Older Adults and Addiction

Michael Weaver, MD

Division of General Medicine and

Division of Addiction Psychiatry

Virginia Commonwealth University

School of Medicine

Farley Lecture SeriesMarch 23, 2012

Objectives

Addiction in Older Adults Screening and Brief Intervention Addiction Treatment with Older

Adults Conclusions Practice Cases

What percentage of older adults (over age 65) are affected by alcohol and

prescription drug abuse? A. 5 B. 7 C. 10 D. 17 E. 25

Prevalence reduced with age

Rates of illicit drug use drop among older cohorts

Addiction problems resolved– Treatment when

young– Too old to hustle

Die earlier Cohort effect

– Current older adult cohort didn’t have ‘crack’ in their youth

Alcohol and prescription drug misuse still affect 17% of older adults

The Age Wave is cresting

First ‘Baby Boomers’ just turned 65

This generation used illicit drugs in youth

Continue to use their drugs into older adulthood

Different from previous generations

Liberto 1992; Saunders 1991

Alcohol abuse in older adults

Community– Heavy use 3-25%– Abuse 3-10%

Primary Care clinics (>1 drink/day)– 12% of women– 15% of men

Hospitalized– 18-44%

Graham 1986; Curtis, et al 1989

Why is it under-diagnosed?

Selection Bias– Surveys miss

nursing homes– Poorer recall

Ageism– “Granny’s cocktails

make her happy”– “He won’t be

around much longer anyway”

Under-recognized– Alcoholism

recognized in only a third of hospitalized older adults

Symptoms of AUD may mimic symptoms of other disorders– Depression, dementia– Diabetes

Smith 1995

Sensitivity to alcohol with age

Older adults more sensitive to alcohol– Reduced total body

water Higher

concentrations– Reduced

metabolism in GI tract

Amount with little effect in youth causes intoxication in older adults

NIAAA 2005

Drinking Guidelines

Over age 65 years:– 1 standard

drink/day for men– Less for women– No more than 2

drinks on any one occasion

– No more than 7 drinks per week

Psychiatric Co-Morbidity Higher risk for substance use among

those with psychiatric disorders– Depression or anxiety disorders– Other psychiatric comorbidities– Personality disorders

Dual diagnosis– Substance use disorder + another major

psychiatric disorder

May present with complex clinical histories and symptoms– Diagnosis challenging– Intoxication and

withdrawal symptoms may be mistaken for other psychiatric or medical symptoms

Contact with health care system is opportunity to intervene

Earlier detection and intervention prevents problems

Myers, et al 1984; Wilsnack 1985; Fillmore 1987

Gender differences

Older men more likely to have alcohol-related problems

Women develop problems later in life– More vulnerable to

social pressure– Higher remission rates

(all age groups)

Hurt, et al 1988; Atkinson & Ganzini 1994

Late-onset alcoholism

Makes up a third of older adults with drinking problems

Alcohol use associated with life losses– career loss due to retirement– death of spouse, change in own health status

Not stereotypical alcoholic—too healthy Milder & more amenable to treatment,

especially brief intervention

Callahan & Tierney 1995; Brennan & Moos 1996

Alcohol effects on older adults

Rate of hospitalizations of older persons for alcoholism is ~1%– Same rate of

hospitalization as for myocardial infarction

Alcohol-related dementia

Highest rate of completed suicide

Adverse reactions when combined with prescription or OTC meds

Some Prescriptions withPotential for Abuse

More common among Older Adults–Sedative-

hypnotics–Opioids

Sedative-Hypnotics

Benzodiazepines– Acute or

generalized anxiety– Insomnia– Seizures

Barbiturates– Insomnia– Headache– Seizures

Sedative misuse/abuse

Self-medicate hurts, losses, affect changes

Older patients prescribed more benzodiazepines than any other age group

Butalbital (Fiorinal) contributes to medication rebound headaches

Other Sleeping Pills

Bind to BZ receptor subtypes– Zolpidem

(Ambien)– Zalaplon

(Sonata)– Eszopiclone

(Lunesta)

Behavioral pharmacological profile similar to benzodiazepines– Drug liking, good effects, monetary street value

Recommended for short-term use, many taken long-term

May cause hazardous confusion & falls

Risky prescriptions: Sedatives

Problematic for– Alcohol abuse– Sedative misuse

Benzodiazepines– Valium, Xanax, Ativan,

Librium, etc.– Try anti-anxiety

antidepressants or psychotherapy

Z-drugs (zolpidem, etc.)– Sleep hygeine– Side effects of other

meds– Ramelteon (Rozerem)

Opioid Painkillers

Short-acting Tylenol #3

(codeine) Darvon

(propoxyphene) Vicodin

(hydrocodone) MSIR (morphine) Percocet

(oxycodone) Dilaudid

(hydromorphone) Actiq (fentanyl)

Long-acting MS Contin

(morphine) OxyContin

(oxycodone) Dolophine

(methadone) Duragesic

(fentanyl)

Opioid misuse/abuse Use pain med to sleep,

relax, soften negative affect

Dose requirement reduced with age– Reduced GI absorption– Reduced liver metabolism– Change in receptor

sensitivity Short-acting are the most

easily & widely available Defeat extended-release

mechanism Problems

– Sedation, confusion– Respiratory depression

Risky prescriptions: Opioids

Problematic for older adults who misuse opioid analgesics

Try non-narcotic alternatives– NSAIDs– Anticonvulsants– NSRI

antidepressants– Topical analgesics

Prescription drug abusein older adults

Reduced ability to absorb & metabolize meds with age

Increased chance of toxicity or adverse effects

Med-related delirium or dementia wrongly labeled as Alzheimer’s

Impact on Healthcare Providers

Medication misuse causes adverse health consequences for patient

Worsens prognosis of coexisting medical and/or psychiatric conditions

Significant proportion of practice is dealing with consequences of unrecognized/untreated addiction

Leads to practitioner frustration

Screening for addiction

High level of suspicion

Non-judgmental Caring Free of hostility

History-taking can be therapeutic

Why screen patientsfor addiction?

Medical problems– Cardiovascular

disease– Stroke– Cancer

Spread of disease– HIV, HBV, HCV

Mental health– Depression– Anxiety– Sleep problems

Financial difficulties Legal problems Work-related issues Interpersonal

problems– Family issues

Screening makes a difference

Patients reduce alcohol and tobacco use when this is addressed by a clinician

Research shows benefits from screening and brief intervention for illicit and prescription drug abuse

Screening Tool forAlcohol Abuse

CAGE Questions– Cut down– Annoyed– Guilty– Eye-opener

Affirmative response to 1 or more is positive test in older adult

Screening in older adult

Collateral information– Family– Friends– Senior center staff

Drivers Volunteers

Ask in terms of effects on health problems

Medication interactions

The 5 “A’s”

ASK about alcohol and drug use

ADVISE all patients to quitASSESS willingness to

changeASSIST patients in quittingARRANGE for follow-up

ASK about alcohol and drug use

Have you ever used …– Tobacco products– Caffeinated

beverages– Alcohol– OTC drugs of abuse– Prescription drugs

of abuse– Illicit drugs

When did it begin? How often? How much? When was the last

use?

APA 2000

Diagnosis ofAlcohol Abuse/Dependence

Continued substance use despite adverse consequences

Use in larger amounts or for longer periods than intended

Preoccupation with acquiring or using Inability to cut down, stop, or stay

stopped, resulting in a relapse Use of multiple substances of abuse

Weaver & Cotter 1998

Brief Intervention

Motivate patients to change problem behavior

Multiple brief sessions

Bridge to treatment or sufficient itself

Same impact as more extensive counseling

Most cost effective

Patient Behavior

Ambivalence– Attracted to

problem behavior (substance use)

Denial– Unable to admit

problem to themselves

– Actively conceal Common to many

chronic conditions

Motivation

Probability of certain behaviors

State of readiness to change

May fluctuate from one situation to another

Clinician’s goal is to increase the patient’s intrinsic motivation– change arises from

within rather than being imposed from without

Example techniques

Amplify self-motivational statements

A typical dayGood

things/less good things

ADVISE all patients to quit

A strong recommendation to change substance use is essential

"Based on the screening results, you are at high risk of having or developing a substance use disorder. It is medically in your best interest to stop your use of [insert specific drugs here].”

Recommend quitting before problems (or more problems) develop– Give specific medical reasons– Medically supervised detoxification may be necessary

Elements of Brief Intervention

FRAMES– Feedback– Responsibility– Advice– Menu– Empathy– Self-efficacy

Feedback

Present information to client– Based on history,

exam, labs, etc. Increase awareness

of adverse consequences

Help make the case for change in drinking, med use, or illicit substances

Responsibility

Client has the ultimate responsibility for change

Practitioner can’t force client to change

Client chooses goals, not practitioner– Should be realistic– Clarify client’s goals– Develop

discrepancy

Advice and Menu

Give clear, concrete advice to change

Give choices (menu)– 3 is ideal– Making a choice

is first step to making a change in behavior

Empathy

Listen carefully Clarify client’s

meaning Don’t impose

practitioner’s values on client

Self-efficacy

Build up client’s belief in ability to succeed

Be optimistic Simple goals

early– Success breeds

success– Increases self-

confidence

Types of treatment

Detoxification 12-Step groups Outpatient

counseling– Cognitive-behavioral– Case management

Intensive outpatient Inpatient Residential

12-Step Groups

A.A., N.A., C.A. Group format Anonymous No cost No affiliations or

endorsement Different groups

have different characteristics– “Gray A.A.” for Older

Adults

Which of the following characteristics of attendees

is the best predictor of success in Alcoholics

Anonymous? A. Male gender B. Christian religious denomination C. Frequency of meeting

attendance D. NO history of depression

Success with 12-Step

More groups=more abstinence

No threshold, but at least 2 meetings/week best

Not affected by– Gender– Religion– Psychiatric

diagnosis– Novice

Addiction Counseling

Motivational Interviewing

Network therapy Family therapy Supportive

psychotherapy Building Social

Networks

Twelve-Step facilitation

Perceptual Adjustment Therapy

Rational Recovery

Medication Management

Brief Intervention

Treatment in older adults Focus on coping

– Depression, loneliness– Losses

Rebuild social support network– Socialization groups– Alumnae meetings

More compliant Outcomes as good

or better than younger patients

Treatment works Sustained remission

rates of up to 60%– Better success than

treatment of hypertension, diabetes

Every $1 spent on treatment saves $7 in costs to society

Lots of new research

Summary

Older adults more sensitive to effects of alcohol and drugs than younger patients

Higher doses increase the risk of adverse drug events

Substance abuse is under-diagnosed in older adults

Screen for substance abuse in all older patients, avoid stereotyping

Summary

Encourage older adults to keep a medication list and discuss prescription, OTC, supplement and alcohol use with health care providers

Watch for signs of medication-related problems (falls, confusion, etc).

Older adults respond well to treatment for substance abuse with good outcomes

Questions?

Cases for Group Discussion

References Prochaska JO, DiClemente CC, Norcross JC: In

search of how people change: Applications to addictive behaviors. American Psychologist 1992;47:1102

Miller WR, Rollnick S: Motivational Interviewing: Preparing people to change addictive behavior. NY: Guilford Press 1991

Weaver MF, Jarvis MAE, Schnoll SH: Role of the primary care physician in problems of substance abuse. Archives of Internal Medicine 1999;159:913

Bien TH, Miller WR, Tonigan JS: Brief interventions for alcohol problems: a review. Addiction 1993;88:315

References Substance Abuse and Mental Health Services

Administration (SAMHSA): Results from the National Survey on Drug Use and Health: National Findings. Office of Applied Studies, Rockville, MD: SAMHSA; 2008

American Psychiatric Association (APA): Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: APA 2000