Substance Use Disorders: Assessment and Treatment, 2nd Edition _ ___________________________________
Tom : Not very likely. I guess I could have just said no when they asked me to go with them. I might still be bored, but I wouldn’t be in trouble. OLDER ADULTS Compared with the general population, substance use prob- lems are less common among older adults. While illicit drug use typically declines after young adulthood, nearly 1 million adults aged 65 and older live with an SUD as reported in 2018 data. While the total number of SUD admissions to treatment facilities between 2000 and 2012 differed slightly, the propor- tion of admissions of older adults increased from 3.4% to 7.0% during this time (NIH, 2020). However, the number of older adults who abuse illicit drugs and alcohol is increasing. For example, among persons aged 60 to 64, the rate of current illicit drug use increased from 1.1% in 2003–2004 to 3.9% in 2013 (SAMHSA, 2014b). This increase may be driven by aging baby boomers who tend to have a history of higher rates of use of alcohol and of nonmedical use of prescription and over-the- counter medications. Use of illicit drugs, such as marijuana, cocaine, and heroin, is also on the rise among older adults. Substance abuse is especially dangerous for older adults. Age-related physiological changes make older adults more susceptible to the effects of alcohol consumption and drug ingestion. Alcohol is more toxic in older adults because changes in metabolism, distribution, and elimination in the aging body lead to central nervous system effects at lower levels of intake. According to the National Institute on Aging (2020), alcohol abuse among older adults can worsen many medical condi- tions—such as diabetes, hypertension, and ulcers—and is associated with an increased risk of some kinds of cancers, immune system disorders, brain damage, and liver disease. Older adults face particularly serious consequences from the misuse of prescription drugs as well. The problems associated with prescription drug abuse in older adults result not only from age-related changes in metabolism, but also from the combined interactions among the prescription drugs and their interactions with alcohol (University of Buffalo, 2015). Many older adults ingest medications that interact adversely with alcohol. Further complicating the detection of substance abuse in older adults is the problem that signs, and symptoms of substance abuse may mimic those of other conditions such as dementia and depression. In addition, older adults who use substances may not be forthcoming with healthcare professionals during routine office visits and other encounters with the healthcare system (University of Buffalo, 2015). Indeed, many older peo- ple may view their usage—particularly of alcohol—as a private matter. Families of individuals with alcohol use disorder may deliberately or inadvertently deny or enable drinking behav- ior. Professionals may also hold personal views that minimize the significance of substance use among older adults. Family members and healthcare professionals alike may believe that older people should be able to live their lives as they choose. Despite the availability of effective interventions for substance
use in the older population, many professionals may secretly harbor the belief that treating alcohol or drug use in older people is ineffective. To recognize the abuse of alcohol, it is important to initially identify older adults who may be drinking risky amounts. However, substantial misunderstanding exists about what constitutes “normal” alcohol use. The National Institute on Aging (2020) defines appropriate alcohol intake for people aged 65 and older as no more than seven drinks per week or no more than three drinks on any single day. Yet even these guidelines should take into account the older person’s weight, the potential interactions with any medications used, and the specific drinking history or drinking context. Screening has been shown to be efficacious, and universal screening for the use of alcohol, psychoactive prescriptions, and illicit drugs is recommended as part of routine mental and physical health visits in a range of settings where older adults encounter healthcare professionals (SAMHSA, 2020a). Screening should include direct questions about the frequency and quantity of alcohol use, alcohol-drug interactions, and prescription drug use. Specifically, professionals should ask questions about antidepressants, antianxiety medications, sleeping pills, narcotics, and over-the-counter medications. Some providers employ the “brown bag approach,” in which the older adult brings all the medications he or she currently uses to the provider’s office in a brown paper bag. Once the topic is initiated, indirect questions about the consequences of substance abuse behavior for the older person’s health and life can be raised. Savvy professionals often embed questions about alcohol or drug use in the context of activities of daily living and health habits such as diet and exercise. People with cognitive impairment may be unable to respond to the questions. In such cases, input from family and friends close to the older adult may be necessary to obtain relevant information. The older adult’s permission to question others should be obtained and interviews should be conducted in private, if possible. It is important to use a nonconfrontational approach with others because family members may not know about a problem or may be unwilling to respond honestly to questions about drinking or drug use. In some cases, family members may react based on long-standing personal and family issues resulting from the substance abuse. To assess substance addiction, questions should be asked about alcohol- or drug-related problems, a history of previ- ous attempts to curtail usage, and any withdrawal symptoms associated with the substance. If the person is considered dependent on alcohol, a referral should be made to a special- ized alcohol treatment program for older adults. Older adults who are defensive about any medication taken or confused about their prescription drugs, or who use multiple providers and pharmacies to obtain medications, should likewise be referred appropriately.
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