Substance Use Problems and Aging: Brief Screening And Focused Interventions

1. Substance Use Problems and Aging:Brief Screening And Focused Interventions PRISM 6 Sept 25, 2008 George K Dreher

3. Substance Use and Aging • Illicit substance misuse less frequent among elderly but as their numbers increase … • Demographic shifts with boomers use of all mood altering substances (except nicotine) at a higher rate than their parents • Long term effects are yet to be adequately studied for many substances (the literature is very sparse…)

6. Substance Use and Aging Hidden problem / under our radar: • Symptoms mimic / masked by common physical / /mental / social aging problems • Elders / those around them in denial • Health care providers rarely ask about amounts / effects • Life problems secondary to use less obvious especially if living alone • Amounts used stable but blood alcohol levels for a given dose are higher with aging

7. Older Substance Abusers In one study were more likely than a younger subset to: • Have co-occurring other mental health diagnosis • Abuse benzodiazepines (OTC Rx too?) • Have memory loss & sleep problems (Solomon & Stark 1993) • Toothless from chronic smoking (CDC 1997)

8. Alcohol Use and Aging Alcohol misuse rates incidence over 65 of 2 to 10 % • From 1992 - 2002 3x increase in abuse / dependence in those over 65 to 3.1%(National Household Survey on Drug Use and Health) • Binge / excessive use risen to 8.3%(National Household Survey on Drug Use and Health ) • Those seeking routine medical care have rate of 15% or greater • Most of these have not been diagnosed by providers

9. Alcohol Effects With Aging Alcohol effects increased by: • Less stomach Alcohol Dehydrogenase (AD) makes more EtOH available for absorption • Reduced blood flow through the liver => longer to metabolize a given amount • Loss of lean body mass = less water for given amount of alcohol to mix into • Overall BAL for given dose increased 30% to 40% more when over 65 compared to younger patients

10. Alcohol Effects With Aging Women have greater BAL / given dose due to: • Life-long have lower amounts of AD in stomach • Generally smaller weight with less lean body mass

11. Alcohol Impact With Aging At any given BAL seniors have less ability to counter the impact: • Reduced CNS reserve • Worse balance • Reduced coordination • Slowed reaction time • Ongoing other illness / poor nutrition / Rx in use

12. Alcohol Impact With Aging Multiple medications interactions add to the impact • Acetaminophen • Antidepressants • Aspirin • Benzodiazepines • NSAIDs • Digoxin • Opiates • Heparin • Hypoglycemics • Sleep aids • Others …

13. GI bleeding Hypertension Arrhythmias and cardiomyopathy Depression / anxiety Insomnia Hepatitis / Pancreatitis Reduced nutritional absorption Cognitive impairments Osteoporosis Reduced immunity GI Cancer risk Bone marrow function Proximal muscle strength loss Peripheral neuropathy Etc. Medical Problems caused by / worsened by EtOH

14. Alcohol Use and Hypertension • Drinking 3 - 4 drinks a day associated with a 50% greater risk of hypertension compared to non-drinkers • Women having 2 - 3 drinks a day had a 40% increase in rates of hypertension Ref # 6

15. Adverse Drug Reactions (ADR) More common in seniors including from: • the use of OTC and street drugs • Often on multiple drugs • Overuse of drugs (accidental or not) • Chronic diseases • Reduced metabolism / elimination • Nutritional deficiencies

16. Fatal Medication Errors (FME) Increase with Use of Alcohol and /or Street Drugs • Between 1983 and 2004 FMEs increased: • At home with EtOH / Street Drug use increased = 3195% • All accidents in the home = 69% • At home without use = 563% • Outside the home with EtOH / Street Drug use home = 555% • Outside the home without use = 360% • Arch Intern Med July 28, 2008 168:

17. However not all high risk users will present with problems …Therefore better to screen everyone.

18. Primary Care Role • Assessment • Active education / intervention • Referral when needed • Monitor maintenance process • Engage family in their own treatment

19. What is Safe Alcohol Use? • Two standard drinks per day for males and one per day for females associated with physical and mental health benefits in younger population • Seniors likely to be similarly helped by 1 std drink/day for males and perhaps less for females. • Problematic if more than this or > 4 std drinks on any given day

20. Levels of Use • Abstinence = none in the previous year (was there a prior problem?) • Low Risk Use = use within guidelines and no problems from use (Rx interactions?) • At Risk Use = use above the safe limits => evaluate / educate / monitor • Problem Use / Abuse = currently occurring adverse results from use at whatever level of use => intervene • Dependence = Loss of control / use despite problems from use / preoccupation with use / physiologic changes => possible detoxification / specialty treatment ?

21. Other Substance Misuse • Rising rate of illicit drug use from 2002 to 2005: • Age 50 to 55 increase from 3.4% to 5.2 % • Age 55 to 59 increase from 1.9% to 3.4% • Most have been using for many years => an emerging cohort effect #6 (National Household Survey on Drug Use and Health)

22. Geriatric Opiate Maintenance • Methadone maintenance patients ages 55 to 86 in treatment for more than 10 years: • Nicotine use was greatest current health hazard for many • Had survived by controlled use of opiates in spite of dependence / avoiding excessive alcohol use / living by their wits rather than violence / use of quality narcotics & clean needles / enrollment in methadone programs # 9 • Geriatric Suboxone population is surfacing

23. Don’t Forget … • Nicotine • Caffeine

24. Other problems … Bangor Daily News Sept. 9, 2006 71 yr old woman arrested for selling her prescribed methadone 10mg tablets (675 pills / mo). There was a question of whether she was doing this voluntarily to help pay her bills or if she was being intimidated by the purchaser …

25. SBIRTScreening, Brief Interventions, Referral and Treatment • Multiple studies show this to be an effective primary care / hospital strategy to significantly reduce use for all age levels • Reduced levels of use is associated with improving health / physical functioning / role functioning / mental health / social functioning

26. Brief Screening • Part of annual evaluation or • Adding new possibly interactive medications or • Appearance of potentially related medical / social / mental problems

27. Assessment Tools • Validated screening questionnaires • Lab tests • Collateral Information • Review of prior medical / emotional problems • Assessment of current medical and mental health problems

28. Brief Screening over age 65for Dependence CAGE - Any one (+) should prompt further inquiry - One (+) worrisome in those over 65 - Two or more (+) highly suggestive of problems with use TACE - More specific for women with similar interpretation (T = Tolerance)

29. Brief Screening MAST-G (Handout) 24 Questions Specifically designed for older adults Sensitivity = 95% Specificity = 78% (+) Predictive value = 89% (-) Predictive value = 87%

30. AUDIT-C • 1) How often did you have an alcohol containing drink in the last year? (Monthly or less / 2-4 times a month / 2-3 times a week / 4 or more times a week) • 2) How many drinks did you have on a typical day when you were drinking in the past year? (1or 2 / 3 or 4/ 5 or 6 / 7 to 9 / 10 or more) • 3) How often did you have 6 or more drinks on one occasion in the past year? (Never / less than monthly / monthly / weekly / almost daily) • Score from 0 to 4 for each and add up • score greater than 3 for seniors considered (+) requiring further evaluation

31. There does not have to be … • Overt withdrawal • Obvious tolerance • Legal Issues • Complaints by others

32. Widows • Many were using heavily with their partner before their death and may be seen as only having a problem since the illness / death of the other • Unless this is assessed, compromising assumptions will interfere with treatment • Higher rate of over-used prescribed / psychoactive drugs in this population

33. Negative Stressors Problem drinkers found to have more: • Negative life events / losses • Chronic illness • Less material resources • Less social support / loneliness / reduced social skills • Depression • May be less connected to health care • Need to incorporate these into treatment plans (Brennan & Moos 1995)

34. Substance Use Screening Labs • BAL • Elevated MCV and low BUN • GGTP elevation • Ethylglucuronase level (Mayo Lab #91696) • Drugs of Abuse Screen (Mayo Lab #81410)

35. New onset of: Anxiety / depression / mood swings Memory loss / episodic disorientation New problems in decision making Poor hygiene Falls / bruises / burns Family conflict / social isolation Idiopathic seizures Financial problems Sleep problems Headaches Incontinence Poor nutrition Signs / Symptoms of Alcohol Use

36. Common Alcohol Related Health Problems • Anemia or other reduced marrow function • Distal neuropathy • Proximal muscular weakness • Arrhythmia / cardiomyopathy • Dementia • Incontinence • Hypertension • Reduced glucose control • Osteoporosis • Hepatitis • Pancreatitis • Malignancies of upper GI tract / esophageal varices • Trauma / fractures

37. Elder Withdrawal is Different • Reports that similar amounts / duration of use take longer to clear (Brower, Mudd, Blow, et al 1994) • Greater degree / duration of: • sleeplessness, • cognitive problems (processing time), • weakness, • hypertension

38. Intervention Spectrum • Prevention / Education • Brief Advice • Brief Intervention • Formal Specialized Treatments

39. Motivational Interviewing • Contemplation = helping the patient understand the connection between their substance use and the secondary problems Stages of Change (Miller and Rollick) • Pre-contemplation • Contemplation • Decision • Action • Maintenance Slips ?

40. Prevention / Education • What are their perceptions of use? • Both positives and negatives • Comparisons of their use with established risk levels for EtOH / risks with any illicit use. • Current / potential medical consequences • Do they want to change? • Barriers to changing use patterns?

41. Brief Advice • State medical associated problems • “Common problem” & avoid shame based comments • Change takes a little effort but is likely to improve several areas of functioning • “How can I help?”

42. Brief Interventions • Disease model => less shame but still accountable for choices • Change is possible • You are concerned about their use • You are here to help and not to judge • Specialized resources available if they cannot change on their own

43. Treatment Plan • Clearly defined goals • Limitation of use / harm avoidance / warm turkey / abstinence from use ? • Health problems to be treated ? • Mental health needs / treatment ? • Need for specialized treatment ?

44. Medications • No clear data on efficacy of Naltrexone / Acamprosate in the older population • Disulferam Vs. medical stress of reaction • Antidepressants ? • Baclofen ? • Topiramate ?

45. Age Specific Treatment • Studies suggest that both professional and mutual-help groups work better if; • Age-specific • Larger print readings • Slower pace / patience • Daytime meetings • Non-confrontational yet honest

46. Harm Reductionit’s a chronic disease and a learning process P R O B l E M S Time

47. Recovery • The act of regaining, retaking, or conquering again • A regaining of balance • A getting well again, bringing back to consciousness • The time needed for recovering • The thing gained in recovering Webster’s Unabridged Dictionary

48. Perspective • You may be one of a dozen interactions that will eventually move a person towards change • The longest journey begins with a lot of packing …

49. One Story …

50. Ageing and Substance Use IssuesBibliography • Substance Abuse Among Older Adults: A Guide for Treatment Providers, DHHS Pub. # (SMA) 05-4083 • Substance Abuse Among Older Adults TIP # 26, DHHS Pub. # (SMA) 07-3918 • Brody J, Personal Health; Hidden Plague of Alcohol Abuse by the Elderly The New York Times April 2, 2002 • Bowley, D Woman 71, Implicated in Sale of Methadone Bangor Daily News Sep 9, 2006 P 1 • Alexander F, Drinking in Retirement Communities Alcohol & Drugs GENERATIONS Summer 1988: 58-61 • Oslin D W, The Changing Face of Substance Misuse in Older Adults Psychiatric Times Nov 2006: P 41- 43