Substance Abuse and the Elderly in the primary care setting
Substance Abuse and the Elderly Margaret Brawner / Pfeiffer University / Charlotte, NC / 2014 Medical system “ill-prepared” for wave of older adult substance abusers • Adults 60+: substance abuse one of U.S. fastest growing health problems. comin Medical system • Gerontologists in short supply. • Physicians receive little-to-no training in addiction. • Few age-specific treatment programs. • Baby boomers retiring: 10,000 a day. • 85+ fastest-growing demographic. Image: www.edofdreams.com SAMHSA, 2012; Doweiko, 2014; Bartels and Blow, 2011 ) “The lack of identifying and treating SUDs may ruin the last stage of life for countless older adults.” (SAMHSA, 2012) Alcohol: scope of the problem • 19 percent of older adults aged 50-64 are “at risk” drinkers (drinking more than the NIAAA recommendations of 1 per day) and 23 percent report binge drinking (4-5 drinks). (Naegle, 2012) • 2013: Center for Disease Control reports alcohol accounts for more than 21,000 deaths among adults 65 or older each year. (Doweiko, 2014) • An estimated 1 in 4 older adults may be adversely affected by combining alcohol and medication (especially CNS depressants.) Can cause unintentional addiction and death. Potentiation: 1 + 1 = 3. (Bartels and Blow, 2011) Patterns of older adult substance use disorders • Early-onset: • substance use disorders develop before age 65. • psychiatric and physical problems tend to be higher than late-onset (Bogunovic, 2012). • Late-onset: • substance abuse develops after stressful life situation (death of partner, retirement.) • boredom and loneliness high risk factors. • Addiction can occur unintentionally (Bogunovic, 2012). Chronic pain is a high risk factor for both categories (Shallow, 2014). Prescription drug misuse often overlooked in elderly (Doweiko, 2014). The use of alcohol with pain pills is a common occurrence.(Neagle, 2012). Signs and symptoms of alcohol use disorders in elderly • Wanting to stay alone much of the time • Memory problems after having a drink • Loss of coordination (walking unsteadily, frequent falls) • Irritability, sadness, depression • Failing to bathe or keep clean • Having trouble concentrating • DSM-5 categories rarely apply to elderly (Doweiko, 2014; SAMHSA, 2003) Polling Question What type of psychoactive medication is associated with the most emergency department visits related to prescription medication misuse among older adults? A. Pain pills B. Sedatives/tranquilizers C. Anti-depressants (Bartels and Blow, 2011) Emergency department visits A. Pain pills (43.5%) B. Medications for anxiety or insomnia (31.8%) C. Anti-depressants (8.6%) (Bartels and Blow, 2011) Most abused opioid medications • Oxycodone (OxyContin) • Oxycodone/acetaminophen (Percocet) • Hydrocodone (Vicodin) (Prescription Drugs April 13, 2010) Opioids: scope of the problem • Overdose deaths overall involving opioid pain relievers (OPR), also known as opioid analgesics exceed deaths in U.S. involving heroin and cocaine combined. ( Bartels and Blow, 2011) • Opioids are the most frequently reported emergency department-related visits involving prescription misuse among older adults. (Bartels and Blow, 2011). • 2014 CBS News report: death rates from prescription opioid medications in the 45-64 age groups increased significantly in recent years. (Swallow, 2014; CDC, 2013)) Death rates from prescription opioids Significant increases in 45-54 and 55-64 age groups Swallow, 2014; CDC, 2013 Signs and symptoms of opioid abuse • • • • • • • • • Confusion Depression Delirium Insomnia Parkinson’s-like symptoms Weakness or lethargy Loss of appetite Falls Changes in speech; slurring (Bartels and Blow, 2011) Signs and symptoms of opioid abuse • • • • • • • Loss of motivation Memory loss Family or marital discord New difficulty with activities of daily living (ADL) Difficulty sleeping Drug seeking behavior Doctor shopping (Bartels and Blow, 2011) Factors contributing to substance abuse • • • • • • • • Chronic pain Anxiety Sleep problems Lack of awareness of reduced ability to well-absorb and metabolize chemicals. Lack of a support system Disability. Older adults bound to their homes due to disability are at high risk for SUDs. Depression. Alcohol and depression is the most common co-occurring disorder among older adults. Isolation. Older adults are more likely to drink at home alone and see friends less often. (SAMHSA, 2012) Factors contributing to substance abuse • Grief (loss of spouse, job, ability to function.) • Trauma (elder abuse). • Boredom / loneliness. Particularly for late onset drinking. • Family history of alcoholism • Gender: men more at risk for alcohol abuse; women more at risk for psychoactive medication abuse. • Previous history of substance abuse • Cognitive impairment (SAMSHA, 2012) Protective Factors • Married • Supportive, safe living environment • Gerontologist trained in addiction supervising diverse medications • Adequate income to meet needs (medical expenses likely to far exceed those of younger adult) • Annual substance abuse screening including psychoeducation. (SAMHSA recommends for 60+) • Wellness factors including eating, sleeping, exercise, spirituality. • Linkage to age-specific groups and activities • Access to transportation (SAMSHA, 2012) Barriers to identifying and treating older adults for substance abuse • Lack of awareness of chemical’s effects • SUDs often mimic symptoms of other disorders, making diagnosis difficult (Doweiko, 2014. • The 15-minute “managed care” appointment factor • Older adults living alone: an SUD may go undetected (Doweiko, 2014). • Denial may be particularly glaring in an older adult substance abuser, whose generation and culture may have adopted the Moral Model of addiction (Doweiko, 2014). • Familial shame (Doweiko, 2014). Barriers to identifying and treating older adults for substance abuse • DSM-5: the substance use disorder criteria rarely apply to older adult substance abusers (Doweiko, 2014). • Ageism: widespread assumption that treating older adults for substance use disorders a waste of time and health care resources (SAMHSA, 2012). • Lack of age-specific treatment programs (Doweiko, 2014) Special Treatment Needs • Elderly likely to present with: - multiple medical conditions - cognitive problems - mobility problems - emotional issues (grief, loneliness, depression) - sensory deficits (hearing/vision) - lack of support system • Treatment for older adult requires more medical management than standard. -- Detoxification can take up to 28 days. -- Patients are likely taking multiple prescription medications. Antabuse not well-absorbed. Doweiko, 2014; SAMSHA,, 2012 Engaging and retaining the older adult SAMSHA 2012 Expert Panel and other addiction professionals recommend: • Supportive, non-confrontational approaches • Age-specific group treatment • Address emotional issues common to older adults (grief, depression) • Develop social support network • Setting: calm, low stimulation (Naegle, 2012) • Pace and content (slower pace; simplified content) • Staff trained in gerontology / pharmacology / addiction • Linkage (to social services, hospitals, activities, doctors) SAMHSA recommends adults 60+ receive annual SUD screening. (SAMSHA, 2012; Steinhagen and Friedman, 2008) Engaging and retaining the older adult • Integrating substance abuse, health, mental health, and aging services to provide comprehensive, holistic care tailored to the needs of the older consumer who presents with co-occurring, multiple needs. • Specific, simple goals/objectives • Culturally sensitive • Offering services in home and community-based settings where older adults congregate. • Outreach services • Extended stay treatment (SAMSHA, 2012; Steinhagen and Friedman, 2008) Image: www.medindia.net Recommended screening tools • SMAST-G: The Short Michigan Alcoholism Screening Instrument – Geriatric Version (SMAST-G). Short-form tailored to the needs of older adults. If positive, use SBIRT (Neagle, 2012). • SBIRT is also an appropriate intervention for combinations of psychoactive medications and alcohol (a common occurrence) (Neagle, 2012). • CAGE-AID (detects alcohol and psychoactive drug use) (Neagle, 2012). • Opioid Risk Tool (up to 82 years old) (SAMSHA, 2012). SAMSHA, 2012 Ages 17-82 Questions and Answers ?