November 24, 2025 • 35 mins
The most dangerous phrase in senior health might be “I’ve always handled it fine.” We dive into how aging reshapes the risks of alcohol, benzodiazepines, opioids, nicotine, and today’s ultra‑potent cannabis—and why familiar habits can turn hazardous after 65. Drawing on frontline cases and recent research, we unpack the baby boomer lived experience, from “mother’s little helper” to daily cocktail hours in senior communities, then connect it to the biology of aging: slower metabolism, reduced kidney and liver function, impaired balance, and sharper sensitivity to side effects.
You’ll hear why DSM‑5 criteria still apply but require age‑aware interpretation, what “code cannabis” looks like in the ER when edibles or high‑THC products masquerade as stroke, and how subtle red flags—poor sleep, irritability, shakiness, forgetfulness, falls—signal a brewing problem. We get practical about safer detox for older adults, the reality of kindling with alcohol withdrawal, and the medication decisions that matter: when to taper sedatives, how to avoid dangerous interactions, and why nutrition and B‑vitamins can’t be an afterthought. Two real-world cases ground the lessons—titrating decades‑long benzodiazepine and Z‑drug use while reducing fall risk, and using naltrexone strategically for late‑onset alcohol use without tipping a patient into instability.
If you care for an older adult—or you are one—this conversation offers clear steps to lower risk and raise quality of life: rethink sleep meds, reduce alcohol use, check cannabis potency, simplify regimens, and choose therapy and support groups that fit your season of life. Subscribe, share this with a friend or colleague, and leave a review with your biggest takeaway so we can keep building smart, stigma‑free care for older adults.
To contact Dr. Grover: ammadeeasy@fastmail.com
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_00 (00:00):
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr.
Casey Grover, an addictionmedicine doctor based on
(00:20):
California's Central Coast.
For 14 years, I worked in theemergency department, seeing
countless patients strugglingwith addiction.
Now I'm on the other side of thefight, helping people rebuild
their lives when drugs andalcohol take control.
Thanks for tuning in.
Let's get started.
Today's episode is on addictionin the older adult.
(00:44):
As you've heard me say, I am themedical director for one of our
local drug and alcohol treatmentprograms, and I do monthly
educational lectures for thestaff.
And this month, they wanted meto talk about the unique issues
that come up when treating aperson over 65 who has
addiction.
So I found a few great articleson PubMed on the topic and
(01:04):
combined some great informationfrom those articles with what I
am seeing in my practice.
And the end result was thislecture.
And how timely.
I got a call right after I gavethe lecture that a local dentist
had retired after 45 years ofpractice and had found that his
alcohol consumption had gone upin retirement and he wanted to
see me.
So with that, let's get intothis lecture on addiction in the
(01:28):
older adult.
Okay, so this lecture is gonnabe on addiction in the older
adult.
And I've not given this onebefore.
This is my first time givingthis presentation.
Hopefully, we all learnsomething together.
When we speak about olderAmericans or older people in
general, I'm gonna be speakingspecifically about what we see
(01:50):
in America, but we're speakingabout people over age 65.
And culturally, there's a livedexperience that they've had that
we have to understand theirrelationship with substances.
And then we also have tounderstand for all human beings
how the body changes as we age.
So for Americans over age 65, wecall them the baby boomers.
(02:14):
And this was post-World War IIAmerica.
America's economy was booming,there was a higher quality of
life, technology was becomingmore prevalent.
And we also had pharmaceuticalcompanies making new medicines.
So for baby boomers compared toprevious generations, baby
boomers here in the US had ahigher exposure to drugs and
(02:35):
alcohol compared to those thatcame before them.
And you've ever heard the termthe swinging 60s?
The 60s were a time in Americaof a lot of social change, the
civil rights movement,experimentation with drugs and
alcohol.
And we have to understand thatlived experience of a lot of
these people.
The other thing is I mentionedthat pharmaceutical companies
(02:56):
started to bring new drugs tomarket.
Unfortunately, some of whichwere addictive and we didn't
really quite understand theimpact of them yet.
And while the term mother'slittle helper can be used to
refer to a number of differentpharmaceuticals that came out
during that time, most oftenmother's little helper refers to
diazepam, also known as Valium,which we've talked about as a
(03:20):
sedative, and it was widelymarketed for all sorts of
ailments.
And I'll share a brief familystory about Valium, just again,
give the context for sociallywhat this generation has lived
through.
So my wife and I were visitingone of our family members, and I
think she's in her early 80s,and she struggled with addiction
(03:42):
and has been sober now for manyyears.
And we were just chatting aboutthe work that we do as doctors,
my wife and I.
If anyone doesn't know, my wifeis the very talented Dr.
Reb Close.
So Reb and I were speaking aboutour work in addiction, and she
talked about really her firstexperience with drugs and
alcohol was with Valium ordiazepam.
And she was put on it when shewas 15.
(04:04):
And I remember asking, givenwhat I know and what I do now,
why would they put you on Valiumwhen you were 15?
And she said, Oh, my mom was onit and she wanted it to be
easier to get through mymenstrual cycle.
And I was just, wait, what?
Why was your mother on Valiumtoo?
And she said, Oh, she had ahusband and children, and
Thursdays were really hard.
And just culturally, at thetime, it was just, don't feel
(04:28):
good, take a pill.
And benzodiazepines for thisgeneration is something that
some of them have been on fordecades and decades.
I have one patient who has beenon a benzodiazepine longer than
I've been alive.
So, again, that's the socialstory and lived experience of
this generation in America.
Now, unfortunately, we also haveto consider in the older person,
(04:52):
the body changes with time, andthat affects how addiction
manifests, what substances dothe body, and what we need to do
for treatment.
People's hearing and visiontends to get worse.
Cognition or the ability tothink through problems and
problem solve is decreased.
We have less emotionalresilience as we age, our
(05:13):
balance changes, we losestrength, we specifically lose
muscle mass, the function of ourorgans, heart, kidney, lungs,
liver changes.
And as we age, we tend to getmore medical conditions, we tend
to be on more medications, andyet we are increasingly
sensitive as we age tomedications, specifically around
side effects and interactions.
(05:34):
And we also are therefore moresensitive to drugs and alcohol
themselves.
So let's keep that in mind as westart talking through the
specific problem of substanceuse in people over 65.
So the first question is how bigof a problem is this?
Most recent numbers I saw thatthe estimate of the current
(05:54):
prevalence or how common it isto have substance use disorders
in people over 65 is 4%.
So you might not think that's ahuge number.
It's definitely higher for thegeneral population.
But this population of babyboomers in America is aging, and
so we are getting more people inthat over 65 category as time
(06:16):
goes on.
As of 2023, there wereapproximately 60 million
Americans over 65.
So you do the math, and that'sabout 2.5 million Americans over
65 with a substance usedisorder.
So it adds up.
In terms of what they are using,nicotine is very common in
(06:36):
people over 65 in America.
14% of people over 65 usenicotine.
11% of Americans over age 65binge drink.
And then, as I referenced,prescription medications are
also a big issue for thisgeneration.
Around 10% of people over 65 inthe US are on benzodazipines,
(07:00):
and a similar number are onprescription opioids.
Cannabis is on the rise acrossAmerica in every age group, and
the over 65 group is noexception.
Currently, about 8% of olderadults use cannabis.
Over-the-counter meds are aparticular concern in people
(07:20):
over 65, not so much in thatthey're crushing and snorting
Benadryl to suggest really a usedisorder behavior, but more that
there's a lot of ongoingsymptoms, insomnia, pain,
anxiety.
And older Americans, when theystudy it, are shown to be heavy
users of over-the-countermedications, often taking more
(07:42):
than is recommended on thepackage.
In terms of illicit substances,I have patients in my practice
over 65 who use all sorts ofstuff that have vitamine,
cocaine, fentanyl, whatever.
But that tends to be theexception rather than the rule.
Illicit substance use over 65 inAmericans is less than 1%, but
certainly possible.
(08:03):
Now, let's explore some of theissues that people over 65 may
run into, just given how Americahas changed since they were
born.
So the first thing is cannabisis different.
So if you went to high school inthe 1970s and you used cannabis,
it was about 1% THC.
(08:26):
And it was really just smoked asjoints or just a cannabis
cigarette functionally.
And you can see here on thescreen, as we've bred cannabis
to be stronger over time, as of2022, most cannabis was getting
close to 20%.
And now most cannabis is 25 to30% THC.
And a lot of my patients over 65don't realize that.
(08:47):
I'll ask them, you're usingcannabis, what type?
And they'll be like, Doc, it'sjust pot.
And just the industry haschanged.
And one of my patients, I had toshow her on her package that she
was using 23% THC cannabis, andshe was floored.
She just, I didn't know any ofthis.
Cannabis has also changed in itsforms.
We now have edible cannabisproducts and cannabis drinks.
(09:11):
This is a picture of a cannabisproduct.
It's a two-fluid ounce bottlethat's slightly bigger than a
shot of liquor.
And these beverages contain 100milligrams of THC.
Now, most people don't know whata standard serving of THC is,
THC being the downer chemical incannabis that makes us high.
(09:33):
And we as doctors don't actuallyknow either.
We think that the recreationaldose of cannabis is somewhere
between two and a half and 15milligrams.
And so someone who doesn't knowanything about cannabis sees
this tiny little bottle and islikely going to drink the whole
thing.
Unfortunately, it was really notwell labeled on the package how
to portion out each servingbecause it's meant, you can see
(09:57):
on there, they're saying 10milligrams per serving, and it's
supposed to be 100 milligrams inthe bottle, but it's really not
that well labeled to be able tosay this is how I get only this
much.
Take a look at this.
This is actually a THC infusedjoint.
So these pre-rolled joints are43 and 40% THC.
(10:18):
And take a look at the packageon the left.
That is 864 milligrams of THC inthat package, and that's four
joints.
So that's 215 milligrams of THCper joint.
That is drastically strongerthan any cannabis that people
used of this generation whenthey were in their teenage
(10:40):
years.
At the hospital, a code is usedto signal some sort of medical
emergency or issue.
And so we, when we work in theemergency department, if someone
has a potential stroke, we willpage overhead code stroke so
that everybody knows to respondand the person gets the tests
and treatments that they need ifit is a stroke.
(11:03):
And I mentioned my spouse andcolleague, Dr.
Reb Close, she's done a lot ofwork studying overdoses here in
Monterey County.
And she's identified a trend ofwhat she calls code cannabis,
where an older person is broughtto the hospital with a suspected
stroke because they're confusedor they or they're dizzy or they
can't balance.
And it ultimately is found thatno stroke has happened, but they
(11:27):
consumed cannabis eitherintentionally and didn't realize
how strong it was, or theydidn't mean to consume a
cannabis product that did, andno one can really tell until
they get to the emergencydepartment and run all the
tests.
So she calls this code cannabis,meaning we think it's a stroke,
but it turns out to be cannabisintoxication.
And if you take a look, here aresome examples of a candy gummy.
(11:51):
We all know Sour Patch Kids.
And take a look at the labelabove it, stony patch.
The colors are the same, thefonts are almost the same.
Sour than sweet is on bothpackages.
And you can see it's fairlysubtle if you're not paying
attention to realize that thepackage above has THC and the
(12:13):
one below does not.
And if you remember, as we age,sometimes we develop issues with
vision and being able to seeclearly.
An older individual who's notable to see the package clearly
probably would not be able todistinguish between these, which
might result in them takingcannabis without knowing it when
they mixed up a package of agummy versus a THC-infused
gummy.
(12:34):
Coming back to the culturalexperience of Americans over 65,
these are some advertisementsgoing back many years
advertising cigarettes.
If you look on the left, that isa picture of Ronald Reagan
advertising Chesterfieldcigarettes.
Obviously, Ronald Reagan was avery loved president of this
(12:55):
generation.
Take a look at the middleadvertisement.
More doctors smoke camels thanany other cigarette.
Yes, believe it or not,physicians used to recommend
cigarettes for weight loss.
And I certainly had medicalschool professors that recalled
earlier in their careers theywould actually stop to smoke
(13:15):
between seeing patients.
And again, on the right, that'san ad for Newport, really
highlighting the pleasure andjoy of smoking.
I'm old enough to still remembersmoking sections on planes.
Culturally, cigarette use wasjust much more common for
Americans over 65 when they wereyoung people.
And I've had a number of mypatients tell me when I asked
them, do you smoke?
(13:36):
And they said, well, I used to,but everybody did back then.
Now we need to ask the questionwhen we come to make a diagnosis
of an addiction, is it the sameprocess for someone who's over
65 versus under 65?
And unfortunately, as we age,our body physiologically or in
(13:59):
terms of how it works, itchanges.
We get more mental healthconditions, we get more memory
issues, we develop more medicalproblems.
And sometimes addiction canactually manifest differently,
and we need to look fordifferent things.
So you guys have seen this chartbefore.
This is the DSM 5 diagnosiscriteria for an addiction.
(14:20):
It's the same for everysubstance.
We use the substance for longerperiods or in larger amounts.
We have a desire to cut down andunsuccessful efforts to cut down
when we try.
We spend a lot of time to usethe substance and get the
substance.
We get cravings for thesubstance.
We use the substance and then wecan't fulfill major role
obligations at work, school, andhome.
(14:41):
We use the substance despitehaving social and interpersonal
problems.
We give up social, occupational,recreational activities because
of the substance.
We use the substance insituations where it's
potentially dangerous.
The substance is continueddespite knowledge of having
persistent problems and thentolerance, the need to consume
more with time, and thenwithdrawal, meaning that we need
(15:03):
to use the substance to not feelsick.
And those 11 criteria are thesame for any human being for any
substance.
You just put in alcohol.
Alcohol is often taken largeramounts over a longer period of
time.
You put in cannabis.
Cannabis is often taken inlarger amounts over a longer
period of time.
It's the same 11 criteria forany addiction.
So practically it's the samewhen it comes to making a
(15:26):
diagnosis of addiction in termsof do they meet criteria and
which criteria do they meet?
But it turns out that actuallysome of these criteria look
different in adults over 65.
One of the criteria is that thesubstance is taken in greater
amounts than intended.
As we talked about, we are moresensitive to the effects of
(15:48):
medications and substances as weage.
So a person's use might be thesame or even less over time, but
as they're older and they weighless and they can't tolerate it
as much, they actually mightfunctionally be using more.
For people that have been onsubstances for decades and
decades, they may not realizethat their chronic use is
(16:09):
problematic.
So they really haven't tried orbeen unsuccessful in cutting
down because they didn't thinkthere was a problem.
We also have to realize that alot of older adults stay home.
They might be homebound, theymight be retired.
They don't have a lot of rolesin school or workplace or home.
So they're not missing any ofthose obligations because they
don't necessarily have thoseobligations to miss.
(16:32):
People give up other activitiesbecause of the substance.
They may just not have as manyactivities that they do.
And again, you will also seethat withdrawal, as we'll talk
about shortly, can lookdifferent as we age.
So it may not be immediatelyrecognized as withdrawal.
And unfortunately, we also seethat as we age, or our risk of
(16:52):
falls goes up and our ability toreact quickly while driving goes
down.
So using substances in whatmight be considered normal use
actually does increase the riskof serious complications.
So again, the 11 criteria arethe same, but we just have to
look for slightly differentthings.
The other thing is that as ourorgan systems change and our
(17:13):
health changes as we age,substance use might just look
different.
In other words, we might notlook for usual things to make us
think, gosh, could this be aproblem with addiction in the
first place?
So we see more mental healthsymptoms with substance use in
people over 65, particularlydisturbed sleep, anxiety,
(17:34):
depression, irritability.
Sometimes it's more physicalsymptoms like being shaky,
coordination of balance beingmore off.
The stomach is more sensitive tothings like nausea and vomiting.
Unfortunately, as we'll talkabout, people over 65 are at
higher risk of falls and havetrouble maintaining good
nutrition no matter what.
(17:56):
So we may see those problemsshow up earlier in a person's
use of substances.
As we age, our brain ages too,and the cognitive changes that
happen with aging are gonna bemore apparent when someone's
using substances.
Substances accelerate thosecognitive changes.
And then a lot of times we'llsee just social interactions
(18:16):
change.
People might be more withdrawn,they might not be as connected
to family.
So the diagnosis is the same,but we need to look for other
things when making thosediagnostic decisions with the
DSM criteria.
And then just could this be asubstance use problem in
general?
We're just going to look fordifferent stuff because it may
manifest differently in olderadults.
Now, in terms of treatingaddiction at the highest level,
(18:40):
there's no difference, right?
We have medications, we havemutual support groups, and we
have counseling and therapy.
And that doesn't change nomatter who you are or how old
you are.
But each of those might be alittle bit different when we're
working with a person who's over65.
So the first thing is let's talkabout detox.
(19:00):
And detox is not a medical term,but everybody knows the term.
And so I use it to say I need tostop the substance.
I've got to get through thewithdrawal period.
Unfortunately, as we age, wetolerate stress on the body
less.
And that's in general.
When you're 16 years old and youhave a urinary tract infection,
no big deal, right?
Cranberry juice and anantibiotic, and you don't even
(19:22):
miss a beat.
A person who's 90 years oldmight have to be hospitalized
for several days because of aurinary tract infection.
So we just tolerate stress lessas we age.
We have less reserve, if youwill.
So we are more sensitive towithdrawal as we age and we
tolerate it less well.
So adults over 65 when choosingto quit a substance,
(19:46):
particularly one with adangerous withdrawal syndrome
like alcohol, may need a veryhigh level of care.
Dr.
Lee Goldman, he's one of theaddiction docs here in Monterey
County with me, usuallyrecommends hospitalization for
folks over 70 when they'recoming off of alcohol, just
because they can be much morevulnerable.
Now, the other thing is withmore years on the planet, people
(20:08):
with addiction have had moreyears to start and stop
substances, to go throughwithdrawal, to try to quit.
And unfortunately, like riding abike, our brain gets good at
something we do a lot of, right?
So you want to learn a newmusical instrument, what do they
say?
Practice, practice, practice.
Unfortunately, when we use asubstance and stop, our brain
(20:28):
learns the withdrawal pathway.
And withdrawal can worsen intime as those brain pathways
strengthen.
And we know this best withalcohol.
It's called kindling, which isbasically that it's been studied
that as people start and stopalcohol multiple times, the
withdrawal usually gets worseeach time.
So a great question to asksomeone when they're deciding to
(20:50):
quit substances what's the worstwithdrawal that you have?
And someone who's had really badalcohol withdrawal is likely to
have it again, particularly asthey've started and stopped
multiple times and they getolder.
Now, I mentioned that as we age,we tend to have more medical
issues.
The two organs that do the vastmajority of breaking down the
(21:11):
medications and substances thatwe put in our body are the liver
and kidney.
And years of stress on the bodyin general means that the liver
and kidney function may decreaseover time.
And so we often have to eitheravoid certain classes of
medications or adjust the dosingbecause the person's not able to
(21:32):
tolerate it because their liverand kidney function has changed
with time.
So gabapentin, for example,which we use very liberally in
addiction medicine, it turns outis only secreted by the kidneys.
So somebody who has kidneyproblems, we really don't use
it.
We can use it with a mild amountof kidney dysfunction, but for
severe kidney dysfunction, wereally avoid it.
(21:54):
Now, the other thing is as wehave more medical conditions, we
tend to be put on moremedications.
And the more medications wetake, the more likely we are to
have medication interactions.
And for example, let's saysomebody who has chronic back
pain and got all put on opioids,and then they start to develop
an opioid use disorder, theirback pain's still there.
And let's say they're on a bloodthinner because of a regular
(22:14):
heartbeat, it reduces the numberof classes of medications that
we can use to treat their painbecause it might have a
dangerous interaction with theirblood thinner.
A couple other things that areunique to older adults.
The first is poor nutrition.
It turns out our hunger andthirst reflexes decrease as we
age, and food may not taste asgood as we age as well.
(22:38):
So older adults tend to eat anddrink less.
They're more likely to developmalnutrition and also
dehydration.
And particularly with alcohol,some people will really just
drink alcohol and not eat.
And it really puts people atrisk for malnutrition,
particularly with B vitamins.
So usually when we get peopleoff of alcohol, we want to get
them on B vitamins.
(22:59):
And this can happen with othersubstances, but it's a unique
additional problem with alcohol.
Dementia is the process wherethe brain ages and our
short-term memory starts todecline.
Initially, we might see what'scalled mild cognitive impairment
or some inability to remembercertain things, and it
progresses to dementia.
And it can be really hard whenwe're trying to get someone into
(23:22):
treatment and you need to takethis medicine at this time and
go to this appointment, and youneed to go to therapy at this
time.
And what did your therapist talkabout?
When they have troubleremembering, it makes it much
harder to follow through on thetreatment recommendations.
And then the last thing isfalls.
We see so many falls in the over65 group.
We lose muscle mass, our balancechanges, we may get neuropathy
(23:44):
in our feet.
And falls are a big problembecause when you are bedbound
after a bad fracture of a leg,for example, you lose muscle
mass so fast and it's hard toget it back.
It's just hard to eat, it's hardto toilet if you've broken an
arm.
Pain control can be challenging.
And so, as you can imagine, anysubstance that's going to impair
(24:06):
someone's ability to function,like alcohol or cannabis or
anything, is going to increasethe risk of falls as well.
Now, there are other more socialissues that come up that are
that develop newly after age 65.
And an article that I wasreading on this topic talked
about early onset and late onsetsubstance use in older people.
(24:29):
And what they talk about is somepeople start using substances at
an early age, say in their 20s,and they continue it through
their life.
That's what's called earlyonset.
Late onset is where people starthaving a problem with a
substance much later in life,let's say 65, 70, and beyond.
And a lot of the late onsetgroup comes from major life
changes.
(24:50):
So retirement, right?
Getting up every day, having apurpose, staying busy, having to
stay sober, we do see anincrease in some people in the
use of particularly alcoholafter retirement when they're
bored and don't know what elseto do.
Loss of a spouse.
You can imagine how isolatinglosing a spouse that you've had
for decades is.
(25:11):
People might find that they'rejust home by themselves all the
time with nothing to do.
We also find that culturallyhuman beings love alcohol, and
that continues into senior andretirement communities.
Some national data here in theUS: two-thirds of Americans in
senior and retirementcommunities drink, and up to 15%
(25:31):
are heavy drinkers.
And I will share personally, mygrandparents spent the last
years of their life at a seniorcommunity here in Monterey
County.
And yeah, there were drinkingevents almost every day, wine
tastings, cocktail hour,champagne brunch.
And my grandparents actuallycommented that their alcohol use
went up when they went into thesenior retirement community.
(25:55):
Unfortunately, being over 65poses some unique barriers to
getting into addictiontreatment.
One of them might just befeeling out of place in a
treatment program, particularlyresidential.
Not all residential programs oreven outpatient programs are
designed to accommodate theneeds of people as they age.
(26:17):
There might not be as muchequipment around to accommodate
people with limited uh mobility.
They might not have bars to getup off the toilets, for example.
Limited mobility is a majorchallenge.
Getting in and out of a car intoa wheelchair to go to an
appointment.
Transportation in and of itselfis also challenging.
Limited finances and insurance,and you can see where this all
(26:38):
mixes together.
Let's imagine a person's over65, they're wheelchair dependent
after a stroke, they didn't havea lot of extra income, they're
surviving on Social Security,they don't have a car, they
don't have the money to pay fora taxi ride.
They might be just reallyisolated in their home because
they really can't get anywhere.
It's hard, time-consuming, andexpensive to get to
(27:01):
appointments.
So that this can be a challengeas well.
Now, the last thing is ourbehavioral interventions to
treat addiction.
And those include things liketherapy and mutual support
groups.
And those are largely unchanged.
If you're under 65 or over 65,just a few comments that I would
make.
If someone's going to be seeinga therapist, they're going to
(27:21):
need to have some experience inworking with Americans over 65,
or I should say, people over 65in general, just because they
have a unique lived experienceand face some unusual and
different challenges as theyage.
Again, things like the loss of aspouse, retirement, changes in
mobility, et cetera.
As I tell my patients, you knowwhat?
Picking a therapist is likegoing to a car dealership and
(27:44):
buying a car.
You and I might go together, youlike the sedan, I like the
truck.
We're both right.
You go to a therapist, that's asedan.
When you need a truck, just saythank you, and that you need to
find a therapist that's rightfor you.
And mutual support meetings arethe same way, right?
If you go to an AA meeting andyou don't get a good vibe, it
doesn't mean meetings are notfor you.
You've just got to find theright meeting where you feel at
(28:05):
home.
The other thing I mentioned thatI skipped over, unfortunately,
is sometimes people over 65 feelvery out of place getting
treatment for addiction becausethey think there's a bunch of
young people.
They've been homeless, they wereusing meth, they were using
fentanyl.
I worked my whole life.
I have a 401k.
I just have alcohol as aproblem.
And I've seen it both ways.
I've had young people go toprograms where they feel like
(28:26):
it's too many folks that areover 50 drinking alcohol if
that's that's their problem, andthey feel out of place as a
young person.
And I've had my older patientssay, I don't like that.
It's all these young folks thatI don't understand.
So it's really just finding aplace where people feel
comfortable.
Okay, let's go through a coupleof cases that just illustrate
some of the points that we made,and then we can stop and take
questions.
So these are two of my patients.
(28:47):
I've changed their information,so you can't identify them.
Okay.
75-year-old me was referred tome to quote, take over my Xanax
and Ambien.
He'd been with a primary carephysician for many years, was on
four milligrams of alprazelam,that's Xanax, and 12.5
milligrams of zulpadem, that'sambient.
And this is somebody who reallyhadn't had any mental health
services besides working with atherapist a little bit.
(29:11):
This was a gentleman who had astroke.
He was in a wheelchair, he hadatrial fibrillation and had
required treatment with a bloodthinner.
He had problems with hisprostate, which had led to
urinary incontinence, so he hada catheter in place, and then
high blood pressure, highcholesterol, depression,
anxiety.
I put his medications up on thescreen.
You can see this person's onseven different meds and
(29:32):
actually no history ofaddiction.
We'll talk about that in just asec.
This patient was referred to mebecause the primary care doctor
was not comfortable managingthese potentially addictive
medications.
Alprazolam is a benzodazepine,and ambien is a Z drug, which is
like a cousin of a benzedazpinefor sleep.
And so I started digging intothe history what's going on,
what resources does this personhave?
(29:53):
This man lives alone.
He cannot drive because of hisstroke.
He has no family nearby.
He drank alcohol.
Socially and smoke cigarettesregularly, didn't think either
one was a problem.
So, what did we do?
Uh, the first thing is we saidthe Z drug, the ambience, is
gonna put you at a high risk fora fall.
So we changed the sleeping medfrom zolpidam or ambien to
(30:16):
ramaron, also known asretazepine.
We were a little nervous aboutsleeping meds in general, but
this person was just adamantthat he could not sleep.
And then we started the processof weaning him down on his
alpraisolam.
So came to me on four milligramsof alpraisolam, and we've weaned
him down to two and a half tothree milligrams a day, and
we're just going really slowbecause this guy's been on
(30:37):
alpraisolam for longer than I'vebeen alive.
I we, as we spoke about, he'svery isolated, really can't get
mental health services viatelemedicine.
So I keep trying to find himsomeone in person that he can
get to, or an inexpensive way toget him to the peninsula to get
services.
And I think I may have a lead,but I've been working on it for
quite a while.
So, what can we learn from thisfirst case?
(30:58):
Case in point, more medicalconditions, more complicating
factors, harder to get aroundwith mobility.
And then the catheter obviouslyprovides an issue as well, and
the transportation is limited.
We didn't really talk aboutthis, but Medicare sometimes is
great insurance and sometimesit's not.
And here in Monterey County,mental health services for
(31:19):
Medicare is definitely underresourced.
And then the other thing is,this man is really not addicted
to his sleeping meds or hisalpraza lam.
His doctor just did not want toprescribe them after his primary
retired and he got referred to anew primary doctor.
Physicians are much morecautious now with controlled
substances.
And I call this individual amedication orphan because no one
(31:42):
knows what to do with him.
So, of course, they sent him toaddiction medicine.
And I'm like, it's not really anaddiction.
You're not craving, you're notcompulsively using.
And so the best thing we'retrying to do is get in mental
health services and try to weanhim down off some of those meds
to reduce his fall risk.
Okay, case two.
A 79-year-old female wasreferred to me, quote, because I
drink too much.
She was also beginning to havesome issues with her memory,
(32:04):
talked to her primary doctor,and she was motivated to quit
alcohol.
Her pattern of drinking involvedcocktails every evening, usually
about 5 p.m.
or so.
Medical history includedanxiety, hypertension, diabetes,
and acid reflux on fourdifferent medications, including
insulin.
Alcohol, if you didn't know,does really affect our body's
(32:26):
use of energy and storing ofenergy.
And it makes us more prone toboth high and low blood sugars,
depending on where we are in ourcycle of alcohol consumption.
And this person lives in abeautiful senior community here
in Monterey County where thereare a lot of social events.
So this person wanted to quitalcohol.
And so I said, why don't we trya naltrexone?
We've talked about naltrexone.
It reduces the pleasure inalcohol and makes cravings less
(32:49):
intense.
So I said, We tend to drinkaround maybe four or five.
Why don't we take a naltrexonean hour before?
And I said, I just want to makesure you're not going to have
any withdrawal.
Have you had any withdrawal inyour life?
And she said, Nope, nowithdrawal.
I think I'm going to be A-OK.
And just my gut instinct wasjust, oh gosh, Casey, I just,
you didn't really do a goodenough job finding out if she's
going to have withdrawal.
(33:09):
And I just cold called her and Isaid, It's Dr.
Grover, I'm just worried aboutyou.
Are you having any withdrawal?
And she goes, Doc, I think I am.
Second day off of alcohol, shegot some withdrawal, she got
some shakiness, she got somenausea.
So we put her on a little bit ofValium, needed just a few doses.
And then she was able to stopand get through it, and we kept
her on naltrexone.
(33:31):
She is still sober.
I saw her a couple of weeks ago.
She and her husband love totravel.
And of course, every trip theygo on, there's wine testing and
bars at their senior community.
There's loads of wine tastingand social cocktail events.
But the naltrexone's really beenworking.
Unfortunately, my patientdeveloped some dizziness.
She felt very unsteady on herfeet.
(33:53):
And so she saw neurology, shesaw physical therapy.
We went through this whole bigworkup.
And ultimately, it was felt tobe a side effect of naltrexone.
And we weighed the risks andbenefits and decided to
discontinue the naltrexonebecause of the risk of falling.
But we ultimately decided toswitch it to only as needed
naltrexone that if she decidedshe was having a craving, she
(34:15):
could take it.
So, case two, take home points.
As I mentioned, be wary ofwithdrawal.
As we age, we are more sensitiveto it and less tolerant of it.
Social circumstances,particularly in senior
communities, can be verytriggering.
And then again, medications aregreat, but unfortunately, we do
often get more side effects andwe don't tolerate those side
(34:35):
effects as well.
Before we wrap up, a huge thankyou to the Montage Health
Foundation for backing mymission to create fun, engaging
education on addiction.
And a shout out to the nonprofitCentral Coast Overdose
Prevention for teaming up withme on this podcast.
Our partnership helps me get theword out about how to treat
(34:58):
addiction and prevent overdoses.
To those healthcare providersout there treating patients with
addiction, you're doinglife-saving work, and thank you
for what you do.
For everyone else tuning in,thank you for taking the time to
learn about addiction.
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
(35:19):
treated.
Together, we can make it happen.
Thanks for listening.
And remember, treating addictionsaves lives.
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr.
Casey Grover, an addictionmedicine doctor based on
(00:20):
California's Central Coast.
For 14 years, I worked in theemergency department, seeing
countless patients strugglingwith addiction.
Now I'm on the other side of thefight, helping people rebuild
their lives when drugs andalcohol take control.
Thanks for tuning in.
Let's get started.
Today's episode is on addictionin the older adult.
(00:44):
As you've heard me say, I am themedical director for one of our
local drug and alcohol treatmentprograms, and I do monthly
educational lectures for thestaff.
And this month, they wanted meto talk about the unique issues
that come up when treating aperson over 65 who has
addiction.
So I found a few great articleson PubMed on the topic and
(01:04):
combined some great informationfrom those articles with what I
am seeing in my practice.
And the end result was thislecture.
And how timely.
I got a call right after I gavethe lecture that a local dentist
had retired after 45 years ofpractice and had found that his
alcohol consumption had gone upin retirement and he wanted to
see me.
So with that, let's get intothis lecture on addiction in the
(01:28):
older adult.
Okay, so this lecture is gonnabe on addiction in the older
adult.
And I've not given this onebefore.
This is my first time givingthis presentation.
Hopefully, we all learnsomething together.
When we speak about olderAmericans or older people in
general, I'm gonna be speakingspecifically about what we see
(01:50):
in America, but we're speakingabout people over age 65.
And culturally, there's a livedexperience that they've had that
we have to understand theirrelationship with substances.
And then we also have tounderstand for all human beings
how the body changes as we age.
So for Americans over age 65, wecall them the baby boomers.
(02:14):
And this was post-World War IIAmerica.
America's economy was booming,there was a higher quality of
life, technology was becomingmore prevalent.
And we also had pharmaceuticalcompanies making new medicines.
So for baby boomers compared toprevious generations, baby
boomers here in the US had ahigher exposure to drugs and
(02:35):
alcohol compared to those thatcame before them.
And you've ever heard the termthe swinging 60s?
The 60s were a time in Americaof a lot of social change, the
civil rights movement,experimentation with drugs and
alcohol.
And we have to understand thatlived experience of a lot of
these people.
The other thing is I mentionedthat pharmaceutical companies
(02:56):
started to bring new drugs tomarket.
Unfortunately, some of whichwere addictive and we didn't
really quite understand theimpact of them yet.
And while the term mother'slittle helper can be used to
refer to a number of differentpharmaceuticals that came out
during that time, most oftenmother's little helper refers to
diazepam, also known as Valium,which we've talked about as a
(03:20):
sedative, and it was widelymarketed for all sorts of
ailments.
And I'll share a brief familystory about Valium, just again,
give the context for sociallywhat this generation has lived
through.
So my wife and I were visitingone of our family members, and I
think she's in her early 80s,and she struggled with addiction
(03:42):
and has been sober now for manyyears.
And we were just chatting aboutthe work that we do as doctors,
my wife and I.
If anyone doesn't know, my wifeis the very talented Dr.
Reb Close.
So Reb and I were speaking aboutour work in addiction, and she
talked about really her firstexperience with drugs and
alcohol was with Valium ordiazepam.
And she was put on it when shewas 15.
(04:04):
And I remember asking, givenwhat I know and what I do now,
why would they put you on Valiumwhen you were 15?
And she said, Oh, my mom was onit and she wanted it to be
easier to get through mymenstrual cycle.
And I was just, wait, what?
Why was your mother on Valiumtoo?
And she said, Oh, she had ahusband and children, and
Thursdays were really hard.
And just culturally, at thetime, it was just, don't feel
(04:28):
good, take a pill.
And benzodiazepines for thisgeneration is something that
some of them have been on fordecades and decades.
I have one patient who has beenon a benzodiazepine longer than
I've been alive.
So, again, that's the socialstory and lived experience of
this generation in America.
Now, unfortunately, we also haveto consider in the older person,
(04:52):
the body changes with time, andthat affects how addiction
manifests, what substances dothe body, and what we need to do
for treatment.
People's hearing and visiontends to get worse.
Cognition or the ability tothink through problems and
problem solve is decreased.
We have less emotionalresilience as we age, our
(05:13):
balance changes, we losestrength, we specifically lose
muscle mass, the function of ourorgans, heart, kidney, lungs,
liver changes.
And as we age, we tend to getmore medical conditions, we tend
to be on more medications, andyet we are increasingly
sensitive as we age tomedications, specifically around
side effects and interactions.
(05:34):
And we also are therefore moresensitive to drugs and alcohol
themselves.
So let's keep that in mind as westart talking through the
specific problem of substanceuse in people over 65.
So the first question is how bigof a problem is this?
Most recent numbers I saw thatthe estimate of the current
(05:54):
prevalence or how common it isto have substance use disorders
in people over 65 is 4%.
So you might not think that's ahuge number.
It's definitely higher for thegeneral population.
But this population of babyboomers in America is aging, and
so we are getting more people inthat over 65 category as time
(06:16):
goes on.
As of 2023, there wereapproximately 60 million
Americans over 65.
So you do the math, and that'sabout 2.5 million Americans over
65 with a substance usedisorder.
So it adds up.
In terms of what they are using,nicotine is very common in
(06:36):
people over 65 in America.
14% of people over 65 usenicotine.
11% of Americans over age 65binge drink.
And then, as I referenced,prescription medications are
also a big issue for thisgeneration.
Around 10% of people over 65 inthe US are on benzodazipines,
(07:00):
and a similar number are onprescription opioids.
Cannabis is on the rise acrossAmerica in every age group, and
the over 65 group is noexception.
Currently, about 8% of olderadults use cannabis.
Over-the-counter meds are aparticular concern in people
(07:20):
over 65, not so much in thatthey're crushing and snorting
Benadryl to suggest really a usedisorder behavior, but more that
there's a lot of ongoingsymptoms, insomnia, pain,
anxiety.
And older Americans, when theystudy it, are shown to be heavy
users of over-the-countermedications, often taking more
(07:42):
than is recommended on thepackage.
In terms of illicit substances,I have patients in my practice
over 65 who use all sorts ofstuff that have vitamine,
cocaine, fentanyl, whatever.
But that tends to be theexception rather than the rule.
Illicit substance use over 65 inAmericans is less than 1%, but
certainly possible.
(08:03):
Now, let's explore some of theissues that people over 65 may
run into, just given how Americahas changed since they were
born.
So the first thing is cannabisis different.
So if you went to high school inthe 1970s and you used cannabis,
it was about 1% THC.
(08:26):
And it was really just smoked asjoints or just a cannabis
cigarette functionally.
And you can see here on thescreen, as we've bred cannabis
to be stronger over time, as of2022, most cannabis was getting
close to 20%.
And now most cannabis is 25 to30% THC.
And a lot of my patients over 65don't realize that.
(08:47):
I'll ask them, you're usingcannabis, what type?
And they'll be like, Doc, it'sjust pot.
And just the industry haschanged.
And one of my patients, I had toshow her on her package that she
was using 23% THC cannabis, andshe was floored.
She just, I didn't know any ofthis.
Cannabis has also changed in itsforms.
We now have edible cannabisproducts and cannabis drinks.
(09:11):
This is a picture of a cannabisproduct.
It's a two-fluid ounce bottlethat's slightly bigger than a
shot of liquor.
And these beverages contain 100milligrams of THC.
Now, most people don't know whata standard serving of THC is,
THC being the downer chemical incannabis that makes us high.
(09:33):
And we as doctors don't actuallyknow either.
We think that the recreationaldose of cannabis is somewhere
between two and a half and 15milligrams.
And so someone who doesn't knowanything about cannabis sees
this tiny little bottle and islikely going to drink the whole
thing.
Unfortunately, it was really notwell labeled on the package how
to portion out each servingbecause it's meant, you can see
(09:57):
on there, they're saying 10milligrams per serving, and it's
supposed to be 100 milligrams inthe bottle, but it's really not
that well labeled to be able tosay this is how I get only this
much.
Take a look at this.
This is actually a THC infusedjoint.
So these pre-rolled joints are43 and 40% THC.
(10:18):
And take a look at the packageon the left.
That is 864 milligrams of THC inthat package, and that's four
joints.
So that's 215 milligrams of THCper joint.
That is drastically strongerthan any cannabis that people
used of this generation whenthey were in their teenage
(10:40):
years.
At the hospital, a code is usedto signal some sort of medical
emergency or issue.
And so we, when we work in theemergency department, if someone
has a potential stroke, we willpage overhead code stroke so
that everybody knows to respondand the person gets the tests
and treatments that they need ifit is a stroke.
(11:03):
And I mentioned my spouse andcolleague, Dr.
Reb Close, she's done a lot ofwork studying overdoses here in
Monterey County.
And she's identified a trend ofwhat she calls code cannabis,
where an older person is broughtto the hospital with a suspected
stroke because they're confusedor they or they're dizzy or they
can't balance.
And it ultimately is found thatno stroke has happened, but they
(11:27):
consumed cannabis eitherintentionally and didn't realize
how strong it was, or theydidn't mean to consume a
cannabis product that did, andno one can really tell until
they get to the emergencydepartment and run all the
tests.
So she calls this code cannabis,meaning we think it's a stroke,
but it turns out to be cannabisintoxication.
And if you take a look, here aresome examples of a candy gummy.
(11:51):
We all know Sour Patch Kids.
And take a look at the labelabove it, stony patch.
The colors are the same, thefonts are almost the same.
Sour than sweet is on bothpackages.
And you can see it's fairlysubtle if you're not paying
attention to realize that thepackage above has THC and the
(12:13):
one below does not.
And if you remember, as we age,sometimes we develop issues with
vision and being able to seeclearly.
An older individual who's notable to see the package clearly
probably would not be able todistinguish between these, which
might result in them takingcannabis without knowing it when
they mixed up a package of agummy versus a THC-infused
gummy.
(12:34):
Coming back to the culturalexperience of Americans over 65,
these are some advertisementsgoing back many years
advertising cigarettes.
If you look on the left, that isa picture of Ronald Reagan
advertising Chesterfieldcigarettes.
Obviously, Ronald Reagan was avery loved president of this
(12:55):
generation.
Take a look at the middleadvertisement.
More doctors smoke camels thanany other cigarette.
Yes, believe it or not,physicians used to recommend
cigarettes for weight loss.
And I certainly had medicalschool professors that recalled
earlier in their careers theywould actually stop to smoke
(13:15):
between seeing patients.
And again, on the right, that'san ad for Newport, really
highlighting the pleasure andjoy of smoking.
I'm old enough to still remembersmoking sections on planes.
Culturally, cigarette use wasjust much more common for
Americans over 65 when they wereyoung people.
And I've had a number of mypatients tell me when I asked
them, do you smoke?
(13:36):
And they said, well, I used to,but everybody did back then.
Now we need to ask the questionwhen we come to make a diagnosis
of an addiction, is it the sameprocess for someone who's over
65 versus under 65?
And unfortunately, as we age,our body physiologically or in
(13:59):
terms of how it works, itchanges.
We get more mental healthconditions, we get more memory
issues, we develop more medicalproblems.
And sometimes addiction canactually manifest differently,
and we need to look fordifferent things.
So you guys have seen this chartbefore.
This is the DSM 5 diagnosiscriteria for an addiction.
(14:20):
It's the same for everysubstance.
We use the substance for longerperiods or in larger amounts.
We have a desire to cut down andunsuccessful efforts to cut down
when we try.
We spend a lot of time to usethe substance and get the
substance.
We get cravings for thesubstance.
We use the substance and then wecan't fulfill major role
obligations at work, school, andhome.
(14:41):
We use the substance despitehaving social and interpersonal
problems.
We give up social, occupational,recreational activities because
of the substance.
We use the substance insituations where it's
potentially dangerous.
The substance is continueddespite knowledge of having
persistent problems and thentolerance, the need to consume
more with time, and thenwithdrawal, meaning that we need
(15:03):
to use the substance to not feelsick.
And those 11 criteria are thesame for any human being for any
substance.
You just put in alcohol.
Alcohol is often taken largeramounts over a longer period of
time.
You put in cannabis.
Cannabis is often taken inlarger amounts over a longer
period of time.
It's the same 11 criteria forany addiction.
So practically it's the samewhen it comes to making a
(15:26):
diagnosis of addiction in termsof do they meet criteria and
which criteria do they meet?
But it turns out that actuallysome of these criteria look
different in adults over 65.
One of the criteria is that thesubstance is taken in greater
amounts than intended.
As we talked about, we are moresensitive to the effects of
(15:48):
medications and substances as weage.
So a person's use might be thesame or even less over time, but
as they're older and they weighless and they can't tolerate it
as much, they actually mightfunctionally be using more.
For people that have been onsubstances for decades and
decades, they may not realizethat their chronic use is
(16:09):
problematic.
So they really haven't tried orbeen unsuccessful in cutting
down because they didn't thinkthere was a problem.
We also have to realize that alot of older adults stay home.
They might be homebound, theymight be retired.
They don't have a lot of rolesin school or workplace or home.
So they're not missing any ofthose obligations because they
don't necessarily have thoseobligations to miss.
(16:32):
People give up other activitiesbecause of the substance.
They may just not have as manyactivities that they do.
And again, you will also seethat withdrawal, as we'll talk
about shortly, can lookdifferent as we age.
So it may not be immediatelyrecognized as withdrawal.
And unfortunately, we also seethat as we age, or our risk of
(16:52):
falls goes up and our ability toreact quickly while driving goes
down.
So using substances in whatmight be considered normal use
actually does increase the riskof serious complications.
So again, the 11 criteria arethe same, but we just have to
look for slightly differentthings.
The other thing is that as ourorgan systems change and our
(17:13):
health changes as we age,substance use might just look
different.
In other words, we might notlook for usual things to make us
think, gosh, could this be aproblem with addiction in the
first place?
So we see more mental healthsymptoms with substance use in
people over 65, particularlydisturbed sleep, anxiety,
(17:34):
depression, irritability.
Sometimes it's more physicalsymptoms like being shaky,
coordination of balance beingmore off.
The stomach is more sensitive tothings like nausea and vomiting.
Unfortunately, as we'll talkabout, people over 65 are at
higher risk of falls and havetrouble maintaining good
nutrition no matter what.
(17:56):
So we may see those problemsshow up earlier in a person's
use of substances.
As we age, our brain ages too,and the cognitive changes that
happen with aging are gonna bemore apparent when someone's
using substances.
Substances accelerate thosecognitive changes.
And then a lot of times we'llsee just social interactions
(18:16):
change.
People might be more withdrawn,they might not be as connected
to family.
So the diagnosis is the same,but we need to look for other
things when making thosediagnostic decisions with the
DSM criteria.
And then just could this be asubstance use problem in
general?
We're just going to look fordifferent stuff because it may
manifest differently in olderadults.
Now, in terms of treatingaddiction at the highest level,
(18:40):
there's no difference, right?
We have medications, we havemutual support groups, and we
have counseling and therapy.
And that doesn't change nomatter who you are or how old
you are.
But each of those might be alittle bit different when we're
working with a person who's over65.
So the first thing is let's talkabout detox.
(19:00):
And detox is not a medical term,but everybody knows the term.
And so I use it to say I need tostop the substance.
I've got to get through thewithdrawal period.
Unfortunately, as we age, wetolerate stress on the body
less.
And that's in general.
When you're 16 years old and youhave a urinary tract infection,
no big deal, right?
Cranberry juice and anantibiotic, and you don't even
(19:22):
miss a beat.
A person who's 90 years oldmight have to be hospitalized
for several days because of aurinary tract infection.
So we just tolerate stress lessas we age.
We have less reserve, if youwill.
So we are more sensitive towithdrawal as we age and we
tolerate it less well.
So adults over 65 when choosingto quit a substance,
(19:46):
particularly one with adangerous withdrawal syndrome
like alcohol, may need a veryhigh level of care.
Dr.
Lee Goldman, he's one of theaddiction docs here in Monterey
County with me, usuallyrecommends hospitalization for
folks over 70 when they'recoming off of alcohol, just
because they can be much morevulnerable.
Now, the other thing is withmore years on the planet, people
(20:08):
with addiction have had moreyears to start and stop
substances, to go throughwithdrawal, to try to quit.
And unfortunately, like riding abike, our brain gets good at
something we do a lot of, right?
So you want to learn a newmusical instrument, what do they
say?
Practice, practice, practice.
Unfortunately, when we use asubstance and stop, our brain
(20:28):
learns the withdrawal pathway.
And withdrawal can worsen intime as those brain pathways
strengthen.
And we know this best withalcohol.
It's called kindling, which isbasically that it's been studied
that as people start and stopalcohol multiple times, the
withdrawal usually gets worseeach time.
So a great question to asksomeone when they're deciding to
(20:50):
quit substances what's the worstwithdrawal that you have?
And someone who's had really badalcohol withdrawal is likely to
have it again, particularly asthey've started and stopped
multiple times and they getolder.
Now, I mentioned that as we age,we tend to have more medical
issues.
The two organs that do the vastmajority of breaking down the
(21:11):
medications and substances thatwe put in our body are the liver
and kidney.
And years of stress on the bodyin general means that the liver
and kidney function may decreaseover time.
And so we often have to eitheravoid certain classes of
medications or adjust the dosingbecause the person's not able to
(21:32):
tolerate it because their liverand kidney function has changed
with time.
So gabapentin, for example,which we use very liberally in
addiction medicine, it turns outis only secreted by the kidneys.
So somebody who has kidneyproblems, we really don't use
it.
We can use it with a mild amountof kidney dysfunction, but for
severe kidney dysfunction, wereally avoid it.
(21:54):
Now, the other thing is as wehave more medical conditions, we
tend to be put on moremedications.
And the more medications wetake, the more likely we are to
have medication interactions.
And for example, let's saysomebody who has chronic back
pain and got all put on opioids,and then they start to develop
an opioid use disorder, theirback pain's still there.
And let's say they're on a bloodthinner because of a regular
(22:14):
heartbeat, it reduces the numberof classes of medications that
we can use to treat their painbecause it might have a
dangerous interaction with theirblood thinner.
A couple other things that areunique to older adults.
The first is poor nutrition.
It turns out our hunger andthirst reflexes decrease as we
age, and food may not taste asgood as we age as well.
(22:38):
So older adults tend to eat anddrink less.
They're more likely to developmalnutrition and also
dehydration.
And particularly with alcohol,some people will really just
drink alcohol and not eat.
And it really puts people atrisk for malnutrition,
particularly with B vitamins.
So usually when we get peopleoff of alcohol, we want to get
them on B vitamins.
(22:59):
And this can happen with othersubstances, but it's a unique
additional problem with alcohol.
Dementia is the process wherethe brain ages and our
short-term memory starts todecline.
Initially, we might see what'scalled mild cognitive impairment
or some inability to remembercertain things, and it
progresses to dementia.
And it can be really hard whenwe're trying to get someone into
(23:22):
treatment and you need to takethis medicine at this time and
go to this appointment, and youneed to go to therapy at this
time.
And what did your therapist talkabout?
When they have troubleremembering, it makes it much
harder to follow through on thetreatment recommendations.
And then the last thing isfalls.
We see so many falls in the over65 group.
We lose muscle mass, our balancechanges, we may get neuropathy
(23:44):
in our feet.
And falls are a big problembecause when you are bedbound
after a bad fracture of a leg,for example, you lose muscle
mass so fast and it's hard toget it back.
It's just hard to eat, it's hardto toilet if you've broken an
arm.
Pain control can be challenging.
And so, as you can imagine, anysubstance that's going to impair
(24:06):
someone's ability to function,like alcohol or cannabis or
anything, is going to increasethe risk of falls as well.
Now, there are other more socialissues that come up that are
that develop newly after age 65.
And an article that I wasreading on this topic talked
about early onset and late onsetsubstance use in older people.
(24:29):
And what they talk about is somepeople start using substances at
an early age, say in their 20s,and they continue it through
their life.
That's what's called earlyonset.
Late onset is where people starthaving a problem with a
substance much later in life,let's say 65, 70, and beyond.
And a lot of the late onsetgroup comes from major life
changes.
(24:50):
So retirement, right?
Getting up every day, having apurpose, staying busy, having to
stay sober, we do see anincrease in some people in the
use of particularly alcoholafter retirement when they're
bored and don't know what elseto do.
Loss of a spouse.
You can imagine how isolatinglosing a spouse that you've had
for decades is.
(25:11):
People might find that they'rejust home by themselves all the
time with nothing to do.
We also find that culturallyhuman beings love alcohol, and
that continues into senior andretirement communities.
Some national data here in theUS: two-thirds of Americans in
senior and retirementcommunities drink, and up to 15%
(25:31):
are heavy drinkers.
And I will share personally, mygrandparents spent the last
years of their life at a seniorcommunity here in Monterey
County.
And yeah, there were drinkingevents almost every day, wine
tastings, cocktail hour,champagne brunch.
And my grandparents actuallycommented that their alcohol use
went up when they went into thesenior retirement community.
(25:55):
Unfortunately, being over 65poses some unique barriers to
getting into addictiontreatment.
One of them might just befeeling out of place in a
treatment program, particularlyresidential.
Not all residential programs oreven outpatient programs are
designed to accommodate theneeds of people as they age.
(26:17):
There might not be as muchequipment around to accommodate
people with limited uh mobility.
They might not have bars to getup off the toilets, for example.
Limited mobility is a majorchallenge.
Getting in and out of a car intoa wheelchair to go to an
appointment.
Transportation in and of itselfis also challenging.
Limited finances and insurance,and you can see where this all
(26:38):
mixes together.
Let's imagine a person's over65, they're wheelchair dependent
after a stroke, they didn't havea lot of extra income, they're
surviving on Social Security,they don't have a car, they
don't have the money to pay fora taxi ride.
They might be just reallyisolated in their home because
they really can't get anywhere.
It's hard, time-consuming, andexpensive to get to
(27:01):
appointments.
So that this can be a challengeas well.
Now, the last thing is ourbehavioral interventions to
treat addiction.
And those include things liketherapy and mutual support
groups.
And those are largely unchanged.
If you're under 65 or over 65,just a few comments that I would
make.
If someone's going to be seeinga therapist, they're going to
(27:21):
need to have some experience inworking with Americans over 65,
or I should say, people over 65in general, just because they
have a unique lived experienceand face some unusual and
different challenges as theyage.
Again, things like the loss of aspouse, retirement, changes in
mobility, et cetera.
As I tell my patients, you knowwhat?
Picking a therapist is likegoing to a car dealership and
(27:44):
buying a car.
You and I might go together, youlike the sedan, I like the
truck.
We're both right.
You go to a therapist, that's asedan.
When you need a truck, just saythank you, and that you need to
find a therapist that's rightfor you.
And mutual support meetings arethe same way, right?
If you go to an AA meeting andyou don't get a good vibe, it
doesn't mean meetings are notfor you.
You've just got to find theright meeting where you feel at
(28:05):
home.
The other thing I mentioned thatI skipped over, unfortunately,
is sometimes people over 65 feelvery out of place getting
treatment for addiction becausethey think there's a bunch of
young people.
They've been homeless, they wereusing meth, they were using
fentanyl.
I worked my whole life.
I have a 401k.
I just have alcohol as aproblem.
And I've seen it both ways.
I've had young people go toprograms where they feel like
(28:26):
it's too many folks that areover 50 drinking alcohol if
that's that's their problem, andthey feel out of place as a
young person.
And I've had my older patientssay, I don't like that.
It's all these young folks thatI don't understand.
So it's really just finding aplace where people feel
comfortable.
Okay, let's go through a coupleof cases that just illustrate
some of the points that we made,and then we can stop and take
questions.
So these are two of my patients.
(28:47):
I've changed their information,so you can't identify them.
Okay.
75-year-old me was referred tome to quote, take over my Xanax
and Ambien.
He'd been with a primary carephysician for many years, was on
four milligrams of alprazelam,that's Xanax, and 12.5
milligrams of zulpadem, that'sambient.
And this is somebody who reallyhadn't had any mental health
services besides working with atherapist a little bit.
(29:11):
This was a gentleman who had astroke.
He was in a wheelchair, he hadatrial fibrillation and had
required treatment with a bloodthinner.
He had problems with hisprostate, which had led to
urinary incontinence, so he hada catheter in place, and then
high blood pressure, highcholesterol, depression,
anxiety.
I put his medications up on thescreen.
You can see this person's onseven different meds and
(29:32):
actually no history ofaddiction.
We'll talk about that in just asec.
This patient was referred to mebecause the primary care doctor
was not comfortable managingthese potentially addictive
medications.
Alprazolam is a benzodazepine,and ambien is a Z drug, which is
like a cousin of a benzedazpinefor sleep.
And so I started digging intothe history what's going on,
what resources does this personhave?
(29:53):
This man lives alone.
He cannot drive because of hisstroke.
He has no family nearby.
He drank alcohol.
Socially and smoke cigarettesregularly, didn't think either
one was a problem.
So, what did we do?
Uh, the first thing is we saidthe Z drug, the ambience, is
gonna put you at a high risk fora fall.
So we changed the sleeping medfrom zolpidam or ambien to
(30:16):
ramaron, also known asretazepine.
We were a little nervous aboutsleeping meds in general, but
this person was just adamantthat he could not sleep.
And then we started the processof weaning him down on his
alpraisolam.
So came to me on four milligramsof alpraisolam, and we've weaned
him down to two and a half tothree milligrams a day, and
we're just going really slowbecause this guy's been on
(30:37):
alpraisolam for longer than I'vebeen alive.
I we, as we spoke about, he'svery isolated, really can't get
mental health services viatelemedicine.
So I keep trying to find himsomeone in person that he can
get to, or an inexpensive way toget him to the peninsula to get
services.
And I think I may have a lead,but I've been working on it for
quite a while.
So, what can we learn from thisfirst case?
(30:58):
Case in point, more medicalconditions, more complicating
factors, harder to get aroundwith mobility.
And then the catheter obviouslyprovides an issue as well, and
the transportation is limited.
We didn't really talk aboutthis, but Medicare sometimes is
great insurance and sometimesit's not.
And here in Monterey County,mental health services for
(31:19):
Medicare is definitely underresourced.
And then the other thing is,this man is really not addicted
to his sleeping meds or hisalpraza lam.
His doctor just did not want toprescribe them after his primary
retired and he got referred to anew primary doctor.
Physicians are much morecautious now with controlled
substances.
And I call this individual amedication orphan because no one
(31:42):
knows what to do with him.
So, of course, they sent him toaddiction medicine.
And I'm like, it's not really anaddiction.
You're not craving, you're notcompulsively using.
And so the best thing we'retrying to do is get in mental
health services and try to weanhim down off some of those meds
to reduce his fall risk.
Okay, case two.
A 79-year-old female wasreferred to me, quote, because I
drink too much.
She was also beginning to havesome issues with her memory,
(32:04):
talked to her primary doctor,and she was motivated to quit
alcohol.
Her pattern of drinking involvedcocktails every evening, usually
about 5 p.m.
or so.
Medical history includedanxiety, hypertension, diabetes,
and acid reflux on fourdifferent medications, including
insulin.
Alcohol, if you didn't know,does really affect our body's
(32:26):
use of energy and storing ofenergy.
And it makes us more prone toboth high and low blood sugars,
depending on where we are in ourcycle of alcohol consumption.
And this person lives in abeautiful senior community here
in Monterey County where thereare a lot of social events.
So this person wanted to quitalcohol.
And so I said, why don't we trya naltrexone?
We've talked about naltrexone.
It reduces the pleasure inalcohol and makes cravings less
(32:49):
intense.
So I said, We tend to drinkaround maybe four or five.
Why don't we take a naltrexonean hour before?
And I said, I just want to makesure you're not going to have
any withdrawal.
Have you had any withdrawal inyour life?
And she said, Nope, nowithdrawal.
I think I'm going to be A-OK.
And just my gut instinct wasjust, oh gosh, Casey, I just,
you didn't really do a goodenough job finding out if she's
going to have withdrawal.
(33:09):
And I just cold called her and Isaid, It's Dr.
Grover, I'm just worried aboutyou.
Are you having any withdrawal?
And she goes, Doc, I think I am.
Second day off of alcohol, shegot some withdrawal, she got
some shakiness, she got somenausea.
So we put her on a little bit ofValium, needed just a few doses.
And then she was able to stopand get through it, and we kept
her on naltrexone.
(33:31):
She is still sober.
I saw her a couple of weeks ago.
She and her husband love totravel.
And of course, every trip theygo on, there's wine testing and
bars at their senior community.
There's loads of wine tastingand social cocktail events.
But the naltrexone's really beenworking.
Unfortunately, my patientdeveloped some dizziness.
She felt very unsteady on herfeet.
(33:53):
And so she saw neurology, shesaw physical therapy.
We went through this whole bigworkup.
And ultimately, it was felt tobe a side effect of naltrexone.
And we weighed the risks andbenefits and decided to
discontinue the naltrexonebecause of the risk of falling.
But we ultimately decided toswitch it to only as needed
naltrexone that if she decidedshe was having a craving, she
(34:15):
could take it.
So, case two, take home points.
As I mentioned, be wary ofwithdrawal.
As we age, we are more sensitiveto it and less tolerant of it.
Social circumstances,particularly in senior
communities, can be verytriggering.
And then again, medications aregreat, but unfortunately, we do
often get more side effects andwe don't tolerate those side
(34:35):
effects as well.
Before we wrap up, a huge thankyou to the Montage Health
Foundation for backing mymission to create fun, engaging
education on addiction.
And a shout out to the nonprofitCentral Coast Overdose
Prevention for teaming up withme on this podcast.
Our partnership helps me get theword out about how to treat
(34:58):
addiction and prevent overdoses.
To those healthcare providersout there treating patients with
addiction, you're doinglife-saving work, and thank you
for what you do.
For everyone else tuning in,thank you for taking the time to
learn about addiction.
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
(35:19):
treated.
Together, we can make it happen.
Thanks for listening.
And remember, treating addictionsaves lives.
Popular Podcasts
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
The Bobby Bones Show
Listen to 'The Bobby Bones Show' by downloading the daily full replay.