Substance Abuse and Elderly Women

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1 Substance Abuse and Elderly Women Raquel Lugo. M.D. Assistant Professor of Psychiatry Yale University School of Medicine Financial Disclosure Raquel Lugo, M.D. has no financial disclosures nor conflicts of interest to report. 1

2 Substance Abuse in Elderly Women The following section of the presentation was researched and prepared by: Zinaida Boutaeva, M.D. Fellow in Addiction Psychiatry at Yale University Sh School of fmdii Medicine Lily Arora, M.D. Fellow in Addiction Psychiatry at Yale University School of Medicine Financial Disclosure Lily Arora, M.D. has no financial disclosures nor conflicts of interest to report. Financial Disclosure Zinaida Boutaeva, M.D. has no financial disclosures nor conflicts of interest to report. 2

D. has no financial disclosures nor conflicts of interest to report. Financial Disclosure Zinaida Boutaeva, M.D. has no financial disclosures nor conflicts of interest to report. 2

3 Among adults significantly fewer females than males reported use of alcohol, cigarettes, marijuana, cocaine, and any illicit drug. However, the gender difference in adults has narrowed in recent years. Among 12 to 17-year olds, rates of female and male alcohol, cigarette, and illicit drug use are similar. During the period between and , females generally initiated alcohol use at later ages than males. But during , the gender difference in age-specific rates of alcohol initiation became negligible. Since the early 1970s rates of marijuana initiation have consistently declined among females and males in every age group except the 10- to 14-year-olds. Among year olds, a significantly higher percentage of females than males reported the non-medical use of psychotherapeutics (e.g. painkillers, tranquilizers, sedatives and stimulants) in the past year. 3

During the period between 1961-65 65 and 1986-90, females generally initiated alcohol use at later ages than males.

4 Among adult women, the highest prevalence of any illicit drug use in the past year was found among those age 18-34, those who were unemployed, those who had never married, those who initiated substance use at an early age (at age 15 or younger), and those with one or more of four mental syndromes included in the survey. About 30 percent of females compared to 35 percent of males who needed drug treatment received it in the past year. Among adult women who needed but did not receive treatment: - 40% were age 18-25, - 41% were alcohol dependent, - 28% had some college, - 55% worked full or part time, - 32% lived with two or more children under age 18 - and 71% had initiated alcohol or drug use before the age of 15. An estimated 62,000 or 2.3 percent of all pregnant under age 44 reported using any illicit drug in the past month. About a fifth (21.2%) of pregnant women under age 44 had used alcohol in the past month. Of this pregnant, alcohol-using group, nearly a third reported having three or more drinks on the days they drank. About a fifth (21.5%) of pregnant women under age 44 said they had smoked cigarettes in the past month. And more than a quarter of these pregnant smokers reported heavy smoking in the past month -- i.e., one or more packs of cigarettes each day. 4

About 30 percent of females compared to 35 percent of males who needed drug treatment received it in the past year.

5 Women who were pregnant reported a significantly lower prevalence of past month use of alcohol, marijuana, and any illicit drugs than non-pregnant women with or without children. This suggests that women may have reduced or stopped use of substances during pregnancy, but increased use after they gave birth. Over their lifetimes, women with substance problems are less likely to seek treatment than men!!! Women experience more barriers to treatment entry and to staying clean and sober than men because they: Lack social support from those in their networks Are more likely to live in poverty Have more responsibilities for children and childcare Have more mental health problems Have greater needs for weekend and evening services Experience more negative influences from drug-using romantic partners 5

Over their lifetimes, women with substance problems are less likely to seek treatment than men!

6 Women are more likely to seek treatment in non-specialty addiction treatment settings Some subgroups of women may need specially designed services Older women Women from specific ethnic or minority groups Women in the perinatal period Women with eating disorders Women who are victims of violence Once in treatment, women do as well as or better than men For these reasons getting them in is critical Women seek care in settings that aren t equipped to treat addictions (e.g., psychiatric settings) Women avoid treatment overall Women who try to seek care may not be able to attend because Care is not available when they are Services that meet their needs are not available Child care Transportation Mental health services Women seek care in settings that aren t equipped to treat addictions (e.g., psychiatric settings) Women avoid treatment overall Women who try to seek care may not be able to attend because Care is not available when they are Services that meet their needs are not available Child care Transportation Mental health services 6

7 Prevention and Treatment Prevention and screening of latelife alcohol misuse ARPS Nearly all pts were able to complete while waiting for a scheduled appt (median time 15 min). 67% participants reported learning new information; 78% had never discussed alcohol with MD, ARPS identified nearly all drinkers detected by the CAGE, SMAST, and AUDIT; detected hazardous and harmful drinkers not identified by these measures. SCREENING INSTRUMENT SENSITIVITY Compared to LEAD: Sensitivity ARPS: 93% Specificity ARPS: 63% Sensitivity sharps: 92% Specificity sharps: 51% Sensitivity AUDIT: 28% Specificity AUDIT: 100% Sensitivity SMAST-G: 52% Specificity SMAST-G: 96% 7

67% participants reported learning new information; 78% had never discussed alcohol with MD, ARPS identified nearly all drinkers detected by the CAGE, SMAST, and

8 Treatment guidelines 1. Supportive age specific group treatments 2. Address loss early (family, friends, function, and finances) 3. Teach skills to rebuild social support network 4. Employ staff experienced in working with elders 5. Get help coordinate with experts in other settings 6. Slower pace & age-appropriate content (Be Brief) 7. Create a culture of respect for older clients 8. Broad, holistic approach to treatment recognizing age-specific psychological, social & health aspects 9. Adapt treatment to address gender issues (SAMHSA, 1998; Schonfeld & Dupree, 1997; 1998) NIDA website Elder Specific Brief Intervention Projects Project GOAL (Guiding Older Adult Lifestyles) (Fleming et al., 1999) Brief physician advice for 156 adult at-risk drinkers Reduced consumption (35%-40%) at 12 months Health Profile Project (Blow and Barry 2000) Motivational enhancement session reduced d at-risk drinking at 12 months (n=454) Staying Healthy Project American Society on Aging (California - Cullinane et al 2003.) More than 4300 people screened About 6% drinking more than recommended Almost 40% reduction of alcohol use Treatment Facilities Of the responding facilities, relatively few programs (17.7%) were specifically designed for older adults (i.e. over age 65). Facilities with such programs tended to be associated with hospitals, particularly those with a psychiatric inpatient service. Importantly, the number of facilities with special programs for older adults did not correlate with size of the older population in each state. 8

Create a culture of respect for older clients 8. Broad, holistic approach to treatment recognizing age-specific psychological, social & health aspects 9.

9 Elder-Specific Approaches Kofoed et al. (1987) Elder Specific group - Better treatment compliance, fewer relapses than those in mixed-age treatment When relapses did occur, longer periods between Kashner et al. (1992) 137 VA inpatients (ages 45+) randomly assigned to either: 1- Older Alcoholic Rehabilitation (OAR) program: Reminiscence therapy, goal of developing patient self-esteem and peer relationships or 2- Traditional care program - confrontation to focus on patients' past failures and present conflicts 12 Month follow-up: OAR patients twice as likely to report abstinence OAR patient care costs were 2.5 % lower Response to OAR was best for ages 60 NIDA References References 1. U.S.Bureau of the Census, 1996). 2. Thomas L. Patterson, Ph.D. and Dilip V. Jeste, M.D. The Potential Impact of the Baby-Boom Generation on Substance Abuse Among Elderly Persons Psychiatr Serv 50: , September Change in the pattern of illegal drug use in an inner city population over 50: an observational study.j Addict Dis. 2004; 23(2): (ISSN: ) 4. Schlaerth KR ; Splawn RG ; Ong J ; Smith SD Loma Linda University School of Medicine, Department of Family Medicine, Campus Street, Suite 11121, Loma Linda, CA 92350, USA. 5. Joseph C. Gfroerer,* B.A., Michael A. Penne, M.P.H., Michael R. Pemberton, Ph.D., Ralph E. Folsom, Jr., Ph.D. OAS SAMSHA, Chapter 5. The Aging g Baby Boom Cohort and Future Prevalence of Substance Abuse 6. Emanuel Rivers, MD, MPH, Ehsan Shirazi, MD, Taruna Aurora, MD, Marie Mullen, MD, Kyle Gunnerson, MD, Brendan Sheridan, BS, Laura Eichhorn, BS and Michael Tomlanovich, MD Cocaine Use in Elder Patients Presenting to an Inner-city Emergency Department 7. Schutte KK, et al Successful remission of late-life drinking problems: a 10-year follow-up J Stud Alcohol May;62(3): Substance Abuse Among Older Adults SAMSHA Fact sheet Treatment Improvement Protocol (TIP) Series Joan A. Masters, RN, PhD, GNP Moderate Alcohol Consumption and Unappreciated Risk for Alcohol-Related Harm Among Ethnically Diverse, Urban-Dwelling EldersGeriatr Nurs 24(3): , Mosby-Year Book, Inc. 10. Substance Abuse in the Elderly: Alcohol and Prescription Drugs Robert C. Abrams M.D.1 and George S. Alexopoulos M.D. New York Hospital, Westchester Division, 20 Bloomingdale Road, White Plains, New York Tivis LJ, Brandt EN Jr. Alcohol consumption among the elderly: dispelling the mythsj Okla State Med Assoc Jul;93(7): Kessler, R, National Comorbidity Survey Repliocation Journal of Clinical Psychiatry June

(1992) 137 VA inpatients (ages 45+) randomly assigned to either: 1- Older Alcoholic Rehabilitation (OAR) program: Reminiscence therapy, goal of developing patient self-esteem and peer relationships

Substance Abuse Treatment in the Elderly

Substance Abuse Treatment in the Elderly Lawrence Schonfeld, Ph.D. Professor, Dept. of Aging & Mental Health Institute Florida Mental Health Institute Admissions Age 55 or Older by Primary Substance at