Substance Misuse and Alcohol Use Disorders   28  

Madeline A. Naegle and Donna McCabe

OVERVIEW

Evidence of alcohol and drug use by persons aged 50 years and older is increasing as more people live longer, continue community living, and continue substance use habits established in youth and middle adulthood. Approximately, 57 million persons aged 50 to 64 years now live in the United States, and there are another 37.8 million persons aged 65 years and older. The projected increase in persons aged 65 years and older is expected to double from 40.3 million in 2010 reaching 83.7 million by 2050 (U.S. Census Bureau, 2014). Population growth predicts greater numbers of older adults with substance-related problems, perhaps as many as 5.7 million by 2020, and nurses should be prepared to identify and intervene with these health problems (Han, Gfroerer, Colliver, & Penne, 2009). The estimated one third of the older population who are minority group members will also grow. Drug and alcohol use in minorities are grossly understudied and nursing interventions with these groups of older adults should be culturally competent and tailored to substance use patterns (Andrews, 2008; Grant et al., 2004).

BACKGROUND AND STATEMENT OF PROBLEM

Health care problems linked to substance use and excess alcohol consumption are costly to society with direct and indirect economic costs, including costs of illness ($24.6 billion) and crime ($21 billion) estimated in 2006 (Bouchery, Harwood, Sacks, Simon, & Brewer, 2011). Illicit use of opioids costs another $50 billion (Hansen, Oster, Woody, & Sullivan, 2011). Nearly 22% of community-dwelling older adults use potentially addictive prescription medication (Simoni-Wastila & Yang, 2006), and risks for psychological and/or physical dependence associated with this phenomenon are considerable (Simoni-Wastila, Zuckerman, Singhal, Briesacher, & Hsu, 2005). These costs are anticipated to rise as the middle-aged population, high users of analgesics, grows (Wu & Blazer, 2011).

The drug most commonly misused by older adults is alcohol, followed by nicotine and psychoactive prescription drugs. More and more older people report using marijuana (Moore et al., 2009). Although moderate alcohol use by adults has been inversely associated with the risk for cardiovascular heart disease, findings have been inconsistent and research on older adults is limited (Mukamal et al., 2006). Moderate alcohol use has also been linked to improved cognitive function in both older men and women (McDougall, Becker, Delville, Vaughn, & Acee, 2010; Stampfer, Kang, Chen, Cherry, & Grodstein, 2005), but these findings should not be the basis for nonalcohol consumers to begin drinking in late life. Similarly, older adults treated for alcohol use disorders earlier in life are at risk if they return to drinking. Excess alcohol use can result in high personal and medical costs at all ages but especially so for older adults. Alcohol-attributable conditions are often not recognized and reported as such, resulting in underestimation, although almost 12% of nursing home admissions are attributable to excessive drinking (Substance Abuse and Mental Health Services Administration [SAMHSA], 2010). Of persons seen in primary care who are older than 60 years, 15% of men and 12% of women regularly drank in excess of the National Institute Alcohol Abuse and Alcoholism (NIAAA) recommended levels (i.e., one drink per day and no more than three drinks on any one occasion; Fink, Elliott, Tsia, & Beck, 2005). Heavy consumption has been shown to decrease the likelihood that older people will use preventive medical services, such as glaucoma screening, vaccinations, and mammograms (Fink et al., 2005). This population is at risk for falls, motor vehicle accidents, and other unintentional injuries (NIAAA, 2015). Looking to the future, of the estimated 57 million late middle-aged persons (50–64 years old), 14% are drinking heavily, with 9% of them “at-risk” drinkers, and 23% reporting binge drinking (consumption of four to five drinks on an occasion; Blazer & Wu, 2009; Merrick et al., 2008).

The burden of disease linked to tobacco use is the heaviest among older individuals and the leading cause of premature death for those (Sachs-Ericsson, Collins, Schmidt, & Zvolensky, 2011) who have smoked the longest and have the most health problems. In 2004, 18.5 million Americans older than 45 years smoked, (about 42% of all adult smokers) and in 2001/2002, 14% of adults older than 65 years reported tobacco use in the prior month (Moore et al., 2009). Smoking-related deaths number 300,000 annually in this age group (Centers for Disease Control and Prevention [CDC], 2009).

As baby boomers age, their lifetime illicit drug use is anticipated to continue at levels similar to their use in younger years, increasing the number of persons 55 years and older using illicit drugs like marijuana and cocaine; (National Institute on Drug Abuse [NIDA], 2010). The number of persons aged 50 years and older who use marijuana is projected to increase from 4.2%. Use of illicit drugs will increase from 4.7% (4.3 million), and nonmedical use of psychotherapeutic drugs is projected to increase from 4.2% (SAMHSA, 2010). There have been dramatic increases in prescribing and use of opioid analgesics and synthetic opioids over the past decade. There is evidence of accidental overdose in adolescent, adult, and older adults. Although the rates of prescription drug misuse and abuse is lower among older adults, associated mortality rates for drugs like oxycodone, fentanyl, oxymorphone, tramadol, and related drugs has been higher among persons of older age. The drugs most commonly used in this age group are tranquilizers, sedatives, and opioids obtained by prescription. This pattern is more common for those in palliative care, and persons with noncommunicable diseases accompanied by chronic pain, placing them at high risk for negative outcomes (Moore et al., 2009; West, Severtson, Green, & Dart, 2015).

Patterns of substance use vary in subpopulations and some differences among groups are noteworthy. The success of antiretroviral therapies has extended life, and more than half of HIV cases in the United States will soon be persons 50 years and older (Justice, 2010). Older individuals who are HIV positive report higher rates of both alcohol and illicit drug use. One American sample recorded rates of substance use at 22%, alcohol use at 14% and tobacco use at 39.5% in HIV-positive persons aged 50 to 59 years (Vance, Mugavero, Willig, & Raper, 2011).

Differences in alcohol use by race, for example, are more evident with age. Although Caucasian adults outnumber African American drinkers, low-income, older African American males have the highest risk for alcoholism and related problems as well as more legal problems than Whites (Zapolski, Pedersen, McCarthy, & Smith, 2014) this is evident in men older than 50 years.

Given the need for treatment, coupled with older adults’ reluctance to seek help for mental health problems (less than 3% of older people visit a mental health professional) nurses and health professionals caring for older adults in all settings need to know how to screen for a substance use disorder (Bartels et al., 2004). Psychiatric disorders often co-occur with alcohol use and misuse in older adults, with prevalence rates ranging from 12% to 30% (Oslin, 2005); depression occurrs both independently and as a consequence of excess drinking, and is frequent in male smokers (Kinnunen et al., 2006).

The metabolic changes of aging are key to health problems related to drug or alcohol use, resulting in increased morbidity in advancing age. Older persons respond differently to alcohol because of decreased total body water and rates of alcohol metabolism in the gastrointestinal tract; increased sensitivity to alcohol combined with decreased tolerance (U.S. Department of Health and Human Services [USDHHS], 2004a). Most alcohol consumers drink less as they age, and only 4.1% of those 65% to 75% and 1.6% of those older than 75 years report a lifetime alcohol use disorder (Wu & Blazer, 2014). More dramatic behavioral changes are evident at lower doses of all drugs and adverse physical responses result in morbidity or mortality, curtailing intake. Social and legal problems occur more frequently and are more pronounced than in younger people, especially for older women (Blow & Barry, 2003). Because the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) criteria may be less applicable to older adults, these criteria must be interpreted and applied in age-appropriate ways. Even when a person does not meet the DSM-5 criteria for a moderate or severe use disorder, alcohol consumption at levels of more than seven drinks weekly and more than three drinks at a time for persons older than 65 years can result in health consequences. Excess alcohol use compromises health by interfering with the absorption and utilization of prescribed drugs and nutrients. Excessive alcohol consumption may place the older individual at risk for falls, self-neglect, and diminished cognitive capacity. Long-term excess alcohol use is related to the development of common medical problems such as sleep disorders, restlessness and agitation, liver function abnormalities, pneumonia, pancreatitis, gastrointestinal bleeding, and trauma as well as chronic diseases, particularly neuropsychiatric and digestive disorders, diabetes, cardiovascular disease, and pancreatic or head and neck cancer (Rehm et al., 2009).

ASSESSMENT OF SUBSTANCE USE DISORDERS

Substance use and related disorders involve 10 classes of drugs and are categorized as mild, moderate, or severe according to the number of symptoms described in 11 diagnostic criteria (see as follows). Older people may treat negative and physical and psychological symptoms by “self-medicating” with alcohol and other drugs. A significant number of older adults continue heavy alcohol consumption at 60 years and older (Merrick et al., 2008). Whether a disorder is diagnosed and categorized as mild, moderate, or severe depends on the nature and number of symptoms demonstrated. Pathological patterns of use, including social and health problems, can be linked to frequency of the substance used; the length of time of use (a 12-month period or more), and the specific substance. Most individuals who have severe substance use disorders have developed patterns of alcohol/and or drug use before age 60 years, with one half to two thirds of older adult alcoholics having developed moderate to severe problems early in life. “Late-onset alcoholism” and patterns of prescription drug abuse, marked by increased use and/or overreliance on either, can emerge secondary to losses, chronic illness, and psychological traumas. Social use of alcohol, for example, may change to “at risk” drinking or prescription use to drug misuse when someone has lost a spouse, partner, or job; is estranged from family or is facing serious illness. Risks are higher for those with any combination of circumstances listed.

Alcohol Use Disorders

The most common substance use disorders in older adults are those of alcohol use, including interactions of alcohol with prescription and over-the-counter (OTC) drugs (Wu & Blazer, 2014).

A substance use disorder is diagnosed when a maladaptive pattern of use is evidenced by 11 criteria occurring over a 12-month period (modified from American Psychiatric Association [APA], 2013). Behaviors indicate impaired control over use of a substance (Criteria 1−4), with an inability to cut down on use, and persistent failures at control (Criterion 2), the use and recovery from use may occupy significant periods of time (Criterion 3) with the result that other role obligations are neglected (Criterion 5). Craving or an intense desire to use a drug may occur (Criterion 4) and use persists despite social and interpersonal problems worsened by use (Criterion 6); there is a growing tendency to withdraw from work or recreational activities (Criterion 7).

“At-risk” drinking is a pattern that may not appear to cause alcohol-related problems at first but, with this continued pattern, can result in harmful consequences to the user or others. Regular alcohol and tobacco use, for example, is linked to insomnia (Tibbitts, 2008), a common complaint of older persons. Negative consequences of use include accidents, physical and/or mental health problems, and/or social and legal problems. For people older than 60 years, continuing to drink the same amounts of alcohol that did not appear to cause problems earlier in life can result in adverse consequences. Such outcomes are determined by the individual’s response to alcohol, the use of prescription drugs (alcohol interacts with at least 50% of prescription drugs), and co-occurrence of other chronic medical or psychiatric disorders. Similarly, a decline in visual, auditory, or other perceptual capacities make alcohol consumption hazardous. Heavy drinking has been correlated with ulcers, respiratory disease, stroke, and myocardial infarction.

Severe substance use disorders are chronic, recurring illnesses. One may achieve sobriety and recovery, using medication, self-help, and psychotherapy. Sobriety may be interrupted by brief “slips” and “relapses,” after which the individual returns to efforts toward recovery. Severe substance use disorders have two components. First, physiological dependence, induced by certain drugs, such as alcohol, tobacco, benzodiazepines, barbiturates, amphetamines, and opioids, which is evidenced in “tolerance,” the need for increasing amounts of a substance to achieve the desired effect, and “withdrawal,” a characteristic pattern of symptoms after use of a substance is suddenly stopped. Second, craving accompanies withdrawal, so there is also psychological dependence, the perceived need to use the drug. Psychological dependence is evidenced in moderate and severe substance disorder and is more difficult to resolve than physiologic dependence.

Illicit Drug Use

Illicit drug use is less prevalent than excess alcohol use or prescription drug misuse in late adulthood. Recent trends seen in the baby boomer generation, however, suggest that this may be changing. Marijuana use, for example, is now more prevalent among persons aged 55 years and older than among adolescents with 3 million adults older than 50 years reporting marijuana use and 2.1 million or 2.3% reporting nonmedical use of prescription drugs (West et al., 2015; SAMHSA, 2010). Of drug users 50 years and older, approximately 10% to 12% have a drug use disorder (Wu & Blazer, 2014). Recent data from emergency room admissions indicate growing numbers of older adults (largely male) using heroin and cocaine as well as marijuana (SAMHSA, 2008). Clinical observation suggests that older people are rarely asked about illicit drugs, that is, cocaine, despite strong evidence of its associated cardiovascular risks. The result is an absence of accurate information on prevalence of illicit drug use among older adults, estimated to be in excess of 5.2% among persons 50 years and older (Chait, Fahmy, & Caceres, 2010; SAMHSA, 2012).

Recovery From Severe Substance Use Disorders

Many older persons are “in recovery” or have established long sobriety from the use of alcohol, cocaine, heroin, or other drugs. The components of recovery have been described by the Betty Ford Institute Consensus Panel (2007). Recovery is defined as a lifestyle voluntarily maintained by an individual that includes sobriety, varying levels of personal health, and citizenship. Adverse circumstances and life stressors may contribute to an individual’s relapse to alcohol or drug use. Transitions that come with aging, the numbers of losses with increased age, and the onset of chronic illness may all be “triggers,” to return to drug use posing threats to recovery and risks for a return to regular, maladaptive patterns of use (relapse). On a positive note, good treatment outcomes and rates of recovery for older persons are higher than in any age group. Nurses can contribute positively by supporting the patient’s attendance at self-help group meetings, continued involvement in treatment such as methadone or buprenorphine maintenance, active community and family involvement, and/or group or individual psychotherapy.

In this chapter, the term drug applies to OTC medications, prescription medications, nicotine, alcohol, and illicit drugs. Herbs and food supplements are also used frequently by older adults. Although knowing the chemical composition of drugs of abuse is essential to understanding their effects on mind and body, this chapter focuses primarily on substance use disorders, and the effects and consequences for health of excessive use and using drugs in combination, as well as nursing assessment and intervention strategies. Please refer to www.drugabuse.gov for a full listing of drugs of abuse and their chemical properties.

Psychoactive Drug Misuse and Abuse

Drug misuse, defined as use of a drug for reasons other than for which it was intended, occurs with increasing frequency with advancing age because (a) prescriptions for multiple medications and cognitive changes, ranging from early signs of dementia, can lead to medication misuse; (b) failure to discard expired medications; (c) trading medications with friends and companions; and (d) combining both nonprescription and prescription medications and alcohol. The most common resulting problems are related to (a) overdose, (b) additive effects, (c) adverse reactions to drugs used, or (d) drug interactions, especially with alcohol. Older adults account for 30% of national expenditures on all prescription drugs, and nonmedical use of prescription drugs increases in persons older than 60 years (NIDA, 2015). A recent rise in trends of opioid misuse has resulted in higher rates of mortality for older adults than for younger users. Opioid and synthetic opioids as factors in suicide among older adults is an increasing trend (West et al., 2015).

The regular use of numerous drugs for multiple medical conditions (i.e., polypharmacy) is complicated by the older adult’s use of alcohol or illicit drugs (Letizia & Reinbolz, 2005). In persons aged 18 to 70 years treated for falls, 40% of men and 8% of women tested positive for alcohol and/or benzodiazepines (9% and 3%, respectively), or both (Boyle & Davis, 2006).

Prescription drug use or misuse contributes to falls and cognitive impairment. Abuse of psychoactive drugs is a growing health problem for older adults and the few research findings listed factors correlating with drug abuse are isolation, history of substance-related or mental health disorder, bereavement, chronic medical disorders, female gender, and exposure to prescription drugs with abuse potential. Few older adults are lifetime illicit drug users (Wu & Blazer, 2014), other than marijuana users, who are growing in number. However, substance abuse by older adults, one in four of whom receives prescriptions for drugs with abuse potential, is becoming more common. Drugs—other than nicotine or tobacco—most commonly misused are benzodiazepines, sedative hypnotics, and opioid analgesics (Wu & Blazer, 2014).

Smoking and Nicotine Dependence

Today’s older Americans have smoked at rates among the highest of any U.S. generation (American Lung Association [ALA], 2010), resulting in many health problems and contributing to the estimated 438,000 American deaths annually caused by smoking. Nearly 20 of every 100 American adults aged 45 to 64 years (19.9%) and nearly 9 of every 100 adults aged 65+ years (8.8%) are current smokers (CDC, 2015).

Although these rates in older adults have decreased in recent years, vulnerability to the effects of smoking is evident. Men have been found to be more than twice as likely as women to die of stroke secondary to smoking (ALA, 2006). The risk of dying of a heart attack for men aged 65 years and older is twice that for women smokers and 60% higher than for nonsmoking men of the same age. Smokers also have significantly higher risks than nonsmokers for Alzheimer’s disease and other types of dementia, and smoking plays a role in heart and lung disease, cancer, osteoporosis, diabetes, erectile dysfunction, and visual disorders like macular degeneration and nuclear cataracts (ALA, 2010; Whitmer, Sidney, Selby, Johnston, & Yaffe, 2005).

Polysubstance Abuse

Polysubstance abuse, the misuse, abuse, or regular use of three or more drugs, is common in older adults. Prescription analgesics are frequently prescribed for chronic pain, a common complaint in older persons, and depending on the class of drug, can induce dependence. Older problem drinkers, as well, report more severe pain, greater disruption of activities caused by pain, and frequent use of alcohol to manage pain (Brennan, Schutte, & Moos, 2005). These findings underscore the importance of monitoring drinking and medication use in patients who present with complaints of pain, especially those with histories of any heavy drug use or substance use disorders, including alcohol and nicotine.

ASSESSMENT OF SUBSTANCE USE

The nurse should review data collected on the most recent nursing and medical histories and the most recent physical examination. When patients are using alcohol, there may be deviations in standard liver function tests (LFTs) and elevations in gamma-glutamyl transferase (GGT) and carbohydrate-deficient transferrin (CDT) levels; 50% to 70% of heavy drinkers will have percentage of CDT greater than 2.6 (Miller, Cluver, & Anton, 2009). Physical signs, such as ecchymosis, spider angiomas, flushing, palmar erythema, or sarcopenia may be evidence of heavy use. The patient may have an altered level of consciousness, changes in mental status or mood, poor coordination, tremor, increased deep tendon reflexes, or a positive Romberg sign. Increased lacrimal secretions, nystagmus, and sluggish pupil reactivity may also be noted on examination (Letizia & Reinbolz, 2005). Patients who report use of marijuana and/or other drugs should have toxicology tests to establish baseline use level. Findings can be effectively used in a motivational interview and brief interventions and/or counseling.

Nurses need to assess and document frequent changes in drug-using habits and record these in substance use histories, dating from first use to the current situation. Ask whether the individual ever experienced problems related to drug or alcohol use, spontaneously stopped using a drug or alcohol, or is in recovery and participating in self-help programs such as Alcoholics Anonymous or Narcotics Anonymous.

In taking the patient history, ask about a history of smoking, alcohol use in the form of number of standard drinks, OTC medications, prescription and recreational drugs, herbal, and food and drink supplements. Record this information using the Quantity Frequency (QF) Index (Khavari & Farber, 1978). Another helpful technique in assessing drug use is the “brown bag” technique. Ask the client to bring in a brown bag containing all the prescribed OTC, food supplements, and other legal or illicit drugs that he or she consumes weekly. Use these to develop the history and to open a discussion about the implications of drug use with the patient. Be sure to talk with the client about how using the drug is meaningful or helpful (i.e., relieves pain, relieves feelings of loneliness, anxiety, or comfort).

Screening, brief intervention, and referral to treatment (SBIRT) has been found to be effective with adults and older adults for smoking, illicit drug and prescription drug abuse, and alcohol use, and should be part of the nursing evaluation (Schonfeld et al., 2010). Despite federal agency guidelines supporting its use, it is rarely used with older adults. SBIRT has demonstrated efficacy and feasibility in reducing patients’ alcohol consumption, decreasing dependence symptoms (Babor et al., 2007; SAMHSA, 2008), and improving general and mental health (Madras et al., 2009) following its use by nurses and nurse practitioners.

How to Use SBIRT

SBIRT begins with screening an individual using a valid and age-appropriate screening tool. The goal of the screening is to identify alcohol use behaviors that place the individual at risk for health problems. Short, well-tested questionnaires that identify risk include the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), the Short Michigan Alcohol Screening Test-Geriatric version (SMAST-G), the Alcohol Use Disorder Identification Test (AUDIT), the Drug Abuse Screening Test (DAST), and so forth.

Although screens can often be done by paper and pencil, older adults may respond to administration by the nurse or trained personnel. A positive score on the screening tool for excess alcohol use or for smoking, can be determined by a brief 3- to 5-minute session, including advice to cut down. SBIRT is not effective with individuals with severe substance use disorders and physiological dependence on alcohol.

Blow et al. (2005) recommend modifying the brief intervention for older adults to include the following points:

If the patient declines change at this time, the discussion is dropped. The topic of possible change, however, should be raised at the next visit. When the screening instrument (AUDIT, SMAST-G) score indicates dependence on alcohol or nicotine, referrals to specialty treatment and information needed to access a provider or a specialty health care agency are in order.

Referral: For in-depth assessment and/or diagnosis and/or treatment,

Treatment: Depending on the health care setting, between 1% and 10% of patients may need some level of treatment—to ensure safe withdrawal and reinforce decreased intake of cessation.

Although the U.S. Preventive Services Task Force recommends screening older adults for excess alcohol use, screening is not frequently done. Health providers, family members, and friends may overlook excess use because no one identifies how drug use is disrupting their lives. They may feel, based on advanced age, the patient should be free to engage in whatever behavior he or she wishes. Health professionals may be pessimistic that older persons can change long-standing behaviors, so they may not ask about drug and alcohol use. Evidence suggests that many health professionals doubt the effectiveness of alcohol or drug treatment (Vastag, 2003). In addition, health care providers may not recognize the association of drug use, smoking, or excessive alcohol use and health problems like chronic obstructive pulmonary disease (COPD), stroke, or depression.

Recurrent and prolonged substance use disorders are now recognized as chronic conditions, characterized by slips and relapses, and conditions that respond to treatment (McLellan, Lewis, O’Brien, & Kleber, 2000). Interventions and treatment can be matched to stages of the disease (acute phases, exacerbations, and stages of recovery) for improved outcomes.

Screening Tools for Alcohol and Drug Use

Screening for alcohol and other drug use is equally important in the community and hospital setting. A QF Index, such as the Khavari Alcohol Test (KAT), asks respondents to report their (a) usual frequency of drinking, (b) usual amount consumed per occasion, (c) maximum amount consumed on any one occasion, and (d) frequency of consumption of the maximum amount (Allen & Wilson, 2003). The KAT consists of the four questions noted previously that are asked for each type of beverage (beer, wine, spirits, and liqueurs) and can be administered in 6 to 8 minutes (Khavari & Farber, 1978). The amounts are then compared with NIAAA norms for persons older than 65 years, which are one drink per day for men and women and no more than three drinks per occasion. Additional questions, such as (a) “Did you ever feel you had a problem related to alcohol or other drug use?” and (b) “Have you ever been treated for an alcohol or drug problem?” will yield important additional information.

Short Michigan Alcohol Screening Test-Geriatric Version

The SMAST-G is an effective tool for screening older adults in all settings. The complete drug use history can be obtained in the comprehensive assessment. The original instrument from which this version was derived has a sensitivity of 93.9% and a specificity of 78.1% (Blow et al., 1992). The SMAST-G is composed of 10 questions and is quickly administered. It has outcomes equal to the parent instrument. Each positive response counts as 1 point.

Alcohol Use Disorders Indentification Test (AUDIT)

This 10-item questionnaire has good validity in ethnically mixed groups and scores classify alcohol use as hazardous, harmful, or dependent; administration: 2 minutes (Saunders, Ashland, Babur, de la Fuente, & Grant, 1993). The AUDIT has been found to have high specificity in adults older than 65 years (Babur, Higgins-Biddle, Saunders, & Monteiro, 2001).

Fagerström Test for Nicotine Dependence-Revised

This six-question scale provides an indicator of the severity of nicotine dependence: scores less than 4 (low to moderate dependence), 4 to 6 (moderate dependence), and 7 to 10 (highly dependent on nicotine). The questions inquire about first use early in the day, amount and frequency, inability to refrain, and smoking despite illness. This instrument has good internal consistency and reliability in culturally diverse, mixed-gender samples (Pomerleau, Carton, Lutzke, Flessland, & Pomerleau, 1994).

INTERVENTIONS AND CARE STRATEGIES

Interdisciplinary collaboration is essential to providing a range of treatment modalities for substance use disorders and related problems because drug and alcohol use affects physical, mental, spiritual, and emotional health. Primary care providers, psychologists, dentists, nurses, and social workers should all be equipped to detect and refer a problem, and all dimensions of health should be addressed in treatment and aftercare. The least intensive approaches to treatment for older adults should be implemented first and should be flexible, individualized, and implemented over time. Older persons are disinclined to seek or continue care with mental health or addictions specialists. Brief interventions and motivational interviewing have been found effective in producing short-term reduction in alcohol consumption for older persons, both for men and women. There are some findings that motivational interviewing is more effective with smoking than brief advice (Ballesteros, González-Pinto, Querejeta, & Ariño, 2004; Wutzke, Conigrave, Saunders, & Hall, 2002). Research findings also suggest that once enrolled in treatment for a substance use disorder, older people treated for alcohol or opioid dependence with medications, such as naltrexone, methadone, or buprenorphine; as well as individualized, supportive, and medically based psychosocial interventions have better outcomes than younger people (Satre, Mertens, Arean, & Weisner, 2004).

Inpatient Hospitalization

Older adults who report using alcohol should be screened for alcohol use (Nicholas & Hall, 2011) on admission to any care facility. A small but important percentage will be at risk for the development of acute alcohol withdrawal syndrome (AWS) on sudden cessation of drinking. Patients at highest risk have (a) a history of consuming large amounts of alcohol, (b) coexisting acute illness, (c) previous episodes of AWS or seizure activity, (d) a history of detoxification, and (e) intense cravings for alcohol (Letizia & Reinbolz, 2005). Symptoms of withdrawal are intense and of greater duration than in younger persons with onset of withdrawal as early as 4 to 8 hours after the last drink and persisting up to 72 hours. The clinical symptoms determine the need for detoxification and determine medical and nursing decisions. Clinical judgments follow a history, including history of drug and alcohol use, and physical and mental status assessments.

A 10- to 28-day period of acute care hospitalization in a mental health unit or alcohol and drug treatment center is indicated for the older person addicted to alcohol, benzodiazepines, heroin, amphetamines, or cocaine when (a) living situations and access to the drug makes abstinence unlikely; (b) there is a likelihood of severe withdrawal symptoms; (c) comorbid physical or psychiatric diagnoses, such as depression and accompanying suicidal ideation or a chronic physical illness, are present; (d) daily ingestion of alcohol or a sedative hypnotic has been higher than recommended doses for 4 weeks or more; and (e) mixed addiction, as in alcohol and benzodiazepines or cocaine and alcohol, is present. It is helpful if programs specifically designed to meet the needs of older persons are available (USDHHS, 2004a).

Ambulatory Care

Persons dependent on alcohol, tobacco, and heroin can be successfully withdrawn in community-based care through the collaboration of a medical doctor or nurse practitioner and family members and friends. Specialists in addiction should be sought as supervisors or collaborators in the process. Older persons drinking at risky levels or abusing alcohol or other drugs are generally treated in the community. Tobacco-cessation protocols are now available directly to consumers as well as to primary care providers and mental health professionals.

Residential Treatment

Residential treatment is available in specialty care centers, therapeutic communities, and some long-term care facilities. Programs designed specifically for the older person are beneficial in their focus on the specific health care needs and challenges to abstinence faced by older people. These long-standing habits of use, a diminished social network, and the risks of social isolation, and health implications of heavy alcohol and prescription drug use make behavioral change particularly challenging.

Therapeutic Communities

Therapeutic communities provide long-term (up to 18 months) treatment and are abstinence-oriented programs. They use the 12-step Alcoholics Anonymous model of individual and group counseling, as well as participation in a social community, to address drug-related problems. For the isolated, older drug user with a history of frequent relapse, these are good treatment options.

Pharmacological Treatment

Agents for pharmacological treatment of substance abuse and dependence are more available but not all are appropriate for use with older adults, because of metabolic changes with aging. The best outcomes of pharmacological interventions are achieved by the combination of medication with individual and/or group counseling. Attendance at 12-step programs also supports adherence to treatment regimens.

Severe Alcohol Use Disorder and Medication-Assisted Treatment

There is strong evidence that naltrexone can decrease cravings and consumption in heavy drinkers. It is available in liquid form for oral use and is now available in injectable, long-acting form. It is marketed as Vivitrol or Vivitrex. These extended-release formulations of naltrexone act up to 28 days to decrease the euphoric effects of, and craving for alcohol (Bartus et al., 2003). Evidence suggests that this treatment is well tolerated by older people (Oslin, Pettinati, & Volpicelli, 2002). Contraindications for its use include renal problems, acute hepatitis, or liver failure. Study findings stress the importance of psychosocial interventions to improve adherence to pharmacological interventions for alcohol dependence, a finding similar to those regarding smoking cessation (Mayet, Farrell, Ferri, Amato, & Davoli, 2005). Acamprosate calcium (Campral), a recent addition to prescription drug choices, has variable outcomes in reducing the craving for and consumption of alcohol. Disulfiram (Antabuse), used to deter alcohol consumption, produces an elevation in vital signs and severe gastrointestinal symptoms if alcohol is ingested and is poorly tolerated by alcoholics older than 55 years. In addition, it must be taken every day to achieve aversive effects on consumption. The best outcomes with this medication occur when working with the patient’s family members and support persons.

Opioid Dependence

The use of methadone, an opioid agonist, assists the opioid-dependent person to focus on psychological and life problems. The drug buprenorphine—both an opioid antagonist and agonist—is longer acting and now available. Both are dispensed in institution-based clinic settings or by physicians specifically credentialed to prescribe and monitor buprenorphine. Evidence supports added benefit of psychosocial treatment for patient adherence to pharmacological treatment (Amato et al., 2008).

Smoking

Bupropion in doses of 75 mg with administration begun 2 weeks before the smoker intends to quit has proved a helpful adjunct to smoking cessation. Nicorette transdermal patches and nicotine gum are now available OTC and there is research support for their pharmacological contribution to smoking cessation. The dosage of transdermal patches is determined by the number of cigarettes smoked (level of substance use disorder). The best outcomes with smoking cessation result from a combination of individual or group psychosocial support and medication (CDC, 2014).

Models of Care

Individualized care plans should be developed for older adults at risk for substance use disorders in accordance with the classes of drugs used and the mild, moderate, or severe nature of the disorder. Individualizing care allows flexibility for patient and nurse. Evidence is emerging, however, on models of care for older adults with complex health problems. For example, in one study, the integration of mental health into primary care increased access to mental health and substance abuse treatment for both Black and White older adult patients who are offered both enhanced specialist services and mental health services at the primary care site (Ayalon, Areán, Linkins, Lynch, & Estes, 2007). Case management has also demonstrated effective outcomes with older adults with multiple social, mental health, and physical needs with problems accessing community services, including substance abuse (Hesse, Vanderplasschen, Rapp, Broekaert, & Fridell, 2007). Guidelines for all interventions should include the following:

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