| True or False | |
| People over the age of 60 are less likely to become addicted to drugs or alcohol. | ____ |
| Pain relievers are the most commonly abused prescription drug. | ____ |
| It’s recommended to drink a glass of red wine daily since it may reduce your chance of a heart attack. | ____ |
| Narcotics should be the last choice for pain relief. | ____ |
| (Answers at end of chapter) | |
I have a question for you: Can an older person become an addict? We often associate drug abuse or alcoholism with the lifestyle of young people, but as we age, the tendency to misuse all kinds of drugs, including prescription pain relievers and alcohol, can actually increase. After all, as we approach middle age and beyond, we are likely to be using some prescription medications. The same is true for alcoholism, which can worsen with age, and can be a frequent cause of death among seniors.
So how do you know when you or a loved one has a problem? And if you’ve always enjoyed having a glass or two of wine at dinner or a couple of beers in the evening to relax, how can you tell if you are still able to “hold your liquor” or if it’s time to cut back? Do your medication dosages need to be adjusted once you pass age 50?
I’m sure you’ve heard the line “the person who drinks more than me is the one who has the problem.” Most people who abuse drugs or alcohol do not think they have a problem. We do, though, have a standard definition of what constitutes abuse.
Abuse is defined as using the medication or substance (e.g., alcohol) in a manner that deviates from medical, legal, and social standards.
Nearly 8 million people use prescription drugs for purposes other than those prescribed. That’s actually more people than those who use such illegal drugs as cocaine, heroin, and methamphetamines combined. Prescription medications are second only to marijuana as an abused substance. As people age, there is a decline in the use of illegal drugs but an increase in the abuse of prescription drugs. Nearly one in five seniors abuses prescription drugs or alcohol. The most commonly abused prescription drugs are opiates, sedatives, and painkillers. No one is abusing their cholesterol or blood pressure medications!
The high incidence of prescription drug abuse can make it challenging for me as a doctor to help my aging patients with pain relief. While I’m concerned about preserving their quality of life, I’m also concerned about the hazards of addiction as well as accidental overdose. As we age, our bodies do not eliminate medications as quickly or as easily, and they stay present in our bloodstreams longer. By the time we’re 70, dosages usually need to be adjusted—sometimes even cut in half. As we age, we are also often taking many different medications that have the potential to interact with each other and cause problems. I know that many of my colleagues are undertreating anxiety disorders, sleeping problems, and chronic pain in their patients because they’re reluctant to prescribe medications with abuse potential. It’s a balance of competing goals—maximizing therapy while at the same time minimizing risk of dependence.
It certainly is normal to take multiple medications as we get older, especially antidepressants and pain relievers. And as I discussed in previous chapters, medications are often effective and necessary as we age. But it’s not normal to be dependent upon them.
What do I mean by “dependent”? Here are some criteria to define dependence:
• Recurrent substance use in physically hazardous situations (e.g., while driving)
• Recurrent legal problems related to drug or alcohol use
• Failure to fulfill work or social obligations
• Continued use despite drug- or alcohol-related social or interpersonal problems
It is quite challenging to wean yourself from a medication once you become dependent, and it should not be attempted without medical supervision. As we get older, we do not always understand how drugs will impact our bodies or might not recognize the impact they are having on our bodies. For instance, our bodies can become dependent on antianxiety medications such as Valium or Xanax. We may not even realize it until we try to stop the medication. Other medications may actually lower our blood pressure without us even being aware of it; when we stop the medication, our blood pressure can increase to levels that are dangerously high.
It can be difficult to recognize signs of prescription drug dependence, as they are often similar to the signs of normal aging. Mood swings, memory loss, loss of interests, difficulty sleeping, change in weight, excess sweating, and shaking or tremors are all typical symptoms of substance abuse. These symptoms usually develop over a short period of time—weeks or months—versus symptoms associated with normal aging, which occur gradually, over years. Drug dependence in the elderly is especially dangerous because it often leads to falls and accidental overdoses.
| Substance Use: What’s Normal and Not Normal As We Age | |
| Normal | Not Normal |
| One glass of wine most days of the week | Two or three glasses of wine every day |
| Multiple prescription drugs for chronic medical conditions | Legal troubles involving narcotics |
| Medication for pain relief managed by a doctor | Borrowing medication or lying about refills |
It’s normal to enjoy wine and alcohol. And there are data that show moderate consumption is probably healthy for the heart. As we get older, our consumption of alcohol is certainly different than it was when we were younger.
It is not normal to drink excessively as you approach middle age. Perhaps once a year you get a little too merry at the annual neighborhood Christmas party, but getting drunk on a frequent basis simply is not normal. I’m sure you have also noticed that it takes less alcohol to make you feel tipsy as you get older. As we age, our bodies don’t rid themselves of alcohol as quickly or as easily. The toxins stay in our bloodstreams longer, and we become intoxicated more quickly and with fewer drinks. By the time you reach 60, the amount of alcohol that it takes to make you feel drunk can decrease by a third.
1 Choose your “surroundings” carefully. If you surround yourself with people who drink a lot of alcohol or abuse prescription drugs, you are more likely to engage in that behavior as well. The role of family is also critical in prevention.
2 Ask your physician questions about any potentially addictive drugs you have been prescribed. Especially if you’ve struggled with addictions in the past, talk with your doctor about the size of your dosage and the duration of time you need to take it. You do want your medical conditions treated effectively, but you also do not want your body to become dependent.
3 Dispose of drugs—especially narcotics—that you or your loved one used for a short time. Many people will use sleeping pills or narcotics if they happen to still be in the house. If they’re not around, you cannot use them, or you’ll need to call the doctor and explain why you need a refill.
Alcohol is one of those areas where too much of a good thing can be harmful as we get older. As I mentioned earlier, moderate alcohol consumption does offer some health benefits, but at some point it does more harm than good.
Have you heard of the French paradox? It refers to the fact that the rate of heart disease in France is lower than we would expect given the French lifestyle, which typically includes eating rich foods and drinking wine daily.
Some researchers attribute the low incidence of heart disease to red wine consumption. Red wine contains phenols and flavonoids, which we believe have antioxidant properties. Red wine also contains resveratrol, which is a substance produced by plants; it is found in the skin of grapes. Some studies show that it may prevent blood clots; others have shown that it seems to extend the life of mice. That is always very encouraging, but remember, we’re not mice! Some patients have asked me if they should take resveratrol supplements. I don’t recommend it; we just do not have enough data yet.
Does the French paradox mean you should drink red wine at dinner every night? Probably not. The French, as well as many other Europeans, have a totally different style of living that likely contributes to lower heart disease. It’s not just the consumption of wine.
Approximately 10 percent of the population abuses alcohol. This includes many people in middle age and older. Some people believe that alcohol abuse only starts in the twenties and thirties. That’s a myth. A large percentage of adults first develop drinking problems in their forties, fifties, and sixties.
Problem drinking reduces the quality of life for patients and their families. How do you know when drinking has become a problem?
Here are a couple of questionnaires that physicians often use, that you can use as well:
1. How often did you have a drink containing alcohol in the past year?
| Never | 0 point |
| Monthly or less | 1 point |
| 2-4 times a month | 2 points |
| 2-3 times per week | 3 points |
| 4 or more times a week | 4 points |
2. How many drinks did you have on a typical day when you were drinking in the past year?
| 1 or 2 | 0 point |
| 3 or 4 | 1 point |
| 5 or 6 | 2 points |
| 7 to 9 | 3 points |
| 10 or more | 4 points |
3. How often did you have five or more drinks on occasion in the past year?
| Never | 0 point |
| Less than monthly | 1 point |
| Monthly | 2 points |
| Weekly | 3 points |
| Daily or almost daily | 4 points |
Jason is a 71-year-old widower. He has multiple health problems, including congestive heart failure and severe arthritis. Due to his limited ability to get around, he lives with his daughter, Clare, who functions as a caregiver. Last winter, Jason slipped outside on the ice and broke his right wrist. He underwent surgical repair but had a difficult time at rehabilitation. He was on a small dose of daily morphine to help with pain, since he said Motrin, naproxen, and even Vicodin upset his stomach.
When he came in to see me, he said his pain was worsening. I decided to increase the dose of his morphine, and I ordered additional physical therapy. Jason called me a couple of days after the appointment to tell me that he’d dropped the prescription bottle in the sink and the pills fell down the drain. I’m usually a bit suspicious of stories like this, but I’ve known Jason a long time and believed him to be honest.
Two months after that, Jason returned for a follow-up appointment with Clare. He seemed a bit disheveled, and Clare said he’d been having trouble sleeping. “Could you give him a sleeping pill?” she asked. I suspected the lack of sleep might be related to his pain, so I asked how he’s been managing his pain. “That’s another thing,” Clare remarked. “I don’t think the pain meds are strong enough.” Over the next 6 months, Jason came in several more times with additional health complaints. I grew concerned because he had been on pain medication for a relatively long period of time after wrist surgery. After talking with Jason and Clare in more detail and screening Jason for drug dependence, it became clear to me that he’d become dependent on the morphine.
Although he still had some pain, I slowly tapered him off of the morphine dosage while at the same time adding a nonsteroidal anti-inflammatory medication as well as Tylenol for pain relief. I also had him resume physical therapy three times a week. Within 6 weeks, he was off all narcotics and doing much better, with very little pain.
In men, a total score of 4 or more is considered positive and the person needs help. In women, a total score of 3 or more is considered positive.
Sometimes I even shorten the questionnaire to:
How many times in the past year have you consumed xor more drinks in a day?
x = 5 for men and x = 4 for women
If the answer is more than once, I then ask more questions. You may have heard of the CAGE questionnaire.1 This is also a set of questions (shown on the following page) that you can ask to help determine if there is potential abuse.
1. Have you ever felt the need to cut down on drinking?
2. Have you ever felt annoyed by criticisms of your drinking?
3. Have you ever had guilty feelings about your drinking?
4. Do you ever take a morning eye opener (a drink first thing in the morning to steady your nerves or get rid of a hangover)?
One “yes” response suggests the need for closer examination.
Moderate alcohol consumption is considered “normal,” but how do you know what’s considered moderate and what’s excessive? The guidelines below suggest healthy limits for alcohol consumption:
• For healthy men up to age 65: no more than 4 drinks in a day and no more than 14 drinks in a week
• For healthy men over age 65: no more than 3 drinks in a day and no more than 7 drinks in a week
• For all women, independent of age: no more than 3 drinks in a day and no more than 7 drinks in a week
Those are the maximum amounts. By no means are those the amounts you should strive for. After the age of 65, especially, men and women should be cautious about alcohol consumption; a normal limit is about 1 or 2 drinks a day.
There are effective treatments for alcohol abuse. The key is to recognize the abuse and develop a comprehensive treatment strategy.
Answers to true/false statements: False, True, True, False