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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 51-53

Elderly male with late-onset heroin dependence


1 Department of Psychiatry, Institute of Mental Health, Pt. Bhagwat Dayal Sharma University of Health Sciences, Rohtak, Haryana, India
2 State Drug Dependence Treatment Centre, Rohtak, Haryana, India

Date of Submission26-Mar-2021
Date of Decision19-Apr-2021
Date of Acceptance30-Apr-2021
Date of Web Publication05-Aug-2021

Correspondence Address:
Dr. Akansha Bhardwaj
Triveni Hostel, PGIMS Campus, Rohtak, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_12_21

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  Abstract 


Substance use disorders usually have their onset during the adolescent period. However, in rare cases environmental and psychosocial factors can contribute toward a later onset. We describe a case of an elderly male who initiated his heroin use for the first time at 65 years of age and eventually developed dependence. This late-onset of heroin use was mediated by contextual factors such as loneliness, boredom, and easy access to heroin while craving and withdrawal symptoms served as maintaining factors. He responded well to a combination of opioid antagonist and nonpharmacological approaches focusing on activity scheduling and social support. As the demographic transition and societal changes take place, the elderly population with substance use problems will increase. There is an urgent need to upgrade substance abuse treatment services to meet the specific needs of the elderly using supportive and nonconfrontational approaches with special focus on improving social support access.

Keywords: Elderly, late-onset dependence, loneliness, opioid dependence, substance use


How to cite this article:
Bhardwaj A, Arya S, Rathee S, Gupta R. Elderly male with late-onset heroin dependence. J Geriatr Ment Health 2021;8:51-3

How to cite this URL:
Bhardwaj A, Arya S, Rathee S, Gupta R. Elderly male with late-onset heroin dependence. J Geriatr Ment Health [serial online] 2021 [cited 2021 Dec 9];8:51-3. Available from: https://www.jgmh.org/text.asp?2021/8/1/51/323103




  Introduction Top


As per the 2011 census, the elderly population in India was approximately 104 million, representing around 8% of the total population.[1] Over the past 3 decades, life expectancy has risen from 59.6 to 70.8 years.[2] As life expectancy improves, demographic transition will eventually translate to higher physical and mental health care needs in the geriatric population.[3] There is also evidence that the proportion of elderly individuals with substance use disorders is bound to increase with time.[4] Historically, the elderly population have not demonstrated high rates of substance use compared with younger adults, and neither have they presented in large numbers to deaddiction centers. This has resulted in a misconception that older adults do not use or abuse substances, hence under identifying substance use among older adults.[5] However, the substance use rate among the elderly is significant and requires urgent attention.[6]

Two long-term patterns of substance use have been described among the elderly: “early-onset” and “late-onset.” The first group includes individuals with a long history of substance abuse, who continue to abuse as they age, whereas the latter includes individuals who start using substance at later stages of life.[7] This late-onset substance abuse accounts for <10% of substance abuse among the elderly.[8] A number of predisposing factors have been identified for late-onset including physical or mental health decline, financial strain, family issues, loneliness, and environmental factors. [9,10]

We present a case of opioid and tobacco use disorder, in a 67-year-old man, who initiated opioid use in the form of heroin at the age 65 years of to overcome his loneliness and then became dependent on it. This case is unique in the sense that the onset of substance use is at very later stages and patients like these are rarely seen in clinics. We would like to use this example to stimulate discussion with regard to elderly substance use.


  Case Report Top


A 67-year-old retired man presented to the deaddiction center outpatient department with a history of opioid use for the last 2 years. He lost his wife due to ischemic heart disease around 10 years ago. Since then, he reported feeling lonely and to overcome this, he would often work for late hours at his office. After retiring at age of 60 years, such feeling of loneliness became very prominent. He would report of sense of emptiness and lack of joy in general activities. In order to pass his time, he would sit at neighborhood tea stall for the most part of the day, playing cards and interacting with friends. On occasions, he would visit his daughter's house for few hours. About 2 years back at 65 years of age while passing time at the tea stall, he came in contact with a group of young men who would chase street heroin among themselves. He observed them for over a month and inquired about this new stuff. The group boasted about the numbing effects and high of the substance and offered him to try it. He, despite resisting their offer numerous times, eventually gave in to the temptation with the hope that chasing street heroin may help him pass his time and feel less lonely. Within few weeks, he started chasing on regular basis and doubled his dose to almost one gram per day and then eventually to two grams per day. Over few months, the patient developed craving, tolerance and would exhibit characteristic withdrawal symptoms if he failed to chase street heroin. He would spend all his day being under the influence of the substance and would not feel bored or sad. Within a year he had spent all his savings as well his pension on procuring the street heroin. He would enjoy his time initially with the group and later on by himself. He stopped visiting his daughter and became more recluse. Over the past 2 months, the patient had increasingly become weaker and difficulty in arranging money to procure street heroin. After repeated attempts from his daughter, he decided to seek treatment for his problem. He has also been a smoker for the past 40 years.

No history of injectable drug use was reported. No incidents of difficulty breathing/bluish discoloration/excessive drowsiness/seizures were reported after intake of street heroin. There was no significant medical or psychiatric history in the past or family. The patient was not on any other medications.

His mental status examination was within the normal limits, scoring 30/30 on Mini-mental status examination. He was in preparation stage of motivation. Routine laboratory investigations did not reveal any significant abnormalities.

Due to his age and poor social support, inpatient admission was done with a diagnosis of opioid and tobacco dependence. During the initial week, the patient was detoxified symptomatically, using tramadol and paracetamol for his pain and body ache, clonazepam for anxiety and sleep-related difficulties. Nonpharmacological interventions were planned and discussed. Craving management and assertive training were done. Activity scheduling was planned to effectively pass his daytime. His social support was strengthened by putting him in touch with a local elderly group that would meet in the morning on a daily basis, attending regular prayers in a temple in the evening, and planning regular visits to a nearby old age home.

The patient was discharged with tablet Naltrexone 25 mg OD. The patient remained in contact with the treatment services for a period of 4 months after which he dropped out. During his follow-up visits, he was abstinent and reported significant improvement in his boredom and loneliness. He was regularly attending temple rituals and old age home meetings.


  Discussion Top


India is undergoing major sociodemographic changes, owing to the lower death rate and greater longevity, resulting in the rapid increase in the old age population.[11] In the past, compared with younger adults, older adults had lower rates of alcohol and other illicit drug use. However, with changing demographic transition the number of elderly substance users is likely to rise.[12]

New-onset substance users in the geriatric age group account for a very small percentage.[8] A variety of potential causes have been cited for new-onset substance abuse including: financial strains, trouble sleeping, family conflict, and mental or physical health decline (depression, memory loss, major surgeries, etc.)[9] Other social factors common in late-life which can be contributory in substance use or misuse include: bereavement (death of spouse, family member, or friends), caregiving of an ill spouse, change in living arrangement, joblessness, and loneliness.[5]

Here, we describe a case of new-onset heroin use in a 67-year-old widowed male due to loneliness and boredom. Loneliness can lead to a number of consequences, such as physical and mental ailments, poor quality of life, and increased risk of mortality. Loneliness has also been related to smoking and alcohol misuse.[13] Over the years, societal changes such as erosion of the joint families, migration for better job prospects, and increasing financial independence among the elderly are few of the reasons leading to the alienation of elderly parents.[11]

Such conditions can give rise to decreased social support and loneliness, where different substances can be initiated as maladaptive coping strategies. Since the elderly are more prone to acute and chronic effects of different substances, they are likely to show dependent behavior much quickly and suffer from graver complications.[9] It is imperative that with changing circumstances, strategies to strengthen social support are promoted. Different initiatives which can help reducing loneliness include incorporation of recreational activities, physical exercise, improving networking with social support programs, social engagement-directed discussions, coaching, use of the internet, pet therapy, and use of companion robots,[14] as well as culture-specific interventions including participation in religious congregations.[11]

As the number of elderly substance users increases, it would increase the demand for relevant treatment services which need to be delivered through supportive and nonconfrontational approaches with a special focus on improving social support and treatment access. Currently, most substance abuse treatment settings in India lack such multidisciplinary approach. There is an urgent need to sensitize and upgrade substance abuse treatment services to meet the specific needs of elderly patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Buvneshkumar M, John KR, Logaraj M. A study on prevalence of depression and associated risk factors among elderly in a rural block of Tamil Nadu. Indian J Public Health 2018;62:89-94.  Back to cited text no. 1
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GBD 2019 Demographics Collaborators. Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950-2019: A comprehensive demographic analysis for the Global Burden of Disease Study 2019. Lancet 2020;396:1160-203.  Back to cited text no. 2
    
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Sarkar S, Parmar A, Chatterjee B. Substance use disorders in the elderly: A review. J Geriatr Ment Health 2015;2:74-82.  Back to cited text no. 4
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Kuerbis A, Sacco P, Blazer DG, Moore AA. Substance abuse among older adults. Clin Geriatr Med 2014;30:629-54.  Back to cited text no. 5
    
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Bogunovic O. Substance abuse in aging and elderly adults. Psychiatr Times 2012;29:1-3.  Back to cited text no. 6
    
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Roe B, Beynon C, Pickering L, Duffy P. Experiences of drug use and ageing: Health, quality of life, relationship and service implications. J Adv Nurs 2010;66:1968-79.  Back to cited text no. 7
    
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Wu LT, Blazer DG. Illicit and nonmedical drug use among older adults: A review. J Aging Health 2011;23:481-504.  Back to cited text no. 8
    
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Dowling GJ, Weiss SR, Condon TP. Drugs of abuse and the aging brain. Neuropsychopharmacology 2008;33:209-18.  Back to cited text no. 9
    
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Kazemi F, Motalebi SA, Mirzadeh M, Mohammadi F. Predisposing factors for substance abuse among elderly people referring to Qazvin addiction treatment centers, Iran (2017). JQUMS 2018;22:26-35.  Back to cited text no. 10
    
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Grover S. Loneliness: Does it need attention! J Geriatr Ment Health 2019;6:1-3.  Back to cited text no. 11
    
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Cho J, Bhimani J, Patel M, Thomas MN. Substance abuse among older adults: A growing problem. Curr Psychiatry 2018;17:14-20.  Back to cited text no. 12
    
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Malcolm M, Frost H, Cowie J. Loneliness and social isolation causal association with health-related lifestyle risk in older adults: A systematic review and meta-analysis protocol. Syst Rev 2019;8:1-8.  Back to cited text no. 13
    
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Poscia A, Stojanovic J, La Milia DI, Duplaga M, Grysztar M, Moscato U, et al. Interventions targeting loneliness and social isolation among the older people: An update systematic review. Exp Gerontol 2018;102:133-44.  Back to cited text no. 14
    




 

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