It’s about time Tackling substance misuse in older people

1. It’s about time Tackling substance misuse in older people

2. Older people and substance misuse – who are we talking about? • No fixed definition, age-wise, of ‘older people’ with substance misuse problems. • Alcohol services for older people often targeted at those aged 50/55 and over. With ‘ageing heroin-using population’, those aged 40 and over are defined as older. Research literature uses a variety of age thresholds. • In keeping with this flexibility, we don’t offer a particular definition – we wanted to scope out wide range of issues in this area. • Briefing covers alcohol, illicit drugs, and prescription and over-the-counter (OTC) medications.

3. Background facts and figures Alcohol: • Those aged 65 + make up 3% of both men and women in treatment. BUT – around 1.4 million people in this age group currently exceed recommended drinking limits (Wadd et al 2011). • Across 2002-10, marked increase in alcohol-related hospital admissions for older people: Men aged 65+ 136% Women aged 65+ 132% • In 2010, almost half a million alcohol-related hospital admissions for those aged 65+; accounted for 44% of all these admissions, though comprise just 17% of population (Wadd and Papadopoulos 2013).

4. Background facts and figures Prescription and over-the-counter (OTC) medications: • Data about prevalence of misuse is limited. • But – we know that those aged over 65 use about one third of all prescribed drugs, often including benzodiazepines (anxiety and insomnia) and opioid analgesics (which includes codeine) (EMCDDA 2008). • 2011 NTA report: in 2009-10, 16% (32,510) of people in drug treatment services reported problems with use of prescribed/OTC medications. 2% reported it as primary problem. • Polydrug use can be an issue, particularly where prescribed and OTC medications interact with alcohol.

5. Background facts and figures Illicit drugs: • Number of people aged 40 and over in drug treatment is rising – ‘ageing heroin-using population’. • Illicit drug use among older people isn’t confined to this, however – Fahmy et al (2012): “Use of some illicit drugs, particularly cannabis, has increased rapidly in mid- and late-life”. • Highlights that “prevalences may rise as populations for whom illicit drug use has been more common and acceptable become older.”

6. Routes into substance misuse for older people • ‘Early onset’/‘late onset’ distinction for older people with alcohol problems; about one third develop problems later in life, often as a result of stressful events linked to the ageing process, including retirement and bereavement. Social isolation and loneliness also key. • Same distinction can be made for illicit drugs. ‘Early onset’ = ageing heroin users, people not growing out of casual drug use. Recent studies have also documented instances of ‘late onset’ use: “Older people are often exposed, as a matter of course, to many of the stress factors that may trigger drug use, such as bereavement, financial restrictions, isolation and ill health” (Ayres et al 2012). • Increased levels of discomfort and pain in older age play role in misuse of prescribed/OTC medications, which can be intentional or inadvertent.

7. Risks associated with substance misuse for older people • “Physiological changes associated with ageing mean that older people are at increased risk of adverse physical effects of substance misuse” (Royal College of Psychiatrists 2011) • Physical problems associated with alcohol use: coronary heart disease, hypertension and strokes; liver problems, including cirrhosis; cancer of the liver, oesophagus and colon. • Mental health problems: depression and cognitive impairment may be associated with alcohol misuse. • Alcohol may interact with prescribed/OTC medications, exacerbating side effects or causing other problems. Also associated with falls in the elderly. • Long-term medical conditions, incl. Hepatitis C, can be a particular issue for older people with a history of drug problems, although they may not be receiving treatment. • Higher risk of overdose for older drug users, especially where alcohol and benzodiazepines are being used ‘on top’ of illicit drugs, particularly opiates. • May be vulnerable to exploitation from others.

8. Barriers to support Service barriers: • Older people may feel uncomfortable in mixed-age services • Home visits may not be offered • Age cut-off may exist (e.g. residential services) Professional attitudes: • Lack of awareness that substance misuse is a problem for older people • Reluctance to ask ‘embarrassing questions’ • Attitude that they are ‘too old to change’; belief that it’s wrong to ‘deprive’ them of their ‘last pleasure in life’ Personal barriers: • Feeling embarrassed about asking for help • Sense of ‘failure’ in the past, or feeling that ‘it’s too late’ • Limited awareness of ‘safe’ levels of alcohol consumption, or non-identification of consumption as problematic (“I’ve always been a heavy drinker”)

9. Positive interventions (I) • Important to identify interventions that can be implemented in mixed-age services. • Social groups/activities to develop social network/build confidence. • Meaningful engagement – importance of finding ‘substitute’ for work for those who’ve retired. • Home visits (e.g. to address mobility/transport difficulties). • Adaptations, in assessment and support, to take account of cognitive impairment. • Peer support, from ‘real peers’.

10. Positive interventions (II) • Non-time limited support/different outcomes for some older people can be important. • For those who are drinking at risk, abstinence may not be required; for those with long-term problems, this may not be a realistic goal. • BUT – flipside can be ‘dangerous myth’ that recovery doesn’t apply to older people. • Majority of older people with alcohol problems not dependent, but drinking at risk. • Brief interventions can be delivered by GPs; other health and social care professionals well-placed to do this, too (e.g. those working in older people’s mental health services, in residential services and for social care providers).

11. Email: gemmal@drugscope.org.uk www.drugscope.org.uk