Addiction leads to tragic ends

Over the past 15 years, the reported incidents of fatal drug overdoses among Hawaii residents 60 and older have nearly quadrupled.

The numbers are still relatively small. But a good chunk of the increase has been attributed to a rise in the abuse of prescription drugs.

Physicians, psychiatrists and others who treat older patients say they are seeing more cases in which the legitimate use of powerful painkillers, anti-anxiety medications and other such pharmaceuticals eventually transforms into misuse and abuse — sometimes with deadly results.

And they expect the problem to continue growing as Hawaii’s senior population increases, the medications remain readily accessible and health care providers and others become more adept at recognizing addictions among older residents.

"In the last three years, it has just exploded," said Alan Johnson, chief executive of Hina Mauka, Hawaii’s largest alcohol and drug treatment agency.

In 2005, Johnson’s agency served 1,500 adults in its drug treatment program, and only 15 — or 1 percent — were over age 50. This year, the number hit 245, or 16 percent of the overall total.

The growing problem of prescription drug abuse among Hawaii residents of all ages has mirrored national trends and generated media stories and increased public awareness, especially in the last year or two.

But the effect on Hawaii’s older residents has received much less attention, partly because the numbers, though increasing, remain small and the problem is more difficult to recognize among seniors, who often are on multiple medications for multiple ailments.

"I believe it remains a hidden problem," said Dr. Scott Miscovich, a Windward Oahu family physician who has patients in their 70s dealing with the issue.

One of his patients, a 65-year-old retired law enforcement officer, didn’t realize he had a dependency problem until a month’s supply of his pain medications was stolen earlier this year and he couldn’t get a refill.

Desperate to not go through withdrawal, the retired officer, who is dealing with chronic pain from multiple on-the-job injuries and two knee replacements, turned to a dealer on the streets.

Even though he knew the transaction was illegal, he purchased $600 worth of Percocet, one of the painkillers he was taking.

The man, who told his story to the Honolulu Star-Advertiser on the condition he not be identified, said he takes painkillers not to get high, as some do, but just to be functional.

He said he didn’t believe he had an addiction problem, although he eventually was taking twice the prescribed dosage and turned to relatives to "borrow" pills when his monthly supply was depleted.

"All I wanted to do was achieve a feeling of normalcy," he said.

Wanting to feel normal and be functional are not uncommon goals of those taking opiates to deal with chronic pain, according to Miscovich, who heads a state task force that is expected to recommend to the Legislature next month how to revise Hawaii’s drug laws to better address the prescription drug abuse problem.

For older residents, opioid pain relievers and benzodiazepines (drugs such as Xanax and Valium used to treat anxiety, insomnia and other conditions) are two of the mostly commonly prescribed medications that are potentially addictive.

The abuse problem is being driven in part by baby boomers who are hitting retirement age, want to stay active and are accustomed to popping pills to fix whatever ailments they have.

The overwhelming majority, physicians say, use their medications appropriately and as intended. But misuse enters the picture when people take the drugs because of the euphoric feeling they get.

That includes some older residents bored by retirement, according to local psychiatrists.

The line between what is an appropriate use and what isn’t sometimes is fuzzy, and underlying behaviorial disorders that can contribute to addictions further muddy the picture, health care providers say.

Also, the symptoms normally associated with chemical dependency, such as memory lapses and disorientation, are typical signs of aging, helping to mask the problem further.

The 65-year-old retiree said if he stopped taking his pain pills, he would be too miserable to do anything.

"All your energy leaves your body," he said. "You don’t want to do nothing because your body is suffering so much."

The rise of the abuse problem is reflected in the rise of fatal drug overdoses here.

In the five-year period through 2013, the number of fatalities for residents 60 and older totaled 132, a 288 percent increase from the five-year period through 2003, according to data from the Department of Health’s Injury Prevention and Control Program. The fatalities included deaths from prescription and illicit drugs.

Of the 132 deaths, at least 66 were due to prescription drugs, the numbers showed. In the 1999-2003 period, only 28 were attributed to prescribed medications.

The statistics also indicated that many of the overdoses were accidental, reflecting the dangers of misusing powerful medications or mixing them with illicit substances.

Of the 225 fatal overdoses reported from 1999 to 2013, about half were unintentional, while another 26 percent were deemed suicides. Intent could not be determined in the remaining fatalities.

For that 15-year period, Dan Galanis, epidemiologist for the injury prevention program, analyzed about a half dozen different causes of death for residents 60 and older, including falls, drownings, motor vehicle accidents and suffocation.

Drug poisoning was the only one that increased substantially.

What’s more, the 288 percent increase in overdoses far outpaced the 35 percent jump in the population of that age group.

Elisa Yadao, a senior vice president for Hawaii Medical Service Association, Hawaii’s largest health insurer, said prescription drug misuse isn’t a big problem for her organization because of programs in place to monitor and manage medication use of its members.

But the issue clearly is on HMSA’s radar.

"The potential for elderly individuals to misuse prescription medication is increasing simply because there are now more prescription medications available," Yadao said in an email to the Star-Advertiser. "This is a particular concern for HMSA because elderly patients are more sensitive to medications, increasing their risk for impairment and side effects. Some of the prescription medications that are a concern include medications for insomnia, pain, depression and anxiety. In general, as patients get older, their need for these types of medications increases."

Hina Mauka’s Johnson also noted that the longer people take painkillers, the more sensitive they become to pain, subsequently requiring even greater doses to deal with their condition.

"It becomes a vicious circle," he said.

Johnson said families have contacted his organization not knowing what to do about a grandparent who has developed a dependency problem. In several cases, the craving apparently was so great that the grandparent asked a grandchild to purchase drugs from a street dealer, Johnson said.

"These are experiences we’re not used to dealing with," he added.

The abuse problem is compounded because many physicians are not trained to spot addictions and continue to prescribe the medications without realizing underlying behaviorial issues may be factors, according to Johnson.

If a behaviorial specialist is treating that patient, the specialist and the patient’s medical doctor often don’t communicate, something that needs to change to effectively combat the problem, Johnson and Miscovich say.

More likely can be done as public awareness about the issue builds, particularly if the patients themselves acknowledge something’s wrong.

One of Miscovich’s patients, a 60-year-old downtown resident, recognized early on that he was becoming too dependent on painkillers to deal with chronic and severe back pain.

"You stop taking it, and your body goes through some mean gyrations," said the 60-year-old, who also shared his story on the condition he not be named. "You become so dependent that you don’t know if it’s the pain medication or the actual injury that’s causing the pain."

With Miscovich’s help, the 60-year-old has substantially reduced the amount of painkillers he is taking and has turned to acupuncture, which seems to be working.

The man said a relative was not so fortunate.

She became addicted to pain medications to deal with a severe back injury she suffered nearly 20 years ago in Nuuanu. When the drugs didn’t satisfy her body’s cravings, the woman turned to heroin.

She died in June. She was in her early 50s.