Substance misuse in later life: challenges for primary care: a review of policy and evidence

Gaining Recovery in Addiction for Community Elders (GRACE) Project: The Impact of Age-Specific Care on Clinical Outcomes and Health Care Resource Utilization in Older Adults With Substance Use Disorder in an Interprofessional Addiction Clinic

BACKGROUND

The prevalence of substance use disorders (SUDs) in older adults has been increasing, necessitating tailored and effective addiction care for this aging demographic.

AIMS

The purpose of this study was to assess the impact of age-specific, interprofessional addiction care on clinical outcomes and health care resource utilization in older adults with SUD.

METHODS

This quasi-experimental study directly compares patients enrolled in the Gaining Recovery in Addiction for Community Elders (GRACE) Project, an interprofessional age-specific addictions treatment program, with age-matched older adults who received conventional "treatment as usual" (TAU). Through retrospective comparative analysis, substance use outcomes, mental and physical health improvements, and inappropriate use of emergency services were examined among 78 older adults with SUD.

RESULTS

Clinical outcomes and health care resource utilization were superior for older adults who received age-specific addictions care through the GRACE Project, as compared to mixed-age conventional "TAU." GRACE patients had improved treatment adherence, fewer relapses, and longer treatment engagement. While both groups exhibited significant reductions in depression and anxiety scores, GRACE patients showed greater improvements. This group demonstrated superior control of both hypertension and diabetes. Importantly, they had fewer inappropriate emergency department visits and avoidable hospitalizations than conventional "TAU."

CONCLUSIONS

Addiction treatment delivered by an interprofessional team to meet the unique strengths and needs of older adults has the potential to improve treatment adherence and more favorable long-term outcomes in substance use, mental health, and chronic medical conditions. Nurses are poised to lead interprofessional teams to meet the growing demand for specialized addiction treatment and integrated care for older adults.

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.

Predictors of evidence-based psychotherapy initiation among veterans with co-occurring PTSD and substance use disorder

Objective

To compare initiation of PTSD evidence-based psychotherapy (EBP) between Veterans with and without a co-occurring substance use disorder (SUD), and identify factors associated with EBP initiation among Veterans with PTSD-SUD.

Method

A national sample of Veterans with PTSD (n = 301,872) and PTSD-SUD (n = 94,515) were identified from VA Electronic Health Record data. Treatment initiation was defined as having at least one mental health encounter associated with Cognitive Processing Therapy or Prolonged Exposure therapy. Generalized estimating equations were used to compare EBP initiation between Veterans with and without co-occurring SUD, and to identify patient- and facility characteristics associated with EBP initiation among Veterans with PTSD-SUD.

Results

The majority of Veterans were 30 - 44 years old, male sex, and Non-Hispanic White. No significant differences were observed in EBP initiation between Veterans with and without a co-occurring SUD (OR=1.00, p=0.985). Among Veterans with PTSD-SUD, co-occurring bipolar disorder (OR=0.83, p=.000), co-occurring psychotic disorder (OR=0.69, p=.000), service connection (OR=0.94, p=.001), female sex (OR=0.87, p=.000), and being 60 years or older (OR=0.57, p=.000) were associated with a reduced likelihood of initiating a PTSD EBP. Having a co-occurring anxiety disorder (OR=1.06, p=.020), MST history (OR=1.95, p=.000), and high risk for suicide (OR=1.15, p=.000) were associated with an increased likelihood of initiating EBP.

Discussion

These findings support VA provision of EBP for Veterans with PTSD regardless of the presence of co-occurring SUD. Identifying characteristics that increase or reduce the likelihood of EBP initiation may provide insight into treatment pathways and subgroups warranting augmented outreach.

Association between chronic disease and substance use among older adults in Tennessee

Background

Substance use and misuse have a negative impact on health care outcomes, specifically in the older adult population. Older adults are at risk due to several factors occurring toward the end of life such as changing family dynamics, loss of friends and loved ones, and chronic diseases. Substance use in older adults with chronic diseases in rural areas remains poorly studied. This study examines older adults greater than 55 of age in the state of Tennessee, U.S.A.

Design and methods

Data was extracted from the 2019 National Behavioral Risk Factor Surveillance System (BRFSS) with a subsample for the State of Tennessee (N = 6242) and individuals over age 55 (N = 3389).

Results

At least 33.7% (N = 1143) of older adults have a chronic disease, and 24.4% (N = 828) have at least two or more chronic diseases. Alcohol use in the past month was reported in 29.4% of older adults; however, chronic disease status was not associated with alcohol use. Marijuana use and smoking in the past month were significant for older adults with two or more chronic diseases. Low income and less high school education were associated with chronic disease and smoking.

Conclusions

Marijuana use and smoking were found to be significant in older adults with chronic disease, but not with alcohol use. Preventative measures such as screening tools, education, and providing resources to patients should be targeted to populations at risk to promote overall health outcomes.

Recurrent risk of hospitalization among older people with problematic alcohol use: a multiple failure-time analysis with a discontinuous risk model

BACKGROUND AND AIMS

Older people with problematic alcohol use vary in psychosocial functioning, age of onset for problem drinking and use of other drugs. The study measured the differential risks of all-cause, alcohol-, polydrug- and psychiatric-related repeated hospitalizations among older people with problematic alcohol use.

DESIGN

A linked register-based cohort study with discontinuous multiple-failure (time-to-repeated-event) data. Hospitalization and mortality were considered as failure.

SETTING

Sweden, March 2003-November 2017, using data from the Addiction Severity Index (ASI) register linked to National Inpatient Register and the Swedish cause of death register.

PARTICIPANTS

Participants aged 50 years and older (n = 1741; 28.2% women), with one or more alcohol problem days in the 30 days before an ASI assessment.

MEASUREMENTS

Five mutually exclusive latent classes of problematic alcohol use, identified with 11 ASI items, were the independent variables: 'late onset with fewer consequences (LO:FC; reference group)'; 'early onset/prevalent multi-dimensional problems (EO:MD)'; 'late onset with co-occurring anxiety and depression (LO:AD)'; 'early onset with co-occurring psychiatric problems (EO:PP)'; and 'early onset with major alcohol problem (EO:AP)'. Covariates included socio-demographic characteristics, previous hospitalization and Elixhauser comorbidity index. Outcome measurements included recurrent hospitalization and/or mortality due to: (a) all-cause, (b) alcohol-related disorders and diseases (c) polydrug use and (d) other psychiatric disorders.

FINDINGS

During the study period, more than 75% were hospitalized at least once or died. 57.3% were hospitalized with alcohol-related, 8.5% with polydrug use and 18.5% with psychiatric-related diagnoses. Compared with LO:FC, EO:PP had higher risk for all-cause [adjusted hazard ratio (aHR) = 1.27, 95% confidence interval (CI) = 1.02-1.59] and alcohol-related (aHR = 1.34, 95% CI = 1.02-1.75) hospitalizations. Adjusted risks for polydrug-related hospitalization were 2.55, 95% CI = 1.04-6.27 for EO:MD and 2.62, 95% CI = 1.07-6.40 for EO:PP. Adjusted risk for psychiatric-related hospitalization was higher for LO:AD (aHR = 1.78, 95% CI = 1.16-2.73 and EO:PP (aHR = 2.03, 95% CI = 1.22-3.38).

CONCLUSIONS

Older addiction service users in Sweden have varying risks of hospitalization due to alcohol use, polydrug use and psychiatric disorders. Older people with problematic alcohol use who have multiple needs and are assessed in social services may benefit from earlier interventions with an integrated focus on substance use and mental health.

Experiences of a therapist-guided internet-delivered intervention for hazardous and harmful drinking. A qualitative study

BACKGROUND

Alcohol is the third leading risk factor for burden of disease in the world, causing significant health damage to the individual as well as costs to the surroundings and society as whole. Internet-delivered psychological interventions may help the individual to address alcohol consumption at an early stage before it develops into more serious problems. There is a need to investigate how participants experience internet-delivered interventions for hazardous and harmful drinking to optimize its usefulness in the target population.

METHODS

The present study was part of an open pre-post pilot trial to evaluate the feasibility and acceptability of a therapist-guided internet-delivered cognitive behavioural intervention for hazardous and harmful alcohol use. The aim was to investigate participants` experiences of the intervention and the ways in which the intervention helped them to address their alcohol consumption. Fifteen participants were selected from the open pre-post trial (n = 32), and semi-structured interviews were conducted immediately after participants had completed the treatment. The interviews were analysed using Thematic Analysis.

RESULTS

The results indicate that most of the participants found the intervention to be useful. Participants reported that the intervention made them more aware of the consequences of excessive drinking and gave them tools to cope with their alcohol consumption. Among the perceived advantages were the flexibility and anonymity of the intervention and therapist support. Participants called for more individualisation of the treatment to meet individual needs.

CONCLUSIONS

A therapist-guided internet-delivered intervention for hazardous and harmful drinking can help individuals to address their alcohol consumption and give them tools to cope with their drinking. Future studies should examine the feasibility of tailoring modules to individual needs.

Marijuana use experiences and expectancies of urban youth in India

Objective:

To gain information on the marijuana experiences and expectancies of youth in an urban Indian area, which may be used for forming the framework for the development of effective primary prevention strategies in the future.

Method:

This was a cross-sectional study conducted in various colleges of Mumbai; 260 students from three colleges who were above 18 years were selected by systematic random sampling. The participant had to fill a sociodemographic questionnaire and marijuana effect expectancy questionnaire (MEEQ-B) and it was analyzed by using the SPSS software.

Results:

A significant association was found between negative marijuana expectancies and type of family, with cannabis users and non-users, who want to try cannabis and those who are aware of the legal issues and harmful effects of cannabis.

Conclusion:

Preventive drug education should begin in early adolescence and should deter or delay drug use through changes in knowledge, attitude, behavior, and expectation. Adolescent drug education must meet the needs of those naive to drugs as well as those experiencing initial drug exposure. This is the first study which highlights the youth experiences and expectancies about marijuana in India.

Illicit Drug Use in Older Adults: An Invisible Epidemic?

Illicit drug use/misuse among older adults is understudied, although current trends point to older adults being the fastest-growing segment in the United States and other developed countries. There is a need for further insight into drug use patterns in older adults, who face their own set of socioeconomic, medical, and psychiatric problems. We reviewed the literature for data related to use/misuse of heroin and stimulants (cocaine, amphetamines, and methamphetamines) among people over the age of 40 years. We focused on prevalence rates of use/misuse of these substances, comorbidities, diagnostic challenges, screening tools, and treatment recommendations specific to the geriatric population.

Validation of the AUDIT and AUDIT-C for Hazardous Drinking in Community-Dwelling Older Adults

BACKGROUND

One of the best-known tools in screening for hazardous drinking is the Alcohol Use Disorders Identification Test (AUDIT) and its abbreviated form, the AUDIT-C. The aim of the present study is to determine the cut-offs of both instruments in identifying hazardous drinking in older adults.

METHOD

A sample of 1577 older adults completed a questionnaire regarding alcohol behavior. Hazardous drinking was defined as drinking >10 units/week. Receiver operating characteristics (ROC) curves of AUDIT and AUDIT-C were calculated and cut-off scores were derived.

RESULTS

Respectively 27.3% and 12.3% of older men and women drank >10 units/week. For the AUDIT the best trade-off between sensitivity and specificity was using a cut-off of ≥5 for men and ≥4 for women, which yielded in men sensitivity and specificity values respectively of 80.7% and 81.3% and in women 100% and 71.7%, respectively. We found the AUDIT-C to perform well with an optimal cut-off of ≥5 for men and ≥4 for women, which generated in men sensitivity and specificity values respectively of 76.5% and 85.3% and in women 100% and 74.1%, respectively.

CONCLUSION

The AUDIT-C is accurate and sufficient in screening for hazardous drinking in community-dwelling older adults if the cut-offs are tailored by gender.

Community Based Interventions for Problematic Substance Use in Later Life: A Systematic Review of Evaluated Studies and Their Outcomes

Problematic substance use (PSU) in later life is a growing global problem of significant concern in tandem with a rapidly ageing global population. Prevention and interventions specifically designed for older people are not common, and those designed for mixed-age groups may fail to address the unique and sometimes complex needs of ageing communities. We report findings from a systematic review of the empirical evidence from studies which formally evaluated interventions used with older people and reported their outcomes. Nineteen studies were included, of which thirteen focused solely on alcohol-related problems. Eight interventions utilised different types of screening, brief advice and education. The remaining drew on behavioural, narrative and integrated or multi-disciplinary approaches, which aimed to meet older people's needs holistically. Quality assessment of study design helped to review evaluation practice. Findings point to recommendations for sustainable and well-designed intervention strategies for PSU in later life, which purposefully align with other areas of health and well-being and are delivered in locations where older people normally seek, or receive, help. There is further scope for engagement with older people's own perspectives on their needs and help-seeking behaviours. Economic evaluation of the outcome of interventions would also be useful to establish the value of investing in targeted services to this underserved population.