Good morning everybody. My name is Lou Treveson. I'm a clinical professor of psychiatry at Creighton University School of Medicine, also adjunct at Yale University where I was an addiction and geriatric psychiatrist for approximately 30 years. Today we're going to be talking about substance related and addictive disorders in older adults. I have no conflicts of interest to disclose for this presentation. The objectives will be to summarize the prevalence of substance use disorders in older Americans, identify the signs and symptoms of an older person with substance use disorder, and to be able to describe the evidence-based treatments for the older person with a substance use disorder. First, we'll talk a little bit about prevalence and we'll talk about definitions as well here. The group that we'll be talking about are baby boomers. We've been around for a long time. We were born between 46 and 64. I am a baby boomer. We will present with more substance use disorders and substance use treatment going forward. The use of the term of the age of 65 is an old definition to describe older Americans that may be somewhat arbitrary. Some people are not old when they're 75 and other folks are older when they're 50s and early 60s, so it's a gray line there. Perhaps a term like older adults is more appropriate and has been used more frequently in the current literature. I may switch back and forth between elderly, older, and geriatric. The information in the presentation is based primarily on people older than 50 or 55 years of age, even though that seems very young. There are occasionally people with medical problems and other issues that appear older at that age. The principal substance use by older Americans are all the usual suspects. Tobacco, of course, is still very big. Alcohol is big and growing in this group. Opioids is also a problem, including misuse. Even though that's not a quote politically correct term these days, misuse of prescription medications. Also, the use of illicit drugs is on the rise, including heroin, fentanyl, and other synthetic opioids. Stimulants and cocaine are still out there. Cocaine is less and stimulants are more. Cannabis, of course, has grown hugely with the legalization of that recently, now in almost 35 or 38 states. Other sedatives and muscle relaxants will also be touched on. Let's look at current cigarette smoking of adults in the United States. The highest group of smokers these days are among 25 to 44. The younger group is actually smoking less. The highest is also 45 to 64, which also includes some of the older adult generation. You can see from the numbers below that there are about 28.3 million current smokers of combustible cigarettes in the United States. This does not take into account the people who are vaping. About eight out of every 100 adults over 65 is somebody who still continues to smoke tobacco. This is a graph of the age groups that are the same as they are in the United States from Ireland, interestingly. You can see that the youngest, 15 to 17 or 18 years old, are lower. As you get into the 18 to 24 and up to the 45 to 54 and 55 to 64, it's fairly high and drops off as it gets older. The 45 to 64-year-olds are going to be moving forward. The rates of alcohol use in older Americans. Older adults have consistently had lower rates of alcohol use and high-risk drinking and alcohol use disorder over the past 40 years. Between 2000 and 2013, there's been huge increases in the number of people who use alcohol, who engage in high-risk or risky drinking, and who have been documented with alcohol use disorder. This may be part of just getting older, and it also may be related to the pandemic and COVID-19 issues with loneliness and isolation. This is a national poll of healthy aging from the University of Michigan. This is from, I think, 2020. It just gives you a snapshot of alcohol use in the past year for adults age 50 to 80. You can see that 67% of people actually drank some alcohol in the past year. You can see that 27% had six or more drinks on at least one occasion, and 23% had three or four drinks on a typical day of drinking, and then 20% drank at least four times per week. Alcohol is quite prevalent and continues to be quite popular, especially among older adults. The projections for alcohol use in older Americans. Older Americans will increase from 40 million in 2010 to 80 million in 2030. This should produce a substantial increase in the number of people, older adults with high-risk drinking and alcohol use disorder. Again, it may be exacerbated by the onset of COVID-19 and the pandemic lockdowns. Of course, this increased greatly. I think everybody's aware of the idea of increased loneliness, lack of access to personal medical care. Screening and substance abuse treatment is also hard to get to. Of course, there were virtual, just like this, inventions with Zoom meetings and virtual psychiatry and substance abuse treatment, but many older folks are not that savvy, including this one here, with technical things to do. It became more difficult for older folks. This is a slide that I found that shows the total opioid consumption of the G7 countries. It used to be the G8 countries, but I think Russia got expelled several years ago. This is the defined daily doses of opioids in a country per million inhabitants. You can see that the United States, starting in the late 90s, early 90s and mid 90s, zoomed to the top. We were down in the depths there with everybody else for quite a while. It's gone up in all of the modern Western economies, which is the G7 countries, but most notably in the United States, United Kingdom, Canada and Germany, but we were leading the pack and we continue to do that today. This is a slide that shows the national drug-involved overdose deaths, and it's from the Centers for Disease Control, and it shows you the three waves of what we call the opioid epidemic is now really a drug-involved overdose because it involves stimulants as well, but primarily it was originally driven by opioids, and you can see the heroin, which is the yellow line, was low for a while, and then gradually it was around 2% or so people were using heroin, and then it shot up in the mid-2010s primarily because people who were given prescription opioids were taken off. I've had many patients who were, you know, taken off by their primary care doctors and went to the street heroin, and then you can see in the blue line, which is synthetic opioids, i.e. fentanyl, parfentanil, now nidazine and others, and the gray line, the stimulants, are increasing, and they continue in the next up and through 2023 to be very difficult. This is another graph that shows the older adult overdose deaths were increasing at least through 2016, and you can see that 65 and over is pretty steady and low, but if you look at the 45 to 54 and the 55 to 64 groups, they're shot up incredibly high, and this is, of course, a national epidemic. Now, I wanted to touch base here with the NSDUH data just to talk about briefly how people get prescription pain relievers. What it shows is that most people, if you look at the gray area here in the pie chart, you know, get their misused prescription pain reliever or other misused medication from a friend or a relative. Neither buy it or bought it from or took it out of their medicine cabinet when they were visiting, and most of those people got it from a single doctor, so, you know, the idea that every person who is misusing pain pills is getting them from multiple doctors is not accurate. Most likely, it's more likely from one doctor and from a friend, and the main reason, you know, in the past year, in NSDUH 2018, and this remains constant throughout the time of the National Survey of Drug Use and Health is measured at SAMHSA. You know, most people take it because they want to relieve some physical pain. You know, there are a small group of people, you know, do it for the increase or decrease the effect of another drug, you know, or to relax or relieve tension, but most people take it to relieve physical pain. This is also another graph from National Survey of Drug Use and Health from earlier, but these remain constant through the current years that, you know, up to 44.5% of people in the United States were given prescriptions for psychotherapeutic use, and, you know, pain relievers were, you know, the most prominent, but it also includes lots of tranquilizers, which I think the benzodiazepines fell under, of course, stimulants and other sedatives. So, what is the definition of medication misuse? And so, this is important to know, and this means taking any extra doses, missing doses, not filling prescriptions, not understanding directions, or incorrect timing, and you might be able to see how older adults or older people might mess this up. As a matter of fact, I think most people, it's been my experience, don't necessarily take their medication the way the doctor prescribed, including yours truly. Risk factors, you know, include being female for medication misuse, social isolation, a history of substance use or other psychiatric disorder, of course, polypharmacy, and multiple prescribers. I'll talk a little bit more about that later. And then prescribed drugs with abuse potential, i.e. benzodiazepines or other pain relievers like OxyContin. And then, of course, most people have chronic medical problems, so this is a risk factor. The older prescription pain use disorder patient often has multiple medical problems, higher incidence of chronic pain, common mood disorders, misunderstands directions. So, it's a question of, you know, a misuse versus a use disorder, and then multiple prescribers get in there. And so, it's always important to be aware of that. Rationalization and denial among family members, peers, and carriers. Most doctors and family members can't believe that another family member, especially an older person, might be taking too much OxyContin, you know, or Percocet or Valium. And, of course, then there's also deficits that you see in the office if you're a caregiver are presumed due to age. So, that's sort of a barrier or a stereotype that providers may exhibit. Then there's also the interaction with alcohol and other drugs. And again, there's also another over-representation of females. I think the Rolling Stones said it in the 1970s when they called it Valium and Amphetamine's Mother's Little Helper, if anybody remembers that song. So, it was prevalent even back then. So, clinical pearls, you know, a recognizing misuse of prescribed medications. If you're dealing with an older adult, any symptom, almost any symptom that is presented should be considered a drug side effect until proven otherwise. So, I mean, have a keen sense for this going into your interview with the patient. Falls could be due to set of hypnotics or opioid pain meds. GI distress could be due to alcohol, incontinence, alcohol, sedative hypnotics. Constipation, of course, is a side effect of opioids. Depression, of course, alcohol and opioids. Anxiety, steroids. I mean, if anybody knows anybody that's on steroid daper, you can see what can happen to people. They get very anxious sometimes. And then also it could be due to alcohol withdrawal. And confusion could be due to any CNS active agent, including, you know, anticholinergic medications. And of course, insomnia could be due to medication misuse. This is a slide that shows that older adults between the ages of 50 and 64 abuse illicit drugs. And this is from 10 years ago. So, it's somewhat outdated. But these trends are continuing. And, you know, the percentage of older adults, you can see the older group, 50 to 54, is climbing way back here. And also the 60 to 64 year group. And of course, 50 to 59 is right in the middle. Still able to get around, still able to go out and solicit or try to get illicit drugs. This is a continuing problem. I have to mention cannabis. You know, it's a controversial substance these days as it's legalized recreationally and medically in the 35 or 38 states now. And then there are also, you know, Delta 8s and Delta 5 variants that are not necessarily illegal, yet you can still get the same effect from them. And you can see that, you know, the baby boomers, which were people 65 and older, you know, or between 50 and 64, you know, have all been using more and more cannabis. And this has caused lots of problems. You know, it is touted to have helped many people with sleep and with anxiety, but it also has, you know, contributes to confusion, to memory problems, to depression. And it is clearly on the rise in the older adult. And this has been borne out in NISARC and NISDA data. I want to talk a little bit about alcohol use disorder. And, you know, whenever you talk about alcohol use disorder, you want to talk about the age of onset. You know, there's early onset alcohol use disorder and there's late onset alcohol use disorder. And you would be thinking I'd just be talking about late onset since it's an older adult group that we're talking about. But most of, two-thirds of the older problem drinkers happen to be early onset alcohol use disorder folks. They're usually drinking alcohol before the age of 60. They usually have chronic alcohol-related medical problems. We've been able to keep them alive longer with medical care. They usually have a positive family history, more antisocial characteristics, have intractable, of course, get into legal problems, have serious psychiatric comorbidities, and particularly major effect disorders. So I worked at the VA for 30 years, and I can tell you that we kept lots of very severe early onset alcohol use disorder folks alive with continuously detoxing them safely and trying to get them into treatment. We always try to scratch our head about how can we improve it, but we may have been providing the, you know, the gold standard just by keeping them alive. And then there's late onset. Now, this is more commonly associated with older folks, though it's not the most common. But usually drinking starting after, or heavy drinking starting after 60 years old may have fewer psychological consequences, fewer psychological, physiological consequences, and also begin alcohol misuse after, they often begin after a stressful event like loss of a spouse, retirement, loss of a job. They usually have a more milder clinical picture, more emotionally stable. They may have better adherence to treatment and a lower recidivism rate, but they apparently, at least in one study by both, or two studies by Dave Oslin and Lemke back in the early 2000s, had a similar response to treatment. And this may possibly be due to the fact that as people get older, they start becoming much more aware of getting to the finish line, so to speak, and more motivated to try and control their drinking. And then I just wanted to review the psychosocial stressors of aging, which some of us have experienced, including role and status change, especially retirement. You know, all of a sudden having free time on your hands, if you've been a busy person, most of your life can be a little bit stressful after being first incredibly freeing, but then can become stressful. There's also income changes. Physical health decline is on the horizon. You can have cognitive changes, you know, not remembering people's names, not doing the usual things you do every day sometimes contributes to cognitive changes. Widowhood can be a big stressor. Shrinking social networks, and of course, the one that's, I think, the most damaging for most folks is if you have a loss of independence and become dependent on somebody else. This is very stressful. So in summary, you know, older populations of patients are changing. We're increasing the age cutoffs, but you have to consider people with medical factors and other life factors as an earlier age that to be more like an older adult. No longer defined by age, but more likely by health status and psychosocial factors. Older patients may also use different substances, including all the usuals right there. All right, screening and evaluation. Barriers to identification, I covered those a little at the beginning. You know, physician factors, patient factors, and diagnostic factors. I think I've covered some of this already, but, you know, clearly physician factors, you know, older adults don't get into trouble with drinking and using fentanyl and or abusing oxytocin. There's also a lack of knowledge about treatment still with primary care folks and ED folks. Patient factors include denial, shame, and guilt. You know, there seems to be a little bit more acceptance of a harm reduction approach to substance use disorder these days and less stigma, although it still remains quite big. But back in the day when the baby boomers were using these drugs and alcohol, stigma was a big deal, except perhaps for tobacco at the time. Diagnostic factors include comorbid medical conditions. We talked about that. Age-related changes may be, you know, attributed to age-related changes rather than to the drug or alcohol. So there may be fewer overordering signs, and the DSM criteria seem to be less applicable in the older adults. So I'm gonna talk a little bit about screening here for tobacco. You can see these four tests up here. These are primarily for research purposes. You know, tobacco, again, is not as stigmatized. I mean, there's, you know, we try to, you know, to stigmatize it, to get people to stop. But people, and lots of folks have stopped smoking combustible cigarettes. The best way to screen for smoking tobacco is to just ask the patient. Screening tests for alcohol use disorder in older adults. There's the Michigan's Alcohol Screening Test Geriatric version. There's a short version, which is a 10-question one, which is good. And then the audits and the CAGE and the Senior Alcohol Misuse Indicator, or SAMI. At the VA, where I worked, we primarily used the Audit C, which is the three-question one that you can have them fill out, or you can work with them with, and the CAGE. The nice thing about the Audit C is that it gives you a current assessment of how much somebody's drinking. And you can see that the evaluation, if you get a score of three or more points on questions one through three, or a report of drinking four or more drinks on one occasion, then that's reason to refer for a, or to do a more comprehensive assessment. The CAGE gives you a lifelong history of alcohol use disorder or alcohol risky drinking. And, you know, have you tried to cut down? Have you been, have you, anybody been annoyed? Have you ever felt guilty? And of course, have you ever had an eye-opener? I mean, Jim Morrison in The Doors explained it very well. You know, I woke up this morning and I got myself a beer. I mean, this was, this is, you know, if that is, if you get a yes on any one of these, it's a reason for a comprehensive in an older adult. In a younger adult, it would be two or more, I believe. This is a picture of the short Michigan alcohol screening test just for your information. I'm not going to spend time on each of the questions, but it's something that you can give your folks while they're in the waiting room. And hopefully they answer that truthfully. And then you can look at it and ask them questions about it, which it's a good time saver and can be very helpful. And then screening for a potential medication misuse and opioid use disorder, prescription pain, medically, you know, prescription pain medicine misuse. Of course, the validated in the, there's only one validated in the elderly, and that's the screener and opioid assessment for patients with pain revised or the SOAP-R. There are other good ones, however, to use, including the NIDA TAPS tool and the STOP, which is the screening tool of older persons, potentially inappropriate prescriptions, which has been around for a long time, is accessible online, and that covers lots of medications, not just prescription pain medications. Other screening tools include the NIDA drug use screening tool, quick screen, the opioid risk tool. And then, of course, if you have questions, you can always go to the NIDA resource guide on their webpage. It's very helpful and easy to understand and navigate through. I thought I would add this, the cannabis use disorder test. This is something that you can give people while they're waiting. Cannabis use is much more prevalent, not only in older folks, but in younger folks. And it will give you an idea of whether or not their cannabis use is, how prevalent it is, and whether it's causing them any problem. And you can see down from the bottom that a score of eight or more may indicate hazardous cannabis use. And if you have the 12 or more on these eight questions when you add them up, it can be, indicate that they have a cannabis use disorder. And so this is a good screening tool to use with somebody who you know is chronically using cannabis. This is a schema of a workflow that you can follow. Of course, you do a substance misuse screening. You know, if it's negative, you reinforce healthy behavior. If it's positive, you have two pathways you can go down. You can go down to the substance misuse and try to do a brief intervention. And if they do fairly well on follow-up, you can continue to follow with them and manage them as an outpatient, or maybe not having to refer to a substance use specialist. However, if they meet the substance use disorder level of treatment, you can try doing brief counseling and treatment. But if that doesn't work, you should send them to a specific substance use treatment and or apply, you know, add pharmacotherapy. There's plenty of pharmacotherapy out there to help with substance use disorders in younger adults and older adults. In summary, there are many usable screening instruments to help the clinician ascertain substance use in the older population. Some are self-administered, some are clinician administered. The most important thing to remember that I have found with most primary care folks in particular and even with specialist psychiatry folks is to just remember to ask about substance use. Sometimes if you don't ask, they're not gonna tell you. If you ask, they often will tell you. They feel that, you know, especially in a non-confrontative way and a more motivational interview and kind of, you know, empathic way. Okay, treatment. So general principles, age-specific treatments appear to potentiate treatment effects. That's very important to remember. Older folks like to be in groups with other older folks for treatment. If they're gonna be in group treatment. And you wanna have folks that have a familiarity with older folks. History, behavior, likes, those kinds of things. Treatment considerations include biological, psychotherapeutic, and social. I mean, comorbid medical illnesses you have to pay close attention to. They're more likely to have them. Comorbid, start slow, go slow, keep going as tolerated. This is the geriatric psychiatrist mantra. And if you're an addiction psychiatrist and you're treating older folks, you should remember start low, go slow, but keep going as tolerated or until you get, you know, a satisfactory response. Monitor very closely. Psychotherapeutic, look again at stage of life factors, loss, change in life, cognitive abilities. Social factors include, I mean, it's just like child psychiatry in some ways. You have to use family intervention sometimes. And sometimes it's important to rally the family because they may not believe that grandma's drinking a bottle of wine every night. But this is important. And then also group therapies work very well. In terms of tobacco use disorder, we have biological treatments and nicotine replacement. I'm gonna talk here, I'll give you a picture of the nicotine replacement options. There are more options than this now, obviously. And we also have looked at, you know, vaping to use. And, but we've found that the most, especially in my work at the VA, the transdermal patch and the nicotine gum seem to work very well. The transdermal patch gives you a nice even flow. You know, it's available without prescription. You don't have to adjust the dose. And what can happen is that, you know, you can give them the gum when they have cravings. And this gives them a little jolt. It's not quite the same as inhaling something, you know, into your lungs and getting the kind of jolt you would from a combustible cigarette. Varenicline is a medication that you can give to older adults. You can see here that it's an alpha-4, beta-2, nicotinic acetylcholine receptor partial agonist. There's no dose adjustment in older adults. Bupropion SR works very well. It also has activity at the nicotinic acetylcholine receptor. And it's also been known to make tobacco smoke taste bad. It's well tolerated in the advanced age. And it's been shown to be effective in people with COPD as well. So it's not a problem there. As a matter of fact, with nicotine replacement therapy is very effective in people over 60 years of age. And the effectiveness of Varenicline and Bupropion were not significantly different according to age groups. Tobacco use disorder can also be treated with psychotherapeutic treatments, cognitive behavioral therapy, and brief interventions work. Brief interventions work very well with older adults. Cognitive behavioral therapy, you should be sure that people do not have cognitive deficits. If you're trying this. And then of course, 12 step groups work very well as well. Alcohol use disorder, biological treatments include detox and then of course, maintenance medications. The treatment of alcohol withdrawal, they're at a higher risk for delirium, prolonged confusion and falls. There's not as robust of an outpouring in withdrawal. So they may not have seizures right away and the symptoms may be delayed. And they often need inpatient treatment for their alcohol withdrawal. And their post withdrawal of the acute phase can last for weeks to months. So serious alcohol withdrawal can be difficult for older adults. This is a picture of a standard alcohol withdrawal timeline from 1953, which was right around the time I was born. And it shows the change in language, but it also shows that in younger adults, you get a robust outpouring of problems with hallucinations and seizures early on. And then the autonomic activity occurs later. In older folks, the autonomic, the delirium starts earlier and lasts longer and there's not as many seizures. These are some of the maintenance medications. Well, these are the only maintenance medications for alcohol. And you can give them to older adults. You need to be very careful. There's naltrexone, there's Vivitrol or injectable naltrexone, acamprosate and disulfiram. This is the study, those are retention and treatment study that was one of the original, I think this was from Volpicelli and showed the retention and treatment with naltrexone versus placebo with alcohol. The important thing to remember is that keeping people in treatment, we did not have to necessarily be abstinent. They could be using up to. Hello, I'm back. Again, more difficulties, I guess, being an older adult gives you more difficulties with connections as well. Sorry about that. This is just a slide that shows the number of studies that were done to get FDA approval for naltrexone. And you can see that the experimental favor was prevalent. Again, opioid use disorder in older adults. This is becoming more of an issue. Most of the methadone maintenance treatment folks, about five or 6% are over the age of 55. They may do better in treatment with methadone. And they have similar rates of medical and psychiatric problems. And they're more likely to be married. And overall, they did significantly better in treatment. However, you gotta watch out for sedation, polypharmacy, QTC prolongation, and constipation. Buprenorphine, again, is very usable in older adults. I'm gonna try to go a little bit faster here. You gotta monitor liver functions. And be sure to, if there's a problem with impaired renal function, it's not, there's no problem with half-life and renal function. But if there's liver failure, you should use the monoproduct and not the suboxone. Naltrexone can be used. The problem with naltrexone is the same for older folks. And that is, you need to be abstinent for seven to 10 days before you start it. Otherwise, you can cause a severe withdrawal. And then start low and go slow, but keep going. And then you can use the injectable as well with older adults. Again, psychosocial treatments. Address issues of loss and isolation. Age-specific treatments. Slower pace. Use experienced staff. And be alert to cognitive changes. Generally, a brief intervention also works. This, you know, it's usually two to three, 10 to 15 minute sessions. Education, assessment, and feedback. The trials that proved this were project guiding older adult lifestyles or project goal. And then it's usually, it works very well with older folks' brief interventions. This is an example of a brief intervention to give you an acronym. Frames, feedback, responsibility, give advice, a menu of change for options, be empathic, and try to help self-efficacy. In terms of alcohol use disorder, relapse prevention, motivational introduction works. Individual psychotherapy works. Cognitive behavioral, not to be used with documented cognitive decline. And 12-step facilitation works very well as well. Alcohol use disorder, social treatments. 12 steps, many older folks do well and they can find groups with older adults in them. Rational recovery. Again, CBT and family interventions are very important. This is a steps to ensure success of treatment in substance use disorder with older adults. Again, screen for SUDs during primary care visits. Use validated screening tools. Use a brief intervention strategy and motivational interview to try to engage them. Again, use specialized treatment programs for individuals who fail less intensive strategies. And then if needed, detoxification should be completed in an inpatient setting. In summary, treatments are available. Start low and go slow in older populations. Again, age-specific treatments appear to be more efficacious in general and should be combined with pharmacological treatment when possible. Age-specific treatments include building relations and support use of less confrontation and older adult only environments. Now, this is really my final slide. And it was put out by some pharmacists and I decided to add it to this presentation in particular because it talks about medication reconciliation and developing a medication action plan. So it works not only for prescription pain medications, but any person that you have that's older. If you have, when you treat an older person, any person really, but more importantly, older folks because they tend to be on many medications some of which may not be, need to assess the actual medications, whether or not it's a beneficial therapy and whether you can simplify their treatment. And then assess for drug-drug interactions and if needed, consult the pharmacist. They can be very helpful. And then also assessment of the patient. Is there, is there a need for a drug-drug interaction or is there any problem with elimination or toxicity? Is there, identify their functional status and deficits and redress medication resources. Identify goals and care and adjust the medications that are consistent. So it's just a helpful wheel to sort of look at things and try to simplify people's medication regimens, which of course is really very important in this age group. This is just a list of references that you can use or peruse. And I would say that NIDA and SAMHSA are both really excellent for finding information on older adults. All right, I think we're ready for questions and answers. Caroline Cruz, hello, what is your advice for treatment for individuals with cognitive decline that can't participate in outpatient or inpatient residential programs? I have patients declined by programs due to cognitive decline. This is very difficult. You know, if you have lots of cognitive decline, you may need to try to, you may need to, so Caroline Cruz-Ortiz, this is a very difficult problem. This is a group of people that may be very difficult to treat. I mean, if you're being, you know, this is not uncommon, actually. You know, substance abuse treatment programs often say, well, we can't take them because there's cognitive problems. And basically, you know, my answer to that is that substance abuse folks need to be much more cognizant of people with cognitive decline. You can work with them. You just may need to explain things closer, and you need to keep them in a group to themselves. Sarah Ruka, you mentioned some differences in alcohol withdrawal with older adults. Are there differences with benzo abuse and withdrawal in this population? Yes, I think that, you know, there's lots of problems with benzo abuse, and there's lots of difficulty getting older adults off of benzos. You know, benzodiazepine, once they're benzodiazepine dependent, trying to wean them off is very difficult and, you know, may require help with, you know, from family members or a spouse or partner, and it may involve getting them to try and reduce it in very small qualities over long periods of time. If that can't be done, then they need to be hospitalized. And if they're hospitalized, you can, you know, put them on a, on a something like gabapentin or divalproate, you know, Depakote, and try to detox them. I'm back. I'm so sorry for the technical difficulties, but I hope I answered some questions. Thank you very much for your time and attendance.

substance-related disorders

older adults

baby boomer generation

screening tools

age-specific interventions

psychosocial therapies

cognitive decline

care coordination