March/April 2018

A Perfect Storm: Aging, Drugs, and Chronic Pain
By John Dyben, DHSc, MCAP, CMHP
Today's Geriatric Medicine
Vol. 11 No. 2 P. 18

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.

Drugs
Drug overdose has become the leading cause of accidental death in the United States with opiates as the category of drug responsible for most of these deaths.3 This means that a person living in the United States is statistically more likely to die from drug overdose than from a motor vehicle accident. This is largely fueled by both an increase in easily available illicit opioids such as heroin, and relatively easy and legal access to powerful prescription opioids.

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.

Alcohol
There are currently more than 2.5 million older adults in the United States who meet criteria for an alcohol use disorder, and this number is expected to fully double by the year 2020. Alcohol remains the No. 1 chemical that drives persons over the age of 50 into chemical dependency treatment, and because health risks associated with drinking increase with age, the American Geriatrics Society recommends at least annual alcohol use disorder screenings for adults aged 65 and older. Because nearly one-half of all Americans aged 65 and older consume alcohol, and the body becomes more sensitive to its effects with aging, this seems particularly relevant. Unfortunately, despite this increase in alcohol use disorders in older adults, this population continues to represent only a small fraction of patients receiving treatment, meaning the nation is experiencing increasing numbers of older adults with alcohol use disorders that remain untreated.4

Prescription Drugs
The potential for misuse and abuse of prescription medication is prevalent in older adults for two reasons. First, older adults have greater access to medications with abuse potential, such as benzodiazepines and opiates, which are commonly prescribed to combat symptoms associated with aging. Second, with multiple medications older adults are more likely to be confused about dosages and interactions. Aging patients often present with multimorbidity or having more than one significant medical condition that is a subject of treatment. This can result in multiple medications being prescribed, and confusion about these medications can easily result in overuse of prescriptions with addictive potential.5

Illicit Drugs
It is estimated that by 2020, illicit drug use among older adults will have increased by 50% since 2001. Marijuana is reported to be the most commonly used illicit drug, followed by illicit prescription drug use, with other illicit drugs, such as cocaine, heroin, hallucinogens, and inhalants making up smaller percentages.6 This trend is often associated with the fact that the baby boomer generation now aging into older adulthood espoused ideas about drug use much different from previous generations and continue to bring those beliefs into midlife and beyond.

Chronic Pain
Another commonly experienced phenomenon in older adults is chronic pain, and it is one of the most ubiquitous conditions presented to health care professionals working with this population.7 At the same time, chronic pain is often difficult to address, especially when the cause of the pain is idiopathic. When patients present with fractures, wounds, bulging disks, and others in a long list of quantifiable conditions, the root of the problem is evident, and treatment has a targeted direction. However, patients often present with complaints of pain that has no clear cause, and this complicates treatment.

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
Now all of the following relevant and consequential factors come together:

• The size of the older adult population is increasing in proportion to the rest of the population.
• People are living longer, putting increased pressure on the health care system to address age-related ailments.
• Members of the new generation of older adults are far more likely to use and overuse alcohol and drugs.
• The very process of aging makes the human body more susceptible to the effects of all substances. As we age we have more body fat, less muscle mass, and less total body water. This results in slower metabolism, meaning that a glass of wine or an opiate pill will have a greater impact on a 70-year-old than on a 30-year-old.
• There remains an underlying belief, including among health care professionals, that older adults are not susceptible to SUDs.
• Chronic pain affects most older adults and can be truly debilitating if not properly addressed.

Enter Opiate Analgesics
Given the complexities of this storm, it is no surprise that opiate analgesics became an almost irresistible port in the storm, both for patients suffering from pain and for prescribers who were pressed for time and pressured to provide a solution or relief. Unfortunately, the promise of relief from pain with little risk of side effect was simply not real and has led to tragic consequences.

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
Treatment of older adults with SUDs must be tailored to address the unique needs associated with aging and should include the adult children and close friends of a patient as a critical part of the therapeutic process.11 Older adults needing treatment for SUDs, especially when co-occurring with chronic pain, have vastly different physical, psychological, social, and spiritual needs.

Physical Needs of Older Adults
Compared with younger adults, older adults in acute behavioral health care are more likely to have two or more chronic medical conditions, including chronic pain and moderate to severe physical impairment.12 Older adults who live in adult communities and have mental health or SUD concerns are significantly more likely than those without such disorders to have a high medical morbidity.13 These issues are typically not accounted for in treatment programs that are not specifically designed to treat 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
Depression, anxiety, and dementia are three of the most common mental health diagnoses for older adults.14 Treatment strategies that address these psychological issues in parallel with issues related to SUDs need to be incorporated into a supportive and nonconfrontational setting.15

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
Major changes associated with aging such as changing social status, deaths of loved ones, and changes in social support systems are significant risk factors for the development of SUDs and other psychological and physical problems.5 Generational cohorts are made up of individuals who are likely to be experiencing the same changes as well as to have similar life values and can provide unique social support for navigating these difficult issues. Providing treatment services to older adults within the context of their generational cohorts increases engagement, which is imperative for successful treatment.

Spiritual Needs of Older Adults
Socially supportive spiritual practices have been demonstrated to increase the sense of meaning and to ameliorate feelings of anxiety and depression among persons with SUDs.18 Spiritual approaches to older adult treatment may be effective in helping them reframe past and current struggles in order to draw from a wealth of experience that can help them cope with aging and the associated changes.19

Addressing Chronic Pain
Medical professionals who have been providing opiates to their patients for many years are largely not bad actors. They are professionals tasked with providing relief to suffering and were taught to believe that opiates are the answer. Today we know better and the Centers for Disease Control and Prevention has now published guidelines for prescribing opioids for chronic pain with the first directive being that opioids should never be the first choice for pain treatment. They should, in fact, be a last resort.10 However, this leads to the obvious question of what is the appropriate course of action to address chronic pain?

Reframing Pain
Unfortunately, some level of pain is an inescapable part of the human experience. An ingrained societal belief that no one should experience pain is a contributing factor to the current epidemic of addiction and overdoses. The question to stop asking is "How bad is your pain on a scale of one to 10?" The question to begin asking is "How is your ability to function impacted by 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.

Nonpharmacological Treatments
Recent research has found that acetaminophen and NSAIDs are as effective at treating pain and sometimes more so than opiates.20 Pharmacological interventions that do not incite or exacerbate SUDs do exist and should be the first medications used. However, there are numerous nonpharmacological interventions that have efficacy in ameliorating chronic pain.

• Cognitive behavioral therapy can help individuals reframe their experience and literally change the way they experience pain by changing the way they think about pain.
• Behavior modification can often provide observations to patients on movements or activities that exacerbate pain and promote development of new practices that don't cause or worsen injury.
• Meditation, mindfulness, yoga, and other such practices can help individuals move the focus away from pain, resulting in a decrease of pain experience.
• Neuropsychological tools including biofeedback and neurofeedback can help retrain a brain that has become wired to experience pain and to interpret it as intolerable.

Conclusion
No one should suffer needlessly, but we must take great care in our attempts to ameliorate suffering so that we do not create far worse suffering. Relief from both addiction and chronic pain is possible but is neither quick nor easy. But it's well known that few things worth having ever are.

— 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.

References
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