Older adults are particularly vulnerable to misuse and abuse of prescription medications. Persons ages 65 and older make up less than 15 percent of the population but they consume about one-third of all prescription medications. 1 Older adults take more potentially addictive medications than any other age group. 2 One in four older adults has used psychoactive medications with abuse potential, and such use is likely to grow as the population ages. 3 Although illicit drug use is relatively rare among older adults compared to younger adults and adolescents, there is increasing evidence that prescription drug misuse and abuse is a growing problem in the older population. 3 The prevalence of prescription drug abuse in older adults may be as high as 11%. 4 Definitions For our purposes, prescription drug misuse is the use of a medication other than as directed or indicated, including taking too little or too much of a drug, taking it too often, or taking it for too long, whether harm results or not. 5 Prescription drug misuse can be either willful or accidental. Non-adherence with a medication regimen is a broad category of prescription drug misuse. Prescription drug abuse refers to intentionally taking medications that are not medically necessary, or for the experience or feeling a drug causes. 6 The pathway from appropriate medication use, through misuse to abuse can result from patient behavior, prescriber behavior, or both. 3 PRESCRIPTION DRUG MISUSE Increased medication use affords the opportunity for older adults to accidentally or intentionally misuse prescription medications. Patient Behaviors Prescription drug misuse by older adults can take many forms: 3, 7 Taking more of a drug than prescribed Missing doses Not following instructions Using drugs that have expired Page 1 of 10
Not knowing about side effects Sharing or borrowing drugs Taking the wrong drugs Using a drug for other than the prescribed reason Combining drugs with alcohol or other substances. Prescriber Behaviors Prescriber-related factors also place older adults at risk for prescription drug misuse, serious adverse effects, or abuse and dependence. Prescribing practices that are potentially dangerous include: 3, 8 ordering medications without adequate diagnoses or other indications for use, failure to consider the influence of aging on the effects of drugs in the body, prescribing multiple drugs from the same therapeutic class, prescribing a drug at a higher dose and/or for a longer duration than recommended, prescribing for too long a duration without appropriate monitoring of drug reactions and patient adherence with the prescribed regimen, selecting drugs known to have a high risk for side effects or that are potentially inappropriate for use in older adults, ordering drugs without knowing or reviewing whether they interact adversely with other medications the patient is taking, failing to determine whether the patient uses alcohol or other substances with abuse potential, and failing to provide adequate instructions for regarding how and when to take medications and what side effects to expect and report. Consequences of Prescription Drug Misuse Prescription drug misuse can lead to treatment failure increased health resource utilization - additional physician visits - laboratory tests - preventable emergency room visits and hospital admissions. Prescription drug abuse may proceed on a continuum from appropriate use for medical or psychiatric conditions through nonmedical use or misuse, to persistent abuse and dependence. Page 2 of 10
Risk of Prescription Drug Misuse Most prescription drug misuse by older adults is unintentional and there are many factors that contribute to or increase the risk of misuse: 7, 9 The use of numerous medications for chronic conditions, frequently with uncoordinated care between multiple prescribers. Inappropriate prescribing (e.g., prescribing the wrong medication or an inappropriate dose). Instructions and package inserts written in small print or confusing language. Limited English language proficiency and low health literacy. Memory problems making it difficult to keep track of medication schedules. Hearing or vision problems that interfere with the ability to take medications correctly. Failure to tell the doctor about over-the-counter medications, vitamins and herbals. Willingness of doctors to prescribe drugs for sleeplessness, anxiety and depression without investigating and treating the root cause of these problems. PRESCRIPTION DRUG ABUSE Prescription drug abuse the intentional taking of prescription drugs that are not medically necessary is present in 12% to 15% of elderly individuals who seek medical attention. 9 Data from the National Survey on Drug Use and Health indicate that nonmedical use of prescription medications is second only to alcohol abuse among adults older than 55. 10 The Drug Abuse Warning Network (DAWN), which monitors emergency rooms across the nation, reported that emergency department (ED) visits involving drug misuse and abuse by adults aged 50 or older more than doubled between 2004 and 2008. 11 One-fifth of ED visits were made by persons aged 70 or older.. Among ED visits made by older adults, pain relievers were most commonly involved (43.5%), with narcotics the most popular type, followed by drugs used to treat anxiety or insomnia (31.%) and antidepressants (8.6%) More than one-third of ED visits made by older adults misusing or abusing pharmaceuticals resulted in a hospital admission; of these, nearly a quarter resulted in an admission to the intensive care unit. Nonmedical use of psychotherapeutic drugs among adults aged 50 years and older is projected to double over two decades, to 2.7 million by the year 2020, 12-13 with 4.4 million in need of substance abuse treatment. 14 Page 3 of 10
Commonly Abused Medications The most common prescription medications abused by people of any age are 15 Opioids usually prescribed to treat pain; Central nervous system (CNS) depressants used to treat anxiety and sleep disorders; and Stimulants most often prescribed to treat attention deficit hyperactivity disorder. Common Opioid Prescription Medications 16 Generic Name Brand Name morphine MS Contin, Kadian, Avinza codeine Tylenol with Codeine, Robitussin AC hydrocodone Vicodin, Lortab, Zydone oxycodone OxyContin, Percodan, Percocet, Tylox, Roxicet fentanyl Duragesic In the older adult, benzodiazepines prescribed to treat insomnia and anxiety, opioid analgesics to manage pain related to arthritis and hip fractures, as well as alcohol and over-the-counter medications are the primary drugs of abuse. 9 Many of these drugs can result in dependence in the older adult. Using lower doses may decrease the risk of abuse or dependence. However, fear of addiction, both by the patient and their doctor often results in inadequate treatment of anxiety, insomnia and pain and opens the door to self-management and prescription drug misuse or abuse. 4 Consequences of Prescription Drug Abuse Compared to younger adults, when older adults abuse medications significantly more health problems arise due to increased sensitivity to medications, slower metabolism, a decrease in volume of distribution, and possible cognitive impairment, which makes self-monitoring of medication use and following directions from health care providers difficult. The misuse and abuse of psychoactive drugs by older adults can result in drowsiness, sedation, confusion, memory loss and other impairment of cognitive function, which in turn may lead to falls and other accidents. Commonly Prescribed Depressants 16 Brand Name Benzodiazepines diazepam Valium alprazolam Xanax clonazepam Klonopin Non-benzodiazepine sleep medications zolpidem eszopiclone zaleplon Barbiturates secobarbital mephobarbital pentobarbital Ambien Lunesta Sonata Seconal Mebaral Nembutal Page 4 of 10
Organ systems can be damaged by prescription drug abuse and there may be a profound impact on the social and economic spheres of the older adult s life, with negative impact on self-esteem, coping skills and relationships, adding to other cumulative life losses. Once exposed to psychoactive drugs, older adults may be at greater risk for the development of dependence than their younger counterparts due to factors associated with aging. 3 For instance, with age the liver becomes less efficient at filtering out medications from the body. This slowed drug metabolism not only increases the risk of serious side effects, but may result in dependence or addiction at lower doses than a younger person. 17 Also, aging brains are more sensitive to the effects of drugs that act on the central nervous system. Risk Factors for Prescription Drug Abuse in Older Adults Older women have been found to be at greater risk for prescription drug abuse than older men or younger women. Compared with older men, older women take more psychoactive drugs, especially benzodiazepines, and are more likely to be long-term users of these medications. 8 Social isolation or loss of social supports, factors related to the provider and health care system, depression, and history of mental health problems or substance abuse may increase vulnerability for abusing prescribed medications. 3, 8 Exposure or access to prescribed medications with abuse potential may be the single greatest risk factor for prescription drug abuse by older adults. 3 Families and caregivers may be able to help prevent abuse by being alert to the symptoms and early warning signs, and knowledgeable about the abuse potential of certain medications. 11 Recognizing Prescription Drug Abuse The older adult does not fit the typical drug abuser profile, and the signs of prescription drug abuse are less obvious in older adults than in younger people. Symptoms of drug abuse and dependence can be difficult to assess. Traditional signs of abuse (e.g. missed time from work, legal problems, etc.) are not as common in the older adult. There are currently no validated screening instruments for identifying and diagnosing drug abuse in the geriatric population, 3 and the guidelines and screening tests used are often designed for younger people and may not be easily applied to older adults. 18 Many of the diseases caused by substance abuse such as high blood pressure, stroke, dementia, or ulcers are common disorders in later life, so health care providers and family members may not think of drug abuse as a cause. 18 Page 5 of 10
Many of the symptoms of prescription drug abuse mirror common signs associated with aging, such as shaky hands, mood swings, balance issues, confusion and memory loss, 9 thus making it even harder to subjectively detect in older adults. Some warning signs such as sleep problems, falls, anxiety, depression, and memory problems can also be signs of other health conditions. As a result, doctors and family members often do not realize that the person has a problem, and people may not get the help they need. There are however, some very specific behaviors suggestive of drug abuse. Here are 7, 16, 19 some warning signs to look for if you suspect an older adult has a drug problem: Excessive worry about whether mood-altering drugs are really working. Worrying about having enough medication on hand. Giving excuses as to why they need the pills. Frequent requests for refills of certain medicines. Self-medicating by increasing doses of prescribed drugs that aren t helping anymore or supplementing prescribed drugs with over-the counter drugs. Complaints about doctors who refuse to write prescriptions for medications they want. "Doctor shopping" moving from provider to provider in an effort to get several prescriptions for the same medication. Paying for medications out-of-pocket rather than using prescription drug insurance. Behavior or mood change. Withdrawl from family, friends, neighbors and lifelong social practices. Sleeping during the day or signs of sleep disturbances. Falls or other unexplained injuries, which might be a result of excessive sedation. Changes in personal grooming and hygiene. Remorse or concern about taking pills. Receiving the same medication from more than one physician or pharmacy at approximately the same time. Annoyance or discomfort when others talk about their use of medications. Sneaking or hiding pills. Seniors who abuse medications acquire them in the same way as younger drug abusers, including forging or altering prescriptions, impersonating physicians on the phone, seeking out prescribers with a reputation for writing prescriptions under dubious circumstances, doctor shopping to obtain prescriptions from multiple prescribers, filling prescriptions at different pharmacies to evade detection, ordering medications from illegitimate internet pharmacies, frequent visits to the emergency department for vague complaints with the hopes of obtaining pain or anti-anxiety medications, and sharing or 9, 20 borrowing prescription drugs from family and friends. Page 6 of 10
PREVENTING PRESCRIPTION DRUG MISUSE AND ABUSE A primary reason for continued escalation of prescription drug misuse and abuse is lack of education among all segments, including physicians, pharmacists, and the public. 21 For the older adult population, addressing the factors related to willful and inadvertent misuse of prescription medication is a necessary part of prevention and early intervention. 9 With one-fifth of ED visits by older adults involving pharmaceutical misuse or abuse occurring among adults aged 70 or older, caregivers (e.g., adult children of aging parents) may be able to help prevent abuse by being alert to the symptoms and dangers. Education for caregivers about the abuse potential of certain medications and the early warning signs of abuse may be needed. 11 Tactics to prevent medication misuse and 7, 20, 22 abuse include: Improving medication adherence. Questions to Ask 16 Asking some simple questions can also uncover a substance abuse problem. For example, the CAGE questionnaire, originally developed for alcohol, has been modified to include drug use and has been tested in older adults with some success. CAGE includes four basic questions, with the modified version asking about drinking and drug use: 1. Have you felt you ought to cut down on your drinking or drug use? 2. Have people annoyed you by criticizing your drinking or drug use? 3. Have you felt bad or guilty about your drinking or drug use? 4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves, get rid of a hangover or, get the day started (as an eye-opener)? Research suggests that answering yes to just one of these questions can identify a potential problem with substance use. Making sure that older adults understand how to take medications and what to avoid when taking a prescription medication. Encouraging older adults to share concerns and ask questions about their medication. Encouraging older adults to inform health care providers of all medications they take regularly. Encouraging older adults to keep a current medication list, including prescription drugs, OTC products, supplements and herbals AND provide it to all their health care providers. Providing aids, such as medication tracking charts and personal drug records. Addressing communication barriers, including low health literacy, vision and hearing impairments and language barriers. Community informational and interventional support programs. Page 7 of 10
Educating prescribers and other health care providers about the severity of the problem concerning prescription misuse and abuse. Adequate treatment by health care providers of the underlying medical problems that yield symptoms (e.g. insomnia, pain and anxiety) rather than just symptom management. Standardized screening protocols for physicians to assess for drug misuse or abuse. Transitional care programs and home-based medication reviews. There is another, often overlooked, serious unintended consequence from prescription drug misuse. Older adults who keep large supplies of leftover medications in their medicine cabinets contribute to the risk for accidental poisoning of children who can access these drugs and provide a source of drugs for others to abuse. A majority of abused prescription drugs are obtained from family and friends, 23 including from the home medicine cabinet. Page 8 of 10
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