1-855-337-6227 www.marylandMACS.org Substance Use Disorders in - PowerPoint PPT Presentation

1-855-337-6227 www.marylandMACS.org

Substance Use Disorders in Older Adults Mi Mich chae ael l Fi Fing ngerho erhood, od, MD MD, , FACP CP, , DF DFAS ASAM, AM, AAH AAHIV IVS

Disclosures • Non None

Objectives • Incr crea ease se ab abil ilit ity t y to o ef effect ectiv ivel ely y dia iagnose ose su substance stance use se dis isor order er in in the he old older er ad adult lt • Be ab e able le to o re recomm commend end ef effecti ective e tre reat atmen ment op options ions for or the he ol older er ad adult lt wi with s h substance bstance use se dis isor order der

A “hidden problem” • La Lack ck of of sc scre reeni ening ng in in pr prim imar ary y ca care re • La Lack ck of of ag age-ap appr propr opria iate e sc scre reeni ening ng tool ools • La Lack ck of of guid idel elin ines es for or as asse sess ssin ing ol older er ad adult lts • Si Signs an s and sy symptom oms s of of ha harmful rmful use se overla erlap p wi with o h othe her r con condit itions ions • Age geis ist bi bias as

Detecting problematic substance use Lehmann & Fingerhood. NEJM 2018;379:2351-60

Challenges in detecting problematic use • Relying on older patient’s report of frequency and quantity of substance su stance use se ca can n le lead ad t to o undere deresti stimat ation ion of of the he pr proble oblem • Old lder er ad adult lts s an and fam amil ily y mem ember ers s may no y not ap appre recia ciate e del eleter erio ious us conse con sequen uences es of of lo long-ti time e pat atterns erns of of dri rinking king or or dru rug use se • Ha Harm rm ca can n co come me fr from om lo lower er am amounts ounts of of su substances stances

Psychosocial Contributors in Older Adults • St Stig igma a – “addict or alcoholic” • Ber erea eavem ement ent an and gri rief ef is issu sues es • So Soci cial al is isol olat ation ion an and lo lonel elin ines ess • Red educe ced se self lf-reg regar ard or or se self lf es estee eem • Fam amil ily y con conflict flict an and es estra rang ngem ement ent • Proble oblems s in in man anag agin ing tim ime/ e/bor boredom edom • Phys ysic ical al pai ain

Patient vignette 1 • KL is a 6 L is a 67F 7F reti retire red nurse se wh who ha o had ri right ht total al kn knee ee re repla lace cemen ment co compli licat cated ed by y jo join int in infec ection tion re requiri iring ng prolonge olonged cou course se of of an antibi ibioti tics, cs, ha hardware are re removal al wi with s h spac acer er an and fin inal ally ly re repla lacem cement ent of of ha hardware. are. Sh She has e has bee een on on oxy xyco codone done 15 5 mg four our tim imes es dai aily ly for or 4 m 4 mon onths. ths. • She se Sh e sees es or orthoped thopedics ics in in f/ f/u u an and is is t tol old sh she sh e shou ould ld not t be on e on an any y fu furth ther er op opio ioid ids s as as sh she is e is no now w 2 2 wee eeks ks ou out t si since ce the he la last st su surg rger ery. . Sh She is e is t tol old to o tak ake ib e ibupr prof ofen en • Is th s this is ap appropriat opriate e med edic ical al ca care? re?

Opioid “detoxification”? • Ass Asses ess s for or pas ast wi withd hdra rawal al • Are Are op opioi ioids s be bein ing g st stopp opped ed or or tap apere ered? • Is med s medic icat ation ion tre reat atmen ment for or op opioi ioid use se dis isor order der bei eing pla lanned ned?

Patient vignette 2 • EB is is a 72 a 72 F F se seen en f for or in init itia ial vi l visi sit. Sh She h e has as a h a his istor ory y of of ch chronic onic pai ain in in hi hips an s and kn knee ees. s. He Her r pre reviou ious s provi vider er wi will ll no o lo longer er pre rescribe scribe oxy xycodone codone as as for or the he pa past st 2 2 mon onth ths s he her 30 r 30 day scr y scrip ipt t ra ran n ou out after 2 weeks. Tearful and fearful that providers won’t help her. Can anno not tak ake NS e NSAID AIDs. s. Sh She ad e admit its s tha hat sh she o e often en tak akes es oxy xyco codone done wh when en sh she is e is u upset. set. • Sh She li e lives es alo alone e in in se senior ior ho housi using ng ap apar artmen tment; t; 2 d 2 dau aught hter ers- both h wi with d h dif ifficu iculti lties es (med edical ical an and so soci cial). al). Non Non-smok smoker; er; no o al alcohol cohol. • Ho How shoul w should you ou ca care re for or he her? r?

Themes in older adults with substance use disorder • Li Livin ing g al alone one • Se Sense se of of is isol olat ation ion (des espit ite e fam amil ily) y) • Substance as a “friend” • Sh Sham ame • Fea ear r of of ho how t w to o li live wi e witho hout ut su substance stance

Opioids and aging • 2010 analysis of Medicare claims data- older adults who were prescribed opioids (in comparison to those prescribed NSAIDs), had significantly higher rates of cardiovascular events, fractures, hospitalizations and death; risk for gastrointestinal bleeding was not lower • Euphoria from opioids diminishes with age

American Geriatrics Society Beers Criteria • Avoi oid NS NSAI AIDs, Ds, muscle scle re rela laxa xants nts an and tra ramadol adol (ad added ed 20 2019) 9) • Avoi oid op opio ioid ids s if if hi hist stor ory y of of fal alls ls or or fracture fracture • Avoi oid tri ricy cycli clics cs- am amit itri ript ptyl ylin ine

Patient vignette 3 • BR is a 82F brought to the ER by neighbor with “syncope”, but it is no is noted ed tha hat sh she h e has as al alco cohol hol on on he her bre r breat ath h an and he her BAL r BAL is is 22 228 8 mg/dl. l. Whe When n co confr nfront onted ed sh she b e becom ecomes es tea earful. ful. He Her r so son goe oes t s to o he her hom r home e an and fin inds s hi hidden en min inia iatures ures thr hroug oughout hout he her apa r apartmen tment. t. • Ho How do w do you ou ap approach oach ca cari ring ng for or he her? r?

MAST-G In th In the e past t ye year: r: 1. . When hen talking alking with th others, hers, do you ou ev ever er underestimate underestimate ho how w much ch you ou actu tually ally drin rink? k? 2. . Aft fter er a fe few drin rinks, ks, ha have ve you ou so somet etimes imes not t ea eaten ten or r be been en able ble to sk skip p a meal because you didn’t feel hungry? 3. . Does Does ha having ving a fe few drinks rinks he help lp decrea ecrease se your our sh shakine akiness ss or r tremors? remors? 4. . Do Does es alcohol cohol so sometimes etimes make ake it ha hard rd fo for r you ou to re remember ember pa parts rts of t f the he day ay or r night? ght? 5. . Do Do you ou usually sually take ake a drink rink to re relax lax or r calm lm your our nerves erves?

MAST-G 6. Do 6. Do yo you dri rink k to o tak ake e yo your r min ind off off yo your ur probl roblem ems? s? 7. 7. Ha Have you e you ev ever er in incre crease ased yo your ur dri rinking king af after er ex exper erie ienci ncing ng a lo a loss ss in in yo your ur li life fe? 8. 8. Ha Has a do s a doctor ctor or or nurse rse ev ever er sa said id the hey we y were re wo worrie rried or or con concerned cerned ab about out yo your ur dri rinking king? 9. 9. Ha Have you e you ev ever er mad ade rul e rules es to o man anag age e yo your ur dri rinking? king? 10 10. Wh When en yo you fe feel el lon lonel ely, y, doe oes s ha havin ing a d a dri rink k he help lp?

MAST-G • Greater reater th than fi five ve "y "yes es" " answer ers s indic dicates tes an alc lcoh ohol ol pro roble blem m with th a sen sensitivi sitivity ty of of 91 91-93% 3% and a sp d a spec ecifici ficity ty of of 65 65-84% 4% wh when en co comp mpared ared to to DSM DSM cr criteria teria

Alcohol and Aging • Dy Dysp sphori horia a pre redomin ominat ates es • Incr crea eased sed ri risk sk of of ce cere rebel bella lar r toxici xicity • Nutrit tritional ional problem oblems s mor ore e co common mon • Alc Alcohol ohol wi withd hdra rawal al sy symptom oms s more ore li likel ely c y con onfus fusion/ag ion/agit itat ation ion ra rathe her r tha han tre remor or an and tac achycar cardia. ia.