When Joseph Puglisi’s beloved grandfather died, it naturally came as a blow. But the real shock was the cause of death. “I lost my grandfather to opioid abuse,” Puglisi says, “and didn’t even know it till he was on his deathbed.”
Puglisi remembers his grandfather as a kind and fun-loving man whose life changed dramatically after he was diagnosed with arthritis. To relieve the pain, the patriarch and family protector turned to prescription drugs and eventually began self-medicating with fentanyl. The escalation didn’t stop there.
“He was emaciated, but I thought it was the effect of the medications, not knowing that it was an addiction,” Puglisi explains. “I knew he was an alcoholic and that he sometimes smoked marijuana, but I thought he was sticking to just those vices. It wasn’t until after his death that I found out he had started taking heroin, too.”
Learning the truth made Puglisi angry. “I wanted answers to where he got those drugs, and why he chose not to tell anyone about his addiction.” His grandfather was “pretty secretive,” to say the least – even his part-time caregiver was unaware of the opioid abuse – and Puglisi recalls feeling devastated: “I knew he still had years ahead of him, but also felt he was too old to be abusing drugs and should have known better.”
The end came when, at age 65, Puglisi’s grandfather overdosed on a combination of fentanyl and heroin. Even then, an “almost unbearable” stigma remained. “Everyone in his community said my grandpa was a junkie,” Puglisi says.
In hiding his addiction, Puglisi’s grandfather endured a lonely struggle, but he was far from alone. The National Institute on Drug Abuse estimates that 1 million adults 65 and older have a substance abuse disorder. According to a recent study by Northwestern University, the number of opioid-related deaths of Americans ages 55 and up soared 1,886% between 1999 and 2019.
Researchers at Northwestern University have found that many baby boomers who overdose on opioids use drugs recreationally, a practice that began in their youth. Some refer to it lightly as “grandma and grandpa on drugs.” But the rise of addiction and overdoses in older adults – and the best ways to help those at risk – is more complex than that suggests.
Behind the Overdose Data: ‘Death by Despair’
Although some started taking drugs for fun back in the Woodstock era, many older adults now use opioids recreationally to escape emotional pain. “Half of all suicides are overdoses – it’s a phenomenon of death by despair,” says Gary Kennedy, MD, professor of psychiatry and behavioral sciences at the Albert Einstein College of Medicine in Bronx, NY, and director of the Division of Geriatric Psychiatry at Montefiore Medical Center.
Kennedy sees a correlation between the rise in overdoses in this age group and the pandemic. “Because of COVID, people have experienced social isolation and economic challenges,” he says. “Many baby boomers have not had the opportunity to get health care and support.”
Another contributing factor is the easy availability of highly addictive meds, especially those used to treat chronic pain. Fentanyl, in particular, poses “a huge problem,” says Lewei Allison Lin, MD, associate professor of psychiatry and director of the Addiction Psychiatry Fellowship program at the University of Michigan and a research scientist at VA Ann Arbor Healthcare System. “Every time a person uses fentanyl, their chances of overdose get higher, especially if fentanyl is mixed with other drugs.”
Meanwhile, many older patients take opioids along with a sedative to treat insomnia. One such tranquilizer, benzodiazepine, contributed to an estimated 16% of overdose deaths in 2020. The use of benzodiazepine in combination with an opioid significantly raises the risk of death, according to Susan W. Lehmann, MD, director of the geriatric psychiatry hospital day program at Johns Hopkins Medicine in Baltimore and associate professor of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine. “In fact,” she says, “when the two are taken concurrently, it’s four times the risk.”
Another Danger Zone: Street Drugs
While many find it hard to imagine their grandparents getting high, a growing number of older adults are using illegal hard drugs – and that includes heroin. “Older adults may have started taking prescription opioids and become addicted, but then their doctor would not prescribe them anymore,” Lehmann explains. “Or they could not afford them anymore. And heroin is less expensive.”
Of course, the ingredients of opioids sold on the street vary, and so does their strength. “These drugs are a lot more potent now, and we don’t know a lot about what other substances could be mixed into them,” Lin says, adding, “When a drug is more potent, there are a lot more pathways that can lead to overdose once you take it.” Regardless of where the drugs came from, it’s essential for doctors to get their older patient on an opioid withdrawal regimen as soon as possible. Methadone, the synthetic opioid best known as a treatment for heroin addiction, can be effective in treating other kinds of opioid dependence.
“Typically, older patients with opioid addiction don’t need as much methadone as younger ones do,” Kennedy notes. “By the ages of 55 to 60, many ‘graduate’ off of methadone, because they’ve physically made all the progress they can taking it.” Buprenorphine, a medication that eases the effects of withdrawal, can also be helpful, according to recent research.
Supporting an Older Patient
What’s the best way to help a parent or grandparent with an opioid problem? Rule one: Don’t throw up your hands. “Addiction is actually a very treatable illness,” Lin says. “A large proportion of people who have it get better.” The process begins with a foundation of trust and understanding, especially between patient and doctor. “It’s also important to realize that addiction is physically doing something to your parent or grandparent’s brain,” Lin adds. “Your family member is dealing with a brain craving. That means all they think about is taking the drug they are addicted to.”
Older addicts often feel too ashamed to admit that they need treatment. “The most important part of helping someone deal with opioid addiction is to address the stigma,” Lin continues, emphasizing that the caretaker needs to encourage – not judge – the patient. “Read up on the underlying causes of opioid addiction. Your parent or grandparent could have depression or anxiety.”
And express your concerns carefully. “What tends to work best is motivational interviewing,” Kennedy says. “You don’t act like your parent or grandparent’s parent. You say instead, ‘Are you having difficulty with opioids? If you are ... let me help you.’ Ask the question, ‘Are you ready to get help?’ If your parent or grandparent responds with ‘Not now,’ then say, ‘Help me understand what is keeping you from getting help then.’ You may hear something you never knew.”
Although older family members are often reluctant to talk about a drug problem, stories of recovery can be inspiring. “I worked with a patient, a man aged 65, who is now living on his own and doing well,” Kennedy says. That patient hadn’t suffered from depression – he was simply relying on opioids to relieve pain – and now he’s taking methadone as part of his treatment. Says Kennedy, “It’s working.”
Final rule: Take care of yourself as well as your loved one. “It took me time to get over my grandfather’s death and move on,” says Puglisi, who is now a successful businessman in Las Vegas. According to the experts, that’s perfectly OK.
