Substance Abuse Among Older A dults Alexis Kuerbis, LCSW, PhDa,*, Paul Sacco, Alison A. Moore, MD, MPHd
PhD, LCSW
b
, Dan G. Blazer,
MD, PhD
c
,
KEYWORDS Older adults Alcohol Prescription medication Substance use Assessment Assessment tools Brief interventions Treatment KEY POINTS Although the current proportions of older adults with substance use disorders remain low compared with the general population, a growing proportion and number of older adults are at risk for hazardous drinking, prescription drug misuse, and illicit substance use and abuse. The identification of problematic substance use with older adults can be difficult because of overlapping symptoms with medical disorders that are common in older age. The assessment should include a respectful and nonstigmatizing approach along with direct questions about drinking, prescription medication, and illicit drug use. Several brief interventions centered on education about the harms of substance use have been shown to be effective with older adults. For older adults with more severe substance use problems, more intensive treatments geared toward a general population have been shown to be effective for older adults; however, treatments tailored for older adults have shown particular promise.
INTRODUCTION
The initial wave of the baby boom generation turned 65 years old in 2011, a generation that comprises 30% of the total US population.1 The size of this generation and their longer life expectancies2 led the US Census Bureau to project that the number of older adults will increase from 40.3 million to 72.1 million between 2010 and 2030.3 Historically, older adults have not demonstrated high rates of alcohol or other drug use
a Department of Mental Health Services and Policy Research, Research Foundation for Mental Hygiene, Inc, Columbia University Medical Center, 3 Columbus Circle, Suite 1404, New York, NY 10019, USA; b University of Maryland School of Social Work, 525 West Redwood Street, Baltimore, MD 21201, USA; c Department of Psychiatry and Behavioral Sciences, Academic Development, Duke University, DUMC 3003, Durham, NC 27710, USA; d Department of Medicine, Division of Geriatrics, David Geffen School of Medicine at UCLA, 10945 Le Conte Avenue, Suite 2339, Los Angeles, CA 90095, USA * Corresponding author. E-mail address: [email protected]
Clin Geriatr Med - (2014) -–http://dx.doi.org/10.1016/j.cger.2014.04.008 geriatric.theclinics.com 0749-0690/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
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Kuerbis et al
compared with younger adults4,5 or presented in large numbers to substance abuse treatment programs.6 These facts have helped to perpetuate a misconception that older adults do not use or abuse mood-altering substances. Indeed, substantial evidence suggests that substance use among older adults has been underidentified7,8 for decades. The aging of the baby boom generation creates a new urgency to effectively identify and treat substance use among older adults. Baby boomers are distinct compared with past generations as they came of age during the 1960s and 1970s, a period of changing attitudes toward and rates of drug and alcohol use.9,10 The prevalence rates of substance use disorder (SUD) have remained high among this group as they age,5 and both the proportions and actual numbers of older adults needing treatment of SUD are expected to grow substantially. SUD rates among people older than 50 years are projected to increase from about 2.8 million in 2006 to 5.7 million in 2020.11 There is, therefore, widespread recognition among both generalists and specialists in gerontology and psychiatry,3,12,13 and health care overall, of the need for more information about assessment and interventions related to problematic substance use among older adults. PREVALENCE OF SUBSTANCE USE AMONG OLDER ADULTS Alcohol Use
Despite increasing rates of illicit and prescription drug misuse among adults older than 65 years,5,6,10 alcohol remains the most commonly used substance among older adults.6,10 Therefore, most of the research on substance use among and treatment of older adults has centered on alcohol use disorders (AUD). Among the population at large, older adults reduce their alcohol use as they age.14–17 As of 2002, among individuals aged 65 years and older in the general population, the estimated prevalence is 1.2% for the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) alcohol abuse and 0.24% for DSM-IV alcohol dependence.18 Prevalence estimates inclusive of those older than 50 years are higher (2.98% for all AUD). Within heath care settings, the rates of AUD among older adults ranges up to a proportion of 22%.19–21 Although these rates are lower than for younger adults, they are likely impacted by the underreporting of heavy drinking,7 difficulties with differential diagnoses of AUDs in older adults, and unidentified comorbidities.22 At-risk drinking is more prevalent among older adults than AUD and is likely responsible for a larger share of the harm to the health and well-being of older adults. Guidelines provided by the American Geriatrics Society and the National Institute for Alcohol Abuse and Alcoholism recommend that older adults drink no more than 7 standard drinks (12-oz beer, 4- to 5-oz glass of wine, 1.5 oz of 80-proof liquor) per week.10,16 Prevalence rates for older-adult at-risk drinking (defined as more than 3 drinks on one occasion or more than 7 drinks per week) are estimated to be 16.0% for men23,24 and 10.9% for women.20,21 There is also a substantial proportion of the older-adult population who are binge drinkers (generally defined as 5 or more standard drinks in one drinking episode, though definitions vary for older adults).25 Rates of older-adult binge drinking are 19.6% for men and 6.3% for women using data from the 2005–2006 National Survey on Drug Use and Health.20,26 In a study of community-based older adults who reported drinking one or more drinks in the previous 3 months, 67% reported binge drinking in the last year.25 Tobacco Use
Tobacco use is quite prevalent among older adults, with about 14% of those aged 65 years and older reporting tobacco use in the last 12 months,10 and just more
Substance Abuse Among Older Adults
than 6% used tobacco and alcohol together in the last 12 months. Clinical trials examining smoking cessation interventions demonstrate that older-adult smokers tend to be long-term, heavy smokers who are also physiologically dependent on nicotine.27–29 Illicit Substance Use
Illicit drug use is more prevalent among American older adults than among older adults in almost any other country in the world.30 Results from the 2012 National Survey on Drug Use and Health revealed that rates of past month use of illicit substances doubled on average (from 1.9%–3.4% to 3.6%–7.2%) among 50 to 65 year olds between 2002 and 20125—a statistically significant increase driven by the baby boom generation.5,11 Generally, individuals aged 50 to 64 years report more psychoactive drug use than older groups.24,31,32 For example, in 2012, 19.3% of adults aged 65 years and older reported having ever used illicit drugs in their lifetime, whereas 47.6% of adults between 60 and 64 years of age reported lifetime drug use. Among those that do use illicit substances, 11.7% meet the criteria for pastyear SUD.31 There are no recommendations for safe levels of illicit drug use among older adults.33 Cannabis use by older adults is considerably more prevalent than other drugs. Among adults aged 50 years and older in 2012, 4.6 million reported past-year marijuana use, and less than one million reported cocaine, inhalants, hallucinogens, methamphetamine, and/or heroin use in the past year. These rates are consistent with those reported by other studies.24,31 With the passage of medical marijuana legislation and relaxed enforcement of drug possession related to marijuana, the prevalence rate of use among older adults may increase as they use it to cope with illness-related side effects,20 potentially facilitating an increase in recreational use. Prescription, Nonprescription, and Over-the-Counter Medication Use
Older adults take more prescribed and over-the-counter medications than younger adults,22,34 increasing the risk for harmful drug interactions, misuse, and abuse. A cross-sectional community-based study of 3005 individuals aged 57 to 85 years found that 37.1% of men and 36.0% of women used at least 5 prescription medications concurrently.35 The study also found that about 1 in 25 of the participants were at risk for a major drug interaction, and half of these situations involved nonprescription medications. In 2012, 2.9 million adults aged 50 years and older reported nonmedical use of psychotherapeutic medications in the past year.5 Estimates of prescription medication misuse among older women are 11%.36 Blazer and Wu32 reported that 1.4% of adults aged 50 years and older used prescription opioids nonmedically in the last year, which was higher than sedatives, tranquilizers, and stimulants (all
PhD, LCSW
b
, Dan G. Blazer,
MD, PhD
c
,
KEYWORDS Older adults Alcohol Prescription medication Substance use Assessment Assessment tools Brief interventions Treatment KEY POINTS Although the current proportions of older adults with substance use disorders remain low compared with the general population, a growing proportion and number of older adults are at risk for hazardous drinking, prescription drug misuse, and illicit substance use and abuse. The identification of problematic substance use with older adults can be difficult because of overlapping symptoms with medical disorders that are common in older age. The assessment should include a respectful and nonstigmatizing approach along with direct questions about drinking, prescription medication, and illicit drug use. Several brief interventions centered on education about the harms of substance use have been shown to be effective with older adults. For older adults with more severe substance use problems, more intensive treatments geared toward a general population have been shown to be effective for older adults; however, treatments tailored for older adults have shown particular promise.
INTRODUCTION
The initial wave of the baby boom generation turned 65 years old in 2011, a generation that comprises 30% of the total US population.1 The size of this generation and their longer life expectancies2 led the US Census Bureau to project that the number of older adults will increase from 40.3 million to 72.1 million between 2010 and 2030.3 Historically, older adults have not demonstrated high rates of alcohol or other drug use
a Department of Mental Health Services and Policy Research, Research Foundation for Mental Hygiene, Inc, Columbia University Medical Center, 3 Columbus Circle, Suite 1404, New York, NY 10019, USA; b University of Maryland School of Social Work, 525 West Redwood Street, Baltimore, MD 21201, USA; c Department of Psychiatry and Behavioral Sciences, Academic Development, Duke University, DUMC 3003, Durham, NC 27710, USA; d Department of Medicine, Division of Geriatrics, David Geffen School of Medicine at UCLA, 10945 Le Conte Avenue, Suite 2339, Los Angeles, CA 90095, USA * Corresponding author. E-mail address: [email protected]
Clin Geriatr Med - (2014) -–http://dx.doi.org/10.1016/j.cger.2014.04.008 geriatric.theclinics.com 0749-0690/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
2
Kuerbis et al
compared with younger adults4,5 or presented in large numbers to substance abuse treatment programs.6 These facts have helped to perpetuate a misconception that older adults do not use or abuse mood-altering substances. Indeed, substantial evidence suggests that substance use among older adults has been underidentified7,8 for decades. The aging of the baby boom generation creates a new urgency to effectively identify and treat substance use among older adults. Baby boomers are distinct compared with past generations as they came of age during the 1960s and 1970s, a period of changing attitudes toward and rates of drug and alcohol use.9,10 The prevalence rates of substance use disorder (SUD) have remained high among this group as they age,5 and both the proportions and actual numbers of older adults needing treatment of SUD are expected to grow substantially. SUD rates among people older than 50 years are projected to increase from about 2.8 million in 2006 to 5.7 million in 2020.11 There is, therefore, widespread recognition among both generalists and specialists in gerontology and psychiatry,3,12,13 and health care overall, of the need for more information about assessment and interventions related to problematic substance use among older adults. PREVALENCE OF SUBSTANCE USE AMONG OLDER ADULTS Alcohol Use
Despite increasing rates of illicit and prescription drug misuse among adults older than 65 years,5,6,10 alcohol remains the most commonly used substance among older adults.6,10 Therefore, most of the research on substance use among and treatment of older adults has centered on alcohol use disorders (AUD). Among the population at large, older adults reduce their alcohol use as they age.14–17 As of 2002, among individuals aged 65 years and older in the general population, the estimated prevalence is 1.2% for the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) alcohol abuse and 0.24% for DSM-IV alcohol dependence.18 Prevalence estimates inclusive of those older than 50 years are higher (2.98% for all AUD). Within heath care settings, the rates of AUD among older adults ranges up to a proportion of 22%.19–21 Although these rates are lower than for younger adults, they are likely impacted by the underreporting of heavy drinking,7 difficulties with differential diagnoses of AUDs in older adults, and unidentified comorbidities.22 At-risk drinking is more prevalent among older adults than AUD and is likely responsible for a larger share of the harm to the health and well-being of older adults. Guidelines provided by the American Geriatrics Society and the National Institute for Alcohol Abuse and Alcoholism recommend that older adults drink no more than 7 standard drinks (12-oz beer, 4- to 5-oz glass of wine, 1.5 oz of 80-proof liquor) per week.10,16 Prevalence rates for older-adult at-risk drinking (defined as more than 3 drinks on one occasion or more than 7 drinks per week) are estimated to be 16.0% for men23,24 and 10.9% for women.20,21 There is also a substantial proportion of the older-adult population who are binge drinkers (generally defined as 5 or more standard drinks in one drinking episode, though definitions vary for older adults).25 Rates of older-adult binge drinking are 19.6% for men and 6.3% for women using data from the 2005–2006 National Survey on Drug Use and Health.20,26 In a study of community-based older adults who reported drinking one or more drinks in the previous 3 months, 67% reported binge drinking in the last year.25 Tobacco Use
Tobacco use is quite prevalent among older adults, with about 14% of those aged 65 years and older reporting tobacco use in the last 12 months,10 and just more
Substance Abuse Among Older Adults
than 6% used tobacco and alcohol together in the last 12 months. Clinical trials examining smoking cessation interventions demonstrate that older-adult smokers tend to be long-term, heavy smokers who are also physiologically dependent on nicotine.27–29 Illicit Substance Use
Illicit drug use is more prevalent among American older adults than among older adults in almost any other country in the world.30 Results from the 2012 National Survey on Drug Use and Health revealed that rates of past month use of illicit substances doubled on average (from 1.9%–3.4% to 3.6%–7.2%) among 50 to 65 year olds between 2002 and 20125—a statistically significant increase driven by the baby boom generation.5,11 Generally, individuals aged 50 to 64 years report more psychoactive drug use than older groups.24,31,32 For example, in 2012, 19.3% of adults aged 65 years and older reported having ever used illicit drugs in their lifetime, whereas 47.6% of adults between 60 and 64 years of age reported lifetime drug use. Among those that do use illicit substances, 11.7% meet the criteria for pastyear SUD.31 There are no recommendations for safe levels of illicit drug use among older adults.33 Cannabis use by older adults is considerably more prevalent than other drugs. Among adults aged 50 years and older in 2012, 4.6 million reported past-year marijuana use, and less than one million reported cocaine, inhalants, hallucinogens, methamphetamine, and/or heroin use in the past year. These rates are consistent with those reported by other studies.24,31 With the passage of medical marijuana legislation and relaxed enforcement of drug possession related to marijuana, the prevalence rate of use among older adults may increase as they use it to cope with illness-related side effects,20 potentially facilitating an increase in recreational use. Prescription, Nonprescription, and Over-the-Counter Medication Use
Older adults take more prescribed and over-the-counter medications than younger adults,22,34 increasing the risk for harmful drug interactions, misuse, and abuse. A cross-sectional community-based study of 3005 individuals aged 57 to 85 years found that 37.1% of men and 36.0% of women used at least 5 prescription medications concurrently.35 The study also found that about 1 in 25 of the participants were at risk for a major drug interaction, and half of these situations involved nonprescription medications. In 2012, 2.9 million adults aged 50 years and older reported nonmedical use of psychotherapeutic medications in the past year.5 Estimates of prescription medication misuse among older women are 11%.36 Blazer and Wu32 reported that 1.4% of adults aged 50 years and older used prescription opioids nonmedically in the last year, which was higher than sedatives, tranquilizers, and stimulants (all
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