Substance Use Disorders in Older Adults
J.D. is a 74-year-old male with a history of polysubstance abuse who presents to the emergency department with suicidal ideation. Recently, he had begun using cocaine in order to cope with various life stressors. In the past, he has used heroin, LSD, and marijuana. He has engaged in substance abuse treatment on several different occasions. J.D. has held various jobs, but now is unemployed and receives Social Security payments.
America’s geriatric population is growing. As it does, substance use disorders among older adults are increasing in prevalence. Physicians today will see and need to treat more patients like J.D. In 2000 and 2001, 1.7 million adults age 50 years and older were in need of substance abuse treatment. This number will likely increase to 4.4 million by 2020.1 Much of the research on substance abuse in older persons has focused on alcohol. However, other drugs of abuse are also of increasing concern, especially with the maturation of the baby boomers, who have higher rates of lifetime illicit drug use than older cohorts.2 Because of changing patterns of drugs of abuse in older populations, this review will focus on substances other than alcohol.
The study of substance use disorders in older persons can be undertaken from many different approaches. One approach can be according to drug type: prescription, illicit, over-the-counter, and herbal drugs. The literature often groups alcohol, illicit drugs, and prescription drugs together without distinction. A second approach may be to examine the problem according to different patterns of use, whether it is abuse, dependence, or misuse; this approach is not often used. Another approach may be to examine cohorts. Studies that take a cohort perspective generally compare older adults to younger adults. It may be helpful to compare cohorts within the geriatric population, such as individuals age 65-74, 75-84, and 85 years and older. Finally, one might evaluate geriatric drug use from a cultural perspective; however, little is known about the cultural aspects of substance use disorders in older persons.
This review will approach substance use disorders in older adults according to drug type and not according to other patterns of use. We will examine prescription and illicit drug use as separate issues among older adults.
Prevalence of Substance Use in Older Adults
Determining the prevalence of substance use disorders in older persons poses a unique challenge for two main reasons: (1) older people may be less likely than their younger counterparts to report their own substance use,3 and (2) physicians may underrecognize and underreport substance use disorders in older adults. In one study of 310 elderly admissions to a substance abuse consultation service, only a relatively small percentage of benzodiazepine users were referred, a surprising find given that benzodiazepines are used by a substantial portion of the older population.4
Information regarding the prevalence of prescription drug abuse and dependence among older persons is sparse, and often comes from studies with limited sample sizes within substance abuse treatment centers. For example, the prevalence of opiate abuse among older patients with chronic pain is approximately 2%.5 Respectively, the prevalence of prescription narcotic and benzodiazepine dependence is estimated to be 1.4% and 11.4% among geriatric patients receiving outpatient psychiatric care.6 Between 1974 and 1993, 16% of all geriatric admissions to the Mayo Inpatient Addiction Program represented prescription drug use disorders.7 Little information is available regarding geriatric prescription substance use disorders in the general population.
Rates of illicit substance use disorders in older adults vary according to research setting: the general population, emergency departments, and substance abuse treatment centers each manifest different rates of use (Table). Studies in this area have either examined illicit drugs as a whole or individually.
Estimated rates of geriatric illicit substance use disorders in the general population come from the 2006 National Survey on Drug Use and Health, which examined illicit drug use as a whole. “Illicit drug use” in this study was defined as the use of marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, as well as the non-medical use of prescription-type pain relievers, tranquilizers, sedatives, and stimulants. In 2005, 0.4% of adults age 65 years or older had reported illicit drug use in the previous month. In 2006, this number had not changed significantly at 0.7%. However, the portion of the elderly population using illicit drugs is likely to continue growing. Americans age 50-54 years nearly doubled their reported illicit drug use between 2002 and 2006, from 3.4% to 6.0%, respectively.2 This cohort represents the baby boomers.
Illicit substance use disorders in older adults are more commonly seen in the emergency department. The prevalence of cocaine use in this setting ranges from 1.9% to 2.0%. The respective rates of PCP and marijuana use are estimated to be 2.2% and 2.5%.3,8 In substance abuse treatment centers, the estimated rates of illicit substance use disorders in older persons vary (Table).4,9
Some information regarding the prevalence of substance use disorders in older adults does not distinguish prescription from illicit drugs. One Veterans Affairs (VA) study of older adults in psychiatric or substance abuse programs estimated combined substance abuse or dependence rates at 9%, excluding alcohol.10
Risk Factors for Substance Use in Older Adults
Some studies have identified potential risk factors for substance use disorders in older persons, including gender and certain social situations. Female gender may be a risk factor for prescription drug dependence, as was found to be true in a study of 100 patients at the Mayo Inpatient Addiction Program who were dependent on prescription drugs.7 Marital status (being either single, separated, or divorced) and living alone are also risk factors for drug abuse in older adults; however, this study did not differentiate whether these medications were prescription or over-the-counter.11 It has been hypothesized that the pharmacokinetic changes that take place in the elderly may lead to an increased potential for abuse of benzodiazepines or opiates; however, the available data are not sufficient to make such a conclusion.12
Little research has been done to identify potential risk factors specific to illicit drug use among older persons.
Adverse Effects of Substance Abuse in Older Adults
Several studies have been conducted to assess the adverse effects that drugs of abuse have on older adults. Studies of this nature are largely confined to sedative-hypnotics and narcotics, and do not distinguish between use, abuse, and dependence in their sample populations. Potential adverse effects include falls, fractures, decreased mobility, and cognitive decline.
An association between falls and the use of benzodiazepines by older persons has been repeatedly shown.13 Narcotics, however, have not been found to be an independent risk factor for falls.14 Fractures are more common among older people who use opiate analgesics.15 However, with regard to the relationship between benzodiazepine use in older persons and fractures, studies are conflicting. Some researchers have reported an increase in hip fracture risk, while others have not found this association.16-19 Certain disabilities are also potential adverse effects of benzodiazepine use in older adults. Older individuals who use benzodiazepines are more likely to develop mobility disability and activity-of-daily-living disability than non-users their age.20 Cognitive decline is also an adverse effect of benzodiazepine use in older persons. Older people who chronically use benzodiazepines score significantly lower on the Mini-Mental State Examination than non-users their age.21 Other studies suggest that pressure ulcers, urinary incontinence, and motor vehicle accidents may also be adverse effects of sedative-hypnotic use in older adults.22-24
While much is known about the adverse physical effects of illicit drug use, there is little research in this area that is specific to the elderly.
Treatment of Substance Abuse in Older Adults
Information regarding intervention and treatment of non-alcoholic substance use disorders in older persons comes from studies that are specific to chronic benzodiazepine use. It is important to note that, while the participants in these studies were chronic benzodiazepine users, not all of them necessarily fulfilled criteria for benzodiazepine dependence; the studies did not make this distinction. They nonetheless provide valuable information regarding potential treatment in either context.
Several treatment methods have been shown to be effective in the reduction or discontinuation of chronic benzodiazepine use in older adults. These are: encouragement by a physician to reduce use, short-term benzodiazepine substitution, and medication taper. Regarding the latter method, cognitive behavioral therapy (CBT) may be useful as an adjunct to treatment.
Encouragement by a patient’s general practitioner to cut down on benzodiazepine intake, either in the form of a letter or as an offer for a short consultation, may safely result in reduced geriatric substance intake. This was true in one study conducted among 284 patients of general practitioners in England. Although the study population was not exclusive to the elderly, the “typical” patients who participated were elderly females who were taking benzodiazepines for insomnia.25
Another way to treat benzodiazepine dependence is to discontinue use after a brief period of benzodiazepine substitution. This method was studied in the hospital setting, where most geriatric patients with histories of chronic benzodiazepine use discontinued use after one week of receiving either trazodone or low-dose lormetazepam substitutes.26,27
Gradual taper is also an effective way to treat benzodiazepine dependence in older persons. In terms of outcomes, older patients do just as well as their younger counterparts with this method of treatment and experience less severe withdrawal symptoms. This was shown in a study comparing 19 older patients to 22 younger patients.28
Cognitive behavioral therapy may enhance the effectiveness of taper in the treatment of benzodiazepine dependence in older adults. This depends on the reason for which patients were originally prescribed benzodiazepines. Among older patients who use benzodiazepines for insomnia, CBT as an adjunct to taper enhances the likelihood of successful withdrawal and discontinuation.29,30 Although this is not true for older patients who use benzodiazepines as anxiolytics, CBT does reduce anxious symptoms for these patients during taper.31
Specific to illicit drugs, little research has been done on the treatment of substance use disorders in older persons. A study by Moos et al,10 however, has shown that when older patients are admitted to the hospital for substance use disorders, they receive services less oriented toward these disorders and more toward medical management. This study compared older and younger patients admitted to VA substance abuse treatment programs. It is important to note that this study included, but was not exclusive to, illicit substance users in its sample population.10
Recovery in Older Adults
With regard to recovery from prescription substance use disorders, available information is specific to patients recovering from chronic benzodiazepine use. Research provides insight into relapse rates, predictors of relapse, and ways in which recovering patients improve. Up to 42% of older patients recovering from chronic benzodiazepine use will relapse within 24 months of treatment.32 The predictors of relapse are as follows: treatment condition, insomnia severity at the end of treatment, and psychological distress. This is true for patients who used benzodiazepines for insomnia and who withdrew from them in the context of CBT, medication taper, or both.32 Improvements in cognitive and psychomotor tasks take place for elderly patients recovering from long-term benzodiazepine use. Such improvements are seen 24-54 weeks after successful withdrawal. With regard to potential improvements in mood and sleep, however, such patients do not differ from their counterparts who continue to use benzodiazepines.33
Much of the research studies that provide information on illicit substance use disorders in older adults include, but are not exclusive to, illicit substance users in their sample populations. In other words, abusers of alcohol, illicit drugs, and prescription drugs were grouped together in the population samples of many of these studies. Nevertheless, they offer valuable data on geriatric recovery in the following areas: factors that predict either abstinence or relapse and mortality in the context of substance use disorders.
Certain factors are positively associated with successful long-term recovery from geriatric illicit substance use. These include having an abstinence goal, longer length of stay in treatment, and the absence of family or friends who encourage use.34,35 Specific to methadone maintenance, older people have been shown to be more successful with recovery if they are married.36
Older persons in recovery need to be aware of the factors that are associated with relapse, which are unmarried status, more prior substance abuse service use, a psychiatric diagnosis, prior treatment in a psychiatric unit, and shorter length of stay in treatment.37,38 Specific to methadone maintenance patients, exposure to illegal drug use in neighborhoods and social networks is a predictor of relapse.39
Moos and colleagues40 have described mortality rates and predictors of mortality for substance abuse patients in VA medical centers in the four years after an episode of care. Twenty-four percent of such patients had died by that time. Predictors of earlier mortality included older age, unmarried status, alcohol psychosis, organic brain disorder diagnoses, several medical diagnoses, more prior inpatient and outpatient medical care, and an episode in an extended-care unit. On the other hand, more prior outpatient mental healthcare and remitted status predicted lower mortality.40
Outcome of the Case Patient
As J.D. reported to the emergency department physician that he planned to commit suicide, he was admitted to the inpatient psychiatric unit. His antidepressant medications were adjusted, and he received substance abuse counseling during his inpatient stay. During the course of treatment, he reported improved mood and denied suicidal ideation. J.D. also reported a resolve to “stay clean.” He was subsequently discharged from the hospital to an assisted living facility as a transition to independent living. After one month in the assisted living facility, J.D. successfully moved into an adult living community that provided activities and socialization. His mood symptoms currently remain well-treated, and he has not had a relapse for substance abuse.
The available information about substance abuse and dependence disorders in older adults suggests that this is an increasingly important and prevalent issue. While the magnitude of this problem is increasing, our knowledge about this area is not keeping pace. This review suggests that important information regarding demographics, identification, treatment, and recovery issues for substances other than alcohol needs much more attention and formal evaluation for older persons. The maturation of the baby boomers is a reminder that different cohorts within a population can have an important impact on specific health problems; in this case the spectrum of substance use disorders in sub-cohorts of older adults. These factors indicate a growing need, as well as an increasing opportunity for research about substance abuse disorders in older persons.
The authors report no relevant financial relationships.
Dr. Winkel is a Resident Physician, University of Utah Psychiatry Residency Program; and Dr. Bair is Associate Director, SLC VAMC GRECC, and Professor, Geriatric Internal Medicine and Geriatric Psychiatry, University of Utah School of Medicine, Salt Lake City.
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