Increases Reveal a Blind Spot in Screening and Treatment
By Holly Broce, MHA, LCADC, President, Opioid Treatment Program (OTP) Division, Pinnacle Treatment Centers
For the past two years, our attention has been on the coronavirus pandemic. For good reason. The virus and everything related to it – from the tragic loss of life to the disruptions in our daily lives to the divisions over public policies and mitigation measures – has dominated news headlines, social media feeds, and conversation among families, colleagues, and friends.
Meanwhile, behind the scenes, the opioid epidemic has gotten worse.
For those of us who work in addiction treatment, it’s been heartbreaking. Before the pandemic arrived, we were making progress. We thought we could see the light at the end of the tunnel. Between 2000 and 2017, the number of deaths due to opioid overdose increased at unprecedented rates.
- 6,242 deaths in 2000
- 12,991 in 2005
- 19,687 in 2010
- 42,435 in 2016
- 47,600 in 2017
That’s a 662 percent increase over twenty years.
Then, in 2018, opioid overdose deaths dropped to 46,802.
That’s a modest decrease, but to those of us working on the front lines, it was the first glimmer of hope we’d seen in years. We were cautiously optimistic that our work in offering lifesaving, evidence-based treatment like MAT to people with opioid use disorder (OUD) had paid off.
Then the pandemic arrived.
Then, early last year, we began to see the opioid overdose statistics from 2019 and 2020. The glimmer of hope we saw in 2018 faded, because these are the opioid overdose numbers we see now:
- 50,178 deaths in 2019
- 69,061 in 2020
- 73,453 in the 12-month period ending April 2021
Those reports hit us hard, but we didn’t flinch. We’d been there before, and we knew how to help. Then, early this year, researchers from Northwestern University published a study that revealed a hidden crisis. Their work showed a disproportionate increase in opioid overdose among adults over age 55 – specifically among non-Hispanic African-American men.
A Crisis Within a Crisis: Opioid Addiction Among Older Adults
We’ll approach this subject with a wide lens at first, then narrow our focus. When people think of the opioid crisis – despite the fact that medical professionals repeat, ad nauseam, that opioid addiction can affect anyone, anywhere, anytime – they typically think white, young, rural. That’s a stereotype driven partially by the media, and partially by the data. The opioid crisis tore through the rural U.S. like wildfire. From West Virginia to California, Kentucky to Ohio to Wyoming, opioid addiction and overdose spiked dramatically.
Those numbers got plenty of press.
And while those numbers rose, they also rose among people over the age of 55.
Here are the wide lens, big picture statistics:
- Between 2006 to 2014, opioid-related emergency room visits increased 220% among people 65 and over.
- Between 1999 and 2019, 79,883 people 55 and over died of opioid overdose:
- 59% men
- 41% women
- From 1999 to 2019, opioid overdose deaths among those 55 years and older increased 10-fold:
- 518 deaths in 1999
- 10,292 deaths in 2019
Now let’s narrow our focus and look at what happened with non-Hispanic Black men over the same period:
- In 1999, around 1,500 Black men over age 55 died of opioid overdose
- In 2019, around 26,000 Black men over age 55 died of opioid overdose
That’s shocking.
That’s an increase of more than 1,600 percent.
But there’s more to the data than that. Until 2012, opioid overdose rates among Black men over 55 increased at about the same rate as other demographic groups over age 55. Then, the trend lines diverged. Whereas the opioid overdose death rate for all other groups remained relatively constant, the rates for Black men spiked dramatically between 2012 and 2019.
In math language, the slope of the trend line for all demographic groups except Black men stayed between 1 and 6 from 1999 to 2019. Looking at a graph with a line going left to right, a line with a slope of 1 is essentially flat and represents very little increase over time. A line with a slope of 6 rises slowly and represents modest increases over time. In this study, the trend line for Black men stayed steady at around 2 between 1999 and 2015. Then, suddenly, between 2012 and 2019, the slope jumped from around 2 to around 11, indicating steep increases and a totally different trend than all other racial/ethnic groups represented on the graph.
In plain language, the lines on a graph for almost all groups rose a little, while the line for Black men went nearly vertical. Have a look at this graphic to see what we’re talking about.
We can’t ignore those numbers.
But why did this happen?
Drug Use Among People Over Age 55
Experts don’t agree on exactly why the opioid overdose fatality rates among Black men rose so dramatically, but they do have ideas that make logical sense.
Again, we’ll start with a wide lens and then narrow our focus.
Ageism and Addiction Screening
The authors of the Northwestern University study say that many people, including medical professionals like primary care physicians and emergency room personnel, might not see the signs of addiction in people over 55 – much less people over 65 or 75 – because they don’t think to look there. Dr. Lori Ann Post, a study author, put it this way:
“Many are Baby Boomers who, in their youth, were using recreational drugs and…they’ve continued using into their older age. That sort of flies in the face of our stereotypes. We don’t think of them as recreational drug users, but it’s a growing problem. We’re talking grandmas and grandpas doing drugs, and to the point of overdosing. We don’t think of them seriously. That needs to change.”
That’s a valuable insight the medical community, and the addiction treatment community specifically, should take seriously. A selective blindness toward drug addiction in people that remind us of our grandparents may explain the increasing overdose rate among the older demographic in general, but it doesn’t explain the specific increase among Black men.
Insurance Coverage, Access, and Trauma
Dr. Mary Ann Mason, another study author, points to what are known collectively as social determinants of health. Black men over 55, compared to the other demographic groups in the study, are more likely to live in areas where the following factors are present:
- Unstable housing
- Polluted air and water
- Inconsistent transportation
- Insufficient access to:
- Education
- Jobs
- Income
- Healthcare
- Healthy food
In addition, compared to the other demographic groups in the study, Black men over 55 are more likely to have experienced racism, discrimination, violence, and have contact with the criminal justice system during the course of their lives. Collectively, these social determinants of health are known to increase rates of diabetes, obesity, and heart disease. In addition, in the words of Dr. Mason:
“These sorts of things can create a trauma which can be related to people seeking relief in substances. This is also a population that is underinsured and has limited access to health care and drug treatment programs.”
Finally, data cited in the study show higher rates of prescriptions for buprenorphine – a first line treatment for opioid use disorder – among white patients than for other demographic groups, including black men.
How to Address the Problem
Awareness and access are the keys to supporting Black men over 55 with opioid use disorder. There’s a mantra in the addiction treatment community that goes like this: the right treatment at the right time saves lives. There’s another that goes like this: anytime is the right time, but now is best. Taken together, what these two mantras tell us is that this specific demographic needs lifesaving treatment – and they need it now.
To get the right support to the right people and places, Dr. Mason advises us to:
- Initiate or increase outreach to older adults in the Black community. The most effective way to do this is by finding people in the community itself to spread the information that evidence-based treatment for opioid addiction works and is available.
- Train people with regular contact with older people, such as nurses, community leaders, and people who work for Meals on Wheels, to recognize the signs of opioid misuse, addiction, and overdose.
- Increase screening for addiction for older people by making it a regular part of checkups or routine visits for other medical issues.
- Increase access to all phases of healthcare, including addiction treatment, by adapting delivery systems to accommodate people with transportation, mobility, and seeing or hearing problems.
These system-wide changes require new attitudes toward older people and new attitudes toward where, when, and how we screen for addiction. The foundation for all the above – increased access, expanded care, enhanced screening, awareness initiatives, community outreach – was established through the hard work of treatment professionals and community partners during the years 2017 and 2018, when the opioid crisis had the attention of the nation.
What we need now is that level of focus applied to the new normal: a lingering pandemic, rising overdose death rates, and increases in addiction in places and people we didn’t realize were experiencing increases – like older adults in general, and older Black men over 55 in particular. Dr. Mason believes – and we concur, because we are ever optimistic – that when given access to appropriate treatment, the wisdom, perspective, and life experience earned over a lifetime gives older adults an advantage, and increases their chance at meeting and overcoming the challenges of addiction.