The Psychedelic Age Continues: Drugs, Boomers and Older
Adults
Juan Harris MBA, MS, CAP, CAPP, SAP, CET, CMHP, CGAC, ICADC
Program Director Center for Older Adult Recovery
CARON / HANLEY Inc., West Palm Beach, FL1
Aging is Changing
• 1400 average life span– 33 years of age
• 1900 average life span– less than 49
• 2000 statistical– 50 year old can expect to live
another 30 years
2
Myths About Aging
• Majority of persons are senile or demented
• Majority of older persons feel miserable most of the time.
• Most older people cannot work as effectively as younger persons.
• Most old persons are unhealthy and need assistance with daily activities.
• Majority of older persons are socially isolated and lonely.
Who’s Old?
• Aging is :– Discovery of the real
self… (Cicero)– Metamorphosis of the
soul with aging that allow for the emergence of precursors of wisdom and the discovery of new values and meanings not possible by younger generations…(Plato)
5
6
7
What does the research tell us?
Baby Boomers
• Boomers won’t go quietly!!• Youthquake shake-up• Emotional Retirement Planning• Treatment differences• Increase of illicit drugs?
8
Drug Use
Use of any of the following in past year:1. Marijuana?2. Cocaine?3. Crack?4. Heroin?5. Hallucinogens (such as LSD,
PCP)?6. Substances - sniffed or inhaled?
Recorded by interviewer - YES/NO format. Any YES responses results in a Flag for further assessment.
10
Baby Boomers “Come of Age”
• Current Problem: lack of knowledge of substance use in elders
• Substance use in elders will be a huge problem in < 20 years b/c boomers:– Accepting of alcohol and drug use
• Used more in youth• Use more NOW
– Use more psychoactive Rx drugs now– 3-4x more emotional disorders
11
Substance Use - Type by Gender – 50 and
Older
57.7
42.3
71.1
28.9
41.9
58.1
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
Any Illicit Use Marijuana Prescription
Male Female
The need to screen for illicit drug
use.
An increasing
trend among older
adults?
Statistics• In 1992, the number of older Americans admitted to
treatment facilities was near 6.6% of all admissions nationwide;
• By 2008, the number of admissions from this age group reached 12.2%.
• Statistically, alcohol addiction has remained the primary substance abuse disorder for people age 50 and older, and this still holds true today.
• However, seniors are now abusing more illicit substances—such as cocaine, heroin, and marijuana—and legal prescription drugs than before.
Statistics• In 1992, admissions for prescription drug abuse involving older
adults were at 0.7%, yet this figure jumped to 3.5% by 2008.
• Marijuana abuse admissions rose from 0.6% in 1992 to 2.9% in 2008.
• Heroin abuse admissions more than doubled—from 7.2% of admissions in 1992 to 16.0% in 2008.
• Most significantly, cocaine abuse admissions almost quadrupled, from 2.9% in 1992 to 11.4% in 2008.
• While these substances of abuse increased among older adults, alcohol abuse saw a decline in admissions among this age group.
Statistics
• Older adult admissions involving alcohol as the primary substance of abuse were once 84.6% of admissions in 1992, but fell to 59.9% by 2008.
• This shift in primary substances of abuse has caused alarm among the health community,
• Not only in regards to treatment for the current generation of older Americans, but also in terms of preparing for the onset of the aging Baby Boomers.
Statistics
• In 1992, 13.7% of older adult admissions to treatment facilities were experiencing multiple substance abuse disorders.
• In 2008, this figure tripled to 39.7% of older adult admissions.
• Researchers state that this incline is mostly due to the rise of cocaine addiction among this age group.
• In 1992, the percentage of older American admissions
involving cocaine as the primary substance of abuse in comorbid cases was at 5.3%, but by 2008 this more than tripled to 16.2%.
statistics• Cocaine abuse was also responsible for the rise in
addictions that occurred within the last five years.
• About 26.2% of addictions started in the last five years among older adults involved cocaine as the primary substance of abuse, with prescription drug abuse following close behind at 25.8% of recent addictions.
• Even though almost 75% of older adults admissions still pertain to an addiction that began before the age of 25, addictions that were initiated within the last five years among this age group grew—most involved illicit substances.
Diagnosis and Assessment
RAISING THE ISSUE• Describe what you see (e.g., “I’ve noticed you’ve
been having difficulty walking.” “As far as I can tell, you’ve eaten only biscuits this week. Is there a problem with your meals?”).
• Avoid saying that the person’s problems will go away if they stop drinking.
• Try saying, “You don’t seem to be your old self these days. How are you feeling? Would you be interested in having someone to talk to about it?”
Diagnosis and Assessment
HARM REDUCTION
• If you are worried about yourself or someone else there are things you can do to reduce the harm:– talk to a professional about your concerns– always eat before you drink, alternate alcoholic drinks
with soft drinks and don’t mix different types of alcohol– be aware of the facts about alcohol– never tell a long term drinker to just stop drinking -
alcohol is a physically addictive substance and sudden withdrawal can be fatal
Do you help them “cope”?• What may be appropriate at a younger
age may not work with older adults.• Coping may be your strategy. Surviving
may make sense to you. • Older adults may no longer see the
necessity of living at any cost. • Older adults may have a sense of
urgency about making things right. • The transgenerational dilemma: your
development issues may be in conflict with theirs.
Signs and Symptoms of Substance Signs and Symptoms of Substance Use Problems in Older AdultsUse Problems in Older Adults
• AnxietyAnxiety• Blackouts, dizzinessBlackouts, dizziness• DepressionDepression• DisorientationDisorientation• Mood swingsMood swings• Falls, bruises, burnsFalls, bruises, burns• Family problemsFamily problems• Financial problemsFinancial problems• HeadachesHeadaches• IncontinenceIncontinence• NestingNesting
• Increased tolerance Increased tolerance • Legal difficultiesLegal difficulties• Memory lossMemory loss• New problems in New problems in
decision makingdecision making• Poor hygienePoor hygiene• Seizures, idiopathicSeizures, idiopathic• Sleep problemsSleep problems• Social isolationSocial isolation• Unusual response to Unusual response to
medicationsmedications• Decline in ADLsDecline in ADLs
Symptom IdentificationSymptom Identification• Applying quantity and frequency levels appropriate for Applying quantity and frequency levels appropriate for
younger adults to elders may cause failure to identify younger adults to elders may cause failure to identify substance use problemssubstance use problems
• Warning signs can be confused with or masked by Warning signs can be confused with or masked by concurrent illnesses and chronic conditions, or concurrent illnesses and chronic conditions, or attributed to agingattributed to aging– Sleep problems associated with chronic conditions, Sleep problems associated with chronic conditions,
particularly cardiovascular disease and painparticularly cardiovascular disease and pain– Falls attributed to poor lower body strength, poor Falls attributed to poor lower body strength, poor
balance, or vision limitationsbalance, or vision limitations– Anxiety attributed to psychosocial concerns Anxiety attributed to psychosocial concerns – Confusion/memory problems associated with Confusion/memory problems associated with
Alzheimer’s disease or other dementiasAlzheimer’s disease or other dementias
Diagnosis and Assessment
• Early Onset Alcoholism– Long history chronic alcoholism– Started drinking age 14 – 20– Gradual increase tolerance– Multiple attempts to quit– Multiple treatment or detox experiences
23
Diagnosis and Assessment
• Late Onset Alcoholism
–Started age 50+–Losses–Toxic effects–Shame–Grief
24
Diagnostic Criteria Diagnostic Criteria for Substance for Substance Dependence Dependence
in Older Adultsin Older AdultsThe Treatment Improvement Protocol The Treatment Improvement Protocol
(TIP #26) Consensus Panel (TIP #26) Consensus Panel determined:determined:
DSM-IV criteria for substance abuseDSM-IV criteria for substance abuse
and dependence may not be and dependence may not be
adequate to diagnose older adults adequate to diagnose older adults
with substance use problemswith substance use problems
DSM-IV Dependence DSM-IV Dependence CriteriaCriteria
Tolerance Withdrawal Use in larger amounts or for longer than intended Desire to cut down or control use Great deal of time spent in obtaining substance
or getting over effects Social, occupational, or recreation activities
given up or reduced Use despite knowledge of physical or
psychological problem
Applying DSM-IV Criteria Applying DSM-IV Criteria to Older Adultsto Older Adults
ToleranceTolerance Even low intake may cause Even low intake may cause problems due to body problems due to body changeschanges
WithdrawalWithdrawal May not develop May not develop physiological dependencephysiological dependence
Use in larger amounts or for longer than intended
Cognitive impairment Cognitive impairment interferes with self-interferes with self-monitoringmonitoring
Desire to cut down or control use
Same across life spanSame across life span
Time in obtaining substance or getting over effects
Negative effects with Negative effects with relatively low userelatively low use
Activities given up or reduced
May have fewer activitiesMay have fewer activities
Use despite knowledge of problems
May not know problems are May not know problems are related to userelated to use
Diagnosis and Assessment
• Assessment tools– Geriatric Depression Scale– MAST-G– S-MAST-G– CAGE– Folstein MMSE– Millon MCMI II– Audit
28
Diagnosis and Assessment
• Blood / Alcohol Content– 1.5 oz Liquor– 12 oz Beer– 5 oz Wine or– 12 oz Winecooler
29
Diagnosis and Assessment
• Initial Screening–Physical condition–Emotional status–Personal care / cognitive
functioning–Available support system–Motivation for accepting help
30
Diagnosis and Assessment
• Information collected from– Older adult– Spouse– Sons and daughters– Physician– Clergy– Friends
31
Diagnosis and Assessment
• Methods of collecting information– Older adult interview– Older adult self-reporting– Family and significant others– Interviews / Documentation – Medical records
32
Diagnosis and Assessment
• Problems Assessing Older Adults– Beliefs– Attitudes– Perspectives– Differential diagnosis– Assessment tools– Prolonged effects– Age = specific criteria
33
Diagnosis Issues
Assessment ChallengesClinicians and physicians not trained in gerontology
and substance abuse,
Combined with the care giver’s lack of training and knowledge of healthy behaviors of older adults
Creates a defense known as “double denial” (Kagan & Shafer, 2001).
These combined factors may hinder recognizing older adults at risk, or may
Create a perception of substance use as normal for coping with trauma issues and psychosocial stressors common in this stage of life (Colleran, 2002.
Problems with Definitions
• Substance Misuse• At-risk or Hazardous Use• Problem Use • Substance Abuse • Substance Dependence
Special Assessments
• Functional Abilities– Activities of Daily Living (ADLs)– Instrumental Activities of Daily Living
(IADLs)– SF-36
• Comorbidities– Physical– Psychiatric
• Affective disorders• Suicide risk
• Sleep Disorders
Special Assessments
• Cognitive Impairments– Dementia
• Orientation/Memory/Concentration Test • Folstein Mini-Mental Status Exam (MMSE)
– Delirium• Confusion Assessment Method (CAM)
– Other cognitive impairments• Trauma from falls, MVA, accidents• Wernicke-Korsakoff syndrome
Suicide Risk Items *1. Has anyone in your family ever committed
suicide? 2. If yes, who in your family committed suicide?3. Have you ever thought about taking your
life?4. How recently have you thought about killing
yourself?5. Do you have a plan for doing this? (response
selected from list of plans provided)6. Have you ever been in the care of
psychiatrist, psychologist, or other professional because of severe depression or mental problems?
7. Do you keep firearms in the house?8. If yes, ask how many guns are in the house?* Adapted from Brown & Bongar (2004) Assessing risk for completed suicide in elderly
patients: Psychologists' views of critical risk factors. Professional Psychology: Research and Practice.
40
Short - Geriatric Depression Scale
1. Are you basically satisfied with your life? 2. Have you dropped many of your activities
and interests? 3. Do you feel that your life is empty? 4. Do you often get bored? 5. Are you in good spirits most of the time? 6. Are you afraid that something bad is going to happen to you? 7. Do you feel happy most of the time? 8. Do you often feel helpless? 9. Do you prefer to stay at home, rather than going out and doing new things?10. Do you feel you have more problems with memory than most?11. Do you think it is wonderful to be alive now?12. Do you feel pretty worthless the way you are now?13. Do you feel full of energy?14. Do you feel that your situation is hopeless?15. Do you think that most people are better off than you are?
Scoring:
5-9 = mild to moderate depression
10+ = serious levels of depression
Screening and Assessment Recommendations for
Older Adults Every person over 60 should be
screened for alcohol and drug abuse as part of regular physical examination “Brown Bag Approach”
Screen or re-screen if certain physical symptoms are present or if the older person is undergoing major life transitions
Interviewer's impressions of the personafter completing the "Brown Bag Review" ofprescriptions:
1. Does not correctly recall the purpose of one or more medications
2. Reports the wrong dose/amount of one or more medications
3. Takes one or more medications for the wrong reasons or symptoms
4. Needs education and/or assistance on proper medication use
Medication Misuse – “Brown Bag” Review
Medication Use: Client Interview Items
• Takes more than one type of prescribed medication• Difficulty remembering how many meds to take• Prescriptions from two or more doctors• Felt worse soon after taking meds• Taking meds to help sleep• Uses up meds too fast• Takes meds for nervousness or anxiety• Doctor/nurse expressed concern about use of meds• Take pain relieving meds• Take pills to deal with loneliness, sadness• Saving old medications for future use• Chooses between cost of meds and other necessities• A family member reminds them to take pills• Uses dispenser or other method to help remind• Fails to take meds supposed to• Borrow someone else's meds• Feel groggy after taking certain medications
OTC Medication Use – Client Interview Items
1. Do you frequently take aspirin, Tylenol, Advil, or other non-prescription pills for pain?
2. Do you ever tell your physician about the type of non-prescription pills you buy?
3. Do you use herbal pills such as Ginkgo, Saw Palmetto, St. John's Wort?
4. Do you take non-prescription pills or remedies for improving your memory?
5. Have you ever felt worse soon after taking over-the counter remedies?
6. Are you taking medications to help you sleep?7. Do any of the non-prescription pills you take make
you feel groggy? 8. Do you use plants or herbs to make your own remedies such
as garlic, or aloe?
Practitioner Barriers Practitioner Barriers to Identificationto Identification
Ageist assumptionsAgeist assumptionsFailure to recognize symptomsFailure to recognize symptomsLack of knowledge about screeningLack of knowledge about screeningPhysician discomfort with Physician discomfort with
substance abuse topicsubstance abuse topic- 46.6% of primary care physicians - 46.6% of primary care physicians found it difficult to discuss prescription found it difficult to discuss prescription drug abuse with their patientsdrug abuse with their patients
(CASA, 2000)(CASA, 2000)
Individual Barriers Individual Barriers to Identificationto Identification
Attempts at self-diagnosis Attempts at self-diagnosis Description of symptoms attributed to Description of symptoms attributed to
aging process or diseaseaging process or diseaseMany do not self-refer or seek Many do not self-refer or seek
treatmenttreatment- Although most older adults (87 percent) see - Although most older adults (87 percent) see
physicians regularly, an estimated 40 percent of physicians regularly, an estimated 40 percent of those who are at risk do not self-identify or seek those who are at risk do not self-identify or seek services for substance abuse services for substance abuse (Raschko, 1990)(Raschko, 1990)
Screening and Assessment Recommendations for
Older Adults Ask direct questions about
concerns Preface question with link to medical
conditions of health concerns Do not use stigmatizing terms (i.e.
drug addict)
Future Directions
Risk and Protective Factors/Prevention/Early Identification
Drug of Choice• Illicit, Prescription, Alcohol
Patterns of use• Drug use trajectories• Re-emergence of addiction in late life• Late-life onset of substance use disorder
Screening, Assessment and Diagnosis Identification and treatment of
psychiatric comorbidities
The Alcoholic Brain
• Smaller, lighter and more shrunken.• More extensive shrinkage in cortex.• Vulnerability to shrinkage greater with age.
– Enlargement of the ventricle system.– Reduced weight and volume.
• Decreased blood flow and metabolism.• Women may be more vulnerable.
51
Normal Brain SPECT Images
53
ALCOHOL17 Years of Heavy weekend
use
54
Alcohol
55
45 year old with 25 years history of daily use; underside surface view; marked overall decreased activity
44 year old with 18 years of daily use; underside surface view; marked overall decreased activity
56
57
Cocaine
Methamphetamine
58
~ 24 year old ~2 years use
~ 28 year old ~8 years use
Marijuana
59
~ 18 year old ~
3 years use
4 times a week
60
Heroin
~ 40 year old ~7 years methadone
use10 years heroin use
Before and After Recovery
61
Active substance abuse One year alcohol and drug free
Before and After Recovery
62
Active substance abuse
One year alcohol and drug free
FACTORS INFLUENCING OUR BELIEFS
Cohort EffectHistorical Events
63
Generational Experiences
Today’s OA Baby Boomers Gen X
Depression Sexual Openness
Rap
WWI/WWII Vietnam/Gulf Gen War
Prohibition Illicit Drugs Raves
Advent TV Advent PC’s Advent Web
Antibiotics Transplants Cloning
Automobile Air Travel Space
64
Intervention
Are all interventions SUCCESSFUL?
65
INTERVENTION
Presenting reality as a united front
66
67
Dysfunctional Families Are
Blindfolded – don’t see
Gagged – don’t talk
Ear muffed – don’t hear
Handcuffed – don’t touch
Lassoed – don’t reach out
Shackled – don’t step out of line
Hobbled – don’t go for help
68
The Five Freedoms
• Seeing and hearing what is• Saying what you feel and think• Feeling what you feel• Asking for what you want• Taking risks on your own behalf
69
70
Sandwich Generation
Group of adult children and
others who are responsible for three or more generations of
people
Accidental Addicts
• Possible problems with patient medical condition– Requires drug therapy / not receiving drug– Wrong drug taken– Too little / much of correct drug taken– Result of adverse drug-reaction– Result of drug / drug, drug / food, drug /
lab. Int– Result of drug for not valid indication
71
Accidental Addicts
• Patient – Doctor Communication Questions– What drug have I been prescribed?– How does this drug work?– Why am I taking this drug?– What are the side-effects of this drug?– How long should I take this drug?
72
Factors Influencing our Beliefs
• If we are to help…– We must be sensitive to the values and
beliefs held by older adults– We must be sensitive to the values and
beliefs of family members– We must examine our values and beliefs
73
Factors Influencing our Beliefs
• When grandma got ‘tipsy’ we all thought it was ‘cute’
• Let him drink, he’s not hurting anybody.
• What difference does it make at his age
• It’s okay for Grandpa to get ‘drunk’ but not Grandma
74
Factors Influencing our Beliefs
• Myths– Older people can’t learn– Reconstructive surgery– Too old to be depressed– It is worth it– Last remaining friend
75
Factors Influencing our Beliefs
• Stereotypes– Man under bridge– Town drunk– Daily drinker– Younger person– Skid row bum
76
Older Adult Treatment
• Older adult facts– Age specific treatment most
effective– Highest rate of recovery– Tendency to follow direction
77
Older Adult Treatment
• Special Treatment Needs– Extended / Appropriate Detox– Slower transition– Speech, hearing, vision, nutrition– Medical, Psychological, Psychiatric – Grief, loss, rest periods, recreation– Treating Whole Person
78
Older Adult Treatment
• Special Issues for Older Adults– Denial– Alcoholics Anonymous– Women’s Issues– Men’s Issues
79
Older Adult Treatment
• Groups for Older Adults• Grief• Life Transition• Relapse• Women / Men Alumni
Support• Sober Seniors• Nutrition• Continuing Care
• Dual Diagnosis• Wellness• Storytime• Meditation• AA / Big Book• Nicotine• RET• Regular Group
Therapy
80
Continuing Care
• Components of Continuing Care– Health Care Concerns– Coping Mechanisms– Spirituality– Living Situation– Support System– Community Resources– Alumni or AA Contact
81
Prevention of Substance Abuse Among Older Adults:
Protective Factors• Female • Higher Religiosity • Fewer Mental/Physical Health
Problems • Lower SES• Positive Coping Styles• More Social Supports
Thank You
For more information, please contact…
Hanley Center933 45th Street
West Palm Beach, FL 33407(Office) 561-841-1136
Email: [email protected]: hanleycenter.org
Toll Free: 866-4HANLEY
