2/12/2019

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Equal but Different: The Hidden Epidemic of Chemical Use in People 50+

Brenda J. Iliff, MA, LADC, CAC, CMAT

Executive Director

Hazelden Betty Ford Naples

November 14, 2018

FOCUS Conference Wisconsin Dells, WI

What is Old?

• Feeling old is more a state of mind that a chronological count down

• Functional capacity is more a factor than age

Why Does it Matter?

Cohorts

How they see the world

May be in more than one generation

Continuum

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Earlier Cohorts

• Increased risk physiologically

• Increased beliefs around drinking and drugs

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Binge Drinking

Male Female

Adults 5 4

60+ 3 2

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Boomers

LEADING EDGE

Vietnam

Civil Rights

Sex, Drugs, Rock and Roll

Looking for meaning.....

TRAILING EDGE

After Kennedy’s assassination

No draft

Consumer debt

…..and purpose

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Fact

Addiction is estimated as high at 17% (National Clearinghouse for Alcohol and Drug Information)

Opioid misuse almost doubled among 50+ last decade (SAMSHA)

Hospitalization rate quintupled in the last two decades for 65+ from Opioids (AARP)

Alcohol is involved in many overdoses for older adults

42% of opioid overdoses were 45+

Many mislabeled as heart failure or falls

9.7% binge drink (adult vs. senior definition) (NSDUH, 2016)

Trifecta

Opioids

Benzodiazepines

Alcohol

Alcohol Interactive Medications

• Over 50% of people on alcohol interactive medications reported drinking alcohol (BMC Geriatrics, 2017).

• 77.8% of older adults who drank used alcohol interactive medications (Alcoholism: Clinical and Experiential Research, 2015).

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Why Epidemic Proportions?

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• Sheer numbers• Silver Tsunami

• Flower Child within• Relief like in response to stressor

• Opioid Epidemic• Pain is the 5th vital sign

• Polypharmacy

Where the Research is Pointing to…

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• As society ages, rates of alcohol and drug abuse will continue through the year 2020 (Simoni-Wastalia & Yang, 2006)

• By 2020 up to 5.7 million people over the age of 50 will have substance use disorder (Han, Gfroerer, Colliver, & Penne, 2009)

• Older adults are less likely than younger adults to recognize the need for treatment (Han. et. Al., 2008)

Risk at 50+

• Pro-substance mindset

• Years of pain and anxiety add up

• Medical advances

• Opioid epidemic

• Polypharmacy

• Slower metabolism

• Losses

• Health concerns

• Social isolation

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PHYSICAL

Male (alcohol)

Female (prescriptions)

White

Chronic pain

Chronic physical illness

Polypharmacy

Physical disabilities

Poor health

SOCIAL

Losses

Retirement (unplanned)

Living alone

Social isolation

Lower economic status

Avoidance coping style

Risk Factors

Hope at 50+

• Higher recovery rates

• Draw on lifetime of experience

• Tend to be more disciplined about recovery

• Relish recovery

Resources at 50+

Strength from the past

Strong values

Review values

Re-evaluate priorities–open to new concepts

Value health and independence

Compliance

Open to other avenues than pills (spirituality)

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Young vs. Old

YOUNG/OLD

Ages 45-75

May be age 75+

Functioning good

Health good

Independent

Addiction will lead to Old/Old

OLD/OLD

May be age 75+

May be age 50+

Functioning poor

Health poor

Dependent

Recovery leads to Young/Old

Early Onset Addiction

• Longer history of addiction

• Higher proportion of men than women

• Cognitive loss more severe

• Multiple attempts to quit

• More legal, medical and psychosocial problems

• Impulsiveness, aggressiveness

• 2/3 of alcoholics

Late Onset Addiction

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• Started at age 45+• More women than men• Family history less prevalent• Most are educated or affluent• Losses• Toxic effect• Cognitive loss less severe• Shame• Less severe medical complications• More receptive to treatment

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Medicare Part D

2016 Data

• 1/3 received opioid prescription; Medicare doesn’t usually pay for Medication Assisted Treatment (MAT)

• ½ million Part D recipients received high amounts of opioids

• 20% of high opioid group are at serious risk

• Medicare generally doesn’t pay for treatment

• Doctor shopping

4 or more providers or pharmacies

Benzo and Opioid Risks

Exposure

Excessive sedation

Falls

Cognitive Impairment

(SAMSHA, 2011)

Opioid Deaths

• 2000 to 2015, the number of opioid deaths quadrupled

• 55-64 year olds increased eight-fold

• 65-74 year olds increased seven-fold

• Benzos were involved in 1/3 of opioid deaths

• During past 10 years opioid misuse doubled in 50+

• While Medicare will pay for opioids it may not pay for treatment

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Incorrect Diagnoses

• “Causes of many overdoses over 60 are written off as age-related.”

- Dr. Andrew Kolodny

Executive Director, Physicians for Responsible Opioid Prescribing

The Vicious Cycle

Opioid or Benzo Use

Falls

PainNot eating or drinking

Depression

/Anxiety

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Do No Harm

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• Use CDC’s Guideline for Prescribing Opioids for Chronic Pain

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Myths

• Opioids are effective long-term for chronic pain

• The risk of addiction is minimal

• Older people are less likely to get addicted

• Taking meds at bedtime reduces risks

• My doctor prescribed it

• There won’t be any discontinuation syndrome

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Assessing Risks

• Evaluate risk factors for opioid-related harms

• Check PDMP for high dosages and prescriptions from other providers

• Use urine drug testing to identify prescribed substances and undisclosed use

• Avoid concurrent benzodiazepine and opioid prescribing

• Arrange treatment for opioid use disorder if needed.www.cdc.gov/drugoverdose/prescribing/guideline.html

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Prevalence of Drug Use of People Over 50

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• 2.2% reported misusing medications

• 3.3% reported cannabis2016 National Survey on Drug Use and Health

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My Doctor Prescribed It…

Talk about all medication

Talk about all supplements

Over the counters

Brown bag review

Pharmacist review

What’s the Big Deal?

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At Risk

• Multiple diseases, medications, providers and pharmacies

• Allergies

• Pain

• Sleep problems

• Self medication

• Extended medical treatment

Carol Colleran (Consultant to Hazelden in Naples Boomers Plus Program) author of Aging and Addiction, Hazelden, 2002

Medication Compliance

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• Vision

• Misunderstanding instructions, hear• Opening bottles

• Handling pills

• Mental confusion

• Unable to afford• Take intermittently

• Multiple providers

• Water intake

• Common justifications

Difficulty in Diagnosing

• Less objective measures (job, structure, legal, roles)

• Strong shame

• Denial

• Family is not around to report

• User may use less than they did historically

• Other problems mask abuse

• Complexity

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• Unexplained bruises• Heart abnormalities• Eating poorly• Speech changes• Change in sleep patterns• Shaking• Disorientation• Memory loss• Frequent falls• Poor coordination• Headache• Injuries• Gastritis• HIV/AIDS• Elevated cholesterol

• Blackouts• Depression• Irritability• Fatigue• Elevated blood glucose• Heart disease• Cancer• Hypertension• Stroke• Pancreatitis• Cirrhosis• Infections• Liver problems• Decrease in immune system

Medical Concerns or Substance Misuse?

Physical Signs and Symptoms

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Decrease in activities of daily living

Health complaints Unexplained

burns/bruises/falls Decreased mobility Hygiene concerns Malnutrition/weight loss Blurred vision Slurred speech HIV/AIDS

Increase in sleep Loss of function Memory loss Sleep complaints Multiple doctors/pharmacies Mixing up appointments Chronic health complaints

Behavioral Changes

Isolation Secretiveness – hiding supply Change in friends/loss of friends Risky behavior (unprotected sex, driving, walking drunk) Missing events/cancelling events Multiple social hours throughout day Multiple medical providers Multiple pharmacies Nesting Giving up activities

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Accidental Addicts–Physical

• Misunderstand medications• Age related changes and medications

• ↑ body fat• ↓ body water content• ↓ gastrointestinal tract function• ↓ liver and kidney functions

• Neuro-brain more rigid• Taking multiple medications• Multiple ailments• Chronic pain• Slower mental functions• Body doesn’t tolerate change as well

Accidental Addicts–Behavior

• Nesting• Mixing up things-appts/meds• Multiple medical providers/pharmacies• Receive poor monitoring of all meds• Blue pill vs. green pill• Unintentionally misuse medications• Risky Behaviors (driving, unprotected sex)• May not be able to read labels/open bottles• Secretiveness• Hiding/Sneaking• Giving up activities

How to Talk About Concerns

Preserve dignity

Non-judgmental

Shame issues

“The Will”

Describe what you see

Stay away from labels– Alcoholic-use “alcohol problem”

– Addict

– Quit drinking

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F R A M E S

F- Specific, nonjudgmental, Feedback

R- Personal Responsibility to change

A- Clear Advice and recommendations

M- Offer Menu of options

E- Use an Empathetic communication style

S- Support Self-efficacy

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Address Family Concerns

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• Get involved when crisis• Babysitting• Energy draining• Caregiver–physically exhausted• Airing dirty laundry• Myths of addiction around aging• Double life–live distance• No public consequences• Health–somatic complaints of family• Family split on action plan• Tired of it!

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Screening Tools

CAGE screening– Cut down/Control

– Annoyed/Angry

– Guilt/Shame

– Eye Opener/Earlier

Interviews Knowledge of substance abuse and aging issues Alcohol Related Problems Survey www.aboutmydrinking.org Knowledge of framing addiction DSM5 Short Michigan Alcoholism Scanning Test-G IADL–Instrumental Activities of Daily Living

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Screening Tools

Alcohol:– Alcohol Use Disorders Identification Test (AUDIT)

– Alcohol Use Disorders Identification Test-C (AUDIT-C)

– National Institute on Alcohol Abuse and Alcoholism (NIAAA) Single-Item Screen

– Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G)

– Senior Alcohol Misuse Indicator

Cannabis:– Cannabis Use Disorder Identification Test-Revised (CUDIT-R)

Multiple substances:– Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)-Lite

– Brief Addiction Monitor

– CAGE Questionnaire Adapted To Include Drugs (CAGE-AID)

– National Institute on Drug Abuse (NIDA) Quick Screen V1.0

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Co-occurring Disorders

• Depression

• Anxiety

• Bi-polar

• Schizophrenia

• Cognitive Disorders

• PTSD

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Mental Health Screening

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• Trauma Screening Questionnaire

• Elder Abuse Suspicion Index

• Co-occurring Conditions in General

• Comorbidity Alcohol Risk Evaluation Tool (CARET)

• Cognition

• Mini-Mental Status Exam (MMSE)

• Confusion Assessment Method (CAM)

• Montreal Cognitive Assessment

Screening Tools for mental health concerns

Depression Cornell Scale for Depression in Dementia (CSDD) Geriatric Depression Scale (GDS)-Short Form Patient Health Questionnaire (PHQ)

Anxiety Beck Anxiety Inventory (BAI) Penn State Worry Questionnaire (PSWQ) Obsessive-Compulsive Inventory-Revised

PTSD, Trauma Symptoms, and Abuse PTSD Checklist Primary Care PTSD Screen for DSM-5

Barriers to Help for People 50+

• Stigma• Denial• Shame• Myths of aging• Financial concerns• Skepticism about treatment• Health care providers• “The Will”• Family• Fear• Lack of training (professionals)

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Health Care Providers Barriers

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• Myths

• Detoxification longer

• Takes up beds longer in public settings

• Slower paced

• Ageism

• Like to talk

Move slower

Take more time

Want choices

Like own environment

Residential Models

Minimal .5 ASAM Interventions

Myths of Addiction for people 50+

• It’s life’s last pleasure

• He has strong willpower

• The physician prescribes those pills

• She’s too old to change

• Drinking is good for his heart

• You can’t help someone until they want it

• At her age, what difference does it make

• She’s enjoying life–it’s all she has

• Less likely to recovery

Treatment Options

• Explore least intensive first• Brief intervention• Intervention• Motivational counseling• Detoxification• Treatment settings

• Outpatient• Day treatment• Residential• Hospital based

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Most Serious Detox Needs• Alcohol

• Benzodiazepines

• Opiates

• Aging Individuals

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Limited Medical Detox Needs• Marijuana

• Cocaine

• Meth

Alcohol• Acamprosate

• Disulfiram

• Naltrexone

Opioids• Naltrexone

• Buprenorphine

• Methadone

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Medication Interventions

Medical

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• Thorough Medical Screening

• Chronic Pain

• Dementia

• Multiple Medications

• Medicare

• Funding

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Spirituality Concerns

• Purpose

• Meaning

• Spirituality after 70 is different

• Understanding of Higher Power

• Understanding keeps changing

• End of life as we know it

Education or Therapy

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• Describe the purpose of group

• May be polite rather than honest

• May not confront denial

• Sidestep difficult issues

• Women defer to men

• Frequently give advice vs. insight

• May need to leave room (bladder)

• May need to stand or walk (pain)

• Hearing concerns

Women at 50+

Rewired for self-reflection

Empty nest

Resurgence of eating disorders

Perimenopause and menopause

Old trauma may surface

Sexual dysfunction

Looking for fountain of youth

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Recovery Planning

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Medicines

Assertive linkages

Aging Services

Wrap around services

Mental health services

Recovery Support Groups

Transportation

Medical

References

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