Seniors face higher risk for painkiller dependency

Susan Schubert woke up in the hospital in the worst pain of her life.

The petite 62-year-old was used to hurting. After 12 miserable years, she'd finally given in and gotten back surgery, hoping to relieve at least some of the ache she felt with every step.

Recovery would be tough. But she hadn't expected this.

"I thought it would be just for a little while and that the pain would go away. ... I kept thinking 'I'm going to get better,'" Schubert said.

At the hospital, her doctor used morphine to alleviate the pain. And when it was time to go home, three weeks later than anticipated after the 2002 surgery, Schubert got the first of her many prescriptions for painkillers known as oxycodone.

The narcotic, known for its allure as a street drug, is designed to mask extreme discomfort. Details are fuzzy, but Schubert remembers it helped to pop six or seven pills a day to handle sudden shooting pain. Her plan to return to work at Hillsborough County's budget office in six weeks turned into sluggish six-month effort simply to move using a walker.

For the next eight years, opioid prescription medications became central to Schubert's ability to function, something fairly common for older adults living with chronic lower back and arthritic pain. Also common: The longer she stayed on them, the more her dependence grew.

A former California sheriff's deputy, she knew the painkillers were addictive, and she diligently avoided increasing the amount of oxycodone she took, despite what she perceived as worsening pain.

But her efforts were being undermined by a reality she could not control. As Schubert's body was getting older, its physiological ability to efficiently process medications was weakening and changing.

The build-up of narcotics and other prescriptions in Schubert's body led to her collapse the day after Christmas 2009. Her adult son, who had dropped by her Temple Terrace townhouse for a visit, found her nearly comatose on the kitchen floor. Her lungs hadn't been taking in enough oxygen, and filled with carbon dioxide.

Schubert went to a hospital emergency room, and then spent several days detoxifying, miserable and ready to "crawl up the walls." Her accidental overdose - one in which she never took more than the prescribed medication -- nearly put one more name on the state's 1,183 oxycodone death tally for 2009.

"I would have been dead. I have no doubt about that," said Schubert, now 70.

Schubert's ordeal isn't unusual, given the nation's growing infatuation with prescription drugs, especially among baby boomers. Nearly half of American children, teens and adults take at least one prescription medication. Thirty-seven percent of those 60 and older juggle five or more prescription drugs a month, says the National Center for Health Statistics.

Designed to heal, prescription drugs also carry certain risks, depending on a person's health, weight, gender and, yes, age. Seniors accustomed to taking a drug for years may think changes are unnecessary, but human aging and an increased tolerance to a medication can alter its effect.

"When you age, certain processes in your body don't happen as fast. You don't clear the drug as fast as you used to, or the drug can actually build up," said Glen Whelan, an associate professor with the University of South Florida's college of pharmacy. "Not only are you getting more drug in the system, you can also be more sensitive to the effects of that drug as you age."

No one wants to admit they're not as fast, strong or healthy as they once were. But older adults have more health problems than any other part of the population, and more chronic pain, including arthritis. Starting at about age 30, the human physique goes through gradual but serious changes, from reduced water retention to thickening arteries to a decrease in the lungs' ability to produce oxygen.

Narcotics, such as the oxycodone pills Schubert took, can magnify those normal, unavoidable changes. And drugs known to make a person drowsy can affect focus, balance and cognitive abilities already weakened by age.

A drug isn't safe just because it's a prescription drug, said Barbara Krantz, medical director and chief executive of The Hanley Center for addiction treatment in West Palm Beach. "It can be lethal."

Rafael Miguel, an anesthesiologist and pain specialist at Brandon Pain Medicine, said the Tampa Bay area is full of people like Schubert: active, older adults suffering from constant lower back pain. He never treated Schubert, but said an appropriate dose of an opioid can be an effective part of a larger geriatric pain management plan.

Indeed, a narcotic such as oxycodone is a recommended alternative to sedatives known to be more dangerous for adults 65 and older.

"Narcotics are a very safe alternative in the right hands," Miguel said.

Certainly, Schubert thought she took every precaution when it came to her pain management. She never took more than the prescribed number of painkillers, she quit drinking wine, she took a friend to nearly all of her doctor appointments so they could ask questions and take notes.

She talked to multiple doctors about the times she felt her blood pressure drop and she got dizzy -- once behind the wheel of her car and one morning passing out over her bowl of oatmeal. Never once did she equate the problem to her medication or aging.

"Those were warning signs, but I didn't know it was related to the opiates," she said.

Schubert tried alternative treatments, but she was too scared and too dependent to give up on the short-acting drugs and a 12-hour time-release companion.

"The pain was so frightening because it was so disabling," she said. "I think I feared the pain so much more than I feared the medication."

Fear like that is very real, said Seddon Savage, an associate professor at Dartmouth College Medical School and president of the American Pain Society. It doesn't necessarily mean the person in pain is addicted.

Instead, it's a sign of medical dependence, she said, something that happens to nearly everyone who takes medications regularly.

The body's natural painkillers, such as endorphins, block pain messages to the brain. Synthetic opiates, however, are much stronger and can eventually override the body's ability to naturally assess pain.

But older adults need to know it isn't just opiates that can trigger problems, Savage said. A person who drops his blood pressure medication, for example, may experience palpitations and increased blood pressure rates for a short time.

Weaning oneself off any drug is possible, but it should be done carefully and under medical supervision, Savage said. Dependent persons won't have cravings afterward, unlike addicts, who are predisposed to compulsive and inappropriate use of drugs. But they must deal with the pain another, non-narcotic way.

By 2005, Schubert had given up trying to return to work. She struggled to exercise in five-minute bursts. She kept attending church and orchestra concerts with friends who worried about her constant pain and increased moodiness. She hated the motorized scooter and wheelchair she needed to travel any distance.

Days spent analyzing multimillion-dollar budgets were now filled asking church friends for rides to pain clinics.

"I felt very hopeless and frightened as to what was going on with me," she said. "Didn't I have enough that I was dealing with?"

She'd visited six different pain clinics since 2002, and some she knows were questionable. At least once she waited for four hours in a waiting room, sitting with twenty- to fortysomethings she would have tagged as junkies during her days in law enforcement.

"I looked at their faces. I could tell who was in pain by looking at their face," she said. "I said to myself, 'These are addicts coming for their fix.'"Kendra Craven sat next to her once whip-smart friend from Temple Terrace United Methodist Church during many of those clinic visits. Craven said watching Schubert grow gradually dependent on the narcotics was difficult, especially because they didn't appear to help. But never did she think Shubert had a problem processing the drugs, or that she was an addict. Many of Schubert's friends said the woman growing more irritable and absent-minded over time appeared to be just another senior citizen fighting chronic illness. "You don't stop and think it might be the medication causing the problem," she said.

The Substance Abuse and Mental Health Administration estimates that by 2020, 5 million older Americans will be dealing with substance abuse. That's twice the number from 1999, and can be attributed in part to the increase in prescription drug abuse.

The Hanley Center's Krantz said her rehabilitation center has seen a steady rise in the number of geriatric patients it serves; the oldest was 98.

Addiction is harder to identify in older people for several reasons. It may be more difficult to pinpoint what is causing a problem; it could just be the patient's age or health, and there's the likelihood the person mixes alcohol with other substances.

"In that age group, the perception is that an addict is a junkie on skid row, and that's not the case," Krantz said.

But elderly persons, especially those dealing with chronic pain, are prone to look for the most convenient care, said pain specialist Miguel, who is active in the American Society of Interventional Pain Physicians. That could mean visiting so-called "pill mills," where physicians are less likely to completely evaluate a patient's condition.

Unsuspecting seniors can slip into drug dependence or addiction if disreputable pain clinics overprescribe for geriatric patients.

"The pill mills are no better than drug dealers hidden behind white lab coats," Miguel said.

Schubert said some of her doctors fit that description. And after spending hours in a waiting room, who wouldn't choose five-minute visits, where a doctor fills your prescription as you enter the exam room. Two minutes for a 30-day prescription, and just one question asked: Are you still in pain?

And yes, she was.

Those clinics have been grabbing headlines for months. Police raids and customers who look nothing like Schubert are regular features on nightly newscasts across the Bay area and the state.

Cops aren't the only ones fighting the pill mills. The interventional pain physicians' group has been lobbying for a state and national prescription drug database aimed at curbing the estimated 40,000 prescription drug deaths each year, Miguel said. And last week, the group recommended additional training for all doctors who can prescribe opioids for pain. Effective pain management doesn't rely on prescription medications alone, said Dartmouth's Savage. Injections, spine stimulation and other alternative procedures can reduce, minimize or eliminate chronic pain.

That includes devices such as the "tens" unit Schubert now wears: an electrical muscle stimulator taped onto her back.

"I'm not the same as I was 12 years ago," she said of her abilities today. "But I am two to three times better than I was five years ago, seven years ago."

Seniors who rely only on medication need to be proactive, said Whelan, the USF pharmacist. Talk to your doctor about changing medications any time your health changes, or whenever you feel like a drug's effects are changing. Also, don't be afraid to talk about natural or herbal remedies you might be taking. It can have a major effect on other meds, he said.

"You don't want the patient to think they don't need pain control and they suffer needlessly," he said. "That's an important point. It should be a strong balance."

That's the lesson Schubert learned. She has accepted that she won't be able to kayak or hike mountains anymore. But she can be active - getting around on her motorized scooter and taking water aerobics. "I'm feeling so liberated from what I call my eight years of living under a rock," she said.

Though Schubert is getting older, she believes she's getting better. Before, the fog of narcotics convinced her she was chained to an endless stream of doctor's visits. Now, she's checking in with her primary care physician every six months.

At 70, she's finally asking: What's next?