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Older adult opioid overdose death rates on the rise - 4 times higher for African-American Men
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'We don't think of Baby Boomers as recreational drug users, but it's a growing problem.
Opioid overdose deaths increased drastically among older Black men over a decade
Black Men Have 4 Times Higher Opioid Overdose Fatality Rate Among Older Adults....coincides with CDCs 3rd wave in the opioid epidemic characterized by increased presence of fentanyl.
Between 1999 and 2019, opioid-related overdose deaths increased exponentially in U.S. adults ages 55 and older, from 518 deaths in 1999 to 10,292 deaths in 2019: a 1,886% increase.
Opioid overdose deaths among older adults increased significantly from 1999 to 2019, especially among non-Hispanic Black men.
African-American men experienced the largest increases in opioid overdose deaths among older adults since 2013, the study found. By 2019, the opioid overdose fatality rate among non-Hispanic Black or African-American males ages 55 and up was 40.03 per 100,000 population - four times greater than the overall opioid fatality rate of others of the same age.
"We need to inform the services that cater to older adults, such as meal-delivery or housekeeping services, about these potential issues and how to recognize the signs of drug misuse, like confusion, falls and asking for medication too often or off cycle," Post said. Mason pointed out that the disproportionate rates among Black men require addressing the social determinants of health that drive drug misuse in the first place.
"Many of us think drug misuse is a problem of the young. However, older adults are experiencing an explosion in fatal opioid overdoses," said Maryann Mason, an associate professor of emergency medicine at Northwestern University Feinberg School of Medicine.
•Number of opioid overdose deaths in older Americans increased 1886% between 1999 and 2019
•Among older adults, African-American men experienced a disproportionate share of fatal overdoses
•Older adults often not screened for substance misuse, because it doesn't match stereotype
•'They're invisible. We don't think of them' as having drug addiction
A new Northwestern Medicine study that analyzed 20 years of fatal opioid overdose data in adults 55 and older paints a much different picture. Between 1999 and 2019, opioid-related overdose deaths increased exponentially in U.S. adults ages 55 and older, from 518 deaths in 1999 to 10,292 deaths in 2019: a 1,886% increase.
Press release
Chicago --- A common stereotype for an "older adult" might include early-bird specials, dentures and tickets to the matinee show.
A new Northwestern Medicine study that analyzed 20 years of fatal opioid overdose data in adults 55 and older paints a much different picture. Between 1999 and 2019, opioid-related overdose deaths increased exponentially in U.S. adults ages 55 and older, from 518 deaths in 1999 to 10,292 deaths in 2019: a 1,886% increase.
"Many of us think drug misuse is a problem of the young. However, older adults are experiencing an explosion in fatal opioid overdoses," said Maryann Mason, an associate professor of emergency medicine at Northwestern University Feinberg School of Medicine.
The findings were published Jan. 11 in JAMA Network Open.
"Many are Baby Boomers who, in their youth, were using recreational drugs and, unlike in previous generations, they've continued using into their older age," said senior author Lori Post, the Buehler Professor of Geriatric Medicine and professor of emergency medicine and medical social sciences at Feinberg. "That sort of flies in the face of our stereotypes of the 'older adult.' We don't think of them as recreational drug users, but it's a growing problem."
In the 20-year span, 79,893 people in the U.S. aged 55 to 80 died by opioid overdose, with about half being between 55 and 64 years old, Mason said. The annual overall death rate per 100,000 people 55 years and up ranged from a low of 0.9 in 1999 to a high of 10.7 in 2019 and increased annually from 2000 on, the study found.
Post said ageism is one of the contributing factors for the increase in fatal opioid overdoses among older adults, explaining that doctors often don't screen for drug misuse during appointments with older people because "it doesn't fit the stereotype of what it means to be old."
"They're invisible," Post said. "We're talking grandmas and grandpas doing drugs, and to the point of overdosing. We don't think of them seriously. Not as potential victims of domestic abuse, physical or sexual assault or drug addiction. That needs to change."
African-American men experienced the largest increases in opioid overdose deaths among older adults since 2013, the study found. By 2019, the opioid overdose fatality rate among non-Hispanic Black or African-American males ages 55 and up was 40.03 per 100,000 population - four times greater than the overall opioid fatality rate of others of the same age.
"It's really a big question what was going on with that population that wasn't going on with other populations," Mason said. "It's suggestive of the beginning of the third wave of the opioid epidemic, when fentanyl began making its presence in the normal drug supply. Older Black men are more involved in illicit drug use, while other populations are more involved in prescription drug use."
Mason noted that Black men are also more likely to have experienced trauma, lack access to health insurance and health care, don't trust health care providers and are undertreated for pain compared to other subpopulations of older adults.
The study suggested other contributing factors in the exponential increase among older adults. They could include social isolation and depression; exposure to medically prescribed opioids for chronic conditions such as arthritis and cancer, which increase with age; declining cognitive function that may interfere with taking opioids as prescribed. In addition, the body's ability to metabolize opioids decreases with age, meaning people are more vulnerable to overdose.
"We need to inform the services that cater to older adults, such as meal-delivery or housekeeping services, about these potential issues and how to recognize the signs of drug misuse, like confusion, falls and asking for medication too often or off cycle," Post said.
Mason pointed out that the disproportionate rates among Black men require addressing the social determinants of health that drive drug misuse in the first place.
Other Northwestern authors on the paper include Dr. Howard Kim and Rebekah Soliman.
Funding for the study was provided by the Buehler Center Smith Gerontology Endowment Research Fund and the Institute for Policy Research Summer Undergraduate Research Assistant Program award.
https://news.northwestern.edu/stories/2022/01/older-adult-opioid-overdose-death-rates-on-the-rise/&fj=1
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JAMA Netw Open. 2022
Factors associated with OUD among older adults include an increased number of chronic conditions, polypharmacy, and greater injury risk due to falls and fractures.8
By 2019, the opioid overdose fatality rate among older non-Hispanic Black men was 40.03 per 100,000 persons. This rate was four times greater than the overall opioid overdose fatality rate for older adults.
"This suggests to me that Black men may have had more involvement with illicit opioid use than other subgroups of older adults."
High rates of drug use among Black men may also be linked to social determinants of health such as poverty, poor housing, lack of access to health care and substance use treatment, and experiences of trauma living in communities with high burdens of violence and low resources, she added.
Deaths among non-Hispanic Black men appear to account for the disproportionate increase in rates of opioid overdose deaths for all older adults since 2013. This is concerning and may signal future increased rates of opioid overdose deaths for older adults, given that the proportion of older adults who are non-Hispanic Black is growing rapidly compared with non-Hispanic White men.23
It is notable that the beginning of the increase in opioid overdose deaths among older non-Hispanic Black men coincides with what the Centers for Disease Control and Prevention24 has identified as the third wave in the opioid epidemic characterized by the increased presence of fentanyl, a powerful synthetic opioid in the drug supply. However, it is unclear why other older adult subgroups did not experience concomitant increases in opioid overdose rates. These differences could be, among other factors, related to differences in the characteristics of the drug supply accessed by subgroups and/or whether substances contributing to the overdose were illicit or prescription. Further investigation is needed to elucidate the reasons behind these disparities.
Our findings on sex and racial and ethnic disparities in opioid overdose deaths among older adults offer a starting point for further investigation. Further research is needed to address the reasons behind the increase in opioid overdose deaths in older adults and the factors associated with racial disparities. For example, more information is needed regarding older non-Hispanic Black men who die due to opioid overdose, including substance misuse history, presence of a diagnosed SUD, past treatment episodes,47 presence of medical conditions, social isolation, and mental health disorders. This information can help to inform intervention, treatment, and prevention approaches for older adults with SUD.
In general, during the last 20 years, men have consistently had higher rates of opioid overdose deaths compared with women.19 Racial and ethnic group disparities in rates of opioid drug overdose deaths have fluctuated between 1999 and 2019. As the epidemic escalated, rates for non-Hispanic White adults rose exponentially compared with other groups, driving up the overall rate of opioid overdose deaths. However, from 2017 to 2019 (the latest year for which data are available), the gap between non-Hispanic Black and non-Hispanic White adults has narrowed as rates rose for the former group and modestly declined for the latter group.20
The prevalence of chronic conditions treated with opioids such as arthritis and cancer increases with age, so exposure to medically prescribed opioids among older adults is higher, thus the potential risk for fatal overdose in this population increases.10-12 Aging decreases the body's ability to metabolize opioids, a potential contributor to fatal overdoses.13,14 A decline in cognitive functioning may interfere with taking opioids as prescribed, again a potential contributor to fatal overdoses.15 Social isolation and depression increase with age and are associated with SUD, which may play a role in opioid overdose deaths among older adults.16,17 In addition, the present generation of older adults uses substances at higher rates than previous generations.4,18 The higher prevalence may contribute to opioid overdose deaths in older adults in combination with physical changes associated with aging.4
Figure 1 shows that rates of opioid overdose deaths among those 55 years and older increased each year from 2000 to 2019, with the largest increase from 2015 to 2016 (1485). From 1999 to 2019, the annual rate of opioid overdose deaths among those 55 years and older increased 10-fold, from 0.90 per 100 000 population in 1999 to a high of 10.70 per 100 000 population in 2019.
The steepest trajectory and outlier was that of non-Hispanic Black men, who had a slope of 11.07, almost twice that of non-Hispanic American Indian or Alaska Native men (6.24). The rates for non-Hispanic Black men ranged from a low of 2.24 deaths per 100 000 population to a high of 40.03 deaths per 100 000 population.
Before 2013, the highest rates in older adults were found among Hispanic or Latino men, non-Hispanic Black men, and non-Hispanic American Indian or Alaska Native men and women. However, in 2013, the rates diverged for non-Hispanic Black men, with steep rate increases for each subsequent year, and this subgroup had the highest rates of any of the 10 subgroups. In 2019, the year with the highest overdose rate for all population segments 55 years and older, the rate of opioid overdose fatalities for non-Hispanic Black men was nearly 4 times higher. Meanwhile, rates for Hispanic or Latino men and American Indian or Alaska Native men and women fluctuated with small increases after 2013.
Both racism and ageism may be associated with these disparities. In terms of racism, many potential factors could contribute to higher fatality rates among the non-Hispanic Black population in general and among men in particular. These factors include the consequences of structural racism,25,26 such as disparate access to SUD treatment27; bias in pain treatment28; residential concentration in low-resource communities with limited access to good schools, health care, and healthy foods29; medical mistrust30; and racially biased drug policies.31 In addition, factors associated with ageism and aging complicate our understanding of these trends.
The US Preventive Services Task Force recommends screening adults of all ages for unhealthy alcohol and drug use.32 However, screening for substance misuse among older adults is often lacking.33 Several factors may contribute to this lack of screening, but ageism in particular reflects widely held beliefs among clinicians and the public that older adults do not develop or experience SUD.33-35
Another factor may be mistaken attribution of signs of SUD, such as declines in physiological and mental functioning to the process of aging.33 Alternatively, aging-related changes in functioning may mask signs of SUD.33 In addition, the stigma of SUD, which may be more acute among older adults,36 may cause them to hide or fail to disclose substance misuse to clinicians.33
Medications for OUD are well established as effective in treating OUD and preventing overdose deaths.37 However, less than 10% of older adults admitted for treatment report these medications as part of their OUD treatment plan.38 Buprenorphine hydrochloride is the most commonly prescribed agonist for SUD, and it offers distinct advantages for older adults compared with alternatives methadone hydrochloride and naltrexone hydrochloride.39 Prescriptions for buprenorphine have grown between 2009 and 2018 for adults aged 55 to 80 years,40 but rates of buprenorphine use are still low among older adults seeking OUD treatment.38
The news is not all bleak for older adults with SUD. Because older adults use health care more often than younger adults,23 and owing to recent changes in health care coverage (including the Affordable Care Act and Medicaid expansion) that have made health care more accessible to all, opportunities for SUD screening in health care settings are increasing. To take advantage of this opportunity, expanded training is needed for physicians, advanced nurse practitioners, nurses, home health care workers, and other clinicians as well as other elder support service professionals who supply meal home delivery and transportation services. In addition, training in recognition of the signs of SUD in older adults, referral to SUD screening, and implementation of SUD screening as recommended by the US Prevention Task Force are needed.32
The uniqueness of older adults with SUD suggests that for SUD treatment, as with most forms of health care, a one-size-fits-all model is not likely to provide optimum success. Some evidence suggests that older adults are more successful with higher-dosage treatment models, but more information is needed to match older adult needs with treatment modalities.43,44 Treatment for SUD must take into account issues unique to older adults, and more specifically among older non-Hispanic Black men with SUD. For example, it has been reported that older adults are less comfortable attending group therapy than younger adults.45 It is speculated that this difference may be due in part to generational prohibitions against discussing trauma and internalized stigma regarding substance misuse.23 Specific to non-Hispanic Black men, issues of mistrust and experiences of racism will need to inform treatment models. This may require use of credible messengers (eg, those with similar lived experience) to achieve outreach and treatment goals. We use the concept of a credible messenger adapted from the Cure Violence prevention program model.46 Credible messengers can relate to the target population. They are considered credible because they are a part of the community being served, can relate to high-risk individuals, are respected by high-risk individuals, and have the ability to engage, connect, and empathize with them. In most cases, credible messengers have relevant lived experience and are therefore seen as having "been there and done that" with regard to risk behaviors, which allows them to reach the target population in ways that others cannot. Both outreach workers and violence interrupters should be credible messengers, allowing them to reach the target population in ways that others cannot. Other considerations for tailoring SUD treatment for older adults include the medical complexity of older adults who disproportionately experience physical health comorbidities and polypharmacy, which may interact with their SUD recovery, accessibility for those with limited mobility, transportation needs, and accommodations for hearing and vision impairments36,39
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