If a person is prescribed a potentially abusable medication that could have dangerous consequences if overused and goes on to do so in the setting of the stress and in fear of facing the end of life, that harm and efforts to mitigate it can be seen as a private matter between the patient and the treatment team. However, harm to third parties uninvolved in the treatment who might gain access to the patient’s medications is another matter.
On the surface, the commitment to deter diversion seems straightforward; but those who intentionally misuse substances often have social contacts who do the same. And while it might be a relief to the patient to exclude such individuals from visiting, or to supervise them when they do, to ensure they do not think their medication supply is being targeted, such supervision also might be seen as overly restrictive, punitive, and as a loss. All medications should be secured and accounted for.
A 75-year-old man with extremely painful, metastatic lung cancer was in home hospice and being treated with long- and short-acting opioid analgesics. Unbeknownst to the family, their 22-year-old granddaughter, who became quite solicitous and attentive to him, visiting often during this period, was diverting immediate-release opioid tablets for her and her friends’ recreational use. It wasn’t until his death that her addiction became obvious when the supply ran out and she began using opioids, licit and illicit, purchased on the street. She and a friend with whom she had been sharing her grandfather’s pills bought counterfeit pills from a street dealer, unrecognizable as a fake version of the same immediate-release opioid she had been diverting. Both were found dead of an illicit fentanyl overdose a month after the patient’s death.
At any age, substance use and addiction are vexing clinical problems in need of an open-minded and caring assessment and treatment. In older people, because they are more likely to struggle with a range of painful and non-painful medical conditions, substance use can have an even greater deleterious impact on patients and their families. These problems have gotten worse in recent decades, a trend that is likely to continue. Thus, it is important to set aside concerns about offending the patient or of being embarrassed or fearing judgment when reporting about such difficulties so that people can work with their clinicians in a setting of mutual trust and honesty. Although validated resources for working with this population are few, much of what is known still applies, and caring clinicians can prepare themselves with this knowledge to optimize management of substance use and the related medical and psychological issues for older individuals and at any stage in the life cycle.
Steven Passik, PhD, is the vice president, Scientific Affairs and head of Clinical Data Programs at Millennium Health in San Diego. Adam Rzetelny, PhD, is a clinical psychologist in New York City and a consultant to the pharmaceutical industry.
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