It’s about time Tackling substance misuse in older people

Older people and substance misuse – who are we talking about?  No fixed definition, age-wise, of ‘older people’ with substance misuse problems.  Alcohol services for older people often targeted at those aged 50/55 and over. With ‘ageing heroin- using population’, those aged 40 and over are defined as older. Research literature uses a variety of age thresholds.  In keeping with this flexibility, we don’t offer a particular definition – we wanted to scope out wide range of issues in this area.  Briefing covers alcohol, illicit drugs, and prescription and over-the-counter (OTC) medications.

Background facts and figures Alcohol:  Those aged 65 + make up 3% of both men and women in treatment. BUT – around 1.4 million people in this age group currently exceed recommended drinking limits (Wadd et al 2011).  Across , marked increase in alcohol-related hospital admissions for older people: Men aged % Women aged %  In 2010, almost half a million alcohol-related hospital admissions for those aged 65+; accounted for 44% of all these admissions, though comprise just 17% of population (Wadd and Papadopoulos 2013).

Background facts and figures Prescription and over-the-counter (OTC) medications:  Data about prevalence of misuse is limited.  But – we know that those aged over 65 use about one third of all prescribed drugs, often including benzodiazepines (anxiety and insomnia) and opioid analgesics (which includes codeine) (EMCDDA 2008).  2011 NTA report: in , 16% (32,510) of people in drug treatment services reported problems with use of prescribed/OTC medications. 2% reported it as primary problem.  Polydrug use can be an issue, particularly where prescribed and OTC medications interact with alcohol.

Background facts and figures Illicit drugs:  Number of people aged 40 and over in drug treatment is rising – ‘ageing heroin-using population’.  Illicit drug use among older people isn’t confined to this, however – Fahmy et al (2012): “Use of some illicit drugs, particularly cannabis, has increased rapidly in mid- and late-life”.  Highlights that “prevalences may rise as populations for whom illicit drug use has been more common and acceptable become older.”

Routes into substance misuse for older people  ‘Early onset’/‘late onset’ distinction for older people with alcohol problems; about one third develop problems later in life, often as a result of stressful events linked to the ageing process, including retirement and bereavement. Social isolation and loneliness also key.  Same distinction can be made for illicit drugs. ‘Early onset’ = ageing heroin users, people not growing out of casual drug use. Recent studies have also documented instances of ‘late onset’ use: “Older people are often exposed, as a matter of course, to many of the stress factors that may trigger drug use, such as bereavement, financial restrictions, isolation and ill health” (Ayres et al 2012).  Increased levels of discomfort and pain in older age play role in misuse of prescribed/OTC medications, which can be intentional or inadvertent.

Risks associated with substance misuse for older people “Physiological changes associated with ageing mean that older people are at increased risk of adverse physical effects of substance misuse” (Royal College of Psychiatrists 2011) Physical problems associated with alcohol use: coronary heart disease, hypertension and strokes; liver problems, including cirrhosis; cancer of the liver, oesophagus and colon. Mental health problems: depression and cognitive impairment may be associated with alcohol misuse. Alcohol may interact with prescribed/OTC medications, exacerbating side effects or causing other problems. Also associated with falls in the elderly. Long-term medical conditions, incl. Hepatitis C, can be a particular issue for older people with a history of drug problems, although they may not be receiving treatment. Higher risk of overdose for older drug users, especially where alcohol and benzodiazepines are being used ‘on top’ of illicit drugs, particularly opiates. May be vulnerable to exploitation from others.

Barriers to support Service barriers: - Older people may feel uncomfortable in mixed-age services - Home visits may not be offered - Age cut-off may exist (e.g. residential services) Professional attitudes: - Lack of awareness that substance misuse is a problem for older people - Reluctance to ask ‘embarrassing questions’ - Attitude that they are ‘too old to change’; belief that it’s wrong to ‘deprive’ them of their ‘last pleasure in life’ Personal barriers: - Feeling embarrassed about asking for help - Sense of ‘failure’ in the past, or feeling that ‘it’s too late’ - Limited awareness of ‘safe’ levels of alcohol consumption, or non-identification of consumption as problematic (“I’ve always been a heavy drinker”)

Positive interventions (I) Important to identify interventions that can be implemented in mixed-age services. Social groups/activities to develop social network/build confidence. Meaningful engagement – importance of finding ‘substitute’ for work for those who’ve retired. Home visits (e.g. to address mobility/transport difficulties). Adaptations, in assessment and support, to take account of cognitive impairment. Peer support, from ‘real peers’.

Positive interventions (II)  Non-time limited support/different outcomes for some older people can be important.  For those who are drinking at risk, abstinence may not be required; for those with long-term problems, this may not be a realistic goal.  BUT – flipside can be ‘dangerous myth’ that recovery doesn’t apply to older people.  Majority of older people with alcohol problems not dependent, but drinking at risk.  Brief interventions can be delivered by GPs; other health and social care professionals well-placed to do this, too (e.g. those working in older people’s mental health services, in residential services and for social care providers).