A QUESTION OF VALUES SUBSTANCE MISUSE THE ELDERLY

Professor Ilana Crome

Keele University

21 March 2013

Thanks to colleagues and friends

Prof Peter Crome Dr Tony Rao Dr Martin Frisher Dr Roger Bloor Dr Alex Baldacchino Drs Ishbel Moy & Harvinder Sidhu, our

future! And many other collaborators…

Professor Ilana CromeDr Karim DarDr Stefan JanikiewiczDr Tony RaoDr Andrew Tarbuck

OVERVIEW Why is it important What current research tells us How do we deal with it now The future

Peter’s contributions

Peter’s Principles Style - Non judgemental, non

confrontational Demystify and destigmatise What’s special and distinctive? Proactive and positive Evidence and uncertainties Chronic disease - resilience but

vulnerability Dignity, integrity, (e)quality and

compassion

Substance misuse is:

HARMS COSTWHY IS IT IMPORTANT?

WHY IS IT IMPORTANT? Scale of the problem Burden of disease Lifespan issue Mortality Financial costs Societal impact

Older people will constitute ~25% of the UK population by 2020; currently 18% over 65s

Overall increase in older people using alcohol and illicit substances over past decade

National surveys of alcohol, illicit drugs, prescription drugs, presentations to Accident and emergency units, presentations to specialist services, hospital admissions (poisoning, drug related mental disorders, alcohol related physical disorders)

Prediction: set to double in the next 2 decades

CONTEXT

13% men,12% women over 60 still smoke Smoking largest cause of premature death 45% NHS prescriptions for over 65s, twice Alcohol consumption above adult ‘safe

limits’: 20% in men, 10% in women over 65 Highest alcohol death rate in aged 55-74 5% over 45s used any illicit drug over the

previous year, 0.7% used a Class A drug Increasing over 40s coming into treatment

– 17% in drug treatment units are over 40

How much do older people use?

0 5000 10000 15000 20000

Illicit drugs

Physical inactivity

Fruit and vegetable intake

High Body Mass Index

Cholesterol

Alcohol

Tobacco

Blood pressure

EUROPEAN DISEASE BURDEN ATTRIBUTABLE TO SELECTED LEADING RISK FACTORS (2000)

Number of Disability-Adjusted Life Years (000s)

Most difficult to give up(among those who consume in previous year)

NIGHT LIFE AND RECREATIVE DRUG USE IN EUROPEA study in 10 European Cities 1998

0

10

20

30

40

50

tobacco alcohol cannabis heroin ecstasy LSD

Lifespan perspectiveEarly life difficulties – maltreatment,

distress – associated with substance use disorder and psychiatric comorbidity

90% people who use substances problematically have started before the age of 19

Addiction can be a life long problem

Cannabis case grandmother is spared prison

Peter’s contribution NO LONGER ONLY A YOUNG MAN’S DISEASE ILLICIT DRUGS

May 2011

POISONING - ANTIDEPRESSANTS

May 2011

POISONING - PARACETAMOL

May 2011

PERSPICACITY

May 2011

Per capita alcohol consumption in the UK, 1984-2008

7

7.5

8

8.5

9

9.5

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

Year

Alc

ohol

Con

sum

ptio

n in

the

UK

in li

tres

per h

ead

SOURCE: British Beer and Pub Association 2008

Alcohol-related mortality per 100,000 in the UK from 1984 – 2008 trebled

4

5

6

7

8

9

10

11

12

13

14

15

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

Year

Mor

talit

y pe

r 100

,000

SOURCE: UK Office of National statistics, the Scottish Government and the Northern Ireland Department of Health.

Harms and costs ALCOHOL - all time high 3rd leading cause of death £21 billion per annum 1 million children £2.7 billion - health ~£7 billion crime-related £6.4 bn - workplace Family, friends and wider communities - not

quantified – child protection, divorce, homeless

DRUGS Increased for a decade £15 billion per annum 300,000 children 3% - £ 0.5 bn – NHS 6% - £1bn - deaths 90% is due to crime

COSTS – GREATER FOR OLDER More than 10 times -The cost of alcohol-related inpatient

admissions in England for 55 to 74 year olds was £825.6m compared to £63.8m for 16 to 24 year olds in 2010/11.

8 times as many 55 to 74 year olds (454,317) were admitted as inpatients compared to 16 to 24 year olds (54,682).

The cost of alcohol-related inpatient admission was £1,993.57m, over 3 times greater than the cost of A&E admissions, £636.30m.

The cost of alcohol-related inpatient admissions for men was £1,278.4m, just under double the cost for women, £715.1m.

PRICING AND POLICY

DISTINCTIVE RISKS AND

COMPLICATIONS

HARMS

Substance use decreases with age, but can be more dangerous

Older people are at increased risk of the adverse physical effects as substances accumulate due to decreased metabolism

Brain sensitivity to drugs may be increased Women metabolise faster; more severe

effects earlier, present later; more comorbidity

May not have dependence eg withdrawal

Distinctive issues

Distinctive issues INTERACTIONS AND MISTAKES Physical and mental health problems – eg

sleep, anxiety, pain - hypnotics, anxiolytics and analgesics with abuse potential

Complexity, long term chronic disorders Self management in partnership –

embedded in preventative, communities and team based, continuity, responsive, flexible coordinated and integrated

Self harm a serious risk Psychiatric problems associated with

substance use eg intoxication, withdrawal, dependence, anxiety, depression, psychosis, cognitive dysfunction

Psychosocial factors eg bereavement (spouse, friends, family), retirement, boredom, loneliness, homelessness, loss of income,

Precipitants and complications

Alcohol with symptoms PETER HAS SEEN ALCOHOL

PROBLEMS IN MEMORY CLINIC Memory problems 22.5% Sleeping problems 38.5% Feeling sad or blue 16.8% Tripping, falling 17.8% Gastrointestinal 24.1%

Physicians should notice alcohol use complications Hypertension 30% Depression 12% Gout 7.6% Diabetes 5.2% Ulcer disease 4.1% Liver condition 3.5% Pancreatitis 0.6%

Alcohol with medications Antihypertensives 31.7% Ulcer medications 18.2% NSAID 17.9% Antiplatelet 17.3% Non-prescription 12.7% Antidepressants 11.9% Sedatives 10.1% Opioids 6.7% Nitrates 4.3% Warfarin 4.4% Seizure 0.6%

HOW DO WE DEAL WITH IT NOW?

BARRIERS TO DETECTION – AND HOW TO RESPOND

Training – competence, screening tools Stigma, moral weakness – non-judgmental, non-

confrontational Under-reporting – comprehensive history Mis-attribution of symptoms, under-diagnosis –

awareness of subtle presentations, high index of suspicion

Ageism – ‘that is all she has left’ Stereotyping – older, higher social class, more

educated, women

DETECTION - AWARENESS

Altered/erratic behaviour or symptoms Poor response to treatment for

medical illness, request for prescription drugs, sharing, storing

Past personal history/family history of substance misuse & legacy of personal, legal, occupational deficits

Illegal activities

THE 5 A’s ASK – all drugs, dependence, ambivalence,

non-judgemental ASSESS – motivation, goals, complications ADVISE – ‘brief intervention’ – feedback,

information, self help material ASSIST – coping strategies, hope, self

esteem ARRANGE – admission – severe addiction,

polysubstance, social, comorbidity, relapse

DAPA-PC Drug and Alcohol Problem Assessment for Primary Care (Blazer) Computerized screening system quickly

identifies substance problems in primary care

Can be used by psychiatrists as well DAPA-PC is self administered, internet

based, automatic scoring Generates patient profile for medical

reference Presents unique motivational messages and

advice for the patient

Information technology Save clinicians’ time Patients to be screened in the waiting room Clinician to follow-up with a patient only when

prompted by the results of screen Computerized screening may lend itself to a

more honest revelation regarding drug use compared with face-to-face discussions.

Acceptability of computers by the elderly will only increase.’

Peter has been interested in this for a long time

TREATMENT AND POLICY

CURRENT RESEARCH WHAT DOES IT TELL US?

Alcohol dependence was last among 30 medical conditions in proportion of care received as evidence would recommend

Senile cataract 78.7%Breast cancer 75.7%Prenatal care 73.0%Hypertension 64.7%Asthma 53.5%Diabetes Mellitus 45.4%Urinary Tract Infection 40.7%Atrial Fibrillation 24.7%Alcohol Dependence 10.5%

Source: McGlynn E., et al., (2003). The quality of health care delivered to adults in In the United States. New England Journal of Medicine, 348.

Trials and guidelines Usually dictated by clinical trials

Complex patients excluded ie unrepresentative samples eg older, substance users, comorbidity

Combined treatments rarely studied

Guidelines are not for older people

May 2011

PHARMACOLOGICAL TREATMENTS

May 2011

Peter’s first randomised clinical trial!

May 2011

Pharmacological treatmentMedication Licensed Age limits Specific old

ageDiazepam Alcohol

withdrawalNot in children

<half adult doseIn anxiety

Chlordiazepoxide

Alcoholwithdrawal

Not in children

< half adult dose for anxiety

Disulfiram Alcohol deterrent

Not in children

None

Methadone Opiate addiction

Not in children

Caution

Subutex Opiate addiction

>16 years None

Lofexidine Opiate detox’n

Not in children

Caution

NRT Nicotine withdrawal

> 18 years None

Bupropion Smoking cessation

> 18 years Caution

Pharmacological treatments

Need to diagnose dependence Management of withdrawal symptoms Maintenance of abstinence eg methadone,

buprenorphine;nicotine replacement, bupropion

Prevention of complications Relapse prevention Psychiatric conditions eg depression Physical conditions eg diabetes

SYSTEMATIC REVIEW OF TREATMENT FOR OLDER PEOPLE WITH SUBSTANCE PROBLEMS

Ishbel Moy Martin Frisher

Peter CromeIlana Crome

Overview of Study Findings - Myths dispelled

Value in treating older adultsPhysicians can helpBrief Advice and Motivational Enhancement are

equally successful for both older and adult population

Respond positively Have the capacity to changeNumber achieving follow-up goal is at least as good

as compared with younger adultsEffective treatment in elder-specific or adult

programme – could do even better

Overview of Study Findings Good outcomes in substance use, mental and

physical health, and social functionBoth older men and women are capable of achieving

abstinence if given access to alcohol abuse programs

Should be encouraged to seek treatment for substance dependence

Recovery prospects encouraging, long-term management further research

Older age should not be a barrier to addressing drinking problems - something Peter has done

Addiction Research Unit Comprehensive

assessment Single detailed

counselling session Follow up to check on

progress Basic treatment

scheme of 3 hours of assessment and advice is effective in reducing alcohol problems in moderately dependent drinkers

Motivational interviewing/enhancement Non-confrontational

principles and style Increase effectiveness of

more extensive psychosocial treatments

Could be effective as preparation for more intensive treatments

Potentially more cost effective

COST EFFECTIVENESS Economic benefits –

saving of £5 for every £1 invested

Social benefits also Alcohol interventions

are highly cost effective in comparison with other health care interventions

No such thing as a safe limit Adult safe limits may not apply For some healthy older people, 1 US (14 gm alcohol)

drink a day, and no more than 7 a week (UK unit = 8 gm IE 1.5 units daily)

More than 3 US drinks a day is harmful Should not drink and drive, swim, use machinery.

Should eat before drinking Drink more slowly ie over two hours For those with comorbid conditions, on medications, no

alcohol may be appropriate Under review by the Chief Medical Officer

‘Safe’ limits

Key Issues for Doctors Prevention of disease of later life Prevention of functional decline Early identification of disease with rapid

response Supporting participation Application of evidence-based approaches Ageing, multiple pathology, vulnerability and

resilience

Key Issues for Older People Finance Housing Food Warmth Family Work Health Participation and functional status Cognitive decline

THE FUTURE

TRAINING – ROLE MODEL, KNOWLEDGE, SKILLS, ATTITUDES

May 2011

Not an optional extra – improve attitudes, reduce stigma, reverse therapeutic nihilism

Royal Medical Colleges - Undergraduate, specialist post graduate, continuing professional development - competencies

Multidisciplinary specialists - Old age psychiatrists, geriatricians, addiction specialists, nursing, psychology, social care and other allied professionals

Training

The future – not only baby boomers!

A UK based research programme on older substance misusers

Prescription drug use Any particular intervention, specific

programme, service model can be recommended - over long term

Policy implementation RCPsychiatrists Information Guide – Peter is

contributing

A question of values? Dignity, integrity, compassion and (e)quality

Health eg mental illness, cognitive impairment

Life circumstance eg poverty, in prison, family conflict, social isolation

Behaviour eg substance misuse, crime Status eg older, victim of abuse, refugee,

immigrant Personal quality eg low self esteem,

impaired functional life skills

19 March 2013 Guardian