wmsbg 2012 older adults addic
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Dr. Micheal Weaver, VCU presented on Older Adults and Addiction on Friday, March 23rd for the Farley Professional Lecture Series.TRANSCRIPT
Older Adults and Addiction
Michael Weaver, MD
Division of General Medicine and
Division of Addiction Psychiatry
Virginia Commonwealth University
School of Medicine
Farley Lecture SeriesMarch 23, 2012
Objectives
Addiction in Older Adults Screening and Brief Intervention Addiction Treatment with Older
Adults Conclusions Practice Cases
What percentage of older adults (over age 65) are affected by alcohol and
prescription drug abuse? A. 5 B. 7 C. 10 D. 17 E. 25
Prevalence reduced with age
Rates of illicit drug use drop among older cohorts
Addiction problems resolved– Treatment when
young– Too old to hustle
Die earlier Cohort effect
– Current older adult cohort didn’t have ‘crack’ in their youth
Alcohol and prescription drug misuse still affect 17% of older adults
The Age Wave is cresting
First ‘Baby Boomers’ just turned 65
This generation used illicit drugs in youth
Continue to use their drugs into older adulthood
Different from previous generations
Liberto 1992; Saunders 1991
Alcohol abuse in older adults
Community– Heavy use 3-25%– Abuse 3-10%
Primary Care clinics (>1 drink/day)– 12% of women– 15% of men
Hospitalized– 18-44%
Graham 1986; Curtis, et al 1989
Why is it under-diagnosed?
Selection Bias– Surveys miss
nursing homes– Poorer recall
Ageism– “Granny’s cocktails
make her happy”– “He won’t be
around much longer anyway”
Under-recognized– Alcoholism
recognized in only a third of hospitalized older adults
Symptoms of AUD may mimic symptoms of other disorders– Depression, dementia– Diabetes
Smith 1995
Sensitivity to alcohol with age
Older adults more sensitive to alcohol– Reduced total body
water Higher
concentrations– Reduced
metabolism in GI tract
Amount with little effect in youth causes intoxication in older adults
NIAAA 2005
Drinking Guidelines
Over age 65 years:– 1 standard
drink/day for men– Less for women– No more than 2
drinks on any one occasion
– No more than 7 drinks per week
Psychiatric Co-Morbidity Higher risk for substance use among
those with psychiatric disorders– Depression or anxiety disorders– Other psychiatric comorbidities– Personality disorders
Dual diagnosis– Substance use disorder + another major
psychiatric disorder
May present with complex clinical histories and symptoms– Diagnosis challenging– Intoxication and
withdrawal symptoms may be mistaken for other psychiatric or medical symptoms
Contact with health care system is opportunity to intervene
Earlier detection and intervention prevents problems
Myers, et al 1984; Wilsnack 1985; Fillmore 1987
Gender differences
Older men more likely to have alcohol-related problems
Women develop problems later in life– More vulnerable to
social pressure– Higher remission rates
(all age groups)
Hurt, et al 1988; Atkinson & Ganzini 1994
Late-onset alcoholism
Makes up a third of older adults with drinking problems
Alcohol use associated with life losses– career loss due to retirement– death of spouse, change in own health status
Not stereotypical alcoholic—too healthy Milder & more amenable to treatment,
especially brief intervention
Callahan & Tierney 1995; Brennan & Moos 1996
Alcohol effects on older adults
Rate of hospitalizations of older persons for alcoholism is ~1%– Same rate of
hospitalization as for myocardial infarction
Alcohol-related dementia
Highest rate of completed suicide
Adverse reactions when combined with prescription or OTC meds
Some Prescriptions withPotential for Abuse
More common among Older Adults–Sedative-
hypnotics–Opioids
Sedative-Hypnotics
Benzodiazepines– Acute or
generalized anxiety– Insomnia– Seizures
Barbiturates– Insomnia– Headache– Seizures
Sedative misuse/abuse
Self-medicate hurts, losses, affect changes
Older patients prescribed more benzodiazepines than any other age group
Butalbital (Fiorinal) contributes to medication rebound headaches
Other Sleeping Pills
Bind to BZ receptor subtypes– Zolpidem
(Ambien)– Zalaplon
(Sonata)– Eszopiclone
(Lunesta)
Behavioral pharmacological profile similar to benzodiazepines– Drug liking, good effects, monetary street value
Recommended for short-term use, many taken long-term
May cause hazardous confusion & falls
Risky prescriptions: Sedatives
Problematic for– Alcohol abuse– Sedative misuse
Benzodiazepines– Valium, Xanax, Ativan,
Librium, etc.– Try anti-anxiety
antidepressants or psychotherapy
Z-drugs (zolpidem, etc.)– Sleep hygeine– Side effects of other
meds– Ramelteon (Rozerem)
Opioid Painkillers
Short-acting Tylenol #3
(codeine) Darvon
(propoxyphene) Vicodin
(hydrocodone) MSIR (morphine) Percocet
(oxycodone) Dilaudid
(hydromorphone) Actiq (fentanyl)
Long-acting MS Contin
(morphine) OxyContin
(oxycodone) Dolophine
(methadone) Duragesic
(fentanyl)
Opioid misuse/abuse Use pain med to sleep,
relax, soften negative affect
Dose requirement reduced with age– Reduced GI absorption– Reduced liver metabolism– Change in receptor
sensitivity Short-acting are the most
easily & widely available Defeat extended-release
mechanism Problems
– Sedation, confusion– Respiratory depression
Risky prescriptions: Opioids
Problematic for older adults who misuse opioid analgesics
Try non-narcotic alternatives– NSAIDs– Anticonvulsants– NSRI
antidepressants– Topical analgesics
Prescription drug abusein older adults
Reduced ability to absorb & metabolize meds with age
Increased chance of toxicity or adverse effects
Med-related delirium or dementia wrongly labeled as Alzheimer’s
Impact on Healthcare Providers
Medication misuse causes adverse health consequences for patient
Worsens prognosis of coexisting medical and/or psychiatric conditions
Significant proportion of practice is dealing with consequences of unrecognized/untreated addiction
Leads to practitioner frustration
Screening for addiction
High level of suspicion
Non-judgmental Caring Free of hostility
History-taking can be therapeutic
Why screen patientsfor addiction?
Medical problems– Cardiovascular
disease– Stroke– Cancer
Spread of disease– HIV, HBV, HCV
Mental health– Depression– Anxiety– Sleep problems
Financial difficulties Legal problems Work-related issues Interpersonal
problems– Family issues
Screening makes a difference
Patients reduce alcohol and tobacco use when this is addressed by a clinician
Research shows benefits from screening and brief intervention for illicit and prescription drug abuse
Screening Tool forAlcohol Abuse
CAGE Questions– Cut down– Annoyed– Guilty– Eye-opener
Affirmative response to 1 or more is positive test in older adult
Screening in older adult
Collateral information– Family– Friends– Senior center staff
Drivers Volunteers
Ask in terms of effects on health problems
Medication interactions
The 5 “A’s”
ASK about alcohol and drug use
ADVISE all patients to quitASSESS willingness to
changeASSIST patients in quittingARRANGE for follow-up
ASK about alcohol and drug use
Have you ever used …– Tobacco products– Caffeinated
beverages– Alcohol– OTC drugs of abuse– Prescription drugs
of abuse– Illicit drugs
When did it begin? How often? How much? When was the last
use?
APA 2000
Diagnosis ofAlcohol Abuse/Dependence
Continued substance use despite adverse consequences
Use in larger amounts or for longer periods than intended
Preoccupation with acquiring or using Inability to cut down, stop, or stay
stopped, resulting in a relapse Use of multiple substances of abuse
Weaver & Cotter 1998
Brief Intervention
Motivate patients to change problem behavior
Multiple brief sessions
Bridge to treatment or sufficient itself
Same impact as more extensive counseling
Most cost effective
Patient Behavior
Ambivalence– Attracted to
problem behavior (substance use)
Denial– Unable to admit
problem to themselves
– Actively conceal Common to many
chronic conditions
Motivation
Probability of certain behaviors
State of readiness to change
May fluctuate from one situation to another
Clinician’s goal is to increase the patient’s intrinsic motivation– change arises from
within rather than being imposed from without
Example techniques
Amplify self-motivational statements
A typical dayGood
things/less good things
ADVISE all patients to quit
A strong recommendation to change substance use is essential
"Based on the screening results, you are at high risk of having or developing a substance use disorder. It is medically in your best interest to stop your use of [insert specific drugs here].”
Recommend quitting before problems (or more problems) develop– Give specific medical reasons– Medically supervised detoxification may be necessary
Elements of Brief Intervention
FRAMES– Feedback– Responsibility– Advice– Menu– Empathy– Self-efficacy
Feedback
Present information to client– Based on history,
exam, labs, etc. Increase awareness
of adverse consequences
Help make the case for change in drinking, med use, or illicit substances
Responsibility
Client has the ultimate responsibility for change
Practitioner can’t force client to change
Client chooses goals, not practitioner– Should be realistic– Clarify client’s goals– Develop
discrepancy
Advice and Menu
Give clear, concrete advice to change
Give choices (menu)– 3 is ideal– Making a choice
is first step to making a change in behavior
Empathy
Listen carefully Clarify client’s
meaning Don’t impose
practitioner’s values on client
Self-efficacy
Build up client’s belief in ability to succeed
Be optimistic Simple goals
early– Success breeds
success– Increases self-
confidence
Types of treatment
Detoxification 12-Step groups Outpatient
counseling– Cognitive-behavioral– Case management
Intensive outpatient Inpatient Residential
12-Step Groups
A.A., N.A., C.A. Group format Anonymous No cost No affiliations or
endorsement Different groups
have different characteristics– “Gray A.A.” for Older
Adults
Which of the following characteristics of attendees
is the best predictor of success in Alcoholics
Anonymous? A. Male gender B. Christian religious denomination C. Frequency of meeting
attendance D. NO history of depression
Success with 12-Step
More groups=more abstinence
No threshold, but at least 2 meetings/week best
Not affected by– Gender– Religion– Psychiatric
diagnosis– Novice
Addiction Counseling
Motivational Interviewing
Network therapy Family therapy Supportive
psychotherapy Building Social
Networks
Twelve-Step facilitation
Perceptual Adjustment Therapy
Rational Recovery
Medication Management
Brief Intervention
Treatment in older adults Focus on coping
– Depression, loneliness– Losses
Rebuild social support network– Socialization groups– Alumnae meetings
More compliant Outcomes as good
or better than younger patients
Treatment works Sustained remission
rates of up to 60%– Better success than
treatment of hypertension, diabetes
Every $1 spent on treatment saves $7 in costs to society
Lots of new research
Summary
Older adults more sensitive to effects of alcohol and drugs than younger patients
Higher doses increase the risk of adverse drug events
Substance abuse is under-diagnosed in older adults
Screen for substance abuse in all older patients, avoid stereotyping
Summary
Encourage older adults to keep a medication list and discuss prescription, OTC, supplement and alcohol use with health care providers
Watch for signs of medication-related problems (falls, confusion, etc).
Older adults respond well to treatment for substance abuse with good outcomes
Questions?
Cases for Group Discussion
References Prochaska JO, DiClemente CC, Norcross JC: In
search of how people change: Applications to addictive behaviors. American Psychologist 1992;47:1102
Miller WR, Rollnick S: Motivational Interviewing: Preparing people to change addictive behavior. NY: Guilford Press 1991
Weaver MF, Jarvis MAE, Schnoll SH: Role of the primary care physician in problems of substance abuse. Archives of Internal Medicine 1999;159:913
Bien TH, Miller WR, Tonigan JS: Brief interventions for alcohol problems: a review. Addiction 1993;88:315
References Substance Abuse and Mental Health Services
Administration (SAMHSA): Results from the National Survey on Drug Use and Health: National Findings. Office of Applied Studies, Rockville, MD: SAMHSA; 2008
American Psychiatric Association (APA): Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: APA 2000