DQA Focus 2018: Equal but Different – The Hidden Epidemic of … · 2/12/2019 1 Equal but Different: The Hidden Epidemic of Chemical Use in People 50+ Brenda J. Iliff, MA, LADC,
Post on 28-Aug-2020
0 Views
Preview:
Transcript
2/12/2019
1
Equal but Different: The Hidden Epidemic of Chemical Use in People 50+
Brenda J. Iliff, MA, LADC, CAC, CMAT
Executive Director
Hazelden Betty Ford Naples
November 14, 2018
FOCUS Conference Wisconsin Dells, WI
What is Old?
• Feeling old is more a state of mind that a chronological count down
• Functional capacity is more a factor than age
Why Does it Matter?
Cohorts
How they see the world
May be in more than one generation
Continuum
2/12/2019
2
Earlier Cohorts
• Increased risk physiologically
• Increased beliefs around drinking and drugs
4
Binge Drinking
Male Female
Adults 5 4
60+ 3 2
5
Boomers
LEADING EDGE
Vietnam
Civil Rights
Sex, Drugs, Rock and Roll
Looking for meaning.....
TRAILING EDGE
After Kennedy’s assassination
No draft
Consumer debt
…..and purpose
2/12/2019
3
Fact
Addiction is estimated as high at 17% (National Clearinghouse for Alcohol and Drug Information)
Opioid misuse almost doubled among 50+ last decade (SAMSHA)
Hospitalization rate quintupled in the last two decades for 65+ from Opioids (AARP)
Alcohol is involved in many overdoses for older adults
42% of opioid overdoses were 45+
Many mislabeled as heart failure or falls
9.7% binge drink (adult vs. senior definition) (NSDUH, 2016)
Trifecta
Opioids
Benzodiazepines
Alcohol
Alcohol Interactive Medications
• Over 50% of people on alcohol interactive medications reported drinking alcohol (BMC Geriatrics, 2017).
• 77.8% of older adults who drank used alcohol interactive medications (Alcoholism: Clinical and Experiential Research, 2015).
9
2/12/2019
4
Why Epidemic Proportions?
10
• Sheer numbers• Silver Tsunami
• Flower Child within• Relief like in response to stressor
• Opioid Epidemic• Pain is the 5th vital sign
• Polypharmacy
Where the Research is Pointing to…
11
• As society ages, rates of alcohol and drug abuse will continue through the year 2020 (Simoni-Wastalia & Yang, 2006)
• By 2020 up to 5.7 million people over the age of 50 will have substance use disorder (Han, Gfroerer, Colliver, & Penne, 2009)
• Older adults are less likely than younger adults to recognize the need for treatment (Han. et. Al., 2008)
Risk at 50+
• Pro-substance mindset
• Years of pain and anxiety add up
• Medical advances
• Opioid epidemic
• Polypharmacy
• Slower metabolism
• Losses
• Health concerns
• Social isolation
2/12/2019
5
PHYSICAL
Male (alcohol)
Female (prescriptions)
White
Chronic pain
Chronic physical illness
Polypharmacy
Physical disabilities
Poor health
SOCIAL
Losses
Retirement (unplanned)
Living alone
Social isolation
Lower economic status
Avoidance coping style
Risk Factors
Hope at 50+
• Higher recovery rates
• Draw on lifetime of experience
• Tend to be more disciplined about recovery
• Relish recovery
Resources at 50+
Strength from the past
Strong values
Review values
Re-evaluate priorities–open to new concepts
Value health and independence
Compliance
Open to other avenues than pills (spirituality)
2/12/2019
6
Young vs. Old
YOUNG/OLD
Ages 45-75
May be age 75+
Functioning good
Health good
Independent
Addiction will lead to Old/Old
OLD/OLD
May be age 75+
May be age 50+
Functioning poor
Health poor
Dependent
Recovery leads to Young/Old
Early Onset Addiction
• Longer history of addiction
• Higher proportion of men than women
• Cognitive loss more severe
• Multiple attempts to quit
• More legal, medical and psychosocial problems
• Impulsiveness, aggressiveness
• 2/3 of alcoholics
Late Onset Addiction
18
• Started at age 45+• More women than men• Family history less prevalent• Most are educated or affluent• Losses• Toxic effect• Cognitive loss less severe• Shame• Less severe medical complications• More receptive to treatment
2/12/2019
7
Medicare Part D
2016 Data
• 1/3 received opioid prescription; Medicare doesn’t usually pay for Medication Assisted Treatment (MAT)
• ½ million Part D recipients received high amounts of opioids
• 20% of high opioid group are at serious risk
• Medicare generally doesn’t pay for treatment
• Doctor shopping
4 or more providers or pharmacies
Benzo and Opioid Risks
Exposure
Excessive sedation
Falls
Cognitive Impairment
(SAMSHA, 2011)
Opioid Deaths
• 2000 to 2015, the number of opioid deaths quadrupled
• 55-64 year olds increased eight-fold
• 65-74 year olds increased seven-fold
• Benzos were involved in 1/3 of opioid deaths
• During past 10 years opioid misuse doubled in 50+
• While Medicare will pay for opioids it may not pay for treatment
2/12/2019
8
Incorrect Diagnoses
• “Causes of many overdoses over 60 are written off as age-related.”
- Dr. Andrew Kolodny
Executive Director, Physicians for Responsible Opioid Prescribing
The Vicious Cycle
Opioid or Benzo Use
Falls
PainNot eating or drinking
Depression
/Anxiety
23
Do No Harm
24
• Use CDC’s Guideline for Prescribing Opioids for Chronic Pain
2/12/2019
9
Myths
• Opioids are effective long-term for chronic pain
• The risk of addiction is minimal
• Older people are less likely to get addicted
• Taking meds at bedtime reduces risks
• My doctor prescribed it
• There won’t be any discontinuation syndrome
25
Assessing Risks
• Evaluate risk factors for opioid-related harms
• Check PDMP for high dosages and prescriptions from other providers
• Use urine drug testing to identify prescribed substances and undisclosed use
• Avoid concurrent benzodiazepine and opioid prescribing
• Arrange treatment for opioid use disorder if needed.www.cdc.gov/drugoverdose/prescribing/guideline.html
26
27
2/12/2019
10
Prevalence of Drug Use of People Over 50
28
• 2.2% reported misusing medications
• 3.3% reported cannabis2016 National Survey on Drug Use and Health
29
My Doctor Prescribed It…
Talk about all medication
Talk about all supplements
Over the counters
Brown bag review
Pharmacist review
What’s the Big Deal?
2/12/2019
11
At Risk
• Multiple diseases, medications, providers and pharmacies
• Allergies
• Pain
• Sleep problems
• Self medication
• Extended medical treatment
Carol Colleran (Consultant to Hazelden in Naples Boomers Plus Program) author of Aging and Addiction, Hazelden, 2002
Medication Compliance
32
• Vision
• Misunderstanding instructions, hear• Opening bottles
• Handling pills
• Mental confusion
• Unable to afford• Take intermittently
• Multiple providers
• Water intake
• Common justifications
Difficulty in Diagnosing
• Less objective measures (job, structure, legal, roles)
• Strong shame
• Denial
• Family is not around to report
• User may use less than they did historically
• Other problems mask abuse
• Complexity
2/12/2019
12
• Unexplained bruises• Heart abnormalities• Eating poorly• Speech changes• Change in sleep patterns• Shaking• Disorientation• Memory loss• Frequent falls• Poor coordination• Headache• Injuries• Gastritis• HIV/AIDS• Elevated cholesterol
• Blackouts• Depression• Irritability• Fatigue• Elevated blood glucose• Heart disease• Cancer• Hypertension• Stroke• Pancreatitis• Cirrhosis• Infections• Liver problems• Decrease in immune system
Medical Concerns or Substance Misuse?
Physical Signs and Symptoms
35
Decrease in activities of daily living
Health complaints Unexplained
burns/bruises/falls Decreased mobility Hygiene concerns Malnutrition/weight loss Blurred vision Slurred speech HIV/AIDS
Increase in sleep Loss of function Memory loss Sleep complaints Multiple doctors/pharmacies Mixing up appointments Chronic health complaints
Behavioral Changes
Isolation Secretiveness – hiding supply Change in friends/loss of friends Risky behavior (unprotected sex, driving, walking drunk) Missing events/cancelling events Multiple social hours throughout day Multiple medical providers Multiple pharmacies Nesting Giving up activities
2/12/2019
13
Accidental Addicts–Physical
• Misunderstand medications• Age related changes and medications
• ↑ body fat• ↓ body water content• ↓ gastrointestinal tract function• ↓ liver and kidney functions
• Neuro-brain more rigid• Taking multiple medications• Multiple ailments• Chronic pain• Slower mental functions• Body doesn’t tolerate change as well
Accidental Addicts–Behavior
• Nesting• Mixing up things-appts/meds• Multiple medical providers/pharmacies• Receive poor monitoring of all meds• Blue pill vs. green pill• Unintentionally misuse medications• Risky Behaviors (driving, unprotected sex)• May not be able to read labels/open bottles• Secretiveness• Hiding/Sneaking• Giving up activities
How to Talk About Concerns
Preserve dignity
Non-judgmental
Shame issues
“The Will”
Describe what you see
Stay away from labels– Alcoholic-use “alcohol problem”
– Addict
– Quit drinking
2/12/2019
14
F R A M E S
F- Specific, nonjudgmental, Feedback
R- Personal Responsibility to change
A- Clear Advice and recommendations
M- Offer Menu of options
E- Use an Empathetic communication style
S- Support Self-efficacy
40
Address Family Concerns
41
• Get involved when crisis• Babysitting• Energy draining• Caregiver–physically exhausted• Airing dirty laundry• Myths of addiction around aging• Double life–live distance• No public consequences• Health–somatic complaints of family• Family split on action plan• Tired of it!
42
2/12/2019
15
Screening Tools
CAGE screening– Cut down/Control
– Annoyed/Angry
– Guilt/Shame
– Eye Opener/Earlier
Interviews Knowledge of substance abuse and aging issues Alcohol Related Problems Survey www.aboutmydrinking.org Knowledge of framing addiction DSM5 Short Michigan Alcoholism Scanning Test-G IADL–Instrumental Activities of Daily Living
43
Screening Tools
Alcohol:– Alcohol Use Disorders Identification Test (AUDIT)
– Alcohol Use Disorders Identification Test-C (AUDIT-C)
– National Institute on Alcohol Abuse and Alcoholism (NIAAA) Single-Item Screen
– Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G)
– Senior Alcohol Misuse Indicator
Cannabis:– Cannabis Use Disorder Identification Test-Revised (CUDIT-R)
Multiple substances:– Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)-Lite
– Brief Addiction Monitor
– CAGE Questionnaire Adapted To Include Drugs (CAGE-AID)
– National Institute on Drug Abuse (NIDA) Quick Screen V1.0
44
Co-occurring Disorders
• Depression
• Anxiety
• Bi-polar
• Schizophrenia
• Cognitive Disorders
• PTSD
45
2/12/2019
16
Mental Health Screening
46
• Trauma Screening Questionnaire
• Elder Abuse Suspicion Index
• Co-occurring Conditions in General
• Comorbidity Alcohol Risk Evaluation Tool (CARET)
• Cognition
• Mini-Mental Status Exam (MMSE)
• Confusion Assessment Method (CAM)
• Montreal Cognitive Assessment
Screening Tools for mental health concerns
Depression Cornell Scale for Depression in Dementia (CSDD) Geriatric Depression Scale (GDS)-Short Form Patient Health Questionnaire (PHQ)
Anxiety Beck Anxiety Inventory (BAI) Penn State Worry Questionnaire (PSWQ) Obsessive-Compulsive Inventory-Revised
PTSD, Trauma Symptoms, and Abuse PTSD Checklist Primary Care PTSD Screen for DSM-5
Barriers to Help for People 50+
• Stigma• Denial• Shame• Myths of aging• Financial concerns• Skepticism about treatment• Health care providers• “The Will”• Family• Fear• Lack of training (professionals)
2/12/2019
17
Health Care Providers Barriers
49
• Myths
• Detoxification longer
• Takes up beds longer in public settings
• Slower paced
• Ageism
• Like to talk
Move slower
Take more time
Want choices
Like own environment
Residential Models
Minimal .5 ASAM Interventions
Myths of Addiction for people 50+
• It’s life’s last pleasure
• He has strong willpower
• The physician prescribes those pills
• She’s too old to change
• Drinking is good for his heart
• You can’t help someone until they want it
• At her age, what difference does it make
• She’s enjoying life–it’s all she has
• Less likely to recovery
Treatment Options
• Explore least intensive first• Brief intervention• Intervention• Motivational counseling• Detoxification• Treatment settings
• Outpatient• Day treatment• Residential• Hospital based
2/12/2019
18
Most Serious Detox Needs• Alcohol
• Benzodiazepines
• Opiates
• Aging Individuals
52
Limited Medical Detox Needs• Marijuana
• Cocaine
• Meth
Alcohol• Acamprosate
• Disulfiram
• Naltrexone
Opioids• Naltrexone
• Buprenorphine
• Methadone
53
Medication Interventions
Medical
54
• Thorough Medical Screening
• Chronic Pain
• Dementia
• Multiple Medications
• Medicare
• Funding
2/12/2019
19
Spirituality Concerns
• Purpose
• Meaning
• Spirituality after 70 is different
• Understanding of Higher Power
• Understanding keeps changing
• End of life as we know it
Education or Therapy
56
• Describe the purpose of group
• May be polite rather than honest
• May not confront denial
• Sidestep difficult issues
• Women defer to men
• Frequently give advice vs. insight
• May need to leave room (bladder)
• May need to stand or walk (pain)
• Hearing concerns
Women at 50+
Rewired for self-reflection
Empty nest
Resurgence of eating disorders
Perimenopause and menopause
Old trauma may surface
Sexual dysfunction
Looking for fountain of youth
2/12/2019
20
Recovery Planning
58
Medicines
Assertive linkages
Aging Services
Wrap around services
Mental health services
Recovery Support Groups
Transportation
Medical
References
59
1. Administration on Aging, Substance Abuse and Mental Health Services Administration (2012). Issue Brief 5: Prescription Medication Misuse, and Abuse among Older Adults.
2. Analysis of data from the Centers for Medicare and Medicaid Services [Television broadcast]. (2014). In USA Today. Naples, FL: USA.
3. Blow FC, Barry KL. Treatment of older adults. In RF Ries, DA Fiellin, SC Miller, R Saitz, eds., The ASAM principles of addiction medicine, 5th ed. Hagerstown, MD: Wolters KluwerHealth; 2014:541‐554.
4. Bowers, M. P. (2014). Lecture presented in Hazelden Betty Ford Foundation, Naples.5. Breslow, R.A., C. Dong, and A. White, Prevalence of Alcohol‐Interactive Prescription Medication Use Among Current Drinkers:
United States, 1999 to 2010. Alcoholism: Clinical and Experimental Research, 2015. 39(2): p. 371‐379.6. Center for Behavioral Health Statistics and Quality. (2017). 2016 National Survey on Drug Use and Health: Detailed Tables.
Substance Abuse and Mental Health Services Administration, Rockville, MD.7. Colleran, C., Jay, Deborah. Aging and Addiction. Helping Older Adults Overcome Alcohol or Medication Dependence‐A Hazelden
Guidebook. Softcover, Guidebook, 232 pp.8. Culberson, J.W., & Ziska M. (2008). Prescription drug misuse/abuse in the elderly. Geriatrics, 63, 22‐279. Curran, H.V., Collins, R., Fletcher, S., Kee, S.C., Woods, B., & Iliffe, S. (2003). Older adults and withdrawal from benzodiazepine
hypnotics in general practice: Effects on cognitive function, sleep, mood, and quality of life. Psychological medicine, 33, 1223‐12710. Han, B., Gfroerer, J.C., Colliver, J.D., & Penne, M.A. (2009). Substance use disorder among older adults in the United States in
2020. Addiction, 104, 88‐96.11. Holton, A.E., et al., Concurrent use of alcohol interactive medications and alcohol in older adults: a systematic review of
prevalence and associated adverse outcomes. BMC geriatrics, 2017. 17(1): p. 148.12. Iliff, B. (2008). A woman's guide to recovery. Center City, MN: Hazelden.13. Lawton, M., & Brody, E. (1969). Assessment of Older People: Self-Maintaining and Instrumental Activities of Daily Living.
Retrieved October 18, 2016, from http://gerontologist.oxfordjournals.org/content/9/3_Part_1/179.extract.14. Lembke, A., & Chen, J. (2016, September 1). Use of Opioid Agonist Therapy for Medicare Patients in 2013. JAMA Psychiatry,
73(9), 990-992. Retrieved October 28, 2016.
References (cont.)
60
15. National center for Health Statistics (2014). Summary Health Statistics for U.S. Adults: National US Interview Health Survey 2012 Hyattsville, MD 2014. Centers for disease control and prevention.
16. National Highway Traffic Safety Administration. (2010). USA. 17. National Institute of Drug Abuse (NIDA) (2014). Research Report Series: Prescription Drug Abuse; NIH Pub. No. 15‐4881, Dept.
of Health and Human Services, accessed at: http://www.drugabuse.gov/publications/prescription‐drugs‐abuse‐addiction/preventing‐recognizing‐prescription‐drug‐abuse.
18. O'Brien, M. (2005). Successful aging. Concord, CA: Biomed General. 19. Olfson, M., King M., & Schoenbaum, M. (2014) Benzodiazepine use in the United States. JAMA psychiatry. Published online
December 17, 2014.20. Powell, D. J. (2003). Playing life's second half: A man's guide for turning success into significance. Oakland, CA: New Harbinger
Publications. 21. Research Update [Pamphlet]. (2015). Center City, MN: Hazelden Butler Center for Research. 22. SAMHSA. (2012) Older Americans Behavioral Health Issue Brief 2: Alcohol misuse and Abuse Prevention. P. 1. Retrieved from
https://www.acl.gov/sites/default/files/programs/2016‐11/Issue%20Brief%202%20Alcohol%20Misuse.pdf23. Seby K, Chaudhury S, Chakraborty R. Prevalence of psychiatric and physical morbidity in an urban geriatric population. Ind J
Psychiatry 2011; 53(2): 121‐127.24. Simoni‐Wastalia, L., & Yang, H.K. (2006) Psychoactive drug abuse in older adults. The American Journal of Geriatric
Pharmacotherapy, 4, 380‐394.25. Taylor MH, Grossberg GT. The growing problem of illicit substance abuse in the elderly: a review. Prim Care Companion CNS
Disord 2012; 14(4): PCC.11r01320.26. TIP 26 Substance Abuse Among Older Adults. (n.d.). Retrieved October 18, 2016, from http://www.samhsa.gov/27. Williams, R.E., Bosnic, N., Sweeney, C.T., Duncan, A.W., Levine, K.B., Borgan, M., &Cook, S.F. (2008) Prevalence of opioid
dispensings and concurrent gastrointestinal medications in Quebec. Pain Research and Management, 13, 395‐400.28. Won, A.B., Lapane, K. L., Vallow, S., Schein, J., Morris, J.N., & Lipsitz, L. A. (2004). Persistent nonmalignant pain and analgestic
prescribing patterns in elderly nursing home residents. Journal of the American Geriatric Society, 52, 867‐874
top related