1. Meeting the health needs of older drug users Dr Muriel Simmonte NHS Lothian Primary Care Facilitator Team/East Lothian Locality Drug Clinic

2. Trainspotters? “Survivors” – drug users with an early onset of drug use which has persisted for many years “Late starters” – drug users who become involved in drug use at a later age

3. Survivors More likely to have been in long term maintenance treatment Higher incidence of chronic illness related to their drug use including Hepatitis C and HIV Health consequences of long term socio- economic disadvantage Adverse life events – loss of friends and family members, involvement in violence and crime

4. Late starters Often related to stressful life events Previous drug misuse Older people more likely to be prescribed medication including psychoactive medication and analgesia Misuse of prescription drugs and OTC medication

5. Health issues for older drug users Complications of drug use – include blood borne viruses, respiratory disease, cardiovascular disease Mental health and overdose risk Age related health problems Lifestyle and circumstances

6. Blood borne viruses Cumulative risk of hepatitis B and C Undiagnosed hepatitis C - past injectors Untreated hepatitis C – previously declined, not offered, overlooked Additive affect of alcohol on hepatic function HIV infection +/- antiviral treatment Sexual transmission – risk of complacency when no perceived contraceptive needs

7. Respiratory disease COPD, emphysema and lung cancer risk associated with chronic smoking – tobacco and cannabis Exacerbation of asthma with inhaled drugs Lung damage associated with drug inhalation eg cocaine Opportunistic infections in HIV positive patients including PCP

8. Cardiovascular disease Increased risk associated with smoking, diet, alcohol Coronary artery spasm, tachycardia and arrhythmias with cocaine and other stimulants Chronic venous and/or arterial damage secondary to injecting Valvular heart disease

9. Mental health and overdose risk Association between mental health problems and drug use Increasing impact of bereavement, social isolation, anxiety Memory problems and cognitive impairment Increased and increasing risk of drug-related deaths in over 35 age group.

10. Drug-related deaths: Scotland 1996-2000 average 2004-2008 average Total260428 Under 258332%7718% 25 - 3410842%15135% 35 - 444618%13431% 45 & over239%6716% This equates to a near trebling of average annual deaths in the 35 & over age group - from 69 (1996-2000) to 201(2004-2008)

11. Age related health problems Increase in diseases associated with older age: hypertension, IHD, diabetes, COPD Interaction between medical treatments and substitute or illicit drugs Changes in metabolism and tolerance to drugs and alcohol Increased likelihood of chronic painful conditions – back pain, arthritis and headache

12. Lifestyle and circumstances Lack of social support Financial situation Experience of criminal justice system Poor engagement with mainstream health care, especially preventative care

13. Meeting general health needs Awareness of care providers to health needs beyond drug-related care Promoting engagement of drug users in preventive health care e.g. screening, immunisation Pain control issues in drug users: may require specialist services and non pharmacological interventions Awareness of circumstances linked to development of drug dependence in older patients

14. Meeting specific health needs Appropriate adjustment in treatment to reflect metabolic changes BBV prevention, testing and treatment needs Care of chronic illnesses related to drug use Co-morbidity – cognitive impairment, anxiety, depression

15. Lothian NES for drug users Aprox. 4,000 patients 54% age 35 or over 25% age 40 or over 1% age 60 or over Patients attending Primary Care: potential for engagement regarding other health issues

16. Recovery? Long term treatment – positive choice or lack of support to change? Benefits and risks of reduction/detox Lifestyle factors Aspirations