"Geriatric substance abuse is a growing problem that the medical community and the legal community, including those of us who work with seniors and their families, need to be very aware of," said certified elder law Attorney RJ Connelly III. "One of the key issues regarding this topic has been a plethora of information on licit drug abuse among this age group, but little in the way of valid information on illicit drug use."
"The reasoning was that once someone with an addiction aged, they would grow out of their use of street drugs," Attorney Connelly continued. "This is no longer the case as Baby Boomers are bringing their habits into their senior years. And like our blog on the increased potency of marijuana, the drugs on the street today pose a much different hazard to today's senior drug abusers. We are going to discuss one of these drugs in this blog."
Shanice - 67 and Still Using
When I first received the phone intake paperwork on Shanice, from a first glance at the presenting issue of fentanyl abuse, I assumed her to be on the younger side. However, when I met her, her age of sixty-seven surprised me. Her hair was dyed blonde and braided, she was dressed smartly however her short sleeve blouse revealed years of IV drug use as scars could be seen running up both arms, between her fingers, and even on the side of her tattooed neck.
She was from the Roxbury neighborhood of Boston and told me she had used drugs in two distinct periods of her life. Her first run was when she was a late teenager when "my boyfriend and I used weed but he turned me on to smack (heroin) really quick and I ended up hustling on Blue Hill Ave until I got deathly ill from Hepatitis C."
For Shanice, this illness ended up getting her admitted to a treatment program where she flourished in recovery for nearly twenty years, managing to stay clean for the most part, "I had a few slips here and there with alcohol and weed, but stayed away from smack." When she hit her mid-fifties, she was diagnosed with ovarian cysts and was in tremendous pain. "I needed opiates for the pain and that seemed to set off the cycle again." By the time she hit sixty, she was back on the street again, homeless and turning tricks once again. "Let's face it," Shanice said, "who wants an old lady when there are so many young ones out there. So, I found myself shoplifting and busting into cars to get the money I needed."
Her crimes against property led to multiple arrests and incarcerations, and because of this, she lost a housing voucher and is homeless, going from shelter to shelter. "The funny thing is, there's more drugs in the shelters than there are on the streets, guess the hookups (dealers) know they have a captive audience," she said with a sarcastic laugh.
"I'm scared to death now. There's a load of toe tag dope out there, I'm old but I ain't ready to die. I want this part of my life to end, I can't do it anymore." --- Shanice
Shanice told me that her daily routine consisted of waking up, trying to find ways to make money for her heroin, trying to find a dealer, shooting up, and starting the cycle all over again. She half-heartedly bragged about "being able to hit veins that doctors can't even see." But it was fear that brought her in for treatment. "I'm scared to death now. There's a load of toe tag dope (fentanyl) out there, I'm old but I ain't ready to die. I want this part of my life to end, I can't do it anymore."
Shanice knew what Fentanyl could do as it almost took her life one late fall day just a few blocks up from Community College.
"We were getting high with a bunch of others on the porch of a crack house. Some dude comes along and said he had a new batch of dope, and it was sweet. I didn't get it all in when I wake up in the ER. Turned out it was laced with Fent, I never wanted to try that again. Today, it's everywhere, just can't do it no more," she repeated.
What is Fentanyl
Fentanyl, a synthetic opioid, is legally used to treat individuals with chronic severe pain or pain following certain surgeries. It is a Schedule II controlled substance (substances or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous) like morphine but about one hundred times more potent.
For years, China has been the primary source of the drug trafficked into the United States through Mexico. In 2019, China's government banned the production and sale of fentanyl, which put a dent in the drug trade. But in 2020, Chinese vendors began to market fentanyl analogs (A fentanyl analog is a drug that has been designed to mimic the pharmacological effects of the original drug. Some manufacturers create new fentanyl analogs to avoid classification as illegal, policy restrictions on manufacturing, and/or detection in standard drug tests. New fentanyl analogs are being made regularly) and shipping them directly to dealers in the United States and Europe, as well as to the Mexican drug cartels.
Even though fentanyl is a synthetic drug, it still attaches to the opiate receptors in the brain. These neurotransmitters are responsible for both feelings of pleasure and feelings of pain. Once the drug is attached, it not only relieves the pain but produces a euphoric high. It only takes one dose for the body to crave the drug again. This is due to the reward system in the brain and the chemicals released. Fentanyl addiction is characterized by:
Trouble focusing or making decisions.
Slowed heart rate.
Decreased, shallow, or irregular breathing.
Loss of consciousness.
Obviously, the most dangerous side effect of fentanyl use is overdose. And because fentanyl may be mixed with other drugs to increase the potency, its strength is often underestimated. As we pointed out before, this synthetic drug is one hundred times stronger than morphine and fifty times more powerful than heroin.
The Killing Fields of Washington, DC
Washington DC has always been a violent place to live. Last year, the murder rate reached a 16-year high, ranked as the (state equivalent) with the highest homicide rate in 2020, with 24.4 killings reported for every 100,000 residents, according to a report by the Centers for Disease Control and Prevention's National Center for Health Statistics. But as prevalent and deadly as shootings are in the nation's capital, drug overdoses have that number beat.
"But as prevalent and deadly as shootings are in the nation's capital, drug overdoses have that number beat. This is the sixth year in a row that drugs have killed more than guns in Washington, DC."
This is the sixth year that drugs have killed more than guns in Washington. This trend started in 2014, and as gun violence surged, so too did the overdose deaths. And to make this trend even more problematic, the ages of those dying from overdose rose as well.
Edwin Chapman, a seventy-five yead old addiction counselor recently told the Washington Post that the average age of OD deaths in 2014 was fifty-two, and today it is sixty. Although we are looking at Washington, DC, the reality is that overdose deaths among seniors are rising throughout the country.
According to the National Center for Health Statistics, drug overdose deaths between May 2020 and April 2021 numbered more than 100,000 in the United States, and many of these deaths are among older Americans. A new study published in JAMA Network Open reported that in adults aged fifty-five and older, opioid deaths rose tenfold between 1999 and 2019, going from 0.9 deaths per 100,000 to 10.7. Those numbers are significant. In 2019, opioid overdose deaths among those aged fifty-five and above were 10,300 compared to just over 500 in 1999.
The addition of fentanyl has played a leading role in the increases in overdose deaths, and there are even stronger synthetic opioids showing up as well.
Nitazenes Showing Up on Inner-City Streets
A new class of synthetic opioids called nitazines is hitting the streets in major cities. It is a popular, subclass of synthetic opioids that is cheaper to produce and sell. As these gain in popularity, so will the continued increase in overdoses. Protonitazene, said to be three times stronger than fentanyl, is the newest synthetic opioid showing up on the street. Protonitazene is a structural isomer (molecules that have the same molecular formula but have a different arrangement of the atoms in space) of Isotonitazene.
"...Nitazenes are hitting the streets in major cities ... Protonitazene [is] said to be three times stronger than fentanyl...Etonitazene is 1,000 times more powerful than morphine...Isotonitazene is also stronger than fentanyl."
According to Healthline.com, "Isotonitazene, commonly referred to as “iso,” is a synthetic version of etonitazene, an opioid that’s been around since 1957.
One report says the drug is causing about 40 to 50 deaths a month in the United States. That’s up from about six per month last summer.
“Etonitazene [a nitazene developed some 60 years ago and controlled internationally] is 1,000 times more powerful than morphine,” Dr. Yili Huang, the director of the pain management center at Northwell Health’s Phelps Hospital in New York, told Healthline. “Although isotonitazene is less potent than etonitazene that it’s derived from, it’s still more potent than fentanyl. The best way to think about it is that isotonitazene is a stronger cousin of fentanyl and therefore likely even more dangerous."
Because there is a lack of awareness of nitazenes, quick death may occur when combined with other drugs of abuse like benzodiazepines and fentanyl.
The Elephant Opioid
When this hit the streets a few years ago, many believed it was propaganda designed to scare addicts away from using heroin, but as rapid deaths started occurring, it became clear that the danger was real. The synthetic opioid we are talking about is carfentanil.
"Carfentanil is a synthetic opioid that is 10,000 times more potent than morphine and 100 times more potent than fentanyl, which is 50 times more potent than heroin."
Carfentanil is a synthetic opioid that is 10,000 times more potent than morphine and 100 times more potent than fentanyl, which itself is 50 times more potent than heroin. carfentanil is so dangerous that law enforcement agents must treat it as a biohazard when handling it.
Carfentanil is a Schedule II substance under the Controlled Substances Act and is used as a tranquilizing agent for elephants and other large mammals. The lethal dose range for carfentanil in humans is unknown.
Using Naloxone (Narcan)
Naloxone (Narcan) is a drug that is used to reverse the effects of an opioid overdose. It is commonly administered as a nasal spray, and once the spray enters the user’s nostrils, it is absorbed and works as an opioid antagonist in the brain. Naloxone knocks opioids off the opioid receptors in the brain, blocking them from absorbing more opioids, which helps to reduce the negative effects of overdoses.
Naloxone acts in two to three minutes. If the person does not wake up in three minutes, a second dose should be given (rescue breathing should be done while you wait for the naloxone to take effect so that the person gets oxygen to his or her brain). Because this medication does induce instant withdrawal, the victim could be combative and confused upon regaining consciousness.
Naloxone is an opioid overdose reversal drug but is not always effective. The use of straight fentanyl or mixing fentanyl with heroin complicates Narcan administration. A recent study reported 83% of patients required greater than two naloxone doses (usually nasal 2 mg/2 ml) in suspected fentanyl cases before a response was observed. However, for those fatal deaths, 36% had evidence of an overdose within seconds to minutes after drug use meaning that the immediacy of naloxone administration was of the essence.
"...Naloxone only works on overdoses caused by opioids. [It] will not reverse overdose resulting from non-opioid drugs like cocaine, benzodiazepines, or alcohol."
Emergency services are still required as the naloxone molecule will fall off the opioid receptors in the brain within 30 to 90 minutes and the overdose symptoms will return as some opioids can stay in the body for up to twelve hours and return to those receptors.
Finally, naloxone only works on overdoses caused by opioids. This family of drugs includes prescription painkillers like OxyContin, fentanyl, methadone, and Vicodin, as well as street drugs like heroin. Naloxone will not reverse overdose resulting from non-opioid drugs, like cocaine, benzodiazepines (“benzos”), or alcohol.
How Serious is This?
"When our offices first started doing free presentations on drug addiction issues with seniors, many senior care providers felt this was a problem on the street, and not necessarily one that assisted living and long-term care providers needed to worry about," said Attorney Connelly. "But with the graying of America and those seniors coming into care are bringing their boomer behaviors with them, it is something that everyone who works with seniors, whether it be long-term care or home health care, needs to be aware of."
"Nearly every expert in this field that we have spoken to tell us that opioid addiction in seniors goes undetected by primary care providers way too often," stated Attorney Connelly. "Some of the signs of fentanyl and other opioid abuse in seniors are not much different than those in younger people, but other health conditions such as dementia or depression can complicate a substance use disorder diagnosis. Knowing what to look for physically and behaviorally is extremely important for providers."