The Treatment of Addiciton in

Older Adults

Byron Bair,M.D.

Professor Geriatric Internal Medicine & Geriatric Psychiatry

University of Utah School of Medicine

Basic Demographics

• Aging population

– age 65 or older: 130%+ per year

• Life expectancy

– birth: 75 - 79 years

– at age 85: 6 - 8 more years

• Unique features of aging

– physiology changes

– disease presentation

Unique Features of Aging

• Pharmacodynamic changes of age

– increased receptor sensitivity

• opioids, benzodiazapines

– decreased receptor sensitivity

• beta blockers, beta agonists

• Pharmacokenetic changes of age

– absorption: little clinical effect

– distribution: lipid vs water soluble

– metabolism: phase I vs phase II

– excretion: Kidneys, bowels, tears, saliva, sweat

Diagnosis in DSM-5 — Substance use disorder, replaced substance abuse / dependence:

A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least two of the following

occurring within a 12-month period:

●The substance is often taken in larger amounts or over a longer period than was intended.

●There is a persistent desire or unsuccessful efforts to cut down or control use of the substance.

●A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.

●Craving, or a strong desire or urge to use the substance.

●Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home.

●Continued use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by its effects.

●Important social, occupational, or recreational activities are given up or reduced because of use.

●Recurrent use in situations in which it is physically hazardous.

●Continued use despite persistent or recurrent physical or psychological problems caused or exacerbated by the substance.

●Tolerance.

●Withdrawal.

Current severity can be specified in the diagnosis based on the number of symptoms present:

●Mild: Two to three symptoms

●Moderate: Four to five symptoms

●Severe: Six or more symptoms

Substance Use Disorder Geriatrics• Data base & research limited

• Cohort effects

– “Great Depression” vs. “Woodstock”

• Illicit Drugs: life time history = 2.88% men, 0.66% women

– Cocaine / Heroine:

• 13% active users in those with history, age 50+

• 38% VA older adult treatment program

• Over – the – counter / Non prescription:

– Alcohol: occasional use = 50%

– Alcohol SUD: 3% -0.5% (M/F) bimodal distribution

– Tobacco: community dwelling = 15.2% (65-75) 8.4% (75+)

• Prescription

– Sedatives: benzodiazepines; 2%

– Analgesics: narcotics; 2%

– Utah rank 22nd for overdose deaths in US

Treatment Outcomes for Older Adults• Review of randomized controlled trials

– 25 studies met criteria

– Limited: 15 or less participants

– Tracking: pre – post tests

– Results

• Higher treatment exposure: Older adults do better than

younger patients

• Older adults have a heterogeneous response to treatment

Need randomized controlled trials of evidenced-based

practices, including Motivational Interviewing,

cognitive behavioral therapy, and medications

(naltrexone) A Review of Existing Treatments for Substance Abuse Among the Elderly and Recommendations for Future Directions February

18, 2013 Alexis Kuerbis1 and Paul Sacco2 1Research Foundation for Mental Hygiene, Inc, and Columbia University Medical Center. 2University of Maryland, School of Social Work

Older Adults 5 Years after treatment

Compared to young and middle age adults

Older adults are:

• Less likely to be drug dependent at baseline

• Longer retention in treatment

• Less likely to be encouraged to take drugs / ETOH

• 12% higher abstinence last 30 days (52%)

– Older women had highest rates of abstinence

– ETOH only = no differences in age groups

Medical Conditions: Older Adults• Sensory Deficits

– Check or refer for evaluation of:• Vision

• hearing

• Malnutrition– Follow weights: un-intended weight loss > 5lb within 1 month

or 10 lb. in 3 months = high risk morbidity / mortality

• Cognition & Behavior

• Polypharmacy

• Depression

• Functional impairment

• Environmental status

• Prognosis & Life Expectancy

• Patient Goals

• Frailty

Frailty

1

2

3

Functional Capacity

Disability

Time

Treatment Models

• chronic/relapsing substance use disorders (SUD)

in the United States

– episodic treatment vs. continuing care

– Conceptualize as a chronic disease

– Serial patient assessments & monitoring

– modification of patients’ level of care over time based

on:

• phase of illness

• clinical status

• co-occurring conditions

• treatment needs/preferences

Substance Use Disorders Treatment

• provided via a continuum of care

• multiple tiers of clinical services that vary by:

– Setting

– types of treatment

– intensity of services

• Standard levels of care include:

– Inpatient

– Residential

– partial hospital

– intensive outpatient

– outpatient care

Treatment Considerations

The patient’s clinical status and risk of relapse are

monitored systematically and longitudinally

As the patient’s addiction waxes and wanes over

time (ie, experiences periods of abstinence, relapse,

or fluctuations in risk of relapse), the intensiveness

and types of treatment are adjusted along with the

level of care at which treatment is delivered

ASAM Dimensional Approach

Dimension 1 – Acute intoxication and withdrawal potential.

• Manage intoxication / withdrawal

Dimension 2 – Medical conditions and complications

• Treat acute / chronic medical issues that complicate SUD treatment

Dimension 3 – Emotional, behavioral, or cognitive conditions

• emotional, behavioral, or cognitive problems part of the addiction

Dimension 4 – Readiness to change

• Ready to stop or reduce use of substances/addictive behaviors

Dimension 5 – Relapse, continued use or continued problem potential

• Need relapse prevention interventions, groups, structure etc.

• Potential benefit of medications (psychotropic and addiction)?

Dimension 6 – Recovery environment

• Structure, Supervision, Stimuli, Safety, Stress

Matching patient substance use disorder treatment

needs to levels care using ASAM criteria

Evaluation

• Purpose:

– detect factors contributing to the current problem

– improve: function, comfort, dignity, quality of life

• It is common for multiple processes to be

occurring simultaneously in older adults

• Recognize role of Geriatric “frailty”

– aging = reduced reserve capacity

– increased propensity for “small” insults to result in

disability

Evaluation

• History: changes; acute vs chronic

– IADL’s: independent, assist, dependent

• use telephone, shopping, food preparation, housekeeping,

laundry, transportation, finances, medication

– ADL’s: independent, assist, dependent

• bathing, dressing toileting, transfers, continence, feeding

– Detect: common changes from baseline

• new or exacerbation of illness: self /spouse

• death in family

• psycho-social, environmental, economic

• vision, hearing, constipation, fluid intake

Evaluation• Physical Exam

– vital signs:

• weight, height, orthostatic BP, HR, RR, Temp.

– geriatric functional exam:

• get-up-and-go, ROM

– sensory:

• hearing, sight

– neurological

• gait, reflexes

– screening exams:

• PHQ9, GAD7, MOCA, PTSD etc.

Evaluation

• Laboratory

– Blood work:

• lytes, BUN/creatinine, Ca++, Mg++, albumen, (pre-

albumen), LFT’s, CBC & diff., TSH, B12, folate,

FTA, HIV

– Pulse oximetry

– EKG

– Imaging: Chest x-ray, CT without contrast?

– PVR

– Other:

• Other neuropsych. testing

Cognitive Function

Cognition comprises all mental

functions used to deal with the

internal & external world

Selected Cognitive Functions

• Memory

• Attention

• Orientation

• Language

• Writing

• Calculation

• Praxis

• Initiation

• Abstraction

• Planning

• Visuospatial

• Sequencing

• Personality

• Judgement

• Insight

• Behavior

7 D’s of Cognitive Dysfunction• Dementia

– Alzheimer's, Vascular, Mixed, Lewy Body, Frontotemporal

• Delirium

– Drugs +/- infections; acute vs subacute / chronic

• Damaged Brain

– Chemical (ETOH), traumatic, surgical

• Depression:

– Psychiatric disorders, mania, psychosis, PTSD, bereavement

• Developmental Delay

• Deficient Education

• Decision Making Capacity

Delirium: DSM V Criteria

• Disturbance of Consciousness

• Change in Cognition

• Acute Onset (hours - days)

• Result of General Medical Condition

Delirium: Etiology

Common Endpoint for Many Illnesses:

• Infections: UTI, pneumonia

• MI

• Pain

• Dehydration

• Medications / drugs

– intoxicated or withdrawal

Delirium: Significance

• 50-80% of Hospitalized Elderly

• Listed as Discharge Diagnosis: 5 -23%

• M.D. Recognition during course: < 1%

• Length of Stay: 2 x > controls

• Nursing Home D/C: 5 x > controls

• Inpatient Mortality: 8 x > controls

Evaluation: Delirium

• ANY acute change in mental status or behavior

may signal a delirium

• Delirium requires prompt medical evaluation

• differing evaluations is suspicious for delirium

• TREAT UNDERLYING MEDICAL ILLNESS

– haloperidol & lorazepam may help tranquilize to

allow evaluation and intervention but are not “tx”

Unrecognized Medical Issues

• 80% have at least 1 chronic medical condition

• An average of 8 different prescriptions, OTC, herbals

• New “behavioral” symptoms may reflect underlying comorbid disorders or new disorders layered on previous conditions

• 1 set of symptoms may reflect multiple interacting etiologies

Unrecognized Medical Issues

• Sleep disorders

– medications: diuretics, benzodiazepines, caffeine

– symptom of other illness: depression

– sleep apnea: 30 - 70%

• Pain, nutrition, hydration, HTN, CAD, Lipids, etc.

• Substance use disorders

– ETOH, benzodiazepines, opioids, other

• Polypharmacy: Prescription abuse?

– ADE’s: 40-50% vs 2-10% in younger populations

– pharmacodynamic, pharmacokenitic changes of age

Polypharmacy: Unintentional

Prescription Abuse?

• Average person over the age of 65

– 80% have 2 or more chronic medical conditions

– 4.5 prescriptions

– 3.5 over the counter (OTC) medications

– ? Herbals

– 12-17 new prescriptions per year

Polypharmacy: Unintentional Prescription

abuse In Older Adults?

• 596 “unique” admissions

– 15% readmission rate

– range of 2-6 admissions

• Reasons for readmission

– “new” clinical problem

– “clinical failure”

– “other” (scheduled test)

• Discharge medications: 12.8

• 72 hour follow-up discrepancies: 20.2

Polypharmacy and ADE’s

• 75% office visits include prescription

• 15% hospital admissions from ADE

• 50% of hospital stays are complicated by

ADE

• Longer hospitalization = more medications

Treatment Tools

• Trust + Verify

• Random blood / urine tests

• Continuity of care & monitoring

• Substance Abuse Database

Pharmacological Interventions

Restricted Prescription Drugs

• Utah Controlled Substance Database

– Access to providers + designee, pharmacy staff

• Exemptions:

– Prescriptions filled at federal facilities (military or

VA);

– Prescriptions filled at pharmacies licensed by other

states; or

– Controlled substances administered in an in-patient

setting.

Environmental Interventions• Finances and resources

• Assess individual needs before suggesting living

environment

– Supervision

• Independent vs dependent

– Structure

• Self vs external

– Stimuli

• Conducive vs chaotic

– Stress

• Self + others

– Safety

• Home, weapons, medications, driving

Pharmacological Interventions

ETOH Older Adults

• Few trials in older adults

• Inpatient supervised withdrawal

• Outpatient care

– 70% relapse after psychosocial treatments alone

– Psychosocial + Medication: older adults?

– Medications modulate effects of ETOH

• Naltrexone (ReVia, Depade); liver toxicity / opioids;

available as depot

• Acamprosate (Campral): liver safe; opioids

• Disulfiram (Antabuse): highly motivated and compliant

Pharmacological Interventions

Opioids Older Adults

• Structured & Experienced environment

• Agents: Geriatric studies limited

– Buprenorphine – naloxone combo

– Methadone: overdose & cardiac toxicity

– Clonidine: symptomatic relief

Pharmacological Interventions

Benzodiazepines Older Adults

• Structured environment

• Outpatient

– Gradual tapper under supervision

• Inpatient

– Unknown dose or unsafe environment

Utah Centers that Advertise Older

Adult Treatment

• 16 Centers

– https://www.psychologytoday.com/us/treatment

-rehab/elderly-persons-disorders/utah

• 70 Centers

– https://www.drug-rehab-

headquarters.com/utah/category/older-adult-

and-senior-drug-rehab/

• Advertisements vs. Reality

Additional Addition Information

• https://americanaddictioncenters.org/rehab-

guide/elderly/

• https://www.recovery.org/topics/elderly/