Characteristics of older opioid maintenance patients

Different characteristics but comparable hypertension rates between two MMT "twin" clinics

BACKGROUND

Patients in methadone maintenance treatment (MMT) may develop age-related medical problems. Objective: To compare hypertension prevalence and its risk factors between two MMT clinics, having similar treatment guidelines, but different characteristics, one from Tel Aviv (TA) and one from Las Vegas (LV).

METHODS

Prevalence of hypertension (systolic ≥140 and or diastolic ≥90 mmHg BP) among all current 291 MMT patients in TA and 180 patients in LV were studied, including body mass index (BMI), drugs in urine, sociodemographic, and addiction history data.

RESULTS

Hypertension prevalence was comparable in TA (35.4%) and LV (34.4%), however TA patients were older (55.9 ± 9.5 vs. 45.5 ± 13.3, p < 0.001), with fewer females (22 vs. 42.2%, p < 0.001), fewer obese (BMI ≥30) (24 vs. 40.9%, p < 0.001), higher cocaine (21 vs. 7.8%, p < 0.001), and lower cannabis (14.1 vs. 32.4%, p < 0.001) and amphetamines (0 vs. 33.5%) users. Logistic regression found higher BMI to characterize hypertension in both clinics, but in TA also negative urine cocaine, benzodiazepine, and opioids screen, while in LV older age (≥50 y), male gender, and negative urine cannabis screen.

CONCLUSIONS

While TA was characterized with older patients, LV patients had a comparable hypertension rate, as obesity was more prevalent. No drug use was accompanied by higher BMI in TA and therefore associated with hypertension. Weight reduction, hypertension detection and treatment are recommended.

Individuals 45 Years and Older in Opioid Agonist Treatment: A Scoping Review

This scoping review explores the unique challenges and needs faced by ageing individuals, aged 45 and above, in opioid agonist treatment (OAT), noting the earlier onset of age-related impairments among this population. The literature search was conducted in PsycINFO, EMBASE, MEDLINE, CINAHL, and Web of Science. A total of 28 observational studies were included. Five topics were identified: health, treatment, substance use, demographic, and social aspects. Findings reveal that, while health and age-related concerns are often discussed in the literature, limited attention has been given to gender differences, social factors such as financial issues, and psychological factors, which are also critical aspects of the lives of ageing individuals undergoing OAT. This review emphasizes the importance of expanding research to address these gaps, ultimately aiming to improve their overall well-being.

Mental and physical health characteristics of older and younger adults receiving medication for opioid use disorder

Background

Methadone is an effective and widely used medication for opioid use disorder (MOUD). Within in the United States (US), older adults represent an increasing proportion of those receiving MOUD, yet little is known about characteristics of older individuals in these programs.

Objectives

To evaluate mental and physical health characteristics of younger and older adults receiving MOUD and test whether age moderates the relation between physical and mental health variables.

Methods

Data for this secondary analysis are drawn from a cross-sectional survey of a convenience sample of individuals seeking methadone dosing as part of MOUD at four opioid treatment programs in two regions of the US. Descriptive statistics and correlational and moderation analyses examined outcomes of pain severity, pain interference, self-rated health, physical activity, depression, and anxiety across younger (18-49) and older (50+ years) participants.

Results

Analyses included 469 participants (mean [range] age, 41.01 [20-70] years). Older participants reported higher pain severity and interference, less physical activity, and worse self-rated health than those in the younger age group (ps < 0.05). Associations between mental and physical health variables were generally weak-to-moderate in the older age group (r = 0.26 to r = 0.44, p < 0.01), and weak in the younger age group, although age did not moderate associations.

Conclusion

Clinically significant mental and physical health variables are associated among individuals receiving methadone for MOUD, with older adults facing unique challenges.

Clinical implications

Opioid use treatment should include not only pain management but also assessment and treatment of depression and anxiety and optimization of other health behaviors (e.g., physical activity) across age groups. Pain management and health promotion are particularly relevant targets for aging individuals receiving MOUD.

Systematic Review on Mortality in the Elderly on Methadone Maintenance Treatment

Opioid dependence is a serious public health concern, particularly for older individuals who have a high prevalence of comorbid conditions. To effectively manage opioid use disorder (OUD), methadone maintenance treatment (MMT) is crucial; however, the MMT poses certain challenges for the aging population. The purpose of this review is to evaluate the impact of MMT on health outcomes, identify predictive factors for mortality, and assess mortality rates among older individuals receiving MMT. A systematic search was performed across databases, including PubMed, Scopus, Web of Science, and Google Scholar, adhering to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Studies included were published between January 2000 and December 2023, focused on elderly patients (60 years of age and older) receiving MMT and provided information on death rates. A total of 15 studies were examined. The main causes of death for older MMT patients were overdose, respiratory issues, and cardiovascular diseases. The annual mortality rates for these patients ranged from 2% to 10%. Treatment outcomes and mortality were significantly impacted by comorbid conditions. Greater treatment adherence and longer care periods were observed in older individuals, which correlated with better health outcomes and lower mortality. This review makes clear how elderly MMT patients with addiction and chronic health issues require integrated care models. Treatment effectiveness may be further increased by gender-specific interventions. For this aging population, policy reforms and enhanced healthcare support are essential. To enhance clinical results and lower mortality rates among older individuals enrolled in MMT programs, comprehensive age-appropriate care models are crucial. Long-term health outcomes should be investigated further and evidence-based treatments for older individuals with OUD should be developed.

Occurrence of hypertension among patients with opioid use disorder in methadone maintenance treatment

BACKGROUND

Patients in methadone maintenance treatment (MMT) may develop age-related medical problems, but hypertension (HTN) proportion and its occurrence during MMT have not been studied yet. We aimed to evaluate changes in blood pressure (BP) during MMT and characterize current HTN.

METHODS

Of all 1098 ever admitted MMT patients, those with ≥2 BP follow-up measures were included ( n  = 516), of them all current patients ( N  = 245) tested for HTN (systolic BP ≥140 mmHg or diastolic BP ≥90 were detected twice (one week apart) were considered as affected with HTN. Current and earliest during the first, and latest year in MMT of body mass index (BMI), BP, methadone dose and serum level, and drugs in urine were analyzed.

RESULTS

HTN was detected in 89(36.3%) of the current patients. The HTN and non-HTN groups did not differ by sex ( P  = 0.6), age ( P  = 0.2), and duration in MMT ( P  = 0.6), but had higher BMI (27.9 ± 5.2 vs. 25.6 ± 5.2, respectively, P  = 0.001) and fewer had positive urine test findings for any substance (31.5% vs. 44.9%, P  = 0.04). Comparing their earliest measures (before 11.9 ± 5.8 years), BP and BMI increased more among the hypertensive group, independent of methadone dose and serum levels, which significantly reduced over the years. No drug abuse was associated with increased BMI and BP.

CONCLUSIONS

Weight gain was associated with BP elevation and characterized patients who succeeded in drug abstinence during MMT. Healthy nutrition education at admission to MMT may reduce the incidence of weight gain and HTN, therefore identifying HTN and offering treatment for this highly prevalent life-threatening condition among middle-age and older patients in MMT is recommended.

Differences in heroin overdose deaths in Australia by age, 2020-2022: Disease and estimated survival times

Background

The age of people who use illicit opioids has increased, with a clinical picture of accelerated ageing. The study aimed to determine, stratified by age: 1. The circumstances and characteristics of heroin-related toxicity deaths in Australia, 2020-2022; 2. The toxicological profile and autopsy findings; 3. The proportion of cases in which blood 6-acetyl morphine (6AM) was detected, as a measure of survival time.

Methods

Retrospective study of 610 cases of fatal heroin-related drug toxicity in Australia, 2020-2022. Cases were stratified as: <30 years, 30-39 years, 40-49 years, ≥50 years.

Results

Compared to the youngest group, those aged ≥50 years were more likely to have a history of chronic pain (12.4 v 3.3 %), to have their death attributed to combined drug toxicity/disease (20.1 v 3.3 %), and to have evidence of a sudden collapse (21.3 v 11.1 %). There were no differences in free morphine concentrations or glucuronide concentrations. Compared to the youngest group, however, the two older groups were significantly more likely to have 6AM present in blood, a proxy measure of a shorter survival time (52.0, 55.2 v 34.5 %). Compared to the youngest group, cases aged ≥50 years were more likely to be diagnosed with cardiomegaly (44.0 v 16.7 %), coronary artery disease (46.0 v 15.0 %), emphysema (35.0 v 5.1 %), hepatic steatosis (15.4 v 3.4 %), hepatic fibrosis (17.6 v 3.4 %), and cirrhosis (19.8 v 0.0 %).

Conclusions

Older cases of heroin overdose had more extensive heart, lung, and liver disease, and appeared more likely to have shorter survival times.

Health utility among people who regularly use opioids in Australia

INTRODUCTION

Studies of health utilities among people who use opioids have mostly been based on in-treatment populations. We aim to report utility-based quality of life by participants' socio-demographic, drug and treatment characteristics, and to examine the determinants of health utility among people who use opioids regularly.

METHODS

Cross-sectional study of participants who used opioids regularly, recruited across New South Wales, Victoria and Tasmania in 2018-2019. Differences in European Quality of Life (EQ-5D-5L) heath utility scores between socio-demographic and clinical subgroups were assessed using non-parametric Kruskal-Wallis test by rank. To address the unique distribution of EQ-5D-5L health utility scores in the current sample, a two-part model was applied to assess factors associated with health utility.

RESULTS

Among 402 participants enrolled in the study, 385 (96%) completed the EQ-5D-5L questionnaire. The mean health utility of the total sample was 0.63 (SD 0.29). Participants who previously received opioid agonist treatment [OAT] (adj marginal effect (ME) -0.11; 95% confidence interval [CI] -0.20 to -0.02) and those currently in OAT (adj ME -0.13; 95% CI -0.22 to -0.06) reported lower health utility than those who had never received OAT. Participants who used both pharmaceutical opioids and benzodiazepines had lower health utility compared to no pharmaceutical opioids and no benzodiazepines use (adj ME -0.17; 95% CI -0.28 to -0.07).

DISCUSSION AND CONCLUSIONS

Findings provide important health utility data for economic evaluations, useful for guiding allocation of resources for treatment strategies among people who use opioids. Lower health utilities among those using benzodiazepines and pharmaceutical opioids suggests interventions targeting these subgroups may be beneficial.

[Bronchial diseases and heroin use. A systematic review]

INTRODUCTION

Heroin use can cause respiratory complications including asthma, chronic obstructive pulmonary disease (COPD) and bronchiectasis (BD).

OBJECTIVES

A general review of the literature presenting the data on the relationships between heroin consumption and bronchial complications, while underlining the difficulties of diagnosis and management.

DOCUMENTARY SOURCES

Medline, 1980-2022, keywords "asthma" or "bronchospasm" or "COPD" or "bronchiectasis" and "heroin" or "opiate" or "opiates", with limits pertaining to "Title/Abstract". Concerning asthma, 26 studies were included, as were 16 for COPD and 5 for BD.

RESULTS

Asthma and COPD are more prevalent among heroin addicts, who are less compliant than other patients with their treatment. The authors found a positive association between frequency of asthma exacerbations, admission to intensive care and heroin inhalation. Late diagnosis of COPD worsens the course of the disease; emphysema and BD are poor prognostic factors.

CONCLUSION

Bronchial diseases in heroin users can be identified by means of respiratory function exploration and chest CT scans. These tests should be performed frequently in view of optimizing their care, which includes their weaning themselves from addictive substances.

Use, Effects, and Diagnostic Challenges of Cocaine Use in "Baby Boomers" and Older Adults

Introduction

Substance use disorder (SUD) is frequently recognized in the literature as an epidemic in the United States, but less attention has been paid to the scale of the epidemic among people older than 60 years of age. As the cohort of individuals in this age group grows as a proportion of the population-the so-called aging of the population-the incidence of SUD in older adults will increase numerically as well. While most existing literature on SUD in the elderly has focused on alcohol, opioids, and prescription drugs, the number of users of stimulant drugs like cocaine and methamphetamine is also growing. We review literature on the use, effects, and diagnostic challenges of cocaine in adults in the so-called "Baby Boomer generation" (ages 59-77 in 2023), particularly those ≥65 years.

Methods

We performed a literature review of PubMed and Web of Science databases, supplemented by Google Scholar using combinations of "cocaine," "elderly," and "older adults." We searched the reference sections of particularly salient articles and utilized PubMed's and Google Scholars' "Cited By" and "Similar Articles" functions to find additional materials to include. We produced an annotated bibliography containing title and author information for each paper along with its abstract to select the papers to include; each author reviewed this bibliography to determine if articles were relevant, and if so, in which section(s) the material should be included. A total of 66 references have been included in this review.

Results

Both lifetime and current cocaine use appear to be more prevalent among members of the "Baby Boomer generation" than older cohorts. Though there has been limited research to inform clinical care for older adults who use cocaine, negative physical and psychosocial impacts have been noted in the literature. Cocaine use disorder may negatively affect the elderly more than younger users because of the increased vulnerability of their aging bodies to the physiological and cognitive effects of cocaine. Underdiagnosis of cocaine use in the elderly may be attributable to the assumption that any presenting symptoms are due to pre-existing medical conditions or that older adults are less likely to consume cocaine.

Conclusions

There is little information currently in the literature to help clinicians understand patterns and epidemiology of cocaine use, its effects on older adults and their common presentations after experiencing adverse events, and challenges of diagnosing and treating cocaine use in older adults. Additional research is needed to describe use and effects of cocaine on the elderly, particularly on age-related comorbid conditions and interactions with medications.

Cause-Specific Mortality among Patients in Treatment for Opioid Use Disorder in Multiple Settings: A Prospective Comparative Cohort Study

INTRODUCTION

Among people receiving current or previous opioid maintenance treatment (OMT), the leading cause of premature death is an opioid overdose. However, other causes of mortality remain high in this group. An understanding of causes of deaths across multiple settings can be useful in informing more comprehensive prevention responses. The aim of this study was to describe all non-overdose causes of death in three national cohorts (Czechia, Denmark, and Norway) among OMT patients and to explore associations of non-overdose mortality with age and gender.

METHODS

This prospective comparative cohort study used national mortality registry databases for OMT patients from Czechia (2000-2019), Denmark (2000-2018), and Norway (2010-2019). Crude mortality rates and age-standardized mortality rates (ASMRs) were calculated as deaths per 1,000 person years for cause-specific mortality.

RESULTS

In total, 29,486 patients were included, with 5,322 deaths recorded (18%). We found variations in causes of death among the cohorts and within gender and age groups. The leading non-overdose causes of death were accidents in Czechia and Denmark, and neoplasms in Norway. Cardiovascular deaths were highest in Czechia, particularly for women in OMT (ASMR 3.59 vs. 1.24 in Norway and 1.87 in Denmark).

CONCLUSION

This study found high rates of preventable death among both genders and all age groups. Different demographic structures, variations in risk exposure, as well as variations in coding practices can explain the differences. The findings support increased efforts towards screening and preventative health initiatives among OMT patients specific to the demographic characteristics in different settings.

Risk Factors for Substance Use across the Lifespan

Substance use is a perennial public health concern with associated health risks and economic impacts on society. In this article, we present a selective review of the epidemiological and clinical literatures on alcohol and substance use from a lifespan developmental perspective. We compare and contrast risk factors for the initiation of use and the development of a substance use disorder in adolescence, young adulthood, middle-age and later life. During adolescence, alcohol use experimentation is at its peak. Specific risk factors have been identified including trauma and parenting style that can increase the risk of substance use for teenagers. Emerging adults and college students are likely to experiment with other substances in addition to alcohol such as nicotine, marijuana, cocaine, and prescription medication such as Adderall. Middle-age and older adults with alcohol and substance use in their developmental histories may have an undiagnosed alcohol use disorder. Others will develop a late-onset substance use disorder in older age, possibly due to a dearth of social support, coping with bereavement, and medical complication. Based on Social Cognitive Theory, the roles of expectancies and self-efficacy are hypothesized to impact substance use and the risk of substance use disorder across the lifespan. Implications of the present review for future research on age-specific risk factors in alcohol use in relation to underlying developmental processes are considered.

High smoking and low cessation rates among patients in treatment for opioid and other substance use disorders

BACKGROUND

Smoking is a well-documented cause of health problems among individuals with substance use disorders. For patients in opioid maintenance treatment (OMT), the risk for somatic health problems, including preventable diseases associated with tobacco smoking, increases with age. Our aim was to describe smoking among patients entering substance use disorder (SUD) treatment, investigate changes in smoking from the start of treatment to 1-year follow-up, and explore factors related to smoking cessation.

METHODS

We employed data from the Norwegian Cohort of Patient in Opioid Maintenance Treatment and Other Drug Treatment Study (NorComt). Participants were 335 patients entering SUD treatment at 21 participating facilities across Norway. They were interviewed at the start of treatment and at 1-year follow-up. The main outcomes were smoking and smoking cessation by treatment modality. A logistic regression identified factors associated with smoking cessation.

RESULTS

High levels of smoking were reported at the start of treatment in both OMT (94%) and other SUD inpatient treatment patients (93%). At 1-year follow-up most patients in OMT were still smoking (87%), and the majority of the inpatients were still smoking (69%). Treatment as an inpatient was positively associated and higher age was negatively associated with smoking cessation. Most patients who quit smoking transitioned to smokeless tobacco or kept their existing smokeless habit.

CONCLUSION

As illustrated by the high smoking prevalence and relatively low cessation levels in our sample, an increased focus on smoking cessation for patients currently in OMT and other SUD treatment is warranted. Harm-reduction oriented smoking interventions may be relevant.

Ageing and older people who use illicit opioids, cocaine or methamphetamine: a scoping review and literature map

AIMS

To provide an overview of research literature on ageing and older people who use illicit opioids and stimulants by documenting the conceptual frameworks used and content areas that have been investigated.

METHODS

We conducted a scoping review of literature relating to ageing and older people who use illicit stimulants and opioids, defining 'older' as 40 years and above. Primary studies, secondary studies and editorials were included. Searches were conducted in PubMed and Embase in July 2020 and March 2021; the Cochrane library was searched in November 2021. Charted data included methodological details, any conceptual frameworks explicitly applied by authors and the content areas that were the focus of the publication. We developed a hierarchy of content areas and mapped this to provide a visual guide to the research area.

RESULTS

Of the 164 publications included in this review, only 16 explicitly applied a conceptual framework. Seven core content areas were identified, with most publications contributing to multiple content areas: acknowledgement of drug use among older people (n = 64), health status (n = 129), health services (n = 109), drug use practices and patterns (n = 84), social environments (n = 74), the criminal legal system (n = 28) and quality of life (n = 15).

CONCLUSIONS

The literature regarding older people who use illicit drugs remains under-theorized. Conceptual frameworks are rarely applied and few have been purposely adapted to this population. Health status and health services access and use are among the most frequently researched topics in this area.

Primary care and medication management characteristics among patients receiving office-based opioid treatment with buprenorphine

BACKGROUND

Office-based opioid treatment (OBOT) is an evidence-based treatment model for opioid use disorder (OUD) offered by both addiction and general primary care providers (PCPs). Calls exist for more PCPs to offer OBOT. Few studies have been conducted on the primary care characteristics of OBOT patients.

OBJECTIVE

To characterize medical conditions, medications, and treatment outcomes among patients receiving OBOT with buprenorphine for OUD, and to describe differences among patients by age and by time in care.

METHODS

This study is a retrospective review of medical records on or before 4/29/2019 at an outpatient primary care clinic within a nonprofit addiction treatment setting. Inclusion criterion was all clinic patients actively enrolled in the OBOT program. Patients not prescribed buprenorphine or with no OBOT visits were excluded.

RESULTS

Of 355 patients, 42.0% had another PCP. Common comorbid conditions included chronic pain and psychiatric diagnosis. Few patients had chronic viral hepatitis or HIV. Patients reported a median of 4 medications. Common medications were cardiovascular, antidepressant, and nonopioid pain agents. Older patients had a higher median number of medications. There was no significant difference in positive opioid urine toxicology (UT) based on age, chronic pain status, or psychoactive medications. Patients retained >1 year were less likely to have positive opioid UT.

CONCLUSION

Clinical needs of many patients receiving OBOT are similar to those of the general population, supporting calls for PCPs to provide OBOT.

Screening for and Management of Opioid Use Disorder in Older Adults in Primary Care

Opioid use disorder (OUD) is commonly seen in older adults in primary care offices. OUD when left untreated, often leads to overdose deaths, emergency department visits, and hospitalizations due to opioid-related adverse effects, especially respiratory and central nervous system depression. Primary care providers are on the front lines of efforts for its prevention, early detection, and treatment. This includes using the lowest doses of opioids for the shortest possible time for management of pain, routine screening, brief intervention, opioid withdrawal management, prescription of naloxone to prevent overdose death, and treatment with medications and psychosocial interventions for OUD. Referral to addiction treatment centers may be needed in complex cases. This review explores the epidemiology, screening, as well as management of OUD as it pertains to the elderly population.

Effectiveness of incorporating contingency management into a public treatment program for people who use crack cocaine in Brazil. A single-blind randomized controlled trial

BACKGROUND

Smoked cocaine (i.e., crack use) is a severe health problem in Brazil, with the country being reported as having the largest crack market in the world. The objective of this study was to evaluate the effectiveness of incorporating Contingency Management targeting cocaine abstinence into a public treatment program in Brazil.

METHODS

Single-blind randomized controlled trial conducted at Unidade Recomeço Helvétia (URH), a public ambulatory treatment program for persons who use crack and live in the "Crackland" region in downtown São Paulo, Brazil. In total, 98 treatment-seeking individuals who use crack were randomized to one of two treatment conditions. Participants allocated to the control condition (n = 48) received 12 weeks of the standard treatment provided at URH. Participants allocated to the experimental condition (n = 50) received the same treatment in combination with Contingency Management (URH+CM). In URH+CM, participants were provided with vouchers with monetary value for submission of negative cocaine urinalysis twice weekly.

RESULTS

Compared to the URH group, the URH+CM group was significantly more likely to submit a negative cocaine urinalysis during treatment, with odds ratios ranging from 4.17 to 6.78, depending on how missing data was accounted for (p<0.01). Participants receiving Contingency Management also had higher odds of achieving three or more weeks of continuous abstinence (OR= 8.07; 95% CI [2.48, 26.24]), achieved longer durations of abstinence (B = 2.14; 95% CI [0.67, 3.61]), submitted a higher percentage of negative urinalysis (B = 19.85; 95% CI [6.89, 32.82]), and were retained in treatment for a longer period (B = 3.00; 95% CI [1.04, 4.97]), compared to those receiving URH alone (p<0.01 for all).

CONCLUSIONS

The incorporation of Contingency Management was effective in promoting cocaine abstinence and treatment retention. The large-scale dissemination of Contingency Management may be an effective strategy to treat Brazilians with cocaine use disorders.

Large and non-specific somatic disease burdens among ageing, long-term opioid maintenance treatment patients

Objectives

To describe and explore somatic disease burdens of ageing long-term patients in opioid maintenance treatment (OMT), a unique population emerging in countries offering OMT as a long-term treatment.

Methods

We used data from the Norwegian Cohort of Patient in Opioid Maintenance Treatment and Other Drug Treatment Study (NorComt). 156 patients enrolled for at least three of the past five years provided data during structured interviews, including on chronic conditions, somatic treatment received, mental distress (SCL-25), and treatment satisfaction. A somatic disease burden was calculated from a list measuring the recent severity of 16 somatic complaints. A hierarchical multiple linear regression analysis identified correlates of somatic disease burden.

Results

Over half of patients reported at least seven somatic complaints. Reported somatic disease burden was associated with higher mental distress, more chronic conditions, fewer years in OMT, and treatment dissatisfaction. Age was unrelated, and there were few gender differences. These five variables explained 43.6% of the variance in disease burden.

Conclusion

Long-term OMT patients experience a large range of somatic complaints, and at non-acute levels. As OMT secures longevity for opioid-dependent persons, the clinical focus must be adjusted from acute to chronic care. Providers must address how to optimize health and quality of life while in treatment, as treatment may last for many years.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-020-00311-4.

Health-related quality of life of long-term patients receiving opioid agonist therapy: a nested prospective cohort study in Norway

Background

Opioid dependence carries the highest disease burden of all illicit drugs. Opioid agonist therapy (OAT) is an evidence-based medical intervention that reduces morbidity and mortality. There is limited knowledge on the health-related quality of life (HRQoL) of long-term patients in OAT. This study measures HRQoL and self-perceived health of long-term patients on OAT, compares the scores to a Norwegian reference population, and assesses changes in these scores at 1-year follow up.

Methods

We conducted a nested prospective cohort study among nine OAT outpatient clinics in Norway. 609 OAT patients were included, 245 (40%) followed-up one year later. Data on patient characteristics, HRQoL, and self-perceived health was collected. HRQoL was assessed with the EQ-5D-5L, which measures five dimensions (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) on a five-point Likert scale (from “no problems” to “extreme problems”). An UK value set was applied to calculate index values (from 0 to 1) for the EQ-5D-5L and compare them to a Norwegian reference population. Self-perceived health was measured with EQ-VAS (from 0 to 100).

Results

Mean (standard deviation (SD)) EQ-5D-5L index value at baseline was 0.699 (0.250) and EQ-VAS 57 (22) compared to 0.848 (0.200) and 80(19) for the Norwegian reference population. There were large variations in EQ-5D-5L index values, where 43% had > 0.8 and 5% had < 0.2 at baseline. The lowest EQ-5D-5L index values were observed for female patients, age groups older than 40 years and for methadone users. At follow-up, improvements in HRQoL were observed across almost all dimensions and found significant for mobility and pain/discomfort. Mean (SD) overall index value and EQ-VAS at follow up were 0.729 (0.237) and 59 (22) respectively.

Conclusion

The average HRQoL and self-perceived health of OAT patients is significantly lower than that of the general population, and lower than what has been found among other severe somatic and psychiatric conditions. Around 34% had very good HRQoL, higher than average Norwegian values, and around 5% had extremely poor HRQoL.

Australian treatment outcome study: protocol for the 18-20-year follow-up of a prospective longitudinal cohort examining the natural history of heroin dependence and associated mortality, psychiatric and physical health, and health service use

INTRODUCTION

Opioid dependence is a global health priority, currently making the biggest contribution to drug-related deaths. The chronic, long-term persistence of heroin dependence over the life course requires investigation in prospective longitudinal studies, to better understand patterns and predictors of remission and relapse, as well as the impact of changes in substance use on a range of physical and mental health outcomes. Such knowledge is critical in order to identify modifiable risk factors that can be targeted for intervention. Crucial unanswered questions include the following: What are the long-term rates of mortality? What are the long-term patterns and predictors of heroin use, remission, psychiatric health and health service use? What are the long-term physical health consequences of heroin use?

METHODS AND ANALYSIS

The 18-20-year follow-up of the Australian Treatment Outcome Study (ATOS) cohort will examine the natural history of heroin dependence of an existing cohort of 615 people with heroin dependence, who were recruited into the study in 2001-2002. Five waves of follow-up interviews have since been completed, at 3-month, 1-year, 2-year, 3-year and 10-11-year post-baseline. At the 18-20-year follow-up, the ATOS cohort is (on average) approaching their 50s and an average of 30 years have passed since they first used heroin. The 18-20-year follow-up will consist of: (1) a structured interview; (2) physical health assessment; and (3) data linkage. The results of this follow-up will improve our understanding and management of age-related disorders in this population, which if not addressed in the immediate future, has the capacity to overwhelm treatment centres and aged care facilities.

ETHICS AND DISSEMINATION

Ethical approval has been granted for the study (Sydney Local Health District Royal Prince Alfred Zone, Human Research Ethics Committee X18-0512 & HREC/18/RPAH/733). The results of the study will be disseminated through published manuscripts, bulletins and technical reports, as well as conference, seminars, webinar and workshop presentations.

Prevalence of respiratory conditions among people who use illicit opioids: a systematic review

BACKGROUND AND AIMS

There are growing concerns over the respiratory health of people who use illicit opioids due to high rates of opioid inhalation and tobacco smoking in this group. This study aimed to summarize the evidence relating illicit opioid use with poor respiratory health.

METHODS

A systematic review of the literature on the association between illicit opioid use and respiratory health was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance (PROSPERO ID = CRD42017059953). Electronic searches of MEDLINE, Embase, PsycINFO, CINAHL and the Cochrane Library databases were undertaken (English language, published January 1980-November 2018). All study designs excluding case studies were considered. Studies were undertaken in community and hospital settings in the United States (n = 23), United Kingdom (n = 7), Australia (n = 7), the Netherlands (n = 2), Canada (n = 2), Ireland (n = 1), Spain (n = 1) and Iran (n = 1). Measurements of respiratory disease, including asthma and chronic obstructive pulmonary disease (COPD) and related symptoms were extracted. Data on respiratory-related deaths and hospital admissions were also extracted. Meta-analysis of prevalence data was undertaken using a random effects meta-analysis model with parameters estimated using Markov chain Monte Carlo simulation.

RESULTS

Meta-analyses estimated prevalence of asthma in people who inject illicit opioids as 8.5% [95% predictive interval (PrI) = 0.2%, 74.0%] and as 20.2% (95% PrI = 4.2%, 59.2%) in people who inhale illicit opioids. Prevalence of COPD in people who inject illicit opioids was estimated as 2.7% (95% PrI = 0.0%, 50.4%) and as 17.9% (95% PrI = 0.6%, 89.5%) in people who inhale illicit opioids. There was evidence of moderate to extreme heterogeneity across studies.

CONCLUSIONS

There is evidence of increased burden of respiratory diseases in people who use illicit opioids. Due to the heterogeneity of study design and samples, it is difficult to gain accurate estimates of the prevalence of respiratory disease in this population.

Canadian Guidelines on Opioid Use Disorder Among Older Adults

BACKGROUND

In Canada, rates of hospital admission from opioid overdose are higher for older adults (≥ 65) than younger adults, and opioid use disorder (OUD) is a growing concern. In response, Health Canada commissioned the Canadian Coalition of Seniors' Mental Health to create guidelines for the prevention, screening, assessment, and treatment of OUD in older adults.

METHODS

A systematic review of English language literature from 2008-2018 regarding OUD in adults was conducted. Previously published guidelines were evaluated using AGREE II, and key guidelines updated using ADAPTE method, by drawing on current literature. Recommendations were created and assessed using the GRADE method.

RESULTS

Thirty-two recommendations were created. Prevention recommendations: it is key to prioritize non-pharmacological and non-opioid strategies to treat acute and chronic noncancer pain. Assessment recommendations: a comprehensive assessment is important to help discern contributions of other medical conditions. Treatment recommendations: buprenorphine is first line for both withdrawal management and maintenance therapy, while methadone, slow-release oral morphine, or naltrexone can be used as alternatives under certain circumstances; non-pharmacological treatments should be offered as an integrated part of care.

CONCLUSION

These guidelines provide practical and timely clinical recommendations on the prevention, assessment, and treatment of OUD in older adults within the Canadian context.

Substance Use Disorders in Later Life: A Review and Synthesis of the Literature of an Emerging Public Health Concern

Substance use disorders (SUDs) among older persons are among the fastest growing health problems in the United States. The number of older persons is projected to exceed 72.1 million persons by 2030, following a trend of general population growth in the mid-1940s to 1960s. The generation, known as "baby boomers," who refashioned drug use during their 20-30s, are increasingly continuing drug habits into later life. This review aims to assess the epidemiology, impact, and treatment of geriatric SUDs. Academic databases including PubMed, PsychInfo, Ovid, and Medline, were queried up to December 2018 for terms of "geriatric," "older," "elderly," "substance abuse," "drug," "drug use," "drug abuse," "drug dependency," "illicit drugs," and "geriatric psychiatry." Articles identified included 17 government documents, 29 studies based upon government documents, 43 studies not related to US government surveys, 19 review articles, 9 commentary pieces, 4 newspaper articles, 2 textbooks, and 1 published abstract. Evaluated studies and documents together suggest that older individuals are using illicit drugs and meeting criteria for SUDs at higher rates than previous geriatric cohorts resulting in substantial negative impacts on medical and psychiatric conditions. These findings represent a novel trend since previous cohorts of older individuals were thought to rarely use illicit substances. Current treatment models are inadequate to address the new wave of older individuals with SUDs. The fields of geriatrics, addiction, and geriatric psychiatry must work together to establish comprehensive care models and treatment modalities for addressing this emerging public health concern.

Health Related Quality of Life in Individuals Transferred from a Needle Exchange Program and Starting Opioid Agonist Treatment

Background

Opioid agonist treatment (OAT), for the treatment of heroin dependence, has been reported to improve overall health and lower mortality. Drug use and retention in treatment have often been used as measures of treatment success. More recently, however, researchers have suggested that measurements of quality of life should be an outcome in substance use treatment evaluations. In a recent randomized controlled trial we demonstrated high rates of successful rapid referral from a needle exchange program (NEP) to OAT. The aim of this study was to see whether an improvement in health related quality of life (HRQoL) could be seen at 3-month follow-up after starting OAT and whether it was associated with any baseline characteristics. We also wanted to compare our sample to a sample from the general population with regard to HRQoL.

Methods

This was a 3-month follow-up of 71 patients who started OAT. Measurements of HRQoL with EQ-5D (an instrument developed by the EuroQol group) were made at baseline and at three months.

Results

Mean EQ-5D VAS (visual analogue scale) for the study sample at baseline was 47.3, which was lower than a Swedish reference population reporting 83.3. Individuals reporting being prescribed a drug for a psychiatric condition had significantly lower EQ-5D index values. Improvement in EQ-5D index score was significantly less for individuals reporting previous overdoses (-0.10, p=0.025). Individuals reporting previous suicide attempts had significantly lower EQ-5D VAS score at baseline. A significant increase of the EQ-5D VAS difference over time was found with a mean difference of 10.94 (p=0.008) for the total sample.

Conclusion

To our knowledge this is the first time HRQoL as an outcome is reported in a population transferred from a NEP to OAT. Our results indicate that OAT can result in increased HRQoL, even with this type of rapid low-threshold referral.

A hidden aspect of the U.S. opioid crisis: Rise in first-time treatment admissions for older adults with opioid use disorder

BACKGROUND

Older adults with opioid use disorder (OUD) are a medically complex population. The current study evaluated trends in older adults seeking treatment for OUD, with a focus on primary heroin versus prescription opioid use. This study also compared older adults with OUD to the younger OUD population on demographics and drug use behaviors.

METHODS

Publicly available data from state-certified addiction treatment centers were collected via the Treatment Episode Data Set - Admissions (TEDS-A) between 2004-2015. This study utilized Joinpoint Regression to conduct a cross-sectional, longitudinal analysis of trends in first-time treatment admissions for OUD in adults 55 and older (older adults; n = 400,421) versus adults under the age of 55 (n = 7,795,839). Given the rapid increase in older adults seeking treatment for OUD between 2013-2015, secondary outcomes include changes in demographics and drug use between 2012 (as a baseline year) and 2015.

RESULTS

The proportion of older adults seeking treatment for OUD rose steadily between 2004-2013 (41.2% increase; p-trend = 0.046), then rapidly between 2013-2015 (53.5% increase; p-trend = 0.009). The proportion of older adults with primary heroin use more than doubled between 2012-2015 (p < 0.001); these individuals were increasingly male (p < 0.001), African American (p < 0.001), and using via the intranasal route of administration (p < 0.001).

CONCLUSIONS

There has been a recent surge in older adults seeking treatment for OUD, particularly those with primary heroin use. Specialized treatment options for this population are critically needed, and capacity for tailored elder care OUD treatments will need to increase if these trends continue.

Rising incidence of ageing opioid users within the EU wide treatment demand indicator; The Irish opioid epidemic from 1996 to 2014

BACKGROUND

Literature identifies older people who use opioids as a neglected population. Little is known about temporal changes, or about treatment demand among this population.

METHODS

The EU Treatment Demand Indicator (TDI) for Ireland (1996-2014) was analyzed for trends in new opioid treatment admissions, ageing and drug using behaviors. A Joinpoint analysis was conducted.

RESULTS

Data from 18,692 individuals entering treatment for the first time showed that while the trend of age-adjusted incidence declined between 1996 and 2014, incidence among older age groups increased, with a rising incidence not previously observed among those aged 50 years and older. Subgroups of early and late treatment entries, and early and late opioid onset were observed. The median age commencing opioid use increased by three years from 18 to 21 years (U = 326141.5, p < 0.001). The median age entering treatment increased by 11 years (from age 20 to age 31) (U = 145465.5, p < 0.001). The median opioid-using duration prior to treatment increased by 5 years (from 2 to 7 years) (U = 170807.5, p < 0.001). Half of the individuals started injecting within one year of first using opioids. The median time between first injecting and commencing treatment increased by 6 years for men and 2 years for women.

CONCLUSIONS

The study utilizes European TDI data and finds that those entering treatment in Ireland is older, are injecting longer and are taking longer to enter treatment. These findings highlight how TDI data can be used to identify hidden groups at risk of chronic harm which may require prioritizing in policy and practice.

Drug misuse in older people: old problems and new challenges

Very little attention has been paid to the invisible epidemic of substance misuse among older people in the UK. This article looks at the prevalence of substance misuse in the people over the age of 60. The reasons for difficulty in diagnosing substance misuse are explored and ways to improve diagnostic ability are discussed. Substance misuse leads to severe physical and psychiatric morbidity that is being managed by meagre resources. The article provides recommendations on specific issues related to interventions, biological and psychosocial, and training of psychiatrists.

Treatment for opioid use and outcomes in older adults: a systematic literature review

BACKGROUND

Historically, issues relating to problem substance use among older people have received little attention, and have only recently been recognised.

METHODS

A literature review of relevant material was conducted in November 2015 to assess current outcome research among older adults treated for opioid dependence. Multiple electronic databases were searched and results were supplemented by grey literature, library and online searches, and relevant references within selected articles. Retrieved articles were assessed for relevance against the inclusion and exclusion criteria. Results were reviewed to identify major findings and recommendations.

RESULTS

A total of 76 titles were included in the review. Most research conducted on older adults involves alcohol and prescription medications. Older drug users are growing in number and have a unique profile, with many presenting for treatment for the first time aged 50-70 years. Findings reveal (1) opioid treatment numbers are decreasing, however the average age of treatment admissions is increasing, (2) there is no consensus on what old is (3) two distinct types of older opioid substance users exist (early/late onset), (4) older clients achieve better treatment outcomes than younger counterparts, and (5) older women achieve better treatment outcomes than men.

CONCLUSIONS

Findings suggest that little is known about treatment outcomes among older people. Problematic drug use (of which opioids make up the largest proportion) had been incorrectly assumed to end as patients age. Defining an age limit for 'older' is important. Addiction and healthcare services must anticipate and prepare for increased demand by this group.

Cognition and adaptive functioning in older people attending drug and alcohol services

BACKGROUND

Substance use disorders in older adults are expected to increase dramatically in the coming years. Given the increased susceptibility to cognitive deficits in older substance users (defined here as aged 50+ years due to the accelerated health decline observed in this population), it is important to consider the functional correlates of cognitive impairment in these older adults. This study details the cognitive status of older individuals attending outpatient drug and alcohol (D&A) treatment services and seeks to determine of the association of cognitive impairment to self-reported daily functioning.

METHODS

Ninety nine clients aged 50 years or over attending outpatient D&A treatment services in Sydney, Australia participated. Cognition was assessed using the Addenbrooke's Cognitive Examination - Revised (ACE-R). Recent substance use (Australian Treatment Outcome Profile), physical and mental health (SF12, Geriatric Depression Scale), social isolation (Lubben Social Network Scale), and activities of daily living (Bayer ADL Scale) were also assessed.

RESULTS

Nearly two-thirds of participants screened positive for cognitive impairment on the ACE-R; 41% and 65% of clients met the cut-off scores for mild cognitive impairment (MCI) and more severe cognitive impairment, respectively. Self-reported seizure history was a predictor of cognitive impairment.

CONCLUSIONS

The results suggest that cognitive impairment in this group is common. The assessment of cognitive status for this older group of patients should not only include the identification of cognitive impairment but also encompass mental health and social functioning. A greater understanding of the needs of this cohort will also enable better co-ordination with other health and welfare services tailored to this population.

Quality of life as an outcome of opioid use disorder treatment: A systematic review

BACKGROUND AND AIMS

The recent opioid epidemic has prompted renewed interest in opioid use disorder treatment, but there is little evidence regarding health-related quality-of-life (HRQoL) outcomes in treatment programs. Measuring HRQoL represents an opportunity to consider outcomes of opioid use disorder treatment that are more patient-centered and more relevant to overall health than abstinence alone. We conducted a systematic literature review to explore the extent to which the collection of HRQoL by opioid treatment programs is documented in the treatment program literature.

MATERIALS AND METHODS

We searched PubMed, Embase PsycINFO and Web of Science for papers published between 1965 and 2015 that reported HRQoL outcome measures from substance abuse treatment programs.

RESULTS

Of the 3014 unduplicated articles initially identified for screening, 99 articles met criteria for further review. Of those articles, 7 were unavailable in English; therefore 92 articles were reviewed. Of these articles, 44 included any quality-of-life measure, 17 of which included validated HRQoL measures, and 10 supported derivation of quality-adjusted life year utility weights. The most frequently used validated measure was the Addiction Severity Index (ASI). Non-U.S. and more recent studies were more likely to include a measure of HRQoL.

CONCLUSIONS

HRQoL measures are rarely used as outcomes in opioid treatment programs. The field should incorporate HRQoL measures as standard practice, especially measures that can be used to derive utility weights, such as the SF-12 or EQ-5D. These instruments provide policy makers with evidence on the impact of programs on patients' lives and with data to quantify the value of investing in opioid use disorder treatments.

Den aldrende LAR pasienten

Background:

Opioid maintenance treatment (OMT) secures a low mortality in a vulnerable population and is often a lifelong treatment. One would therefore expect an increasing prevalence of OMT among the elderly. This article describes a study with three elements; a literature review, an investigation of occurrence and an exploration of elderly patients’ needs and experiences.

Material and methods:

PsycINFO, Ovid Medline and Embase were searched with reference words for opioid maintenance and age. Norway has a national cohort study of patients in OMT describing recruitment, retention in treatment, age and mortality. A prognosis of numbers in treatment older than 50 and 60 years were extrapolated based on probabilistic premises. Finally, a qualitative interview study of OMT patients in two municipalities near Oslo was performed. Five OMT patients aged between 58 and 64 years were interviewed with open questions on thoughts, needs and experiences.

Findings:

The review points to an increasing population with psychiatric and somatic comorbidities and diverse needs. Their opinions and experiences seem largely unexplored. The population estimates indicate that Norway by 2018 will have between 3084 and 3567 individuals older than 50 years and between 201 and 302 individuals older than 60 years in OMT. The qualitative study demonstrated that the elderly OMT patient typically attributes their being alive to OMT. It is a life with a high prevalence of ailments and diseases. Their somatic diseases are mostly adequately treated by their GP, but they feel left alone with a high level of mental problems and loneliness. They miss follow-up from the OMT and social services and are not met on existential thoughts and sorrow for their life. A wish to end OMT during their lifetime is noteworthy. This would necessitate a close collaboration with the OMT services and support from a social network.

Conclusions:

The study points to insufficient knowledge of and strategies to meet an increasing number of individuals with composite problems in OMT. The numbers will remain too small to warrant specially designed local projects, but large enough to necessitate awareness and competencies in the ordinary municipal health and social services.

Sexual risk behaviors and HIV risk among Americans aged 50 years or older: a review

Although HIV-related sexual risk behaviors have been studied extensively in adolescents and young adults, there is limited information about these behaviors among older Americans, which make up a growing segment of the US population and an understudied population. This review of the literature dealing with sexual behaviors that increase the risk of becoming HIV-infected found a low prevalence of condom use among older adults, even when not in a long-term relationship with a single partner. A seminal study by Schick et al published in 2010 reported that the prevalence of condom use at last intercourse was highest among those aged 50–59 years (24.3%; 95% confidence interval, 15.6–35.8) and declined with age, with a 17.1% prevalence among those aged 60–69 years (17.1%; 95% confidence interval, 7.3–34.2). Studies have shown that older Americans may underestimate their risk of becoming HIV-infected. Substance use also increases the risk for sexual risk behaviors, and studies have indicated that the prevalence of substance use among older adults has increased in the past decade. As is the case with younger adults, the prevalence of HIV infections is elevated among ethnic minorities, drug users (eg, injection drug users), and men who have sex with men. When infected, older adults are likely to be diagnosed with HIV-related medical disorders later in the course of illness compared with their younger counterparts. Physicians are less likely to discuss sexual risk behaviors with older adults and to test them for HIV compared with younger adults. Thus, it is important to educate clinicians about sexual risk behaviors in the older age group and to design preventive interventions specifically designed for older adults.

Cocaine Abuse in Later Life: A Case Series and Review of the Literature

OBJECTIVE

To raise awareness about the growing trend of cocaine abuse in later years as an underdiagnosed, undertreated, and comorbid condition in older individuals. Three cases of cocaine use in patients over the age of 50 years in the Malcolm Randall Veterans Medical Center, Gainesville, Florida, within a 10-day span in 2013 are presented.

DATA SOURCES

PubMed was searched using combinations of keywords, including cocaine, addiction, elderly, and aging, to find articles published between 1986 and 2013.

STUDY SELECTION

In total, 37 articles were selected for inclusion on the basis of their relevance to the objective and importance to the representation of cocaine abuse, including international guidelines for addiction.

DATA EXTRACTION

Each article was reviewed for eligibility. Final decisions were made following full-text review.

RESULTS

Cocaine addiction remains a high-morbidity chronic-relapsing illness with few treatment options. A review of the literature shows that late-life cocaine use is sparsely recognized. Of particular interest are the clinical presentations in which a higher index for detection is warranted. The high rate of medical comorbidity associated with cocaine use, especially cerebrovascular deficits, presents special treatment and social challenges.

CONCLUSIONS

As the number of older individuals admitted for substance use continues to climb, clinicians must adapt to the changing demographics by increasing screening, early detection, and treatment options for older persons.

An Ageing Methadone Population: A Challenge to Aged Persons' Mental Health Services?

Oral administration of methadone has been used as a treatment strategy for opiate addiction for many years. The state of Victoria, Australia, has a long-running methadone program with a large number of participants. Accordingly, a growing number of adults have utilised methadone maintenance treatment for a number of years and are now moving into older age due to advances in medical treatment and harm reduction initiatives. The objective of this review is to examine the literature pertaining to co-occurring mental illness in older methadone treatment participants and to explore the future challenges this growing cohort of ageing adults pose to aged persons’ psychiatry services. As part of a broader study into dual diagnosis in older adults, a search of the Scopus, ProQuest, and CINAHL journal databases was performed. Twenty abstracts from literature published within the previous 15 years (1999–2014) were identified that explored methadone maintenance programs and the older adults maintained on them. A number of researchers have identified the ageing methadone population to have a high degree of comorbid mental illness and psychological distress. Studies also indicate that individuals enrolled in methadone maintenance programs may engage in a degree of continual substance use, potentially leading to deleterious effects on their psychosocial function. An ageing methadone population experiencing a high degree of comorbid mental illness is likely to challenge aged persons’ psychiatry services. These services are likely to be increasingly called on to manage these individuals, particularly within Victoria where few substance use services exist for those over the age of 65. It is essential that aged persons’ psychiatry services prepare to provide care for these individuals in a responsive manner that is inclusive of both their mental health and substitution pharmacotherapy.

Demographic Trends of Adults in New York City Opioid Treatment Programs--An Aging Population

BACKGROUND

The population of adults accessing opioid treatment is growing older, but exact estimates vary widely, and little is known about the characteristics of the aging treatment population. Further, there has been little research regarding the epidemiology, healt h status, and functional impairments in this population.

OBJECTIVES

To determine the utilization of opioid treatment services by older adults in New York City.

METHODS

This study used administrative data from New York State licensed drug treatment programs to examine overall age trends and characteristics of older adults in opioid treatment programs in New York City from 1996 to 2012.

RESULTS

We found significant increases in utilization of opioid treatment programs by older adults in New York City. By 2012, those aged 50-59 made up the largest age group in opioid treatment programs. Among older adults there were notable shifts in demographic background including gender and ethnicity, and an increase in self-reported impairments.

CONCLUSIONS/IMPORTANCE

More research is needed to fully understand the specific characteristics and needs of older adults with opioid dependence.

Are methadone counselors properly equipped to meet the palliative care needs of older adults in methadone maintenance treatment? Implications for training

Today's methadone patients differ greatly from those of the past. Because of the rise of polydrug use and the HIV and hepatitis epidemics, treatment has become much more complex, which multiply the concerns and complexities of treatment. Patients entering methadone programs are also more commonly presenting at ages well into their 50s, 60s, and 70s; and this phenomenon of high rates continues to grow. The majority of these individuals in treatment have presented with a number of significant comorbid medical conditions that will progress and eventually lead to death. This aging cohort must be approached with a modified treatment plan that focuses on management and promoting healthy aging, while attending to their maximum delay of illness, disease, and disability. This article argues that it is necessary for counselors working with this group to adopt a palliative care philosophy. This article also makes recommendations in areas that counselors need to be knowledgeable and skilled in to provide appropriate palliative services specific to this aging population with multiple needs as they near end of life.

Substance use disorders and psychiatric comorbidity in mid and later life: a review

BACKGROUND

Globally, adults aged 65 years or older will increase from 516 million in 2009 to an estimated 1.53 billion in 2050. Due to substance use at earlier ages that may continue into later life, and ageing-related changes in medical conditions, older substance users are at risk for substance-related consequences.

METHODS

MEDLINE and PsychInfo databases were searched using keywords: alcohol use disorder, drug use disorder, drug misuse, substance use disorder, prescription drug abuse, and substance abuse. Using the related-articles link, additional articles were screened for inclusion. This review focused on original studies published between 2005 and 2013 to reflect recent trends in substance use disorders. Studies on psychiatric comorbidity were also reviewed to inform treatment needs for older adults with a substance use disorder.

RESULTS

Among community non-institutionalized adults aged 50+ years, about 60% used alcohol, 3% used illicit drugs and 1-2% used nonmedical prescription drugs in the past year. Among adults aged 50+, about 5% of men and 1.4% of women had a past-year alcohol use disorder. Among alcohol users, about one in 14 users aged 50-64 had a past-year alcohol use disorder vs one in 30 elder users aged 65+. Among drug users aged 50+, approximately 10-12% had a drug use disorder. Similar to depressive and anxiety disorders, substance use disorders were among the common psychiatric disorders among older adults. Older drug users in methadone maintenance treatment exhibited multiple psychiatric or medical conditions. There have been increases in treatment admissions for illicit and prescription drug problems in the United States.

CONCLUSIONS

Substance use in late life requires surveillance and research, including tracking substance use in the racial/ethnic populations and developing effective care models to address comorbid medical and mental health problems.

Demographic and clinical characteristics of middle-aged versus younger adults enrolled in a clinical trial of a web-delivered psychosocial treatment for substance use disorders

OBJECTIVE

Evidence suggests that substance abuse is becoming more prevalent in middle-aged adults. The objective of this secondary analysis was to add to the growing empirical literature on the unique features of middle-aged substance abuse populations.

METHODS

We descriptively compared baseline demographic and clinical characteristics of middle-aged (age 45-62 years, n = 111) and younger (age 18-44 years, n = 395) substance abusers entering a Web-based psychosocial treatment study as part of the National Institute on Drug Abuse Clinical Trials Network.

RESULTS

A significantly greater percentage of middle-aged adults were nonwhite and had a marital status other than single/never married. There was a significant association between frequency of Internet use and the age group. Forty-six percent of middle-aged adults versus 21% of younger adults reported no Internet use in the prior 90 days. A significantly greater percentage of middle-aged adults used cocaine, and a significantly greater percentage of younger adults used marijuana and opioids. Clinically significant cognitive impairment (z < -1.0) was found for the average participant in both groups on logical association of familiar concepts.

CONCLUSIONS

This secondary analysis of a National Institute on Drug Abuse Clinical Trials Network study provides additional information on the unique features of middle-aged substance abusers. Increasing knowledge of similarities and differences between younger and middle-aged substance abusers can help with potential age-specific substance abuse treatment planning.

Correlates of pain in an in-treatment sample of opioid-dependent people

INTRODUCTION AND AIMS

The limited literature on pain in opioid-treatment samples indicates that it is highly prevalent. Understanding the implications of pain on treatment outcomes is important, particularly in light of ageing opioid-treatment cohorts. This study explores correlates of pain, including aberrant behaviours related to prescribed opioids. Our hypothesis is that pain may increase aberrant opioid-related behaviours, including illicit substance use, among opioid-dependent people.

DESIGN AND METHODS

We examined pain in methadone or buprenorphine patients (n = 141) from three treatment services. Measures included basic demographics, Brief Pain Inventory, general mental health, physical health and quality of life measures, pain history and treatments, and an aberrant opioid-related behaviour scale. Univariate and multivariate analyses were used to examine correlates of pain.

RESULTS

Forty percent reported current pain, measured with the first question of the Brief Pain Inventory. Correlates of pain were depression ratings [adjusted odds ratio (OR) 2.24, 95% confidence interval (CI) 1.04, 4.83], anxiety ratings (adjusted OR 4.29, 95% CI 1.88, 9.80) and self-reported health ratings (adjusted OR 0.35, 95% CI 0.16, 0.76). Contrary to our hypothesis, pain was not associated with greater use of illicit opioids, nor any aberrant opioid-related behaviours. Pain was comparable among methadone and buprenorphine patients.

DISCUSSION AND CONCLUSIONS

The lack of association with pain and aberrant behaviours suggest that it should not be assumed that those in opioid treatment misuse medications in response to pain. The high prevalence of depression/anxiety symptoms indicates a need for further work with larger samples to explore pain and co-morbidity among opioid-dependent people.

Pathways to heroin dependence: time to re-appraise self-medication

The self-medication hypothesis emphasizes the role of distressing affect as the primary motivator for the compulsive use that leads to substance dependence. The model also postulates that there will be psychopharmacological specificity between symptom presentation and the primary drug of dependence. In this review, the self-medication hypothesis is examined in relation to the development and chronicity of heroin dependence. It is argued that if self-medication has a role in engendering and extending substance dependence, it should be apparent in the use of a drug that carries such overwhelming personal risk. The psychopathology seen among adult users is certainly consistent with the model. More importantly, however, are the extraordinarily high levels of childhood trauma and psychopathology that occur typically well before the initiation of heroin use. In contrast, the postulate of drug specificity appears less supported by the polydrug use patterns typical of heroin users, and does not appear to be a necessary corollary of the model.