Journal of Gerontological Nursing

Clinical Concepts 

Managing Heroin Addiction in an Outpatient Setting: A Case Study

Kate Driscoll Malliarakis, PhD, ANP-BC, MAC, FAAN

Abstract

Heroin use may be under-recognized among older adults. Baby Boomers are the largest age as well as the largest drug-using cohort in modern history. Although some drug users age out of their addiction, others do not. Nurses caring for older adults may come into contact with heroin users due to associated conditions or sequelae of their drug use that cause them to seek care. Few nurses are prepared to provide the care needed when heroin use accompanies other health problems. Using an individual example, the current article provides guidance for identifying heroin addiction, essential information about heroin use, and resources for guiding patients to experts for the comprehensive care needed for recovery. [Journal of Gerontological Nursing, 41(12), 10–14.]

Abstract

Heroin use may be under-recognized among older adults. Baby Boomers are the largest age as well as the largest drug-using cohort in modern history. Although some drug users age out of their addiction, others do not. Nurses caring for older adults may come into contact with heroin users due to associated conditions or sequelae of their drug use that cause them to seek care. Few nurses are prepared to provide the care needed when heroin use accompanies other health problems. Using an individual example, the current article provides guidance for identifying heroin addiction, essential information about heroin use, and resources for guiding patients to experts for the comprehensive care needed for recovery. [Journal of Gerontological Nursing, 41(12), 10–14.]

Mrs. S. is a 65-year-old Caucasian woman who presented at a primary care practice as a new patient. She was referred by the local emergency department (ED) for follow up. She was seen in the ED 10 days ago for an excision of an abscess in her right groin. She is taking amoxicillin 250 mg four times per day. In her medical history, Mrs. S. noted adult-onset diabetes (controlled by diet); hypertension (controlled by Avapro®150 mg once per day); chronic obstructive pulmonary disease (for which she takes albuterol when necessary and tiotropium, but is currently not using any medications for shortness of breath); and aches and pains in her hands, feet, and back that she attributes to arthritis (for which she takes Percocet®, Vicodin®, and Oxycontin®when it flares up). Her medical history also revealed several bouts of pneumonia (the last episode was 1 year ago), kidney infections (last infection was 6 months ago), and hepatitis (last occurrence was approximately 10 years ago). Her past surgeries include appendectomy, hysterectomy (25 years ago), tonsillectomy (50 years ago), and cholecystectomy (20 years ago). Social history revealed she was widowed 10 years ago after 20 years of marriage. She has one adult daughter living 4 hours away and noted their relationship is difficult.

Mrs. S.'s current physical examination was unremarkable. Her blood pressure was 136/82, pulse was 84, and respirations were 10; her height measured 5′7” and she weighed 120 lbs. Examination of the right groin revealed the excision site was healing well and had no drainage. She was vague about the cause of the abscess.

Mrs. S. continued to be vague regarding questions about the origin of the abscess. She said that she has had these abscesses off and on over the years. Mrs. S. finally said that she has been a heroin user for many years and that she develops abscesses at the injection site. Further questioning revealed that Mrs. S. uses heroin approximately once per week, uses pain pills daily, and drinks regularly. She said that she drank and used drugs heavily when she was in her teens and twenties but stopped when she was in her thirties and forties. When her husband died, she began drinking and using pain pills and, when she could not get pain pill prescriptions, began snorting heroin. When snorting heroin did not work as well as she would have liked, Mrs. S. began injecting it. Mrs. S. had no intention of stopping her heroin, alcohol, and drug use, and claimed she controls her intake; she said that she experiences no consequences of her drug use, except abscesses. She stated that she lives alone and is not hurting anyone.

 

Today, older adults include the Baby Boomer generation, who Hogan, Perez, and Bell (2008) refer to as those born between 1946 and 1964. According to the U.S. Census Bureau, by 2030, all Baby Boomers will have moved into the ranks of the older population (Vincent & Velkoff, 2010). The Baby Boomer population has been decreasing since 1999, and the decline should continue through 2030 due to mortality. However, by 2056, the population of individuals 65 and older is projected to be larger than the population of those younger than 18 (Colby & Ortman, 2014).

Substance abuse is a significant threat to Baby Boomers, as they have been found to use more drugs than older generations (Wu & Blazer, 2011). Even the media acknowledges the issue: Alan Arkin won a 2007 Academy Award for his portrayal of a heroin-using grandfather in Little Miss Sunshine (Turtletaub et al., 2006). Boeri, Sterk, and Elifson (2008) noted that Baby Boomers are the largest age as well as the largest known drug-using cohort in modern history. Winick (1962, p. 5) postulated that addicts “mature out” of their addiction. Hamilton and Grella (2009) posited that chronic heroin users do not mature out of addictions but are motivated by a combination of life experiences to either continue or cease using. Rosen, Hunsaker, Albert, Cornelius, and Reynolds (2011) conducted a comprehensive literature review examining physical and mental health characteristics of older adults in the United States who use heroin. They noted that older adult heroin users may not decrease their drug use as they age. In the current case study, Mrs. S. seemed to “age out” of her drug use, but returned to her active addiction when she matured. Mrs. S. is not alone: the number of Americans 50 and older with a substance use disorder is projected to double from 2.8 million in 2002–2006 to 5.7 million in 2020 (Han, Gfroerer, & Colliver, 2009). Reardon (2012) used the Treatment Episodes Data Set to note that the proportion of older adult admissions reporting heroin as the primary drug doubled from 1992 (7.2%) to 2008 (16%). These figures belie an emerging public health problem for a substance abuse system that is already straining to provide treatment.

Identifying Older Adult Substance Users

Older adult substance abusers may appear in offices or clinics with sequelae of their drug use. Unfortunately, some may go undetected. Taylor and Grossberg (2012) noted that reliable screening instruments or treatment methods do not yet exist for identification and treatment of illicit substance abuse in older adults. Furthermore, symptoms of substance abuse often mimic problems associated with aging, such as sleep problems, fatigue, memory loss or mood swings, falls, loss of interest in social activities/hobbies, and neglect of hygiene/personal appearance (Center for Substance Abuse Treatment, 1998).

Heroin Addiction

Heroin is made from the resin of the poppy plant and is considered an opioid analgesic drug. It was first manufactured in the late 1800s for the treatment of tuberculosis and was also considered a treatment for morphine addiction. Heroin in its purest form is a white powder, but usually appears as brown or black powder because of additives (e.g., sugar, strychnine) used to dilute it. Because heroin is unregulated, additives are unknown and often toxic. Heroin can be snorted, injected, or smoked, and provides a rush or euphoric period accompanied by dry mouth, flushing of the skin, and a feeling of warmth. Nodding, an alternating state of awake and drowsiness, usually follows. The National Institute on Drug Abuse (NIDA) offers many tools to learn about drugs of abuse (Table).

Resources for Substance Abuse Treatment and Education

Table:

Resources for Substance Abuse Treatment and Education

Toxicology Testing

“A Simplified Guide to Forensic Toxicology” provides guidance on toxicology testing for health care providers (access http://www.forensicsciencesimplified.org/tox/Toxicology.pdf). Although this publication highlights the principles of post-mortem forensic toxicology, it outlines what specimens are used for testing, what testing is conducted, and by whom. “Urine Drug Testing for Chronic Pain Management” offers information about drug testing, classes of opioid drugs, and five common classes of drugs and information related to their detection in a urine drug test (access http://www.drugabuse.gov/sites/default/files/files/UrineDrugTesting.pdf).

Treatment Implications

Identifying substance abuse among older adults is important, but, as noted, is not an obvious process. Primary care health professionals must use their awareness of the disease of addiction to dig deeper into patient histories that do not “add up.” A similar process must happen in treatment: older adults need special considerations in the treatment arena. Facilities must be able to manage cognitive impairments from long-term drug use. The pace of treatment interventions must be adjusted and physical accommodations must be made for older adults (Rosen et al., 2011). Wang and Andrade (2013) recommended that health facilities expand coverage to diagnose and deliver effective interventions to meet demands of the aging population.

Return to Case Study

When Mrs. S. returned for follow up 2 weeks later, attending to her addiction was a must. She finished taking the prescribed course of amoxicillin and the wound was healing well. Her lab reports from her ED visit 20 days ago showed that except for a mildly elevated white blood count, her results were within the normal range. Mrs. S. reluctantly agreed to provide urine for a drug screen. She asked for a prescription for Percocet or Vicodin to help her joint pain, but the request was refused because chronic pain responds better to anti-inflammatory medications rather than opioid pain medication. After verifying that beyond her age she has few risk factors for nonsteroidal anti-inflammatory drug use, it was recommended that she take ibuprofen with food on a short-term basis while awaiting her appointment at the pain management clinic. In addition to taking medication, Mrs. S. was encouraged to engage in physical activity, such as swimming or water aerobics, to help reduce her pain. She expressed doubt, anger, and displeasure at the recommendation but agreed to the plan.

Treatment Options for Heroin Addiction

Addiction is a disease of the brain that manifests itself in aberrant behavior and is without cure, but can be contained. Treatment for addiction works and is successful at containing this chronic disease. Two types of treatment are available: medication-assisted treatment and behavioral therapy. Three primary medications are used to treat heroin: buprenorphine, methadone, and naltrexone. Accessing medication for treating addiction may be challenging as there are strict prescribing regulations set by the U.S. Drug Enforcement Administration.

Locating a trusted substance abuse treatment center and an addiction specialist is the first step in treating Mrs. S.'s addiction. A place and an individual to whom to refer patients for comprehensive assessment are needed. Primary care providers are not responsible for providing addiction treatment; rather, their role is to facilitate the opportunity for assessment and treatment of their patients. Providers need to find who their patients should call to schedule an assessment, where their patients should go for assessment, and how much the assessment will cost.

The Substance Abuse and Mental Health Services Administration's Treatment Locator identifies local experts, treatment programs providing buprenorphine treatment for opioid addiction (e.g., heroin, pain relievers), and programs providing methadone for the treatment of opioid addiction.

In addition, referral should be made to local 12-step groups, such as Alcoholics Anonymous®, Narcotics Anonymous®, as well as other groups that align with the self-help process but without spiritual principles. The Table offers a summary of resources.

The Next Visit

Mrs. S. went to her scheduled appointment 1 week later. The toxicology report was reviewed and positive for morphine (70 ng/mL), codeine (<25 ng/mL), and diazepam (0.3 mg/L). Although hard to refute evidence, Mrs. S. was steadfast in her “right to put whatever I want into my body.” Medical consequences of her drug use include exacerbation of her diabetes and hypertension, infections (i.e., an old diagnosis of hepatitis that was drug-related), and a masking of the origins of her chronic pain. Mrs. S. could not see how the disease of addiction affected her.

Mrs. S. bonded with her substances—she believed she needed drugs and alcohol to feel normal. It is essential to help Mrs. S. understand that medications and therapies exist to help her transition from addiction to recovery. Undergoing assessment is only the first step in her recovery process.

One goal is to help Mrs. S. see that getting assessed does not necessarily mean she has to quit everything at once. Unfortunately, Mrs. S. declined to be evaluated, but agreed to take handouts on addiction (from the NIDA website) and a list of Alcoholics Anonymous meetings in the community.

Epilogue

Mrs. S. returned 2 weeks later and admitted she was scared. She could not imagine her life without alcohol or drugs and was not sure she wanted to live if she had to do it “cold turkey.” The goal was to help her see that nothing would be done precipitously and that working on her addiction will be a process. Explaining the process of recovery may help Mrs. S. and begins with her understanding that the new drugs will help her detox and stay clean. Medication-assisted treatment (using such drugs as buprenorphine, naloxone, and Antabuse®) are important tools in the treatment of heroin addiction. Mrs. S. agreed to call the addictionologist for an appointment. It is important for primary care providers to obtain signed releases of information for ongoing contact with the addictionologist. Finally, Mrs. S. has a beginning. Working collaboratively with treatment professionals will give Mrs. S. the “wraparound” care she deserves.

References

  • Boeri, M., Sterk, C. & Elifson, K. (2008). Reconceptualizing early and late onset: A life course analysis of older heroin users. The Gerontologist, 48, 637–645. doi:10.1093/geront/48.5.637 [CrossRef]
  • Center for Substance Abuse Treatment. (1998). Identification, screening, and assessment. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK64420/
  • Colby, S. & Ortman, J. (2014). The Baby Boom cohort in the United States: 2012 to 2060. Retrieved from http://www.census.gov/prod/2014pubs/p25-1141.pdf
  • Hamilton, A. & Grella, C. (2009). Gender differences among older heroin users. Journal of Women & Aging, 21, 111–124. doi:10.1080/08952840902837129 [CrossRef]
  • Han, B., Gfroerer, J.C. & Colliver, J.D. (2009). An examination of trends in illicit drug use among adults aged 50 to 59 in the United States. Retrieved from http://www.chanvre-info.ch/info/en/IMG/pdf/OAS_data_review_OlderAdults.pdf
  • Hogan, H., Perez, D. & Bell, W. (2008). Who (really) are the first Baby Boomers?Joint Statistical Meetings Proceedings, Social Statistics Section, 1009–1016.
  • Reardon, C. (2012). The changing face of older adult substance abuse. Social Work Today, 12, 8.
  • Rosen, D., Hunsaker, A., Albert, S., Cornelius, J. & Reynolds, C.F. III. (2011). Characteristics and consequences of heroin use among older adults in the United States: A review of the literature, treatment implications, and recommendations for further research. Addictive Behaviors, 36, 279–285. doi:10.1016/j.addbeh.2010.12.012 [CrossRef]
  • Taylor, M.H. & Grossberg, G.T. (2012). The growing problem of illicit substance abuse in the elderly: A review. Primary Care Companion for CNS Disorders, 14, 11r01320. doi:10.4088/PCC.11r01320 [CrossRef]
  • Turtletaub, M., Friendly, D.T., Saraf, P., Berger, A., Yerxa, R Producers. , Dayton, J. & Faris, V. Directors. (2006). Little miss sunshine [Motion picture]. United States: Big Beach Films.
  • Vincent, G.K. & Velkoff, V.A. (2010). The older population in the United States: 2010 to 2050. Retrieved from http://www.census.gov/prod/2010pubs/p25-1138.pdf
  • Wang, Y.-P. & Andrade, L.H. (2013). Epidemiology of alcohol and drug use in the elderly. Current Opinion in Psychiatry, 26, 343–348. doi:10.1097/YCO.0b013e328360eafd [CrossRef]
  • Winick, C. (1962). Maturing out of narcotic addiction. Retrieved from http://www.unodc.org/unodc/en/data-and-analysis/bulletin/bulletin_1962-01-01_1_page002.html
  • Wu, L. & Blazer, D. (2011). Illicit and non-medical drug use among older adults: A review. Journal of Aging and Health, 23, 481–504. doi:10.1177/0898264310386224 [CrossRef]

Resources for Substance Abuse Treatment and Education

Nursing Need Source
Treatment centers in the community Substance Abuse and Mental Health Services Administration treatment locator https://findtreatment.samhsa.gov
Buprenorphine treatment programs for opioid addiction Buprenorphine treatment physician locator http://buprenorphine.samhsa.gov/bwns_locator
Programs that specialize in the treatment of addiction American Society of Addiction Medicine http://www.asam.org
Programs providing methadone for the treatment of opioid addiction Opioid treatment program directory http://dpt2.samhsa.gov/treatment/directory.aspx
12-step self-help group Alcoholics Anonymous®http://www.aa.org
Narcotics Anonymous®http://www.na.org
12-step self-help group for spouses and family members Al-Anon http://www.alanon.org
Educational materials about heroin National Institute on Drug Abuse (NIDA) http://www.drugabuse.gov/publications/finder/t/128/heroin
Information on drug testing NIDA http://www.drugabuse.gov/related-topics/drug-testing
Information on medications for treatment of opioid dependence NIDA http://www.drugabuse.gov/publications/drugfacts/prescription-over-counter-medications
Educational materials about alcohol National Institute on Alcohol Abuse and Alcoholism http://www.niaaa.nih.gov/publications/brochures-and-fact-sheets
Authors

Dr. Malliarakis is Assistant Professor and Director of Nursing Leadership & Management Programs, School of Nursing, George Washington University, and Chair, Committee on Impaired Nursing, DC Board of Nursing, Washington, DC.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Kate Driscoll Malliarakis, PhD, ANP-BC, MAC, FAAN, Assistant Professor and Director of Nursing Leadership & Management Programs, School of Nursing, George Washington University, 2030 M Street NW, Suite 300, Washington, DC 20036-3357; e-mail: katemall@gwu.edu.

10.3928/00989134-20151111-01

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