Commentary
Helping patients with addictions get, stay clean
Advise patients to consider programs affiliated with major medical centers or established treatment centers, an expert says.
Once engaged, older adults do well
Among older adults, triggers for SUDs vary considerably from that of their younger counterparts. “We tend to think of this as a population that carries a lot of wisdom and has the coping skills to deal with life,” Olivera J. Bogunovic, MD, a psychiatrist who is medical director of ambulatory services in the division of alcohol and drug abuse at McClean Hospital, Belmont, Mass., said during a separate presentation. “In fact, this is a very vulnerable population at increased risk of mood disorders. For example, many men spend their careers working 60 or 80 hours a week, then they stop working. What is there for them? They sometimes turn to substance abuse. Similarly, older women who lose a loved one may turn to drinking. There’s a lot of room for prevention. The good news is that this group of patients is very responsive to treatment. Once engaged, they do very well.”
Nicotine is the chief addictive substance affecting older adults (17%), followed by alcohol (12% in a binge capacity, dependence 1%), illicit drugs (1.8%), and medications (1.6% for pain medications and 12% on benzodiazepines). Alcohol use disorders encompass a spectrum of problems for this patient population, including at-risk drinking, problem drinking, and dependence. Presentations, complications, and consequences are wide-ranging. “We sometimes miss the symptoms of alcohol use disorders when patients present in emergency rooms,” Dr. Bogunovic said. “Unfortunately, if it’s not treated initially it results in serious medical comorbidities and complications.”
Dr. Olivera J. Bogunovic
The National Institute on Drug Abuse recommends that adults consume no more than two drinks per day, but the quantity is even lower for elderly. “For men it is no more than one drink per day, while for women it’s questionable if that one drink per day is even recommended,” Dr. Bogunovic said. The prevalence of at-risk drinking among older adults ranges from 3% to 25% and the rates for problem drinking range from 2.2% to 9.6%. Alcohol dependence rates, meanwhile, range from 2% to 3% among men and less than 1% among women.
Cross-sectional data indicate a low prevalence of illicit drug use in older adults, but longitudinal data from the National Survey on Drug Abuse and others suggest an increased use of cannabis and prescription opioids. “A lot of people do not think about opioid use disorders in the elderly,” she said. “The prevalence rate in methadone clinics is less than 2%. However, with the epidemic crisis we’re seeing opioid use disorders in the elderly. What’s important to know is that they also respond to medications for treatment, more so with suboxone than with naltrexone, as we know those patients sometimes have complications that need to be treated with pain medication.”
Elderly patients constitute 13% of the population yet they account for 30% of prescriptions, mainly benzodiazepines and prescription opioids. “Two-thirds of patients who are struggling with SUDs struggled with an SUD at some point in their youth,” said Dr. Bogunovic, who holds a faculty position in the department of psychiatry at Harvard Medical School, Boston. “They continue to use for longer periods of time, with some intermittent periods of sobriety. Of those 15% who do have an alcohol use problem, they are prescribed benzodiazepines. That can be a lethal combination, because there is a combined effect of both alcohol and benzodiazepines that can result in hip fractures, subdural hematomas, and other medical comorbidity.”
Risk factors for development of alcohol use disorder in elderly include physiologic changes in the way alcohol is metabolized; gender, family history, or prior personal history of alcohol use disorder; having a concomitant psychiatric disorder; and having a chronic medical illness, such as severe arthritis. Compared with their male peers, older women generally drink less often and less heavily, but they are more likely to start drinking heavily later in life. Older men face an increased risk of alcohol-related problems tied to cumulative use over the years.
“Social factors also play a role, so it’s important to perform a skilled diagnostic interview and a psychiatric evaluation but also to evaluate the motivational stage of change, because that’s the right moment to do the intervention, knowing what the patient’s values are,” she said. Recommended screenings include the Short Michigan Alcoholism Screening Instrument–Geriatric Version (SMAST-G), the SBIRT, the CAGE-AID, and the Opioid Risk Tool. Compliance with treatment tends to be greater in older adults, compared with their younger counterparts. “They don’t like a confrontational approach, so it’s important to communicate with empathy in a straightforward manner and pay attention to what is important to patients and motivate them,” she noted. “Involve family members or other social support whenever possible.”
Relapses are common, but clinicians should encourage patients to continue treatment, “because they can do very well,” Dr. Bogunovic emphasized. “And we can offer them a good life after that.”
Dr. Welsh disclosed that she has consulted for GW Pharmaceuticals and that she has received training fees from Chestnut Health Systems. Dr. Jackson and Dr. Bogunovic reported having no financial disclosures.