HealthChangers Podcast: Addressing substance use disorders in people over 60

By Regence

May 18, 2023

On this episode of HealthChangers, Stephanie Strong, CEO and Founder of Boulder Care and Dr. Mike Franz, Regence’s senior medical director for behavioral health discuss new data from the Centers for Disease Control and Prevention showing drug and alcohol-related deaths are on the rise among Americans over 60.

Podcast Transcript

Ben Furr (BF): Welcome to the HealthChangers podcast presented by Regence, where we share real-life stories and expertise from leaders who are working to make healthcare simpler, personalized and more affordable. I’m your host, Ben Furr.

New data from the Centers for Disease Control and Prevention shows drug and alcohol-related deaths are on the rise among older Americans. Many people consider substance use disorder, or SUD, as mostly a problem for younger people, but it is a growing issue in the older population.

Here to talk more about this important topic is Stephanie Strong, CEO and founder of Boulder Care, which offers telehealth addiction treatment and Dr. Mike Franz, Regence’s senior medical director for behavioral health. Stephanie and Dr. Franz, welcome to HealthChangers.

Mike Franz (MF): Thank you.

Stephanie Strong (SS): Thank you so much for having us.

BF: So, to kick it off, at a high level, how do we define substance use disorder?

MF: I would say that substance use disorder is when the use of some kind of substance, be it alcohol, an opiate, or other illicit substances, gets to the point where it's causing significant impairment in someone's functional activities. And, this can often be accompanied by tolerance, where there's increased need for the substance to have the desired effect, and in some circumstances can be accompanied by withdrawal symptoms. But the core features of a substance use disorder are the use of substances that really create functional challenges in one's life in multiple domains, so relationships, occupationally, and home life would be examples, or one's health or legal implications.

BF: Are there any groups or specific people that are affected more than others?

MF: We're here today to talk about it in older adults, but we know that there has been a lot of focus on younger folks as well. I think we're here to dispel the myth that this is only a younger person's disease or issue. It really can affect almost the entire lifespan. I would say spanning from early adolescence through end of life. And all of those different age ranges really deserve our attention and opportunities for prevention, identification of the issue, engagement and effective treatment.

BF: Stephanie?

SS: That's exactly right. Substance use disorders are increasing in prevalence across all swaths of our population in America, most typically you hear about alcohol and opioid use disorders, which is where Boulder Care is focused in our partnership with Regence in helping to reach more folks who are struggling with these often-lifelong chronic conditions. And as we hear more and more in the news about overdose deaths climbing every year, often it is due to a combination of multiple substances.

We saw that from 2019 to 2020 overdose deaths increased 53% among Americans over age 65, but it's often overlooked in developing solutions and delivering care despite the increasing need.

And as Dr. Franz said, we really define substance use disorder as problematic use that continues despite unintended consequences. And I think that's a really important part of the definition. Folks use alcohol legally and some recreational drugs as well. But really when we start to get concerned is when it starts to impact their health, their happiness and their lives in a way that would really motivate them to make a change. I'm excited to talk more, as Dr. Franz said, about the over-60 population where there is certainly a need. We saw that from 2019 to 2020 overdose deaths increased 53% among Americans over age 65, but it's often overlooked in developing solutions and delivering care despite the increasing need.

BF: Yeah, I was reading the recent press release from the Centers for Disease Control and Prevention, around just the increase in overdoses within the older adult population. 5,000 have died or did die from a drug overdose in the US in 2020, more than twice as many, 11,600 plus died of alcohol-induced causes. Then it increased 18% or alcohol-induced death rates for people aged 65 and older have been increasing since 2011. And I guess it increased 18% from 2019 to 2020. Shocking statistics.

MF: Those really are. And what I really appreciate about Boulder Care is that while we are living in an opiate use epidemic, they don't confine their work just to opioid use disorder, but have also identified alcohol use disorder as an area of opportunity to reach our members and help them with treatment.

I think when we think about medication-assisted treatment, I think a lot of people know about buprenorphine and opioid agonists that are so effective in treating that disorder effectively, unlike anything else we've really ever seen before that became available. But I think what we often forget is the underutilization of medication-assisted treatment for alcohol use disorder. And I think Boulder Care is doing a great service, not just to our members, but helping other providers remember that there is a role for medications in alcohol use disorder, whether it be acamprosate, naltrexone or in some cases disulfiram could be appropriate. But those three medications have a role and can really impact alcohol use.

And as you pointed out, you know, even though these stunning rates of overdose by opiates and the incredible spike in the past few years, you know, I think over a hundred thousand people died of drug overdoses in the previous year, alcohol use disorder kills more people and has for decades because it's so ubiquitous. And people, while they may not die of alcohol intoxication, they end up having shortened lives and dying from the medical comorbidities that develop as a direct result of their alcohol use. This is particularly impactful on the older adult population that we're talking about today.

BF: So, speaking of which, what are the unique causes of substance use disorder in older adults, and why might it be increasing now?

MF: I start off with loneliness and this was exacerbated by the pandemic. I think older adults who were already living alone or relatively isolated, experienced even more isolation. There are now studies that have proven causation between loneliness and poor health outcomes in general. Some have equated loneliness to the equivalent of smoking 15 cigarettes a day. And so, this can bring on desperation and desire to alter one's consciousness and lead to what may be initially some attempts just at numbing or recreation or diversion that then can develop into a true substance use disorder where Stephanie said so eloquently despite untoward consequences, one can't limit or stop their use. And I think that's a big part of it.

I also think the changes of life that happen as we get older, you know, whether it's retirement can be very challenging for some folks. The medical illnesses that develop in older age is a major risk factor for all types of behavioral health conditions, including substance use disorder you know. The loss of loved ones and grief as well, I think that the dulling of our senses, whether it's eyesight or hearing, I guess that leads more to isolation. But there are a lot of great things about getting older and the wisdom that comes with it. But there are some real challenges of it, as well.

SS: You really hit on so many of the societal and individual factors that increase risk for substance use disorders. Loneliness being a major one, as we think about coming out of the COVID pandemic. Often older Americans don't have strong support networks. They're losing friends and family. And similarly, those with SUD face kind of a loss to their support networks potentially they lost of close connections because of their use disorders. And we know that nearly 25% of adults, 65 and older are considered to be socially isolated, which increases your risk of SUD of depression and anxiety. At Boulder Care, we try to develop long-term relationships with our patients. So often we're seeing folks for months or years, and we know that every interaction we have with the patient as we're getting to know them and ask about their day, their health, their goals, that is a therapeutic intervention. But societally we hope that there can be more done just to bring older Americans closer to family and friends and continue to give them things to be excited about in life and hope that makes recovery from SUD worth it.

Nearly 25% of adults, 65 and older are considered to be socially isolated, which increases your risk of SUD of depression and anxiety.

We also are seeing a lot of military veterans. People have experienced trauma, PTSD it can be really hard, you know, recovering with some of those past mental health conditions and trying to find ways to again bring them into community and find peers.

And we also know that substance use tends to be generational, so, it occurs across families and in communities. Many of our older patients are caretaking for their adult children, which just adds to their stress and potentially cravings as they're trying to stop using drugs. So societal healing and all of the things that we can do to help bring people closer and more connected is directly going to help us overcome substance use disorder and other mental health challenges. And particularly important as we think about this population and increasing aging Americans you know, more and more as that cohort of our population grows.

BF: The silver tsunami, so to speak. In terms of how substance use disorder affects different groups differently, is it particularly harmful for people over the age 60? Or how does it affect them uniquely?

MF: Yes, it is particularly harmful for people over the age of 60. You know, as we get older, we don't metabolize substances as well. In general, most of our organs aren't as efficient or as healthy as they once were, even without substance use on top of it. But someone who may have been consuming a certain substance without as much impairment or very little impairment for years, once they stop metabolizing that substance as effectively as they once did, they may become more impaired and may not be aware of that. And then just the length of time of use of a substance is also super significant. So, if someone didn't develop, say, an alcohol use disorder or an opioid use disorder until, say, the age of 40, well, if they're using that chronically for 20 years, by the time they're 60, it's going to take a significant toll on their health.

And I'll just use alcohol as an example. If their use was heavy by that point, they're going to very likely have liver impairment. They may have repeated bouts of pancreatitis; they may be in the early stages of alcohol-induced dementia. It could affect their autoimmune system, and they may be having much more recurrent viral and bacterial infections, their circulatory system, the cardiovascular system. Alcohol can affect just about every part of your body. And you see that, and you know, that 60-year-old is going to appear substantially older than a 60-year-old who hasn't been using. And even for someone who is misusing or abusing opiates, even though we don't see the direct effect of the opiate necessarily as being, as toxic as alcohol to all those end organs, the lifestyle associated with that use and its effect when one is intoxicated and the risk of falls, the accidents the lack of nutrition, the lack of attention to hygiene that can take place over 20 years, again, you're going to have some very significant health impacts. And, Stephanie, Boulder Care does this work all the time. So curious about what your team sees in the older population that they're treating?

Alcohol can affect just about every part of your body.

SS: That very much resonates. You know, folks who have been using substances for decades with alcohol may be problematic use for years and years. And in the drug supply, there have been many changes over the last several years making that more dangerous. So, for patients who may have been injecting heroin for a very long time, some of our patients, you know, now they're in their sixties and they started when they were in their teens and only recently have they reported being really afraid because of fentanyl and other analogs in the drug supply and knowing that an increased risk of overdose death. It's almost impossible to find heroin anymore. So, these things are actually prompting older adults to seek treatment in some cases with us. And it's always such an amazing learning experience for us as providers. When we hear from folks who have been in and out of treatment programs their entire lives and have finally found a method of care and a team that is working for them.

MF: This is where wisdom helps as opposed to maybe the teenager who unwittingly takes that pill thinking, “oh, this will just get me high” and it's fentanyl and you know, these horrible tragedies, where a single, the first time of even taking any pill like that the young person dies from overdose. The older person is like, “I can't get the heroin that I used to get. When I knew what it was, and I knew what it would do to me. And I'm seeing all these people dying around me because all of a sudden, they got a hit of fentanyl and they died. And I don't want that happening to me.” So, there's this motivation to say, “I probably need to do something about this habit.” Yeah, that makes sense.

SS: Yeah. And older adults, as you mentioned, they do have a lot of physical health needs in addition to their addictive disease and may require treatment, but not have a good relationship with a primary care clinician. We've seen everything from cardiology issues to undiagnosed pneumonia and Boulder Care can provide some encouragement to seek care. And with our partnership with Regence, we’re so grateful to have case managers and a lot of support with other in-network providers to help navigate our patients into in-person care or specialty care. Once they are stabilized and a little bit more open to considering getting additional healthcare services, because we've satisfied that acute need, often, as Dr. Franz said, by prescribing medications that help keep people safe and help them feel a little bit more stable, hopefully, until we can work with them more closely to regain some energy and find things in recovery that make them more excited to live and improve their overall health and wellness.

BF: It's really interesting. Just in terms of the dramatic need, I'm wondering for our listeners, how can we connect them to help? What are some first steps they can take either for themselves or a loved one?

MF: You know, I always encourage our Regence members and and others to think of primary care as a first stop, you know, if they have a relationship with the primary care provider. Primary care is behavioral healthcare, especially these days. Primary care prescribes 70 to 80% of all psychiatric medications that are prescribed. More and more primary care homes have integrated behavioral health where they have licensed professional behavioral health providers part and parcel of their staff integrated fully integrated into the team who can do some initial screenings and assessments and some brief treatments. I myself on Fridays I consult to the two largest pediatric primary care clinics in Central Oregon in a consultative model where I never see the patients directly, but I'm able to do chart reviews and work with their behavioral health consultants and PCPs to make treatment recommendations.

"I always encourage our Regence members and and others to think of primary care as a first stop", says Dr. Franz.

And we can manage a lot of behavioral health, mental health, and substance use disorder, within that primary care home without ever the need to refer out.

And increasingly primary care providers are finding how satisfying it can be to provide medication-assisted treatment to members suffering from substance use disorder. In fact, I've heard providers, whether they're in primary care or specialty care, and I'm sure Stephanie can speak to this, say it's the most satisfying thing they've ever done in their career, because they're just dramatically and quickly changing people's lives and getting them back on track. They're getting their jobs back. They're getting their kids back. They're back doing the activities they enjoy doing because they're getting comprehensive treatment. But sometimes primary care isn't enough and that's why we do have specialty behavioral health in organizations such as Boulder Care, which really can deliver a more specialized level of treatment. And, some of the additional services. I'd love to hear Stephanie talk about what they offer, including their peer support services, which I think is really unique.

SS: Thank you, Dr. Franz. We would encourage not only patients who may be considering treatment Regence members to come to our website (www.boulder.care) but also primary care clinicians. It's core to our mission to help enable PCPs to provide addiction treatment to manage patients with this disorder. As Dr. Franz said, we have primary care clinicians on our team who've delivered babies. They've done healthcare in all different settings and find that when you're able to help someone start recovery, it is one of the most transformational things you can do as a provider. So, hoping we can all continue to work together to serve Regence members and other supports that Boulder offers, I think are also really meaningful to Regence members today. One of them being peer support. Every Boulder patient has access to a peer, someone with lived experience in recovery, but also specialized training in helping to link people to resources, conduct motivational interviewing, connect with empathy, having been through many of these same experiences before and work with patients to develop a long-term relationship.

We do have folks on our peer team who are over 65 and have been through recovery programs for years and years and love connecting with our patients on some of their unique challenges and goals. We also offer a lot of support with many of the things that can disrupt someone's recovery journey in hopes of just eliminating friction. Everything from pharmacy issues to insurance questions, to helping someone find work or safe housing. So we have a full dedicated team focused on eliminating all of these barriers that are common for people so they can focus on their recovery and their health.

BF: That's awesome. I'm also thinking in terms of, you know, the topic of stigma comes up quite a bit. How does it relate to this particular population and condition of substance use disorder?

MF: It's a great question and I think it's an area where we're still struggling to get the data on it. But I think, you know, anecdotally and from experience I would say, unfortunately, this population probably holds onto that stigma, I should say, about behavioral health more than younger populations. My own sense, and again, I'd love to back it with some more data, is that over the past 10 to 20 years, we've really made some progress with the stigma around mental health and substance use disorder. And I think COVID, you know, one of the silver linings kind of turbocharged that. I think, you know, everybody's family was touched by behavioral health during covid, if not a family member, then ourselves directly. Just such a challenging time and just really brought that out. And I think my sense is there's just a lot less stigma, but the older population, I think just because they lived in a time where behavioral health conditions and especially substance use disorder was kept more in the closet, may struggle more in regards to overcoming the stigma issue. So, in my opinion, we still have our work cut out for us, especially with that population might be a little bit harder to engage. But again, that's where I would defer to Stephanie and her team as far as what they've seen. And if there's anything that seems to help with that.

I do think older Americans and really anyone who would benefit from a private experience can look to telemedicine.

SS: Well, I think we are chipping away at stigma for SUD. Unfortunately, largely because it is so prevalent now that everyone feels the impact in their own lives with themselves or a loved one. But in many ways that is helping to make conversations easier. I do think older Americans and really anyone who would benefit from a private experience can look to telemedicine, which is one of the things Boulder Care looks to do in offering a virtual care model as a way to have a private experience on your own terms when you're seeking treatment or information about overcoming SUD, recognizing that it can be really hard to go to a local facility and worry about being seen. In addition to the lack of access to a specialty provider and many communities across the US and certainly in Washington, Oregon, some of the rural areas where we're treating patients today. But I think also families can support their loved ones maybe not by immediately addressing the substance use or that behavior, but by asking how they're doing, checking in, spending more time with loved ones who may be struggling with isolation or loneliness as we talked about earlier in our discussion. And just finding ways to be there for loved ones if you're worried about their health making sure that they're not alone.

BF: And for those who have some, I wouldn't say tech phobia, but for those who aren't comfortable with a smartphone or a computer, how does telehealth work for that population? How are they best engaged?

SS: It's certainly something we focus on. I think we started seeing patients several years ago with an initial cohort of 100 individuals and 10% of our initial population were folks over 65. And that let us really test and learn and build an entire model and a tech product around their unique needs. And what we found is that our older patients are thriving in care.

We need to continue to refine our tools and processes so that we can best support any level of tech literacy, but over time they really appreciate the benefits of telemedicine and build strong relationships with their virtual care team.

We have a lot of tools and supports specifically to help with things like getting started with technology, setting up the mobile app to receive care via video visit, ensuring people have access to Wi-Fi and data, and if not having callbacks like audio-only and picking up the phone and having a call, engaging their loved ones or family in care to help with technology barriers or any other issues that they may be experiencing. A team of dedicated support specialists to walk through any type of troubleshooting. And of course, now seeing the results that prove out over time, you know, are older patients are actually coming to more visits. They have no-show rates lower than the average population. They have a net promoter score indicating satisfaction in care of 90, which is slightly higher than the average patient in the Boulder Care model, despite having pretty high NPS across the board and higher retention rates of 70% at six months in care, which is more than triple what you'd see in a typical medication treatment program. So, I think what we've learned is that there may be some initial education and support. We need to continue to refine our tools and processes so that we can best support any level of tech literacy, but over time they really appreciate the benefits of telemedicine and build strong relationships with their virtual care team.

BF: I think we make a lot of assumptions about older adults too, in terms of their comfort level with technology. A lot are more savvy than we give them credit for, so I'm glad to hear there's a hybrid approach.

Technology can help enable services, not replace them.

SS: I agree. I think they're incredibly resilient and resourceful and brilliant people and we underestimate maybe some of the other barriers that are more formidable than technology. Asking, you know, a 90-year-old to get in a car and go to the doctor every week is really hard for the older family members in my life and I'm sure others can relate. And if we're able to kind of meet people where they are and develop tools and processes that really work for them fitting seamlessly into their life at any age or location you know, there are ways to overcome these, these challenges that technology can help enable services, not replace them.

BF: Yeah. Meeting them where they're at. I love it. So, this has been a really good conversation. Any final thoughts for our listeners? Any key takeaways as we wrap up?

MF: I'm just thrilled that Regence and Boulder Care been able to form this partnership and it's in the service of our members, and glad to say that it's available to our commercially insured as well as our Medicare Advantage members. So, all ages and this focus that we've had on older adults today, I think has been really important. It's an often-neglected population, so we just encourage our members and their families to seek out Boulder Care, whether it's through their website or you can get, also get it through regence.com and get yourself or your loved one the services that you deserve. And I really appreciate Stephanie's time today and the ongoing partnership.

Telemedicine can often be a private and really accessible option.

SS: Likewise, Dr. Franz, we're so grateful that Regence is making programs like Boulder Care available to members and education and support and sessions like this. And if I can maybe just finish with a real story from a Regence member shared with her permission just to highlight what impact this work can have. One of our patients is a woman in her late sixties who is a mother and grandmother sought treatment for opioid use disorder with us over two years ago. She said she would feel a sense of shame going to in-person treatment. As we talked about earlier, telemedicine can often be a private and really accessible option for folks. And her goals included reuniting with her family. Her son had become estranged largely due to her use disorder, and she developed a love for riding motorcycles inspired by his love for bikes and Harley Davidsons. So, she joined a group of other women where she was a peer mentor, and they would ride together. And after working through a really challenging path with overcoming opioid use disorder, taking medication, and spending time with her Boulder team, I’m thrilled to report that she has started writing with her son again and getting more time with her granddaughter. So, when we talk about outcomes, these are the many things, clinical and nonclinical, that matter most to us, and the promise of seeking treatment and getting medication for substance use.

BF: I can't think of a better way to end the podcast. So, Dr. Franz, Stephanie, thanks so much for your time.

MF: Thank you.

SS: Thank you.

BF: And that wraps this episode of HealthChangers. Episodes are available on your favorite podcast platforms like Apple Podcasts, Stitcher and Spotify. Just search for HealthChangers. Thanks for listening.