Illicit Substance Use Disorder Among Older Adults

Author: David V. Flores, PhD, LMSW, MPH and Sara K Flores, MD

Key Points

 

Overview

Researchers recently conducted a systematic review of the literature and identified significant correlates of substance abuse to include: Protective factors were identified as:

 

Assessment

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). 

 

Intervention

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:

 

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. 

American Psychiatric Association. (2013). Substance-related and addictive disorders. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th. Retrieved September 20, 2013, 2013, from http://www.dsm5.org/Documents/Substance Use Disorder Fact Sheet.pdf 

Blow, Frederic C., Walton, Maureen A., Chermack, Stephen T., Mudd, Sharon A., & Brower, Kirk J. (2000). Older adult treatment outcome following elder-specific inpatient alcoholism treatment. Journal of substance abuse treatment, 19(1), 67-75. doi: http://dx.doi.org/10.1016/S0740-5472(99)00101-4 

Center for Substance Abuse Treatment. (2005). Substance abuse relapse prevention for older adults: A group treatment approach (U. S. D. o. H. a. H. Services, Trans.). Rockville, MD: Substance Abuse and Mental Health Services Administration. 

Han, Beth, Gfroerer, Joseph C., Colliver, James D., & Penne, Michael A. (2009). Substance use disorder among older adults in the United States in 2020. Addiction, 104(1), 88-96. doi: 10.1111/j.1360-0443.2008.02411.x 

Institute of Medicine. (2012). The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? In J. Eden, K. Maslow, M. Le & D. Blazer (Eds.), Committee on the Mental Health Workforce for Geriatric Populations Board on Health Care Services, . Washington, DC: Institute of Medicine, The National Academies Press. 

Institute of Medicine. (2012). The mental health and substance use workforce for older adults In whose hands? Washington, DC: National Academy of Sciences. 

Manchikanti, L. (2006). Prescription Drug Abuse: What is Being Done to Add ress This New Drug Epidemic? Testimony Before the Subcommittee on Criminal Justice, Drug Policy and Human Resources. Pain Physician, 9, 287-321A. 

National Alliance on Mental Illness. (2013). Dual Diagnosis and Integrated Treatment of Mental Illness and Substance Abuse Disorder. Retrieved September 25, 2013 http://www.nami.org/Template.cfm?Section=By_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=54&ContentID=23049 

National Institute on Aging. (2013). Alcohol use in older people. Retrieved from http://www.nia.nih.gov/health/publication/alcohol-use-older-people. 

Substance Abuse and Mental Health Services Administration. (2009). The NSDUH Report: Illicit Drug Use among Older Adults. Rockville, MD: SAMHSA. 

Substance Abuse and Mental Health Services Administration. (2011). Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. (HHS Publication No. (SMA) 11-4658). Rockville, MD: Substance Abuse and Mental Health Services Administration. 

Wu, Li-Tzy, & Blazer, Dan G. (2011). Illicit and Nonmedical Drug Use Among Older Adults: A Review. Journal of Aging and Health, 23(3), 481-504.