Transcript The Silver Tsunami - Georgia School of Addiction Studies

Oxycontin With a Whiskey Chaser:
Understanding and Addressing Substance Use
Disorders and Related Co-Morbidities
in Older Adult Populations
Dr. John Dyben
DHSc, MA, MS, MCAP, CMHP
Clinical Director, Hanley Center at Origins
Conclusions
• The older adult population is growing
• Substance abuse and chronic pain are common
and have a synergistic effect when co-occurring.
• These problems are under recognized
• Screening and assessment imperative
• Treatment for this problem must be specialized
Our Relationships with
Mood Altering Substances
Essentially all persons in our culture have one of five “relationships” with moodaltering substances (alcohol and other legal drugs, illicit drugs, prescription drugs).
These are (in order of severity of risk and potential pathology):
Abstinence
Non-addiction
Dependence
Use
Abuse
Addiction
4
What is Addiction?
“…a primary, chronic, neurobiologic disease
with genetic, psychosocial, and environmental
factors influencing its development
and manifestations. It is characterized by
behaviors that include one or
more of the following: impaired control over
drug use, compulsive use, continued use
despite harm, and craving.”
AAPM, APS, ASAM
Liaison Committee on Pain and Addiction (2001)
5
What is Addiction?
“…often is characterized by the 5 C’s”
Chronic disease
Impaired Control over use
Compulsive use
Continued use despite harm
Craving
AAPM, APS, ASAM – Liaison Committee on Pain and Addiction (2001)
Older Adults & Substance Abuse
• Common problem amongst older adults
• Less likely to be recognized or addressed
• Correlates with hip fractures and dementia
• Causes and exacerbates health problems
Older Adults & Chronic Pain
• Chronic pain is a “complex physical and
psychological phenomenon lasting longer than
three months, which may not have an
identifiable cause.”
• Chronic pain impacts:
▫ Up to 50% of community-dwelling older adults.
▫ Up to 80% of nursing home residents.
Stewart, Schofield, Elliott, Torrance & Leveille (2014).
Caron Survey
• Survey of 1000 persons aged 35-50 w/ parents 60+
• 51% believe substance abuse not a growing problem
for adults 60+
• 87% expect that physicians will fully explain proper
use and side effects of drugs before prescribing.
• 37% believe that alcohol use is not a problem in
conjunction with use of prescription medications.
Alcohol Abuse
Alcohol Abuse
• More than 2.8 Million older adults today
• Expected to double by 2020
• Number one drug of choice for older adults
• AGA recommends annual screenings
Prescription Drug Abuse
Prescription Drug Abuse
• More prevalent in older adults
▫ Increased access
▫ Multiplicity of medications
• Hard to nail down prevalence. 1%-26%
• >65 = 13% of population; but 1/3%+
prescriptions
Illicit Drugs
• Estimated 4.8 million
older adults in 2010
• Marijuana by far
most common illicit
drug of abuse.
• The face of drug
abuse is changing!
Chronic Pain & Substance Abuse
• Both are neurobiological conditions with evidence of
disordered CNS function.
• Both are mediated by genetics and environment.
• Both may have significant behavioral components.
• Both may have serious harmful consequences if untreated.
• Both often require multifaceted treatment.
(SAMHSA, 2011)
Chronic Pain & Substance Abuse
• Risks associated with long-term opioid
treatment of chronic pain include:
▫ Tolerance
▫ Dependence
▫ Hyperalgesia
▫ Addiction
17
Copyright Thomas L. Purcell, M.D.
Physiology of
The Older Adult
18
Body Composition
Older Adult:
• Less water
• Less muscle mass
• More fat
Total Body Water:
• Average adult male 58% TBW
• Average adult female 48% TBW
• Average older adult 43% TBW
Total body water includes:
•
•
•
•
Blood
Extracellular fluid
Intracellular fluid
Cerebral – spinal fluid
Copyright Thomas L. Purcell, M.D.
19
Copyright Thomas L.
Purcell, M.D.
Pay Attention to the Signs
• Abnormalities in bloodwork
• Unexplained changes in sleep or behavior
• Unexplained injuries
• Decline in ADLs
• Fluid retention
Screening and Assessment
• CAGE
▫ Have you ever tried to Cut down on your use?
▫ Have you been Annoyed by others’ concern?
▫ Have you ever felt Guilty about use?
▫ Have you ever needed an “Eye opener”?
Screening and Assessment
• Michigan Alcohol Screening Test – Geriatric
▫ MAST-G
▫ 24 question, self-report
• Simple screening for Benzodiazepine abuse
▫ “Have you noticed decrease effectiveness?”
▫ “Have you tried to stop?”
Treatment Needs of Older Adults
Treatment Needs of Older Adults
• Physical needs
▫ More likely to have 2+ chronic medical conditions
▫ More likely to have severe physical impairment
▫ Slower metabolism
▫ Detox and treatment will take longer
Treatment Needs of Older Adults
• Psychological Needs
▫ Depression, anxiety, dementia
▫ Relevant approaches:




Practiced physical activity
Cognitive Behavioral Therapy
Problem Solving Therapy
Interpersonal Therapy
Treatment Needs of Older Adult
• Social Needs of Older Adults
▫ Major Changes
 Changing social status
 Deaths of loved ones
 Changes in social support
• Social environment influences use
Treatment Needs of Older Adult
• Social Needs of Older Adults
▫ Treatment should:
 Support long-term social
support systems
 Be age specific
 Be cohort driven
Treatment Needs of Older Adult
• Spiritual Needs
▫ Most significant predictor of healthy adjustment
▫ Socially supportive spiritual practices
▫ Reframe past and current struggles
▫ Not necessarily religious but may be
Treating Chronic Pain
•
Chronic pain is both individual and
subjective. Pain that may be manageable for
one person may be debilitating for another.
•
One important aspect of psychotherapy is
validation for the patient that the pain is
real and has far-reaching side effects.
•
Once that has been established,
psychotherapy can help people cope with
the daily effects of living with chronic pain.
Treating Chronic Pain
• The goal of psychotherapy in the treatment of
chronic pain will have two primary functions:
▫ Amelioration of pain by addressing
psychogenic properties.
▫ Development of skills for coping with
chronic pain that has primary biomedical
origin.
Treating Chronic Pain
• Psychotherapy can help people with chronic pain by:
▫ Coaching patients in behaviors that limit the
degree to which pain affects daily life.
▫ Developing strategies to encourage and reward
normal activities and discourage manipulative
behaviors.
▫ Encouraging thought patterns that give the patient
more control over mood and level of anxiety.
Treating Chronic Pain
• Psychotherapy can help people with chronic pain by:
▫ Developing strategies that increase the sense of
control the patient has over his or her life.
▫ Helping the patient develop social relationships
and a sense of self-worth to combat isolation and
pain-related depression.
Treating Chronic Pain
• Cognitive Behavioral Therapy
• Behavior Modification
• Meditation/Mindfulness/Yoga
• EMDR/Biofeedback/Neurofeedback
• Pharmacological Interventions
Generational Cohorts
• Groups of people born within a given time frame
• Experienced common events
• Lives shaped by formational experiences
• Effects remain through lifespan
• Relevant for cultural awareness
The Good Warriors
• Born 1908 to 1929
• World War II
• The Great Depression
• Prohibition
• Institutional authority trusted
The Baby Boomers
• Born between 1946 to 1964
• Vietnam
• Civil Rights Movement
• “Sex, Drugs, & Rock and roll”
• Institutional authority feared and distrusted
Conclusions
• The older adult population is growing
• Substance abuse and chronic pain are common
and have a synergistic effect when co-occurring.
• These problems are under recognized
• Screening and assessment imperative
• Treatment for this problem must be specialized
References
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• Arean, P. (2012). Psychotherapy for late-life depression. Psychiatric Times,
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• Ariyabuddhiphongs, V. (2012). Older adults and gambling: A review.
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• Berkowitz, E. N., & Schewe, C. D. (2011). Generational cohorts hold the key
to understanding patients and health care providers: Coming-of-age
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• Bogunovic, O. (2012). Substance abuse in aging and elderly adults.
Psychiatric Times, 29(8), 39-40.
References
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References
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References
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References
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Images
• All images used by permission of Dollar Photo
Club and downloaded from dollarpotoclub.com
Questions?
Dr. John Dyben
Hanley Center at Origins
[email protected]
originsrecovery.com
561-841-1254