Farley Lecture Series             March 23, 2012Older Adults and Addiction            Michael Weaver, MD      Division of ...
Objectives Addiction in Older Adults Screening and Brief Intervention Addiction Treatment with Older Adults Conclusion...
What percentage of older adults (over age 65) are affected by alcohol and prescription drug            abuse? A.   5 B. ...
Prevalence reduced with age   Rates of illicit drug use    drop among older    cohorts   Addiction problems    resolved ...
The Age Wave is cresting             First ‗Baby Boomers‘              just turned 65             This generation used  ...
Alcohol abuse in older adults   Community    – Heavy use 3-25%    – Abuse 3-10%   Primary Care clinics    (>1 drink/day)...
Why is it under-diagnosed?   Selection Bias                     Under-recognized    – Surveys miss nursing              ...
Sensitivity to alcohol with age   Older adults more    sensitive to alcohol    – Reduced total body      water        Hi...
Drinking Guidelines                   Over age 65 years:                    – 1 standard drink/day                      f...
Psychiatric Co-Morbidity   Higher risk for              May present with    substance use among           complex clinic...
Gender differences Older men more likely  to have alcohol-  related problems Women develop  problems later in life    – ...
Late-onset alcoholism Makes up a third of older adults with drinking  problems Alcohol use associated with life losses  ...
Alcohol effects on older adults Rate of hospitalizations  of older persons for  alcoholism is ~1%   – Same rate of     ho...
Some Prescriptions with  Potential for Abuse                  More common                   among Older                  ...
Sedative-Hypnotics   Benzodiazepines    – Acute or generalized      anxiety    – Insomnia    – Seizures   Barbiturates  ...
Sedative misuse/abuse Self-medicate hurts,  losses, affect changes Older patients  prescribed more  benzodiazepines than...
Other Sleeping Pills   Bind to BZ receptor      Behavioral    subtypes                  pharmacological profile    – Zol...
Risky prescriptions: Sedatives   Problematic for    – Alcohol abuse    – Sedative misuse   Benzodiazepines    – Valium, ...
Opioid Painkillers        Short-acting               Long-acting   Tylenol #3 (codeine)                               MS...
Opioid misuse/abuse   Use pain med to sleep, relax,    soften negative affect   Dose requirement reduced    with age    ...
Risky prescriptions: Opioids               Problematic for older                adults who misuse                opioid a...
Prescription drug abuse        in older adults Reduced ability to  absorb & metabolize  meds with age Increased chance o...
Impact on        Healthcare Providers Medication misuse causes adverse health  consequences for patient Worsens prognosi...
Screening for addiction             High level of suspicion             Non-judgmental             Caring             ...
Why screen patients             for addiction?   Medical problems            Financial difficulties    – Cardiovascular ...
Screening makes a difference               Patients reduce                alcohol and tobacco                use when thi...
Screening Tool for                Alcohol Abuse   CAGE Questions    –   Cut down    –   Annoyed    –   Guilty    –   Eye-...
Screening in older adult               Collateral information                – Family                – Friends           ...
The 5 ―A‘s‖ ASK about alcohol and drug use ADVISE all patients to quit ASSESS willingness to change ASSIST patients in...
ASK about alcohol and drug use   Have you ever used …       When did it begin?    – Tobacco products         How often?...
Diagnosis of     Alcohol Abuse/Dependence   Continued substance use despite adverse    consequences Use in larger amount...
Brief Intervention   Motivate patients to    change problem    behavior   Multiple brief sessions   Bridge to treatment...
Patient Behavior   Ambivalence    – Attracted to problem      behavior (substance      use)   Denial    – Unable to admi...
Motivation        Probability of certain         behaviors        State of readiness to         change        May fluct...
Example techniques Amplify self-  motivational  statements A typical day Good things/less  good things
ADVISE all patients to quit A strong recommendation to change substance  use is essential "Based on the screening result...
Elements of Brief Intervention                  FRAMES                   –   Feedback                   –   Responsibilit...
Feedback   Present information to    client    – Based on history,      exam, labs, etc. Increase awareness  of adverse ...
Responsibility         Client has the          ultimate responsibility          for change         Practitioner can‘t   ...
Advice and Menu Give clear,  concrete advice to  change Give choices  (menu)    – 3 is ideal    – Making a choice is    ...
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    ...
Types of treatment          Detoxification          12-Step groups          Outpatient counseling             – Cogniti...
12-Step Groups           A.A., N.A., C.A.           Group format           Anonymous           No cost           No a...
Which of the following characteristics of attendees isthe best predictor of success in    Alcoholics Anonymous? A.   Male...
Success with 12-Step More groups=more  abstinence No threshold, but at  least 2  meetings/week best Not affected by    ...
Addiction Counseling   Motivational         Twelve-Step    Interviewing          facilitation   Network therapy      P...
Treatment in older adults   Focus on coping    – Depression, loneliness    – Losses   Rebuild social support    network ...
Treatment works         Sustained remission          rates of up to 60%          – Better success than            treatme...
Summary Older adults more sensitive to effects of  alcohol and drugs than younger patients Higher doses increase the ris...
Summary Encourage older adults to keep a  medication list and discuss prescription,  OTC, supplement and alcohol use with...
Questions?
Cases for Group Discussion
References Prochaska JO, DiClemente CC, Norcross JC: In search of  how people change: Applications to addictive behaviors...
References   Substance Abuse and Mental Health Services    Administration (SAMHSA): Results from the National    Survey o...
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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.

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Wmsbg 2012 Older Adults Addic

  1. 1. Farley Lecture Series March 23, 2012Older Adults and Addiction Michael Weaver, MD Division of General Medicine and Division of Addiction Psychiatry Virginia Commonwealth University School of Medicine
  2. 2. Objectives Addiction in Older Adults Screening and Brief Intervention Addiction Treatment with Older Adults Conclusions Practice Cases
  3. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 14. Some Prescriptions with Potential for Abuse  More common among Older Adults – Sedative- hypnotics – Opioids
  15. 15. Sedative-Hypnotics Benzodiazepines – Acute or generalized anxiety – Insomnia – Seizures Barbiturates – Insomnia – Headache – Seizures
  16. 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. 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. 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. 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. 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. 21. Risky prescriptions: Opioids  Problematic for older adults who misuse opioid analgesics  Try non-narcotic alternatives – NSAIDs – Anticonvulsants – NSRI antidepressants – Topical analgesics
  22. 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. 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. 24. Screening for addiction  High level of suspicion  Non-judgmental  Caring  Free of hostility  History-taking can be therapeutic
  25. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 35. Example techniques Amplify self- motivational statements A typical day Good things/less good things
  36. 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. 37. Elements of Brief Intervention  FRAMES – Feedback – Responsibility – Advice – Menu – Empathy – Self-efficacy
  38. 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. 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. 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. 41. Empathy  Listen carefully  Clarify client‘s meaning  Don‘t impose practitioner‘s values on client
  42. 42. Self-efficacy Build up client‘s belief in ability to succeed Be optimistic Simple goals early – Success breeds success – Increases self- confidence
  43. 43. Types of treatment  Detoxification  12-Step groups  Outpatient counseling – Cognitive-behavioral – Case management  Intensive outpatient  Inpatient  Residential
  44. 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. 45. Which of the following characteristics of attendees isthe 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. 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. 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. 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. 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. 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. 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. 52. Questions?
  53. 53. Cases for Group Discussion
  54. 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. 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

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