According to the Centers for Disease Control and Prevention, from 2019 to 2020, deaths from drug overdoses increased 29%. The genesis of the problem lies in an industry that was far too eager to stop pain through medications that were initially touted as non-addictive. Many state and local governments are reticent to address a problem that has killed more than 800,000 Americans since 2000. Drug settlement money and state legislation targeting the implementation of drug monitoring systems are beginning to turn the tide in the war against opioid misuse, with certain areas of the country more affected than others. The problem remains a far-reaching one, affecting older adults and those who seek to intervene.
Sponsored by the Administration for Community Living (ACL), in 2021, the APS TARC conducted a study of the impact of the opioid epidemic on APS during the COVID-19 pandemic. APS TARC used a two-step process to identify challenges, successes, and issues of concern when investigating and intervening in cases of opioid-related abuse. In April 2021, the APS TARC conducted telephone interviews with 11 state-level APS administrators from “hot-bed states,” (states in which opioid overdoses and deaths were highest). Interview findings informed individual and small group interviews, conducted May-June 2021, with local APS workers from 10 states.
- No APS program had a policy specific to older adults and opioids.
- Most APS administrators were unable to provide data-driven responses related to the number of opioid-related APS reports.
- When opioids were involved, allegations typically concerned self-neglect, followed by caretaker neglect, and facility drug diversion.
- Substantiated perpetrators of opioid abuse were mostly family members, but facility staff were involved at times.
- A major challenge working cases involving opioids was that the alleged perpetrator was present in the home when APS field staff attempted to interview the older adult. Other challenges included addressing the level of pain of the older adult and getting physicians to order lab work or encountering delays in lab work to confirm the presence or absence of opioids in the bloodstream.
- The COVID-19 pandemic made it difficult for most field staff to investigate opioid-related cases due to public health restrictions related to in-person investigations.
- Most staff thought cases involving opioids were harder to substantiate than other abuse cases due to the difficulty of proving if and how medication was missing and denial by the older adult if the alleged perpetrator was a family member.
- APS staff identified impacts that opioid misuse had on clients: inability to have pain managed adequately, homelessness, poverty, and, in more than one case, a hastened death.
- Frequently suggested mechanisms for prevention were increased levels of formal and informal supports and services, particularly concerning medication management.
- Improvements in intervention included giving APS the ability to perform background checks, more frequent use of electronic medical boxes to dispense, holding perpetrators accountable to timeframes for remediation, and creating policies to facilitate greater access and trust for APS staff working cases.
- A critical component to maximally helping older adults involved with opioid misuse was working with community partners.
- APS staff stressed that available resources were inadequate and emphasized the need for greater financial assistance, enhanced and targeted training, access to specialists in addiction, and resources for homeless individuals.
Opioid-related cases involving older adults are highly individualized and poorly resolved using a cookie cutter approach. Many people with addictions were functioning, albeit at a baseline level, and were competent to live their lives in the manner they chose. Staff recognized that the presence of a strong family and friend network would prevent many cases of opioid misuse and associated self-neglect. Specific intervention suggestions included the ability of APS to perform background checks for caregivers, increased use of electronic medicine boxes, and a greater variety of available resources. Interviewees stressed that current mental health resources are ineffective and in extremely short supply, especially in rural areas. More effective monitoring and targeted legislation in many states were regarded as helpful for prevention of opioid-related cases.
Particularly where opioid misuse and older adults are concerned, it is vitally important to enhance APS collaboration with community partners and build stronger relationships with medical professionals, law enforcement, first responders, pharmacists, home health providers, mental health counselors, and faith communities. Working with these professionals through multidisciplinary teams continues to be a viable approach for improving communication and cooperation.
Increasing Resources to Address the Problem
Training was the most consistent need identified by APS staff related to opioid addiction and its effects on older adults and their caregivers. Staff emphasized the need for training from law enforcement to learn how to identify if a person was abusing substances, how to remain as safe as possible during the interview, and how to use better techniques for investigating cases.
There are simply not enough resources to assist older adults enmeshed in the opioid epidemic. More financial resources should be dedicated to hiring addiction specialists to assist with complex cases. Resources dedicated to critical mental health services are painfully inadequate — a consistent theme sounded across our interviews. Medical professionals are needed to provide better healthcare in general and, specifically, to prevent doctor shopping. A dire need exists for older adults’ transportation to medical professionals to help them manage pain as well as to have enough staffing for healthcare and social services to help with the problems caused by opioid addiction and misuse. Also mentioned was the need for more services for older adults left homeless because of the opioid problem.
Study participants provided a number of insightful suggestions for research: studying the long-term effects of opioid addiction on older adults and their families and assessing short-term and long-term effects of APS intervention for clients new to the system as well as for those repeatedly in need of help. Additionally, staff suggested examining the trajectory of intergenerational opioid misuse and its intersection with APS.
Three other studies are particularly important to conduct. First, research should critically examine aspects of cases involving a combination of opioids with other drugs, such as methamphetamines and alcohol, and cases in which polyvictimization is involved. Such research should compare case intervention outcomes in rural, urban, and tribal areas and frame the study using the Contextual Theory of Elder Abuse to include micro-macrosystem aspects of the problem.
Second, research should deeply examine alleged and substantiated perpetrators; robust information is notably missing in much of the available opioid data. Gathering these data is especially important for guiding intervention for the older adult and for the perpetrator as well as stopping the cycle of recidivism peculiar to these cases.
Finally, studying the aspects of self-neglect when opioids are involved is also crucial, specifically examining similarities and differences between opioid-driven self-neglect and other forms of self-neglect.
For older and younger adults with disabilities, APS serves as a central lifeline in preventing and intervening in abuse, neglect, and exploitation that is associated with the problems of opioids and related drugs. Targeted training and resources can enhance both the safety of APS investigatory staff and the clients they serve. Consistent and quality data collection on opioid-related APS cases needs to occur, as well as research on perpetrators.
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