Addictive and Co-Occurring Disorders in Late Life David W. Oslin, M.D. University of Pennsylvania,...
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Transcript of Addictive and Co-Occurring Disorders in Late Life David W. Oslin, M.D. University of Pennsylvania,...
Addictive and Co-Occurring Disorders in Late Life
Addictive and Co-Occurring Disorders in Late Life
David W. Oslin, M.D.University of Pennsylvania, School of Medicine
And
Philadelphia, VAMC
Hazelden Research Co-Chair on Late Life Addictions
Translating Positive findings in Aging to Translating Positive findings in Aging to Younger AdultsYounger Adults
Age Group
Age >59
Age 40 - 59
Age <40
DisclosuresDisclosures NIMH
K08 Award ACSIR
NIDA Center for Studies on Addiction
NIAAA R01
VA Merit Early Entry MIRECC HSRD Merit Award
Industry Support DuPont Pharma Forest Labs Hazelden Foundation Pfizer
Relevance of comorbidity to an aging Relevance of comorbidity to an aging populationpopulation
Cohort changes in exposure – we will see more elderly patients using illicit substances (current and past abuse)
Consequences may be greater in older adults Direct toxicity / withdrawal Indirect interactions with medications or other illnesses
Comorbidity is a significant issue perhaps uniquely so for the elderly Cognition Minor depression Suicide Anxiety and personality problems
Changing environment Social isolation Limited resources Limited access to care
Comorbidity and Drug/Alcohol DependenceComorbidity and Drug/Alcohol Dependence
Higher than expect rates in representative community samples
Markedly higher rates in treatment seeking samples
Increased morbidity and mortality particularly suicide
Presents diagnostic difficulties
Poor prognostic factor
Call for integrated care system
SuicideSuicide
Highest rates of suicide occur in late life among men.
Depression causes a 5.8 fold increase in risk of suicide compared to death from other causes
Heavy drinking (3+ drinks/day) causes a 8.9 fold increase in risk of suicide compared to death from other causes
Moderate drinking (1-2 drinks/day) causes a 10.6 fold increase in risk of suicide compared to death from other causes
Grabble, et al. 1997
The difficultyThe difficulty
Extremely limited research
Drug and alcohol dependence are exclusions to most geriatric trials
Age >65 is almost always an exclusion for drug and alcohol trials
What is the Extent of the Issues?What is the Extent of the Issues?In the CommunityIn the Community
Current / Last 12 months
Alcohol Dependence 2 - 4 %
Medication misuse ? Overall
Chronic Benzodiazepine use 5 – 20%
Nicotine dependence 10 - 15 %
Illicit Substance dependence < 1 %
Pathological Gambling 1 – 2 %
Baby Boomers AgingBaby Boomers Aging
91 – 92 01 – 02 Percent Increase
18-29 6.5 7.0 8%
30-44 3.0 6.0 100%
45 – 64 1.4 3.5 150%
65+ 0.3 1.2 300%
Grant, et. al. Drug and Alcohol Dependence 2004
Veterans (Age 60 and Over) in Addiction Veterans (Age 60 and Over) in Addiction TreatmentTreatment
Alcohol Only 51.8%
Street Drugs Only 9.1%
Prescription Medications only 3.6%
Alcohol and Street Drugs 26.4%
Alcohol and Prescription Medications 5.5%
Street Drugs and Prescription Medications 0.9%
All three categories of substances 1.8%
Missing data 0.9%
Schonfeld et al. 1990Sample of 110 subjects in a special geri-addiction program
Past History of Heavy drinking/alcoholismPast History of Heavy drinking/alcoholism
Many older adults especially those of the “Woodstock” generation will enter late life with a past history of alcohol or drug abuse
5 fold increase in late life mental disorders (depression and dementia)
Treatment of late life depression (3-5 yr outcomes) 88% of those without an alcohol history
significantly improved 57% of those with an alcohol history
significantly improved
Saunders et al. 1991, Cook et al. 1991
Behavioral Health Laboratory (BHL): Behavioral Health Laboratory (BHL): Links To Primary CareLinks To Primary Care
Behavioral Health Laboratory (BHL): Behavioral Health Laboratory (BHL): Links To Primary CareLinks To Primary Care
Research to Practice:Research to Practice:Behavioral Health LaboratoryBehavioral Health Laboratory
The BHL is an automated telephone assessment and triage service for patients identified by primary care providers as having depressive symptoms or at-risk drinking.
The depression and alcohol clinical reminder system generates a consultation request to the BHL.
The BHL conducts a brief telephone (20-30 minutes) assessment generating a report for the PCP including diagnosis, severity, and general treatment recommendations.
Drug Use Among Primary Care Patients with Drug Use Among Primary Care Patients with Minor or Major DepressionMinor or Major Depression
<50 Years 50-64 years 65 + years
n=205 n=323 n=112
Use in past year 24.4 20.7 2.7
Past history of use 20.5 20.4 1.8
Types of Substance Use Among Older Types of Substance Use Among Older Adults (50+) Adults (50+)
Use in Past Year
Only a past history
n=70 n=22
Cocaine 54.3 36.4
Heroin 7.1 0
Marijuana 58.6 77.3
Amphetamines 1.4 9.0
LSD 1.4 4.5
Inhalants 1.4 0
Barbiturates 1.4 0
Drug Use Among Older Patients with Minor Drug Use Among Older Patients with Minor or Major Depressionor Major Depression
No Hx of Drug use
Only a past Hx
Use in the past year
Diff (by column)
n=342 n=22 n=70
Nicotine use 36.5 68.2 68.6 c>a, b>a
At-risk drinker 10.5 31.8 27.1 c>a, b>a
Cognitive screen 4.2 (4.2) 6.6 (4.8) 4.8 (4.0) b>a
Suicide 12.5 13.6 28.6 c>a
Manic symptoms 7.0 0.0 18.6 c>a
Psychotic symptoms 9.9 9.1 21.4 c>a
PTSD 27.0 18.2 37.1
TreatmentTreatment
Depression Alcohol Aging TrialDepression Alcohol Aging Trial
Hypotheses Among older adults with major depression and
comorbid alcoholism, naltrexone combined with sertraline improves the outcomes of both drinking and mood.
Reduction in alcohol consumption will be associated with improved mood regardless of randomization.
Naltrexone will lead to a reduction in alcohol consumption independent of changes in mood.
Concurrent Treatment of Depression Concurrent Treatment of Depression Complicated by Alcohol DependenceComplicated by Alcohol Dependence
Current depressive syndrome Current alcohol dependence Age 55 and over 10 sessions of compliance enhancement therapy 1/2 of subjects are randomly assigned to receive
naltrexone 50 mg All subjects receive sertraline 100 mg Outcomes at 3 months
(Oslin, 2004)
Pre-Treatment Clinical CharacteristicsPre-Treatment Clinical Characteristics
Placebo Naltrexone p value
HDRS Score 23.4 (5.0) 20.1 (5.7) 0.011
Percent Days Heavy Drinking- 75.8 (29.1) 59.2 (35.6) 0.032
Percent Days Drinking 82.4 (24.5) 75.5 (29.3) 0.270
Drinks/ Drinking Day 10.2 (6.8) 6.5 (3.9) 0.006
ASI-Alcohol Score 0.67 (0.18) 0.64 (0.17) 0.433
PCS 43.8 (8.5) 46.1 (10.3) 0.325
MCS 33.2 (9.6) 38.1 (11.5) 0.061
% with Primary Depression 68.6 65.7 0.799
Relationship between heavy drinking during Relationship between heavy drinking during the trial and depression outcomesthe trial and depression outcomes
No Relapse Relapse p
Completed Research (%) 83.7 84.0 0.886
Depression Remitted 63.3 32.0 0.011
HDRS – end of trial 8.8 (6.7) 12.7 (8.2) 0.013
Overall Treatment OutcomesOverall Treatment Outcomes
Well42%
Relapsed only11%
Depressed only24%
Depressed and Relapsed
23%
Substance Induced Depression in the Substance Induced Depression in the elderly?elderly?
Less than 50% resolution of symptoms early in treatment
No relationship between clinical impression of primary vs. secondary depression and early response
Not just DependenceNot just Dependence
Moving beyond DSM in conceptualizing risk
Disease and BehaviorDisease and Behavior
Substance dependence Follows the biomedical model of an illness
At-risk use Public health model Recognizes risks (health, economic, etc.)
associated with use in individuals not suffering with the “disease”
Most relevant for alcohol, medications, marijuana and nicotine.
What about moderate or abusive drinking What about moderate or abusive drinking (non-dependent drinking)(non-dependent drinking)
Most common pattern of drinking among those with depression
May be beneficial for heart disease
Safety concerns may be less with newer medications (SSRIs) than older meds (TCAs)
Response to Standard Depression Care Response to Standard Depression Care Among the ElderlyAmong the Elderly
PROSPECT study Remission of depression (men only)
Non-drinkers – 41 % Moderate drinkers – 18.2%
PRISM-E study (preliminary) Remission of depression (men only)
Non-drinkers – 33.8 % Moderate drinkers – 6.3 %
(Personal Communication, 2002)
Telephone Disease Management for Telephone Disease Management for Depression and At-Risk DrinkingDepression and At-Risk Drinking
To develop a method for delivering high quality depression and alcoholism treatment in Primary Care, CBOCs, and other clinics in which there are significant transportation, staff resource, or other impediments to the delivery of face-to-face MH/SA care.
To develop methods for translating effects demonstrated in randomized clinical trials to clinic populations.
TreatmentsTreatments
Telephone Disease Management is algorithm driven care delivered by a Behavioral Health Specialist.
Enhanced Usual care. The PCP can monitor, treat, and/or refer. The PCP is provided a diagnosis and references for treatment options.
Improvements with TDMImprovements with TDM
0
5
10
15
20
25
30
35
40
45
TDM Usual Care
Depression Remission
Alcohol Remission
Overall Remission
Oslin, et. al. 2003
Is Sedative/Hypnotic Use a Co-Is Sedative/Hypnotic Use a Co-Occurring Problem?Occurring Problem?
Association with falls
Association with memory impairment
?Association with treatment of depression
How to Define Inappropriate How to Define Inappropriate Benzodiazepine UseBenzodiazepine Use
Chronic Use (>3 months)
Use of long-acting agents
Undocumented response
Lowest effective dose (harm reduction)
Sedative/Hypnotic UseSedative/Hypnotic UseA Disappearing Problem?A Disappearing Problem?
0
5
10
15
20
25
Depressed Non-depressed
Men
Women
M:W p= 0.0393, Positive: Negative p=0.002
Types of Sedative/Hypnotics UsedTypes of Sedative/Hypnotics Used
Percent
Xanax 32.7
Ativan 24.1
Restoril 13.1
Klonopin 11.1
Valium 10.6
Librium 6.0
Tranxene 4.5
Barbituates 2.0
Serax 2.0
Dalmane 1.0