Treating Substance Use Disorder In Older Adults
Treating Substance Use Disorderin Older AdultsUPDATED 2020TREATMENT IMPROVEMENT PROTOCOLTIP 26
TIP 26TREATING SUBSTANCE USE DISORDERIN OLDER ADULTSChapter 5—Treating Drug Use and PrescriptionMedication Misuse in Older AdultsKEY MESSAGES Illicit drug use and prescription medication misuse do occur in older adults, but they aretreatable.Regular screening and assessment can helpyou learn whether an older client is strugglingwith drug use or prescription medicationmisuse.Education and brief interventions are oftenenough to help older adults prevent, reduce,or stop drug use and prescription medicationmisuse. Most older clients who use illicit drugsor misuse prescription medication do not needcare from programs or providers that specializein substance use disorder (SUD) treatment.Age-specific and age-sensitive treatments areuseful in reducing drug use and prescriptionmedication misuse and related health risks.These treatments are designed to meet thespecial physical, cognitive, and social needs ofolder individuals. For many older adults, theseadaptations can make all the difference inhelping them start, stay in, and benefit fromtreatment.Chapter 5 of this Treatment ImprovementProtocol (TIP) will benefit healthcare, behavioralhealth service, and social service providers whowork with older adults (e.g., physicians, nursepractitioners [NPs], physician assistants, nurses,social workers, psychologists, psychiatrists, mentalhealth counselors, drug and alcohol counselors, peerrecovery support specialists). It addresses drug use,prescription medication misuse, and SUDs otherthan alcohol use disorder among older adults.Prescription medications are some of the mostcommonly misused substances in this population,803and rates of substance misuse in general areincreasing. These increases result, in part, from thesize of the aging baby boomer generation (thoseborn from 1946 to 1964) and the fact that babyboomers are living longer and have higher ratesof lifetime substance misuse, including SUDs, thanpast generations.Many older adults who misuse substances donot need specialized SUD treatment. Preventionstrategies and brief interventions are often enough.Even so, research shows that older adults do benefitfrom addiction treatment.804,805,806 In fact, older adultsin addiction treatment programs are more likely thanyounger adults to complete treatment, and olderadults have nearly as good or better outcomes.807,808Thus, as the older population in the United Statesgrows, the need for a full range of treatmentapproaches that meet the unique requirements ofolder adults will continue to increase.Organization of Chapter 5 ofThis TIPThis chapter of TIP 26 addresses rates ofdrug use and prescription medication misuse,including drug use disorders, among older adultsas well as treatment and recovery managementapproaches that meet older adults’ specificneeds.The first section of Chapter 5 describes illicitdrug use and prescription medication misuse,including drug use disorders, among olderadults. Definitions and facts are discussed as wellas the physical, mental, social, and economiceffects of drug use disorders.The second section describes how to identify,screen, and assess for drug use disorders in olderadults. The parts of screening, brief intervention,and referral to treatment (SBIRT) are discussed,along with specific tips for screening older adults.131
TIP 26Treating Substance Use Disorder in Older AdultsThe third section describes the continuum of carefor older adults with drug use disorders, whichranges from brief interventions for prescriptionmedication misuse to inpatient detoxificationand rehabilitation for older adults with drug usedisorders.adults with drug use disorders. It covers topicssuch as family member involvement in treatmentand linking older adults to evidence-supported,community-based recovery support groups suchas Narcotics Anonymous (NA) and AlcoholicsAnonymous (AA).The fourth section discusses specific treatmentapproaches for older adults with drug usedisorders. These approaches include acutecare, overdose treatment, medically supervisedwithdrawal, medication maintenance therapy,psychosocial approaches, age-specific treatmentoptions, referral management, and carecoordination.The sixth section provides clinical scenarios. Thissection uses clinical case material to show howto apply approaches and strategies discussed inChapter 5 to older clients.The fifth section provides an overview ofrecovery management strategies for olderFor definitions of key terms you will see throughoutChapter 5, refer to Exhibit 5.1.The seventh section identifies targeted resourcesto support your practice. A more detailed resourceguide is in Chapter 9 of this TIP.EXHIBIT 5.1. Key Terms Addiction*: The most severe form of SUD, associated with compulsive or uncontrolled use of one or more substances. Addiction is a chronic brain disease that has the potential for both recurrence (relapse) andrecovery.Age-sensitive: Adaptations to existing treatment approaches that accommodate older adults’ uniqueneeds (e.g., a large-print handout on the signs of substance misuse).Age-specific: Treatment approaches and practices specifically developed for older adults (e.g., an olderadult specialty group in a mixed-age SUD treatment program).Caregivers: Informal caregivers provide unpaid care. They assist others with activities of daily living(ADLs), including health and medical tasks. Informal caregivers may be spouses, partners, familymembers, friends, neighbors, or others who have a significant personal relationship with the person whoneeds care. Formal caregivers are paid providers who offer care in one’s home or in a facility.809 Most olderadults do not need caregivers and are as able to address their own needs as younger adults, whether ornot substance misuse is a factor in their lives.Diversion: A medical and legal term describing the illegal sharing of a legally prescribed, controlledmedication (e.g., an opioid) with another individual.Drug–drug interaction: The interaction of one substance (e.g., alcohol, medication, an illicit drug) withanother substance. Drug–drug interactions may change the effectiveness of medications, introduceor alter the intensity of side effects, and increase a substance’s toxicity or the concentration of thatsubstance in a person’s blood. Potentially serious interactions can also occur with certain foods,beverages, and dietary supplements.810Drug use: The full range of severity of illicit drug use, from a single instance of use to meeting criteria for adrug use disorder.Illicit substances: Illicit substances include cocaine, heroin, hallucinogens, inhalants, methamphetamine,and prescription medications that are taken other than as prescribed (e.g., pain relievers, tranquilizers,stimulants, sedatives).Continued on next page132Chapter 5
Chapter 5—Treating Drug Use and Prescription Medication Misuse in Older AdultsTIP 26Continued Mutual-help groups: Groups of people who work together on obtaining and maintaining recovery. Unlike peer support (e.g., the use of recovery coaches or peer recovery support specialists), mutual-help groupsconsist entirely of people who volunteer their time and typically have no official connection to treatmentprograms. Most are self-supporting. Although 12-Step groups such as AA and NA are the most widespreadand well researched type of mutual-help groups, other groups may be available in some areas. They rangefrom groups affiliated with a religion or church (e.g., Celebrate Recovery, Millati Islami) to purely seculargroups (e.g., SMART [Self-Management and Recovery Training] Recovery, Women for Sobriety).Peer support: The use of peer recovery support specialists (e.g., someone in recovery who has livedexperience in addiction plus skills learned in formal training) to provide nonclinical (i.e., not requiringtraining in diagnosis or treatment) recovery support services to individuals in recovery from addiction andto their families.Prescription medication misuse: The full range of severity of problematic use of prescription medication(meaning using a medication to feel good, using more than prescribed or in a way not prescribed, orusing medication prescribed to someone else), from mild misuse to meeting criteria for an SUD.Psychoactive substances: Substances that can alter mental processes (e.g., cognition or affect; in otherwords, the way one thinks or feels). Also called psychotropic drugs, such substances will not necessarilyproduce dependence, but they have the potential for misuse or abuse.811Recovery*: A process of change through which individuals improve their health and wellness, live a selfdirected life, and strive to reach their full potential. Even individuals with severe and chronic SUDs can,with help, overcome them and regain health and social function. This is called remission. When thosepositive changes and values become part of a voluntarily adopted lifestyle, that is called being in recovery.Although abstinence from all substance misuse is a cardinal feature of a recovery lifestyle, it is not theonly healthy, pro-social feature.Relapse*: A return to substance use after a significant period of abstinence.Remission: A medical term meaning a disappearance of signs and symptoms of the disease or disorder.The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines remissionas present in people who previously met SUD criteria but no longer meet any SUD criteria (with thepossible exception of craving).812 Remission is an essential element of recovery.Substance misuse*: The use of any substance in a manner, situation, amount, or frequency that cancause harm to users or to those around them. For some substances or individuals, any use wouldconstitute misuse (e.g., underage drinking, injection drug use).Substance use disorder*: A medical illness caused by repeated misuse of a substance or substances.According to DSM-5,813 SUDs are characterized by clinically significant impairments in health and socialfunction, and by impaired control over substance use. They are diagnosed through assessing cognitive,behavioral, and psychological symptoms. SUDs range from mild to severe and from temporary to chronic.They typically develop gradually over time with repeated misuse, leading to changes in brain circuitsgoverning incentive salience (the ability of substance-associated cues to trigger substance seeking),reward, stress, and executive functions like decision making and self-control. Multiple factors influencewhether and how rapidly a person will develop an SUD. These factors include the substance itself; thegenetic vulnerability of the user; and the amount, frequency, and duration of the misuse. Note: A severeSUD is commonly called an addiction. A mild SUD is generally equivalent to what previous editions ofDSM called substance abuse; a moderate or severe SUD is generally equivalent to what was formerlycalled substance dependence.* The definitions of all terms marked with an asterisk correspond closely to those given in Facing Addiction inAmerica: The Surgeon General’s Report on Alcohol, Drugs, and Health. This resource provides a great deal of usefulinformation about substance misuse and its impact on U.S. public health. The report is available online t/files/surgeon-generals-report.pdf).Chapter 5133
TIP 26Drug Use and PrescriptionMedication Misuse Among OlderAdultsDrug use and prescription medication misuse aregrowing problems among older adults. In the nextdecade, approximately 20 percent of the U.S.population will be over age 65.814 As the largebaby boomer population ages up, drug use andprescription medication misuse will likely increase.This group has higher rates of illicit drug use than pastgenerations,815,816 and their misuse of pain medicationand other prescription medication is significant.Taking opioids for pain is one pathway to druguse or prescription medication misuse for olderadults. They may start taking opioids for pain andbecome physically dependent.Other than alcohol and tobacco, the mostcommonly misused substances among olderadults are psychoactive prescription medications,such as opioids and benzodiazepines (i.e.,medications for sleep, pain, and anxiety). Researchshows that older adults also use cannabis, cocaine,and heroin. For example, past-year cannabis useby older adults increased from 2006 to 2013 by57.8 percent for adults ages 50 to 64 and by 250percent for adults ages 65 and older.817Drug use and prescription medication misuse canlead to many negative health outcomes for olderadults, such as: Increased risk of injury and falls.Problems with thinking (also called cognitiveimpairment).Harmful drug–drug interactions.Prescribed medication is not always misused onpurpose. Older adults: Can accidentally take more of a prescribed 134medication than they meant to.Can accidentally mix up medications.May not know the potential risk of harmfuleffects of using certain substances (e.g.,over-the-counter [OTC] medications, dietarysupplements) while taking medication, evenwhen taking it as prescribed.Treating Substance Use Disorder in Older Adults Overdose, which can be fatal.Suicide.Liver and heart disease.Sleep problems.Drug use and prescription medication misuse havenegative economic effects. They cost the UnitedStates billions of dollars each year, including 193billion for illicit substances in 2007818 (the last yearin which those numbers were reported) and 78.5billion for prescription opioids in 2013819 (the lastyear in which those numbers were reported). Druguse and prescription medication misuse also lead togreater healthcare costs. Older adults already usemore healthcare resources than younger adults. Asolder adults with drug use disorders age, they are atan increased risk of co-occurring medical conditions,which means they will use more healthcareservices.820,821,822Drug use and prescription medication misuseamong older adults negatively affect relationships,families, and friends. Many family members,friends, and caregivers recognize but minimizedrug use or prescription medication misuseamong older adults. Well-meaning family andfriends may assume that drug use and prescriptionmedication misuse in older adults cannot be treated,especially if the behavior has been going on for awhile. They may feel that the time for treatment haspassed or that previous attempts at treatment maketrying again pointless.823,824 Often, friends and familyview the use of certain substances by older adults asone of their “last pleasures” or distractions in life.825Ageist, incorrect beliefs about drug use andprescription medication misuse among olderadults can prevent older adults from gettingtreatment. Treatment access for older adults is key,as research increasingly shows that SUD treatmentfor older adults can reduce or stop drug use andprescription medication misuse and improve health/quality of life.826,827,828,829,830Prescription Medication MisusePrescription medication misuse includes: Taking larger doses of a medication thanprescribed.Changing the dose without guidance from theprescriber.Chapter 5
Chapter 5—Treating Drug Use and Prescription Medication Misuse in Older Adults Taking a medication for reasons other than itsintended purpose.Taking someone else’s medications.Older adults are prescribed and use moremedication than any other age group. From 2015to 2016:831 An estimated 87.5 percent of adults ages 65 andolder took at least one prescription medicationin the past 30 days, versus 67.4 percent of adultsages 45 to 64 and 35.3 percent of those ages 18to 44.Adults ages 65 and older were the largestgroup of people taking five or more prescriptionmedications in the past 30 days (39.8 percent)compared with adults ages 45 to 64 (19.1percent) and adults ages 18 to 44 (3.9 percent).Age-related changes to metabolism and body fataffect the medication dosage that older adultsneed and increase the risk of older adults feelingnegative effects of medication. For example,older adults are very likely to feel memory-relatedand psychomotor effects of benzodiazepines andopioids. Also, older adults have a higher rate ofco-occurring conditions than do younger adults,which means they take more medication and aremore likely to experience harmful drug–drug,alcohol–drug, and drug–co-occurring conditioninteractions.832,833Providers face challenges when prescribing forolder adults in general and need to exercise extracaution. One challenge is that a medication maynot have a recommended dosage for older adults,in which case providers should prescribe theminimum dosage needed to achieve a positiveoutcome. Prescribers also need to think aboutwhat formulation of a medication will work bestfor an older patient and what dosing schedulewill be easiest to follow. Yet another commonchallenge is that older patients may be takingunnecessary medication given their specificclinical conditions. Such medication should bediscontinued, consulting with the patient andusing tapering as appropriate.834,835 Also, somemedications are potentially inappropriate forolder adults: see the Chapter 6 text box on theAmerican Geriatrics Society Beers Criteria .Chapter 5TIP 26Younger people tend to misuse psychoactiveprescription medication for mood effects(i.e., wanting to feel very happy or euphoric),but older adults tend to develop drug usedisorders because they are using drugs ormisusing prescription medication to treat theirchronic pain, anxiety, depression, and sleepissues.836,837,838OpioidsThe United States is facing an opioid useand overdose crisis. (See SAMHSA’s TIP 63,Medications for Opioid Use Disorder, for moreinformation; -006). The years 2006 to2013 saw an increase in calls to U.S. poison controlcenters about older adults’ misuse of prescriptionopioids, including misuse of prescription opioidsfor self-harm.839Chronic pain is one of the most common reasonsfor taking medication. Older adults have thehighest rate of chronic pain of any age group,840leading to more clinic visits and increasedprescribing of opioid medication. Older adults withopioid use disorder (OUD) and chronic pain mayhave a hard time accepting that they have OUD.BenzodiazepinesBenzodiazepines (e.g., lorazepam, alprazolam,clonazepam) are mainly used to treat sleep andanxiety disorders. Benzodiazepines are thoughtto be safer than barbiturates and nonbarbituratesedative-hypnotics.841 However, the physicaldependence potential for benzodiazepinesis very high. Long-term use or misuse ofbenzodiazepines in older adults has many risks.Results from more than 68 clinical trials show thatbenzodiazepines, no matter how long they areused (either short-, intermediate-, or long-acting)can lead to cognitive impairment. The greater thedose, the greater the impairment.842135
TIP 26Many older adults experience adverse drugreactions because they are managing numerousprescribed medications (sometimes frommultiple prescribing physicians). Adversedrug reactions are not necessarily the result ofintentional or accidental misuse; rather, theyresult from complying with a dangerous regimenof drugs.Multiple MedicationsThe aging process causes changes to the bodythat increase the chances of older adults feelingnegative effects of medication. For example,older adults have decreased ability to metabolizedrugs. Older adults often take more than onemedication.843 Negative effects are more likelyto occur when older adults take many OTC orprescription medications.844 Taking more than onemedication that affects the central nervous system(CNS) increases the risk of:845 Problems with daily functioning.Cognitive impairment.Falls.Death.Coprescribing of opioid and benzodiazepinemedications is a concern. The risk of death increaseswith the dose of benzodiazepine prescribed.846 In2016, th
Substance use disorder*: A medical illness caused by repeated misuse of a substance or substances. According to DSM-5,813 SUDs are characterized by clinically significant impairments in health and social function, and by impaired control over substance use. They are diagnosed through ass
2. Assessment and Diagnosis in Substance Use Disorder 3. Epidemiology of Substance Use 4. Acute Effects of Alcohol, Opioid and Cannabis Use 5. Health Hazards of Long Term Alcohol, Opioid and Cannabis Use 6. Treatment Principles and Issues in Manage-ment of Substance Use Disorder - An Overview 7. Pharmacotherapy of Substance Use Disorder 8.
F41.1 Generalized anxiety disorder F40.1 Social phobia F41.2 Mixed anxiety and depressive disorder F33 Recurrent depressive disorder F43.1 Post-traumatic stress disorder F60.31 Borderline personality disorder F43.2 Adjustment disorder F41.0 Panic disorder F90 Hyperkinetic (attention deficit) disorder F42 Obsessive-compulsive disorder
9417 Depersonalization disorder SOMATOFORM DISORDERS 9421 Somatization disorder 9422 Pain disorder 9423 Undifferentiated somatoform disorder 9424 Conversion disorder 9425 Hypochondriasis MOOD DISORDERS 9431 Cyclothymic disorder 9432 Bipolar disorder 9433 Dysthymic disorder 9434 Major depres
Adolescent Substance Use Disorder Treatment Zachary W. Adams, Ph.D., HSPP. . Identify drivers of substance use problems and implement evidence- . NIDA Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide. www.drugabuse.gov. NIDA for Teens.
Module 6: Approaches to Addressing Substance Use Disorder with Patients Identified by the PDMP 1. Learn how to integrate the PDMP with other screening tools to help identify those who may require substance use disorder . Substance misuse by patients is commonly encountered by healthcare providers in a variety of settings. However, evidence .
Some children and teens with these symptoms may have . bipolar disorder, a brain disorder that causes unusual shifts in mood, energy, activity levels, and day-to-day functioning. With treatment, children and teens with bipolar disorder can get better over time. What is bipolar disorder? Bipolar disorder is a mental disorder that causes people to experience . noticeable, sometimes extreme .
Subthreshold Bipolar. Disorder. Bipolar II Disorder. Bipolar I Disorder. Psychiatrist. General Medical. No Treatment. Adapted from: Merikangas, et al.1 in Arch Gen Psychiatry. 2007;64(5):543552- The proportion of individuals with bipolar I disorder, bipolar II disorder or subthreshold bipolar disorder
Electromagnetic compatibility (EMC) of automotive components is measured according to CISPR 25, substituting the vehicle environment with line impedance stabilization networks (LISN). Recent research shows that LISNs, developed for low voltage networks, are not ideal to measure conducted emissions of high voltage (HV) components because of changed characteristic impedances and additional .
