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NEVER TOO OLD – OLDER PEOPLE AND SUBSTANCE MISUSE SCOTTISH DRUGS FORUM GLASGOW 18 November 09.

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Presentation on theme: "NEVER TOO OLD – OLDER PEOPLE AND SUBSTANCE MISUSE SCOTTISH DRUGS FORUM GLASGOW 18 November 09."— Presentation transcript:

1 NEVER TOO OLD – OLDER PEOPLE AND SUBSTANCE MISUSE SCOTTISH DRUGS FORUM GLASGOW 18 November 09

2 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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4 Overview Prevalence and epidemiologyPrevalence and epidemiology Treatment evidence and outcomesTreatment evidence and outcomes Practical interventionsPractical interventions

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6 Substance misuse is:

7 MYTHS ABOUT ADDICTION AND OLDER PEOPLE At your age what does it matter?At your age what does it matter? It is just a phase - you grow out of it.It is just a phase - you grow out of it. It’s your age – there is nothing you can do about it.It’s your age – there is nothing you can do about it. Illicit drug use: no longer a young man’s disease?Illicit drug use: no longer a young man’s disease? Drug use and the older person – a contradiction in terms?Drug use and the older person – a contradiction in terms?

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9 Cannabis case grandmother is spared prison

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11 Projecting drug use among aging baby boomers in 2020? (Colliver et al 2006) >50 years old 1999/ Past year marijuana users 1% (719,000) 2.9% (3.3 m) Any illicit 2.2% (1.6 m) 3.1% (3.5 m) Non-medical use 1.2% (911,000) 2.4% (2.7 m)

12 Prevalence A snap shot of general population studies and clinical studies

13 Some methodological issues Invisible epidemic – ageism, denial by professionals and families, stereotypes, difficult diagnosis, non- specificInvisible epidemic – ageism, denial by professionals and families, stereotypes, difficult diagnosis, non- specific Age varies from 75 – alcohol metabolism declines with age and results in greater damageAge varies from 75 – alcohol metabolism declines with age and results in greater damage What is a standard drink or ‘safe limit’ for older people?What is a standard drink or ‘safe limit’ for older people? Other drug use: prescribed, OTT, interactionsOther drug use: prescribed, OTT, interactions Terminology: application of use, misuse, dependenceTerminology: application of use, misuse, dependence Medical complications without being ‘dependent’Medical complications without being ‘dependent’

14 Some methodological issues Gender: women metabolise faster; more severe effects earlier or lower levels of drinking; present later; more comorbidity especially abuseGender: 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 combinationMeasurement: relevant, reliable, across substances and in combination Comparability between studies - Community studies miss out heavier drinkersComparability between studies - Community studies miss out heavier drinkers

15 Is it a problem for older people? Receive most prescriptions dispensed by NHSReceive most prescriptions dispensed by NHS Multiple medications – 1/10 receive at least one potentially inappropriate drug – (up to 40%) (Lechevallier- Michel et al 2004)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)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)Psychoactive medications with abuse potential are being used by 1 in 4 older people (Simoni & Yang 2006)

16 Is it a problem? Over the last ten years there has been an overall increase (numbers and rate) in older peopleOver the last ten years there has been an overall increase (numbers and rate) in older people Using illicit substances and alcoholUsing illicit substances and alcohol Hospital admissions for poisoning, drug related mental disorders, alcohol related physical disordersHospital admissions for poisoning, drug related mental disorders, alcohol related physical disorders Drug related deaths and alcohol related deathsDrug related deaths and alcohol related deaths Usually men > women, older usually use lessUsually men > women, older usually use less

17 Is it a problem? Opiate dependent people do survive into old ageOpiate dependent people do survive into old age USA: Lifetime prevalence rates for illicit drug dependence is 1% over 60s (Hinkin 2002)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 benchmarksAlcohol 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 youngerOlder 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 populationBoth groups had high rates of lifetime psychiatric illness and substance use disorder and poor general health compared to general population

18 Health conditions among ageing addicts Hser et al survivors 58.4 years (33 year cohort)108 survivors 58.4 years (33 year cohort) Used heroin for 29.4 yearsUsed heroin for 29.4 years Current use : 84% used cigarettes, 17.6% drank alcohol daily, 23% heroin, 21% marijuana, 11% cocaine. 6% amphetaminesCurrent use : 84% used cigarettes, 17.6% drank alcohol daily, 23% heroin, 21% marijuana, 11% cocaine. 6% amphetamines 51% hypertension, 22% hyperlipidemia51% hypertension, 22% hyperlipidemia 13% elevated blood glucose, 50% overweight13% elevated blood glucose, 50% overweight 33% abnormal pulmonary function33% abnormal pulmonary function

19 Health status 50% abnormal liver function50% abnormal liver function 94% tested positive for Hep C, 86% for Hep B, 3.8% for syphilis and 27% for TB94% 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 populationPerceived themselves as having worse physical functioning, worse emotional well being, less energy and worse general health when compared to the general population Probably conservative estimatesProbably conservative estimates

20 Older opiate addicts (Sidhu et al 2007) Health Problems

21 Results: Profile of Older Opiate Misuser in Stoke-On-Trent Age range >50 yearsAge range >50 years 95% of cohort were white Caucasian males95% of cohort were white Caucasian males 85% were single at time of study; 50% had separated/divorced by age 35yrs.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.Limited education: 65% had no qualifications; 30% had between 4-9 ‘O’ levels. 90% were currently unemployed; 10% have never been in employment.90% were currently unemployed; 10% have never been in employment.

22 Results: Substance Misuse History Lifelong polydrug users:Lifelong polydrug users: Licit drugs: Nicotine (100% of cohort) Licit drugs: Nicotine (100% of cohort) Alcohol (47%) Alcohol (47%) Illicit drugs: Cannabis (75%), Amphetamines (60%), Crack (50%), Hallucinogens (20%) Illicit drugs: Cannabis (75%), Amphetamines (60%), Crack (50%), Hallucinogens (20%) Current substance use: Cannabis (55%), Crack (35%) and Benzodiazepines (35%)Current substance use: Cannabis (55%), Crack (35%) and Benzodiazepines (35%)

23 Results: Opiate Misuse History Opiate use was usually started in late 20’sOpiate use was usually started in late 20’s Average age first exposed to heroin 29.8 years (range years: SD=8.8years)Average age first exposed to heroin 29.8 years (range years: SD=8.8years) Average length of heroin use 18.5 years (range 6-38 years; SD-8.7years)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 heroinIn 20% of cases a major life event had occurred prior to using heroin

24 Results: Diverse Range of Health Problems Special health needs highlighted Present in study Special health needs highlighted Present in study in national guidelines in national guidelines Infectious disease Infectious disease Hepatitis C √ (67%)Hepatitis C √ (67%) Hepatitis B √ (50%)Hepatitis B √ (50%) HIV X ( 0% - only 10% tested)HIV X ( 0% - only 10% tested)Medical Respiratory disease √ (25%)Respiratory disease √ (25%) Diabetes √ (10%)Diabetes √ (10%) Not mentioned Musculoskeletal pain (35%)Not mentioned Musculoskeletal pain (35%)

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

26 Special health needs Despite the complaint of memory loss in 25% of cohort, in only 1 patient was mini mental state examination documented.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.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.55% of cohort had no documentation of Hepatitis B and C status. 15% sample were receiving opiate analgesia for musculoskeletal pain.15% sample were receiving opiate analgesia for musculoskeletal pain.

27 Results: Treatment Outcomes Positive outcomesPositive 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 outcomeNegative outcome –Only 22% showed consistently negative opiate urine samples in the previous 6 months.

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

29 Conclusions Study has substantiated the special health needs which older substance misusers experienceStudy has substantiated the special health needs which older substance misusers experience Current national guidance does not provide evidence based management specific to older opiate usersCurrent national guidance does not provide evidence based management specific to older opiate users UK guidance appropriate for this group needs further development in terms of 4:UK guidance appropriate for this group needs further development in terms of 4: –Screening & assessment –Specific treatment regimes & medication licences –Service delivery in multidisciplinary teams (e.g. geriatricians, old age psychiatrists, psychologists, physiotherapists)

30 Recommendations: Good practice – clinical governance issues Supportive non-confrontational by trained personnel who can prevent ridiculeSupportive non-confrontational by trained personnel who can prevent ridicule Inaccessible: homebound, transportation, ruralInaccessible: homebound, transportation, rural Create a safe environment, financial problemsCreate a safe environment, financial problems Explanations simple, content age specific, paceExplanations simple, content age specific, pace Literacy and language, and sensory, needsLiteracy and language, and sensory, needs

31 Recommendations: Good practice Recommendations: Good practice Implementation of ‘what works in adults’Implementation of ‘what works in adults’ Adaptation - addiction and old age servicesAdaptation - addiction and old age services Evidence base for the older age group: length, dosage, type of interventionEvidence base for the older age group: length, dosage, type of intervention Development of protocols and care plansDevelopment of protocols and care plans InnovationInnovation Flexible, adaptive, optimistic and long termFlexible, adaptive, optimistic and long term

32 Recommendations: Assessment A thorough, ongoing assessment which includes a comprehensive historyA thorough, ongoing assessment which includes a comprehensive history Many tools for screening, assessment and monitoring outcome but for adultsMany tools for screening, assessment and monitoring outcome but for adults Neurocognitive impairmentNeurocognitive impairment Semi-structured interviews increase identificationSemi-structured interviews increase identification Severity of substance use, misuse and dependence.Severity of substance use, misuse and dependence. Substance use and mental disordersSubstance use and mental disorders

33 Assessing elderly patients (Parker, Hospital Doctor , and Crome personal communication!) Guard against clinical ageism: not an indicator of ability to function, benefit from treatment, quality of lifeGuard against clinical ageism: not an indicator of ability to function, benefit from treatment, quality of life Comprehensive geriatric assessment is key to effective practiceComprehensive geriatric assessment is key to effective practice Functional assessment is a useful clinical toolFunctional assessment is a useful clinical tool Geriatric medicine oriented towards problems (but must not neglect diagnosis)Geriatric medicine oriented towards problems (but must not neglect diagnosis) Don’t write ‘poor’ historian: consider reasons for poor history eg hearing aid, confusionDon’t write ‘poor’ historian: consider reasons for poor history eg hearing aid, confusion

34 Recommendations Social admission is a myth and not a medical diagnosisSocial admission is a myth and not a medical diagnosis Understand ‘geriatric giants’: falls, confusion, decreasing mobility, incontinence, (iatrogenesis, frailty)Understand ‘geriatric giants’: falls, confusion, decreasing mobility, incontinence, (iatrogenesis, frailty) Manage underlying causeManage underlying cause Learn to recognise deliriumLearn to recognise delirium Drug therapy is often the cause of symptomsDrug therapy is often the cause of symptoms

35 Instruments G-MAST - Geriatric version of MAST >5 positive {MAST, SMAST, B-MAST (Michigan Alcohol Screening Test)}G-MAST - Geriatric version of MAST >5 positive {MAST, SMAST, B-MAST (Michigan Alcohol Screening Test)} SMAST-G shorter version of the G-MASTSMAST-G shorter version of the G-MAST CAGE - 4 questions >2 positive (Hinkin 2002)CAGE - 4 questions >2 positive (Hinkin 2002) Alcohol related problems survey for older people (ARPS) and Short ARPS (shARPS)Alcohol related problems survey for older people (ARPS) and Short ARPS (shARPS) AUDIT (Alcohol use disorders test) or AUDIT -5 (Philpot et al 2003)AUDIT (Alcohol use disorders test) or AUDIT -5 (Philpot et al 2003) MAST-G and CAGE most appropriate Beullens et al 2004MAST-G and CAGE most appropriate Beullens et al 2004 NO VALIDATED INSTRUMENTS FOR DRUG MISUSE NO VALIDATED INSTRUMENTS FOR DRUG MISUSE

36 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

37 NICE guidelines and others Psychosocial interventionsPsychosocial interventions Opioid detoxificationOpioid detoxification Methadone and burprenorphineMethadone and burprenorphine NaltrexoneNaltrexone Community interventions in vulnerable substance misusersCommunity interventions in vulnerable substance misusers Department of Health ‘Orange’ book 2007Department of Health ‘Orange’ book 2007 SIGN guidelines – ScotlandSIGN guidelines – Scotland By and large comorbidity and vulnerable age groups are excluded

38 Pharmacological treatment MedicationLicensed Age limits Specific old age Diazepam Alcohol withdrawal Not in children 16 years None Lofexidine Opiate detox’n Not in children Caution NRT Nicotine withdrawal > 18 years None Bupropion Smoking cessation > 18 years Caution

39 Pharmacological treatment options Drugs not investigated/licensed for over 65sDrugs not investigated/licensed for over 65s Benzodiazepines – caution due to accumulation but need to give enough to cope with withdrawalBenzodiazepines – caution due to accumulation but need to give enough to cope with withdrawal Acamprosate, disulfiram and naltrexone with utmost cautionAcamprosate, disulfiram and naltrexone with utmost caution Methadone and buprenorphine supervisedMethadone and buprenorphine supervised Nicotine replacement and bupropion if not C/ANicotine replacement and bupropion if not C/A

40 OUTCOME STUDIES OLDER PEOPLE Do older people recover?

41 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

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

43 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

44 Studies Included 2500 titles generated.2500 titles generated. 50 studies thought to be appropriate and full articles obtained.50 studies thought to be appropriate and full articles obtained. 16 studies fulfilled inclusion criteria: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

45 Evidence - Review of 16 studies on older substance misusers Current evidence based guidance does not include over 50sCurrent evidence based guidance does not include over 50s Mainly alcohol (11); smoking (3); opiates (1) and prescription drugs (1) in over 50sMainly alcohol (11); smoking (3); opiates (1) and prescription drugs (1) in over 50s 2 studies in the UK2 studies in the UK Some in services for older people; some in mixed age servicesSome in services for older people; some in mixed age services Almost all treatments were variety of psychological interventionsAlmost all treatments were variety of psychological interventions

46 Results Time period: ; 14 of these after 1990.Time period: ; 14 of these after Country: 13 in US, 2 in UK, 1 in Canada.Country: 13 in US, 2 in UK, 1 in Canada. Settings: 5 studies conducted in primary care, 4 in outpatient setting, 1 inpatientSettings: 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.Sample size: 24 to 3,622; some of the larger studies had a relatively small proportion of adults in ‘older’ age range.

47 Demographic information: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 >70% Caucasian participants. Ethics approval: 6 studies described ethical approval or exemption.Ethics approval: 6 studies described ethical approval or exemption.

48 Results Measures: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

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

50 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.

51 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.

52 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.

53 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…………

54 Thanks to colleagues Dr Roger BloorDr Roger Bloor Prof Peter CromeProf Peter Crome Drs Ishbel Moy & Harvinder SidhuDrs Ishbel Moy & Harvinder Sidhu And many other collaborators…sorry not to mention by nameAnd many other collaborators…sorry not to mention by name


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