Addiction in Older Adults (Baby Boomers come of age....again) by Maureen Strohm, MD, as presented within the GWEP 2018 January Conference

1. Addiction in Older Adults:
Baby Boomers come of age …again
M AUREEN ST ROHM, M D
S U N R I S E H EA LT H G M E CO N S O RT I U M FA M I LY M E D I C I N E
P RO G R A M D I R EC TO R A N D A S S I STA N T D I O
S O U T H E R N H I L L S H O S P I TA L
L A S V EG A S , N E VA D A

2. Case 1 – Why should I stop now?
74 yo man seen in follow up after ED visit for abdominal pain, nausea and vomiting.
◦ 6 weeks earlier, he had been hospitalized for UGI bleed, requiring 7u PRBC transfusion
◦ Drinking “a handle” of vodka every 3 days, including 2 drinks in the morning before walking his dog
◦ He has “cut down” for now, since his wife has been so concerned about the pancreatitis and “liver
inflammation” diagnosed at the ED visit
◦ States he and his college buddies have been drinking this way for the past 40+ years, so there is no
need to change now
6 months later, readmitted for confusion and ataxia, and blurred vision but no diplopia.
Symptoms cleared quickly with IV thiamine
◦ He consented to formal treatment however, left after only 2 weeks, and relapsed to his former
pattern
◦ After 2 other attempts at inpatient rehab, geropsych admission for depression, he and his wife
decide it’s ok, because he is a “happy drunk” and gets too depressed when he attempts abstinence

3. Case 2 – Why test if she doesn’t use anymore?
43 yo woman admitted 6 weeks earlier for repeated bouts of malignant hypertension, leading
to multiple evaluations for secondary causes.
◦ PH cocaine use, none in past 5 years, and drinking on weekends when her mother has parties at their house.
◦ She acknowledged drinking excessively on the weekend prior to admission.
Drug screen was not done on admission because “she hasn’t used any cocaine in past 5 yrs,”
◦ UDS in am after admission was +cocaine metabolites.
◦ She reported this was due to “sidestream” cocaine at the party.
She had numerous admissions over the next few years for severe HTN, progressive renal
failure, and ultimately ESRD on dialysis.
She was in remission from her cocaine addiction at the time of her death years later.

4. Case 3 – Like daughter, like mother
68 yo woman is admitted to observation for chest pain, likely ACS.
◦ Multiple admissions over the past several months. Repeated cardiac evaluations,
including coronary angiography, revealed minimal evidence of CAD, insufficient to
explain her symptoms.
◦ Her story is recognized by night attending as the mother of patient in Case 2 and
recommends that the team order a drug screen as part of her admission evaluation.
◦ UDS is positive for cocaine metabolites.
◦ She denies having a “problem” with her cocaine use and declines further evaluation
and treatment
◦ Years after her daughter died from her ESRD, she continued to use cocaine and drink
excessively.

5. Case 4 – these meds help me get through day
86 yo woman with severe, degenerative arthritis and chronic pain is seen for her
chronic pain management and HTN. She controls her arthritis pain symptoms
with hydrocodone/acetaminophen twice daily, and uses a walker on most days
◦ She also takes lorazepam prn for anxiety, and citalopram for her depression
◦ Her primary social activity is having lunch with her friends 2-3 times weekly
◦ She enjoys having a glass of wine most nights, as well as with her “ladies lunches”
◦ She refuses to stop her narcotic and BZD medication regimen because she cannot get
through the day without pain otherwise

6. So what’s it all about?
• Describe the continuum of substance use, identifying the
risks at each stage
• Define guidelines for moderate drinking
• Implement universal screening for all patients
• Utilize DSM V criteria as diagnostic aid
• Focused intervention in elderly on multiple substances

8. Substance Use Continuum:
All levels carry risk
Abstinence – perhaps due to PH, FH
◦Non Problematic Use - “social use”
◦Problem Use - public health issue, increasing risk
◦ Abuse - 50% may progress to dependence
◦ Dependence – abstinence is only option

9. Spectrum of Substance Use Disorders
At-Risk….possible problems in 3-5 years
Problem Use…non-compulsive use associated with
negative consequences.
Dependence…compulsive use, loss of control and
associated negative consequences.

10. Mental Disorders in Older Persons:
A Silent Epidemic
• Alzheimer’s and other Memory Disorders
• Alcohol Related Dementia shows greater decline over 2 yrs than AD
• Depression, Anxiety Disorders, Severe Mental Illness, Alcohol Abuse
• Past addiction leads to 5 fold increase in later life depression and
dementia
• Suicide: Highest Rate among age 75+
• Heavy drinking (3+ drinks/day) causes 8.9 fold increase in suicide risk
• At risk drinking (1-2 drinks/day) causes 10.6 fold increase in suicide risk

11. What happens as we age?
Basic Physiological changes
% Body Fat doubles to 30%
◦ Fat soluble drugs accumulate (diazepam)
◦ Total body water decreases: water soluble drugs concentrate (alcohol)
Renal function – declines with age
Musculoskeletal function
◦ Loss of mass, force and speed of contraction – leads to postural changes and falls
Brain changes
◦ Decreased cortical neurons
◦ Decreased blood flow 15-20%
◦ Increased sensitivity to medications

12. Basic Physiological changes
Sensory changes
◦ Visual and hearing losses; olfactory changes
Liver changes
◦ Variable decrease in hepatic blood flow, limiting first pass metabolism
◦ Decreased reduction, oxidation, hydrolysis
◦ Some drugs accumulate – long acting benzodiazepines
◦ Short acting drugs undergo conjugation; not affected by age

13. What about alcohol – how much is too much?
Guidelines for “healthy drinking limits”
◦ No more than 7 drinks per week
◦ No more than 3 drinks per occasion
◦ Women and all men over age 65
What about other drugs (opioids, benzodiazepines)?
◦ Any use with no therapeutic effect
◦ Use in combination with certain other meds or in certain illness
◦ Loss of control and craving

15. Prescription medications
Older adults account for 30% of all Rx drug use but only represent
13% population
Average 5.7 prescription meds / patient
2-4 OTC meds/vitamins/supplements / patient
Most medications are not specifically tested in elderly population
Chart diagnoses are present in fewer than 20% of elderly patients on
antidepressants and anxiolytics

16. How is Addiction defined?
- American Society of Addiction Medicine
Addiction is a primary, chronic disease of brain reward, motivation, memory and
related circuitry.
◦ Dysfunction … leads to characteristic biological, psychological, social and spiritual
manifestations … reflected in an individual pathologically pursuing reward and/or
relief by substance use and other behaviors.
Addiction is characterized by inability to consistently abstain, impairment in
behavioral control, craving, diminished recognition of significant problems with
one’s behaviors and interpersonal relationships, and a dysfunctional emotional
response.
◦ …addiction often involves cycles of relapse and remission.
◦ Without treatment or engagement in recovery activities, addiction is progressive and
can result in disability or premature death.

17. DSM V Substance Use Disorders:
Pathological behaviors in 4 domains
1. Impaired control
2. Social impairment
3. Risky use
4. Pharmacological indicators (tolerance and withdrawal)

18. DSM V Substance Use Disorder Criteria
2 of 11 symptoms in past 12 months
IMPAIRED CONTROL:
•Consuming more alcohol or other substance than originally planned
• Worrying about stopping or consistently failed efforts to control one’s use
• Spending a large amount of time using drugs/alcohol, or doing whatever is needed to obtain them
SOCIAL IMPAIRMENTS:
• Use of the substance results in failure to “fulfill major role obligations” such as at home, work, or
school.
• “Craving” the substance (alcohol or drug)
• Continuing the use of a substance despite health problems caused or worsened by it (mental health,
psychological or physical health.
•Continuing the use of a substance despite its having negative effects on relationships with others (for
example, using even though it leads to fights or despite people’s objecting to it).

19. DSM V Substance Use Disorder Criteria,
cont’d
RISKY USE:
•Repeated use of the substance in a dangerous situation (for example, when having to
operate heavy machinery or when driving a car)
• Giving up or reducing activities in a person’s life because of the drug/alcohol use
PHARMACOLOGIC INDICATORS: Tolerance and Withdrawal
• Building up a tolerance to the alcohol or drug. Tolerance is defined by the DSM-5 as
“either needing to use noticeably larger amounts over time to get the desired effect or noticing
less of an effect over time after repeated use of the same amount.”
• Experiencing withdrawal symptoms after stopping use. Withdrawal symptoms typically include,
according to the DSM-5: “anxiety, irritability, fatigue, nausea/vomiting, hand tremor or seizure in
the case of alcohol.”

20. Dependence:
Simpler Definition
Three C’s...
Compulsion to Use
Loss of Control
Negative Consequences

21. Adding other drugs to the mix
Finnish study of 1,000 fatal alcohol overdoses:
• median BAC 0.33% with alcohol alone
• Lower median BAC 0.13%- 0.27% for alcohol combined with a variety
of Rx medications
In 2010, alcohol was involved in:
• 18.5% of ED visits for opioid overdose
• 27.2% of ED visits for benzodiazepine overdose
• 22.1% of opioid overdose deaths
• 21.4% of benzodiazepine overdose deaths

22. Combining alcohol with other drugs
Alcohol, by itself, can shut off
vital reflexes in the medulla and
pons and cause death.
Combining alcohol with
benzodiazepines and narcotic
pain medications increases the
risk of overdose deaths.

23. SBIRT – start with screening
SCREENING
• Universal – New patients, “annual exams,” and red flags
• AUDIT-3
BRIEF INTERVENTION
• Simply asking about use makes a difference
• Assess Stages of Readiness for Change
• Utilize Motivational Interviewing style to increase engagement
REFERRAL TO TREATMENT

24. Annual Screen
Keep it simple!
Staff initiated
New patient
“Annual exam”
Red Flags

25. Annual Screen - AUDIT 3

26. Annual screen, continued

27. What is Motivational Interviewing?
It is a person-centered counseling
style for addressing the common
problem of ambivalence about
change.
Miller and Rollnick, 2013

28. Ambivalence: a normal stage in
the change process

29. Characteristics of Motivational Interviewing
◦Collaborative
◦Goal-oriented
◦Accepting and Empathetic
◦Evokes the patient’s own reasons for
change
Miller and Rollnick, 2013

30. Contrasting MI and ‘Traditional’ interactions
MI
Collaborative
Strengthen internal
motivation
Patient’s reasoning
based on their situation
and values
Primary strategy uses
experiences and
resources of the patient
TRADITIONAL
Directive/Prescriptive
Persuade/externally
motivate
Considers only
medical rationale
Patient depends on
provider for strategy
and resources
Approach
Motivation
Reasoning
Strategy

31. Worst Case Scenario When We Take the Wrong Roles in
the Treatment of Chronic Diseases
When the Doctor assumes
responsibility for change
When the Patient focuses on the
medical aspects
• Excess focus on medical options
• Overprescribing, overtesting
• Polypharmacy and side effects
• Resentful towards patients that are
‘noncompliant’ or ‘unfixable’
• Placation and avoidance
• Frustrated and Helpless
• Excess focus on testing,
medications, and the “next new
treatment”
• Passive Involvement
• Disease progresses and
medications escalate
• Surgeries occur that might have
been prevented
• Frustrated and Helpless
MI offers a language that helps to set the roles straight

32. Four Processes in MI
Miller and Rollnick, 2013
Engaging
Focusing
Evoking
Planning

33. What is Empathy?
Understanding or feeling another person’s
experience
We can reflect this by noticing what they
are:
◦ Saying (verbalizing)
◦ Showing (affect)
◦ Hinting (implied)

34. Empathy Effect
Miller et al, 1980
Miller & Baca, 1983
Counsel in a reflective,
empathic manner—
Resistance decreases
Change talk increases
Counsel in a directive,
confrontational manner—
Resistance increases
Change talk decreases Patterson & Forgatch, 1985
Miller et al. 1993

35. Spirit of MI
Collaboration
Acceptance
Evocation
Compassion

36. Spirit of MI: Acceptance
Acceptance
Absolute
Worth
Autonomy
Accurate
Empathy
Affirmation

37. Change
Talk Strategies
Skills: OARS
Open ended questioning
Affirming
Reflective Listening
Summarizing
Style and Spirit:
Empathy, Acceptance, Evocation,
Collaboration, Compassion
Berg-Smith Training 2013, Adapted from Miller and Rollnick, 1991-2013

38. The Way Out of Ambivalence
◦ Ready
◦ Willing
◦ Able

39. Willing: Importance of Change
Discrepancy between current behavior and a value or goal
determines importance of change.
Develop discrepancy and willingness to change increases.

40. Able: Confidence to Change
If people are willing to change, they then need effective
avenues for change.
Building self-efficacy builds confidence in change.

41. Ready: Prioritizing Change
A behavior change needs to move up the hierarchy of
importance.
Dealing first with other life needs,
allows a behavior change to be given
more priority.

42. Recognizing Change Talk

44. and Elicit – ChangeTalk
D A R N - CAT
Desire to change:

45. D A R N – C A T
Ability to change:
“ I could …”

46. D A R N – C A T
Reasons to change:

47. D A R N – C A T
Need to change:

48. Encourage & Reinforce Change Talk
D: desire -- Want, wish, like
A: ability -- Can, could, able
R: reason -- Specific reason for change
N: need -- Need to, have to, must, important
COMMITMENT LANGUAGE PREDICTS CHANGE
C: commitment — Will, intend to, going to
A: activation — Ready to, willing to (w/o specific commitment)
T: taking steps — Report recent specific action toward change
Amrhein et al., 2003
DARN CAT

49. Why Pharmacotherapy?
• Withdrawal management
• Relapse prevention
• Cognitive enhancement
• Treatment of complications – Hep C, HIV, cirrhosis, MCI
• Treatment of co-morbidities

50. Pharmacotherapy for Addiction
• Alcohol dependence – Naltrexone, acamprosate, Antabuse
• Opioids – buprenorphine, methadone
• Nicotine – nicotine replacement, bupropion, varencline
• Cocaine - ?
• Other meds – antidepressants, mood stabilizers,
antipsychotics

51. Meds which increase risk
• Benzodiazepines
• Sleep enhancers
• Stimulants

52. Referral to Treatment
Things to Avoid:
Refer to peer support alone
Simple referral
Treat concurrent disorder
alone
Abstinence as only outcome
Be careful about groups
Things to Learn:
Brief Intervention and Referral
Management
CBT or other evidence based
therapy
Patients may have their own
goals
Toxicity is often dose
dependent

53. Key Principles
• Greater need for structured treatment settings
• Closer monitoring, slower process overall
• Integrated care
• Long term follow up

54. Final Points
• Screen for Substance Use Disorders is important across the
lifespan
• Challenges with “entrenched” use of alcohol, prescription
drugs
• Illicit drug use doesn’t necessarily “burn out” or “die off”
with aging
• Universal screening, brief intervention and MI strategies
are useful tools to learn and use

55. … I get by with a little help from
my friends
THANK YOU!