A Perfect Storm: Aging, Drugs, and Chronic Pain
Chronic pain requires specialized attention without which quality of life is affected, often resulting in depression, isolation, or substance abuse.
It is estimated that by the year 2030, approximately one-fifth of the United States population will be over the age of 65 as those of the baby boomer generation reach this landmark age.1 This coming generation of older adults is projected to have a longer life span than former generations, which will increase the actual number of older adults. Imagine a family where everyone lives in the same home. If grandparents and great-grandparents live in the home, there is a higher number of older adults. At the same time, this new older generation has tended to have fewer children than past generations, which increases the percentage of older adults within the population. In this case, we can imagine a family where parents have four children and so the parents make up 33% of the household. If that family only had two children, then the parents would make up 50% of the household. Both of these factors contribute to the changing dynamic of the aging population and the tripling of the percentage of the population over the age of 65 from 4.1% in 1900 to 13.1% in 2010.2
This trend is having a dramatic effect on the burden of national health care as increasing numbers are expected to live to the age of 85 and beyond, and, among older adults, chronic illnesses and impairments are expected to increase from around 22 million sufferers in 2005 to about 38 million by 2030.2 Along with the typical health concerns related to aging, mental health concerns including depression, anxiety, dementia, and substance use disorders (SUDs) will naturally increase in this population, and the mental health community is largely ill-equipped to effectively address these issues within the context of aging.
Unfortunately, the brain does not recognize whether opioids come from a physician or a street pusher; however, both legally prescribed and illicit opioids present a dangerous risk of dependence, SUDs, overdose, and death. With increasing frequency, health care professionals who treat SUDs are finding patients who became addicted to prescribed opiates and then turned to street drugs when the prescriptions became unavailable to them.
This phenomenon of addiction, the most severe form of SUD, to opioids is complicated by use of other substances including alcohol and other prescription and illicit drugs, and older adults are not protected from the problems because of their age. Historically, an idea accepted by many was that if an individual had not developed an addiction by the age of 40, then they would never develop one. We now know this to be untrue. Older adults are struggling with problems related to alcohol, prescription drugs, and even illicit drugs at higher levels than ever.
By way of definition, chronic pain is generally described as persistent pain that lasts longer than 12 weeks or, if due to an injury, longer than should normally be expected based on a normal course of healing.8 Chronic pain is a true malady and, without management, it can have a significant negative impact on quality of life. Associated suffering can lead to depression, isolation, problematic substance use, and other problems.
A 2011 study of more than 7,000 adults aged 65 and older found that 52.9% had complained of bothersome pain in the past month.9 This translates to more than 18 million older adults suffering from this in the United States. Furthermore, among those reporting pain in the past month, the vast majority of just under 75% reported that they were experiencing pain in multiple sites, and the presence of these pains is strongly associated with a decrease in physical function.
Cue the Storm
Enter Opiate Analgesics
What we now know is that there is little to no evidence that long-term opioid use is effective for long-term treatment of chronic pain, and there's some indication that it can actually worsen the experience of pain in patients.10 This effect, known as hyperalgesia, is caused by long-term opiate use that essentially lowers an individuals' base pain threshold, effectively rendering them more and more sensitive to stimuli. What we also know for certain is that long-term opioid use is strongly correlated with addiction and other deleterious health conditions that can and do lead to death.
We see now that a disturbing result of flooding our nation with these powerful opiates for decades is a dramatic exacerbation of the problem of SUDs and overdoses. The solution to the problem of pain has created and exacerbated far worse problems. With older adults the problem is further complicated by the fact that given the broad lack of understanding of the prevalence of SUDs in the older adult population, there are few programs designed to treat older adults with these and comorbid conditions. Treatment for SUDs in the United States is largely designed for a younger population and is largely unprepared to effectively meet the more complex needs of the older adult patient.
Uniqueness in Treating Older Adults
Physical Needs of Older Adults
Appropriate treatment of these patients on an outpatient basis should include active case management and communication between clinical and medical providers in order to ensure that physical needs are addressed concomitantly with psychological needs. Inpatient settings should provide for ongoing medical care of physical needs, which necessarily includes coordination with primary physicians to ensure continuity of health care while a person is in treatment.
Psychological Needs of Older Adults
One study found that practiced physical activity was significantly positively associated with decreased distress in older adults. Important to this finding was the conclusion that the physical health benefits of exercise were only part of the equation, as 39% of the decrease in distress was associated with mastering a task resulting in an improved sense of self-worth.16
For those patients with comorbid depression, cognitive behavioral therapy, problem-solving therapy, and interpersonal therapy are evidence-based practices with a history of effective symptom resolution in the older adult population.17
Social Needs of Older Adults
Spiritual Needs of Older Adults
Addressing Chronic Pain
Mike, a 68-year-old college professor, was focused on chronic back pain that had persisted for five years following a car accident. He was able to do all of the things he loved including work, fish, and spend time with his grandchildren, but he continued to experience pain. He began using opioids and eventually developed physical dependence and SUD. As a result, he became unable to teach, fish, or even spend time with his grandchildren. His overall quality of life became worse. He sought treatment and today continues to experience some pain but has retained all of his ability to function, which is far more important to him.
— John Dyben, DHSc, MCAP, CMHP, is the chief clinical officer for Origins Behavioral Healthcare in West Palm Beach, Florida, and is a noted expert on the dynamics, treatment, and epidemiology of substance use disorders and related comorbidities.
2. Spitzer WJ, Davidson KW. Future trends in health and health care: implications for social work practice in an aging society. Soc Work Health Care. 2013;52(10):959-986.
3. American Society of Addiction Medicine. Opioid addiction 2016 facts and figures. https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf. Accessed January 3, 2018.
4. Schonfeld L, King-Kallimanis BL, Duchene DM, et al. Screening and brief intervention for substance misuse among older adults: the Florida BRITE project. Am J Public Health. 2010;100(1):108-114.
5. Morgan ML, Brosi WA, Brosi MW. Restorying older adults' narratives about self and substance abuse. Am J Fam Ther. 2011;39(5):444-455.
6. Mattson M, Lipari RN, Hays C, Van Horn SL. A day in the life of older adults: substance use facts. The CBHSQ Report; Substance Abuse and Mental Health Services Administration website. https://www.samhsa.gov/data/sites/default/files/report_2792/ShortReport-2792.html. Published May 11, 2017.
7. Reid MC, Eccleston C, Pillemer K. Management of chronic pain in older adults. BMJ. 2015;350:h532.
8. Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015;162(4):276-286.
9. Patel KV, Guralnik JM, Dansie EJ, Turk DC. Prevalence and impact of pain among older adults in the United States: findings from the 2011 National Health and Aging Trends Study. Pain. 2013;154(12):2649-2657.
10. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain — United States, 2016. JAMA. 2016;315(15):1624-1645.
11. Substance Abuse and Mental Health Services Administration. The NSDUH Report: illicit drug use among older adults. https://archive.samhsa.gov/data/2k11/WEB_SR_013/WEB_SR_013_HTML.pdf. Published September 1, 2011.
12. Seitz DP, Vigod SN, Lin E, et al. Characteristics of older adults hospitalized in acute psychiatric units in Ontario: a population-based study. Can J Psychiatry. 2012;57(9):554-563.
13. Lin WC, Zhang J, Leung GY, Clark RE. Chronic physical conditions in older adults with mental illness and/or substance use disorders. J Am Geriatr Soc. 2011;59(10):1913-1921.
14. Flood M, Buckwalter KC. Recommendations for mental health care of older adults: part 2 — an overview of dementia, delirium, and substance abuse. J Gerontol Nurs. 2009;35(2):35-47; quiz 48-49.
15. Blazer DG. Illicit and nonmedical drug use among older adults: a review. J Aging Health. 2011;23(3):481-504.
16. Cairney J, Faulkner G, Veldhuizen S, Wade TJ. Changes over time in physical activity and psychological distress among older adults. Can J Psychiatry. 2009;54(3):160-169.
17. Arean PA. Psychotherapy for late-life depression. Psychiatr Times. 2012;29(8):35-38.
18. Diaz N, Horton EG, Green D, McIlveen J, Weiner M, Mullaney D. Relationship between spirituality and depressive symptoms among inpatient individuals who abuse substances. Couns Values. 2011;56(1-2):43-56.
19. Lawton PH, La Porte AM. Beyond traditional art education: transformative lifelong learning in community-based settings with older adults. Stud Art Educ. 2013;54(4):310-320.
20. Berthelot JM, Darrieutort-Lafitte C, Le Goff B, Maugars Y. Strong opioids for noncancer pain due to musculoskeletal diseases: not more effective than acetaminophen or NSAIDs. Joint Bone Spine. 2015;82(6):397-401.