1. 1 Prescription Drug Nonmedical Use and Abuse in Older Women Drug abuse in the 21 st century: what lies ahead for the baby boomers? Linda Simoni-Wastila, Ph.D. University of Maryland, Baltimore School of Pharmacy National Institute on Drug Abuse Bethesda, Maryland September 16-17, 2004

2. 2 Introduction Purpose: To review the evidence of illicit drug use among aging women  Focus: prescription drug misuse and abuse  The Hidden Problem:  Under-recognized  Under-screened  Under-treated

3. 3 Today’s Discussion Context: Older women and risk Substance use in older adults Prescription drugs with potential for misuse and abuse Continuum and extent of prescription drug use  abuse Risk and protective factors Gaps in knowledge Conclusions - Implications for research

4. 4 Older Women and Risk Mature women may be particularly at risk for Rx misuse and abuse  Greater likelihood for exposure  Biology: body size; hormones; body fat; metabolic differences  Propensity for care seeking  propensity for treatment Consequences of Rx misuse and abuse  Cognitive impairment and increased sedation  falls/injury; depression; suicide; interactions w/ alcohol and other drugs

5. 5 Substance Abuse in Older Adults Nearly 2.8 M people aged 50 and older – or 3.5% – have used 1 or more illicit substances in the past year Of these past-year users, 16.0% (446,844) may have illicit drug abuse or dependence problems  262,032 are male (58.6%)  184,812 are female (41.4%) Two substances of choice:  Prescription drugs  Marijuana (2002 NSDUH)

6. 6 Substance Use - Type by Gender – 50 and Older (2002 NSDUH)

7. 7 Substance Use in Older Adults Alcohol use is also high in 50+ population – 2.3 Million, or 14.1%, meet criteria for alcohol abuse/dependency  1.84 Million are male (80.0%)  459,000 are female (20.0%) (2002 NSDUH)

8. 8 Rx Drugs With Potential for Misuse and Abuse Interest is only on those Rx drugs with abuse potential, a la CSA  Opioid analgesics (morphine, Dilaudid, OxyContin, Darvon, Percocet)  CNS stimulants (Ritalin, amphetamine)  Minor tranquilizers (Valium, Ativan, Librium)  Sedative-hypnotics (Seconal, amobarbital, Noctec)

9. 9 Continuum of Rx Use in Older Adults Proper Use Misuse (by patient and/or provider) Abuse Dependence (APA, DSM-IV, 1994)

10. 10 Prescription Drug Misuse Any Rx drug can be “misused” Misuse = “Non-medical use” = Any use that is outside of medically prescribed regimen, eg:  Non-compliance  Taking different dose  Sharing  Obtaining from non-medical source  Taking for psychoactive effects  Use with alcohol

11. 11 Prescription Drug Abuse Abuse = use resulting in  Decline in work, school, or home performance  Legal problems  Use in risky situations  Continued use despite social/personal consequences (APA, DSM-IV, 1994)

12. 12 Prescription Drug Dependency Dependency = use resulting in  Tolerance  Withdrawal sx  Decline in normal activities  Unsuccessful attempts to cut down or control use  Use for longer period or larger amounts than intended  Use consumes lot of time to acquire and/or recover from effects  Continued use despite knowledge that it caused physical and/or psychological problems (APA, DSM-IV, 1994)

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14. 14 Extent of the Problem: Medical Exposure General US population 1  Women = 20.0%  Men = 12.5% Among elders aged 65 and older, 21.7%, or 7.22M, receive at least 1 abusable Rx annually 2  Women = 24.6%  Men = 17.7% 1 Simoni-Wastila et al, Sub Use and Misuse, 2004 2 Simoni-Wastila et al, under review, 2004

15. 15 Medical Exposure to Abusable Rx Drugs by Gender and Age Simoni-Wastila et al, under review, 2004

16. 16 Extent of the Problem: Misuse General population: 4.0%, or 8.27M, misuse Rx drugs annually  Opioids – 2.4% (4.84M)  Tranquilizers – 1.5% (2.98M)  Stimulants – 1.1% (2.35M)  Sedatives – 0.9% (1.84M) Estimates of elder Rx misuse ranges from 0.6% of elders (300k) to >5.0% (2.8 M) Simoni-Wastila and Strickler, Am J Pub Health 2004

17. 17 Extent of the Problem: Abuse and Dependency General population: 0.6-0.9%, or 1.3-2.1M individuals may be abusing Rx drugs  Opioids: 0.2-0.6% (1.5M)  Tranquilizers: 0.2% (509k)  Stimulants: 0.2% (437k)  Sedatives: 0.1% (155k) The elderly: ? Simoni-Wastila and Strickler, Am J Pub Health; 2002 NSDUH, SAMHSA

18. 18 Risk Factors for Prescription Drug Misuse and Abuse - General Population Most consistent correlates in the general population for Rx misuse and addiction  Female gender  Young age  Older age  White race  High SES  Poor physical health  Mental illness

19. 19 Role of Gender in Rx Drug Misuse and Abuse Females 1.43X more likely than males to misuse any Rx drug (95% CI 1.19-1.69)  Driven by opioid analgesics (OR 1.41) and minor tranquilizers (OR 1.54)  Stat significance disappears when do not control for daily ETOH and illicit drug use Simoni-Wastila et al, Sub Use Misuse 2004 Females 1.49X more likely than males to have abuse/dependency on Rx drugs (95% CI 1.06-2.08)  Driven by opioid analgesics (OR 2.00) and minor tranquilizers (2.00) Simoni-Wastila and Strickler, AJPH 2004 Gender NOT statistically significant predictor of stimulant or sedative-hypnotic misuse or abuse/dependency

20. 20 Risk Factors for Rx Misuse and Abuse in Older Women Among older women, possible risk factors include:  Social isolation  Lower SES and education  Poor health  Current or history of behavioral health problems  Loss of economic and social support  HC system factors

21. 21 Social Isolation and Health Status CharacteristicAnnual Prevalence of Abusable Rx E+ Widowed/Divorced/Separated Married 24.6% 19.9% Lives Alone Lives w/ Spouse 23.8% 20.0% Poor/Fair Health Good/Excellent Health 34.2% 18.0% 0 ADLs 1-2 ADLs 3-4 ADLs 5-6 ADLs 17.1% 31.0% 39.0% 40.7% Simoni-Wastila et al, under review, 2004

22. 22 Baby Boomers “Come of Age” Current Problem: lack of knowledge of substance use in elders Substance use in elders will be a huge problem in < 20 years b/c boomers:  Accepting of alcohol and drug use  Used more in youth  Use more NOW  Use more psychoactive Rx drugs now  3-4x more emotional disorders

23. 23 Adults 50 and Older in Population and Needing Treatment (in millions) Gfroerer et al., SAMHSA, 2003

24. 24 Research Gaps Data inadequacies  Lack of data sources  Small number of elders  Cross-sectional data  Lack of medical information Definitional issues of misuse and abuse in elders

25. 25 Diagnosis and Treatment Gaps No screening/assessment tools specific to Rx drugs Dx and tx strategies not age- or gender-sensitive Efficacy of treatment modalities not tested in elders, women Absence of clinical guidelines Problems in organization and financing of health care

26. 26 Conclusions We need to better understand elder Rx misuse and abuse  Prevalence  Diagnosis  Prevention  Treatment Older women are at special risk for Rx misuse and abuse  Gender- and age- specific risk and protective factors