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Substance Use Disorders in Older Adults

Mi Mich chae ael l Fi Fing ngerho erhood,

• d, MD

MD, , FACP CP, , DF DFAS ASAM, AM, AAH AAHIV IVS

• Non

None

Disclosures

• Incr

crea ease se ab abil ilit ity t y to

• ef

effect ectiv ivel ely y dia iagnose

• se su

substance stance use se dis isor

• rder

er in in the he old

• lder

er ad adult lt

• Be ab

e able le to

• re

recomm commend end ef effecti ective e tre reat atmen ment op

• ptions

ions for

• r the

he ol

• lder

er ad adult lt wi with s h substance bstance use se dis isor

• rder

der

Objectives

• La

Lack ck of

• f sc

scre reeni ening ng in in pr prim imar ary y ca care re

• La

Lack ck of

• f ag

age-ap appr propr

• pria

iate e sc scre reeni ening ng tool

• ols
• La

Lack ck of

• f guid

idel elin ines es for

• r as

asse sess ssin ing ol

• lder

er ad adult lts

• Si

Signs an s and sy symptom

• ms

s of

• f ha

harmful rmful use se overla erlap p wi with o h othe her r con condit itions ions

• Age

geis ist bi bias as

A “hidden problem”

Detecting problematic substance use

Lehmann & Fingerhood. NEJM 2018;379:2351-60

• Relying on older patient’s report of frequency and quantity of

su substance stance use se ca can n le lead ad t to

• undere

deresti stimat ation ion of

• f the

he pr proble

• blem
• Old

lder er ad adult lts s an and fam amil ily y mem ember ers s may no y not ap appre recia ciate e del eleter erio ious us con conse sequen uences es of

• f lo

long-ti time e pat atterns erns of

• f dri

rinking king or

• r dru

rug use se

• Ha

Harm rm ca can n co come me fr from

• m lo

lower er am amounts

• unts of
• f su

substances stances

Challenges in detecting problematic use

• St

Stig igma a – “addict or alcoholic”

• Ber

erea eavem ement ent an and gri rief ef is issu sues es

• So

Soci cial al is isol

• lat

ation ion an and lo lonel elin ines ess

• Red

educe ced se self lf-reg regar ard or

• r se

self lf es estee eem

• Fam

amil ily y con conflict flict an and es estra rang ngem ement ent

• Proble
• blems

s in in man anag agin ing tim ime/ e/bor boredom edom

• Phys

ysic ical al pai ain

Psychosocial Contributors in Older Adults

• KL is a 6

L is a 67F 7F reti retire red nurse se wh who ha

• had ri

right ht total al kn knee ee re repla lace cemen ment co compli licat cated ed by y jo join int in infec ection tion re requiri iring ng prolonge

• longed cou

course se of

• f

an antibi ibioti tics, cs, ha hardware are re removal al wi with s h spac acer er an and fin inal ally ly re repla lacem cement ent

• f
• f ha

hardware.

• are. Sh

She has e has bee een on

• n oxy

xyco codone done 15 5 mg four

• ur tim

imes es dai aily ly for

• r 4 m

4 mon

• nths.

ths.

• Sh

She se e sees es or

• rthoped

thopedics ics in in f/ f/u u an and is is t tol

• ld sh

she sh e shou

• uld

ld not t be on e on an any y fu furth ther er op

• pio

ioid ids s as as sh she is e is no now w 2 2 wee eeks ks ou

• ut

t si since ce the he la last st su surg rger ery. . Sh She is e is t tol

• ld to
• tak

ake ib e ibupr prof

• fen

en

• Is th

s this is ap appropriat

• priate

e med edic ical al ca care? re?

Patient vignette 1

• Ass

Asses ess s for

• r pas

ast wi withd hdra rawal al

• Are

Are op

• pioi

ioids s be bein ing g st stopp

• pped

ed or

• r tap

apere ered?

• Is med

s medic icat ation ion tre reat atmen ment for

• r op
• pioi

ioid use se dis isor

• rder

der bei eing pla lanned ned?

Opioid “detoxification”?

• EB is

is a 72 a 72 F F se seen en f for

• r in

init itia ial vi l visi

• sit. Sh

She h e has as a h a his istor

• ry

y of

• f ch

chronic

• nic pai

ain in in hi hips an s and kn knee ees.

• s. He

Her r pre reviou ious s provi vider er wi will ll no

• lo

longer er pre rescribe scribe

• xy

xycodone codone as as for

• r the

he pa past st 2 2 mon

• nth

ths s he her 30 r 30 day scr y scrip ipt t ra ran n ou

• ut

after 2 weeks. Tearful and fearful that providers won’t help her. Can anno not tak ake NS e NSAID AIDs.

• s. Sh

She ad e admit its s tha hat sh she o e often en tak akes es oxy xyco codone done wh when en sh she is e is u upset. set.

• Sh

She li e lives es alo alone e in in se senior ior ho housi using ng ap apar artmen tment; t; 2 d 2 dau aught hter ers- both h wi with d h dif ifficu iculti lties es (med edical ical an and so soci cial). al). Non Non-smok smoker; er; no

• al

alcohol cohol.

• Ho

How shoul w should you

• u ca

care re for

• r he

her? r?

Patient vignette 2

• Li

Livin ing g al alone

• ne
• Se

Sense se of

• f is

isol

• lat

ation ion (des espit ite e fam amil ily) y)

• Substance as a “friend”
• Sh

Sham ame

• Fea

ear r of

• f ho

how t w to

• li

live wi e witho hout ut su substance stance

Themes in older adults with substance use disorder

• 2010 analysis of Medicare claims data- older adults who were

prescribed opioids (in comparison to those prescribed NSAIDs), had significantly higher rates of cardiovascular events, fractures, hospitalizations and death; risk for gastrointestinal bleeding was not lower

• Euphoria from opioids diminishes with age

Opioids and aging

• Avoi
• id NS

NSAI AIDs, Ds, muscle scle re rela laxa xants nts an and tra ramadol adol (ad added ed 20 2019) 9)

• Avoi
• id op
• pio

ioid ids s if if hi hist stor

• ry

y of

• f fal

alls ls or

• r fracture

fracture

• Avoi
• id tri

ricy cycli clics cs- am amit itri ript ptyl ylin ine

American Geriatrics Society Beers Criteria

• BR is a 82F brought to the ER by neighbor with “syncope”, but it

is is no noted ed tha hat sh she h e has as al alco cohol hol on

• n he

her bre r breat ath h an and he her BAL r BAL is is 22 228 8 mg/dl.

• l. Whe

When n co confr nfront

• nted

ed sh she b e becom ecomes es tea earful.

• ful. He

Her r so son goe

• es t

s to

• he

her hom r home e an and fin inds s hi hidden en min inia iatures ures thr hroug

• ughout

hout he her apa r apartmen tment. t.

• Ho

How do w do you

• u ap

approach

• ach ca

cari ring ng for

• r he

her? r?

Patient vignette 3

In In th the e past t ye year: r:

1. . When hen talking alking with th others, hers, do you

• u ev

ever er underestimate underestimate ho how w much ch you

• u

actu tually ally drin rink? k? 2. . Aft fter er a fe few drin rinks, ks, ha have ve you

• u so

somet etimes imes not t ea eaten ten or r be been en able ble to sk skip p a meal because you didn’t feel hungry? 3. . Does Does ha having ving a fe few drinks rinks he help lp decrea ecrease se your

• ur sh

shakine akiness ss or r tremors? remors? 4. . Do Does es alcohol cohol so sometimes etimes make ake it ha hard rd fo for r you

• u to re

remember ember pa parts rts of t f the he day ay or r night? ght? 5. . Do Do you

• u usually

sually take ake a drink rink to re relax lax or r calm lm your

• ur nerves

erves?

MAST-G

6.

• 6. Do

Do yo you dri rink k to

• tak

ake e yo your r min ind off

• ff yo

your ur probl roblem ems? s? 7.

• 7. Ha

Have you e you ev ever er in incre crease ased yo your ur dri rinking king af after er ex exper erie ienci ncing ng a lo a loss ss in in yo your ur li life fe? 8.

• 8. Ha

Has a do s a doctor ctor or

• r nurse

rse ev ever er sa said id the hey we y were re wo worrie rried or

• r con

concerned cerned ab about

• ut yo

your ur dri rinking king? 9.

• 9. Ha

Have you e you ev ever er mad ade rul e rules es to

• man

anag age e yo your ur dri rinking? king? 10

• 10. Wh

When en yo you fe feel el lon lonel ely, y, doe

• es

s ha havin ing a d a dri rink k he help lp?

MAST-G

• Greater

reater th than fi five ve "y "yes es" " answer ers s indic dicates tes an alc lcoh

• hol
• l

pro roble blem m with th a sen sensitivi sitivity ty of

• f 91

91-93% 3% and a sp d a spec ecifici ficity ty of

• f

65 65-84% 4% wh when en co comp mpared ared to to DSM DSM cr criteria teria

MAST-G

• Dy

Dysp sphori horia a pre redomin

• minat

ates es

• Incr

crea eased sed ri risk sk of

• f ce

cere rebel bella lar r toxici xicity

• Nutrit

tritional ional problem

• blems

s mor

• re

e co common mon

• Alc

Alcohol

• hol wi

withd hdra rawal al sy symptom

• ms

s more

• re li

likel ely c y con

• nfus

fusion/ag ion/agit itat ation ion ra rathe her r tha han tre remor

• r an

and tac achycar cardia. ia.

Alcohol and Aging

• Incr

crea eased sed vuln lnerabili erability y to

• phys

ysio iologi logical cal ef effects ects – De Decr crea ease sed le lean an muscle scle mas ass – De Decr crea ease sed total al bod

• dy

y wat ater er – Le Less ss ef efficie icient nt li liver er en enzy zymes es tha hat metabol aboliz ize e al alcohol cohol – Incr crea eased sed ef effecti ective e con concent centration ration of

• f al

alcohol cohol, , hi highe her r an and lo longer er la last stin ing blood lood al alco cohol hol le level els

• Addit

ition ional al ri risk sks – Alc Alcohol

• hol-medi

edication cation in inter eractions actions – Co Co-mor morbid bid ch chron

• nic

ic il illn lness esses es – Wom

• men

en exp xper erie ience nce al alcohol cohol-rel elat ated ed ha harm rms s at at lo lower er le level els t s tha han men en

Increased risks of alcohol even at “low consumption”

• RT is a

is a 79 79M su succes ccessf sful ul busine sinessm ssman an wi with H h HTN N an and re recu current rent dep epre ress ssion ion wi with p h poor

• or sl

slee eep an and worrie

• rries

s ab about

• ut hi

his m s mem emor

• ry.

. At in init itia ial e l eval aluat ation ion he he p per erfor

• rms

s wel ell l on

• n co

cogni niti tive e tes estin ing but t you

• u

learn that he has two “stiff drinks” every evening, and often has a t a thi hird af after er a st a stre ressful ssful day. He He is d is def efen ensi sive e ab about

• ut hi

his d s dri rinking king bec ecause ause thi his has s has bee een a lo a longstand standin ing pat attern ern tha hat he he e enjo joys. ys.

• Ho

How concerned w concerned ar are y e you

• u ab

about

• ut hi

his d s dri rinking king?

Patient vignette 4

• Prevalence of past-month binge alcohol use and alcohol use

disorder among adults ages 50+ increased significantly from 2005/2006 to 2013/2014

• In 2014, 65% of adults aged 60-64 and 56% of adults aged 65+

reported drinking (NSDUH, 2015)

• Ear

arly ly Onset: set: 2/3 of older adults

• La

Late e Onset: set: more likely to be triggered by stressful life event (loss

• f spouse, retirement, medical disability, pain, sleep problem)

Alcohol: the most commonly used substance

• Dr

Drin inking king Gu Guid idel elin ines es for

• r Old

lder er Adults: lts: Adult lts s over er ag age 65 e 65 w who ho ar are hea e healt lthy an y and do no

• not

t tak ake med e medic icat ation ions s sh shou

• uld

ld not ha have mo e more re tha han:

• 3

3 dri rinks ks on

• n a g

a giv iven en day

• 7

7 dri rinks ks in in a w a wee eek Ar Are e ol

• lde

der ad adult lts s ad adheri ering ng to

• th

thes ese e gu guid ideli elines? nes?

National Institute on Alcohol Abuse and Alcoholism

• Prevalence of he

heavy dr y drin inking king (5 or more drinks on one day on each of 5 or more days in past 30 days): – 5.6% of aged 50-54 year olds, 3.9% of aged 55-59 – 4.7% of aged 60-64, 2.1% of 65+

• Prevalence of bin

inge e dri rinking king (5 or more drinks on same occasion

• n at least 1 day in past 30 days):

– 23.0% of aged 50-54, 15.9% of aged 55-59, – 14.1% of aged 60-64, 9.1% of aged 65+

Findings from 2013 NSDUH

“What happens if you go a few days without drinking?”

• Wit

ithd hdra rawal al may no y not occu

• ccur

r until il days ys af after er ce cess ssat ation ion. .

• Confusion
• nfusion ra

rathe her r tha han tre remor mor is is of

• ften

en the he pre redom

• min

inant ant cl clin inica ical l si sign; ; may ne y need ed t to

• in

inter ervie iew w fam amil ily y mem ember ers

• Se

Sever erit ity y of

• f wi

withd hdra rawal al in incre creas ases es wi with a h age. e.

• If

f no

• hi

hist stor

• ry

y of

• f se

sever ere wit e withd hdra rawal al an and no

• co

co-mor morbid bid med edic ical al con condit itions, ions, wi withd hdra rawal al ca can n be ma e manag aged ed wi with s h suppor

• rti

tive e ca care re at at ho home. e.

• If

f a h a his istor

• ry

y of

• f se

sever ere e wi withd hdra rawal al- mon

• nit

itor

• r in

in th the in e inpat atie ient nt sett settin ing an and tre reat at wi with s h sym ymptom

• m dri

riven en use se of

• f

ben enzodi zodiaze azepines ines

Alcohol detoxification ?

• Di

Disu sulf lfiram iram

• Aca

campr prosat

• sate
• Na

Nalt ltre rexone

• ne

Pharmacologic treatment for alcohol use disorder?

• SL

SL is is 7 78M 8M wi with h Alz Alzhe heim imer ers dem emen entia ia ca cared red for

• r at

at ho home e by y hi his s dau aught hter er an and so son-in in-la law. . He He ha has had s had in incre creasi asing ng ep epis isod

• des

es of

• f

ag agit itat ation ion an and hi his d s dau aught hter er in inquires ires ab about

• ut the

he us use of e of ca cannabi nnabis s to

• he

help lp wit with a h agit itat ation ion.

• Wha

hat do y

• you
• u ad

advis ise? e?

Patient vignette 5

• CR

R is is 82 82M wit with H h HTN N an and GE GERD an RD and wi with re h recu curre rrent nt dep epre ress ssion ion wh whic ich is b h is bei eing tre reat ated ed wi with 2 h 2 di differen erent t an antid idep epressant ressants.

• s. Hi

His s dep epres ressi sion

• n is

is mu much ch im impr proved ed, , bu but he he c continu

• ntinues

es to

• exp

xperi erience ence anxiety and stress, primarily related to worries about his wife’s ca cancer ncer an and he her po r poor

• r he

heal alth.

• h. He

He rep repor

• rts

ts tha hat he he h has as dec ecid ided ed to

• go
• to
• a m

a mar arij ijuana uana dis ispen ensa sary y an and try can y cannabi nabis s to

• se

see e if if it it c can an he help lp hi his m s mood

• od an

and hi his an s anxi xiety

• Ho

How do w do you

• u re

resp spond

• nd?

?

Patient vignette 6

• Pre

reval alence ence of

• f mar

arij ijuana ana use se in increas creased ed fr from

• m 20

2002 02/20 2003 03 t to

• 20

2012 12/20 2013 – 45 45-64 age group………increased from 1.6% to 5.9% – 65+ age group…………increased from 0.0% to 1.3%

• Old

lder er ad adult lts s ag age 50 e 50+ + wi with m h mar arij ijuana uana use se – Fre requen uently tly beg egan an use se in in tee een yea ears – Often en ha have e othe her r co co-morb morbid id su substance bstance use se an and men ental al dis isor

• rder

ders

• Maj

ajority

• rity of
• f ol
• lder

er mar arij ijuana ana use sers s per ercei ceive e no

• ri

risk sk or

• r sl

slig ight ht ris risk k fr from

• m fre

frequen uent use se (e. e.g.

• g. 3

3 tim imes es/wee eek) k)

Marijuana use is increasing among older adults

(Choi et al. J Subst Abuse Treat, 2017; Choi et al, 2016)

Adverse Health Effects of Marijuana Use

Volkow et al., NEJM 2014

• Com
• mple

plex x su substance stance

• Older adults often see if as “safer” alternative to alcohol, il

illi lici cits, or

• r

pha harm rmac aceut eutical ical med edic icat ation ions

• In al

all ag l ages es, sh shor

• rt

t ter erm use se is is ass associa

• ciated

ed wi with – Impai aired red sh shor

• rt-term

erm mem emor

• ry,

, im impai aire red ju judgment ent/mo /motor

• r

coor coordinat ination, ion, dri rivin ing sk skil ills ls – De Decr crea ease sed motivation, ivation, in incre creas ased ed an anxi xiety – Paranoia Paranoia an and psy sychosi chosis s as as do dose se-res esponse ponse ef effect ect

Deleterious impact of marijuana on physical and mental health

• Epi

pidiole diolex

– To t

• tre

reat t se sever ere e ep epilep epsy sy, in n pati tien ents ts with th Len enno nox-Gas astaut taut and nd Dra ravet et Syn yndr drom

• me
• Dr

Drona

• nabinol

binol

– To t

• tre

reat t ano nore rexia a with th wei eight t los

• ss

s in n pati tien ents ts with th AIDS DS

• Cesa

esame met

– Syn ynth thetica etically ly de deri rived, ed, si simi milar lar to TH

• THC

– For

• r na

naus usea ea/vomitin

• miting du

due t e to c

• chem

emoth ther erapy

• FDA

A consider nsiders s an any y pr product duct des esigned igned to impact pact the he bo body y to be be a drug rug

• FDA

A does es not t consider nsider THC and nd CBD BD pr products

• ducts as

s dieta tary y su supplemen pplements ts

• So

Some me compan anies ies are re ma marketing ting pr produ

• ducts

cts in ways ys that hat violat late fed eder eral al food d and and drug rug act ct

Reminder: Only 3 products have FDA approval

• KT is a

is a 70 70M see seen for

• r in

init itia ial vi l visi

• sit. He

He ha has a hi s a hist stor

• ry

y of

• f Typ

ype 2 e 2 dia iabetes es mel elli litus s an and hyp yper ertensi ension.

• n. He

He liv lives es wit with h h his is wif wife an e and ha has s 3 3 gr grown wn dau augh ghter ers s an and 8 g 8 gra randchild dchildren ren tha hat he he sees sees re regula larly rly. . He He en enjo joys ys wat atch chin ing sp spor

• rts

s an and gettin ing tog

• gethe

her r wi with h fr frie iend nds s ever ery y Fri riday y nig ight ht to

• pla

lay p y pin inochle

• chle an

and mos

• st tim

imes es th ther ere e is is crack crack cocai cocaine ne use se- “we just unwind and have a good time”.

• Ho

How shoul w should you

• u ad

addre ress ss co cocaine caine use se? Wha hat t if if he he in inst stea ead dra rank nk 3-4 b 4 bee eers s to

• unwi

wind? d?

Patient vignette 7

• Don’t enable
• Confr
• nfront
• nt wi

with c h com

• mpassion

assion

• Rem

emove e sh sham ame

• Buil

ild se self lf-es estee eem

• Gi

Give en e encourage couragement ent/hope /hope

• Undo
• is

isol

• lat

ation ion

• Wor
• rk

k on

• n co

coping ing sk skil ills ls

• Faci

acili litat ate e fin indi ding ng new w w ways ys t to

• st

stay bu y busy sy wi with h use se of

• f pee

eers

Treatment approach for older adults

• Bri

rief ef in inter ervent entions ions an and EDU DUCA CATION TION ar are ef e effecti ective e ea early rly on

• n
• Inter

ervent entions ions sh shou

• uld

ld em empha hasi size ze he heal alth an h and re rela lation ionshi ship ben enef efit its

• Us

Use f e fam amil ily/fr y/frie iend nds s in in a p a pos

• sit

itiv ive e way

• “Undo” shame
• Gi

Give ho e hope pe tha hat li life e ca can im impr prove e

• Wor
• rk

k tog

• gethe

her r to

• def

efin ine e the he ben enef efit its s of

• f ch

chan ange

Intervention

• Par

Partne tner r wi with p h pat atie ients s to

• re

remove e sh sham ame (a e (and nd bla lame) e), , an and re require ire ac accep ceptance ance of

• f re

resp sponsibi

• nsibili

lity y for

• r mak

akin ing a c a cha hang nge

• Offer concern and hope to patients’ that their lives can improve
• He

Help lp pa patie ients ts work

• rk towar

ard tryi ying g to

• mak

ake eac e each h day b y better er tha han the he day be y before

• re

Summary- What should we do?

• Mat

attson tson M, Li Lipari ari RN RN, , Ha Hays ys C, Van an Ho Horn rn SL

• SL. A d

A day i y in the he lif life o e of f ol

• lder

er ad adult lts: s: Su Substance stance use se facts.

• acts. The

he CB CBHSQ HSQ Rep epor

• rt:

t: May y 11, 20 2017. Cen enter er for

• r Beh

ehavio ioral ral He Heal alth h St Stat atis istics ics an and Qual alit ity, , Su Substance stance Abuse se an and Men ental al He Heal alth h Se Servic ices es Admin inis istr trat ation, ion, Roc

• ckvil

kville le, MD. D.

• Le

Lehm hman ann n S, S, Fin inger erhood hood M. Su Substance stance use se dis isor

• rder

ers s in in la later er li life. e. Ne New w En Engl gland and Jo Journ urnal al of

• f Med

edic icine ine 20 2018; 8; 378 78:23 2351-60. 60.

References

QUESTIONS?

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www.marylandMACS.org Additional questions: Tracy Sommer tsommer@som.umaryland.edu 1-855-337-MACS (6227)