The Psychedelic Age Continues: Drugs, Boomers and Older Adults

1. 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, FL

2. 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

3. 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.

4. 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)

6. Young Old Old Old Old

7. What does the research tell us? 7

8. Baby Boomers • Boomers won’t go quietly!! • Youthquake shake-up • Emotional Retirement Planning • Treatment differences • Increase of illicit drugs?

9. Drug Use Use of any of the following in past year: • Marijuana? • Cocaine? • Crack? • Heroin? • Hallucinogens (such as LSD, PCP)? • 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

12. The need to screen for illicit drug use.An increasing trend among older adults?

13. 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.

14. 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.

15. 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.

16. 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%.

17. 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. 

18. 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?”

19. 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

20. 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.

21. Signs and Symptoms of Substance Use Problems in Older Adults Anxiety Blackouts, dizziness Depression Disorientation Mood swings Falls, bruises, burns Family problems Financial problems Headaches Incontinence Nesting Increased tolerance Legal difficulties Memory loss New problems in decision making Poor hygiene Seizures, idiopathic Sleep problems Social isolation Unusual response to medications Decline in ADLs

22. Symptom Identification Applying quantity and frequency levels appropriate for younger adults to elders may cause failure to identify substance use problems Warning signs can be confused with or masked by concurrent illnesses and chronic conditions, or attributed to aging Sleep problems associated with chronic conditions, particularly cardiovascular disease and pain Falls attributed to poor lower body strength, poor balance, or vision limitations Anxiety attributed to psychosocial concerns Confusion/memory problems associated with Alzheimer’s disease or other dementias

23. 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

24. Diagnosis and Assessment • Late Onset Alcoholism • Started age 50+ • Losses • Toxic effects • Shame • Grief 24

25. Diagnostic Criteria for Substance Dependence in Older Adults The Treatment Improvement Protocol (TIP #26) Consensus Panel determined: DSM-IV criteria for substance abuse and dependence may not be adequate to diagnose older adults with substance use problems

26. DSM-IV Dependence Criteria • 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

27. Applying DSM-IV Criteria to Older Adults

28. Diagnosis and Assessment • Assessment tools • Geriatric Depression Scale • MAST-G • S-MAST-G • CAGE • Folstein MMSE • Millon MCMI II • Audit 28

29. Diagnosis and Assessment • Blood / Alcohol Content • 1.5 oz Liquor • 12 oz Beer • 5 oz Wine or • 12 oz Winecooler 29

30. Diagnosis and Assessment • Initial Screening • Physical condition • Emotional status • Personal care / cognitive functioning • Available support system • Motivation for accepting help 30

31. Diagnosis and Assessment • Information collected from • Older adult • Spouse • Sons and daughters • Physician • Clergy • Friends 31

32. Diagnosis and Assessment • Methods of collecting information • Older adult interview • Older adult self-reporting • Family and significant others • Interviews / Documentation • Medical records 32

33. Diagnosis and Assessment • Problems Assessing Older Adults • Beliefs • Attitudes • Perspectives • Differential diagnosis • Assessment tools • Prolonged effects • Age = specific criteria 33

34. Diagnosis Issues

35. Assessment Challenges Clinicians 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.

36. Problems with Definitions • Substance Misuse • At-risk or Hazardous Use • Problem Use • Substance Abuse • Substance Dependence

37. 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

38. 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

39. Suicide Risk Items * • Has anyone in your family ever committed suicide? • If yes, who in your family committed suicide? • Have you ever thought about taking your life? • How recently have you thought about killing yourself? • Do you have a plan for doing this? (response selected from list of plans provided) • Have you ever been in the care of psychiatrist, psychologist, or other professional because of severe depression or mental problems? • Do you keep firearms in the house? • 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.

41. Short - Geriatric Depression Scale Scoring: 5-9 = mild to moderate depression 10+ = serious levels of depression 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?

42. 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

43. Medication Misuse – “Brown Bag” Review • Interviewer's impressions of the person • after completing the "Brown Bag Review" of • prescriptions: • Does not correctly recall the purpose of one or more medications • Reports the wrong dose/amount of one or more medications • Takes one or more medications for the wrong reasons or symptoms • Needs education and/or assistance on proper medication use

44. 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

46. OTC Medication Use – Client Interview Items • Do you frequently take aspirin, Tylenol, Advil, or other non-prescription pills for pain? • Do you ever tell your physician about the type of non-prescription pills you buy? • Do you use herbal pills such as Ginkgo, Saw Palmetto, St. John's Wort? • Do you take non-prescription pills or remedies for improving your memory? • Have you ever felt worse soon after taking over-the counter remedies? • Are you taking medications to help you sleep? • Do any of the non-prescription pills you take make you feel groggy? • Do you use plants or herbs to make your own remedies such as garlic, or aloe?

47. Practitioner Barriers to Identification Ageist assumptions Failure to recognize symptoms Lack of knowledge about screening Physician discomfort with substance abuse topic - 46.6% of primary care physicians found it difficult to discuss prescription drug abuse with their patients (CASA, 2000)

48. Individual Barriers to Identification Attempts at self-diagnosis Description of symptoms attributed to aging process or disease Many do not self-refer or seek treatment - Although most older adults (87 percent) see physicians regularly, an estimated 40 percent of those who are at risk do not self-identify or seek services for substance abuse (Raschko, 1990)

49. 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)

50. 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