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Issues of Substance Use and Medication Misuse in Older Adults Presenter: Linda Shumaker, RN-BC, M.A. Content developed by: Carol Hancock Gold, Ph.D., Retired, Former Senior Research Associate, Penn State University Linda Shumaker, RN-BC, M.A., Outreach Coordinator, PA Behavioral Health and Aging Coalition Margaret E. Hanna, M.Ed., Retired, Former Senior Director, Substance Use Disorder Initiatives, Community Care Behavioral Health 1
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Substance and Medication Abuse/ Misuse in Older Adults Common problem Less likely to be recognized Chronic illness more common Correlates with hospitalizations - dementia and hip fractures Poly-pharmacy issues Co-morbid mental health issues Less likely to be addressed Prescription drug abuse is becoming as common as alcohol abuse in older adults. 2
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DSM 5 DSM 5 Combines the DSM IV categories of substance abuse and substance dependence into a single disorder. They are then measured on a continuum from mild to severe. Each substance is then addressed as a specific disorder. (ie; alcohol use disorder, stimulant use disorder, etc.) 3
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DSM 5 Substance use disorder “describes a problematic pattern of using alcohol or another substance that results in impairment in daily life or noticeable distress”. 4
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DSM 5 (Diagnostic Statistical Manual) Changes DSM IV R Substance Abuse Criteria Recurrent substance use resulting in: Failure to fulfill major role obligations, school, work or home Continued use in situations in which it is physically hazardous Recurrent substance-related legal problems Continued substance use despite having persistent, recurrent social or interpersonal problems 5
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DSM 5 Changes DSM IV R Substance Dependence Criteria Tolerance, as defined by: A need for markedly increased amounts of substance to achieve desired effects Withdrawal as manifested by either Withdrawal syndrome of the substance Or the same or closely related substance is taken to relieve or avoid withdrawal symptoms Substance is often taken in larger amounts or over a longer period than intended 6
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DSM 5 Changes DSM IV R Substance Dependence Criteria Cont. There is a persistent desire or unsuccessful efforts to cut down or control substance use. A great deal of time is spent in activities necessary to obtain the substance, use the substance or recover from its effects. 7
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DSM 5 Changes DSM IV R Substance Dependence Criteria Cont. Important social, occupational or recreational activities are given up or reduced because or substance use. The substance use is continued despite knowledge or having a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance . 8
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DSM 5 Changes DSM 5 changes Diagnostic categories of “Substance Abuse and Substance Dependence” is changed New combined terminology of “Substance Use Disorder”. Substance Use Disorder and Gambling will be found in Chapter on Substance Use Disorders and Addictive disorders. 9
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DSM 5 Changes DSM 5 changes Criteria is merged to diagnose disorders related to the use of alcohol, cigarettes, illicit or prescription drugs and other substances into a single 11-item list of problems associated with those disorders. (such issues as being unable to cut down or control, failing to meet obligations, etc.) Diagnosis is given based on how many criteria on that list them met No disorder (0-1) Mild disorder (2-3) Moderate (4-5) Severe (6 or more) 10
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DSM 5 Changes DSM 5 changes Makes it easier to identify and address drug or alcohol problems before they become dangerous. Individuals who drink heavily at sporting events may be at risk but usually don’t need lengthy treatment. Symptoms of people with substance abuse do not fit into two distinct categories. Guidelines also make it easier for primary care to be reimbursed by insurance for screening for alcohol and drug problems and conducting short counseling sessions. 11
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DSM 5 Changes DSM 5 changes Goal is to educate about the risks and make individuals aware of potential consequences. Though there is a close correlation between the number of symptoms experienced by a person and the severity of the substance use disorder several studies demonstrate that abuse is not necessarily a precursor for dependence. A “spectrum” in the new criteria addresses issues in a broader context A “spectrum” in the new criteria may help allay issues of stigma 12
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DSM 5 In order to be diagnosed with a disorder due to a substance, an individual must display 2 of the following 11 symptoms within 12 months. 13
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DSM 5 Consuming more alcohol or other substance than originally planned Worrying about stopping or consistently failed efforts to control one’s use Spending a large amount of time using drugs/ alcohol, or doing whatever is needed to obtain them Use of the substance results in failure to “fulfill major role obligations” such as at home, work, or school “Craving” the substance (alcohol or drug) 14
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DSM 5 Continuing the use of a substance despite health problems caused or worsened by it. This can be in the domain of mental health (psychological problems may include depressed mood, sleep disturbance, anxiety, or “blackouts”) or physical health Continuing the sue of a substance despite it having negative effects in relationships with others (For example, using even though it leads to fights or despite others objecting to it) 15
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DSM 5 Repeated use of the substance in dangerous situations (for example, operating heavy machinery or driving a car) Giving up or reducing activities in a person’s life because of the drug or alcohol use Building up a tolerance to the alcohol or drug. Tolerance is defined by the DSM-5 as “either needing to use noticeably larger amounts over time to get the desired effect or noticing less of an effect over time after repeated use of the same amount 16
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DSM 5 Experiencing withdrawal symptoms after stopping use. Withdrawal symptoms typically include, according to the DSM-5; “anxiety, irritability, fatigue, nausea/vomiting, hand tremor or seizure in the case of alcohol. 17
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Substance and Medication Abuse/Misuse Illicit Drugs Prescription Medications Over the Counter Medications (OTC) Alcohol Any Combination of the Above Nicotine? 18
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19 Any smoking is considered drug abuse and places the older person at risk for negative health consequences; advancing age increases the likelihood of respiratory and cardiovascular illnesses related to smoking.
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DSM 5 Gambling is in the Behavioral Addictive Disorders Gambling is the only disorder listed, but others can be listed as Behavioral Addiction, Not Otherwise Specified. Rationale is that compulsive behaviors follow the same clinical pattern, physiology, treatment and may derive from the same neural network as compulsive substance use. 20
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Process Addictions Behavioral Addictions - A process addiction is a condition in which a person is dependent upon some form of behavior, such as gambling, love, sex, or shopping, and is a blanket term for any behavioral addiction that does not involve drugs or alcohol. Similar to chemical dependency Continual reward seeking behavior Negative consequences does not cause cessation Process addictions – gambling (lottery most common, followed by casinos). Sex as a process addiction – debate over how to classify it as an addiction. 2010: 16.5% increase in new HIV diagnoses individuals in individuals over 50 21
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Substance and Medication Abuse/Misuse It is estimated that the number of older adults in need of substance abuse treatment will increase from 1.7 million in 2001 to 4.4 million in 2020. This is due to a 50 percent increase in the number of older adults and a 70 percent increase in the rate of treatment need due to a higher abuse rate among older adults. Currently the over 50 group makes up 10% of those in substance abuse treatment, i.e., 1.8 million older adults - predominately for alcohol abuse. “Substance abuse treatment need among older adults in 2020: the impact of the aging baby-boom cohort” - Joseph Gfroerer,, Michael Penne, Michael Pemberton and Ralph Folsom. 22
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Aging of America… Challenges of this growing population requires consideration of different, culturally appropriate responses… Meeting the needs of current older adults. Planning for the coming baby boomers. 23
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Substance and Medication Abuse/Misuse 2011 Study by the Substance Abuse and Mental Health Services Administration found that among adults aged 50 – 59, the rate of current illicit drug use increased from 2.7% in 2002 to 6.3% in 2011. Besides alcohol, the most commonly abused drugs were opiates, cocaine and marijuana. In 2010 the estimates of individuals having one of more substance abuse or mental disorders were 14 – 20% of the over all older adult population. 24
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Substance and Medication Abuse/Misuse Of those in treatment over 65 – alcohol is predominately the drug of choice, but ages 50-64 have more extensive substance abuse treatment histories. The majority of problems in current older adults appear related to: prescription medications alone, alcohol in combination with prescription medications/OTC, or alcohol only. Older adults in increasing numbers are also addicted to illicit drugs – currently as high as 4.1% of the general population.1 1 2007 National Survey on Drug Use & Health: National Findings SAMHSA. 25
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Illicit Drug Use 26
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Older Adults and Illicit Drug Use The National Survey on Drug Use and Health (NSDUH) defines illicit drugs as marijuana/ hashish, cocaine, inhalants, hallucinogens, heroin, or prescription-type drugs used “non-medically”. THE NSDUH Report is published by the Office of Applied Studies, Substance Abuse Mental Health Services Administration. 27
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Older Adults and Illicit Drug Use Nonmedical use is defined as the use of prescription-type pain relievers, tranquilizers, stimulants, and sedatives that were not prescribed for the respondent by a physician, or are being used for the experience or feeling they cause. Includes: Opioid Analgesics, e.g. Darvon, Percocet, OxyContin CNS stimulants such as Ritalin Minor tranquilizers such as Valium, Ativan Sedative/ Hypnotics, e.g. Seconal, Amobarbital 2007 National Survey on Drug Use and Health: National Findings (DHHS Publication No. SMA 08-4343, NSDUH Series H-34). 28
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Older Adults and Illicit Drug Use Current illicit drug use by older adults is the lowest rate of all age groups. Approximately half of baby boomers have tried illicit drugs. Birth cohorts that experience high rates of illicit drug use in earlier ages have shown higher rates of use as they age as compared to other cohorts! Source: The NHSDA Report (National Survey on Drug Use and Health), “Substance Use Among Older Adults;” November 2001. Studies predict that as the baby-boom generation ages, rates of alcohol and drug abuse will continue to increase through the year 2020. Simoni-Wastila, L and Yang, HK Am J Geriatri Pharmacotherapy 2006 Dec;4(4):380-94. 2006. 29
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Older Adults and Illicit Drug Use An estimated 4.8 million adults aged 50 or older (5.2%) had used an illicit drug in the past year. Marijuana use was more common than nonmedical use of prescription medications for those aged 50 -54 and 55 – 59. Non-medical use of prescription drugs was higher among those 65 and older. Source: The NSDUH (National Survey on Drug Use and Health), “Illicit Drug Use among Older Adults;” 2010 - 2011. 30
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Older Adults and Illicit Drug Use Among adults aged 50 – 64 the rate of current illicit drug use increased from 2.7% in 2002 to 6.0% in 2013. For adults aged 50 – 54, the rate increased from 3.4% to 7.9% in 2013. For those aged 55 – 59, the rate of current illicit drug use increased from 1.9% to 5.7% in 2013. Among those 60 – 64 the rate increased from1.1% to 3.9% in 2013. 31
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Older Adults and Illicit Drug Use Proportion of older adults admissions reporting heroin as the primary substance of abuse more that doubled from 7.2% in 1992 to 16% in 2008. Proportion of older adults reporting cocaine as the primary substance increased from 2.8% to 11.4% in the same year. 32
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Older Adults and Drug Abuse/Misuse Women over age 65 more likely to report non-medical use of prescription drugs; however, reports of marijuana use are increasing. Men aged 65 and older were equally likely to report marijuana use as well as nonmedical use of prescription drugs. Source: The NSDUH (National Survey on Drug Use and Health), “Illicit Drug Use among Older Adults;” December 29, 2009. 33
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Older Adults and Drug Abuse/Misuse Of concern is the increasing rate of problem substance use in the “baby boomer” population related to the “nonmedical use” of prescription drugs. Americans are 4.6% of the world’s population but consume 80% of the world’s opioid supply. “Substance abuse treatment need among older adults in 2020: the impact of the aging baby boom cohort.” Groerer, Penne, Pamberton and Folsom. As users of heroin and other opioids get older, their risk for overdose death increases dramatically. 34.
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Older Adults and Drug Abuse/Misuse In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of pills. Center for Disease Control and Prevention, National Vital Statistics System, Mortality File (2015). Number and Age-Adjusted Rates of Drug-poisoning Deaths Involving Opioid Analgesics and Heroin. United States, 2000-2014. Atlanta, GA. Four in five new heroin users started with misusing prescription pain killers. As a result, the rate of heroin overdoses increased an average of 6% per year from 2000 to 2010, followed by a much larger increase of 37% from 2010 – 2013. Hedgegaard MD MSPS, Chen MS PhD, Warner PhD. Drug-Poising Deaths Involving Heroin: United States 2000 – 2013. National Center for Health Statistics Data Brief. 2015: 190: 1 – 8. 35.
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Older Adults and Drug Abuse/Misuse Drug overdose is the leading cause of accidental overdose in the US. 47, 055 lethal overdoses in 2014. 18,893 related to prescription painkillers. 10,574 related to heroin. Center for Disease Control and Prevention, National Vital Statistics System, Mortality File (2015). Number and Age-Adjusted Rates of Drug-poisoning Deaths Involving Opioid Analgesics and Heroin. United States, 2000-2014. Atlanta, GA. 36.
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Older Adults and Drug Abuse/Misuse – Women’s Issue Women are more likely to have chronic pain and be prescribed prescription pain killers; higher doses and, use them longer than men. Prescription pain reliever overdose deaths among women increased more than 400% from 1999 – 2010 and compared to 237% among men. Heroin overdose deaths among women have tripled from 2010 through 2013. Center for Disease Control and Prevention, National Vital Statistics System, Mortality File (2013). Prescription Painkiller Overdoes: A growing Epidemic, Especially Among Women. Atlanta, GA. 37.
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Older Adults and Drug Abuse/Misuse Therapeutic opioid use has increased substantially: yet effectiveness is demonstrated only for short term acute pain. There are multiple adverse consequences – hormonal and immune system effects, abuse and addiction, tolerance and hyperalgesia. Long-term use has shown to increase overall cost of healthcare, disability, rates of surgery and late opioid use. “Therapeutic Opioids: A Ten Year Perspective,” 2007 – Manchikanti, Singh.
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Older Adults and Drug Abuse/Misuse Abuse of prescription drugs, particularly prescription opioids among older adults is projected to become worse over the next several years. (SAMHSA, 1998, 2014)
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National Institute on Drug Abuse, “Drug Facts,” Nationwide Trends; June 2015 41
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Older Adults and Illicit Drug Use The number of current illicit drug users aged 50-59 more than tripled between 2002 and 2012, from 900,000 to more than 3.0 million. 42
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Opioid Epidemic Includes prescription pain killers (Oxycodone; Tramadol; Vicodin; Percocet). Opioids killed more than 28,000 individuals in 2014 (CDC) 2 Million or more Americans abused or were dependent on opioids in 2014 (CDC) More than 75% of individuals with “drug-use” disorders do NOT receive any treatment. (NIH) 43
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Opioid Epidemic Proposed Interventions: Limitations on opioid prescriptions (expanding PT and other alternative pain treatments – requiring that insurance plans cover those treatments). Opioid prescription protocols. Requirement that insurance plans cover substance abuse treatment. Expanding the number of treatment programs 44
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Opioid Epidemic Alternative Interventions: Methadone Given at Methadone clinics. Reduces illicit drug use and keeps people in treatment. Cuts the risk of fatal overdose in half. Suboxone (Combination of the Opioid, Buprenorphine and Naloxone which blocks the high) Reduces illicit drug use and keep people in treatment. Cuts the risk of fatal overdose in half. 43% of Counties don’t have physicians who can prescribe it due to protocols. 45
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Opioid Epidemic Alternative Interventions: Long-lasting opioid blocker Naltrexone – daily pill that blocks the effect of opioids and alcohol. Vivitrol – new extended release - $1000/ month Barnstable County, Mass – offered it to inmates in county corrections 50% have remained sober; 12% were re-incarcerated. Probuphine implant – releases a steady dose over 6 months. Not yet available. 46
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Opioid Epidemic Alternative Interventions: Alcohol Use Disorder Medications Disulfiram – treats chronic alcoholism ; taken once a day Acamprosate – works to prevent drinking; 5th day of abstinence; full effectiveness in 5 – 8 days. Taken 3 times a day Naltrexone – treats alcohol dependence by blocking euphoric effects and feelings of intoxication. 47
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Medication Abuse and Misuse 48
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Medication Abuse and Misuse Adults 65 and older consume more prescribed and over-the-counter medications than any other age group. Older adults are 12% of population but consume 34 % of all prescription medications. Among older Americans (aged 60 and over), more than 76% used two or more prescription drugs and 37% used five or more per month. One of fastest growing health concerns. 49
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Medication Abuse and Misuse (cont.) Adults 65 and older consume: 25- 30% of all medications. 70% of all over-the-counter medications. Average adult over 65 uses 11 different prescriptions over one year. One out of four prescription medications taken by older adults is psychoactive. 50
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Medication Abuse and Misuse (cont.) 60% of prescribed medications are not taken according to directions. Approximately 140,000 die each year as a result. One in four older adults skips dosages of medications or does not fill prescriptions due to cost. Older adult who fail to take their medications are more likely to experience a significant decline in their health. 51
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Medication Abuse and Misuse (cont.) Older adults experience two to three times as many adverse drug reactions as do younger adults. Over ½ of individuals who are hospitalized for adverse drug reactions are over age 65. Special concern - prescription medications and alcohol! 52
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Medication Abuse and Misuse (cont.) Age-related changes affect how we process medications and alcohol: Lean body mass decreases Fat increases Total body water decreases Decrease in the stomach’s ability to metabolize alcohol Renal changes Decreases in liver function Neurotransmitter/brain-related changes 53
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Older Adults and Medications 20% suffer from problems with medications or alcohol and may not know it.1 Likely to be prescribed more long-term prescriptions, as well as multiple prescriptions. Large percentage also use over-the-counter (OTC) medications, herbs and dietary supplements along with prescription medications . Also at risk for prescription drug abuse – intentionally take medications that are not medically necessary: “accidental addicts”. 1 SAMSHA—Get Connected! Linking Older Americans With Medication, Alcohol, and Mental Health Resources. DHHS Pub. No. (SMA) 03-3824. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 2003. 54
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Older Adults and Medications Experience more adverse health consequences with OTC and prescription drug misuse or abuse… Complicated by high rates of co-morbid illnesses. Potential for drug interaction. Changes in drug metabolism with age (resulting in drug activity lasting longer). 55
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Older Adults and Medications Over-use, under-use or irregular use of prescription or OTC drugs are forms of drug misuse. Particular medications of concern include: Those for anxiety, depression, insomnia, other mood disorders. 25% of older adults use psychotherapeutic drugs. OTC and herbal supplements. 56
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Medication Abuse and Misuse Most common medications of abuse: Alcohol Benzodiazepines Over-the-counter sleep aide, cough syrups, etc. Opiates (OxyContin, Oxycodone, Hydrocodone, Methadone, etc.) Marijuana Hallucinogens (LSD, Psilocybin, Ecstasy, Dextromethorphan) Heroin Cocaine/ Crack Stimulants – methamphetamine Handley Center 57
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Risk Factors for Medication Misuse Taking extra doses, missing doses, not following instructions, taking the wrong medications. Using medications that have expired. Not knowing about side effects. Sharing or borrowing medications. Mixing medications or drinking alcohol while taking medications. Going to multiple physicians to get more of the same drug. Going to multiple physicians who are unaware of complete medications regiment. 58
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Risk of Drug Misuse Among Older Persons Increases for Many Reasons: Inappropriate prescribing, especially for women. Failure to tell doctor about OTC, herbs, vitamins. Memory problems. Problems taking medications. Small print on packaging and labels. Health literacy issues, e.g., not understanding the physician’s instructions. Missing or misunderstanding instructions – vision, hearing and/or language barriers. 59
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Medicines and Alcohol Interactions Even social drinking can be a problem for someone taking medications regularly. Examples of dangerous drug-alcohol interactions: Taking aspirin or arthritis medications and drinking alcohol can increase the risk of bleeding in the stomach. Acetaminophen (such as Tylenol) may cause liver damage in people having three or more drinks a day. Alcohol can worsen central nervous system depression in persons taking anti-depressants. National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health – Senior Health, August 2010. 60
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Medicines and Alcohol Interactions Cont. Examples of dangerous drug-alcohol interactions cont.: High does of sedatives mixed with alcohol can be lethal. Drinking alcohol and taking medications for high blood pressure, diabetes, ulcers, gout, and heart failure can make those conditions worse. Cold and allergy medicines that contain antihistamines often makes people sleepy. Drinking alcohol can make this drowsiness worse and impair coordination. Increased risk of gait disturbance and subsequent falls. 61
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Tips for Preventing Medication Errors Always: Ask why each medication is prescribed and what it is intended to do. Make sure you understand when and how to take each medication. Take your medications exactly as directed by your health care provider and ask what to do if you miss a dose. Take a list of all of your medications and their dosages and review all medications with your health care provider at each visit. 62
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Tips for Preventing Medication Errors Always: Use the same pharmacy for all of your prescription medications. Read labels on medication carefully. If you drink alcohol ask your health care provider about the safety of drinking while taking medication. Contact you health care provider immediately if you experience any problems or side effects. 63
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Alcohol 64
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Myths about Alcohol Use/Abuse Feeling sad or depressed is part of growing old. There's nothing you can do to help the older adult. Over-the counter medications and alcohol can be used together safely. Very few women become alcoholics. If an older adult says that drinking is his or her last remaining pleasure, it is generally best to allow the person to continue to drink. 65
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Alcohol and Substance Abuse Alcohol and substance abuse is less likely to be recognized in the older adult: Lack of adequate history Alcohol-related problems may be mistaken for medical or psychiatric problems Older individuals live alone No job-related difficulties Usually no legal problems 66
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Older Adults and Alcohol Abuse The proportion of older adult admissions who reported alcohol as their only substance of abuse decreased from 87.6% in 1992 to 58% in 2009. Older Adults who reported alcohol use in combination with drugs increased from 12.4% to 42% during the same time. The proportion of older adults admitted with co-occurring psychiatric problems tripled from 10.5% in 1992 and 31.4% in 2009. “Older Adult Admissions Reporting Alcohol as a Substance of Abuse: 1992 and 2009.”The TEDS (Treatment Episode Data Set) Report, SAMHSA, November 15, 2011.
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Misuse, Abuse and Addiction…. While the prevalence of alcohol/substance abuse problems in the general population is under 10%, it is estimated that the prevalence for older adults is much higher in healthcare settings. 68
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Older Adults and Alcohol 69
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Older Adults and Alcohol Abuse Types: At Risk - a pattern of use with potential for adverse consequences Individuals whose quantity/ frequency have not changed, but experience problems due to age-related changes in alcohol metabolism, combining alcohol with medications Early Onset (Chronic) – alcohol abusers in adult years who have grown older without treatment Higher incidence of psychiatric co-morbidity Intermittent (Periodic) Same as Early Onset Periods (sometimes lengthy) of abstinence from substances 70
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Older Adults and Alcohol Abuse Types: (cont.) Late Onset – increased consumption of alcohol due to losses or stresses associated with age Represents 1/3 of older adults with alcohol problems (SAMHSA, 2005) Sensitivity/tolerance to alcohol changes in older years More rapid progression of addiction: < 1 year Significant problem for older women 71
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Older Adults and Alcohol Abuse (cont.) Alcohol use appears to decline with age, but lower levels have more impact on the older adult. Approximately 66% of reported cases of alcoholism among older adults are considered early onset - 33% considered late onset. Alcohol use in older adults is often overlooked. SAMHSA, 2005, National Survey on Drug Abuse. 72
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Risk Factors for Alcohol Problems – Late Onset Being female Loss of social and economic support Death of a spouse, friends and other family members Separation from children and loss of home as a result of relocation Social isolation History of mental health problems – anxiety, depression Loss of job – and related income, social status and sometimes, self-esteem – as a result of retirement 73
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Risk Factors for Alcohol Problems – Late Onset Loss of mobility – trouble using public transportation, inability to drive, etc. Impaired vision and hearing, insomnia and memory problems Declining health because of chronic illness Lack of interesting activities, hobbies or employment Family history of addiction 74
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One Drink is Equal to the Following: 75 One 12-ounce can or bottle of regular beer, ale, or wine cooler One 8- or 9-ounce can or bottle of malt liquor One 5-ounce glass of red or white wine One 1.5-ounce shot glass of hard liquor (spirits). The label will say 80 proof or less. Spirits include whiskey, gin, vodka, rum, and other hard liquors.
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Drinking Guidelines for Older Adults The Consensus Panel1 recommends the following usage guidelines for Older Adults: Guidelines for Men No more than one drink per day (1) A maximum of two drinks on any drinking occasion (e.g., New Year's Eve, weddings). Guidelines for Women Somewhat lower than for men 76 1 TIP 26: Substance Abuse Among Older Adults, Frederick C. Blow Consensus Panel Chair, SAMHSA, 1998.
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Alcohol can trigger health problems or make them worse… Increased risk of high blood pressure, heart disease, stroke Impaired immune system Cirrhosis and other liver diseases Decreased bone density and chronic pain Internal bleeding and ulcers Depression, anxiety, amnesia, other MH problems Cancer of the stomach, larynx, pancreas, liver or esophagus Nutritional disorders & sleep disorders Overall increase in mortality1 1 Widlitz & Marin 2002 77
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Protective Factors Access to resources, such as housing and health care Availability of support networks and social bonds Involvement in community activities Supportive family relationships Education (e.g. wise use of medications) and skills Sense of purpose and identity 78
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Co-Occurring Disorders Physical, cognitive and behavioral issues are also more likely to be present in older adults. Co-occurring mental health disorders that often occur at the same time as alcohol or other substance use disorder: Social phobia Generalized Anxiety Disorders Agoraphobia Simple Phobia Post Traumatic Stress Disorder Panic Disorder Major Depression Schizophrenia 79
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Co-Occurring Mental Health Disorders 48% for 50 – 64 years old 61% for those 65 and older 80
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Summary… Substance use disorders are a serious problem for older adults and are: Under-estimated Under-identified Under-diagnosed Under-treated Often have co-morbidity – more at risk for physical and other behavioral health problems. Prescribed medications and OTC are a major factor in most cases of misuse, abuse and dependency. Alcohol is the primary drug of choice of the current generation. 81
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What Can We Do? Increase capability for effective screening and assessment. Develop age-appropriate interventions and treatment approaches for current older adults. Look to approaches that integrate with physical health (e.g. primary care) as well as specialty care. Plan for the increase in need for interventions and treatment protocols for aging baby boomers. 82
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Great Opportunity for Prevention and Early Intervention Educational needs of physicians and other medical personnel. Look for those “teachable moments”: Healthcare/behavioral health care workers Aging professionals Consumers, family members, advocates “Natural” settings and outreach Normalization of the message Integrated approaches Screen for “risky behavior” in all settings. Advocate locally for screening programs for all older adults, e.g., senior health fairs, senior housing. 83
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84 Screening & Assessment
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Screening Process Screening needs to be holistic as the older adult is more likely to have a co-occurring physical, behavioral or cognitive impairment. 85
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Screenings When to Screen? At routine medical exams. If never before – recommended at age 60. During major life transitions, e.g. menopause, recent empty nest, approaching retirement, caretaker for sick relatives or young child. After life events, e.g. minor traffic accidents, loss of housing, decrease in ADL or driving abilities, inability to complete chores and paperwork without mistakes. 86
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Who To Screen? Signs and Symptoms Making excuses, hiding or denying drinking, getting annoyed when asked about drinking. Falls, blackouts or seizures. Bladder and bowel incontinence, urinary retention, difficulty urinating. Dry mouth, dehydration, malnutrition, muscle wasting, anorexia, changes in eating habits. Memory problems, confusing or disorientation, blurred vision, slurred speech. 87
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Who To Screen? Signs and Symptoms (Cont.) Drinking in spite of medical warnings. Arrests for drinking and driving, frequent car accidents. Frequent falls, unexplained bruising, tremor, lack of coordination, problems walking. Increased tolerance to alcohol or withdrawal symptoms if alcohol is removed. Morning drinking. Neglect of home, bills, pets, personal hygiene. 88
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Who To Screen? Signs and Symptoms (Cont.) Persistent irritability and altered mood, depression, anxiety symptoms. Problems with family and friends. Withdrawal from social activities. Sleep problems, unusual fatigue, malaise. Suicidal thoughts or suicide attempts. Unusual restlessness, agitation and aggression. Nausea, vomiting, heartburn, bloating indigestion. 89
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Alcohol Screening Instruments AUDIT - Alcohol Use Identification Test CAGE - Cut down, Annoyed, Guilty, Eye Opener MAST-G - Michigan Alcoholism Screening Test – Geriatric Version ARPS/shARPS/CARPS – Computerized Alcohol-Related Problems Survey 90
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AUDIT (Alcohol Use Disorders Identification Test) 10 question Interview or Self-Administered questionnaire Most often used in SBIRT efforts Designed for use in medical settings or other settings where the individual may present Screens for risky behavior related to alcohol use 91
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CAGE Assessment (Alcohol Abuse) One of the most widely used alcohol screening tests Consists of four questions –one point each A score of two suggests a diagnosis of alcoholism Hinkin et al. (2001) modified for older adults – CAGE-AID; added questions about illicit drug abuse Recent studies say you need to supplement amount and frequency questions for older adults 92
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MAST-G The Michigan Alcoholism Screening Test Geriatric Version (MAST-G) is a well known alcohol screening instrument that has been validated for use with older adults 24 questions – Yes/No response Score 5 or more indicates alcohol problems 93
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Alcohol-Related Problems Survey (ARPS) Self-administered questionnaire – 60 questions1 Medical and psychiatric conditions Symptoms of disease Medication use Physical function and health status Quantity and frequency of alcohol use Episodic heavy drinking Symptoms of alcohol abuse and dependence Drinking after driving shARPS & CARPS (includes ARCS Model of Learner Motivation) 1 Arlene Fink, et.al. 2002, Alison A. Moore, et.al. 2002 94
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Alcohol-Related Problems Survey (ARPS) Classifies drinking as Non-hazardous – no known risk for physical or psychological health events Hazardous – consumption with above risks Harmful – results in adverse events The majority of ARPS “hazardous or harmful drinkers” did not screen positive on the CAGE, AUDIT or MAST Drinkers had medical conditions or used medications that placed them at higher risk 95
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Alcohol-Related Problems Survey (ARPS) Sample ARPS Report Using ARCS Learning Model (Attention, Relevance, Confidence, Satisfaction) Attention - Did You Know? One to two drinks a day may be safe and for some people may prevent heart disease or stroke. BUT, for other people, 1–2 drinks may actually be dangerous. Why? 96
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Alcohol-Related Problems Survey (ARPS) Relevance About Your Alcohol Use You said you drink 3 drinks a day every day About Your Health You said that you have been diagnosed with hypertension are on Coumadin at least once a week are on 6 medications regularly felt depressed most of the time in the past 4 weeks 97
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Alcohol-Related Problems Survey (ARPS) What Does this Mean? Your alcohol use may be risky. Here is why: How much should I drink? Experts recommend that men 65 years of age and older consume 1 or less drink per day. Medicine and alcohol. Many medicines and alcohol interact. . . you reported that you are on Coumadin… you are taking 6 medications regularly. Depression and alcohol. Alcohol can sometimes make you feel even more depressed because. . . 98
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Alcohol-Related Problems Survey (ARPS) Confidence and Satisfaction What Should You Do? Here are some ways to drink less: Drink nonalcoholic wine or beer; put orange juice in champagne; don’t drink at lunch; don’t drink alone…, etc. Speak to your physician about ways to reduce the amount of alcohol you drink, the medications you are taking, your hypertension and other medical conditions, and your risk for depression. Katherine Nguyen, BS, Arlene Fink, PhD, John C. Beck, MD, and Jerilyn Higa, MS Feasibility of Using an Alcohol-Screening and Health Education System With Older Primary Care Patients, JABFP January–February 2001 Vol. 14 No. 1, Page 10
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Substance Abuse Screening Tools Drug Abuse Screening Test (DAST) - 20-question self-test. Does not include alcohol use. Drug Use Disorders Identification Test (DUDIT) 11 question self reporting Cut down, Annoyed, Guilty, Eye-opener – Adapted to Include Drugs (CAGE-AID) SSI-SA - Simple Screening Instrument for Substance Abuse 100
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CAGE-AID Have you ever felt you should cut down on your drinking or drug use? Have people annoyed you by criticizing your drinking or drug use? Have you ever felt bad or guilty about your drinking or drug use? Have you ever had a drink or used drugs first thing in the morning (eye opener) to steady your nerves or to get rid of a hangover? “0” for no and “1” for yes. A score of 1 or above accurately detects 91% of alcohol users and 92% of drug users. A score of 2 or greater is considered clinically significant. Hinkin, 2001, Buschsbaum et. al., 1992; Booth, et. al., 1998 101
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Summary Gather information and determine readiness for treatment Formal instruments administered by trained assessors, clinicians Need medical work-up Consider instruments developed for older adults and/or modify as necessary Contact your local county authority for information about substance abuse services. 102
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103 Treatment
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Special Needs of Older Adults in Treatment Consider the different needs of late-onset problems versus those with early onset problems. Educate about aging and substance abuse problems. Address life changes and help individuals understand possible reasons for substance use. Motivate individuals to follow treatment recommendations by focusing on staying healthy and independent. Center for Substance Abuse Treatment. Substance Abuse Among Older Adults: Tip 26, 1998; National Institute on Aging. Working with Older Patients: A Clinician’s Handbook. 104
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Special Needs of Older Adults in Treatment Educate/ teach older adults ways to address issues of depression and loss. Work with individuals to build their self esteem and social networks. Make sure “detoxification units” meets the special needs of older adults. Assist older individuals in identifying and managing “triggers” of misuse, abuse and addiction. Center for Substance Abuse Treatment. Substance Abuse Among Older Adults: Tip 26, 1998; National Institute on Aging. Working with Older Patients: A Clinician’s Handbook. 105
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Specialized Treatment for Older Adults Need extended detoxification and medical stabilization Need slower transitions between levels of care May have cognitive issues to consider Hearing, speech and vision impairments Need for longer rest, relaxation and recreation periods Nutrition issues Chronic pain may be a problem Grief and loss issues Social support/ loneliness issues 106
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Specialized Treatment for Older Adults (cont.) Current older adults are more complaint with treatment and have treatment outcomes (medical) as good or better than younger patients (Oslin, 1997, Atkinson, 1995) – particularly late onset drinkers. Baby Boomers – treatment programs will need to adapt. 107
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Specialized Treatment for Older Adults (cont.) At this time there are few “rehabilitation units” specializing in older adult and addictions in the country and it is a challenge to find ambulatory care options specifically for older adults. Private treatment centers – 18% address needs of older adults Approximately 5% of facilities have specific tracts for older individuals Targeted older adults programs are rare. 108
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Specialized Treatment for Older Adults (cont.) Medicare will help pay for treatment of alcoholism and drug abuse in both inpatient and outpatient settings if: You receive services from a Medicare-participating provider or facility; A doctor states that the services are medically necessary; and A doctor sets up your plan of treatment. 109
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Specialized Treatment for Older Adults (cont.) Effective treatment models Address aging issues Include family, friends and support Respectful, non-confrontational Peer support Motivational Interviewing Psycho-educational/ workbook-based/ follow-up 110
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Specialized Treatment for Older Adults (cont.) Treatment needs: Psychological needs Physical activity Problem solving therapy Cognitive Behavioral therapy Interpersonal therapy Social needs Changing social status Death of friends and loved ones Changes in social supports 111
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SBIRT Intervention and Treatment SBIRT – Screening, Brief Intervention, and Referral to Treatment – www.ireta.org Health and wellness focus Formal and brief process Used for prevention, risky behavior as well as to screen for serious problems Primary care centers, natural settings “Normalizes” message 112
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SBIRT Intervention and Treatment Program approved by Administration on Aging (AoA), SAMHSA/ Center for Substance Abuse Treatment. Targets community dwelling older adults who are at-risk for/ or experiencing substance abuse problems. Substances include alcohol, prescription medications, over-the-counter medications and illicit drug use. Offered in over 70 sites nationwide. 113
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SBIRT Screening – to identify those at risk Brief Advice - One-time intervention for short consult and informational literature (3-5 minutes) Brief Intervention - One or more short motivational sessions to encourage and promote healthy behaviors Brief Treatment - 1-6 sessions intervention, e.g., MET (Motivational Enhancement Therapy), CBT (Cognitive Behavioral Therapy), etc., provided by trained interventionists Referral to Treatment- for dependent users to receive specialized services and case management 114
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Brief Advice & Brief Interventions Confidential setting Non-threatening, non-judgmental manner Feedback regarding current health information or potential problems associated with level of alcohol or drug use. Prefacing questions with a link to a medical condition can make them more palatable e.g. “I am wondering if alcohol may be the reason why your diabetes isn’t responding as it should?” 115
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Brief Advice & Brief Interventions Stress client’s responsible choice about actions. Advice must be clear about reducing his or her amount of drinking or total consumption. Recommend drinking levels. Offer choice in regards to future behaviors Offer information based on scientific evidence, acknowledge the difficulty of change, and avoid confrontation. Empathy is essential. 116
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Brief Advice & Brief Interventions Avoid using euphemisms that minimize the problem Client may engage in denial and rationalization Those who are inadvertently misusing are unlikely to be defensive about the need for change Use active listening techniques Confirm the problem Characterize the dimensions of the problem Develop an individualized service plan Refer for medical or psychiatric assessment as necessary 117
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Key Components of Brief Intervention1 In 15-20 minute session following survey: Appreciate the problem Identify goals Summarize health habits Educate about standard drink sizes Explore why person drinks and reasons to cut down or quit Develop a drinking agreement Be aware of risk situations that may trigger drinking 118
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Florida’s BRITE Project Brief Intervention and Treatment for Elders (BRITE) – identified non-dependent substance users or individuals with prescription medication issues. Provided effective service strategies prior to the need for more extensive treatment. Initial 3 year state-funded project. Agencies in 4 counties conducted screenings (3497 older adults) for alcohol, medication and illicit substance misuse problems and depression and suicide risk. 119
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Florida’s BRITE Project Cont. Results: Prescription medication misuse was the most prevalent substance use problem, followed by alcohol, over-the-counter and illicit substances. Depression was common among abusers of alcohol and prescription medications. Those who received the “brief intervention” had improvement across all measures. 120
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Florida’s BRITE Project Cont. Brief Intervention and Treatment for Elders (BRITE) - A 3 year pilot project funded by SAMHSA (Grant ended 9/2011). Focused on providing services in primary and emergency health case settings, public health clinics, facilities and sites coordinated by aging services. Older adults had screenings, brief intervention and brief treatment. If needed, they were referred to more extensive treatment. 31 sites in 18 counties Over 20% received interventions 6 Month evaluation demonstrated a decrease in use of alcohol and medications as well as improvement in depressive symptoms. Over 91,000 older adults were screened! 121
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Interventions Project GOAL (Guiding Older Adult Lifestyles) Two ten to fifteen minute physician delivered counseling sessions scheduled one month apart. Advice, education and contracting using a scripted workbook . Follow-up phone call by nurse two weeks after each session. 122
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Interventions (Cont.) Project GOAL: Older adults receiving the brief physician delivered intervention showed 34% reduction in 7-Day alcohol use 74% reduction in the mean numbers of binge-drinking episodes 62% reduction in the percentage of older adults drinking more than 21 drinks per week, compared with a control group. 123
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Issues of Substance and Medication Abuse/Use in Older Adults: What Can We Do? 124
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What Can We Do? Increase education/awareness efforts in the general population and professionals. Use approaches in prevention, intervention and treatment that involve natural systems/pathways for older adults, e.g. integrated with healthcare, other service avenues. Come up with ways to finance/incentivize the development of models for prevention, education, and treatment regarding substance and medication abuse/misuse in older adults. Ensure routine screening for older adults in settings where they frequent. 125
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What Can We Do? (cont.) Build workforce capacity to deal specifically with the needs of the older adult population. Include older adults recovering from substance use disorders in all planning efforts. Include substance use disorders with mental health issues in preparing local planning models for addressing needs of older adults (In PA using County Memorandums of Understanding – MOU’s). 126
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What Can We Do? (cont.) Create opportunities to bring evidenced-based approaches and promising practices to front-line workers (forums, e-learning, incentives, etc.). Remember that reducing and treating substance abuse problems among the older adult population will require an integrated system of care that combines medical and behavioral health services to fully address the spectrum of problems that older adults bring to the primary care setting! The NSDUH, “Illicit Drug Use among Older Adults;” December 29, 2009.
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Collaborative Approach to Care Coordinate care with the individual’s primary care physician. Link to medical care for co-occurring health problems and services that support independence. Involve family members if and when appropriate. Provide age specific treatment; those whose lifestyles and problems are similar. Provide a continuing “plan of care” that links individuals to “older-adult-friendly” groups. 128
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Prevention Promising Practices Project MEDS (Medication Education Designed for Seniors) – Peer delivered education program, Bucks County AAA (RSVP Station) 215-348-0510 Elder Health Program– Consumer drug education program for older adults and their caregivers Elder Health Program, School of Pharmacy, Univ. of MD at Baltimore http://www.pharmacy.umaryland.edu/centers/lamy/ 129
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Prevention Promising Practices Senior Helping Hands – An outreach program that addresses the needs of older adults with substance use disorders and mental illness. St. Cloud Hospital, St. Cloud MN http://www.csbsju.edu/retirees/volunteering-opportunities/senior-helping-hands Florida BRITE – early intervention for older adults through all AAAs, Robert W. Hazlett, Ph.D., CAC, CCS, http://brite.fmhi.usf.edu/BRITE.htm 130
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Resources Substance Abuse Among Older Adults: A Guide for Social Service Providers - http://store.samhsa.gov/product/substance-abuse-among-older-adults-for-social-service-providers/sma04-3971 Prescription and Illicit Drug Abuse - http://nihseniorhealth.gov/drugabuse/improperuse/01.html 131
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Resources (cont.) SAMHSA Guide to Preventing Older Adult Alcohol and Psychoactive Medication Misuse/Abuse: Screening and Brief Intervention – http://www.aoa.gov/AoA_Programs/HPW/Behavioral/docs2/Issue%20Brief%203%20Screening%20Brief%20Interventions.pdf 132
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Resources (cont.) The Elderly and Prescription Drug Misuse and Abuse - http://www.cars-rp.org/publications/Prevention%20Tactics/PT09.02.08.pdf Medicines to treat addiction: http://opinionator.blogs.nytimes.com/2016/02/16/medicines-to-keep-addiction-away/?emc=eta1&_r=0 133
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Resources (cont.) CDC Opioid Guideline Information Guideline Information for Patients - http://www.cdc.gov/drugoverdose/prescribing/patients.html Guideline information for providers - http://www.cdc.gov/drugoverdose/prescribing/providers.html CDC Guideline Resources - http://www.cdc.gov/drugoverdose/prescribing/resources.html 134
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Resources (cont.) SAMSHA—Get Connected! Linking Older Americans With Medication, Alcohol, and Mental Health Resources. DHHS Pub. No. (SMA) 03-3824. Rockville, MD: Center for Substance Abuse Treatment, SAMHSA, 2003 www.samhsa.gov/Aging/docs/GettingConnectedToolkit.pdf Technical Assistance Older Americans Substance Abuse and Mental Health TAC - www.samhsa.gov/Olderadultstac/index.aspx National Institute of Alcohol Abuse and Alcoholism - http://www.niaaa.nih.gov 135
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Resources (cont.) IRETA (Institute for Research, Education and Training in Addictions) - www.ireta.org Administration on Aging - www.aoa.gov/ American Society on Aging– web based training www.asaging.org Brown University CAAS Distance Learning Program www.browndlp.org Aging To Perfection Program - Hanley Center, West Palm Beach, FL lguelzow@hanleycenter.org 136
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Resources (cont.) National Institutes of Health Senior Health - http://nihseniorhealth.gov/drugabuse/preventingsubstanceabuse/01.html Hartford Institute for Geriatric Nursing – http://consultgerirn.org/topics/substance_abuse/want_to_know_more CDC Health Literacy- http://www.cdc.gov/healthliteracy/gettraining.htm 137
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QUESTIONS? 138