Transcript Substance Use, Abuse or Misuse in the Older Adult Population

Substance Abuse/Misuse and
Older Adults
Cori Robin, LCSW
Health and Aging
Rush University Medical Center
Illinois Elder Rights Conference
July 12, 2012 Session T14
Presenter Disclosures
We thank Retirement Research
Foundation’s generous support for
this project for two program years.
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Objectives
• Gain knowledge of current findings and prevalence of
substance use/misuse in older adults
• Understand risk factors that may influence this population’s
use/abuse/misuse
• Understand physiological differences with aging
• Learn about potential treatment efforts to imbed in current
workplace environment
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Rise in Older Adults
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13% of current U.S. population age 60 and older
Expected to increase up to 20 % by 2030
Each year more than 3.5 million Boomers turn 55
Individuals aged 85 and older are the fastest growing
segment of the population.
www.census.gov
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The Need for Change
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Social and human services are going to be overwhelmed with increase in older
adults
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Increased need for age-sensitive substance abuse and mental health prevention
and treatment
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Demand for Substance Abuse and Mental Health services is likely to increase
because the Baby Boom cohort tends to:
– use these services more frequently than current older adult cohort
– be less stigmatized by seeking services.
Blow & Barry, 2011
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Substance Use in Older Adults
• #1 Most common: Nicotine (~18-22%)
• #2 Alcohol (~2-18%)
• #3 Psychoactive Prescription Medications (~2-4%)
• #4 Other Illegal Drugs (marijuana, cocaine,
narcotics) (<1%)
Blow & Barry, 2011
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Levels of Drinking
World Health Organization Standards:
• Harmful drinking: Use of alcohol that causes complications
(includes abuse and dependence)
• Hazardous drinking: Use of alcohol that increases risk for
complications
• Non-hazardous drinking: Use of alcohol without clear risk of
complications (includes beneficial use)
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Drinking in Older Adults
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66% of men, 65% of women used alcohol
3% met full criteria for an alcohol use disorder
At-risk drinking was reported in:
– 17% of men, 11% of women ages 50+
– 19% of all respondents ages 50-64
– 13% of all respondents ages 65+
Binge drinking was reported in:
– 20% of men, 6% of women ages 50+
– 23% of all respondents ages 50-64
– 15% of all respondents ages 65+
Blazer & Wu, 2009a
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65+ age group binge on alcohol more frequently than any other age group
CDC, January 2012
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Substance Use in Older Adults
• Estimated one in five older adults may be
affected by combined difficulties with alcohol
and medication misuse.
• More patients 60 & older are admitted to
hospitals for alcohol connected problems than
for heart attacks
• About 1/4 of nursing home admissions occur
because the patient is unable to manage their
medications.
• Psychoactive medication use indirectly causes
up to 14% of hip fractures in older adults 60+
Hazlett and Schonfeld, 2011
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Prescription Medication Use
• Older Adults are the largest consumers of psychoactive
medications
• 85% of older adults take a prescription medication
• 76% use more than one medication daily
• Older adults constitute 13% of the population & use 1/3 of
the prescriptions
• 20% use tranquilizers daily
• Factors associated with prescription drug abuse in older
adults:
– female sex, social isolation, history of a substance-use or
mental health disorder, and medical exposure to
prescription drugs with abuse potential
Simoni-Wastila & Yang, 2006; Blow & Barry, 2011
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Prescription Medication Use (Cont)
• At least 1 in 4 older adults use psychoactive
medications with abuse potential
• By 2020, non-medical use of prescription drugs
among adults age 50 and over will increase
dramatically
• Older adults average 2-3 serious medication errors
per month
• An estimated 125,000 older adults’ deaths can be
attributed to medication noncompliance at a cost of
$100 billion in the US alone
Wolstenholme, 2011; Simoni-Wastila & Yang, 2006
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Interactions: Medication and Alcohol
Medications with significant alcohol interactions
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Benzodiazepines
Other sedatives
Opiate/Opioid Analgesics
Some anticonvulsants
Some psychotropics
Some antidepressants
Some barbiturates
Blow & Barry, 2011; NIAAA, 1998
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Physiological Aging
• Decrease in percent of body weight composed of
water
• Changes in digestion
• Changes in liver function
• Changes in kidney function
• Other medical factors associated with aging
(multiple medications, sensory issues)
Barry & Blow, 2004
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Medical Risks
1 or More Drinks per Day
Gastritis, ulcers, liver and pancreas problems
2 or More Drinks per Day
Depression, gout, GERD, breast cancer, insomnia, memory
problems, falls
3 or More Drinks per Day
Hypertension, stroke, diabetes, gastrointestinal diseases, cancer
of many varieties
Blow & Barry, 2011
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Signs/Symptoms
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Anxiety
Blackouts
Dizziness
Depression
Disorientation
Mood swings
Falls, bruises, burns
Family problems
Financial problems
Headaches
Incontinence
Increased tolerance to alcohol
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Legal difficulties
Memory Loss
Problems in decision making
Poor hygiene
Seizures
Sleep problems
Social isolation
Unusual response to
medications
Blow & Barry, 2011
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Unique Aspects with Older Adults
Medical & Psychosocial Issues with Aging
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Loss (loved ones, employment, driving, social or economic status)
Financial problems
Transitions in housing
Social isolation
Caregiving for loved ones
Complex medical problems
Multiple medications
Reduced mobility
Cognitive impairment or loss
Sensory deficits
Blow, 2007
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Risk for Psychiatric Illness
Older adults are three times as likely to develop a
mental illness with a lifetime diagnosis of alcohol
abuse.
Common “Dual Diagnoses” include:
• Depression (20-30%)
• Cognitive loss (10-40%)
• Anxiety disorders (10-20%)
Blow & Barry, 2011
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Barriers to Identification
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Assumptions with age
Lack of awareness
Difficulty in recognizing symptoms
Symptoms attributed to other causes
Cultural/social context
Many do not self-refer or seek help
Hazlett and Schonfeld, 2011
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Recommended Drinking Limits
Centers for Disease Control and Prevention:
• Drinking Limits: no more than one drink per day on
average for older men or less than one drink per day
on average for older women
• Binge drinking: drinking four or more drinks during a
single occasion (drinking day) for men or three or
more drinks during a single occasion for women
CDC, 2011
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Standard Drink
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SBIRT Intervention
Intervention to identify non-dependent substance use or prescription medication issues
and to provide effective service strategies prior to their need for more extensive or
specialized substance abuse treatment
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Prescreen quickly identifies older adults who use alcohol and/or the psychoactive
medications targeted for this intervention (opioid analgesics for pain and sedative hypnotics:
benzodiazepines and barbiturates for sleep, anxiety, nerves, agitation)
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Screening quickly assesses the severity of substance use and identifies the appropriate level
of education and/or treatment needed for the individual (primary prevention).
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Brief intervention focuses on increasing insight and awareness regarding substance use and
motivation for behavioral change (secondary prevention).
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Referral to Treatment provides access to specialty substance abuse assessment and care, if
needed.
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Six Month Follow-up uses same screening questionnaire and can help determine if clients
have changed their alcohol and/or psychoactive medication use, or need additional
assistance with their alcohol and/or psychoactive medication use.
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Prescreen Questions
1) In general, would you say your health is:
__ Excellent
__ Very Good
___ Good
2) Do you visit your primary care physician at least one time per year?
__ Fair
__ Poor
__Yes __No
3) Please review the list of medications on back of this page. During the past 3 months, have you used any of these
prescription medications for pain for problems like back pain, muscle pain,
headaches, arthritis,
fibromyalgia,
etc.?
__Yes __No
4) During the past 3 months, have you used any prescription medications to help you fall asleep or for anxiety or
for your nerves or feeling agitated?
__Yes __No
5) In the last 3 months, have you felt you should:
a. lose some weight:
___No
b. cut down or stop smoking:
___No
c. cut down or stop drinking:
___No
d. do more to keep fit:
___No
e. better manage medications:
___No
___Sometimes
___Sometimes
___Sometimes
___Sometimes
___Sometimes
___Quite Often
___Quite Often
___Quite Often
___Quite Often
___Quite Often
___Very Often
___Very Often
___Very Often
___Very Often
___Very Often
6) In the past 3 months, have you fallen or had a fear of falling?
__Yes
__No
7) In the past 3 months, have you had anything to drink containing alcohol (beer, wine, wine cooler sherry, gin,
vodka or other hard liquor)?
__Yes
__No
8) In the past 3 months, have you thought about changing any other things about your health?
Screening
• Screening Instruments
– Substance Consumption
– Substance Consequences
• CAGE, AUDIT, MAST, SMAST
• Older Adult Specific: MAST-G; SMAST-G
– Health Screening Survey
• Universal (not systematic) Screening
• Techniques
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Brief Intervention
After a positive identification of at-risk status, Brief Intervention
is conducted:
1. Identify future goals (related to physical/mental health, social
life/relationships, finances, etc)
2. Summary of health habits
3. Psycho-education on standard drinks, level of consumption and physical
changes with aging and substances
4. Types of older drinkers in U.S.
5. Psycho-education on interaction of alcohol and medications
6. Consequences of at-risk drinking or medication misuse (discuss positive
and negative effects)
7. Reasons to quit or cut down
8. Agreed-upon plan
9. Handling risky situations or triggers
10.Visit summary
Barry, Blow & Schonfeld, 2004
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Techniques of BI
Motivational Interviewing
Principles
Express empathy
Roll with resistance
Support self-efficacy
Develop discrepancy
Miller & Rollnick, 2002
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When Intervening with Older Adults…
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Avoid labels (i.e. addict, alcoholic)
Avoid confrontation or anger
Create a culture of respect
Acknowledge difficulty of behavior change
Create a safe environment
Avoid shaming language
Be non-judgmental
Focus on re-building coping skills and increasing support network
Connect use and symptoms
Connect behaviors and participants’ emotional responses
Relate alcohol and drug use-abuse issues to how it can effect health
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Sources
Barry, K.L., Blow, F.C. & Schonfeld, L. (2004). Health promotion workbook for older adults (adapted to include medication misuse).
Blazer, D.G. & Wu, L.T. (2009). The epidemiology of at-risk and binge drinking among middle-aged and elderly community adults: National survey
on drug use and health. American Journal of Psychiatry, 166, 1162-1169.
Blow, F.C. (2007). Substance abuse screening and interventions for older adults: Evidence-Based Approaches. Presented at American Society on
Aging, San Francisco, CA: June 21, 2007.
Blow, F.C. & Barry, K.L. (2011). Substance use disorders among older adults. Presented at SAMHSA/Substance Abuse Prevention Older Americans
Technical Assistance Center Training, Chicago, IL.
Get Connected! Toolkit: Linking Older Adults With Medication, Alcohol, and Mental Health Resources:
http://www.samhsa.gov/Aging/docs/GetConnectedToolkit.pdf
Hazlett, RW. & Schonfeld, L. (2011). The use and abuse of alcohol, drugs and prescription medication in vulnerable adults. 2011 Florida
Conference on Aging.
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people to change addictive behavior (2nd ed.). New York: Guilford Press.
Older Americans Substance Abuse and Mental Health Technical Assistance Center: http://www.samhsa.gov/OlderAdultsTAC/index.aspx
Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. (1998). Substance Abuse Among Older
Adults: A Guide for Social Service Providers. Treatment Improvement Protocol (TIP) Series 26. Department of Health and Human Services
Publication No. (SMA) 98-3179. Rockville, MD
Simoni-Wastila, L., & Yang, H. K. (2006) Psychoactive drug abuse in older adults. American Journal of Geriatric Pharmacothery, 4: 380–394.
Wolstenholme, B. (2011). Medication-related problems in geriatric pharmacology. Aging Well, 4(3), 8.
.
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Contact Information
Cori Robin, LCSW
Rush University Medical Center
(312) 942-6087
[email protected]
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