Author: David V. Flores, PhD, LMSW, MPH and Sara K Flores, MD
OverviewResearchers recently conducted a systematic review of the literature and identified significant correlates of substance abuse to include:
The Consensus Panel of the Treatment Improvement Protocol (TIP) suggest that older adults 60 years and over should be screened for alcohol and prescription drug abuse as a routine part of their regular physical examination. Barriers to assessing substance use and disorders have been found to include denial, insufficient knowledge, limited research, stigma or shame, lack of financial resources, lack of transportation, cognitive impairment, shrinking social support network, and comorbid conditions that accompany diagnosis (Wu & Blazer, 2011).
The opportunity for screening older adults for substance use and referral for appropriate counseling and treatment is increased due to the need of regularly scheduled medical appointments for chronic conditions associated with aging (Wu & Blazer, 2011). Additionally, early onset drug users will present with more medical, psychiatric, and/or social conditions compared to late onset drug users. Several instruments have been developed for quick identification of substance use including The CAGE assessment of drug and alcohol dependence, The Alcohol Use Disorders Identification Test (AUDIT), and The Drug and Alcohol Problem Assessment for Primary Care (DAPA-PC).
If a substance use disorder is identified, the provider should consider also assessing for a co-occurring mental health disorder, as estimates of 39-50% of adults meeting criteria for a mental illness also meet criteria for substance abuse in any given year (National Alliance on Mental Illness, 2013) and persons with mental illnesses are three times more likely to abuse substances than those without mental illnesses (Substance Abuse and Mental Health Services Administration, 2011). Treatment of the underlying or co-occurring mental illness should be factored into the substance abuse treatment planning and recommendations.
Diagnosis of Substance Use Disorder
Substance abuse disorders create significant impairment in activities of daily living and distress resulting from maladaptive patterns surrounding the use of substances. Symptomatology often includes a combination of withdrawals, increased tolerance, increased time spent on substance use activities, increased amounts of the substance used, unsuccessful efforts to control use, continued usage despite adverse consequences, and a decrease in social, occupational, or recreational activities (American Psychiatric Association, 2000). Moreover, the natural changes in physiology and pharmacokinetics that take place in older adults can increase the older person's sensitivity to substances and manifest as altered physiological or psychological symptomatology (Wu & Blazer, 2011). Substance use disorder in the DSM-5 has combined the DSM-IV categories of substance abuse and substance dependence into a single disorder and is measured along a continuum from mild to severe. Substances are addressed as separate use disorders (e.g., alcohol use disorder, stimulant use disorder, etc.), but are diagnosed based on the same overarching criteria. In previous DSM editions, a diagnosis of substance abuse required only one symptom. Mild substance use disorder in DSM-5 requires two to three symptoms from a list of eleven (American Psychiatric Association, 2013).
The majority of research and literature on substance abuse treatment of older adults has predominantly concentrated on alcohol misuse and has demonstrated greater treatment efficacy and increased outcomes for older women and longer length of treatment (Blow, Walton, Chermack, Mudd, & Brower, 2000). The TIP committee recommends a brief intervention followed by, if necessary, motivational interviewing and contextualized treatment, to include non-confrontational and supportive older adult specific intervention. These contextual strategies should address socioeconomic, psychological, and age specific strategies for the older adult (Center for Substance Abuse Treatment, 2005; Wu & Blazer, 2011). The physician should also assess the patient's motivation for treatment-- "Are you willing to consider changing your substance use habits at this time?" A patient's motivation for change may fall along a continuum from being totally unaware of the problem behavior to being ready to change.The following interventions have been recommend by the Center for Substance Abuse Treatment and have been shown to be effective for treating substance use disorders in older adults:
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