professor ilana crome keele university 21 march 2013
TRANSCRIPT
A QUESTION OF VALUES SUBSTANCE MISUSE THE ELDERLY
Professor Ilana Crome
Keele University
21 March 2013
Thanks to colleagues and friends
Prof Peter Crome Dr Tony Rao Dr Martin Frisher Dr Roger Bloor Dr Alex Baldacchino Drs Ishbel Moy & Harvinder Sidhu, our
future! And many other collaborators…
Professor Ilana CromeDr Karim DarDr Stefan JanikiewiczDr Tony RaoDr Andrew Tarbuck
OVERVIEW
Why is it important What current research tells us How do we deal with it now The future
Peter’s contributions
Peter’s Principles Style - Non judgemental, non
confrontational Demystify and destigmatise What’s special and distinctive? Proactive and positive Evidence and uncertainties Chronic disease - resilience but
vulnerability Dignity, integrity, (e)quality and
compassion
Substance misuse is:
HARMS COSTWHY IS IT IMPORTANT?
WHY IS IT IMPORTANT?
Scale of the problem Burden of disease Lifespan issue Mortality Financial costs Societal impact
Older people will constitute ~25% of the UK population by 2020; currently 18% over 65s
Overall increase in older people using alcohol and illicit substances over past decade
National surveys of alcohol, illicit drugs, prescription drugs, presentations to Accident and emergency units, presentations to specialist services, hospital admissions (poisoning, drug related mental disorders, alcohol related physical disorders)
Prediction: set to double in the next 2 decades
CONTEXT
13% men,12% women over 60 still smoke Smoking largest cause of premature death 45% NHS prescriptions for over 65s, twice Alcohol consumption above adult ‘safe
limits’: 20% in men, 10% in women over 65 Highest alcohol death rate in aged 55-74 5% over 45s used any illicit drug over the
previous year, 0.7% used a Class A drug Increasing over 40s coming into treatment
– 17% in drug treatment units are over 40
How much do older people use?
0 5000 10000 15000 20000
Illicit drugs
Physical inactivity
Fruit and vegetable intake
High Body Mass Index
Cholesterol
Alcohol
Tobacco
Blood pressure
EUROPEAN DISEASE BURDEN ATTRIBUTABLE TO SELECTED LEADING RISK FACTORS (2000)
Number of Disability-Adjusted Life Years (000s)
Most difficult to give up(among those who consume in previous year)
NIGHT LIFE AND RECREATIVE DRUG USE IN EUROPEA study in 10 European Cities 1998
0
10
20
30
40
50
tobacco alcohol cannabis heroin ecstasy LSD
Lifespan perspective
Early life difficulties – maltreatment, distress – associated with substance use disorder and psychiatric comorbidity
90% people who use substances problematically have started before the age of 19
Addiction can be a life long problem
Cannabis case grandmother is spared prison
Peter’s contribution NO LONGER ONLY A YOUNG MAN’S DISEASE ILLICIT DRUGS
May 2011
POISONING - ANTIDEPRESSANTS
May 2011
POISONING - PARACETAMOL
May 2011
PERSPICACITY
May 2011
Per capita alcohol consumption in the UK, 1984-2008
7
7.5
8
8.5
9
9.5
19
84
19
85
19
86
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87
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08
Year
Alc
oh
ol C
on
su
mp
tio
n in
th
e U
K in
litr
es
pe
r h
ea
d
SOURCE: British Beer and Pub Association 2008
Alcohol-related mortality per 100,000 in the UK from 1984 – 2008 trebled
4
5
6
7
8
9
10
11
12
13
14
15
19
84
19
85
19
86
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87
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90
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92
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Year
Mo
rta
lity
pe
r 1
00
,00
0
SOURCE: UK Office of National statistics, the Scottish Government and the Northern Ireland Department of Health.
Harms and costs ALCOHOL - all time high 3rd leading cause of death £21 billion per annum 1 million children £2.7 billion - health ~£7 billion crime-related £6.4 bn - workplace Family, friends and wider communities - not
quantified – child protection, divorce, homeless
DRUGS Increased for a decade £15 billion per annum 300,000 children 3% - £ 0.5 bn – NHS 6% - £1bn - deaths 90% is due to crime
COSTS – GREATER FOR OLDER
More than 10 times -The cost of alcohol-related inpatient admissions in England for 55 to 74 year olds was £825.6m compared to £63.8m for 16 to 24 year olds in 2010/11.
8 times as many 55 to 74 year olds (454,317) were admitted as inpatients compared to 16 to 24 year olds (54,682).
The cost of alcohol-related inpatient admission was £1,993.57m, over 3 times greater than the cost of A&E admissions, £636.30m.
The cost of alcohol-related inpatient admissions for men was £1,278.4m, just under double the cost for women, £715.1m.
PRICING AND POLICY
DISTINCTIVE RISKS AND
COMPLICATIONS
HARMS
Substance use decreases with age, but can be more dangerous
Older people are at increased risk of the adverse physical effects as substances accumulate due to decreased metabolism
Brain sensitivity to drugs may be increased Women metabolise faster; more severe
effects earlier, present later; more comorbidity
May not have dependence eg withdrawal
Distinctive issues
Distinctive issues
INTERACTIONS AND MISTAKES Physical and mental health problems – eg
sleep, anxiety, pain - hypnotics, anxiolytics and analgesics with abuse potential
Complexity, long term chronic disorders Self management in partnership –
embedded in preventative, communities and team based, continuity, responsive, flexible coordinated and integrated
Self harm a serious risk Psychiatric problems associated with
substance use eg intoxication, withdrawal, dependence, anxiety, depression, psychosis, cognitive dysfunction
Psychosocial factors eg bereavement (spouse, friends, family), retirement, boredom, loneliness, homelessness, loss of income,
Precipitants and complications
Alcohol with symptoms
PETER HAS SEEN ALCOHOL PROBLEMS IN MEMORY CLINIC
Memory problems 22.5% Sleeping problems 38.5% Feeling sad or blue 16.8% Tripping, falling 17.8% Gastrointestinal 24.1%
Physicians should notice alcohol use complications
Hypertension 30% Depression 12% Gout 7.6% Diabetes 5.2% Ulcer disease 4.1% Liver condition 3.5% Pancreatitis 0.6%
Alcohol with medications Antihypertensives 31.7% Ulcer medications 18.2% NSAID 17.9% Antiplatelet 17.3% Non-prescription 12.7% Antidepressants 11.9% Sedatives 10.1% Opioids 6.7% Nitrates 4.3% Warfarin 4.4% Seizure 0.6%
HOW DO WE DEAL WITH IT NOW?
BARRIERS TO DETECTION – AND HOW TO RESPOND
Training – competence, screening tools Stigma, moral weakness – non-judgmental, non-
confrontational Under-reporting – comprehensive history Mis-attribution of symptoms, under-diagnosis –
awareness of subtle presentations, high index of suspicion
Ageism – ‘that is all she has left’ Stereotyping – older, higher social class, more
educated, women
DETECTION - AWARENESS
Altered/erratic behaviour or symptoms Poor response to treatment for
medical illness, request for prescription drugs, sharing, storing
Past personal history/family history of substance misuse & legacy of personal, legal, occupational deficits
Illegal activities
THE 5 A’s ASK – all drugs, dependence, ambivalence,
non-judgemental ASSESS – motivation, goals, complications ADVISE – ‘brief intervention’ – feedback,
information, self help material ASSIST – coping strategies, hope, self
esteem ARRANGE – admission – severe addiction,
polysubstance, social, comorbidity, relapse
DAPA-PC Drug and Alcohol Problem Assessment for Primary Care (Blazer) Computerized screening system quickly
identifies substance problems in primary care
Can be used by psychiatrists as well DAPA-PC is self administered, internet
based, automatic scoring Generates patient profile for medical
reference Presents unique motivational messages
and advice for the patient
Information technology Save clinicians’ time Patients to be screened in the waiting room Clinician to follow-up with a patient only when
prompted by the results of screen Computerized screening may lend itself to a
more honest revelation regarding drug use compared with face-to-face discussions.
Acceptability of computers by the elderly will only increase.’
Peter has been interested in this for a long time
TREATMENT AND POLICY
CURRENT RESEARCH
WHAT DOES IT TELL US?
Alcohol dependence was last among 30 medical conditions in proportion of care received as evidence would recommend
Senile cataract 78.7%Breast cancer 75.7%Prenatal care 73.0%Hypertension 64.7%Asthma 53.5%Diabetes Mellitus 45.4%Urinary Tract Infection 40.7%Atrial Fibrillation 24.7%Alcohol Dependence 10.5%
Source: McGlynn E., et al., (2003). The quality of health care delivered to adults in In the United States. New England Journal of Medicine, 348.
Trials and guidelines
Usually dictated by clinical trials
Complex patients excluded ie unrepresentative samples eg older, substance users, comorbidity
Combined treatments rarely studied
Guidelines are not for older people
May 2011
PHARMACOLOGICAL TREATMENTS
May 2011
Peter’s first randomised clinical trial!
May 2011
Pharmacological treatmentMedication Licensed Age limits Specific old
ageDiazepam Alcohol
withdrawalNot in children
<half adult doseIn anxiety
Chlordiazepoxide
Alcoholwithdrawal
Not in children
< half adult dose for anxiety
Disulfiram Alcohol deterrent
Not in children
None
Methadone Opiate addiction
Not in children
Caution
Subutex Opiate addiction
>16 years None
Lofexidine Opiate detox’n
Not in children
Caution
NRT Nicotine withdrawal
> 18 years None
Bupropion Smoking cessation
> 18 years Caution
Pharmacological treatments
Need to diagnose dependence Management of withdrawal symptoms Maintenance of abstinence eg methadone,
buprenorphine;nicotine replacement, bupropion
Prevention of complications Relapse prevention Psychiatric conditions eg depression Physical conditions eg diabetes
SYSTEMATIC REVIEW OF TREATMENT FOR OLDER PEOPLE WITH SUBSTANCE
PROBLEMS
Ishbel Moy
Martin Frisher
Peter Crome
Ilana Crome
Overview of Study Findings - Myths dispelled
Value in treating older adultsPhysicians can helpBrief Advice and Motivational Enhancement are
equally successful for both older and adult population
Respond positively Have the capacity to changeNumber achieving follow-up goal is at least as good
as compared with younger adultsEffective treatment in elder-specific or adult
programme – could do even better
Overview of Study Findings
Good outcomes in substance use, mental and physical health, and social function
Both older men and women are capable of achieving abstinence if given access to alcohol abuse programs
Should be encouraged to seek treatment for substance dependence
Recovery prospects encouraging, long-term management further research
Older age should not be a barrier to addressing drinking problems - something Peter has done
Addiction Research Unit Comprehensive
assessment Single detailed
counselling session Follow up to check on
progress Basic treatment
scheme of 3 hours of assessment and advice is effective in reducing alcohol problems in moderately dependent drinkers
Motivational interviewing/enhancement Non-confrontational
principles and style Increase effectiveness
of more extensive psychosocial treatments
Could be effective as preparation for more intensive treatments
Potentially more cost effective
COST EFFECTIVENESS Economic benefits –
saving of £5 for every £1 invested
Social benefits also Alcohol interventions
are highly cost effective in comparison with other health care interventions
No such thing as a safe limit Adult safe limits may not apply For some healthy older people, 1 US (14 gm alcohol)
drink a day, and no more than 7 a week (UK unit = 8 gm IE 1.5 units daily)
More than 3 US drinks a day is harmful Should not drink and drive, swim, use machinery.
Should eat before drinking Drink more slowly ie over two hours For those with comorbid conditions, on medications,
no alcohol may be appropriate Under review by the Chief Medical Officer
‘Safe’ limits
Key Issues for Doctors
Prevention of disease of later life Prevention of functional decline Early identification of disease with rapid
response Supporting participation Application of evidence-based approaches Ageing, multiple pathology, vulnerability and
resilience
Key Issues for Older People Finance Housing Food Warmth Family Work Health Participation and functional status Cognitive decline
THE FUTURE
TRAINING – ROLE MODEL, KNOWLEDGE, SKILLS, ATTITUDES
May 2011
Not an optional extra – improve attitudes, reduce stigma, reverse therapeutic nihilism
Royal Medical Colleges - Undergraduate, specialist post graduate, continuing professional development - competencies
Multidisciplinary specialists - Old age psychiatrists, geriatricians, addiction specialists, nursing, psychology, social care and other allied professionals
Training
The future – not only baby boomers!
A UK based research programme on older substance misusers
Prescription drug use Any particular intervention, specific
programme, service model can be recommended - over long term
Policy implementation RCPsychiatrists Information Guide – Peter is
contributing
A question of values? Dignity, integrity, compassion and (e)quality
Health eg mental illness, cognitive impairment
Life circumstance eg poverty, in prison, family conflict, social isolation
Behaviour eg substance misuse, crime Status eg older, victim of abuse, refugee,
immigrant Personal quality eg low self esteem,
impaired functional life skills
19 March 2013 Guardian