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Prescription Drug Nonmedical Use and Abuse in Older Women

Drug abuse in the 21st 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

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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

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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

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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

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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)

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Substance Use - Type by Gender – 50 and Older

57.7

42.3

71.1

28.9

41.9

58.1

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Any Illicit Use Marijuana Prescription

Male Female (2002 NSDUH)

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Substance Use in Older Adults Alcohol use is also high in 50+

population – 2.3 Million, or 14.1%, meet criteria for alcohol abuse/dependency1.84 Million are male (80.0%)459,000 are female (20.0%)

(2002 NSDUH)

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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)

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Continuum of Rx Use in Older Adults Proper Use

Misuse (by patient and/or provider)

Abuse

Dependence(APA, DSM-IV, 1994)

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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

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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)

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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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Extent of the Problem: Medical Exposure General US population1

Women = 20.0% Men = 12.5%

Among elders aged 65 and older, 21.7%, or 7.22M, receive at least 1 abusable Rx annually2

Women = 24.6% Men = 17.7%

1Simoni-Wastila et al, Sub Use and Misuse, 20042Simoni-Wastila et al, under review, 2004

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Medical Exposure to Abusable Rx Drugs by Gender and Age

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18.620.1

27.3

20.4

28.3

19.4

24.8

0

5

10

15

20

25

30

65-69 70-74 75-79 80+

Male FemaleSimoni-Wastila et al, under review, 2004

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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

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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

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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

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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

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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

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Social Isolation and Health Status

Characteristic Annual 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

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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

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Adults 50 and Older in Population and Needing Treatment (in millions)

72.5

2.5

112.5

50

20

40

60

80

100

120

1999 2020

Population Needs Treatment

Gfroerer et al., SAMHSA, 2003

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Research Gaps

Data inadequaciesLack of data sourcesSmall number of eldersCross-sectional dataLack of medical information

Definitional issues of misuse and abuse in elders

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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

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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