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Forum Addresses Substance Abuse Over Age 50
by Marie-Jo Proulx

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While the rest of the city was parading and partying Irish-style, the Chicago Task Force on LGBT Aging held a round-table discussion on substance abuse, at Howard Brown Health Center ( HBHC ) . More than 30 attendees from organizations providing healthcare, counseling or social services to LGBT individuals across the Chicagoland region attended the session.

Task Force co-chair Terri Worman began by introducing Dr. Martin J. Gorbien, director of the Section of Geriatric Medicine at Rush University Medical Hospital, who did an excellent job of both moderating the discussion and supplementing each panelist's presentation with insightful commentary and references to research studies.

Gorbien remarked that contrary to the general population, where individuals are categorized as 'seniors' at an increasingly later age, the trend in the LGBT community is to consider people old as soon as they reach 50. He then noted that it is still debated whether LGBT patients would necessarily be better served if they were treated by LGBT physicians and therapists. But the relatively small number of openly gay doctors along with the general reluctance of senior patients to disclose their sexual orientation would seem to make this a moot point.

On this topic, the March 2 issue of the New England Journal of Medicine ( NEJM ) contains an article by H. J. Makadon, a gay doctor who is director of education and professional training at the Fenway Institute in Boston, entitled 'Improving Health Care for the Lesbian and Gay Communities.' Makadon outlines the need for medical students to be schooled in the physical and psychological health issues that are particular to LGBT patients. He stresses the importance of doctors being able to ask all the relevant questions, and for them to learn to do it in an appropriate manner. He also suggests that healthcare providers revamp their forms so they reflect a wider range of relationships and living arrangements. In the case of same-sex couples, something as simple as writing 'parents' instead of 'mother' and 'father' in a child's admission file would go a long way toward that goal.

While none of the panelists mentioned the NEJM article, all seemed to concur with Makadon's observations and recommendations. Kenis Williams of the Haymarket Center, which serves 18,000 clients a year ( mostly from the South Side ) , spoke of the multiple barriers to care and of the lack of specific knowledge about certain patient groups. All panelists agreed with her that the main difficulty in getting reliable data is the lack of funding for research targeting statistically small sections of the population. For example, studies of seniors may not look at alcohol abuse or include information on sexual orientation, and those done in the LGBT community often have very few subjects who are seniors.

Williams added that most of what are considered classic medical training textbooks have only very brief sections on LGBT health issues ( outside of HIV/AIDS ) , much less on LGBT and aging, and nothing on substance abuse in the senior LGBT community. She then presented statistics from the Substance Abuse & Mental Health Services Administration ( the same SAMSHA that deleted a link to LGBT health resources from its Web site earlier this year ) that indicate a 32 percent increase in addiction-related hospital admissions of individuals aged 50 and over since 1995.

Referring to both anecdotal evidence and empirical data, Williams related the common reasons LGBT seniors give for putting off seeing a physician when they begin to feel aches or even suffer from a chronic condition. Perceived and/or real ageism, homophobia and the fact that the pre-Stonewall generation is not used to discussing issues of sexual orientation openly rank at the top of the list.

Pamela McCann from the Office of LGBT Health at the Chicago Department of Public Health offered information on tobacco use by seniors. With smoking rates as much as 70 percent higher in the LGBT community than in the general population according to some studies, McCann underlined the need to develop effective secession mechanisms. She reported that pressure from family members and evidence about the dangers of second-hand smoke have little impact on senior LGBT smokers. Focus groups have instead demonstrated that adverse health events related to tobacco use are a consistent source of motivation for those trying to quit.

Looking at long-term consequences and policy implications, McCann pointed out that LGBT smokers tend to pick up the habit earlier ( sometimes as young as 13 ) , which adds to the cumulative toll on lungs and other organs, potentially making smokers vulnerable to other diseases. But, she warned, as smoking rates decrease due to the success of more customized interventions, longevity will increase, which will, in turn, drive up healthcare costs.

Prescription and over-the-counter ( OTC ) drugs also can lead to substance abuse. Dr. Denys T. Lau of Northwestern University's Buehler Center on Aging spoke of the inappropriate use of medication, which he said both patients and healthcare providers can be responsible for. Occurrences of patients overusing pain killers, antidepressants, Viagra and other drugs in order to increase the desired effect are frequent. Other occurrences that happen often are instances of underuse due to limited access to care, a lack of financial resources and the absence of a social support network. Complex prescription regimens, diminished faculties and Alzheimer's disease often contribute to irregular and detrimental medication consumption by the elderly.

Lau noted the significant risks facing seniors with different ailments who have to take multiple types of medication. While the ones living in the community consume an average of five prescription drugs, nursing home residents typically have up to eight prescriptions to their names. These numbers explain why 35 percent of all geriatric visits to the ER are the result of adverse drug events.

But some doctors, especially older ones, have also been known to over-medicate agitated patients with psychotropic drugs as a form of medical restraints. This practice was more widespread inside nursing homes in the '80s than it is now, Lau said. But today's seniors may remember such reports and as a result remain reluctant to seek care. Moreover, when facing physicians who habitually prescribe obsolete drugs with more side-effects than their newer version, many seniors do not feel they are in a position to second-guess their course of treatment. Few will go online and compare drug profiles.

Cultural competency, or the ability to communicate with patients of different ethnic origins, religious beliefs, social classes, ages and sexual orientations, is an essential tool many doctors are still learning to use. Lau mentioned heterosexism as a main reason some gay men with HIV are not diagnosed. Taking a full sexual history, asking the right questions and scheduling the relevant tests would speed up detection. Conversely, Gorbian said he remembered a time when gay men who showed up in straight doctors' clinics with a sore throat or diarrhea were too often assumed to have HIV/AIDS.

Dr. Will Wong, medical director of the City of Chicago's STD & HIV Health Program, pointed out that as people with HIV are living longer due to improved drug cocktails, they will reach an age where other diseases normally develop. Seniors with HIV, therefore, will encounter additional drug interaction problems for which little study has been done. Wong also remarked that LGBT seniors are more prone to suffer from loneliness and depression than the general population because their primary relationships are not legally recognized.

Paul Fressola, one of HBHC's psychotherapists, presented a grid illustrating the use of hard drugs ( e.g., meth, heroin and cocaine ) by LGBT seniors. It is estimated that 10 percent of those aged 50-75 abuse a hard drug, compared to 1.8 percent in the general population. There is no data for individuals aged 75 and over, and none at all on the senior transgender community.

In closing, HBHC's Director of Behavioral Health and Social Services Braden Berkey emphasized the need to deal with mental health and substance abuse as related issues. In his experience as a clinician, treating one in isolation from the other is a recipe for relapse. He added that only two Chicago providers offer LGBT-specific 12-step programs staffed by culturally competent counselors: HBHC and the Lakeshore Hospital's Valeo. Berkey hopes that their success at keeping clients on the road to recovery will inspire other providers to offer similar services and demonstrate to HMOs that LGBT-competent care is cost-effective.

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