Source: Washington Post Contact: http://washingtonpost.com/wp-srv/edit/letters/letterform.htm Website: http://www.washingtonpost.com/ Pubdate: Tue, 23 Jun 1998 Author: Joseph A. Califano Jr. Note: The writer is president of the National Center on Addiction and Substance Abuse at Columbia University. He was secretary of health, education and welfare from 1977 to 1979. THE FORGOTTEN WOMAN Washington is a Babel of talk of tobacco legislation, patients' rights, taming aggressive managed care companies and reforming Medicare and Medicaid. In this cacophony of political concern about health care, let's hope the administration and Congress don't drown out what former first lady Betty Ford calls "America's hidden epidemic": substance abuse among older women. Prevention and treatment of substance abuse and addiction have long been relegated to the back of America's health care bus. What's so disturbing about the recent report of the National Center on Addiction and Substance Abuse at Columbia University ("Under the Rug: Substance Abuse and the Mature Woman") is its revelation that women age 60 and over are seated in the last row. Of 1.8 million women 60 and over who need treatment for alcohol abuse and alcoholism, only 11,000 -- less than one percent -- receive it. A convicted felon has a far better chance of getting such treatment than an older woman. Presented with a classic description of a mature woman in the early stages of alcohol abuse, only one percent of surveyed primary care physicians with a significant proportion of mature female patients even considered alcohol abuse as a diagnosis. More than 80 percent suggested depression, a diagnosis likely to lead many doctors to prescribe sedating psychoactive drugs that can exacerbate the condition of an alcoholic woman and even kill her. Half of the prescriptions for benzodiazepines -- tranquilizers and sleeping pills -- given to mature women are inappropriate. Contrary to standards set by expert panels, they either should not be prescribed for these women or should be prescribed for shorter periods of time. No wonder 2.8 million women in this age group abuse psycho active prescription drugs. There are 25.6 million women 60 and over in the United States. With a life expectancy of 83 and climbing, a 60-year old woman has more than a quarter of her life ahead of her. Yet our medical system, perhaps reflecting attitudes of society at large, sees these women as though they are within walking distance of the grave. How many of us have said, "What's the point of trying to get mother to quit smoking? She's old and set in her ways." Or, "Let grandma get tipsy at night. She's lonely and has so few pleasures." Or, "At that age what difference does it make if she's taking too many tranquilizers and drinking while she uses sleeping pills. It makes her feel better and she's easier to get along with." It makes a big difference. In good health these women have many years ahead as productive workers and loving parents and grandparents. Within three years of quitting, former female smokers are no more likely to have heart attacks than women who have never smoked, and they are less likely to die from smoking-related cancers than current female smokers. Congress has given plenty of attention to discouraging smoking among young girls. But most members are oblivious to the needs of the 4.4 million mature women whose smoking threatens them with premature death and loss of years of independent living. As Congress frets about the financial future of Medicare, it ignores the hefty costs that substance abuse by older women imposes on the trust fund, costs certain to increase as the number of women over 59 explodes with the baby boomers moving into senior status. Though medical science has demonstrated that one drink generally has the impact on a woman that two drinks have on a man, most physicians treat a woman more like a man. When asked what they considered excessive drinking for mature women, primary care physicians set the standard at 2 1/2 drinks a day. The National Institute on Alcohol Abuse and Alcoholism sets that mark at more than one drink daily. A woman faces signific ant risk of liver cirrhosis if she consumes two drinks a day; that risk doesn't become significant for a man until he belts down more than six drinks a day. Doctors blame their failure to identify substance abuse in women age 60 and older on their lack of knowledge and time, patient denial and physician and patient discomfort in discussing the problem. Medical schools and continuing education (and some female-focused research) can fix the knowledge gap. States should require individuals seeking licenses to practice medicine or certification as specialists to demonstrate their understanding of how to spot and treat substance abuse and addiction. The gaping hole in the medical system's handling of mature women with substance abuse problems is its failure to provide appropriate reimbursement. Three of the top health problems that women age 60 and over face are smoking, psychoactive prescription drug abuse, and alcoholism and alcohol abuse. Many of the others, such as cancer, heart disease and osteoporosis, are caused or exacerbated by substance abuse. Medicare- and Medicaid-eligible mature women are three to five times likelier to be hospitalized for substance abuse-related ailments than for non-substance-abuse related heart attacks. Yet 98 percent of hospital charges for mature women go to treat the consequences of substance abuse; only two percent go to treat the abuse itself. Of physicians who have referred mature women for substance abuse treatment, 20 percent say that a private or public health plan denied coverage. Medicare and managed care and insurance companies should pay doctors to talk to these women, not just to cut, stick, image and slip pills to them. And, as a bill introduced by Sen. Paul Wellstone would require, these programs should accord to treatment for substance abuse the same status they give treatment of other diseases. Copyright 1998 The Washington Post Company - --- Checked-by: Richard Lake