Hello everybody, this is the PCSS training for substance use disorders in older people. That's the providers, clinical support system. My name is Louis Trevisan. I am an associate professor of psychiatry at Yale University School of Medicine, I'm also the National Tele Mental Health substance use disorder lead consultant, and I'm based here at VA Connecticut in West Haven, Connecticut. You can see my contact information if you want to get in touch with me about any questions in the module. Or any questions about National Tele Mental Health Center, please use my phone number or my email that are listed on the title page. My disclosures, I have no relevant financial relationships with ACCME defined commercial interests to disclose. The overarching goal of PCSS is to make available the most effective medication-assisted treatments to serve patients in a variety of settings including primary care,psychiatric care and pain management settings. The educational objectives of this presentation are to review the prevalence of substance use disorders and older people to describe the signs and symptoms of substance use and misuse and all the people. To recognize the fact the psychopharmacology of substance use disorders in older people, and to assess the relevance and importance of psychotherapeutic intervention in older people. To start this presentation of case vignette. In this presentation we'll examine the case of a 75 year old Caucasian female who's been married to the same man for 50 years. And has recently been complaining of feeling more anxious. She has asked her husband to help with this. She has a history of anxiety, not otherwise specified. And is prescribe clonazepam by her primary care physician. Her husband is a retired professor at an Ivy League University. And has a complex medical history including chronic pain from peripheral neuropathy, treated with extended release oxycodone 40 milligrams by mouth every 12 hours. She presents to the emergency department after she became confused was unable to eat her dinner and fell into a light sleep at the dinner table while out to dinner with her husband. We will examine other aspects of this case later on in the presentation. So prevalence of substance use disorders in the older population. One of the main questions that we ask ourselves when we're dealing with older people now is, do we call them elderly? Do we call them geriatric? Or do we talk about them as older adults, mature adults, if you will? Basically, these days, this is the baby boomer generation. These are a huge group cohort of people. Between the ages of 53 or four and 71 to 72 years old these days. They were born between 1946 and 1964. This group will present with some substance use disorders and substance use treatment going forward. The use of greater than 65 years old definition it describes the elderly maybe somewhat arbitrary as discuss earlier. The information in this presentation is basically on persons older than 50 to 55 years of age. And the terminology will vary. So I may use the word older, I may use elderly, I may use geriatric. We're talking about people that are over 50 or 55 years old. And part of the Baby Boomer generation. So the principal substances used by these older patients or older people is tobacco, alcohol, opioids. Particularly non-medical use or non-medical use of prescription medications and illicit drugs, stimulants and cocaine. Marijuana, and sedatives, and muscle relaxants. So in terms of prevalence for tobacco, this is a slide from the CDC and it's about eight to 10 years ago. However, you can see that the age group 45 to 64 moving forward is up to around 22.5% of people smoking tobacco. Now, this has decreased slightly somewhat these days. But this slide is meant to show you that there's a large group of people moving into elder age and that are actually in older age now. Our older adults and they continue to smoke between 15 and 20% of the population. In terms of alcohol use in older Americans, older adults have had consistently lower rates of alcohol use, high risk drinking and alcohol use disorder than younger adults over the past 50 years. However, between the years of 2001 and two and 2012 and 2013, there was a substantial and frankly unprecedented proportional increase relative to the earlier years. So alcohol use is up by over 20%, high risk drinking is up by over 65%, alcohol use disorder is up by 106 or 107%. And the projection is for alcohol in older Americans is that it will increase from around 40 million people in the United States in 2010 to almost double by 2030, around 80 million people. This could produce a substantial increase in the absolute number of older people with high risk drinking and alcohol use disorder. The next topic would be prescription psychotherapeutics non-medical use. This is a slide from a coil over and associates. That was done in 2006, which was trying to project the amount of people using non medical use, non medical use of prescription psycho therapeutics. So this includes opioids and sedative hypnotics. And the projection is that it would increase from you know, pop, you know, just like it says on the, the slide. It increases by almost double in the age 50 to 59. And those people now are moving forward. They're in the 60 to 69 range. So again, this slide and the study, elucidated the fact that there's a large bolus of people who are using our medications and non therapeutically or in the non medical way. This is one slide that I've been using for a while. In presentations that I do about older persons' substance use. And it's remarkable in the fact that it can show you that Americans make up between 4.5 and 5% of the world's population. Yet we do consume 80% of the global opioid supply. As a matter of fact, 99% of the global hydrocodone supply. And you can look at the other statistics that are listed on the slide, some of them are outrageous numbers, they're very huge. Basically, the point is that we are a country that is awash in opioid and prescription pain medications. So the older patient with prescription opioid use disorder, trying to describe who these people are is important. Many of them have multiple medical problems, have had chronic pain. They most often have mood disorders. And sometimes as people get older, they misunderstand directions. I myself, I'm getting a little bit older, I'm in my 60s, and it's sometimes it's unclear about directions. And it's a question about whether they're misusing or whether there's a real use disorder, or whether they're not following the way they're supposed to take their medications. It states here that they often get people to look for multiple prescribers. But we'll see later in the presentation that most people get it from one friend or from one provider, their opioid pain medication. Rationalization and denial among family members, and peers, and caregivers. It's hard for people to grasp the idea that their parents or their grandparent may be abusing oxycodone, or may be drinking a whole bottle of wine at night, to use another medication. But family members and caregivers deny the fact that older people could have problems. And sometimes deficits that show up in the office, like cognitive problems and such, are presumed it's because they're just getting older. Well, it may not be that they're getting older. Lots of older Americans, older adults, older people in the world are very sharp into their 70s and 80s and 90s. And then there's also the possibility of interaction with alcohol and other drugs. And in terms of older patient with prescription opioid use disorder, there is an over representation of females. This is a slide that I placed in here from the CDC that shows the direct correlation for the increase in sales of prescription painkillers and the increase in deaths. I think everybody has been aware of the fact that there is an opioid use disorder crisis in this country, and much of it is probably due to prescription painkillers and prescription opioid misuse. This is a slide that illustrates that between 2000 and 2013. It looks like the actual sales and deaths went down a little bit in 2013 and 14, I can tell you that they rebounded and went back up again in 2015, 16. This is a very interesting slide that sort of counteracts the one girl from the earlier slide about getting pain medications from multiple prescribers. When you look at the source of pain relievers for most recent nonmedical use, and this is for all people older than 12, from SAMHSA and the National Survey on Drug Use and Health, which is a very handy publication. It shows that most people get their pain medications that they misuse from a friend. And obviously their friend has not used all of them and kept them in their medication cabinet or such. And usually, they get them from one doctor or they buy them from a friend. So clearly, most of the avenues that people get, according to the National Survey on Drug Use and Health, that get their prescription pain relievers that they misuse, that they get it from a friend and one physician. This slide is also a really nice slide, which I'm sure many people in this audience will recognize as the truth in their practice. That most people, the main reason that the most recent prescription and pain reliever misuse among people 12 or older are from relief of physical pain. So there are a lot of people with pain out there. And I can tell you that as an addiction psychiatrist that when we heard that the Joint Commission was making pain the fifth vital sign, we sort of rolled our eyes and said, something is going to happen here. Now, that's not the total reason for why everybody gets pain medication now. But it sort of made us wonder, are we going to be over prescribing pain meds to people with chronic pain. It's a controversial topic. But clearly, one of the big issues is that people, and especially older Americans, are in, have take these medications to relieve physical pain. Again, some clinical pearls about the recognition of misuse of prescribed medication. Just remember that any symptom in an older adult could be considered a medication side effect until proven otherwise. So if you have an older adult coming into you and complaining of something, I mean, I know it's basic practice to always review the medications that everybody is on. But please pay special attention to the fact that they may be on medications that could be being abused. If they're complaining of falls, even if it's a one fall, it's their first fall, or history of falls, these could obviously be due to sedative, hypnotics, or opioid pain meds. GI distress, obviously alcohol, incontinence complaints, alcohol and sedative hypnotics. Constipation could be opioids. Of course, depression and anxiety, other psychiatric symptoms such as these, could be due to alcohol misuse, opioid misuse, or even steroids and alcohol. Which I have to say, the number of older guys I see in the gym these days pumping iron has really increased. And there are signs all over the lockers saying, misuse of anabolic steroids is punishable. So, I mean, this is probably something to watch for as well. So obviously any confusion in an older adult, you have to think about a CNS agent. Whether it's an antihistamine, to an opioid, to whatever you think could be possibly causing that. And of course, insomnia Is another sign that medications may be being or alcohol could be being misused. So in terms of what medication misuse is, these are, again more risk factors. It's taking extra doses, taking missing doses, not filling prescriptions, not understanding directions, incorrect timing. I mean, I'm not sure what you people will think about this, but I mean, how many times do you actually take all the medication you're prescribed when you're given medications? I know as a physician, I try to do the best I can, but I'm not prefect. I'm not sure anybody is, and when you have older Americans, or older adults who may forget things, or miss things, this is always a prime suspect with incoming complaints to Akaky Akakievich Bashmachkin your office. Risk factors, again, female. It's not a mistake that during the '60s and '70s, The Rolling Stones made a song called Mother's Little Helper which was about Valium. Physicians have been prescribing medications to women at a higher rate in general than to men. And it sometimes it's around these issues of anxiety or untreated psychiatric conditions. Anyway, social isolation is a problem, polypharmacy and multiple prescriber. Polypharmacy is a problem, multiple prescribers may be less of a problem. I work in the emergency room here sometimes. And I also do tele psychiatry, and I look at the list of medications that people are on, and I'm astounded. I think the average number of medications that older people are on is close to seven or eight. And that's a lot. So always review the pharmacological interactions. They can also be prescribed drugs with abuse potential, or have had them in the pas. Chronic medical problems, and if a patient has, or an older adult does have a history of substance use or psychiatric disorder, be on the lookout. I mean, I'm not trying to be critical here. I am a psychiatrist. But it does make people more vulnerable. This is a slide that I've used for quite a while, that shows, again, from the NSDUH, National Survey of Drug Use and Health, that shows the increase in illicit drug use among the people aged 50 to 59. And it's broken into the two groups there and then combined. These are significant increases. I guess it could be debated whether or not that they're elicit, if it's marijuana anymore. Because it's legal in certain states and not in other states. I mean, it's legal in Massachusetts here, not in Connecticut. VA always looks at it as illicit where I work. And so, I mean, these numbers may not be perfect, but they do show an increase in the use of all types of illicit drugs. Again, I did mention marijuana, Of course, it's very popular these days and there are lots of states, I think there are 10 states now that make it legal. It's very controversial. And we are dealing with the baby boomer generation. And we as a as a group coined the phrase drugs, sex, and rock and roll, although not necessarily in that order. So be aware that as people are getting older, they may be using cocaine, they may be using methamphetamines, they may be smoking marijuana and not just having one too many IPAs. >> All right, I'm going to move in here to a different aspect of this presentation. I want to talk about barriers to identification of substance use in older adults. And I may have touched a little bit on this earlier, but clearly there are physician factors. I know that as a psychiatrist that there are psychiatrists that I work with, that I know that are not oblivious to substance use problems. But clearly, it's at the bottom of their concern and the bottom of their awareness. I think we're making people much more aware that people can have substance use disorders. I know that the primary care folks here at our VA are very aware of substance use disorders. And we have screening reminders in effect in the VA to make sure that we ask everybody about these things so that we don't miss anybody, it becomes more of a population health issue. So physicians and psychiatrists all have stereotypes about not only substance use, but stereotypes about older people, too. So we're living longer now and bringing our issues with us as we get older. So there's also in physician factor that's a barrier is a lack of knowledge about treatment. So it's important to get out there and find out what treatment is available. Patient factors, especially in older people is denial and shame or guilt. I mean, I've had several patients who have been on pain medications and then went and and talked to their primary care doctor outside the VA and got on something else because they were having breakthrough pain, and they were afraid to tell me that they were using too much of their medications. So some people fill early and you can identify them. Others fill early and they feel ashamed, and they move out, and they feel guilty about this stuff. So you have to be able to educate patients to know that it's okay, substance use disorders are chronic illnesses like other medical illnesses. And that we're here to try and treat them. Again, diagnostic factors are important, comorbid medical conditions, age related change,s we've been through this with the falls, anemia, neuropathy, altered cogitation. There may be fewer overt signs. So sometimes as people get older they don't miss work because they have a hangover. Those kinds of things. So there may be less social indicators or warnings that there's a problem with substance use. And the diagnostic and statistical manual criteria are really sort of less applicable as you get older in general. So I wanted to talk a little bit about alcohol. Alcohol was one of the original issues that I was working on here in my academic career at Yale and the VA. And we tried to breakdown people who have alcohol use disorder into two groups, early onset and late onset. So it can be applied to older adults, too. In general, we've been keeping people that have had alcohol use disorder alive longer. And they've been drinking for well before the age of 16 while the baby boomers, they have this and that they have severe alcohol use disorder. They have chronic alcohol related medical problems. And they have a positive family history. They could have psychiatric, serious psychiatric comorbidities, especially major effective disorders or substance use derived effective disorders. They usually less socially adjusted and they have more antisocial characteristics. They may have an intractable course but we managed to keeping them alive, at least at the VA we seem to where we have a high percentage of folks who have alcohol use disorder. Anyway, they may need more medically focused intensive treatment for their addictions. And then we talk about a group of later onset alcohol use disorder people, especially in older adults, and this is people who after 50, 55, 60, they get divorced or they get retired, or they lose their job and can get employed again. They may start drinking more, they may have fewer physiological consequences. They could have, they usually have a milder clinical pitch picture. They may be more emotional stable, there's less anti social traits. They have more social support. We're going to let satisfaction, the one keep them to take away from this is, and matter whether they are early onset or late onset. As people get older, they tend to get more responsive to treatment regardless of the age of onset. Now there are a certain of people with I call it sort of of the DA, who are very chronic and on remitting, and we detox them 20 times a year and try to stabilize them. And that may be the gold standard for those folks and we're not sure what's going on with them. But with other people who have been drinking all their lives and then develop problems, and people who start drinking later and develop problems, they respond to treatment equally well. And it's been positive that that's because, as we're getting older we know that we need to follow the doctor's advice more if we want to live longer. So some of the psycho-social stressors of ageing, I'm going to again reiterate these. These are extremely important when you're dealing with an older person. Role and status change, especially retirement. It's a big leap to think about retirement. I don't know how many folks out there are close to retirement age. But, in fact, I guess, I am and when I think about this, I think, well, what am I going to do? So it can be anxiety provoking, to say the least. Income changes, physical health decline, the cognitive changes, the loss of a spouse, shrinking social networks, and loss of independence are all very important psycho-social stressors as far as the aging population is concerned. So in summary, older populations of patients are changing. Some of them are younger, some of them are older. Most of them have some chronic medical problems most likely chronic pain. When we have increasing age cut offs, they're no longer defined merely by age but more likely by health status and psycho-social factors. And they may be using lots of different substances including alcohol, opioids, prescription medications. And yes, illicit drugs. Substance use disorders in the older population, screening and evaluation, so I'm going to go through some of these slides may be a little bit quicker, maybe not. But the evaluation of tobacco, the Fagerstrom Test for Nicotine Dependence is one that's most often used. And it's really a research instrument. My impression, and these other, the screening devices can be used, the issue is, however though that most people who smoke tobacco because it is legal are very free with telling you how much they smoke and how much they don't smoke. So doing the screening test is not really that important but the main thing is to try to get them to stop smoking. And as primary care doctors, I know out there you do this quite well. I can't say, and I'm not proud to say, that many of us psychiatrists are a little late to the game in terms of trying to evaluate people for tobacco use disorder and getting them to stop smoking. Were behind the curve, and we need to pick it up, and be more population based. Even though it may not look like a huge psychiatric problem to be smoking tobacco. It's clearly a substance use disorder that has a huge impact on people's lives. For alcohol, the screening test that's most often used and there's a list of them here. The ones that are easy to use in your primary care office or even your psychiatric office, or is the short version of the Michigan alcohol screening test, geriatric version. This is, I think I have a picture of it. It'll be coming up later, but the 10 question, a list of questions and they can answer them while they're waiting to see you. The alcohol use disorder's identification tests, the AUDIT is an excellent current drinking assessment tool which can be either filled out by the patient. Or can be administered by a technician. At the VA we use the AUDIT-C which is a three question test. And then of course the CAGE which is cut down, annoyed, guilty and eye opener, I think everybody has learned about CAGE, it's an excellent way to get a history. A historical perspective not only a current checking assessment because it opens up the, when you go through that with somebody, it opens up the conversation. Alcohol-Related Problems Survey is another one that got to use, but it's a little lower on the totem pole there. Here's the picture of this, the short Michigan alcohol screening test, the geriatric version. It's a 10 item question. And all you have to do as a geriatric age patient or an older American is answer yes to two of these. Now, I'm sure that there are several of us out there who can answer [LAUGH] yes to two of these. And what it does mean is that there should be a more complete assessment of their alcohol use. So it doesn't mean that somebody, it leads you to think, okay, I've gotta spend a little bit more time with somebody and ask more pointed question. It doesn't mean they have a problem. It means that there could be a problem. So, it's a nice screening test, specially for older folks. Here's a picture of the AUDIT-C, And you can see that it's a, this is also with use of the AUDIT-C it's a life threshold to get a more comprehensive evaluation. All you need is the score of 3 or more, and I would venture to say that many of us out here probably score close to 3 on this as well. So, it sort of favors, it's very sensitive, not too specific, but it gets you to ask more questions and opens up the conversation. The CAGE, of course, is something that every medical student learns and every resident learns, I assume, in most training programs. But it's good to reiterate this. The interesting thing is I think that, for normal age adults if I can use the word normal Two yeses indicates comprehensive evaluation. If you're looking at somebody who's medically compromised or who's older or geriatric, if they answer yes to one, it means that you should probably do a more comprehensive evaluation. Anyway, that's it for the alcohol. Now screening for opioid misuse and opioid use disorder, there's only one test that's really validated in the elderly and that's the Screening Tool of Older Persons' potentially inappropriate Prescriptions or STOPP. This is a nice instrument and it and works very well, it's been validated So that's good. The Screener and Opioid Assessment for Patients with Pain-revised is out there, that's a good one too, I don't think it's been validated wide as well as the STOPP, but there's several others there that you can use as well. The dast is a take off on the Michigan alcohol screening test for drugs. So it's the same type of self fill clients filling screening test. Summary There are many usable screening instruments to help the clinician ascertain substance use in the older population. Many of them are self administered. Others are clinician administered. And just remember the most important thing is to just ask about substance use. I think, It's been my experience that many patients what they tell me. And what many of the veterans tell me is that sometimes their docs don't ask them about substance use so they didn't help. This is for older people who are on the slippery slope or in trouble or. May be at high risk drinking or have high risk or there are they're stunning to play with their oxycontin or oxy code on prescriptions or and those kinds of things. They don't necessarily mention them to you and there is more than one occasion had an older gentleman here the VA tell me, if my doctor only asked me I would have told him. And I was shocked when I heard this. So I have to make sure that I really iterate that out there. Just ask. The more we talk about substance use disorders, the more understanding we'll have in terms of there being a medical condition rather than a guilt-ridden, shameful, character flaw. I mean, which surrounds many of these substance use disorders and affects older people in general. Okay, treatment. So general principles. I was board certified in geriatrics for 20 years. I let it lapse over the past year. But I can tell you that there are really some general principles about dealing with people that are in the geriatric age range or older adults. And several of them are listed here. The one that always really stuck out and probably many of you remember from medical school or residency is that when you're dealing with, medications, you start low and you go slow, and you keep going. I mean, you keep going until you get your effect. So but we always start a little bit lower in the dose and an increase a little bit Slower. It's always important to remember that co-morbid medical illnesses are out there and that they may affect people's ability to participate in treatment and it may affect the the treatment effects actually. Psychotherapeutic, there are again stage of life factors and and cognitive abilities to think about so somebody with a minimal some MCI, some minimal cognitive. Impairment, it's not really demented, may be able to develop, you know, to deal with a group, but they may not be able to do cognitive behavioral therapy. So, it's important to sort of keep those things in view when you're working with an older population. Also, remember that's when you are dealing with other post, it's a little bit like dealing with children and that there is other families members involve. This mid age adults you know that's the time when they have an spouse of somebody that can help, they don't have a parent or a child that's involve. The older Americans or older adults have younger, usually, daughters and sons who are very invested in their treatment and what's going on. And so you often have to take, the family interventions can be very helpful and information from family members can be very helpful. Also, older people tend to do well in groups with people that are their own age. So, if you send them to a substance use disorder group, or if they're choosing an AA group that might be interesting for them to be in a in a group that's mostly older folks rather than mixed age. In terms of biological treatments for tobacco use disorder, I'm going to talk a little bit about the patch, the gum, and some other medications, nicotine replacement therapy. This is a listing which I'm sure most people are aware of, of the different types of nicotine replacement therapy. There is the transdermal patch, the gum, the inhaler, their spray. Here at the VA, we give everybody that we admit that have, that in psych Or in-patients psych unit anyway that has tobacco problem, we put them on a patch and we give them a gum. And that really, when they have a craving, the patch provides us a steady level of nicotine which relieves some of the craving and some of the problem with not smoking, some of the withdrawal. But then when they get it, when they have a craving or an urge, the gum can give them a little burst of nicotine, which sort of helps. The other medication which is clearly, you know, the best medication to use out there and very well tolerated in the elderly is Varenicline. It's an orally administered Alpha4-Beta2 nicotinic ACH receptor partial agonist. Now that's a mouthful. But what it does is it works as an agonist at lower does at this receptor, at the anticholinergic receptor. And as it gets higher, it sort of cuts it off and you don't get more of a response. So it antagonizes a nicotine response, and there are no dose adjustments in older adults. So you can prescribe it just like you'd prescribe to a younger person. And they've removed the black box warning on causes suicidal ideation. So I mean you should always be careful with anybody who has a substance use disorder or a mental health disorder about suicidal thoughts, but you don't have to steer clear of it because of that anymore. Bupropion, which is an antidepressant that's a weak inhibitor of dopamine uptake, is also well tolerated. And you start low and go slow, but keep going in older folks. And it's unclear about how it sort of helps with smoking, but I can tell you that most people that I've used it with told me that it just makes it an unpleasant experience to smoke, so they don't like the taste of the cigarette when they smoke. Behavioral treatments work if people are not cognitively impaired. Brief interventions work very well in the elderly, they tend to listen to the doctor more. As we get more mature maybe our frontal lobes are more well developed and our executive functioning is better and we can't just tear around like crazy when we were kids. So we tend to listen to people who know things better as we get older, so brief interventions work. Social treatments, groups work very well. AA, Smoke Enders, these kinds of groups work well for the elderly and for tobacco use disorder as well. Alcohol use disorder. So I'm going to talk a little bit about withdrawal management, detoxification, and a little bit about some of the ongoing treatments that we have, which are not the most robust treatments, but they do seem to help. So I directed the alcohol detoxification program here at VA Connecticut for 15 years a while back. It includes in-patient and ambulatory or out-patient. And we had quite a few number of people who was older patients who had alcohol use disorder here at the VA. They have a higher risk of delirium, or delirium tremens. And what happens is they don't seem to have quite the robust outflow of sympathetic tone that younger guys and ladies do with alcohol withdrawal. So they don't get a lot of elevated blood pressure or heart tachycardia, sweats, tremors. But what happens is they get kind of prolonged confusion, they get hypotensive, they often need more fluids, they tend to run drier than younger folks. And so it's a longer protracted withdrawal for older folks. The onset of symptoms may be delayed. You'll see confusion, it looks like they're delirious. Some people think that we use benzodiazepine, and people thought maybe we shouldn't use too many benzodiazepines. The jury is out, I mean you have to take them one by one. And I would use lower doses of benzodiazepines, mostly Ativan because it has no breakdown product so you know what you're giving, and give it more frequently. And more nurse contact with elderly as well, so supportive nursing therapy works very well. So again, in-patient treatment is almost always indicated unless the elderly person is really very robust and really biologically much younger. And this post acute phase can last for a long time, you can have the confusion waxing and waning for up to weeks to months. So we have people in in-patient for quite a while if they're a frail elderly. This is a slide that speaks the truth about alcohol withdraw. It uses not politically correct terminology in some cases, but if you can get past that it give you a very good timeline of when certain withdrawal symptoms happen. And what happens during the course of treatment, when the later onset DT's or delirium tremens or alcohol withdrawal. Delirium starts usually at a later onset, the shakes and seizures and confusion and stuff like that. Seizures actually are within the first couple of days, although they can happen much later as well, especially in the elderly. So this is for normal adults with alcohol use disorder who has a complicated withdrawal. But it gives you a good idea of when you see things, and I've always found this slide to be very instructive, so you have it. Medications for treatment of alcohol use disorder include these mentioned medications, Naltrexone oral and injectable known as Vivitrol, acamprosate, and disulfiram. These are the recommendations for use. Naltrexone can be used in the elderly at regular doses. Again, I would start orally with them and start with a lower dose, instead of 50 milligrams start with 25. And you could go up to 50 every day or even every other day, and it can help with reducing the amount of alcohol or the number of drinking days. Acamprosate, again, is good for people who are on chronic pain medications or on buprenorphine for opioid use disorder. So it's got its FDA approval from studies in Europe. And when we tried to replicate those studies with acamprosate in the United States, they didn't work out too well. But that doesn't mean you can't use it, and it can clearly work in some people very well. Again, you have to evaluate renal function, especially in elderly with this. But you can start, you can dose it just like you'd dose a normal aged person. Disulfiram We usually start with 125 and the elderly. I would not use an frail elderly, if you have a robust elderly person that can that can handle disulfiram, I think that's fine. I would be careful if anybody has any heart disease or liver problems. This is the original study that was done by Volpiceli in 1992, another historic slide that shows the accumulative proportion of people with no relapse that were on naltrexone over the number of weeks receiving the medication versus placebo. Of course, if you look at the bottom under the figure two, alcohol relapse was defined as reported drinking five or more days within one week. So I mean, if you drank more than five days you relapsed. If you're reporting five or more ranks per drinking occasion or coming to treatment appointment with blood alcohol concentration above 100. So I mean if you came to your, they used pretty broad criteria to get naltrexone to market here. But it came at a time which was very crucial when complete abstinence was the only model that was acceptable, which was driven by Alcoholics Anonymous. And it came at a time when we were looking at how medications can help people cut down or manage their drinking. So just because somebody has a blood alcohol concentration of 100, doesn't mean they have alcohol use disorder, that way we'd probably all have alcohol use disorder. So but if people have difficulty with drinking or high risk drinking, naltrexone was very good, and this was a breakthrough study. This is a complicated slide that Dave Filing asked me to put in, and I agreed, it's a very nice slide. He's our alcohol, he's our addictions medicine guy here at Yale. And it's a Cochrane study from 2010 by Rosner, I think they're Swiss or German, I think from Germany. And they looked at 50, I believe, studies using naltrexone in heavy drinking. So we know that it works in people that are at risk drinking, and should be used if it can be tolerated, and in the elderly too. People with heavy drinking it didn't work as well. But if you look at the risk ratio of 0.83, I think what that indicates, if I'm not mistaken, is that one in eight or one in nine people actually got better. So you have a 15% chance of helping somebody, even with heavy drinking, with naltrexone. So it shouldn't just be not used I think in heavy drinking and or alcohol use disorder, but it should be tried and it could help. And of course the way naltrexone works is by blocking the opioid receptor, new receptor, in the nucleus accumbens. And this takes away the rewarding aspect of drinking, so you don't get quite the buzz that you get when you're on naltrexone and you drink alcohol. So if the increasing alcohol level effect is stimulating and nice and warm and really good, this dampens it and seems to help. It's something to try. Psychosocial treatments, again, are very important. But that doesn't mean you shouldn't use medications if somebody, even when they're older, refuses psychosocial treatments. But we always push psychosocial treatments because we think they really help. In the elderly, age specific treatments seem to be more effective. Address issues of loss and isolation, teach skills, and rebuild social supports. I mean these are as important as the medications and the counseling with the doctor. Although counseling with the doctor is very important, and that really goes a long way, which many studies have shown. So I'm trying to be comprehensive here, and we should all be comprehensive. I wanted to give you some ideas about brief intervention for at risk drinking in older populations. Again, older populations of people seem to listen more to the doctor. And generally this involves two or three 10 to 15 minute sessions, education, assessment, feedback. You can use motivational strategies like S&M to listen to what's good about your drinking, what's not so good about your drinking. Having them talk it out rather than just not telling them, I wouldn't just tell them, you can try telling them just don't drink, but that may not work for everybody. So some people you have to help them talk about it rather than just hearing don't drink anymore. [COUGH] So goal setting behavior, look at what's good, what's bad about drinking. So there have been several trials of brief interventions in older adults, I've listed them here. You can look them up and see how they were, but they were done by mainly family practitioners and primary care docs. [COUGH] And they had quite a bit of success. This is a slide, That is just, it's an acronym for you to help remember what to do in a pinch if you don't have it written down in front of you. [COUGH] And feedback from the assessment, sort of trying to get them to accept some responsibility for changing their behavior, offering advice, and giving them a menu of changes, that's really sort of important. There are lots of different ways to help with alcohol and or any other, tobacco, any other drug use. And be empathic. So I know that primary care doctors in particular, and sometimes, and now even more psychiatrists, we have a limited amount of time that we can spend with people. I would take an extra five or ten minutes to be with somebody who in your brief treatment intervention and really make some contact with them because that goes a really long way. And then of course if there are some advances and they're doing well, I think having some ongoing follow-up and enhancing their self-efficacy really works. So paying them off and keeping some praise on them goes a long way. In terms of psychotherapeutic treatments for alcohol use disorder, there's relapse prevention, which we've been doing for a long time, and specialty psychiatric and addiction medicine care, using cognitive behavioral tool boxes and ways to avoid cues and relapses. Motivational interviewing and enhancement, which I mentioned a little bit. It's a little bit like It works well in elderly, especially only if they're really cognitively with it. But, trying to get them lists what's good, what's bad about the drinking, how they could possibly change, where they sort of stumble. And sort of helping them move along, individual psychotherapy works. The combined study many years ago showed that just meeting with the doctor in support of therapy and taking Naltrexone were the main things that helped with alcohol use disorder. Cognitive behavioral therapy works and of course, referrals to AA always helps if people buy into the AA model. And if they don't, it doesn't work. If they do, it seems to work and there's also a 12-step facilitation. So there are clinicians out there that actually know a lot about AA and can actually facilitate what's going on in our AA in a psychotherapeutic way which is very helpful. So some examples of social determinants for treatments for alcohol use disorder are group, 12 steps, CBT, rational recovery if they don't like the spirituality aspects of the AA. Alcoholics anonymous or narcotics anonymous. There are rational recovery groups out there that don't ascribe to a higher power, if people have strong feelings about that. And family interventions again, just wanted to mention that, those are really strong in the elderly. Methadone, so I'm getting down to the opioids here. 5 to 6% of the patients receiving methadone and methadone maintenance are over 50 and 55. This was from 2004. I'm sure that's increased now. I mean, I know that most of the Methadone patients that we have here at our opioid treatment program at the V8 in Connecticut are, I would say the majority of patients are over 50. A lot of the younger patients are on, actually buprenorphine. And we should probably getting more of the older patients on buprenorphine or suboxone as well. So they may do better in treatment than younger patients in methadone maintenance treatment as well. Although, they have similar rates of medical and psychiatric problems. They're more likely to be married as older folks and have support. Many of them have jobs, and overall older folks did significantly better. The main thing you have to watch out for elderly with methadone is the QTc prolongation and torsades de pointes, and constipation, so you have to be on top of that. Methadone clearly has to be distributed in a federally sanctioned methadone maintenance program. So you can't give it from your office unless you're doing it for pain. But you can't really do that for opioid use disorder. So I would stay away from that, project the monitor for QTc. But it works and it can be used in the older folks. Buprenorphine or suboxone, we use suboxone which is a combination of buprenorphine and naloxone. I'm sure a lot of people are learning about suboxone and buprenorphine now, it has quite a street value. It's a partial opioid agonist at the new receptor, it has a lower obese potential than what it has been dealt with a naloxone in it. The naloxone basically, you put the film in your mouth or you can put the tab under your tongue and you let it dissolve across your beautiful surface. And the naloxone doesn't get absorbed. If you tried to crush this up, melt it and inject it, you would have to distill of the naloxone in order to get high on the buprenorphine. So what happens is if you inject the naloxone, it has the higher affinity for the the opioid receptor. So you can't really melt, you can't really inject suboxone. Buprenorphine can be injected and has been and when it was first started out in Sweden many years ago, it's known as Subutex, not suboxone. There were clearly lots of younger folks that were abusing buprenorphine because even though it's a partial agonist, if you injected you get the pharmacokinetic aspect of getting a bolus of it underneath at a lower dose that gets you high. But the average dose is around 16 milligrams, nothing about 32 milligrams usually and then the elderly, a little bit lower 12 milligrams might be adequate those but you can go up to 16. Half life is not altered with impaired renal function and hepatic function, it has a slow dissociation, right, so it last a long time. And you don't get a lot of withdraw once you stop. And it is as effective as methadone for people with moderate use disorders and possibly even those with severe use disorders. So, one of the big things that we've tried to do is we've been trying to give people who we think the more contact. Buprenorphine even though, having them come several times a week, although buprenorphine or suboxone is really done for office based treatment. So, you can start somebody for a week, move up to two weeks up to every month if you're doing fine. So it's less work, but for those people have a more difficult problem, we shorten the time to see them and that seems to help them. Naltrexone for opioid use disorder in older adults. Who might benefit from naltrexone? Usually highly motivated individuals. Individuals with opioid use disorder in full remission who are employed and socially functioning do well with naltrexone. It may be difficult to get people on naltrexone at first, but once they are not using, then they can be started more easily on naltrexone. And naltrexone can be as effective as suboxone. But people who are recently detoxed from methadone or buprenorphine maintenance are usually good candidates for this medication. And those who are leaving prison, although even these days as I've learned, many prisons are starting to people on suboxone while in prison if they have opioid use disorder. But clearly, naltrexone is a preferred method at this point in most places. Those who are leading residential treatment settings, those who sporadically use opioids but are not on methadone or buprenorphine. Those not eligible for methadone and buprenorphine maintenance for whatever reason, and those in a long waiting period for methadone or buprenorphine maintenance can be started on naltrexone as well. And adolescents not wishing to go to methadone or buprenorphine maintenance. Summary, treatments are available. Just remember when you're dealing with older folks, start well, go slow, but keep going, just remember that part. If you don't get a response, you can keep pinching Age specific treatment appears to be more efficacious in general and should be combined with pharmacological treatment when possible, for the elderly or for older folks, cohorted older folks. And age specific treatments including building relations and support, use of less confrontation, and an older adult only environment. So these things seem to help older folks more. I have a case vignette again, I'm going to repeat it. A 75-year-old Caucasian female, who has been married to the same man for 50 years, has recently been complaining of feeling more anxious and has asked her husband to help with this. She has a history of anxiety NOS, not otherwise specified, and is prescribed clonazepam by her primary care physician. Her husband is a retired professor at an Ivy League University and has a complex medical history, including chronic pain from peripheral neuropathy treated with extended-release oxycodone 40 milligrams by mouth every 12 hours. She presents to the emergency department after she became confused, was unable to eat her dinner, and fell into a light sleep at the dinner table while out to dinner with her husband. Upon arrival to the emergency room, she required intubation and was given naloxone IV. Her urine toxicology screen was positive for opioids and benzodiazepines. Her breathalyzer was 0.04 grams per deciliter. She is stabilized and admitted and detoxified. She was weaned off her opioid pain medications with little problem. She is maintained on her clonazepam and transferred to the psychiatry inpatient unit. Case Vignette summary. Older adults can and often do misuse prescription medications. Mixing alcohol, opioids, and benzodiazepines is never a good idea. And use of these medications should be scrutinized and monitored closely in the older adult. They should be scrutinized in any adult actually, but particularly in the older adult. Even smaller amounts of alcohol at levels that are subthreshold for legal intoxication can be deadly in an elderly or medically compromised patient when combined with benzodiazepines and/or opioids. Here are a list of the references, which you can access once you have the slides. And now I just want to say a word about the PCSS Mentor Program. The PCSS Mentor Program is designed to offer general information to clinicians about evidence-based clinical practices in prescribing medications for opioid addiction. PCSS mentors are a national network of providers with expertise in addictions, pain, evidence-based treatment including medication-assisted treatment. Three-tiered approach allows every mentor/mentee relationship to be unique and cater to the specific needs of the mentee. And this comes at no cost. So for more information, please visit pcssNOW.org|mentoring. Second, PCSS offers a discussion forum, which is comprised of our PCSS mentors and other experts in the field, who helped provide prompt responses to clinical case's questions. We also have a mentor on call each month that is available to address any submitted questions to the discussion forum. You can create a new login account by clicking the image on the slide to access the registration page. This slide simply notes the consortium of lead partner organizations that are part of the PCSS project, as well as our contact info, website, and Twitter and Facebook handle to find out more about what we offer. So this is Dr. Travis, and this concludes the presentation on substance-use disorders in the older adult. I wanted to thank you very much for your attention, and welcome any feedback that you have or questions that you may have about the presentation. I'm also available at the phone number that was listed on the title slide and the emails that are listed on the title slide, at both yale.edu and va.gov. I am also an SUD consultant. If you happen to be a VA doc and want consultation, you can call me that way as well. Please feel free to reach out, I'm happy to talk about individual cases or concerns at any time. Thank you very much.
