NEVER TOO OLD OLDER PEOPLE AND SUBSTANCE MISUSE

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NEVER TOO OLD OLDER PEOPLE AND SUBSTANCE MISUSE

• SCOTTISH DRUGS FORUM
• GLASGOW
• 18 November 09

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• Professor Ilana Crome
• Keele University Medical School
• Chair, WG Older Substance Misusers, RCPsych
• Immediate Past President Drug and Alcohol
  Section, European Psychiatric Association
• Dr Alex Baldacchino
• Director Centre for Addiction Research and
  Education Scotland (CARES)
• Ninewells Hospital and Medical School
• Dundee University and NHS Fife

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Overview

• Prevalence and epidemiology
• Treatment evidence and outcomes
• Practical interventions

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Substance misuse is
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MYTHS ABOUT ADDICTION AND OLDER PEOPLE

• At your age what does it matter?
• It is just a phase - you grow out of it.
• Its your age there is nothing you can do about
  it.
• Illicit drug use no longer a young mans
  disease?
• Drug use and the older person a contradiction
  in terms?

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Cannabis case grandmother is spared prison
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Projecting drug use among aging baby boomers in
2020? (Colliver et al 2006)
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Prevalence

• A snap shot of
• general population studies and
• clinical studies

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Some methodological issues

• Invisible epidemic ageism, denial by
  professionals and families, stereotypes,
  difficult diagnosis, non-specific
• Age varies from lt55-gt75 alcohol metabolism
  declines with age and results in greater damage
• What is a standard drink or safe limit for
  older people?
• Other drug use prescribed, OTT, interactions
• Terminology application of use, misuse,
  dependence
• Medical complications without being dependent

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Some methodological issues

• Gender women metabolise faster more severe
  effects earlier or lower levels of drinking
  present later more comorbidity especially abuse
• Measurement relevant, reliable, across
  substances and in combination
• Comparability between studies - Community studies
  miss out heavier drinkers

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Is it a problem for older people?

• Receive most prescriptions dispensed by NHS
• Multiple medications 1/10 receive at least one
  potentially inappropriate drug (up to 40)
  (Lechevallier-Michel et al 2004)
• 4 times greater in women (widowed, less educated,
  lower income, poor mental and physical health,
  social isolation)
• Psychoactive medications with abuse potential are
  being used by 1 in 4 older people (Simoni Yang
  2006)

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Is it a problem?

• Over the last ten years there has been an overall
  increase (numbers and rate) in older people
• Using illicit substances and alcohol
• Hospital admissions for poisoning, drug related
  mental disorders, alcohol related physical
  disorders
• Drug related deaths and alcohol related deaths
• Usually men gt women, older usually use less

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Is it a problem?

• Opiate dependent people do survive into old age
• USA Lifetime prevalence rates for illicit drug
  dependence is 1 over 60s (Hinkin 2002)
• Alcohol consumption in GP (Hajat et el 2004) 5
  men drinking 2.5 women over benchmarks
• Older opioid maintained patients Lofwall et al
  2005 later in life, more medical problems, worse
  general health than younger
• Both groups had high rates of lifetime
  psychiatric illness and substance use disorder
  and poor general health compared to general
  population

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Health conditions among ageing addicts Hser et al
2004

• 108 survivors 58.4 years (33 year cohort)
• Used heroin for 29.4 years
• Current use 84 used cigarettes, 17.6 drank
  alcohol daily, 23 heroin, 21 marijuana, 11
  cocaine. 6 amphetamines
• 51 hypertension, 22 hyperlipidemia
• 13 elevated blood glucose, 50 overweight
• 33 abnormal pulmonary function

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Health status

• 50 abnormal liver function
• 94 tested positive for Hep C, 86 for Hep B,
  3.8 for syphilis and 27 for TB
• Perceived themselves as having worse physical
  functioning, worse emotional well being, less
  energy and worse general health when compared to
  the general population
• Probably conservative estimates

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Older opiate addicts (Sidhu et al 2007) Health
Problems
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Results Profile of Older Opiate Misuser in
Stoke-On-Trent

• Age range gt50 years
• 95 of cohort were white Caucasian males
• 85 were single at time of study 50 had
  separated/divorced by age 35yrs.
• Limited education 65 had no qualifications 30
  had between 4-9 O levels.
• 90 were currently unemployed 10 have never
  been in employment.

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Results Substance Misuse History

• Lifelong polydrug users
• Licit drugs Nicotine (100 of cohort)
• Alcohol (47)
• Illicit drugs Cannabis (75), Amphetamines
  (60), Crack (50), Hallucinogens (20)
• Current substance use Cannabis (55), Crack
  (35) and Benzodiazepines (35)

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Results Opiate Misuse History

• Opiate use was usually started in late 20s
• Average age first exposed to heroin 29.8 years
  (range 16-46 years SD8.8years)
• Average length of heroin use 18.5 years (range
  6-38 years SD-8.7years)
• In 20 of cases a major life event had occurred
  prior to using heroin

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Results Diverse Range of Health Problems

• Special health needs highlighted Present
  in study
• in national guidelines
• Infectious disease
• Hepatitis C v (67)
• Hepatitis B v (50)
• HIV X ( 0 -
  only 10 tested)
• Medical
• Respiratory disease v (25)
• Diabetes v
  (10)
• Not mentioned Musculoskeletal
  pain (35)

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Health problems

• Special health needs highlighted Present
  in study.
• in national guidelines
• Cardiovascular
• P.E./D.V.T v (25)
• Hypertension X ( 0)
  (Inadequate information)
• Cardiac valve destruction X (0) (No
  documentation)
• Psychiatric
• Self harm v
  (42)
• Depression v (40)
• Memory loss v (25)

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Special health needs

• Despite the complaint of memory loss in 25 of
  cohort, in only 1 patient was mini mental state
  examination documented.
• 40 sample with a respiratory complaint did not
  have a diagnosis or treatment plan.
• 55 of cohort had no documentation of Hepatitis B
  and C status.
• 15 sample were receiving opiate analgesia for
  musculoskeletal pain.

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Results Treatment Outcomes

• Positive outcomes
• Methadone maintenance programme 50 in treatment
  for over 3 years.
• The present mean average dose was 51mls of
  methadone, but range of doses varied between
  25mg/ml-94mg/ml.
• All reported reduction in quantity of heroin used
  
• In 60 of the group who were using 300/week
  prior to treatment, amount spent reduced to
  20/week.
• Reduction in intravenous administration whilst in
  treatment (70 to 5).
• Negative outcome
• Only 22 showed consistently negative opiate
  urine samples in the previous 6 months.

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Discussion

• This is the first study of this kind in the UK
• Treatment is associated with positive outcomes
• The older substance misuser has a diverse range
  of health problems i.e. physical and psychiatric
• All special health needs may not have been
  identified as there was no routine screening
• Where they identified, they were
• Not appropriately further assessed investigated
  monitored
• Not treated by a comprehensive multidisciplinary
  team in liaison with other health practitioners

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Conclusions

• Study has substantiated the special health needs
  which older substance misusers experience
• Current national guidance does not provide
  evidence based management specific to older
  opiate users
• UK guidance appropriate for this group needs
  further development in terms of4
• Screening assessment
• Specific treatment regimes medication licences
• Service delivery in multidisciplinary teams (e.g.
  geriatricians, old age psychiatrists,
  psychologists, physiotherapists)
• 
  
• 
  

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Recommendations Good practice clinical
governance issues

• Supportive non-confrontational by trained
  personnel who can prevent ridicule
• Inaccessible homebound, transportation, rural
• Create a safe environment, financial problems
• Explanations simple, content age specific, pace
• Literacy and language, and sensory, needs

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Recommendations Good practice

• Implementation of what works in adults
• Adaptation - addiction and old age services
• Evidence base for the older age group length,
  dosage, type of intervention
• Development of protocols and care plans
• Innovation
• Flexible, adaptive, optimistic and long term

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Recommendations Assessment

• A thorough, ongoing assessment which includes a
  comprehensive history
• Many tools for screening, assessment and
  monitoring outcome but for adults
• Neurocognitive impairment
• Semi-structured interviews increase
  identification
• Severity of substance use, misuse and dependence.
  
• Substance use and mental disorders

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Assessing elderly patients (Parker, Hospital
Doctor 26 4 07, and Crome personal communication!)

• Guard against clinical ageism not an indicator
  of ability to function, benefit from treatment,
  quality of life
• Comprehensive geriatric assessment is key to
  effective practice
• Functional assessment is a useful clinical tool
• Geriatric medicine oriented towards problems (but
  must not neglect diagnosis)
• Dont write poor historian consider reasons
  for poor history eg hearing aid, confusion

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Recommendations

• Social admission is a myth and not a medical
  diagnosis
• Understand geriatric giants falls, confusion,
  decreasing mobility, incontinence, (iatrogenesis,
  frailty)
• Manage underlying cause
• Learn to recognise delirium
• Drug therapy is often the cause of symptoms

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Instruments

• G-MAST - Geriatric version of MAST gt5 positive
  MAST, SMAST, B-MAST (Michigan Alcohol Screening
  Test)
• SMAST-G shorter version of the G-MAST
• CAGE - 4 questions gt2 positive (Hinkin 2002)
• Alcohol related problems survey for older people
  (ARPS) and Short ARPS (shARPS)
• AUDIT (Alcohol use disorders test) or AUDIT -5
  (Philpot et al 2003)
• MAST-G and CAGE most appropriate Beullens et al
  2004
• NO VALIDATED INSTRUMENTS FOR DRUG MISUSE

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Recommendations Critical issues in treatment

• What is an appropriate treatment goal?
• What is motivation for psychological change?
• Regularity and credibility of medical advice?
• How appropriate are techniques for assessment,
  advice, assistance? IT, telephone, larger print
• Ask Assess Advise Assist Prescribe Arrange!
• Adequate fluids, eating as soon as possible
• Anti-epileptics and anti-emetics rarely required

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NICE guidelines and others

• Psychosocial interventions
• Opioid detoxification
• Methadone and burprenorphine
• Naltrexone
• Community interventions in vulnerable substance
  misusers
• Department of Health Orange book 2007
• SIGN guidelines Scotland
• By and large comorbidity and vulnerable age
  groups are
• excluded

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Pharmacological treatment
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Pharmacological treatment options

• Drugs not investigated/licensed for over 65s
• Benzodiazepines caution due to accumulation but
  need to give enough to cope with withdrawal
• Acamprosate, disulfiram and naltrexone with
  utmost caution
• Methadone and buprenorphine supervised
• Nicotine replacement and bupropion if not C/A

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OUTCOME STUDIES OLDER PEOPLE

• Do older people recover?

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Systematic Review of Treatment for Older People
Substance Problems

• Ishbel Moy
• Martin Frisher
• Peter Crome
• Ilana Crome
• School of Medicine and School of Pharmacy
• Keele University

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Search Strategy

• Search conducted May/June 2007, information from
  each study collated and tabulated, report written
  June/July 2007
• PubMed, The Cochrane Library, MEDLINE, Project
  CORK, and EMBASE searched up to January 2007
• Studies generated from expert consensus papers or
  advisors
• Keywords included elderly older people
  addiction substance misuse substance abuse
  treatment alcohol nicotine smoking cessation
  prescription medications benzodiazepines
  illegal drugs illicit drugs

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Inclusion Criteria

• 1 Older defined as 50 years.
• 2 Substances
• - alcohol
• - nicotine
• - prescription medications
• - illicit drugs
• 3 Trials focussing on older people specifically
  
• 4 Trials comparing older with younger
• 5 Pharmacological and psychological treatments
  for addiction

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Studies Included

• 2500 titles generated.
• 50 studies thought to be appropriate and full
  articles obtained.
• 16 studies fulfilled inclusion criteria
• - 9 on alcohol misuse
• - 2 on treatment of alcohol and drug misuse
  (grouped with alcohol misuse for analysis)
• - 3 on smoking cessation
• - 1 on methadone maintenance
• - 1 on prescription medications

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Evidence - Review of 16 studies on older
substance misusers

• Current evidence based guidance does not include
  over 50s
• Mainly alcohol (11) smoking (3) opiates (1) and
  prescription drugs (1) in over 50s
• 2 studies in the UK
• Some in services for older people some in mixed
  age services
• Almost all treatments were variety of
  psychological interventions

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Results

• Time period 1984-2001 14 of these after 1990.
• Country 13 in US, 2 in UK, 1 in Canada.
• Settings 5 studies conducted in primary care, 4
  in outpatient setting, 1 inpatient
• Sample size 24 to 3,622 some of the larger
  studies had a relatively small proportion of
  adults in older age range.

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• Demographic information
• - Age cut-off for older varied, from 50
  years and 65 years.
• - Majority of participants in 14 studies were
  male other 2 were 93 and 100 female.
• - 6 studies gt70 Caucasian participants.
• Ethics approval 6 studies described ethical
  approval or exemption.

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Results

• Measures
• - e.g. baseline quantity/frequency time-line
  follow-back addiction severity index (ASI) Beck
  Depression Inventory physical and psychiatric
  problems.
• - e.g. outcome ASI abstinence drinks/day
  health status formal/informal aftercare

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Results

• Design 5 studies contained a control group.
• Programmes
• Elder-specific programs or examined older
  patients in 7 studies
• Older patients treated in adult addiction
  programs and compared with younger age groups in
  8 studies
• 1 compared outcomes of older adults in both
  elder-specific and adult addiction programs.

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Overview of Study Findings - Alcohol

• Number of patients who achieve their follow-up
  goal is at least comparable to that of other
  populations.
• .
• Those patients in elder-specific treatment appear
  to improve across a wide variety of outcome
  domains.
• Brief Advice and Motivational Enhancement are
  equally successful for both older and adult
  populations.

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Overview of Study Findings - Alcohol

• Potential for good outcomes in those older people
  who seek treatment possible they may have
  achieved even better outcomes in an
  elder-specific program.
• Both older men and women are capable of achieving
  abstinence if given access to alcohol abuse
  programs.
• Value in treating older adults and that they are
  able to respond positively to treatment, but that
  there was a lack of knowledge on long-term
  management.

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Overview of Study Findings Smoking, Heroin,
Prescription Medications

• Smoking
• Intervention with the nurse practitioner led to a
  decrease in smoking.
• Older smokers appeared to benefit as much as
  younger smokers from brief office-based
  counselling.
• .
• Heroin
• Older patients might have fewer problems and do
  very well in treatment for heroin dependence.
• Prescription Drugs
• Participation was associated with a significant
  reduction in benzodiazepine, narcotic and overall
  prescription use the reduction in health care
  utilisation observed may translate to savings in
  health care costs.

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THE WAY FORWARD the ABC

• Advocacy, attitudes
• Better, appropriate treatment
• Care, risk, resilience, recovery
• Dignity, integrity, quality
• Enthusiasm for evidence
• Further research
• Generational training, partnership working
• High priority value older people

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Thanks to colleagues

• Dr Roger Bloor
• Prof Peter Crome
• Drs Ishbel Moy Harvinder Sidhu
• And many other collaboratorssorry not to mention
  by name