Prescription Drug and Alcohol Abuse in an Older Woman
Dr. M was making rounds in the hospital when he received a call from his office telling him that his patient, Mrs. S, was in the emergency room after being involved in a car accident. Mrs. S is a 67-year-old woman who suffered the loss of her husband one year ago due to lung cancer. She has multiple medical problems including hypertension, congestive heart failure, history of an inferior wall myocardial infarction at age 62, coronary artery disease, and severe osteoarthritis. Her medications include amlodipine 10 mg, atenolol 100 mg, furosemide 40 mg, ramipril 5 mg, and digoxin 0.125 mg, all of which are taken once daily. She also takes tramadol 50 mg with acetaminophen 650 mg 4 times daily. Mrs. S arrived in the emergency room appearing drowsy and confused. A full work-up including head computed tomography scan and neurological evaluation did not reveal any focal signs or injuries. A urine toxicology screen was positive for the presence of benzodiazepines, opiates, and barbiturates. A blood alcohol test revealed a level of 0.4 mg/dL. Dr. M was surprised by these findings, as Mrs. S cared for her husband during his cancer treatment and was very responsible about taking her own medications.
He met with Mrs. S’s two daughters in the emergency room. They informed him that they have been increasingly worried about their mother’s use of diazepam, lorazepam, and a headache medicine containing butalbital. In addition, they described a large supply of medications including codeine, morphine, and oxycodone left over from the long period of time when she cared for their father prior to his death. Her daughters believed that Mrs. S has been very anxious and depressed, and has been seeing many different doctors over the past year, getting prescription medications from all of them. She has never had a problem with alcohol, but has continued to drink a glass of wine daily in addition to using increasing amounts of prescription drugs. Dr. M examined Mrs. S, who was now more alert and was asking to go home. Fortunately, no one was seriously injured in the car accident. Her daughters confronted her in the emergency room, telling her she must get help for her drug use and depression. A loud dispute resulted, and Dr. M separated the family. He asked Mrs. S about her other doctors and medications. She became tearful, stating that following the death of her husband she felt “pain inside and out.” She felt embarrassed, guilty, and overwhelmed.
When Dr. M discussed how the car hit by Mrs. S had two children in the backseat, she agreed to get help. She told Dr. M that she had been taking diazepam prescribed by her rheumatologist, a headache medication prescribed by her gynecologist, and lorazepam prescribed by her cardiologist, in addition to using medications from her late husband’s supply. It became clear that Mrs. S had been abusing multiple medications including benzodiazepines, opioids, and barbiturates, and was obtaining drugs from various physicians, in addition to drinking alcohol. Dr. M contacted the hospital chemical dependency treatment unit, but found that they were reluctant to take an older patient with multiple medical problems. He contacted the physician in charge, hoping that he could arrange appropriate treatment for her.
Substance abuse and dependence in older adults is less common than it is in younger persons, but it is also less likely to be recognized. Diagnosis is often more difficult in the elderly, as denial of problems is more frequent and impairments in functioning due to drug use may be attributed to the aging process.1 Older adults are often prescribed sedatives, hypnotics, and analgesics, but may not understand the instructions or appropriate use of these agents. An elderly patient who visits several physicians can easily obtain multiple prescriptions and escalate their use if he or she is seeking relief from feelings of stress, grief, bereavement, depression, and anxiety. Borrowing medications from family members is fairly common and can lead to a greater increase in use.2 Once a habitual pattern is established, many find themselves in a pattern of escalating abuse that results in significant excess morbidity and even mortality.1-3 It is difficult to obtain prevalence rates for prescription drug abuse and dependence among elderly persons. In Veterans Affairs populations, older adults with prior histories of alcohol and drug dependence have been identified as being at high risk for abuse of prescription medications in late life.2 Among a sample of patients enrolled in a large managed care plan, 0.1% of those over the age of 65 were treated for chemical dependency problems.4 This same low prevalence was found in the epidemiologic catchment area studies that surveyed more than 3000 older adults living in the community.1 It is well known that older adults are more likely to be prescribed sedative-hypnotics and benzodiazepines, and are high utilizers of analgesics.
A great deal of problem drug use may be iatrogenic in nature and only identified after a patient is hospitalized for medication-related disorders. Family members who are concerned about the patient’s drug use are vital sources of information and history. The primary care physician is in an extremely important position to evaluate the early signs of prescription drug abuse, such as obtaining medications from multiple sources, decline in functional status, unexplained falls, and confusion that has no clear cause.1,2 Changes in age-related pharmacokinetics and sensitivity to the central nervous system effects of medications make older adults more vulnerable to adverse drug events and interactions. Drug-drug interactions and adverse events account for up to one-third of hospital admissions of older adults.
Recognition of drug abuse in an older patient not only often requires a high index of suspicion but also sympathetic probing regarding patterns of use.3 It is important to approach the patient in a supportive and nonthreatening manner, as denial is central to all substance abuse and may lead to refusal to answer questions. Screening procedures common to geriatrics, such as inquiring about all prescription medications used and asking patients to bring their pill bottles to the visits in a bag, often identify problematic drug use. Screening for warning signs such as poor self-care, neglect of usual routines, and the presence of symptoms of depression, anxiety, or insomnia are also important. Drug use that results in impairment in functioning, threatens health status, or places the adult at risk for harm is considered problematic and often meets criteria for abuse or dependence.1 Tolerance and withdrawal are common if the patient has been escalating his or her use of benzodiazepines, opioids, or sedative-hypnotic agents. Seeking medications from multiple physicians, using medications prescribed for other family members, and combining analgesics or sedatives with alcohol is highly indicative of substance abuse.
The National Institute on Alcohol Abuse and Alcoholism has identified potential problem alcohol use in the older adult as drinking more than one alcoholic beverage per day or more than seven drinks total in one week.2 Unfortunately, identifying potential problematic use of prescription medications is more complex, as elderly patients suffer from chronic pain, anxiety, and insomnia and are often prescribed medications for these conditions. Older adults often visit multiple physicians in different specialties and obtain multiple prescriptions from each. Older persons are also reluctant to discard unused medications, often borrow pills, and may continue to consume a moderate amount of alcohol while taking an increased amount of medications.1,2 As the case patient illustrates, an older adult may suffer a loss or stress and then develop feelings of anxiety and depression that lead to an escalating pattern of drug use in an attempt to reduce his or her distress.
Risk factors associated with substance abuse and dependence in late life include a prior history of alcohol abuse, family history of substance abuse, new onset of medical problems, chronic pain with inadequate treatment, loss of a spouse, recent retirement, and social isolation.1-3 Recognition of substance abuse problems in older women is very low. Women who abuse medications are more likely to be married to an alcoholic or drug abuser, be victims of domestic violence, or suffer from unrecognized psychiatric disorders including depression and anxiety. Elderly patients who are abusing medications are at an extremely high risk for suicide.1,2 In part, this is due to depression, isolation, and the erratic behavior and impaired judgment that accompanies substance abuse. All patients with substance abuse problems should be assessed for depression and suicidal ideation. If suicide risk appears high, emergency inpatient treatment should be an immediate consideration.1
Treatment of prescription drug abuse in an older adult requires a comprehensive approach with strong medical management of comorbid conditions and anticipation of the potential for medical complications during detoxification (Table).1-5 Older adults are far more likely to require inpatient treatment, particularly if they have comorbid medical or psychiatric conditions that require monitoring during the withdrawal period. Outpatient counseling and education may be sufficient for a medically stable patient who is identified early and has strong social supports.3-5 Linkage to outpatient services following inpatient treatment is essential. Older adults are often very successful in treatment. They are frequently more motivated than younger persons and are able to engage in educational and counseling programs.4 Elderly patients are often able to utilize their life experiences and coping skills to address problems with substance use. Cognitive-behavioral interventions have been shown to be effective with older adults, who are more likely to continue in treatment than younger patients.5 Treatment is often complicated by the patient’s chronic medical conditions. An elderly patient suffering from chronic pain will require an individualized care plan that meets his or her needs while minimizing the risk of relapse. Complete abstinence from opioids may be unrealistic for some patients who may require these medications for adequate pain relief; these patients will need additional supervision.1 Use of a primary care physician to prescribe all medications and coordinate care is valuable, as is contact with the pharmacist who fills the patient’s prescriptions.
OUTCOME OF THE CASE PATIENT
After discussion with the Unit Chief of the chemical dependency unit, Mrs. S was admitted for treatment. Dr. M continued to follow her regarding her chronic medical problems. She underwent a detoxification protocol with buprenorphine for her opioid abuse and oxazepam for her benzodiazepine, butalbital, and alcohol abuse. Her course was complicated by fluctuating blood pressures that reached as high as 200/120 mm Hg, requiring the addition of clonidine and increases in her standing doses of atenolol and amlodipine. She was given as-needed doses of promethazine for nausea and ibuprofen for joint pain. After 8 days, she no longer required any buprenorphine or oxazepam. She continued to complain of anxiety, slept only 3-4 hours each night, was often tearful, and chronic joint pain remained a problem. Her appetite was poor. Mirtazapine 15 mg was started after a psychiatric consultation, and the dose was increased to 45 mg at bedtime with some improvement. Gabapentin 100 mg 3 times per day was added for pain, but she continued to be limited by the severity of her arthritis. She was able to engage in 12-step meetings and participated in individual and group counseling, as well as sessions with her family. After a 2-week stay, she returned home but entered a partial hospital program that offered ongoing chemical dependency therapy, psychiatric services, and pain management. Her daughters participated in family education programs offered by the treatment center and were also referred to Al-Anon, a 12-step program for friends and family members of alcoholics.