Transcript Never Too Old – Older People and Substance

NEVER TOO OLD –
OLDER PEOPLE AND
SUBSTANCE MISUSE
SCOTTISH DRUGS FORUM
GLASGOW
18 November 09
Professor Ilana Crome
Keele University Medical School
Chair, WG Older Substance Misusers, RCPsych
Immediate Past President Drug and Alcohol
Section, European Psychiatric Association
Dr Alex Baldacchino
Director Centre for Addiction Research and
Education Scotland (CARES)
Ninewells Hospital and Medical School
Dundee University and NHS Fife
Overview
• Prevalence and epidemiology
• Treatment evidence and outcomes
• Practical interventions
Substance misuse is:
MYTHS ABOUT ADDICTION
AND OLDER PEOPLE
• At your age what does it matter?
• It is just a phase - you grow out of it.
• It’s your age – there is nothing you can do about
it.
• Illicit drug use: no longer a young man’s disease?
• Drug use and the older person – a contradiction
in terms?
Cannabis case
grandmother is
spared prison
Projecting drug use among aging
baby boomers in 2020? (Colliver et al 2006)
>50 years old
1999/2001
2020
Past year
marijuana users
Any illicit
1% (719,000)
2.9% (3.3 m)
2.2% (1.6 m)
3.1% (3.5 m)
Non-medical use
1.2% (911,000)
2.4% (2.7 m)
Prevalence
A snap shot of
general population studies and
clinical studies
Some methodological issues
• Invisible epidemic – ageism, denial by professionals
and families, stereotypes, difficult diagnosis, nonspecific
• Age varies from <55->75 – alcohol metabolism
declines with age and results in greater damage
• What is a standard drink or ‘safe limit’ for older
people?
• Other drug use: prescribed, OTT, interactions
• Terminology: application of use, misuse, dependence
• Medical complications without being ‘dependent’
Some methodological issues
• Gender: women metabolise faster; more severe
effects earlier or lower levels of drinking; present
later; more comorbidity especially abuse
• Measurement: relevant, reliable, across
substances and in combination
• Comparability between studies - Community
studies miss out heavier drinkers
Is it a problem for older people?
• Receive most prescriptions dispensed by NHS
• Multiple medications – 1/10 receive at least one
potentially inappropriate drug – (up to 40%) (LechevallierMichel et al 2004)
• 4 times greater in women (widowed, less educated,
lower income, poor mental and physical health, social
isolation)
• Psychoactive medications with abuse potential are
being used by 1 in 4 older people (Simoni & Yang 2006)
Is it a problem?
• Over the last ten years there has been an overall
increase (numbers and rate) in older people
• Using illicit substances and alcohol
• Hospital admissions for poisoning, drug related
mental disorders, alcohol related physical
disorders
• Drug related deaths and alcohol related deaths
• Usually men > women, older usually use less
Is it a problem?
• Opiate dependent people do survive into old age
• USA: Lifetime prevalence rates for illicit drug
dependence is 1% over 60s (Hinkin 2002)
• Alcohol consumption in GP (Hajat et el 2004) 5% men
drinking 2.5% women over benchmarks
• Older opioid maintained patients Lofwall et al 2005 later in
life, more medical problems, worse general health than
younger
• Both groups had high rates of lifetime psychiatric
illness and substance use disorder and poor general
health compared to general population
Health conditions among ageing
addicts Hser et al 2004
• 108 survivors 58.4 years (33 year cohort)
• Used heroin for 29.4 years
• Current use : 84% used cigarettes, 17.6% drank
alcohol daily, 23% heroin, 21% marijuana, 11%
cocaine. 6% amphetamines
• 51% hypertension, 22% hyperlipidemia
• 13% elevated blood glucose, 50% overweight
• 33% abnormal pulmonary function
Health status
• 50% abnormal liver function
• 94% tested positive for Hep C, 86% for Hep B,
3.8% for syphilis and 27% for TB
• Perceived themselves as having worse physical
functioning, worse emotional well being, less
energy and worse general health when compared
to the general population
• Probably conservative estimates
Older opiate addicts (Sidhu et al
2007) Health Problems
Results: Profile of Older Opiate
Misuser in Stoke-On-Trent
• Age range >50 years
• 95% of cohort were white Caucasian males
• 85% were single at time of study; 50% had
separated/divorced by age 35yrs.
• Limited education: 65% had no qualifications;
30% had between 4-9 ‘O’ levels.
• 90% were currently unemployed; 10% have
never been in employment.
Results: Substance Misuse History
• Lifelong polydrug users:
Licit drugs: Nicotine (100% of cohort)
Alcohol (47%)
Illicit drugs: Cannabis (75%), Amphetamines
(60%), Crack (50%), Hallucinogens (20%)
• Current substance use: Cannabis (55%), Crack
(35%) and Benzodiazepines (35%)
Results: Opiate Misuse History
• Opiate use was usually started in late 20’s
• Average age first exposed to heroin 29.8 years
(range 16-46 years: SD=8.8years)
• Average length of heroin use 18.5 years (range
6-38 years; SD-8.7years)
• In 20% of cases a major life event had occurred
prior to using heroin
Results: Diverse Range of Health
Problems
•
Special health needs highlighted
Present in study
in national guidelines
Infectious disease
• Hepatitis C
√ (67%)
• Hepatitis B
√ (50%)
• HIV
X ( 0% - only 10% tested)
Medical
• Respiratory disease
√ (25%)
• Diabetes
√ (10%)
• Not mentioned
Musculoskeletal pain (35%)
Health problems
• Special health needs highlighted
in national guidelines
Cardiovascular
• P.E./D.V.T
• Hypertension
information)
• Cardiac valve destruction
documentation)
Psychiatric
• Self harm
• Depression
• Memory loss
Present in study.
√ (25%)
X ( 0%) (Inadequate
X (0%) (No
√ (42%)
√ (40%)
√ (25%)
Special health needs
• Despite the complaint of memory loss in 25%
of cohort, in only 1 patient was mini mental
state examination documented.
• 40% sample with a respiratory complaint did not
have a diagnosis or treatment plan.
• 55% of cohort had no documentation of
Hepatitis B and C status.
• 15% sample were receiving opiate analgesia for
musculoskeletal pain.
Results: Treatment Outcomes
• Positive outcomes
– Methadone maintenance programme: 50% in treatment for
over 3 years.
– The present mean average dose was 51mls of methadone, but
range of doses varied between 25mg/ml-94mg/ml.
– All reported reduction in quantity of heroin used
– In 60% of the group who were using £300/week prior to
treatment, amount spent reduced to £20/week.
– Reduction in intravenous administration whilst in treatment
(70% to 5%).
• Negative outcome
– Only 22% showed consistently negative opiate urine samples
in the previous 6 months.
Discussion
• This is the first study of this kind in the UK
• Treatment is associated with positive outcomes
• The older substance misuser has a diverse range of
health problems i.e. physical and psychiatric
• All special health needs may not have been identified as
there was no routine screening
• Where they identified, they were
– Not appropriately further assessed & investigated &
monitored
– Not treated by a comprehensive multidisciplinary team in
liaison with other health practitioners
Conclusions
• Study has substantiated the special health needs
which older substance misusers experience
• Current national guidance does not provide
evidence based management specific to older
opiate users
• UK guidance appropriate for this group needs
further development in terms of4:
– Screening & assessment
– Specific treatment regimes & medication licences
– Service delivery in multidisciplinary teams (e.g.
geriatricians, old age psychiatrists, psychologists,
physiotherapists)
Recommendations: Good practice –
clinical governance issues
• Supportive non-confrontational by trained
personnel who can prevent ridicule
• Inaccessible: homebound, transportation, rural
• Create a safe environment, financial problems
• Explanations simple, content age specific, pace
• Literacy and language, and sensory, needs
Recommendations: Good practice
• Implementation of ‘what works in adults’
• Adaptation - addiction and old age services
• Evidence base for the older age group: length, dosage,
type of intervention
• Development of protocols and care plans
• Innovation
• Flexible, adaptive, optimistic and long term
Recommendations: Assessment
• A thorough, ongoing assessment which
includes a comprehensive history
• Many tools for screening, assessment and
monitoring outcome but for adults
• Neurocognitive impairment
• Semi-structured interviews increase
identification
• Severity of substance use, misuse and
dependence.
• Substance use and mental disorders
Assessing elderly patients (Parker,
Hospital Doctor 26 4 07, and Crome personal
communication!)
• Guard against clinical ageism: not an indicator of ability
to function, benefit from treatment, quality of life
• Comprehensive geriatric assessment is key to effective
practice
• Functional assessment is a useful clinical tool
• Geriatric medicine oriented towards problems (but
must not neglect diagnosis)
• Don’t write ‘poor’ historian: consider reasons for poor
history eg hearing aid, confusion
Recommendations
• Social admission is a myth and not a medical
diagnosis
• Understand ‘geriatric giants’: falls, confusion,
decreasing mobility, incontinence, (iatrogenesis,
frailty)
• Manage underlying cause
• Learn to recognise delirium
• Drug therapy is often the cause of symptoms
Instruments
• G-MAST - Geriatric version of MAST >5 positive
{MAST, SMAST, B-MAST (Michigan Alcohol
Screening Test)}
• SMAST-G shorter version of the G-MAST
• CAGE - 4 questions >2 positive (Hinkin 2002)
• Alcohol related problems survey for older people
(ARPS) and Short ARPS (shARPS)
• AUDIT (Alcohol use disorders test) or AUDIT -5
(Philpot et al 2003)
• MAST-G and CAGE most appropriate Beullens et al 2004
• NO VALIDATED INSTRUMENTS FOR DRUG
MISUSE
Recommendations: Critical issues in
treatment
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What is an appropriate treatment goal?
What is motivation for psychological change?
Regularity and credibility of medical advice?
How appropriate are techniques for assessment,
advice, assistance? IT, telephone, larger print
 Ask Assess Advise Assist Prescribe Arrange!
 Adequate fluids, eating as soon as possible
 Anti-epileptics and anti-emetics – rarely required
NICE guidelines and others
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Psychosocial interventions
Opioid detoxification
Methadone and burprenorphine
Naltrexone
Community interventions in vulnerable substance misusers
Department of Health ‘Orange’ book 2007
SIGN guidelines – Scotland
By and large comorbidity and vulnerable age groups are
excluded
Pharmacological treatment
Medication
Licensed
Age limits
Specific old age
Diazepam
Alcohol
withdrawal
Not in children
<half adult dose
In anxiety
Chlordiaze-poxide Alcohol
withdrawal
Not in children
< half adult dose
for anxiety
Disulfiram
Alcohol deterrent
Not in children
None
Methadone
Opiate addiction
Not in children
Caution
Subutex
Opiate addiction
>16 years
None
Lofexidine
Opiate detox’n
Not in children
Caution
NRT
Nicotine
withdrawal
> 18 years
None
Bupropion
Smoking cessation > 18 years
Caution
Pharmacological treatment
options
• Drugs not investigated/licensed for over 65s
• Benzodiazepines – caution due to accumulation
but need to give enough to cope with
withdrawal
• Acamprosate, disulfiram and naltrexone with
utmost caution
• Methadone and buprenorphine supervised
• Nicotine replacement and bupropion if not C/A
OUTCOME STUDIES
OLDER PEOPLE
Do older people recover?
Systematic Review of
Treatment for Older People
Substance Problems
Ishbel Moy
Martin Frisher
Peter Crome
Ilana Crome
School of Medicine and School of Pharmacy
Keele University
Search Strategy
• Search conducted May/June 2007, information from each
study collated and tabulated, report written June/July 2007
• PubMed, The Cochrane Library, MEDLINE, Project CORK,
and EMBASE searched up to January 2007
• Studies generated from expert consensus papers or advisors
• Keywords included: elderly; older people; addiction;
substance misuse; substance abuse; treatment; alcohol;
nicotine; smoking cessation; prescription medications;
benzodiazepines; illegal drugs; illicit drugs
Inclusion Criteria
1 Older defined as 50+ years.
2 Substances:
- alcohol
- nicotine
- prescription medications
- illicit drugs
3 Trials focussing on ‘older’ people specifically
4 Trials comparing older with younger
5 Pharmacological and psychological treatments for addiction
Studies Included
• 2500 titles generated.
• 50 studies thought to be appropriate and full articles
obtained.
• 16 studies fulfilled inclusion criteria:
- 9 on alcohol misuse
- 2 on treatment of alcohol and drug misuse
(grouped with alcohol misuse for analysis)
- 3 on smoking cessation
- 1 on methadone maintenance
- 1 on prescription medications
Evidence - Review of 16 studies on
older substance misusers
• Current evidence based guidance does not
include over 50s
• Mainly alcohol (11); smoking (3); opiates (1) and
prescription drugs (1) in over 50s
• 2 studies in the UK
• Some in services for older people; some in
mixed age services
• Almost all treatments were variety of
psychological interventions
Results
• Time period: 1984-2001; 14 of these after 1990.
• Country: 13 in US, 2 in UK, 1 in Canada.
• Settings: 5 studies conducted in primary care, 4 in
outpatient setting, 1 inpatient
• Sample size: 24 to 3,622; some of the larger
studies had a relatively small proportion of adults
in ‘older’ age range.
• Demographic information:
- Age cut-off for ‘older’ varied, from 50+ years and
65 + years.
- Majority of participants in 14 studies were male;
other 2 were 93% and 100% female.
- 6 studies >70% Caucasian participants.
• Ethics approval: 6 studies described ethical
approval or exemption.
Results
• Measures:
- e.g. baseline: quantity/frequency; time-line
follow-back; addiction severity index (ASI);
Beck Depression Inventory; physical and
psychiatric problems.
- e.g. outcome: ASI; abstinence; drinks/day;
health status; formal/informal aftercare
Results
Design: 5 studies contained a control group.
Programmes:
• Elder-specific programs or examined older
patients in 7 studies
• Older patients treated in adult addiction
programs and compared with younger age
groups in 8 studies
• 1 compared outcomes of older adults in both
elder-specific and adult addiction programs.
Overview of Study Findings Alcohol
Number of patients who achieve their follow-up goal is at
least comparable to that of other populations.
.
Those patients in elder-specific treatment appear to
improve across a wide variety of outcome domains.
Brief Advice and Motivational Enhancement are equally
successful for both older and adult populations.
Overview of Study Findings Alcohol
Potential for good outcomes in those older people who seek
treatment; possible they may have achieved even better
outcomes in an elder-specific program.
Both older men and women are capable of achieving
abstinence if given access to alcohol abuse programs.
Value in treating older adults and that they are able to
respond positively to treatment, but that there was a lack
of knowledge on long-term management.
Overview of Study Findings –
Smoking, Heroin, Prescription
Medications
Smoking:
Intervention with the nurse practitioner led to a decrease in smoking.
Older smokers appeared to benefit as much as younger smokers from
brief office-based counselling.
.
Heroin:
Older patients might have fewer problems and do very well in
treatment for heroin dependence.
Prescription Drugs:
Participation was associated with a significant reduction in
benzodiazepine, narcotic and overall prescription use; the reduction
in health care utilisation observed may translate to savings in health
care costs.
THE WAY FORWARD – the
ABC……
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Advocacy, attitudes
Better, appropriate treatment
Care, risk, resilience, recovery
Dignity, integrity, quality
Enthusiasm for evidence
Further research
Generational training,
partnership working
• High priority: value older
people…………
Thanks to colleagues
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Dr Roger Bloor
Prof Peter Crome
Drs Ishbel Moy & Harvinder Sidhu
And many other collaborators…sorry not to
mention by name