Risk Factor |
“Young” elder, unmarried, male |
Low income status |
Previous illicit substance use |
Current methadone maintenance |
Licit drug or alcohol use |
Comorbid mental illness, especially depression and/or anxiety |
Substance abuse among close contacts |
Involvement in crime, especially drug crime |
Social isolation/poor social support |
Inmate status |
TREATMENT OF ILLICIT SUBSTANCE ABUSE IN THE ELDERLY
There are relatively few data about the particular challenges of treatment among elderly drug abusers. Much of the existing infrastructure for treatment (similar to the drug scene itself) is geared toward younger users, which may leave older patients feeling alienated. However, certain factors significant for the treatment of younger adults have been shown to apply to elders as well. Pope et al14 note that family participation and history (long recognized for its role in affecting outcomes of drug use earlier in life) remain significant even into older adulthood. For example, having a close family member who is a past or present user appears to make new or continued drug use a more acceptable option; therefore, addressing both this attitude and the presence of negative influences is important in shaping a patient’s outcomes.14
Another point to consider is the ideal setting for treatment of elders with a substance problem. Age-integrated treatment programs (ie, those in which older and younger adults are treated side-by-side) have fared well in the treatment of alcohol abuse in the elderly, but it is less clear whether this would apply to illicit substances.13 Conversely, there are a growing number of support groups specific to alcoholism in the elderly (eg, Seniors In Sobriety, an offshoot of Alcoholics Anonymous), but, as of now, few are specific for illicit drugs. Clearly, elderly substance abusers benefit from treatment tailored to their particular needs and experiences when available.3,20
The complicated medical needs and relative frailty of many elderly patients should lower a clinician’s threshold for admission and inpatient treatment. But in such a case, will the patient receive the most appropriate care on a devoted geriatric psychiatry ward, in which providers may be many years removed from experience with illicit drug use, or on one designed for the treatment of illicit drug use, in which experience with elderly patients may be similarly limited?
Interestingly, the Primary Care Research in Substance Abuse and Mental Health for the Elderly study demonstrated no difference in efficacy in the treatment of elderly alcoholics between those receiving brief intervention sessions at a primary care clinic and those receiving subspecialty care at mental health or substance abuse clinics.30 Whether this finding is applicable to illicit substance abuse has yet to be seen and should not deter primary care providers from timely consultation with experts in geriatric mental health or substance abuse. For the time being, the best solution may be consultation with multiple specialty teams, although bringing more attention to elderly illicit drug users will hopefully encourage providers to become comfortable in all aspects of their care.
The increased susceptibility of older adults to adverse effects of many substances (a phenomenon familiar to anyone with experience in the medical care of older adults) is also relevant to substance abuse treatment. Physiologic changes related to aging, including decreases in total body water and lean mass with a reciprocal increase in total body fat, alter the metabolism of various drugs, often resulting in smaller effective or toxic doses and lower half-lives. Many elderly individuals also have comorbid medical disease, for example, diabetes or other causes of kidney disease, affecting drug excretion or other aspects of metabolism.31
Not only are the elderly more prone to adverse psychotropic effects of abused substances, they are also vulnerable to the deliriogenic effects of certain treatments (for example, opioids, sedative-hypnotics, and medications with anticholinergic effects).32 An older adult with underlying dementing illness (even at a subclinical level, such as mild or subjective cognitive impairment) is more prone to drug-induced delirium and more likely to have a prolonged recovery from an episode. Therefore, in beginning substance abuse treatment among elders, starting slow with less intense treatment (eg, cognitive-behavioral or brief interventions) is preferable to the high-intensity regimens that might be used among younger adults.20
Substance abuse disorders in older adults, as in younger adults, are frequently comorbid with other psychiatric disorders, including depression, anxiety disorders, adjustment disorders, and bereavement.1 The relative dearth of certain psychiatric disorders in older adults, for example, the rarity of chronic psychotic disorders in many geriatric psychiatric practices, may relate to the different spectrums of substances abused. As in younger adults, integrated treatment of both disorders by a single treatment team is ideal, though at present, relatively few providers can be expected to have in-depth knowledge and experience with both geriatric disorders (eg, late-life depression or dementias) and illicit substance use disorders.
CONCLUSIONS AND FUTURE DIRECTIONS
As should be evident from the preceding discussion, the greatest limitation to a modern understanding of illicit substance abuse among the elderly is the lack of data. In the future, as awareness of this phenomenon grows and clinicians begin to consider it as a possibility, hopefully studies of illicit drug use will expand their populations to include a greater number of older adults, and more studies will appear focusing particularly on the elderly. In order to achieve this goal, researchers must understand the difficulties in detecting illicit drug abuse among the aged compared to their younger counterparts, as discussed above. Several years from now, many of the suggestions in this article may be either confirmed or repudiated in the face of better information.
Beyond simply better data on the topic, another potential direction for future research might be the development of screening instruments for elderly illicit substance use and abuse. On the one hand, there are several validated screening instruments for clinical recognition of alcohol abuse disorders, including some specifically adapted for older adults (eg, the Michigan Alcoholism Screening Instrument—Geriatric Version and its shortened version); others, such as the popular CAGE questionnaire (Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers), appear to be less sensitive among older adults.1 On the other hand, there are relatively few validated screening instruments for illicit drug abuse even among higher-prevalence populations (adolescents and young adults), much less instruments that have been validated in the elderly.3 As mentioned above, the Florida BRITE project, while better geared toward prescription drug and alcohol abuse among the elderly, demonstrates the possibility of effective substance abuse screening among this population.29
Drug name: methadone (Methadose and others).
Potential conflicts of interest: None reported.
Funding/support: None reported.
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Articles from The Primary Care Companion for CNS Disorders are provided here courtesy of Physicians Postgraduate Press, Inc.