Addictive and CoOccurring Disorders in Late Life

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Addictive and Co-Occurring Disorders in Late Life

• David W. Oslin, M.D.
• University of Pennsylvania, School of Medicine
• And
• Philadelphia, VAMC

Hazelden Research Co-Chair on Late Life
Addictions
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Translating Positive findings in Aging to Younger
Adults
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Disclosures

• NIMH
• K08 Award
• ACSIR
• NIDA
• Center for Studies on Addiction
• NIAAA
• R01
• VA
• Merit Early Entry
• MIRECC
• HSRD Merit Award
• Industry Support
• DuPont Pharma
• Forest Labs
• Hazelden Foundation
• Pfizer

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Relevance of comorbidity to an aging population

• Cohort changes in exposure we will see more
  elderly patients using illicit substances
  (current and past abuse)
• Consequences may be greater in older adults
• Direct toxicity / withdrawal
• Indirect interactions with medications or other
  illnesses
• Comorbidity is a significant issue perhaps
  uniquely so for the elderly
• Cognition
• Minor depression
• Suicide
• Anxiety and personality problems
• Changing environment
• Social isolation
• Limited resources
• Limited access to care

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Comorbidity and Drug/Alcohol Dependence

• Higher than expect rates in representative
  community samples
• Markedly higher rates in treatment seeking
  samples
• Increased morbidity and mortality particularly
  suicide
• Presents diagnostic difficulties
• Poor prognostic factor
• Call for integrated care system

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Suicide

• Highest rates of suicide occur in late life among
  men.
• Depression causes a 5.8 fold increase in risk of
  suicide compared to death from other causes
• Heavy drinking (3 drinks/day) causes a 8.9 fold
  increase in risk of suicide compared to death
  from other causes
• Moderate drinking (1-2 drinks/day) causes a 10.6
  fold increase in risk of suicide compared to
  death from other causes

Grabble, et al. 1997
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The difficulty

• Extremely limited research
• Drug and alcohol dependence are exclusions to
  most geriatric trials
• Age 65 is almost always an exclusion for drug
  and alcohol trials

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What is the Extent of the Issues?In the Community
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Baby Boomers Aging
Grant, et. al. Drug and Alcohol Dependence 2004
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Veterans (Age 60 and Over) in Addiction Treatment

• Alcohol Only 51.8
• Street Drugs Only 9.1
• Prescription Medications only 3.6
• Alcohol and Street Drugs 26.4
• Alcohol and Prescription Medications 5.5
• Street Drugs and Prescription Medications
  0.9
• All three categories of substances 1.8
• Missing data 0.9

Sample of 110 subjects in a special
geri-addiction program
Schonfeld et al. 1990
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Past History of Heavy drinking/alcoholism

• Many older adults especially those of the
  Woodstock generation will enter late life with
  a past history of alcohol or drug abuse
• 5 fold increase in late life mental disorders
  (depression and dementia)
• Treatment of late life depression (3-5 yr
  outcomes)
• 88 of those without an alcohol history
  significantly improved
• 57 of those with an alcohol history
  significantly improved

Saunders et al. 1991, Cook et al. 1991
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Behavioral Health Laboratory (BHL) Links To
Primary Care
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Research to PracticeBehavioral Health Laboratory

• The BHL is an automated telephone assessment and
  triage service for patients identified by primary
  care providers as having depressive symptoms or
  at-risk drinking.
• The depression and alcohol clinical reminder
  system generates a consultation request to the
  BHL.
• The BHL conducts a brief telephone (20-30
  minutes) assessment generating a report for the
  PCP including diagnosis, severity, and general
  treatment recommendations.

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Drug Use Among Primary Care Patients with Minor
or Major Depression
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Types of Substance Use Among Older Adults (50)
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Drug Use Among Older Patients with Minor or Major
Depression
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Treatment
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Depression Alcohol Aging Trial

• Hypotheses
• Among older adults with major depression and
  comorbid alcoholism, naltrexone combined with
  sertraline improves the outcomes of both drinking
  and mood.
• Reduction in alcohol consumption will be
  associated with improved mood regardless of
  randomization.
• Naltrexone will lead to a reduction in alcohol
  consumption independent of changes in mood.

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Concurrent Treatment of Depression Complicated
by Alcohol Dependence

• Current depressive syndrome
• Current alcohol dependence
• Age 55 and over
• 10 sessions of compliance enhancement therapy
• 1/2 of subjects are randomly assigned to receive
  naltrexone 50 mg
• All subjects receive sertraline 100 mg
• Outcomes at 3 months

(Oslin, 2004)
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Pre-Treatment Clinical Characteristics
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Relationship between heavy drinking during the
trial and depression outcomes
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Overall Treatment Outcomes
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Substance Induced Depression in the elderly?

• Less than 50 resolution of symptoms early in
  treatment
• No relationship between clinical impression of
  primary vs. secondary depression and early
  response

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Not just Dependence

• Moving beyond DSM in conceptualizing risk

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Disease and Behavior

• Substance dependence
• Follows the biomedical model of an illness
• At-risk use
• Public health model
• Recognizes risks (health, economic, etc.)
  associated with use in individuals not suffering
  with the disease
• Most relevant for alcohol, medications, marijuana
  and nicotine.

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What about moderate or abusive drinking
(non-dependent drinking)

• Most common pattern of drinking among those with
  depression
• May be beneficial for heart disease
• Safety concerns may be less with newer
  medications (SSRIs) than older meds (TCAs)

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Response to Standard Depression Care Among the
Elderly

• PROSPECT study
• Remission of depression (men only)
• Non-drinkers 41
• Moderate drinkers 18.2
• PRISM-E study (preliminary)
• Remission of depression (men only)
• Non-drinkers 33.8
• Moderate drinkers 6.3

(Personal Communication, 2002)
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Telephone Disease Management for Depression and
At-Risk Drinking

• To develop a method for delivering high quality
  depression and alcoholism treatment in Primary
  Care, CBOCs, and other clinics in which there are
  significant transportation, staff resource, or
  other impediments to the delivery of face-to-face
  MH/SA care.
• To develop methods for translating effects
  demonstrated in randomized clinical trials to
  clinic populations.

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Treatments

• Telephone Disease Management is algorithm driven
  care delivered by a Behavioral Health Specialist.
  
• Enhanced Usual care. The PCP can monitor, treat,
  and/or refer. The PCP is provided a diagnosis and
  references for treatment options.

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Improvements with TDM
Oslin, et. al. 2003
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Is Sedative/Hypnotic Use a Co-Occurring Problem?

• Association with falls
• Association with memory impairment
• ?Association with treatment of depression

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How to Define Inappropriate Benzodiazepine Use

• Chronic Use (3 months)
• Use of long-acting agents
• Undocumented response
• Lowest effective dose (harm reduction)

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Sedative/Hypnotic UseA Disappearing Problem?
MW p 0.0393, Positive Negative p0.002
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Types of Sedative/Hypnotics Used