Substance Use and Older People

Ilana Crome, Emeritus Professor of Addiction Psychiatry, Keele University, Keele, UK; Honorary Consultant Psychiatrist, South Staffordshire and Shropshire Healthcare NHS Foundation Trust, Stafford, UK; Honorary Professor, Queen Mary University of London, London, UK; Senior Research Fellow, Imperial College, London, UK.Li-Tzy Wu, Professor of Psychiatry, Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA.Rahul (Tony) Rao, Visiting Researcher, Department of Old Age Psychiatry, Institute of Psychiatry, London, UK and Lead for Dual Diagnosis, Mental Health of Older Adults and Dementia Clinical Academic Group, South London and Maudsley NHS Foundation Trust, UK.Peter Crome, Honorary Professor, Department of Primary Care and Population Health, University College London, London, UK; Emeritus Professor of Geriatric Medicine, Keele University, Keele, UK.

• Contributors xviiForeword xxiIntroduction xxivList of Abbreviations xxviSection 1 Legal and ethical aspects of care for older people with substance misuse 11 Negotiating capacity and consent in substance misuse 3Kritika SamsiIntroduction 3Substance abuse and capacity 3Mental capacity legislation 4Mental Capacity Act 2005 4Capacity assessment 5Capacity and unwise decisions 6Consent, barriers to decision making and substituted decision making 6Best interest decisions 8Independent decision makers 8Conclusion 9References 92 Elder abuse 11Jill ManthorpeIntroduction 11Defining elder abuse 11Main reviews 12Alcohol and substance misuse risk factors 12Risk factors among older people 13The effects of elder abuse 14Discussion 15Conclusions and next steps 15References 163 The United States perspective 18Cynthia M.A. Geppert and Peter J. TaylorThe ageing of the baby boomers and its impact on substance abuse 18Ethical and legal aspects of substance misuse in older adults 19Confidentiality 19Informed consent 20Capacity 21Coercion 24Conclusion 25References 254 The European perspective 27Abdi Sanati and Mohammed Abou-SalehIntroduction 27Use and possession 28Crime 28European Convention of Human Rights 28Delivering services for the elderly with substance misuse – ethical aspects 29Research and development 30Policy making 31Some differences between Europe and the USA 31Ethical issues regarding treatment 32Stigma 32Underprescribing controlled drugs 32Summary 33References 345 Clinical medicine and substance misuse: research, assessments and treatment 35Amit Arora, Andrew O’Neill, Peter Crome and Finbarr C. MartinIntroduction 35Why is clinical medicine important? 36Identification 37The health effects of substance abuse 39Challenges for the future 46Research 47Identification tools 47Training and support 48Conclusions 49References 49Section 2 Epidemiology and demography 576 Cigarette smoking among adults aged 45 and older in the United States, 2002–2011 59Shanta R. Dube and Li-Tzy WuIntroduction 59Evaluation methodology 61Results 62Sociodemographic characteristics of older adults: 2002 versus 2011 62National trend in current smoking prevalence: 2002–2011 65Current smoking prevalence by socioeconomic status: 2002 versus 2011 66Adjusted odds ratios of correlates of current smoking: 2002 versus 2011 66Discussion 71Conclusion 72References 737 Epidemiology and demography of alcohol and the older person 75Stephan Arndt and Susan K. SchultzIntroduction 75Main reviews 76Epidemiological estimates of prevalence of alcohol use 76Estimates of alcohol problems based on amount of drinking 76Importance of threshold selection for defining problem use 80Estimating problem use from survey samples 80Summary of epidemiological estimates 81Specific problematic drinking behaviours: binge drinking 81Diagnoses of abuse or dependence 83Older substance abuse treatment populations 84Special populations of older substance users 85Demographic correlates of problem use 86Discussion 87Conclusions and next steps 87References 888 Epidemiology and demography of illicit drug use and drug use disorders among adults aged 50 and older 91Shawna L. Carroll Chapman and Li-Tzy WuIntroduction 91Survey studies 92Studies of treatment-seeking or clinical patients 101Health implications 104Discussion 105Next steps 106References 1069 Epidemiology and demography of nonmedical prescription drug use 109Jane Carlisle MaxwellIntroduction 109Findings 110National surveys 110Emergency department cases 112Treatment admissions 113Drug poisoning deaths 114Discussion 116Conclusions 118Acknowledgement 118References 118Section 3 Longitudinal studies of ageing and substance abuse 12110 Ageing and the development of alcohol use and misuse 123Marja AartsenBackground 123Results 124Differences in alcohol use across cohorts 125Developments in alcohol use within people 126Gender differences 126Different trajectories 126Age and onset of problem drinking 127Discussion 127Explanations for age differences in alcohol use 127Conclusions 128References 12911 Progression from substance use to the development of substance use disorders 133Carla L. Storr and Kerry M. GreenIntroduction 133Substance use progression process 134Risk factors influencing substance use progression 137Individual factors 137Substance properties 139Environmental influences 140Future direction 141Conclusions 143Acknowledgement 144References 14412 Psychopharmacology and the consequences of alcohol and drug interactions 149Vijay A. Ramchandani, Patricia W. Slattum, Ashwin A. Patkar, Li-Tzy Wu, Jonathan C. Lee, Maitreyee Mohanty, Marion Coe and Ting-Kai LiThe extent of alcohol and drug misuse among older adults 149Substance misuse in the general population 149Substance misuse or addiction in clinical settings 150Co-morbidities among older substance misusers 151Psychopharmacology of alcohol and drug misuse in older people 152Neurocircuitry of abused substances 152Alcohol–drug interactions in older adults 155Mechanisms of alcohol–medication interactions 156Significance of the problem 156Concurrent use of alcohol and potentially interacting medications 157Consequences of concurrent use of alcohol and medications 158Clinical presentation and evaluation of substance use disorders in the elderly 158Clinical presentations (case vignettes) 159Medical co-morbidities 161Screening for substance use disorders 161Evaluation of substance use disorders 162Cognitive impairment in the elderly with substance use disorders 163Safety assessment of the elderly with substance use disorders 164Medications for individuals with substance use disorders 164Conclusions 166References 166Section 4 Comprehensive geriatric assessment and special needs of older people 17113 Comprehensive geriatric assessment and the special needs of older people 173Dan Wilson, Stephen Jackson, Ilana B. Crome, Rahul (Tony) Rao and Peter CromeBackground 173Assessment 175Setting 176Barriers to assessment 176High-risk groups 177Presenting problems 177Collateral information 178General principles of assessment 179Screening 182Psychiatric assessment 183Case presentations 184Driving and substance misuse 184Older women and alcohol misuse 184Polysubstance misuse 185The frequent attender 185Alcohol and cognitive impairment 186Pain and substance misuse 187Discussion 187Conclusion 187References 188Section 5 Screening and intervention in health care settings 19314 Screening and brief intervention in the psychiatric setting 195M. Shafi Siddiqui and Michael FlemingOverview 195Screening and assessment for alcohol use disorders 197Single question screen for an alcohol use disorder 197Quantity and frequency questions 198Proxy questions such as CAGE 198Symptoms of abuse or dependence 199Alcohol biomarkers 199Illicit drugs 202Rationale for screening older adults for marijuana, cocaine and other illicit drugs 202Screening for illegal drugs in the psychiatric setting 202Recommended screening questions to detect drug use 202Screening for drug abuse/dependence 203Screening for illicit drug use with toxicology screening 203Prescription drug abuse 204Rationale for screening older adults 204Screening for prescription drug abuse 205Brief intervention for alcohol, prescription drug abuse and illegal drug use 206Summary 208References 20915 Tobacco use cessation 212Daniel J. Pilowsky and Li-Tzy WuIntroduction 212Smoking cessation interventions among older adults 214Multimodal interventions 214Medication-based interventions 216Counselling and behavioural interventions 217Physician-delivered interventions 217Other interventions 218Conclusions 218References 219Section 6 Use of substance abuse treatment services among older adults 22316 Epidemiology of use of treatment services for substance use problems 225Shawna L. Carroll Chapman and Li-Tzy WuIntroduction 225Tobacco cessation service use and characteristics 225Alcohol treatment use and characteristics 230Trend in substance abuse treatment admissions 238Drug abuse treatment use and outcomes 243Substance abuse treatment in general health care settings 245Discussion and conclusion 246References 24717 Implications for primary care 249Devoshree Chatterjee and Steve IliffeBackground 249Implications for primary care 249Different populations at risk 250Screening in primary care 251Scale of benefit 252Co-morbidities and social context 252Conclusions 253References 25318 Addiction liaison services 255Roger Bloor and Derrett WattsIntroduction 255Organizing an addiction liaison service to a general hospital 256Case vignette 1 256Addiction liaison services for older adults 257Essential elements of liaison service provision for older adults 258Screening for alcohol problems in older adults 259Screening for drug use problems 260Case vignette 2 260Summary 261References 26219 Current healthcare models and clinical practices 265Rahul (Tony) Rao, Ilana B. Crome, Peter Crome and Finbarr C. MartinIntroduction 265An ageing population 265Service development and provision 266Integrated care and workforce development 267Conclusions and recommendations 269References 269Section 7 Age-specific treatment interventions and outcomes 27120 Pharmacological and integrated treatments in older adults with substance use disorders 273Paolo Mannelli, Li-Tzy Wu and Kathleen T. BradyIntroduction 273Tobacco 274Alcohol 275Opioids 277Benzodiazepines 278Other substances of abuse 280Stimulants 280Cannabis 281Integrated treatments 281Conclusion and future directions 284References 28521 The assessment and prevention of potentially inappropriate prescribing 295Denis O’MahonyIntroduction 295Inappropriate psychotropic use in elderly patients 296Implicit IP criteria 297Explicit IP criteria 298Applying STOPP/START criteria as an intervention 299Other methods of detection and prevention of IP in older people 307Comprehensive Geriatric Assessment (CGA) 307Pharmacist review and intervention 308Prescriber education, audit and feedback 308Computerized provider order entry with clinical decision support 309Conclusions 309References 31022 Age-sensitive psychosocial treatment for older adults with substance abuse 314Kathleen Schutte, Sonne Lemke, Rudolf H. Moos and Penny L. BrennanIntroduction 314Seven characteristics of age-sensitive treatment 3161 – Supportive and nonconfrontational 3162 – Flexible 3163 – Sensitive to gender differences 3174 – Sensitive to cultural differences 3175 – Focus on client functioning 3186 – Holistic 3197 – Focus on coping and social skills 319Six components of age-sensitive psychosocial treatment 3201 – Biopsychosocial assessment 3202 – Treatment planning 3213 – Attention to co-occurring conditions 3224 – Referrals and care coordination 3255 – Empirically-supported psychosocial interventions 3256 – Adjuncts to psychosocial interventions 328Age-segregated or mixed-age treatment 329Future directions 330Acknowledgements 331References 33223 Integrated treatment models for co-morbid disorders 340Rahul (Tony) RaoIntroduction 340Methodological approach to examining SMCD in older people 341A. Current systems of care for substance misuse and mental disorders 341B. Service implications 342C. Principles underlying integrated treatment models for SMCD in older people 342D. Developing integrated treatment models for older people with substance misuse and co-morbid psychiatric disorders 344E. Research evidence for integrated treatment models 346Future direction and challenges 347References 347Section 8 Policy: proposals for development 35124 Proposals for policy development: drugs 353Susanne MacGregorIntroduction 353Recognition of a need or problem and arguments made to justify the development of policy 354Policy options 356Policy design and implementation 359Conclusion 360References 36025 Proposals for alcohol-related policy development United States 364Ralph Hingson and Ting-Kai LiRecommended low-risk alcohol consumption levels 364Traffic crash risks among the elderly 365Driving policy questions 365Factors to consider when contemplating legal policies 365Summary and conclusions 369References 37026 Proposals for policy development: tobacco 372Michael GivelIntroduction 372Past and present approaches to reduce tobacco consumption 372Phase three anti-tobacco efforts 373Legal approach 373Regulatory and tobacco tax approaches 374Anti-tobacco counter-marketing campaigns 376Recent anti-tobacco proposals 376Product modification and ‘safer’ cigarettes 376Harm reduction 377Cigarette neo-prohibitionism 377Smoke-free movies 377Policy proposals to further reduce tobacco prevalence 378References 37827 Recommendations 383Ilana B. Crome, Peter Crome, Rahul (Tony) Rao and Li-Tzy WuBackground 383Epidemiology 384Clinical presentations 384Education and training 385Who gets treatment – treatment interventions 386Concluding remarks 386Index 388