Addictive and Co-Occurring Disorders in Late Life

Addictive and Co-Occurring Disorders in Late Life

David W. Oslin, M.D.University of Pennsylvania, School of Medicine

And

Philadelphia, VAMC

Hazelden Research Co-Chair on Late Life Addictions

Translating Positive findings in Aging to Translating Positive findings in Aging to Younger AdultsYounger Adults

Age Group

Age >59

Age 40 - 59

Age <40

DisclosuresDisclosures NIMH

K08 Award ACSIR

NIDA Center for Studies on Addiction

NIAAA R01

VA Merit Early Entry MIRECC HSRD Merit Award

Industry Support DuPont Pharma Forest Labs Hazelden Foundation Pfizer

Relevance of comorbidity to an aging Relevance of comorbidity to an aging populationpopulation

Cohort changes in exposure – we will see more elderly patients using illicit substances (current and past abuse)

Consequences may be greater in older adults Direct toxicity / withdrawal Indirect interactions with medications or other illnesses

Comorbidity is a significant issue perhaps uniquely so for the elderly Cognition Minor depression Suicide Anxiety and personality problems

Changing environment Social isolation Limited resources Limited access to care

Comorbidity and Drug/Alcohol DependenceComorbidity and Drug/Alcohol Dependence

Higher than expect rates in representative community samples

Markedly higher rates in treatment seeking samples

Increased morbidity and mortality particularly suicide

Presents diagnostic difficulties

Poor prognostic factor

Call for integrated care system

SuicideSuicide

Highest rates of suicide occur in late life among men.

Depression causes a 5.8 fold increase in risk of suicide compared to death from other causes

Heavy drinking (3+ drinks/day) causes a 8.9 fold increase in risk of suicide compared to death from other causes

Moderate drinking (1-2 drinks/day) causes a 10.6 fold increase in risk of suicide compared to death from other causes

Grabble, et al. 1997

The difficultyThe difficulty

Extremely limited research

Drug and alcohol dependence are exclusions to most geriatric trials

Age >65 is almost always an exclusion for drug and alcohol trials

What is the Extent of the Issues?What is the Extent of the Issues?In the CommunityIn the Community

Current / Last 12 months

Alcohol Dependence 2 - 4 %

Medication misuse ? Overall

Chronic Benzodiazepine use 5 – 20%

Nicotine dependence 10 - 15 %

Illicit Substance dependence < 1 %

Pathological Gambling 1 – 2 %

Baby Boomers AgingBaby Boomers Aging

91 – 92 01 – 02 Percent Increase

18-29 6.5 7.0 8%

30-44 3.0 6.0 100%

45 – 64 1.4 3.5 150%

65+ 0.3 1.2 300%

Grant, et. al. Drug and Alcohol Dependence 2004

Veterans (Age 60 and Over) in Addiction Veterans (Age 60 and Over) in Addiction TreatmentTreatment

Alcohol Only 51.8%

Street Drugs Only 9.1%

Prescription Medications only 3.6%

Alcohol and Street Drugs 26.4%

Alcohol and Prescription Medications 5.5%

Street Drugs and Prescription Medications 0.9%

All three categories of substances 1.8%

Missing data 0.9%

Schonfeld et al. 1990Sample of 110 subjects in a special geri-addiction program

Past History of Heavy drinking/alcoholismPast History of Heavy drinking/alcoholism

Many older adults especially those of the “Woodstock” generation will enter late life with a past history of alcohol or drug abuse

5 fold increase in late life mental disorders (depression and dementia)

Treatment of late life depression (3-5 yr outcomes) 88% of those without an alcohol history

significantly improved 57% of those with an alcohol history

significantly improved

Saunders et al. 1991, Cook et al. 1991

Behavioral Health Laboratory (BHL): Behavioral Health Laboratory (BHL): Links To Primary CareLinks To Primary Care

Behavioral Health Laboratory (BHL): Behavioral Health Laboratory (BHL): Links To Primary CareLinks To Primary Care

Research to Practice:Research to Practice:Behavioral Health LaboratoryBehavioral Health Laboratory

The BHL is an automated telephone assessment and triage service for patients identified by primary care providers as having depressive symptoms or at-risk drinking.

The depression and alcohol clinical reminder system generates a consultation request to the BHL.

The BHL conducts a brief telephone (20-30 minutes) assessment generating a report for the PCP including diagnosis, severity, and general treatment recommendations.

Drug Use Among Primary Care Patients with Drug Use Among Primary Care Patients with Minor or Major DepressionMinor or Major Depression

<50 Years 50-64 years 65 + years

n=205 n=323 n=112

Use in past year 24.4 20.7 2.7

Past history of use 20.5 20.4 1.8

Types of Substance Use Among Older Types of Substance Use Among Older Adults (50+) Adults (50+)

Use in Past Year

Only a past history

n=70 n=22

Cocaine 54.3 36.4

Heroin 7.1 0

Marijuana 58.6 77.3

Amphetamines 1.4 9.0

LSD 1.4 4.5

Inhalants 1.4 0

Barbiturates 1.4 0

Drug Use Among Older Patients with Minor Drug Use Among Older Patients with Minor or Major Depressionor Major Depression

No Hx of Drug use

Only a past Hx

Use in the past year

Diff (by column)

n=342 n=22 n=70

Nicotine use 36.5 68.2 68.6 c>a, b>a

At-risk drinker 10.5 31.8 27.1 c>a, b>a

Cognitive screen 4.2 (4.2) 6.6 (4.8) 4.8 (4.0) b>a

Suicide 12.5 13.6 28.6 c>a

Manic symptoms 7.0 0.0 18.6 c>a

Psychotic symptoms 9.9 9.1 21.4 c>a

PTSD 27.0 18.2 37.1

TreatmentTreatment

Depression Alcohol Aging TrialDepression Alcohol Aging Trial

Hypotheses Among older adults with major depression and

comorbid alcoholism, naltrexone combined with sertraline improves the outcomes of both drinking and mood.

Reduction in alcohol consumption will be associated with improved mood regardless of randomization.

Naltrexone will lead to a reduction in alcohol consumption independent of changes in mood.

Concurrent Treatment of Depression Concurrent Treatment of Depression Complicated by Alcohol DependenceComplicated by Alcohol Dependence

Current depressive syndrome Current alcohol dependence Age 55 and over 10 sessions of compliance enhancement therapy 1/2 of subjects are randomly assigned to receive

naltrexone 50 mg All subjects receive sertraline 100 mg Outcomes at 3 months

(Oslin, 2004)

Pre-Treatment Clinical CharacteristicsPre-Treatment Clinical Characteristics

Placebo Naltrexone p value

HDRS Score 23.4 (5.0) 20.1 (5.7) 0.011

Percent Days Heavy Drinking- 75.8 (29.1) 59.2 (35.6) 0.032

Percent Days Drinking 82.4 (24.5) 75.5 (29.3) 0.270

Drinks/ Drinking Day 10.2 (6.8) 6.5 (3.9) 0.006

ASI-Alcohol Score 0.67 (0.18) 0.64 (0.17) 0.433

PCS 43.8 (8.5) 46.1 (10.3) 0.325

MCS 33.2 (9.6) 38.1 (11.5) 0.061

% with Primary Depression 68.6 65.7 0.799

Relationship between heavy drinking during Relationship between heavy drinking during the trial and depression outcomesthe trial and depression outcomes

No Relapse Relapse p

Completed Research (%) 83.7 84.0 0.886

Depression Remitted 63.3 32.0 0.011

HDRS – end of trial 8.8 (6.7) 12.7 (8.2) 0.013

Overall Treatment OutcomesOverall Treatment Outcomes

Well42%

Relapsed only11%

Depressed only24%

Depressed and Relapsed

23%

Substance Induced Depression in the Substance Induced Depression in the elderly?elderly?

Less than 50% resolution of symptoms early in treatment

No relationship between clinical impression of primary vs. secondary depression and early response

Not just DependenceNot just Dependence

Moving beyond DSM in conceptualizing risk

Disease and BehaviorDisease and Behavior

Substance dependence Follows the biomedical model of an illness

At-risk use Public health model Recognizes risks (health, economic, etc.)

associated with use in individuals not suffering with the “disease”

Most relevant for alcohol, medications, marijuana and nicotine.

What about moderate or abusive drinking What about moderate or abusive drinking (non-dependent drinking)(non-dependent drinking)

Most common pattern of drinking among those with depression

May be beneficial for heart disease

Safety concerns may be less with newer medications (SSRIs) than older meds (TCAs)

Response to Standard Depression Care Response to Standard Depression Care Among the ElderlyAmong the Elderly

PROSPECT study Remission of depression (men only)

Non-drinkers – 41 % Moderate drinkers – 18.2%

PRISM-E study (preliminary) Remission of depression (men only)

Non-drinkers – 33.8 % Moderate drinkers – 6.3 %

(Personal Communication, 2002)

Telephone Disease Management for Telephone Disease Management for Depression and At-Risk DrinkingDepression and At-Risk Drinking

To develop a method for delivering high quality depression and alcoholism treatment in Primary Care, CBOCs, and other clinics in which there are significant transportation, staff resource, or other impediments to the delivery of face-to-face MH/SA care.

To develop methods for translating effects demonstrated in randomized clinical trials to clinic populations.

TreatmentsTreatments

Telephone Disease Management is algorithm driven care delivered by a Behavioral Health Specialist.

Enhanced Usual care. The PCP can monitor, treat, and/or refer. The PCP is provided a diagnosis and references for treatment options.

Improvements with TDMImprovements with TDM

0

5

10

15

20

25

30

35

40

45

TDM Usual Care

Depression Remission

Alcohol Remission

Overall Remission

Oslin, et. al. 2003

Is Sedative/Hypnotic Use a Co-Is Sedative/Hypnotic Use a Co-Occurring Problem?Occurring Problem?

Association with falls

Association with memory impairment

?Association with treatment of depression

How to Define Inappropriate How to Define Inappropriate Benzodiazepine UseBenzodiazepine Use

Chronic Use (>3 months)

Use of long-acting agents

Undocumented response

Lowest effective dose (harm reduction)

Sedative/Hypnotic UseSedative/Hypnotic UseA Disappearing Problem?A Disappearing Problem?

0

5

10

15

20

25

Depressed Non-depressed

Men

Women

M:W p= 0.0393, Positive: Negative p=0.002

Types of Sedative/Hypnotics UsedTypes of Sedative/Hypnotics Used

Percent

Xanax 32.7

Ativan 24.1

Restoril 13.1

Klonopin 11.1

Valium 10.6

Librium 6.0

Tranxene 4.5

Barbituates 2.0

Serax 2.0

Dalmane 1.0