Addiction Among Older Adults

Substances affect older adults differently than others. Geriatrician Lauren Kelly, MD, MPH, discusses how she helps her older adult patients address addiction, noting that treatment is a matter of helping them gain control over their substance abuse. This can mean stopping use altogether, or it can mean using substances in a safer or more moderate fashion.

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Transcript

[00:00:00] 

[00:00:00] Stephen Calabria: From the Mount Sinai Health System in New York City, this is Road to Resilience, a podcast about facing adversity. I'm your host, Stephen Calabria, Mount Sinai's Director of Podcasting. 

[00:00:12] On this episode, we welcome Lauren Kelly, Ph. D., an Assistant Professor in the Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai.

[00:00:21] Dr. Kelly's professional experience and passion is in the care of older adults and seriously ill patients with substance use disorders, including patients living with substance use and chronic pain. 

[00:00:32] She leads the Geriatrics, Palliative, Addiction, and Pain Collaborative at Mount Sinai, an interprofessional meeting to discuss complex cases, improve care coordination, and foster learning in the management of patients with substance use disorders.

[00:00:45] foster learning in the management of patients with substance use disorders.

[00:00:49] Dr. Kelly is also currently developing a first of its kind geriatric co management program at Mt. Sinai's Behavioral Health Center, which offers integrated psychiatry, addiction, and primary care, all under one roof.

[00:01:02] Her perspective comes at a time when rates of substance use and substance related harms have skyrocketed in the older adult population. We're honored to have Dr. Kelly on the show.

[00:01:13] Dr. Lauren Kelly, welcome to Road to Resilience. 

[00:01:16] Lauren Kelly: Thank you. Thank you for having me. 

[00:01:18] Stephen Calabria: Could you give us a overview of your background? 

[00:01:21] Lauren Kelly: Sure. I am a geriatrics and palliative medicine doctor in the Department of Geriatrics and Palliative Medicine at Mount Sinai, and I do outpatient palliative care, so I take care of patients with serious illness.

[00:01:34] I work at the Cancer Center up here at Mount Sinai, and I also see patients in primary care at the REACH Clinic, which is a clinic that cares for patients who use drugs.

[00:01:44] And so we do a lot of management of things like opioid use disorder, alcohol use disorder. And I see older patients and patients with serious illness in that practice. So I tend to veer towards older adults, and patients that have life limiting illness. 

[00:01:58] Stephen Calabria: Now, for those who want more information about the REACH Clinic, you can hear our previous interview with Dr. Leah Habersham, who I believe is a colleague of yours. 

[00:02:07] Lauren Kelly: Yeah, we, we both work with the Addiction Institute at Mount Sinai. She does great work. 

[00:02:13] Stephen Calabria: You work primarily with older adults who suffer from substance use disorder, is that right? Could you tell us off the bat, what are the primary differences in terms of substance use disorder between older adults and younger adults?

[00:02:29] Lauren Kelly: Yeah, so older adults tend to be more sensitive to substances. So there is more consequence associated with substance use in terms of causing things like disorientation, sedation, increased risk of falls, injury related to falls. Substances are also processed by the body in a different way.

[00:02:50] So for example, the liver kind of slows down a little bit as we age. The liver is responsible for processing a lot of substances. Same with the kidneys. And so as the body is aging, it's more sensitive to substances. So it's more consequential, in terms of how it can affect the health. 

[00:03:06] We also see in older adults using substances, we see what looks like an accelerated process of aging, and so older adults using substances have things more frequently, such as cognitive impairment, or they have mobility impairment. 

[00:03:25] The body, in other words, is aging. It seems to be aging faster in the context of chronic substance use.

[00:03:31] Stephen Calabria: What constitutes chronic substance use? Every day? Every hour? Or is it kind of in the eye of the beholder? 

[00:03:39] Lauren Kelly: That's a great question. The data in this area is is not robust in terms of looking specifically at the older adult population. But we do sometimes see a differential in terms of how much comorbidity someone has depending on the substance of, that they're using.

[00:03:58] I'd have to look this up to give you the exact data, but I know a colleague of mine, Ben Han, was looking at methamphetamine use in older adults and actually noted that there's quite a high comorbidity rate associated with methamphetamine use. 

[00:04:12] So, I think your other question, though, is the extent of the exposure- how much use, how frequently and how often?

[00:04:19] I think that's a good question. Obviously, a dose response curve, so to speak. We know a lot about alcohol. We know a lot about tobacco exposure. Some of the other substances, it's a little hazier though. 

[00:04:31] Stephen Calabria: How do you incorporate the concept of resilience into your treatment plans for older adults dealing with substance abuse? And are there any specific strategies or interventions you find particularly effective? 

[00:04:45] Lauren Kelly: Absolutely. We do, in geriatrics, we do comprehensive patient assessments and we focus on multiple domains, specifically the five Ms. 

[00:04:53] So those things are mobility, medications, mind or mood, so cognition and, and mood, multi morbidity or multi complexity, like how many chronic conditions patients are dealing with, and the amount of specialists that folks have to see, to take care of all of those different issues.

[00:05:12] And then the last M is matters most, which indicates, what are the patient's values? What are their goals? And so we really kind of look at that framework and approach patients. And when I'm taking care of patients with substance use disorders, there's quite a high degree of disability.

[00:05:28] There's quite a high degree of chronic illness. And so what we're doing often is just trying to make a story about what's going on, because patients often find me and they're just sort of mixed up about what it is that they should be focusing on. 

[00:05:43] You know, what are their priorities? And oftentimes priorities that patients express are not heard by providers or tend to fall to the wayside, in exchange for the more medical minutia.

[00:05:55] So I think, you know, we'll see patients and, and really the important thing is to ask them, what's important to you? What do you want to focus on today? And you might not hear why I want to stop using heroin. That might not be what the patient wants.

[00:06:08] And maybe you as the provider want that to be the case, but meeting people where they're at, sort of in a harm reduction lens, thinking about what are the patient's priorities.

[00:06:17] I'm also thinking about harms, right, and reducing harms. So, did a patient just have a fall last week, maybe they used fentanyl and they were falling asleep on the sidewalk, and fell and hurt themselves, right? I'm thinking of at least one of my own patients that this happened to.

[00:06:34] Thinking about, Well, maybe they're not quite ready to give up using opioids, but perhaps we can think about safer environments for them to be, finding a comfortable place where there's going to be observation, someone that can be with them. 

[00:06:48] We also give all of our patients Narcan kits or Naloxone kits, that's to reverse opioid overdose.

[00:06:54] And so thinking about meeting patients where they're at and trying to reduce harm. So, to answer your question, I think a lot of what we do is assess patients in these different domains and think about what are specific interventions that we can try to employ in each of those domains.

[00:07:09] Stephen Calabria: I imagine there are a lot of people who would think that when dealing with this patient population the emphasis always has to be on stop using, cut it out, get it out of there. What would you say to those folks?

[00:07:22] Lauren Kelly: Well, that's not the real world. That's not the world that we live in. People have, will, always will use substances, and to think that we can eliminate that is just not practical. We do a lot of what's called motivational interviewing. We kind of listen really carefully. 

[00:07:42] And so if patients are kind of exhibiting some change talk, like let's say, oh, you know, this happened to me again. I messed up with my partner, you know, we're having a really difficult time right now.

[00:07:52] She really wants me to cut back on the cocaine, and it's getting in the way of our relationship. That is an opportunity. That's a moment where you can explore and say, what are you thinking about changing in terms of how you're using cocaine?

[00:08:05] Or sometimes we even say, on a scale of one to ten, how ready are you to make a change with how you're using substances? People say two. Okay, let's say one is they're not willing to change their use, ten is they're ready to go. They're ready to make a change. 

[00:08:20] So the patient says, oh yeah, you know, maybe, maybe I'm a two. Okay, so why aren't you a one? Tell me what makes you a two today and not a one. And so we can kind of use some of these strategies to really hear from the patient what it is their experience is and what are the real world factors that are influencing their behaviors. 

[00:08:40] And that's when we can kind of reflect back to patients and say, I'm hearing that you really want to start cutting back and let's talk about some of the ways we can do that with pharmacotherapy.

[00:08:51] Let's talk about some of the ways we can do that with support groups, peer support groups. And having a close relationship with a doctor, someone that you can see, even if it's just on a monthly basis, which is more frequently than many people go to the doctor, right? 

[00:09:04] But having a relationship with a physician and an interdisciplinary team, I can't emphasize the importance of that enough. Really, we have social workers that work with our patients. At the cancer center, for example, we have chaplains that see our patients who have spiritual care needs. 

[00:09:18] We have nutritionists. We work closely with physical therapists and occupational therapists and speech therapists and people that are really trying to rehabilitate patients. And so really, inviting everyone on that interdisciplinary team to become part of that patient's care. 

[00:09:36] And I think, again, this concept of narrating the patient's story, I think patients come to us in such chaotic circumstances, helping them write a story about, what is going on? What are the biggest priorities?

[00:09:50] Stephen Calabria: What are the things you most often hear?

[00:09:54] Lauren Kelly: Patients sometimes are presented with options for treatment and or surgeries, procedures or other interventions. What we can do in medicine is not always what we should do and being able to hear from the patient, some patients say, Oh, you know, quality of my life is so much more important than the quantity of my life.

[00:10:18] So, yes, there's lots of things we can do to extend the quantity of someone's life. But are those things that the patient ultimately would want, right? Because sometimes in some cases we're thinking about a lot of disability and or not returning to a previous state of health after something catastrophic may occur.

[00:10:36] And so trying to plan, you know, what are those acceptable qualities of life? , what are things that, that might make life not worth living for you if, if you can imagine that, right? And that's sometimes hard as a hypothetical.

[00:10:49] But I think very important in the work that we do around values mapping and goals of care is thinking about who would you identify to speak on your behalf if you couldn't speak for yourself.

[00:11:01] And so assigning a healthcare proxy. That's critical and we try to do that with all of our patients. 

[00:11:07] Stephen Calabria: It sounds like you are here not just to manage the physiological fallout after patients have been using for some time, but also to guide them in a therapeutic way through this journey.

[00:11:20] Older adults may face unique challenges in seeking treatment for substance use disorders such as stigma, limited social support, age related health issues. You're nodding your head for the people listening. How do you address these challenges when fostering resilience in your patients? 

[00:11:37] Lauren Kelly: So you said a lot there. 

[00:11:39] Stephen Calabria: Well, we can bring it down to one. So, stigma.

[00:11:42] Lauren Kelly: Stigma is so pervasive and I find myself just having to undo so much of it when someone walks in because much of its internalized. Patients internalized stigma. And so really just an attitude of respect for people. 

[00:11:57] For example, we often run behind in clinic and so just apologizing, say, Hey, I'm so sorry you've been waiting for so long, but now that I'm with you, you have my full attention. I'm going to really focus on what your needs are. 

[00:12:07] Let's, let's talk. And so really respecting and creating space. Listening, right? So our communication skills are critical in showing respect and there's statements we can make. In palliative care we talk about, we call them nurse statements.

[00:12:24] I wish we had this training for all providers, but statements of respect is, that's one example, but also statements of understanding, like, I understand that this has been such a difficult experience for you.

[00:12:35] Statements of validation, I can't imagine how tough it's been for you to lose your spouse. And even though it happened 15 years ago, it's almost like it happened yesterday. 

[00:12:47] And so giving statements to the patient, A, you're listening, B, you're feeling their emotion, and C, you're reflecting it back to them and that makes people feel really seen and heard. 

[00:12:56] So I think the process of undoing stigma, communication is so key and, and, and holding patients up. I think also addressing stigma directly, right? When it comes up, if patients bring it up, like, I'm so sorry that that happened to you. 

[00:13:12] It sounds like the color of your skin dictated your experience in that situation. I'm so sorry that that happened to you. What can we do to try to change the way that, that might happen for you in the future and how can I support you as a provider to make sure I advocate for what it is that you need?

[00:13:28] Stephen Calabria: I also imagine that for younger people, while there still is a stigma, it's not nearly as great as someone who is, say, in their 70s or 80s, who came of age in a time where addiction was very much not okay and shunned and shamed. 

[00:13:44] Lauren Kelly: Absolutely. Yeah. I mean, it's interesting. We can try to paint broad strokes and say, Oh, you know, pre war folks, the stigma was, was very high. You think about people coming of age in the sixties and seventies, there was a pretty strong culture around substance use at that time. 

[00:14:00] The baby boomer population, for example. But really it's such an individual, right? It's such an individual experience, within families, within cultures, within subcultures, relation to substance use is, it can be very different. 

[00:14:13] So I like to get a sense from people what they've experienced or what their perspective is on how they've been treated related to their substance use. 

[00:14:21] So I ask a lot of questions and I think it's, it's great to, to be taught by your patients, to let them explain to you. What are they using? How are they using? 

[00:14:30] There's a lot of new drugs, synthetic new drugs that are coming out that many of us have never heard of, right?

[00:14:37] And so, where do you get these substances? What effects are you seeing? Being curious and letting patients teach you. 

[00:14:43] Stephen Calabria: You mentioned the vital role of social support as a doctor. Research suggests that social support plays a crucial role in resilience. How do you involve family members or caregivers in the treatment process to enhance resilience among your patients? 

[00:15:01] Lauren Kelly: So, I think people relate to the word family in different ways. So, I think just taking a step back even, to say who matters to you, who is important in your life, what relationships nourish you, and leaning into that, right?

[00:15:16] Trying to call on those supports because those may not be family, right? And, and patients who have used substances long term, you know, they may have, may have a lot of burnt bridges with people in their lives. 

[00:15:30] So getting a sense of who someone's community is and what are the strengths of that community and certainly involving someone, a trusted individual in a visit, for example.

[00:15:42] So for, for my patients that are dealing with serious chemotherapies or other cancer directed treatments, it's really good to have a second set of eyes and ears. So the extent that we can include those individuals in our meetings, I think that can be really, really helpful.

[00:15:59] When it comes to debility and physical decline, I think that's where it becomes really, really challenging. A lot of patients don't have someone to physically care for them, and a lot of patients struggle with stable housing. 

[00:16:15] A lot of patients may not have someone that's calling them and checking in on them every day, and that's where it becomes really, really tough. Also, a lot of patients need to work, and when they're not working and not making any money, particularly if they're undocumented, and then add on top of that serious illness, aging, things like that, it just becomes so tremendous and difficult. 

[00:16:38] And so, to the extent that we can get people home health services, we try as best as we can on that front, getting people home health attendance. We also frequently refer patients who have physical functional decline to things like physical therapy or occupational therapy, and hey, it's not necessarily a family member, someone supporting them, but it's something that gets them out of the house or can come to them in their house and actually provide some stimulation, right?

[00:17:07] Get them up, get them moving around. Hey, I'm doing something great for myself. I exercised today. I feel a little bit stronger. There's also a number of support groups, things that we can lean on, peer support groups.

[00:17:19] The REACH program has a great weekly, in person and also Zoom, meeting for patients who are in our program and we also have extended that to caregivers or people that are in patients' support circles to get their own needs met, right?

[00:17:35] Because that can be difficult. It can be a difficult experience loving or caring for someone who has a substance use disorder. And so, it's really a combination of things that we try to offer people. 

[00:17:45] Stephen Calabria: And based on your experience, those social interventions can make a world of difference.

[00:17:49] Lauren Kelly: Absolutely. Absolutely. That's, honestly, that's a huge part of what I do. I prescribe medication but more than anything else, the relationship that we develop with our patients as well as the way that we can help them strengthen their supports, I think that's like the most important thing.

[00:18:06] Stephen Calabria: The thing is, with social support, you've touched on how so many of these patients have suffered strained relationships. How do you go about rebuilding that? 

[00:18:20] If a patient has alienated perhaps some of the most important people in their lives, which then perhaps led to a cycle of use, where do you start with that? 

[00:18:34] Lauren Kelly: Yeah, it's really, when you say it like that, it's, it's tough. It may be sometimes that patients initiate that distance, right, and it may be sometimes that folks are pushing that individual away. So, being curious about what are the circumstances of that distance.

[00:18:53] Sometimes patients, when they're getting care, when they're feeling cared for by a provider, by the medical team, they may see themselves feeling differently towards themselves, right? More confident. Perhaps it'll increase their sense of self-worth. 

[00:19:10] Maybe it will make them feel like reaching out to a family member might go a little bit better this time, right? If you're building them up in those ways.

[00:19:20] So, I think sometimes there's closed roads and they don't reopen, but, showing care, I feel like it's just as simple as that, really, is showing care and encouraging patients when they feel comfortable to reach out to people they may want to reach out to.

[00:19:37] Stephen Calabria: Closed roads don't mean you stop driving. Older adults may have experienced significant life transitions or traumas that contribute to their substance use disorder. How do you help them reframe their experiences in a way that promotes their resilience and facilitates recovery?

[00:19:56] Lauren Kelly: I think the most important thing is developing a connection to the patient. That's like where it all starts. Because if someone feels safe talking to you, then a lot can come out. A lot can come out in the exchange. 

[00:20:10] On the contrary, if they don't feel safe asking people about their traumas, that's not a good idea, right? And also, what are you going to do about the information when it comes up, right? 

[00:20:23] And asking someone about their trauma and kind of letting it drop there in the room and not attending to it, not giving them resources, not following it up, right? That can be irresponsible. And so I think, A, making a strong connection with the patient so that they feel safe and supported.

[00:20:43] And then B, making sure that you're bringing things up or actually allowing the patient to bring it up themselves and making sure that you're offering a lot of care and resources and support when those things do come out. 

[00:21:00] Stephen Calabria: I imagine there are also some people out there who say, Well, the trick to not using drugs is to just stop using drugs and it falls entirely on the patient and there is a personal responsibility angle. What do we think of that?

[00:21:17] Lauren Kelly: Substance use disorders are, in the way that hypertension and diabetes and other chronic illnesses are diseases of the body, this is a disease as well. And this is a disease that affects neurochemistry, the dopamine circuit. 

[00:21:34] We could get into that. I think there is a serious biological basis for addiction as a medical illness. And there are lots of treatments that we can offer that are effective, that reduce mortality, that improve quality of life for patients, and we're not offering those as much as we should be. 

[00:21:54] There are a lot of providers that don't have great comfort with prescribing medications for substance use disorders. What do you mean I should give Adderall to someone who has a stimulant use disorder?

[00:22:04] That sounds like it's just propagating the problem. Well, maybe, maybe not. I think we're starting to learn more and more about substance use disorder treatment. It is a very active area. We have great data on medications for opioid use disorder. 

[00:22:21] Buprenorphine, methadone, they save lives. They work. So, we should really be using them more and we should make them easier to access for patients, particularly methadone. And that's an area that's evolving.

[00:22:34] There's legislation, MOTA, right now that's aiming to improve access to methadone in the community via pharmacies and making it easier for patients to get methadone in the way that they can get other prescriptions for a month's supply, right? 

[00:22:50] This is the way the United States does things right now, but other countries, places like Canada, you know, they have a pharmacy based program for methadone. 

[00:22:58] It's much easier to access, and it's less stigmatizing to get your medication from a pharmacy than it is to have to stand in line in an opioid treatment program, every day, perhaps, to get dosed where you have to swallow the dose in front of the nurse, that can be a really unpleasant experience for patients. 

[00:23:15] Stephen Calabria: As far as self efficacy goes, what role do you believe self efficacy and empowerment play in fostering greater resilience among older adults with substance use disorders?

[00:23:27] Lauren Kelly: Self-efficacy is really important. What I do is I talk a lot about what the benefits could be to try to motivate patients towards that. And things like, you're going to feel 20 years younger if you're not using alcohol every day. 

[00:23:43] Or, you may experience better relationships with the people around you if you're not using substances and again, this is the motivational interviewing piece, but yeah, self efficacy is critical. If patients feel unmotivated, then that's when you worry more, right? 

[00:24:00] And also, some patients maybe don't see things the way the doctor sees them, right? Maybe they see their use as pretty safe, and maybe they've been using chronically, stably, and there have been no major consequences in their life related to their substance use. 

[00:24:18] And so, they feel efficacious in the way that they're living their lives, perhaps. And so that's where we would take more of a harm reduction approach to again meet them where they're at. 

[00:24:29] I think the distinction is really, What are the harms? What are the, what are the harms that we're seeing come up, and what can we do to mitigate those harms in someone's life? 

[00:24:41] Stephen Calabria: Is the idea of a functioning addict a myth? 

[00:24:45] Lauren Kelly: 

[00:24:47] No. So, uh, I actually take issue with the word addict. It's stigmatizing and we use person-centered language. And so the way that that could sound is, person with a substance use disorder or person with an addictive disorder.

[00:25:02] Yeah, there are plenty of people who have substance use disorders that are functioning. The question is, what does functioning look like, right? 

[00:25:11] And if someone is maintaining a job, having decent relationships with people, feeling fulfilled in their relationships with people, not getting physically injured, getting into car accidents, having traumatic injuries, things like that.

[00:25:25] If someone is kind of managing their use, that, I would consider that to be functional for that person. But if there's a lot of harms that we're witnessing, people are getting injured, people are losing their job, or people are finding hard to maintain work, people are getting incarcerated, people are being threatened with loss of their, of their children, perhaps custody of their children, things like that, I mean, that's where you can say that this has created a lot of problems, and this is not working well for you, and what can we do to help you gain more control over the situation?

[00:26:06] And that may or may not involve stopping using a substance. That might involve using a substance in a different way, in a safer way, in a more moderate fashion, perhaps, for some. 

[00:26:18] Stephen Calabria: How do you address the intersection of mental health issues, such as depression and anxiety, with substance use disorder in older adults?

[00:26:27] Lauren Kelly: It's extremely common. We see depression, anxiety, and other mental health issues in our patients. And you can't address the substance use and not address the mental health issues. They go hand in hand. 

[00:26:43] We see a lot of mood disorders related to substance use. And so, perhaps, the comedown, for example, from cocaine is a really depressive experience.

[00:26:55] And people are just cycling back and forth and withdrawal syndromes with opioids and other substances, that can be really, really awful from a psychological perspective. And so, treating the substance use disorder first and foremost, I think, is really important.

[00:27:11] There are plenty of patients that I'm treating for concurrent substance use and mental health issues, but we often see that if patients are able to get their substance use under control, that it really helps with their mood. It helps with depression. It helps with anxiety. 

[00:27:26] Some patients are also self medicating for their mental health issues with substances. And so trying to find out, what is it about the substance that you find beneficial or helpful, asking that question. 

[00:27:41] I take care of some patients who have cancer and they have really strong fatigue related to their cancer, related to their chemotherapy. And they're using stimulants, and the stimulants are helping them get out of bed in the morning, function, go to work, in some cases.

[00:27:56] And so, not being judgmental of that is important. And, thinking about, maybe I can offer you bupropion and that might help with your mood and with your energy level and things like that. 

[00:28:09] So yeah, just thinking about what treatments we can offer that can kind of kill two birds with one stone, I hate that expression, but trying to treat multiple problems together, I think, is a helpful principle. 

[00:28:22] Stephen Calabria: How has working with this patient population influenced your ideas around resilience and recovery? 

[00:28:29] Lauren Kelly: That's a beautiful question and I love the work that I do. I think it is so wonderful. It's just, everyone has the capacity for change. Everyone has the capacity for joy. And this work reminds me of that every single day. 

[00:28:48] People say, oh, isn't it depressing to do palliative care? No, it's not depressing at all to me. And that is because, we all, at some point, will either personally deal with or have people we care about that are dealing with serious illness and we need to find a way through it.

[00:29:06] And so, there needs to be somebody that helps us do that. And so this just feels very rewarding to be able to participate in people's lives in this way And when you add substance use disorder into the mix, I think it's so hard for some of us to talk to people about this stuff.

[00:29:22] And I think doing this every day, getting to talk to people about this every day, you just see so many amazing stories of resilience, to use a favorite word here.

[00:29:33] Stephen Calabria: What's your favorite example? 

[00:29:35] Lauren Kelly: I'm thinking about one of my patients who, she has since passed away, unfortunately. But she did not like to be hospitalized and she had lung cancer and was hospitalized for breathing difficulty and was given some treatments for her breathing and she actually was on medication. 

[00:29:56] Very high support, high flow nasal cannula oxygen in the hospital. And, she was telling the nurses, my saturation is always, you know, in the 80s. That's just normal for me. And, and she actually left the hospital. 

[00:30:11] She decided to leave the hospital, despite the medical team still thinking she required this oxygen, this type of oxygen support. No, no, no, it's fine. I'll, I'll just use my oxygen at home. And, she walked out of the hospital. She escorted her off of the step down unit. 

[00:30:25] And left the hospital, and went on to live many, many months after that. She knew herself in a way that other people did not. And even though there were risks, she understood the risks. And she accepted the risks.

[00:30:38] And she brought so much joy to people's lives. She was just an incredibly bright and funny, witty, sassy. She was something else and her family adored her. And she just lived life on her own terms. And we celebrated her while she was alive, and we celebrate her after she's died. 

[00:31:01] Stephen Calabria: Last question. In your experience, what are the key elements or characteristics that contribute to long term resilience and successful recovery among older adults with substance use disorder?

[00:31:14] Lauren Kelly: There are things that make it easier for folks to have better control over their substance use. Things like support, so, having a spouse, for example, or if you've lost your spouse. That can make it a lot harder. Having a community.

[00:31:29] We see folks that spiritual or faith communities tend to cope a little bit better. So in addition to having good social support, we also see that in older adults that have developed a substance use disorder later in life, it tends to be related to something that happened, perhaps a loss. 

[00:31:52] Perhaps involuntary loss of employment. An event, so to speak. And perhaps it's, it's, it's more of a reversible condition in that case, versus a substance use disorder that someone develops early in life, which we, we tend to see more of a genetic sort of environmental predisposition there. And those can be, those can be harder to treat. 

[00:32:15] Stephen Calabria: Well, that's it for my questions. Was there anything else you wanted to say?

[00:32:20] Lauren Kelly: Yeah. I think this is a great interview. I'm glad that we talked about all this 

[00:32:25] Stephen Calabria: Dr. Lauren Kelly, thank you so much for your time. 

[00:32:27] Lauren Kelly: Thank you for having me.

[00:32:29] Stephen Calabria: Thanks again to Dr. Lauren Kelly for her time and expertise. That's it for this episode of Road to Resilience. If you enjoyed it, please rate, review, and subscribe to our podcast on your favorite podcast platform. 

[00:32:40] Want to give us feedback or pitch an idea for a future episode? Email us at podcasts at mountsinai. org. 

[00:32:46] Road to Resilience is a production of the Mount Sinai Health System. It's produced by me, Stephen Calabria, and our executive producer, Lucia Lee. From all of us here at Mount Sinai, thanks for listening, and we'll catch you next time.