Hello, my name is Raj Tempe, and I'm the past president of the American Association for Geriatric Psychiatry. I'm going to be talking to you about substance use disorders in late life. Disclosures. I have no complex of interest to disclose for this presentation. The objectives for this presentation are as follows. To describe the epidemiology of substance use disorders in late life, to discuss the assessment of substance use disorders in late life, and to enumerate the evidence-based treatments for substance use disorders in late life. Let's talk a little bit about the epidemiology of substance use disorders in late life. Evidence indicates that one in four older adults has used a psychoactive substance with abuse potential. By 2020, the number of older adults with substance use disorders is projected to reach 2 million. Let's talk about tobacco, which is the commonest substance of abuse among older adults. Past year, use of tobacco among individuals greater than 65 years in age is 14.1% versus 30.2% among adults aged 50 to 64 years. Among older individuals who use tobacco, they are of usually lower income, they are not currently married, and they usually binge drink and use illicit or non-medical drugs use. Now let's talk about alcohol, which is the second most commonly used drug of abuse among the older adults. Approximately half of the individuals 65 years and older drink alcohol. Approximately one-fourth of those 85 years and older drink alcohol. It is estimated that approximately 43% of individuals who are older admitted alcohol use in the past year. The important thing to remember is that about 6.7% of these individuals reported alcohol abuse or dependent symptoms. It has also been noted that 13% of men and 8% of women who are older report at-risk use of alcohol. At-risk use of alcohol means more than 14 drinks for men in a week and more than 7 drinks for women in a week. In this sample, 14% of men and 3% of women reported binge drinking. An important difference was African-American women had higher rates of binge drinking when compared to Caucasian women, 10% versus 6%. Let's look at some of the other drugs of abuse, marijuana, cocaine, inhalants, hallucinogens, methamphetamine, and heroin. Among older adults, the marijuana use was about 0.7% in the past year. Cocaine use was about 0.4%, sorry, 0.04% in the past year. The use of inhalants, hallucinogens, methamphetamines, and heroines was less than 0.2% in the past year. What we also know is that approximately 11.7% of past year drug users met the DSM-IV criteria for past drug use disorder. Now, the risk factors for substance use disorders, especially marijuana and cocaine, are for marijuana, being of male gender, being separated, divorced, or widowed, and having a never married status, and a past year history of major depressive disorder. For cocaine, the risk factors were male gender, Native American or Black race, unemployment, being separated, divorced or widowed, or having a never married status, indicating that substance use disorders are somewhat more among men than in women among older adults. Now let's look at benzodiazepine use. One in 10 older adults have used benzodiazepines in any given year. 3.3% of women and 0.8% of men met the DSM-IV criteria for past year use benzodiazepine dependence. Risk factors, unlike other substances of abuse, female sex is overrepresented in benzodiazepine use disorders. These individuals also have more cognitive impairment. They also have a diagnosis of panic disorder, have more suicide ideation, and they often have trouble obtaining help for their emotional or mental health problems. Let's look at non-medical use of prescriptions in the past year. For opioids, it was 1.4%. Sedatives, it was 0.14%. Tranquilizer, it was 0.46%. And for stimulants, it was 0.16%, indicating that the use of these substances is less among the older adult population than in the younger adult population. Now let's talk a little bit about the opioid crisis situation. We know that 4.6% of the world's population is made of Americans, but we consume 80% of the global opioid supply. Americans tend to consume 99% of the global hydrocodone supply and 66% of the world's illegal drugs. There was an overall increase over the past two decades on opioid consumption at 149%. Those numbers are coming down, luckily, because we have started restricting the prescription of opioids. The increase in opioids were 222% for morphine, 280% for hydrocodone, 319% for hydromorphone, 525% for fentanyl-based, 866% for oxycodone, and 1,293% for methadone. This is not just for older adults. This is for all population together. Now let's look at what an elderly prescription opioid abuser looks like. They often have multiple medical problems. They have higher incidence of chronic pain. They have common mood disorders, major depression, and bipolar disorder. They usually misunderstand directions, misuse versus abuse. They often have multiple prescribers. There is rationalization and denial among family members, peers, or care providers regarding the misuse or abuse of drugs among these individuals. The deficit seen because of substance use is presumed to be because of age. These drugs interact with alcohol and other drugs, and there is an over-representation of females to males when it comes to elderly opioid prescription abusers. So among older adults, most of the substances of abuse are more common in men except for benzodiazepines and opioids. Now this is the data that we have from the 2007 to 2014 National Surveys on Drug Use and Health. This is the average daily use of substances. As you can see, alcohol is the most commonly used substance here, with 6 million individuals using alcohol every day. When it comes to marijuana, it is 132,000 individuals a day, followed by cocaine, which is about 4,300 per day. They did not calculate tobacco use in this group. Now when you look at the number of emergency visits due to drug misuse on an average day for an older adult, non-prescription or prescription pain relievers were the most common at 118 per day, followed by narcotic pain relievers, benzodiazepines, alcohol in combination with drugs, antidepressants or antipsychotics, followed by cocaine, heroin, marijuana, and illicit amphetamines or methamphetamines. So total is about 340 individuals a day. Now what are the risk and protective factors for substance use disorders among older adults? The risk factors include previous history of substance use disorders, co-morbid metric illness, cognitive impairment, family history of substance use disorders, whereas protective factors are being married and having a religious affiliation. What are the consequences of substance use disorders in late life? We all know about this, but I'm going to just restate it again because it's just important to know. When people, older adults use substances, they have, they often have central nervous system dysfunction, including motor coordination and confusion and even dementias. They end up with withdrawal symptoms, including seizures. That is drug-drug interactions, including respiratory depression. These individuals develop medical, neurological, or psychiatric disorders, including depression and anxiety. There is cognitive decline and dementia, especially with alcohol and benzodiazepines. These individuals end up with greater physical disability, including neuropathy and falls. They have higher rates of hospital admissions, greater mortality rates, and the cost of caring for these individuals is also significantly higher than older adults who do not abuse substances. What are the barriers to identification of substance use disorders in older adults? There are three main factors. These include physician factors, which include stereotypes about addiction, saying that older adults do not use substances, stereotypes about older adults indicating that older adults don't know how to get a hold of substances of abuse, and lack of knowledge about treatment, not knowing that older adults with substance use disorders respond to treatments as well, or if not better, than younger adults with substance use disorders. Then there are the patient factors, which include denial of the fact that you are using substances and the feelings of shame and guilt when substances are used. Diagnostic factors include comorbid medical conditions, which may obscure or be used to explain symptoms of substance abuse, namely pain. Age-related changes, falls, anemia, neuropathy, and altered cognition may be thought to be because of an underlying medical condition when the actual culprit may be a substance of abuse. There are fewer overt warning signs, so people tend to have withdrawal symptoms late, so you may not know that the individual has been abusing substances, and the DSM criteria are less applicable because they are meant for younger adults, not specifically for the older adult population. Let's look at a little bit on the early-onset alcoholics versus late-onset alcoholics. Early-onset alcoholics, these are individuals who start drinking before the age of 60 years. They form two-thirds of the older problem drinkers. That means they start abusing alcohol early on in life, and they are now getting older. These individuals have chronic alcohol-related medical problems. They often have a family history of alcoholism. They also have serious psychiatric comorbidities, particularly major depressive disorder. They are less socially adjusted than the age-match controls. They have more antisocial characteristics. They may have an intractable course. They tend to have more legal problems, and they need more medically-focused intensive treatment for their addiction, so the addiction is much worse in younger-onset alcoholics. The late-onset alcoholics are individuals who tend to use alcohol after the age of 60. They are more responsive to treatment. They have fewer psychological—sorry, fewer physiological consequences of disease process due to shorter duration of use, and they often begin to use alcohol or abuse alcohol after a stress-related event or loss, especially loss of a spouse, job, or home. They do have a milder clinical picture. They tend to be more emotionally stable. They have better adherence to treatment. They have lower recidivism rate. They tend to have more social supports and have greater life satisfaction. Now, this is the description of the standard alcoholic drink in the United States, 12-fluid ounce of regular beer, which contains about 5% of alcohol, or an 8 to 9-fluid ounce of malt liquor, which has about 7% alcohol, 5-fluid ounce of table wine, which has about 12% of alcohol, or 1.5-fluid ounce of sure of 80-proof spirit that is called hard liquor, which includes whiskey, gin, rum, vodka, and tequila. Now, the recommendations and susceptibility to alcohol. The NIAAA recommends that for men and women 65 years and older, one drink per day is considered the maximum amount for moderate alcohol use. The age-related volume of distribution results in 20% higher blood alcohol concentration per volume among older adults when compared to the younger adults. There is evidence that indicates that aging interferes with body's ability to adapt to the presence of alcohol. So for the same amount of alcohol consumed, older adults have more complications and more severe symptoms. What are the common screening tests for alcohol use? Common ones are Michigan alcohol screening test, the geriatric version, which is the MAST-G. There is a short version of Michigan alcoholism screening test, geriatric, SMAST-G, the alcohol use disorder identification test, or the AUDIT, alcohol use disorder identification test, five item, AUDIT-5 or AUDIT-PC, alcohol use disorders identification test consumption, the AUDIT-C, and of course, the CAGE. Here is the Michigan, this is the short Michigan alcoholism screening test, geriatric version. It has 10 items. For clients who have answered yes to two or more of these questions, a complete assessment of their alcohol use should be made. This is the AUDIT-C, which has three items. For an individual who has scored more than three points on these questions, or they have report drinking more than six alcoholic drinks on one occasion, we need to have a comprehensive evaluation. So more than three points or more than six alcoholic drinks per sitting have a comprehensive evaluation on the AUDIT-C. For the CAGE questionnaire, the questions are, have you ever felt you should cut down on your drinking? That is the C. Have you have people annoyed you by criticizing your drinking? That is the A. Have you ever felt bad or guilty about your drinking? That is the G. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? That is the I opener. So that is the C-A-G-E. A comprehensive evaluation should be done if even one of these questions is positive when compared to older, younger adults where we need to have two of the questions positive. Opioid use screening, the tests we have are screener and opioid assessment for patients with pain revised. The SOAP-R, current opioid misuse measure, the COM, drug assessment screening tool, DAST, screening tool for older persons potentially inappropriate prescription or stop. Among these, I tend to use the DAST because it is freely available. Now this is the DAST which has 28 items. It looks at substance use over a 12-month period. If you score more than 12 on the 28-item questionnaire, there is a clear chance that you have a substance abuse problem. What are the general principles of treatment of substance use disorders among older adults? One thing we know for a fact from all the studies is that tailored treatments have higher rates of success when compared to general treatments. The treatments can then be divided into biological, psychotherapeutic, and social. Among biological, important factors to consider are the comorbid medical illnesses. And remember the dictum, start low, go slow, don't keep on going. Among the psychotherapeutic treatments, you have to consider the stage of life factors for the older adult and also their cognitive abilities. For social treatments, both family and group interventions have been found to be very helpful. These are the five steps for successful treatment of substance use disorders among older adults. These include screening to be completed during the primary care visits because majority of older adults go to their primary care physician and not to see a specialist. The use of validated screening tools for identification of substance use disorders enable qualifying and quantifying the substance use disorders. Using brief intervention strategies and motivational interviewing initially helps complete the assessment successfully and also helps motivate people to enter treatment. Using specialized treatment programs for only those who fail less intensive strategy. If detoxification is needed because of comorbidity, it should be completed in an inpatient setting whenever possible. Let's look at the treatment for alcohol use disorders. Biological treatments include detoxification and maintenance treatments. Among the maintenance treatments are naltrexone, acamprosate, and disulfide. Detoxification. Older adults are at higher risk for delirium, prolonged confusion, and falls, hence detoxification should ideally be done on the inpatient service. These individuals also have onset of symptoms that is delayed and they're present with confusion rather than tremors as a major sign of alcohol withdrawal. So any older adult who presents with acute or subacute onset of confusion, remember, rule out alcohol use disorder or other drugs of abuse. These individuals often present with hallucinations, tactile and visual, which may continue for weeks or months. These patients need inpatient treatment if there is a history of severe withdrawal or severe or significant medical comorbidity. I for a fact, whenever I see an older adult who has a substance use disorder and we need detoxification, I try to do it on an inpatient setting because it's just much safer. Now these are the three medications used to treat alcohol use disorders among older adults. Naltrexone, acamprosate and dalsulfurate. The naltrexone comes in oral daily dosing 50 or 100 milligrams, 50 milligrams or on a hundred milligram on Monday and Wednesday and 150 milligrams on a Friday. We have the Vivitrol injections, which is 380 milligrams every four weeks. We have acamprosate, which comes in the strength of 666 milligrams, three times a day and dalsulfurate, which comes in the strengths of 250 and 500 milligrams a day. The dalsulfurate should not be taken until 12 hours after the last drink or it can cause severe symptoms. The mechanism of action for naltrexone is that it is an opioid receptor antagonist. So it should not be used in patients using opioid therapy because they will go into severe opioid withdrawal. Acamprosate is thought to reduce excitatory glutamate transmission and block certain glutamate receptors and increase GABA activity. Dalsulfurate, on the other hand, inhibits aldehyde dehydrogenase enzyme. As I said earlier, naltrexone should not be used among individuals who are receiving opioid therapy. Acamprosate, one good thing, it can be used for people who are also receiving opioids. Disulfiram, important point. These individuals, when, you know, use alcohol or any of the alcohol-based products, they end up with tachycardia, diaphoresis, nausea, and vomiting. Adverse effects for naltrexone, mainly dizziness, headache, GI distress. For acamprosate, it is diarrhea and nausea. Among disulfiram, it is dermatitis, drowsiness, or metallic taste in the mouth. Naltrexone should be used cautiously among individuals with liver function. Acamprosate, on the other hand, can be used in individuals with liver dysfunction, but should be used cautiously among individuals with renal insufficiency or chronic renal failure. Disulfiram should be avoided in individuals with cognitive impairment, cardiac disease, severe liver disease, or alcohol intoxication, as these individuals will present with severe withdrawal symptoms. Psychosocial treatments for alcohol use disorders among older adults, few important points. It has to be age-specific, and then it's more effective. It should address the issues of loss and isolation, because that is a big theme among older adults with alcohol use disorders. These programs should teach skills to rebuild social supports. It should also go at a slower pace, so as to let the individual adapt to the changes that they need to bring to their own lives. It should be done with staff who are experienced in dealing with older adults with substance use disorders, and always be alert to cognitive changes, as many of these individuals may not be able to understand or comprehend what's being said in these sessions. So they may need to be reeducated multiple times to learn new skills. Brief interventions are highly effective among older adults with alcohol use disorders. These are usually two to three sessions, which are about 10 to 15 minutes long. They use education, assessment, and feedback as the format. These sessions use motivational strategies, goal setting, behavior modification techniques as their main treatment interventions. There are multiple trials among older adults. The three most cited ones are Project Guiding Older Adult Lifestyle, or the GOAL Project, Health Profile Project, and Staying Healthy Project. These psychosocial interventions have shown to improve alcohol use disorders among older adults by decreasing alcohol consumption. The FRAMES framework, it is F stands for Feedback from the Assessment, R stands for Personal Responsibility for Change, A stands for Advice to Change, M stands for Menu of Change Options, E stands for Empathic Counseling Style, and S stands for Enhanced Client Self-Efficacy for Ongoing Follow-up. It is adapted from Hester and Miller. Psychotherapeutic treatments, these include relapse prevention, motivational interviewing, motivational enhancement therapy, individual psychotherapy, and cognitive behavior therapy. The other treatments include social treatments, that is the 12-step program, like Alcoholics Anonymous, CBT, that is cognitive behavior therapy, and rational recovery. Family interventions are also very helpful in treating alcohol use disorders among older adults. Let's look at nicotine use disorders and the treatments for this disorder. Biological treatments can be divided into nicotine replacement and medication. Among the nicotine replacement, we have the patch, the gum, and medications, and then we have the varnicline and bupropion as the medications for the treatment of nicotine use disorder. These are the three forms of nicotine replacement therapy. The patch comes in the 7 milligram, 14 milligram, and 21 milligrams. The side effect is mainly local-scale irritation. People like the daily dosing, and which may be particularly beneficial for these individuals who have cognitive impairment. The gum comes in 2 milligrams or 4 milligrams. The main side effects are buccal mucosa irritation, sore jaw from chewing, and other side effects because of nicotine. It requires specific dosing for maximal results and should not be used in those older adults who have dentition issues, temporomandibular joint disorders, or those who have dental appliances. The lozenges come in the 2 milligram and 4 milligram dosing. They can cause abdominal pain, nausea, vomiting, diarrhea, headache, and palpitations. It often is easier to use than the gum, but in my personal experience, people like the patch. And among the medications, we have two, varnicline and bupropion SR. The varnicline is an oral-administered alpha-4 beta-2 nicotinic acetylcholine receptor, which is a partial agonist. It antagonizes the nicotine response, and no dosage adjustments are needed for older adults. The dosing schedule is as follows. On day 1 to 3, the dosing is 0.5 milligrams daily. Days 4 to 7, 0.5 milligrams twice daily. And from day 8 on, it is 1 milligram twice daily. Bupropion SR is an antidepressant, which is a weak inhibitor of dopamine uptake. It is well-tolerated, and one study found that advanced age was a positive predictive factor for compliance with treatment. The dosage for the bupropion SR is 1 to 3 days, 150 milligrams a day. Four days on, 150 milligrams twice daily. The bupropion SR should be continued for 7 to 12 weeks, or up to 6 months. This is a representation of the nicotine available in the multiple forms. Now, as you can clearly see, this is the one for regular cigarettes. So the peak effect of nicotine is within 10 minutes. If you look at the nasal spray, it also has the similar pattern for the amount of nicotine that reaches the blood. So the best mimic is actually for the nasal spray, but as we look for the patch, there is a slow buildup of nicotine over a day. For the others, it is variable. So ideally, the spray should be the most beneficial, but because of nasal irritation, because of the spray, people don't tend to like it. I have always found that the patch and the gum are the two that are more commonly used by older adults when compared to the younger adult population, with a lesser number using the lozenges. Psychosocial treatments, very similar to alcohol use disorders. CBT and brief interventions are the two psychotherapeutic treatments, and the social treatments are mainly group interventions. Now, treatment for opioid use disorders, the biological treatments, there are four that are available to us, which includes methadone, buprenorphine, suboxone, and naltrexone. Methadone, it is, as you know, it is a very potent opioid agonist. Five to six percent of older adults receive methadone maintenance. Elderly tend to do better than younger patients with methadone maintenance. They have similar rates of medical and psychiatric problems. They are more likely to be married, and they did better overall in treatment when compared to the younger adults. Adverse effects, very important to remember. They are at increased risk of sedation with polypharmacy, so combining methadone with antipsychotic medications, combining methadone with benzodiazepines should be done cautiously. It can increase the risk of QTC prolongation and torsades, and because it is a highly potent opioid agonist, it can cause significant constipation, so any one of your patients that is taking the methadone, always remember to have a bowel regimen included so as to prevent constipation. Buprenorphine, as you all know, is a partial opioid agonist. The desirable properties for buprenorphine is that it is one of low abuse potential. It is safe if ingested in overdose quantities. It has weak opioid effects as compared to methadone, and its half-life is not altered with impaired renal or hepatic function. It has poor oral bioavailability, so it has to be given sublingually, that means under the tongue, with absorption through the oral mucosa. It has a slow dissociation rate, so it has a prolonged therapeutic effect, and so can be given every day or every other day. It is highly effective or as effective as methadone for people with moderate to severe opioid dependence. These are the various different forms of buprenorphine. There are many different new formulations that are coming out every day, so I have just put this photograph of all the ones that I could find. What about naltrexone? The individuals who would benefit from naltrexone are highly motivated individuals, especially professionals like physicians, people who are former opioid-dependent individuals who are employed and socially functioning, those who recently detoxed from methadone or buprenorphine, those who are leaving prison, those who are leaving residential treatment settings, those who sporadically use opiates but are not on methadone or buprenorphine maintenance, those who are not eligible for methadone or buprenorphine maintenance, those in a long waiting period for methadone or buprenorphine maintenance, those wishing to prevent relapses, adolescents not wishing to go on methadone or buprenorphine maintenance, and healthcare professionals not wishing to go on methadone basically to avoid any issues with their medical licensing. Psychosocial treatments are very important and should always be combined with the medications. Psychotherapeutic treatments include CBT and brief interventions, and social treatments include group therapy. SBIRT, which is the acronym for Screening, Brief Intervention, and Referral to Treatment. Screening is identifying the use of psychoactive prescriptions by interview and using rating scales. Step two is brief intervention using motivational interviewing, using brief intervention workbook, negotiating next steps, and follow-up treatment if needed. And step three is referral to treatment for professional treatment if needed. This is a cartoon that I found very funny. It says, I'm willing to make some changes in my lifestyle as long as I don't have to do anything different. You will find this very commonly with your older adults who have substance use disorder, so they don't want any changes in life, but still want to take care of their substance use problem. So you have to keep them motivated to make changes in their life that are positive for them. This is the trans-theoretical model. I find it very useful. Some people say it is outdated. I find it very useful to show patients on what the different cycles of substance use disorder treatment are. Sorry, the pre-contemplation phase, where people have not yet started thinking about making a change. Contemplation phase, where people have started making thoughts about, you know, making a change with their substance use. Preparation phase, where people are now preparing to start the change. Action phase, where they have started the change. Maintenance phase, where they're continuing with good habits or treatments that they have initiated. And then the relapse and the recycling of these individuals. You have to continue to support the patients through this cycle so as to be successful in avoiding or treating substance use disorders. Motivational interviewing has four different things you need to follow. First is express empathy. Use reflective listening to convey understanding of the patient's point of view and underlying drives. Develop discrepancy between the patient's most deeply held values and their current behaviors. This is a good way of teasing out unhealthy behavioral conflicts and the wish to be good or to be viewed as being good. Rolling with resistance. In this, the therapist responds with empathy and understanding rather than confronting the individual. And you should also support self-efficacy by building the patient's confidence that change is possible. We did an editorial on substance use disorders among older adults. We reviewed all the randomized controlled trials. We only found two pharmacotherapy trials, which evaluated the use of pharmacological agents for substance use disorders among older adults. And older adults here means greater than 50 years of age. One trial evaluated the use of naltrexone when compared to placebo for the treatment of alcohol use disorders among individuals 50 to 70 years in age. The other trial evaluated the use of naltrexone or placebo as adjuncts with sertraline in the treatment of alcohol use disorders among older individuals who are 55 years and older. Both trials showed that the use of naltrexone reduced the rates of relapse among older adults with alcohol use disorders. We did not identify any RCTs that studied the use of buprenorphine, acamprosate, or disulfiram for substance use disorders among older adults. So there is a dearth of data on pharmacotherapy for substance use disorders among older adults. Now, here are the references that we put together. You can use them. They are pretty up to date. Now, four questions and answers to test whether you have found this lecture to be helpful. So the first question is, which of the following is the most common substance use among older adults in the United States? Tobacco, alcohol, cannabis, and cocaine. And the answer is tobacco is the most commonly used substance of abuse, followed by alcohol, cannabis, and cocaine. Which of the following is not a known risk factor for benzodiazepine use among older adults? Male sex, having cognitive impairment, having panic disorder, having suicidal ideation. And the answer is male sex. Remember, male sex is more common in other substances of abuse, except for benzodiazepines and opioid use among older adults. Which of the following is incorrect regarding buprenorphine? It has low abuse potential. It is safe if ingested in overdose quantities. It has a weak opioid effect when compared to methadone. Its half-life is altered with impaired renal and hepatic function. The correct answer is one of the most important things to remember is that buprenorphine's half-life is not altered with impaired renal and hepatic dysfunction. It has low abuse potential. It is safe ingested in overdose quantities, and it has a weak opioid effect when compared to methadone. Which of the following is the only medication that has been studied in randomized controlled trials among older adults with substance use disorders? Methadone, naltrexone, buprenorphine, guanacline. And the answer is naltrexone. If you remember the slide on our editorial we did on pharmacotherapy for substance use disorders, we only found two trials of naltrexone among older adults, that is about 50 years in age in our study, and naltrexone was the only medication. We could not find any other pharmacotherapy among older adults with substance use disorders. Thank you very much for listening to this lecture.

substance use disorders

late life

epidemiology

older adults

risk factors

consequences

assessment and treatment