Dr. Micheal Weaver, VCU presented on Older Adults and Addiction on Friday, March 23rd for the Farley Professional Lecture Series.

1. Farley Lecture Series
March 23, 2012
Older Adults and Addiction
Michael Weaver, MD
Division of General Medicine and
Division of Addiction Psychiatry
Virginia Commonwealth University
School of Medicine

2. Objectives
 Addiction in Older Adults
 Screening and Brief Intervention
 Addiction Treatment with Older Adults
 Conclusions
 Practice Cases

3. 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

4. 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‘ Alcohol and prescription
in their youth drug misuse still affect 17%
of older adults

5. 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

6. 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%
Liberto 1992; Saunders 1991

7. Why is it under-diagnosed?
 Selection Bias  Under-recognized
– Surveys miss nursing – Alcoholism recognized in
homes only a third of
– Poorer recall hospitalized older adults
 Ageism  Symptoms of AUD may
– ―Granny‘s cocktails mimic symptoms of
make her happy‖ other disorders
– ―He won‘t be around – Depression, dementia
much longer anyway‖ – Diabetes
Graham 1986; Curtis, et al 1989

8. 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
Smith 1995

9. 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
NIAAA 2005

10. Psychiatric Co-Morbidity
 Higher risk for  May present with
substance use among complex clinical histories
those with psychiatric and symptoms
– Diagnosis challenging
disorders – Intoxication and
– Depression or anxiety withdrawal symptoms may
disorders be mistaken for other
psychiatric or medical
– Other psychiatric symptoms
comorbidities  Contact with health care
– Personality disorders system is opportunity to
 Dual diagnosis intervene
– Substance use  Earlier detection and
disorder + another intervention prevents
major psychiatric problems
disorder

11. 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)
Myers, et al 1984; Wilsnack 1985;
Fillmore 1987

12. 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
Hurt, et al 1988; Atkinson & Ganzini
1994

13. 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
Callahan & Tierney 1995; Brennan &
Moos 1996

14. Some Prescriptions with
Potential for Abuse
 More common
among Older
Adults
– Sedative-
hypnotics
– Opioids

15. Sedative-Hypnotics
 Benzodiazepines
– Acute or generalized
anxiety
– Insomnia
– Seizures
 Barbiturates
– Insomnia
– Headache
– Seizures

16. 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

17. Other Sleeping Pills
 Bind to BZ receptor  Behavioral
subtypes pharmacological profile
– Zolpidem (Ambien) similar to
benzodiazepines
– Zalaplon (Sonata)
– Drug liking, good effects,
– Eszopiclone monetary street value
(Lunesta)  Recommended for short-
term use, many taken
long-term
 May cause hazardous
confusion & falls

18. 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)

19. Opioid Painkillers
Short-acting Long-acting
 Tylenol #3 (codeine)
 MS Contin
 Darvon
(propoxyphene) (morphine)
 Vicodin (hydrocodone)  OxyContin
 MSIR (morphine) (oxycodone)
 Percocet (oxycodone)  Dolophine
 Dilaudid
(hydromorphone)
(methadone)
 Actiq (fentanyl)  Duragesic
(fentanyl)

20. 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

21. Risky prescriptions: Opioids
 Problematic for older
adults who misuse
opioid analgesics
 Try non-narcotic
alternatives
– NSAIDs
– Anticonvulsants
– NSRI antidepressants
– Topical analgesics

22. Prescription drug abuse
in 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

23. 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

24. Screening for addiction
 High level of suspicion
 Non-judgmental
 Caring
 Free of hostility
 History-taking can be
therapeutic

25. Why screen patients
for addiction?
 Medical problems  Financial difficulties
– Cardiovascular disease  Legal problems
– Stroke  Work-related issues
– Cancer
 Interpersonal
 Spread of disease problems
– HIV, HBV, HCV – Family issues
 Mental health
– Depression
– Anxiety
– Sleep problems

26. 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

27. Screening Tool for
Alcohol Abuse
 CAGE Questions
– Cut down
– Annoyed
– Guilty
– Eye-opener
 Affirmative response
to 1 or more is
positive test in older
adult

28. Screening in older adult
 Collateral information
– Family
– Friends
– Senior center staff
 Drivers
 Volunteers
 Ask in terms of
effects on health
problems
 Medication
interactions

29. The 5 ―A‘s‖
 ASK about alcohol and drug use
 ADVISE all patients to quit
 ASSESS willingness to change
 ASSIST patients in quitting
 ARRANGE for follow-up

30. ASK about alcohol and drug use
 Have you ever used …  When did it begin?
– Tobacco products  How often?
– Caffeinated beverages  How much?
– Alcohol  When was the last
– OTC drugs of abuse use?
– Prescription drugs of
abuse
– Illicit drugs

31. Diagnosis of
Alcohol 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
APA 2000

32. 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
Weaver & Cotter 1998

33. Patient Behavior
 Ambivalence
– Attracted to problem
behavior (substance
use)
 Denial
– Unable to admit
problem to themselves
– Actively conceal
 Common to many
chronic conditions

34. 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

35. Example techniques
 Amplify self-
motivational
statements
 A typical day
 Good things/less
good things

36. 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

37. Elements of Brief Intervention
 FRAMES
– Feedback
– Responsibility
– Advice
– Menu
– Empathy
– Self-efficacy

38. 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

39. 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

40. 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

41. Empathy
 Listen carefully
 Clarify client‘s
meaning
 Don‘t impose
practitioner‘s
values on client

42. Self-efficacy
 Build up client‘s
belief in ability to
succeed
 Be optimistic
 Simple goals early
– Success breeds
success
– Increases self-
confidence

43. Types of treatment
 Detoxification
 12-Step groups
 Outpatient counseling
– Cognitive-behavioral
– Case management
 Intensive outpatient
 Inpatient
 Residential

44. 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

45. 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

46. 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

47. Addiction Counseling
 Motivational  Twelve-Step
Interviewing facilitation
 Network therapy  Perceptual
 Family therapy Adjustment Therapy
 Supportive  Rational Recovery
psychotherapy  Medication
 Building Social Management
Networks  Brief Intervention

48. 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

49. 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

50. 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

51. 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

52. Questions?

53. Cases for Group Discussion

54. 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

55. 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