Trends in substance abuse treatment 1998-2008: increasing older adult first-time admissions for illicit drugs

Risk factors of substance use treatment gaps among a nationally representative sample of black American adults in relation to sexual minority status and health insurance coverage

BACKGROUND

Little research has investigated predictors of specialty substance use treatment gaps among Black adults. This study examined differential odds of experiencing self-reported, past-year treatment gaps among Black adults with respect to sexual minority status and health insurance coverage, accounting for social cofactors.

METHOD

This cross-sectional study comprised 36,098 Black Americans aged 18 and older who completed the 2015-2019 National Survey on Drug Use and Health (NSDUH) and provided responses for all selected survey items. Design-based multivariable logistic regression models were used to examine predictors of drug and alcohol treatment gaps.

RESULTS

Sexual minority Black adults reported greater odds of experiencing treatment gaps to specialty treatment (i.e., inpatient hospital, inpatient/outpatient rehabilitation facility, or mental health center) compared to Black heterosexuals in adjusted models (Gay or lesbian: AOR = 2.01, 95% CI = 1.39-2.89; Bisexual: AOR = 2.35, 95% CI = 1.77-3.12), with bisexual Black women experiencing the greatest odds (AOR = 3.10, 95% CI = 2.33-4.14). Black adults with no health insurance were significantly more likely to report substance use treatment gaps relative to their peers with health insurance coverage (AOR = 50, 95% CI = 1.26-1.78).

CONCLUSION

The results suggest a critical need for more investigations into patterns of specialty substance use treatment gaps within Black populations and for developing sexual identity-affirming mechanisms for closing the disparity gap, particularly for Black sexual minorities and those who lack health insurance coverage.

Specialised residential care for older people subject to homelessness: experiences of residents and staff of a new aged care home in Australia

BACKGROUND

The number of older people experiencing homelessness in Australia is rising, yet there is a lack of specialised residential care for older people subject to homelessness with high care and palliative needs. To address this significant gap, a purpose-built care home was recently opened in Sydney, Australia.

METHODS

This qualitative study explores the experiences of both residents and staff who were living and working in the home over the first twelve months since its opening. Residents were interviewed at baseline (n = 32) and after six months (n = 22), while staff (n = 13) were interviewed after twelve months. Interviews were analysed using a reflexive thematic analysis approach informed by grounded theory.

RESULTS

Three main themes emerged: (1) Challenges in providing care for older people subject to homelessness with high care needs; (2) Defining a residential care service that supports older people subject to homelessness with high care needs, and (3) Perception of the impact of living and working in a purpose-built care home after six months (residents) and twelve months (staff) since its opening. A key finding was that of the complex interplay between resident dependency and behaviours, referral pathways and stakeholder engagement, government funding models and requirements, staff training and wellbeing, and the need to meet operational viability.

CONCLUSION

This study provides novel insights into how the lives of older people subject to homelessness with high care needs are affected by living in a specifically designed care home, and on some of the challenges faced and solved by staff working in the care home. A significant gap in the healthcare system remains when it comes to the effective provision of high care for older people subject to homelessness.

Perceived risk of LSD varies with age and race: evidence from 2019 United States cross-sectional data

PURPOSE

Psychedelics are being explored for their potential therapeutic benefits across a wide range of psychiatric diagnoses and may usher in a new age in psychiatric treatment. There is stigma associated with these currently illegal substances, and use varies by race and age. We hypothesized that minoritized racial and ethnic populations, relative to White respondents, would perceive psychedelic use as riskier.

METHODS

Using 2019 cross-sectional data from the National Survey of Drug Use and Health, we conducted a secondary analysis of 41,679 respondents. Perceived risk of heroin was used as a surrogate for overall risk of illegal substance use; heroin and lysergic acid diethylamide were the only substances queried this way in the sample.

RESULTS

A majority regarded lysergic acid diethylamide (66.7%) and heroin (87.3%) as a great risk if used once or twice. There were clear differences by race, with White respondents and those indicating more than one race having significantly lower perceived risk of lysergic acid diethylamide than respondents from other groups. Perceived risk of use also significantly increased with age.

CONCLUSION

Perceived risk of lysergic acid diethylamide is unevenly distributed across the population. Stigma and racial disparities in drug-related crimes likely contribute to this. As research into potential therapeutic indications for psychedelics continues, perceived risk of use may change.

Substance use among older adults: a review of the literature

OBJECTIVES

To explore studies that have examined the effectiveness of possible interventions to reduce the substance use among older adults.

METHODS

From the search, 295 abstracts were identified and 200 were excluded. Ninety-five remaining articles were reviewed, and 90 were excluded after full text review. Nine articles were included after reviewing bibliographic references on the topic. A total of 14 articles, which all met the inclusion criteria, were considered in the review.

RESULTS

All 14 studies found that pharmacological and non-pharmacological interventions can reduce substance use (alcohol, cocaine, nicotine and benzodiazepines) among older adults (mean age 45 years or older).

CONCLUSIONS

There are promising possibly pharmacological and non-pharmacological interventions that can be used to reduce substance use among older adults. In addition, other studies are needed to expand the therapeutic arsenal in this population.

Familial Predictors of Alcohol and Drug Use-Related Problems Among Middle-Aged and Older Adults

This study evaluated whether recent family member alcohol and substance use problems (ASP) and density of family ASP (i.e., number of members with ASP) predict alcohol-related problems and drug use-related problems among middle-aged and older adults. Data were drawn from participants (age 42-93 years, n=2,168) in the longitudinal Midlife in the United States Study (MIDUS). Poisson regression models revealed that adults' alcohol- and drug use-related problems were predicted by similar problems among family members. In particular, parent and partner ASP, but not child ASP, predicted alcohol-related problems in the middle-aged and combined samples, while only partner ASP predicted participants' drug use-related problems. In addition, density of family ASP predicted alcohol-related problems, but not drug use-related problems. There were no gender interactions. Study findings highlight that understanding how adult children, spouses, and aging parents impact each other's substance use should be a priority of future aging and family research.

High Risk of Substance Use Disorder-Related Outcomes in Veterans Released from Correctional Facilities in Mid to Late Life

BACKGROUND

Veterans Affairs (VA) is likely to encounter a growing number of veterans returning to the community in mid to late life following incarceration (i.e., experiencing reentry). Yet, rates of negative health outcomes due to substance use disorders (SUDs) in this population are unknown.

OBJECTIVE

To determine risk of and risk factors for SUD-related emergency department visits and inpatient hospitalizations (ED/IPH) and overdose death among older reentry veterans compared with never-incarcerated veterans.

DESIGN

Retrospective cohort study using national VA and Medicare healthcare systems data.

PARTICIPANTS

Veterans age  ≥50, incarcerated for  ≤5 consecutive years, and released between October 1, 2010, and September 30, 2017 (N = 18,803), were propensity score-matched 1:5 with never-incarcerated veterans (N = 94,015) on demographic characteristics, reason for Medicare eligibility, and SUD history.

MAIN MEASURES

SUD-related ED/IPH (overall and substance-specific) were obtained from in-/outpatient VA health services and CMS data within the year following release date/index date (through September 30, 2018). Overdose death within 1 year was identified using the National Mortality Data Repository. Fine-Gray proportional hazards regression compared risk of SUD-related ED/IPH and overdose death between the two groups.

RESULTS

The number of SUD-related ED/IPHs and overdose deaths was 2470 (13.1%) and 72 (0.38%) in the reentry sample versus 4402 (4.7%) and 198 (0.21%) in the never-incarcerated sample, respectively. Mid-to-late-life reentry was associated with higher risk of any SUD-related ED/IPH (13,136.2 vs. 2252.8 per 100,000/year; adjusted hazard ratio [AHR] = 2.19; 95% confidence interval [CI] = 2.08, 2.30) and overdose death (382.9 vs. 210.6 per 100,000/year; AHR = 2.24, 95% CI = 1.63, 3.08).

CONCLUSIONS

Older reentry veterans have more than double the risk of experiencing SUD-related ED/IPH (overall and substance-specific) and overdose death, even after accounting for SUD history and other likely confounders. These findings highlight the vulnerability of this population. Improved knowledge regarding SUD-related negative health outcomes may help to tailor VA reentry programming.

Enhancing the Utility of the Health and Retirement Study (HRS) to Identify Drivers of Rising Mortality Rates in the United States

A recent report from the National Academies of Sciences, Engineering, and Medicine (NASEM) highlights rising rates of working-age mortality in the United States, portending troubling population health trends for this group as they age. The Health and Retirement Study (HRS) is an invaluable resource for researchers studying health and aging dynamics among Americans ages 50 and above and has strong potential to be used by researchers to provide insights about the drivers of rising U.S. mortality rates. This paper assesses the strengths and limitations of HRS data for identifying drivers of rising mortality rates in the U.S. and provides recommendations to enhance the utility of the HRS in this regard. Among our many recommendations, we encourage the HRS to prioritize the following: link cause of death information to respondents; reduce the age of eligibility for inclusion in the sample; increase the rural sample size; enhance the existing HRS Contextual Data Resource by incorporating longitudinal measures of structural determinants of health; develop additional data linkages to capture residential settings and characteristics across the life course; and add measures that capture drug use, gun ownership, and social media use.

Older Adult Substance Use Treatment First-Time Admissions Between 2008 and 2018

OBJECTIVES

To see whether the percentage of older adults entering substance use treatment for their first time continued to increase and whether there were changes in the use patterns leading to the treatment episode, particularly an increase in illicit drugs.

DESIGN

Public administrative health record study.

SETTING

The Treatment Episode Data Sets publicly available from the Substance Abuse Mental Health Services Administration from 2008 to 2018.

PARTICIPANTS

Young adults age 30-54 years (N = 3,327,903) and older adults age 55 years and older (N = 453,598) with a first-time admission for a publicly funded substance use treatment.

MEASUREMENTS

Demographic and substance use history variables at admission.

RESULTS

The proportion of older adults going for substance use treatment for the first time continued to increase between 2008 and 2018 relative to younger adults, continuing the trend of increasing first-time admission between 1998 and 2008. For the first time, the primary substance at admission for older adults was an illicit substance only, surpassing alcohol only and the combination of alcohol and illicit drug use. In this period, use of opioids, particularly heroin, and methamphetamine increased among older adults entering treatment.

CONCLUSIONS

As our population ages and substance use trends change, healthcare providers that take care of older adults must have skills to prevent, screen for, diagnose, and treat substance use disorders. Given recent trends in substance use and treatment among older adults, substance use treatment programs must adapt to meet the needs of an older population.

Ageing and older people who use illicit opioids, cocaine or methamphetamine: a scoping review and literature map

AIMS

To provide an overview of research literature on ageing and older people who use illicit opioids and stimulants by documenting the conceptual frameworks used and content areas that have been investigated.

METHODS

We conducted a scoping review of literature relating to ageing and older people who use illicit stimulants and opioids, defining 'older' as 40 years and above. Primary studies, secondary studies and editorials were included. Searches were conducted in PubMed and Embase in July 2020 and March 2021; the Cochrane library was searched in November 2021. Charted data included methodological details, any conceptual frameworks explicitly applied by authors and the content areas that were the focus of the publication. We developed a hierarchy of content areas and mapped this to provide a visual guide to the research area.

RESULTS

Of the 164 publications included in this review, only 16 explicitly applied a conceptual framework. Seven core content areas were identified, with most publications contributing to multiple content areas: acknowledgement of drug use among older people (n = 64), health status (n = 129), health services (n = 109), drug use practices and patterns (n = 84), social environments (n = 74), the criminal legal system (n = 28) and quality of life (n = 15).

CONCLUSIONS

The literature regarding older people who use illicit drugs remains under-theorized. Conceptual frameworks are rarely applied and few have been purposely adapted to this population. Health status and health services access and use are among the most frequently researched topics in this area.

Multimorbidity and Inpatient Utilization Among Older Adults with Opioid Use Disorder in New York City

BACKGROUND

Nationally, there is a sharp increase in older adults with opioid use disorder (OUD). However, we know little of the acute healthcare utilization patterns and medical comorbidities among this population.

OBJECTIVE

This study describes the prevalence of chronic conditions, patterns of inpatient utilization, and correlates of high inpatient utilization among older adults with OUD in New York City (NYC).

DESIGN

Retrospective longitudinal cohort study.

PARTICIPANTS

Patients aged ≥55 with OUD hospitalized in NYC in 2012 identified using data from New York State's Statewide Planning and Research Cooperative System (SPARCS).

MAIN MEASURES

The prevalence of comorbid substance use diagnoses, chronic medical disease, and mental illness was measured using admission diagnoses from the index hospitalization. We calculated the ICD-Coded Multimorbidity-Weighted Index (MWI-ICD) for each patient to measure multimorbidity. We followed the cohort through September 30, 2015 and the outcome was the number of rehospitalizations for inpatient services in NYC. We compared patient-level factors between patients with the highest use of inpatient services (≥7 rehospitalizations) during the study period to low utilizers. We used multiple logistic regression to examine possible correlates of high inpatient utilization.

KEY RESULTS

Of 3669 adults aged ≥55 with OUD with a hospitalization in 2012, 76.4% (n=2803) had a subsequent hospitalization and accounted for a total of 22,801 rehospitalizations during the study period. A total of 24.7% of the cohort (n=906) were considered high utilizers and had a higher prevalence of alcohol and cocaine-related diagnoses, congestive heart failure, diabetes, schizophrenia, and chronic obstructive pulmonary disease. Multivariable predictors of high utilization included being a Medicaid beneficiary (adjusted odds ratio [aOR]=1.70, 95% confidence interval [CI]=1.37-2.11), alcohol-related diagnoses (aOR=1.43, 95% CI: 1.21-1.69), and increasing comorbidity measured by MWI-ICD (highest MWI-ICD quartile: aOR=1.98, 95% CI=1.59-2.48).

CONCLUSIONS

Among older adults with OUD admitted to the hospital, multimorbidity is strongly associated with high inpatient utilization.

Later-life transitions and changes in prescription medication use for pain and depression

BACKGROUND

Over the past two decades, prescription medication use for pain and depression increased dramatically. Most studies consider the early life course, despite a similar increase among those in later life. In this paper, we examine whether and how later life transitions may relate to changes in medication use.

METHODS

We draw on data from the Health and Retirement Study and fixed-effects models to examine whether work, family, and civic transitions in later life are related to changes in the usage of prescription pain and depression medication.

RESULTS

Results show that individuals had higher odds of regularly using prescription pain and depression medications in periods when out of the labor market. Higher odds of depression medication use were also associated with periods of widowhood, and lower odds of use when frequently volunteering. Such relations persist adjusting for reported levels of pain and depression.

CONCLUSION

Our findings call attention to the importance of social ties and the presence of actors that may regulate health behaviors, as well as a change in social context, that may shape medication use in later life.

Hospitalization due to mental and behavioral disorders caused by use of alcohol and psychoactive substances among older adults and elderly people in Brazil: a cross-sectional study

BACKGROUND

It has been estimated that 17% of individuals aged 50 years or older suffer from addiction to legal or illegal drugs. Use of alcohol and psychoactive substances has been correlated with several diseases, e.g. psychiatric conditions and cardiovascular and sexual dysfunctions.

OBJECTIVE

To discuss the Brazilian profile of mental and behavioral disorders caused by use of alcohol and psychoactive substances among older adults and elderly people, over the period from 2008 to 2019.

DESIGN AND SETTING

Cross-sectional study conducted among Brazilians aged 50 years or older.

METHODS

Hospitalization due to mental and behavioral disorders caused by use of alcohol and psychoactive substances was assessed through data obtained from the National Health System Department of Informatics (Departamento de Informática do Sistema Único de Saúde, DATASUS).

RESULTS

Decreasing and steady trends of hospitalization due to mental and behavioral disorders caused by use of alcohol among both men and women at all ages were observed. Similar trends were reported for all age ranges among men and women aged 60 years and older. In contrast, a slight increase was seen among women aged 50 to 59 years.

CONCLUSION

These data are crucial for qualifying mental healthcare for older adults and elderly people and for planning mental health services.

Prevalence, consequences and factors associated with drug use among individuals over 50 years of age in the family perspective

OBJECTIVES

The aim of this study was to investigate the prevalence, consequences and factors associated with drug use among individuals over 50 years of age, from the perspective of their families, with particularly reference to cocaine use.

METHODS

Cross-sectional study based on secondary data with 624 family members of substance users who sought family support in 14 units of the Recomeço Família Program in São Paulo, Brazil.

RESULTS

The participants were predominately men, aged 50 to 59 years (68%); cocaine users (inhaled and/ or smoked); living alone; with a low level of education and were unemployed. They were likely to use family money to pay for their substance use, with a history of theft and aggression against strangers, and were not in treatment. Unlike other participants [≥ 60 years (31.1%)]; who were better educated and retired. In this latter group, 32.8% are alcohol users, 14.8% cocaine users (inhaled and smoked), 32.6% has physically assaulted their family, 39.7% had assaulted someone else and 18.3% had stolen objects or money from home.

CONCLUSIONS

The population has peculiar characteristics of vulnerability (cocaine use and violence) that remain under investigated; not only do routes into treatment for older adults (≥ 60) but appropriate treatment packages need to be developed too.

Using machine learning to advance disparities research: Subgroup analyses of access to opioid treatment

Objective

To operationalize an intersectionality framework using a novel statistical approach and with these efforts, improve the estimation of disparities in access (i.e., wait time to treatment entry) to opioid use disorder (OUD) treatment beyond race.

Data source

Sample of 941,286 treatment episodes collected in 2015–2017 in the United States from the Treatment Episodes Data Survey (TEDS‐A) and a subset from California (n = 188,637) and Maryland (n = 184,276), states with the largest sample of episodes.

Study design

This retrospective subgroup analysis used a two‐step approach called virtual twins. In Step 1, we trained a classification model that gives the probability of waiting (1 day or more). In Step 2, we identified subgroups with a higher probability of differences due to race. We tested three classification models for Step 1 and identified the model with the best estimation.

Data collection

Client data were collected by states during personal interviews at admission and discharge.

Principal findings

Random forest was the most accurate model for the first step of subgroup analysis. We found large variation across states in racial disparities. Stratified analysis of two states with the largest samples showed critical factors that augmented disparities beyond race. In California, factors such as service setting, referral source, and homelessness defined the subgroup most vulnerable to racial disparities. In Maryland, service setting, prior episodes, receipt of medication‐assisted opioid treatment, and primary drug use frequency augmented disparities beyond race. The identified subgroups had significantly larger racial disparities.

Conclusions

The methodology used in this study enabled a nuanced understanding of the complexities in disparities research. We found state and service factors that intersected with race and augmented disparities in wait time. Findings can help decision makers target modifiable factors that make subgroups vulnerable to waiting longer to enter treatment.

Problematic Opioid Use Among Older Adults: Epidemiology, Adverse Outcomes and Treatment Considerations

With the aging population, an increasing number of older adults (> 65 years) will be affected by problematic opioid use and opioid use disorder (OUD), with both illicit and prescription opioids. Problematic opioid use is defined as the use of opioids resulting in social, medical or psychological consequences, whereas OUD is a form of problematic use that meets diagnostic criteria as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Problematic use of opioids by older adults is associated with a number of pertinent adverse effects, including sedation, cognitive impairment, falls, fractures and constipation. Risk factors for problematic opioid use in this population include pain, comorbid medical illnesses, concurrent alcohol use disorder and depression. Treatment of OUD consists of acute detoxification and maintenance therapy. At this time, there have been no randomized controlled trials examining the effectiveness of pharmacological interventions for OUD in this population, with recommendations based on data from younger adults. Despite this, opioid agonist therapy (OAT) is recommended for both stages of treatment in older adults with OUD. Buprenorphine is recommended as a first line agent over methadone in the older adult population, due to a more favourable safety profile and relative accessibility. Use of methadone in this population is complicated by risk of QT interval prolongation and respiratory depression. Available observational data suggests that older adults respond well to OAT and age should not be a barrier to treatment. Further research is required to inform treatment decisions in this population.

Federally Qualified Health Centers Can Expand Rural Access to Buprenorphine for Opioid Use Disorder in Arizona

Medication for Opioid Use Disorder (MOUD) is recommended, but not always accessible to those who desire treatment. This study assessed the impact of expanding access to buprenorphine through federally qualified health centers (FQHCs) in Arizona. We calculated mean drive-times to Arizona opioid treatment (OTP) locations, office-based opioid treatment (OBOT) locations, and FQHCs clinics using January 2020 location data. FQHCs were designated as OBOT or non-OBOT clinics to explore opportunities to expand treatment access to non-OBOT clinics (potential OBOTs) to further reduce drive-times for rural and underserved populations. We found that OTPs had the largest mean drive times (16.4 minutes), followed by OBOTs (7.1 minutes) and potential OBOTs (6.1 minutes). Drive times were shortest in urban block groups for all treatment types and the largest differences existed between OTPs and OBOTs (50.6 minutes) in small rural and in isolated rural areas. OBOTs are essential points of care for opioid use disorder treatment. They reduce drive times by over 50% across all urban and rural areas. Expanding buprenorphine through rural potential OBOT sites may further reduce drive times to treatment and address a critical need among underserved populations.

Association of Medication-Assisted Treatment and Age With Treatment Completion Among Veterans Seeking Non-VA Treatment for Opioid use Disorder at Non-Veterans Health Administration Facilities

BACKGROUND

Medication-assisted treatment has been shown to be effective in treating opioid use disorder among both older adults and veterans of U.S. Armed Forces. However, limited evidence exists on MAT's differential effect on treatment completion across age groups. This study aims to ascertain the role of MAT and age in treatment completion among veterans seeking treatment in non-Department of Veterans Affairs healthcare facilities for opioid use disorder.

METHODS

We used the Treatment Episode Data Set-Discharges (TEDS-D; 2006-2017) to examine trends in treatment and MAT usage over time and TEDS-2017 to determine the role of age and MAT in treatment completion. We examined a subset of those who self-identified as veterans and who sought treatment for an opioid use disorder.

RESULTS

Veterans presented in treatment more often as heroin users than prescription opioid users, and older veterans were more likely to get MAT than younger veterans. We found that before propensity score matching, MAT initially appeared to be associated with a lower likelihood of treatment completion in inpatient ($\beta $ = -1.47, 95% CI -1.56 to -1.39) and outpatient ($\beta $ = -1.40, 95% CI -2.21 to -0.58) settings, and age (50+ years) appeared to mediate the effect of MAT on treatment completion ($\beta $ = -0.54, 95% CI -0.87 to -0.21). After matching, older veterans were more likely to complete substance use disorder treatment ($\beta $ = 0.21, 95% CI 0.01-0.42), while age no longer mediated the effect of MAT, and MAT had a significant positive impact on treatment completion in detox settings ($\beta $ = 1.36, 95% CI 1.15-1.50) and inpatient settings ($\beta $ = 1.54, 95% CI 1.37 -1.71).

CONCLUSION

The results show that age plays an important role in outpatient treatment completion, while MAT plays an important role in inpatient treatment completion. Implications for veterans are discussed.

A Multidimensional Latent Class Analysis of Harmful Alcohol Use Among Older Adults: Subtypes Within the Swedish Addiction Severity Index Registry

OBJECTIVES

The present study aimed to identify multidimensional typologies of harmful alcohol use based on the Swedish Addiction Severity Index (ASI) assessment data on individuals aged 50 years and above.

METHODS

Latent class analysis examined 11 indicators from ASI data on 1747 individuals (men = 1255, women = 492) who reported they were troubled by alcohol problem at least one day in the past 30 days before their assessment. The discriminative validity of the classes was assessed by comparing other measures of individual characteristics and problem severity of other ASI dimensions.

RESULTS

Five subtypes of harmful alcohol use were identified. Two classes with alcohol problems varying in psychosocial functioning, age composition and ages of onset of both regular and heavy drinking. Two with psychiatric comorbidity but varying in violence, criminality, gender composition and ages of onset of regular and heavy drinking. One with high prevalence of concurrent use of other substances, psychiatric, legal, and employment problems.

CONCLUSIONS

The analysis identified, in a national sample, heterogeneous risk groups of older adults with harmful alcohol use. These findings suggest a need for healthcare providers to assess older adults not only for their substance use but also for associated problems and needs. Given these findings, the Addiction Severity Index is a valuable assessment tool for older adults with harmful alcohol use.

Late- and Typical-Onset Heroin Use Among Older Adults Seeking Treatment for Opioid Use Disorder

OBJECTIVE

Analyze 10-year trends in opioid use disorder with heroin (OUD-H) among older persons and to compare those with typical-onset (age <30 years) to those with late (age 30+) onset.

DESIGN

Naturalistic observation using the most recent (2008-2017) Treatment Episode Data Set-Admissions (TEDS-A).

SETTING

Admission records in TEDS-A come from all public and private U.S. programs for substance use disorder treatment receiving public funding.

PARTICIPANTS

U.S. adults aged 55 years and older entering treatment for the first time between 2008 and 2017 to treat OUD-H.

MEASUREMENTS

Admission trends, demographics, substance use history.

RESULTS

The number of older adults who entered treatment for OUD-H nearly tripled between 2007 and 2017. Compared to those with typical-onset (before age 30), those with late-onset heroin use were more likely to be white, female, more highly educated, and rural. Older adults with late-onset were more likely to be referred to treatment by an employer and less likely to be referred by the criminal justice system. Those with late-onset were more likely to use heroin more frequently but less likely to inject heroin than those with typical-onset. Those with typical onset were more likely to receive medication for addiction treatment than those with late-onset.

CONCLUSION

Late-onset heroin use is increasing among older U.S. adults. Research is needed to understand the unique needs of this population better. As this population grows, geriatric psychiatrists may be increasingly called upon to provide specialized care to people with late-onset OUD-H.

Opioid painkiller dependence in a sample of elderly medical inpatients

BACKGROUND

Over the past few years, there has been a growing concern about prescription opioid misuse and dependence in the elderly. Our study aimed to investigate the prevalence of previous and current prescription opioid dependence among elderly medical inpatients recruited from a large German hospital.

METHODS

This cross-sectional study analyzed a cohort of inpatients aged 65 years and older who were assessed with a structured clinical interview. Levels of past and current dependence on opioids benzodiazepines, hypnotics, and non-opioid analgesics were assessed.

RESULTS

Of 2108 elderly inpatients admitted to the hospital during a 6-month period, 400 fulfilled the inclusion criteria and agreed to participate to the survey. Among these 400 subjects, 43 (10.8%) presented with a dependence on opioid analgesics, including 41 with current dependence and 22 (51.2%) with a de novo condition. Addiction severity was considered mild in 65.1% of cases and severe in 11.6% of cases. Tilidine and oxycodone were the most typically reported molecules.

CONCLUSIONS

Further research is warranted, to better understand the possible risk factors of prescription drug misuse, abuse, and addiction in this vulnerable population. Clinicians should be updated and informed regarding both prescription medication misuse potential and safe prescribing practices in the elderly.

Alcohol misuse among older military veterans: an intersectionality theory perspective

BACKGROUND

Alcohol misuse among older adults is an emerging public health issue. Older veterans are particularly at risk of developing substance use dependency due to the enduring impacts of military service. The purpose of this study was to test the theory of intersectionality on alcohol misuse by veteran status and age, veteran status and sex, and veteran status and race.

METHODS

Combined data from the 2016, 2017, and 2018 Brief Risk Factor Resilience Survey (BRFSS) from the Centers for Disease Control and Prevention (CDC) were used in this cross-sectional study. The BRFSS is conducted annually with adults via landline or cellular telephones in all 50 states in the United States, as well as in the District of Columbia, Puerto Rico, and Guam. Alcohol misuse among individuals aged 65+ was examined by veteran status and the interaction between age, race, and sex using survey-weighted logistic regression models.

RESULTS

Results show no interaction between veteran status and age or sex. For the interaction between veteran status and race, significant disparities were found. Black/Other race veterans were significantly more likely to engage in binge drinking and heavy drinking compared to nonveterans of the same race, White veterans, and White nonveterans.

CONCLUSION

Older veterans who are also Black, Indigenous and/or people of color (BIPOC) are at great risk of engaging in alcohol misuse due to the combined stressors from their intersectional identities. Interventions targeting this population should consider the historical, cultural, and systemic factors that contribute to a disproportionally higher rate of binge drinking and heavy drinking among BIPOC veterans.

Substance use disorder and the baby boom generation: Does Berlin outpatient addiction care face a sustained change?

Introduction

The ageing of baby boomers is expected to confront addiction care with new challenges. This cohort had greater exposure to psychoactive substances in youth than earlier cohorts. In this study, we aimed to investigate whether Berlin addiction care is confronted with a sustained change in its clientele initiated by the baby boomers.

Methods

Using data from Berlin outpatient addiction care facilities, we contrasted type of primary substance use disorder and number of comorbid substance use disorders in baby boomers with an earlier and a later cohort. To isolate cohort effects, two‐level random intercept regression models were applied in the overlapping age groups of the baby boomer cohort with each of the other cohorts.

Results

Compared with the earlier cohort, alcohol use disorder lost importance whereas illicit substance use disorder gained importance in the baby boomers. Baby boomers presented a higher number of comorbid substance use disorders than the earlier cohort. Comparing baby boomers with the later cohort, these relationships pointed in the opposite direction.

Discussion and Conclusions

Outpatient addiction care faces a sustained change to more illicit and comorbid substance use disorders. With increasing life expectancy and the ageing of baby boomers marked by higher substance use than previous cohorts, older clients, who had been under‐represented in outpatient addiction care, will gain relevance. Hence, addiction care has to adapt its offers to appropriately meet the changing needs of its clientele.

Evaluating substance use treatment efficacy for younger and older adults

The purpose of this study was to examine the differential efficacy of aftercare substance use treatments for younger (below 40, n = 107) versus older (40+, n = 114) adults (N = 221), using data from a randomized controlled trial in a community-based substance abuse treatment center. The younger adult sample had a mean age of 28.9 while the older adult sample had a mean age of 48.1. Primary outcomes were rates of abstinence and percent use days at 1-year follow-up. Outcomes were compared between standard cognitive behavioral relapse prevention (RP), Mindfulness-Based Relapse Prevention (MBRP), and 12-step-based treatment as usual (TAU). Results showed significant differences by treatment in the older, but not in younger, subsample of participants. Specifically, the older participants in MBRP had significantly higher abstinence rates compared with those in TAU. Further, the older individuals in MBRP had a significantly lower percent of days on which they used compared with those in TAU and RP. Overall, findings suggest that age group may impact aftercare treatment substance use outcomes.

Racial Disparities in Substance Use Treatment Completion Among Older Adults

Background and Objectives

Racial disparities in substance use among young adults have been well documented in the substance use literature, but little attention has been paid to older adults. While being an older adult is positively associated with substance use treatment completion, racial disparities in treatment completion have yet to be examined. The purpose of this study was to determine to what extent racial disparities exist in substance use treatment completion among older adults (65 and older).

Research Design and Methods

This cross-sectional study utilized data from the most recent Treatment Episode Data from the Substance Abuse and Mental Health Services Administration, which documents discharges from a publicly funded substance use treatment program in the United States. A total of 17,942 older adults reported to a substance use treatment program in 2017 and 6,653 met the criteria for the study. Chi-squared tests were used to analyze group differences and a binary logistic regression was used to predict substance use treatment completion.

Results

Results show that Black older adults were 37% less likely to complete a substance use treatment program than Whites (OR = 0.630) while Hispanic older adults were 26% more likely to complete a substance use treatment program than Whites (OR = 1.26).

Discussion and Implications

These results support the findings from similar studies with younger adults and support the theory that racial disparities are prevalent across the life span. Although Hispanics had a higher treatment completion rate than Whites, this is likely a reflection of familismo, where decisions about health treatments is a group process and a steady network of family members are available to provide advice and encouragement. The significant disparity observed between Black and White older adults suggest a need to consider cultural, historical, and systemic factors that affect voluntary termination of substance use treatment among Black older adults.

The effect of legal mandates on substance use disorder treatment completion among older adults

Objective: This study seeks to determine the relationship between referral type (legally mandated versus non-mandated) and substance use disorder (SUD) treatment completion among older adults and by primary substance used.Method: We used data from the Treatment Episode Data Set - Discharges (TEDS-D) from 2011. Using data for persons age 55 and over (n = 104,747), we used propensity score matching (PSM) to address selection bias and attenuate the likelihood of a type I error. Logistic regression models estimated the effect of referral type on treatment completion based on treatment for a primary substance for five categories of substances.Results: In the matched sample, those who faced treatment mandates had 71% greater odds of completing treatment compared with those who entered treatment voluntarily (OR =1.71, 95% CI [1.64, 1.79]). Based on the primary drug used, odds of treatment completion were highest for alcohol, with 86% greater treatment completion for the mandated individuals compared with those entering treatment without a legal mandate (OR =1.86, 95% CI [1.75, 1.97]).Conclusion: These findings suggest that the motivating influence of treatment mandates may encourage completion of SUD treatment among older adults. Although the legal mandates for treatment are punitive, they may act to keep older adults with SUD engaged in treatment, an important factor as treatment completion is inversely related to relapse of a SUD.

Gaps In Access To Opioid Use Disorder Treatment For Medicare Beneficiaries

In 2016 only 13.8 percent of substance use disorder treatment programs offered medication treatment for opioid use disorder for older adults who used Medicare to pay for treatment. With increasing demand for treatment among older adults and a rapidly aging population, improved access to medication treatment for this population is needed.

Substance Use Disorders in Later Life: A Review and Synthesis of the Literature of an Emerging Public Health Concern

Substance use disorders (SUDs) among older persons are among the fastest growing health problems in the United States. The number of older persons is projected to exceed 72.1 million persons by 2030, following a trend of general population growth in the mid-1940s to 1960s. The generation, known as "baby boomers," who refashioned drug use during their 20-30s, are increasingly continuing drug habits into later life. This review aims to assess the epidemiology, impact, and treatment of geriatric SUDs. Academic databases including PubMed, PsychInfo, Ovid, and Medline, were queried up to December 2018 for terms of "geriatric," "older," "elderly," "substance abuse," "drug," "drug use," "drug abuse," "drug dependency," "illicit drugs," and "geriatric psychiatry." Articles identified included 17 government documents, 29 studies based upon government documents, 43 studies not related to US government surveys, 19 review articles, 9 commentary pieces, 4 newspaper articles, 2 textbooks, and 1 published abstract. Evaluated studies and documents together suggest that older individuals are using illicit drugs and meeting criteria for SUDs at higher rates than previous geriatric cohorts resulting in substantial negative impacts on medical and psychiatric conditions. These findings represent a novel trend since previous cohorts of older individuals were thought to rarely use illicit substances. Current treatment models are inadequate to address the new wave of older individuals with SUDs. The fields of geriatrics, addiction, and geriatric psychiatry must work together to establish comprehensive care models and treatment modalities for addressing this emerging public health concern.

Assessment Protocol for Older Adults With Substance Use

This quality improvement project focuses on geriatric syndromes in patients 55 years and older admitted to a Minnesota substance abuse treatment center. Age-specific assessments identify abnormal conditions or geriatric syndromes, which prompt earlier nursing and medical interventions. Nursing staff attended a training program that focused on older adults and the use of the Fulmer SPICES tool for patients over the age of 55 years. Pretest and posttest scores showed a positive change in nursing knowledge with an increase in mean test scores of 10.32 (SD = 1.763) to 12.81 (SD = 1.545), p = .000. A 2-month preimplementation and postimplementation chart audit identified changes in assessment findings using the SPICES tool with an increase in adverse outcomes (1.03%) including sleep problems in 75.4% (n = 43) of the target population.

From adolescence to late aging: A comprehensive review of social behavior, alcohol, and neuroinflammation across the lifespan

The passage of time dictates the pace at which humans and other organisms age but falls short of providing a complete portrait of how environmental, lifestyle and underlying biological processes contribute to senescence. Two fundamental features of the human experience that change dramatically across the lifespan include social interactions and, for many, patterns of alcohol consumption. Rodent models show great utility for understanding complex interactions among aging, social behavior and alcohol use and abuse, yet little is known about the neural changes in late aging that contribute to the natural decline in social behavior. Here, we posit that aging-related neuroinflammation contributes to the insipid loss of social motivation across the lifespan, an effect that is exacerbated by patterns of repeated alcohol consumption observed in many individuals. We provide a comprehensive review of (i) neural substrates crucial for the expression of social behavior under non-pathological conditions; (ii) unique developmental/lifespan vulnerabilities that may contribute to the divergent effects of low-and high-dose alcohol exposure; and (iii) aging-associated changes in neuroinflammation that may sit at the intersection between social processes and alcohol exposure. In doing so, we provide an overview of correspondence between lifespan/developmental periods between common rodent models and humans, give careful consideration to model systems used to aptly probe social behavior, identify points of coherence between human and animal models, and point toward a multitude of unresolved issues that should be addressed in future studies. Together, the combination of low-dose and high-dose alcohol effects serve to disrupt the normal development and maintenance of social relationships, which are critical for both healthy aging and quality of life across the lifespan. Thus, a more complete understanding of neural systems-including neuroinflammatory processes-which contribute to alcohol-induced changes in social behavior will provide novel opportunities and targets for promoting healthy aging.

Older marijuana users in substance abuse treatment: Treatment settings for marijuana-only versus polysubstance use admissions

OBJECTIVE

Growing numbers of older adult marijuana users make understanding the marijuana-related treatment needs and treatment-related characteristics of this age group increasingly important. In this study, we examined four types of marijuana-involved admissions (marijuana as the only substance; marijuana as the primary substance with other secondary/tertiary substances; marijuana as the secondary substance; and marijuana as the tertiary substance) by treatment setting.

METHODS

Data came from the 2012-2017 Treatment Episode Data Set-Admissions (TEDS-A), which includes 851,652 admissions by those aged 55+. Using multinomial logistic regression analysis, we focused on the 120,286 marijuana-involved admissions to test the hypothesis that polysubstance use would be associated with a higher likelihood of using detoxification and rehabilitation settings than ambulatory/outpatient settings.

RESULTS

Of all marijuana-involved admissions, 7.5% were marijuana-only, 12.7% were marijuana-primary, 58.4% were marijuana-secondary, and 21.4% were marijuana-tertiary admissions. Compared to marijuana-only admissions, admissions involving other substances were associated with a higher likelihood of detoxification and rehabilitation than ambulatory/outpatient treatment (e.g., RRR = 5.79, 95% CI = 5.08-6.61 for detoxification and RRR = 3.19, 95% CI = 2.89-3.52 for rehabilitation among marijuana-tertiary admissions). Referral source, first age of marijuana use, race/ethnicity, and homelessness were significant covariates.

CONCLUSIONS

Given increasing numbers of older-adult marijuana users, healthcare providers should screen older adults for marijuana and other substance use, and substance abuse treatment programs should become more responsive to older adults' needs.

Factors Influencing Judgments to Consult Prescription Monitoring Programs: A Factorial Survey Experiment

BACKGROUND

Prescription monitoring programs (PMPs) can provide health care professionals with valuable information. However, few studies have explored providers' decision making for accessing PMPs.

AIMS

This study aimed to identify provider characteristics and situational factors most influencing perceived importance of consulting the PMP for patients in a simulated context.

DESIGN

The study used a cross-sectional factorial survey.

SETTINGS

The survey was administered electronically.

PARTICIPANTS/SUBJECTS

Community pharmacists, advanced practice registered nurses (APRNs), and physicians in Iowa.

METHODS

Participants were recruited by mail which included a link to the online survey. The survey consisted of demographic questions, eight randomly generated vignettes, and one ranked item. The vignettes described a hypothetical prescription using eight experimental variables whose levels were randomly varied. Respondents evaluated each vignette for importance to access the PMP. Analyses used linear mixed-effects models in R (Version 3.5.0).

RESULTS

A total of 138 responses were available for multilevel analysis. Women, physicians, and APRNs rated it more important to consult the PMP for a given prescription compared with men and pharmacists. Accessing a PMP was perceived as more important with cash payments, quantity dispensed, suspicion for misuse, hydromorphone and oxycodone prescriptions, and headache. Advancing age, postoperative pain, and anxiety or sleep indications were associated with less importance.

CONCLUSIONS

Age, indication for prescribing, misuse, and payment mode each independently had greater importance to providers in accessing the PMP. This was the first study to isolate the influence of different controlled substances on how important it was to consult the PMP.

Synthesizing the Strength of the Evidence of Complementary and Integrative Health Therapies for Pain

Objective

Pain and opioid use are highly prevalent, leading for calls to include nonpharmacological options in pain management, including complementary and integrative health (CIH) therapies. More than 2,000 randomized controlled trials (RCTs) and many systematic reviews have been conducted on CIH therapies, making it difficult to easily understand what type of CIH therapy might be effective for what type of pain. Here we synthesize the strength of the evidence for four types of CIH therapies on pain: acupuncture, therapeutic massage, mindfulness techniques, and tai chi.

Design

We conducted searches of English-language systematic reviews and RCTs in 11 electronic databases and previously published reviews for each type of CIH. To synthesize that large body of literature, we then created an “evidence map,” or a visual display, of the literature size and broad estimates of effectiveness for pain.

Results

Many systematic reviews met our inclusion criteria: acupuncture (86), massage (38), mindfulness techniques (11), and tai chi (21). The evidence for acupuncture was strongest, and largest for headache and chronic pain. Mindfulness, massage, and tai chi have statistically significant positive effects on some types of pain. However, firm conclusions cannot be drawn for many types of pain due to methodological limitations or lack of RCTs.

Conclusions

There is sufficient strength of evidence for acupuncture for various types of pain. Individual studies indicate that tai chi, mindfulness, and massage may be promising for multiple types of chronic pain. Additional sufficiently powered RCTs are warranted to indicate tai chi, mindfulness, and massage for other types of pain.

Sex differences in an old adult sample with substance use disorder: A 6 months follow-up study

Substance use disorder (SUD) is a worldwide concern that has its own particularities regarding age and sex. This study aims to assess the differences between old SUD women and men regarding socio-demographics, clinical factors and outcomes. A 6-months follow-up longitudinal study was conducted in an outpatient center, on a convenience sample of 115 SUD old adults (≥65 years old, average age of 71.57). Descriptive, bivariate, and multivariate analyses were performed. Data showed statistical significant differences between men and women related to sociodemographic variables (marital status, coexistence, criminal records and stress factors), medical and psychiatric conditions (women suffer higher rates of depression and anxiety, with worse health-related quality of life), family records (women had more presence of family psychiatric records) and SUD related parameters (men tend to use more alcohol, had an early onset, consume higher doses, report more craving and more tobacco life use while women had higher rates of prescription drugs use). At 6-month follow-up, the whole sample showed excellent rates of adherence and abstinence, without sex differences. The study points out sex differences on several sociodemographic and clinical variables, indicating their specific needs. This research could facilitate better approaches by considering a sex perspective in SUD old adults.

A hidden aspect of the U.S. opioid crisis: Rise in first-time treatment admissions for older adults with opioid use disorder

BACKGROUND

Older adults with opioid use disorder (OUD) are a medically complex population. The current study evaluated trends in older adults seeking treatment for OUD, with a focus on primary heroin versus prescription opioid use. This study also compared older adults with OUD to the younger OUD population on demographics and drug use behaviors.

METHODS

Publicly available data from state-certified addiction treatment centers were collected via the Treatment Episode Data Set - Admissions (TEDS-A) between 2004-2015. This study utilized Joinpoint Regression to conduct a cross-sectional, longitudinal analysis of trends in first-time treatment admissions for OUD in adults 55 and older (older adults; n = 400,421) versus adults under the age of 55 (n = 7,795,839). Given the rapid increase in older adults seeking treatment for OUD between 2013-2015, secondary outcomes include changes in demographics and drug use between 2012 (as a baseline year) and 2015.

RESULTS

The proportion of older adults seeking treatment for OUD rose steadily between 2004-2013 (41.2% increase; p-trend = 0.046), then rapidly between 2013-2015 (53.5% increase; p-trend = 0.009). The proportion of older adults with primary heroin use more than doubled between 2012-2015 (p < 0.001); these individuals were increasingly male (p < 0.001), African American (p < 0.001), and using via the intranasal route of administration (p < 0.001).

CONCLUSIONS

There has been a recent surge in older adults seeking treatment for OUD, particularly those with primary heroin use. Specialized treatment options for this population are critically needed, and capacity for tailored elder care OUD treatments will need to increase if these trends continue.

Personal theories of substance use among middle-aged and older adults with bipolar disorder

OBJECTIVES

Most persons with bipolar disorder (BD) misuse alcohol and/or illicit drugs at some point, yet research specific to older adults with BD is nascent. The current study sought an in-depth understanding of the experiences and meanings of substance use in a sample of adults who self-reported substance misuse.

METHODS

Semi-structured interviews were conducted and thematically analyzed to understand the personal theories of substance use by 12 adults (9 women and 3 men; M = 49 years old) who self-reported diagnoses of BD and regular alcohol or illicit drug use.

RESULTS

Findings provide an in-depth picture of the theories middle-aged and older adults with BD have developed to explain their substance use. Participants' theories suggest multiple reasons for substance use, including self-medication; increased confidence with substance use; rejection of prescribed medications; easy access to alcohol; early social exposure/use as facilitator; and living in a culture of substance use.

CONCLUSION

Findings suggest multiple theories for the comorbid link between BD and substance use, primarily that persons with BD use drugs and/or alcohol to relieve stress or manage symptoms. It is clinically relevant to incorporate personal reasons for actively and regularly using substances as part of personalized substance treatment and BD symptom management.

Aspects of control and substance use among middle-aged and older adults with bipolar disorder

High prevalence rates of alcohol and substance use disorders have been reported among persons with bipolar disorder (BD). In the present study, we explored the daily experiences of middle-aged and older adults living with BD who reported regular substance use and the ways in which participants expressed 'control' in relation to their use of alcohol and other substances. Semistructured, in-depth interviews were conducted with 12 participants (nine women and three men), aged 36-57 years of age (mean = 49 years). Thematic analyses identified emergent themes and patterns in participants' life histories. The theme of 'control' emerged as central to participants' reports, and was organized into four categories: (i) substance use to control BD symptoms; (ii) substance use provides a sense of being in control; (iii) methods of controlled substance use; and (iv) not having control: overreliance on substances. Implications of the present study include the need for nurses to openly discuss the use of alcohol and other drugs with persons with BD, provide health information and screening, and determine whether persons with BD feel they have control over their substance use. Several lines of research with persons who have BD and use substances are suggested.

Interventions in individuals with specific needs

With the growing understanding of substance use problems among special populations like women, gender minority groups, as well as in the geriatric population, there is a drive to develop sensitive interventions catering to their unique needs. This chapter is a short review of psycho-social interventions targeted towards these individuals with specific needs.

Comparing daily drivers of problem drinking among older and younger adults: An electronic daily diary study using smartphones

BACKGROUND

By 2030, numbers and proportions of older adults with substance-use problems are expected to increase. While risk factors for problem drinking in late life have been identified, it remains unknown whether these factors drive daily drinking among older problem drinkers. This study examined the daily drivers of drinking among problem drinkers, moderated by age, utilizing ecological momentary assessment (EMA).

METHOD

Participants (N = 139), ages 20-73, received daily EMA online surveys completed via a smartphone prior to initiation of treatment. Multilevel modeling tested the moderating impact of age on within- and between-person relationships between drinking and focal predictors (mood, loneliness, boredom, stress, poor sleep, social factors, alcohol salience, commitment and confidence not to drink heavily).

RESULTS

Older adults reported greater alcohol consumption when daily boredom levels were higher. Heavier drinking among younger adults was associated with poorer sleep quality. Greater daily confidence, daily commitment and daily alcohol salience did not impact drinking to the same extent for older adults as for younger adults. Greater person-level commitment predicted reduced drinking equivalently across age, but low person-level commitment predicted greater drinking among older adults compared to their younger counterparts.

CONCLUSION

Older adults may have unique daily drivers of drinking that are not fully realized in current research and intervention efforts. Addressing the growing substance-use treatment needs among this population will require identifying the unique drivers of drinking among older adults, such as boredom, when compared to younger adults.

The impact of substance use disorders on clinical outcomes in older-adult psychiatric inpatients

OBJECTIVE

To examine associations among substance use disorder (SUD) and measures of length of stay (LOS) and non-psychiatric medical comorbidity (MEDCO) in older-adult inpatients with serious mental illness (SMI), hypothesizing SUD would be related to worse clinical outcomes.

METHODS

A cross-sectional study analyzed medical records from 2010 to 2016 of 7258 inpatients with SMI ≥ age 50, obtained from a 274-bed psychiatric hospital. Descriptive analyses examined prevalence rates for SUD status (+/-), individual drug classes, and total number of SUDs (polysubstance use disorders). Regression models examined the influence of 2 independent variables of interest: (1) SUD status (+/-) and (2) type of SUD (ie, specific drug), controlling for demographic factors and additional (non-SUD) psychiatric disorders. Two dependent (outcome) variables were examined: LOS and MEDCO.

RESULTS

The overall SUD rate was 26%; cocaine was the most common SUD (≈ 10%). SUD status and additional (non-SUD) psychiatric diagnoses were significantly associated with longer LOS (both P < 0.001). For individual SUDs, cocaine, marijuana, opiates, and alcohol were all significantly associated with LOS (all P < 0.01). SUD status, age, sex, admission status, and race were significantly associated with MEDCO (all P < 0.002). For individual SUDs, barbiturates, opiates, and alcohol were all significantly associated with MEDCO (P < 0.01).

CONCLUSIONS

The prevalence of SUD in this sample underscores concerns related to treating older adults presenting providers with comorbid SUD and SMI. This combination may increase the burden and complexity of care, warranting further investigation into mechanisms and long-term consequences.

Effect of ageing and time since first heroin and cocaine use on mortality from external and natural causes in a Spanish cohort of drug users

BACKGROUND

We aimed to assess the effect of ageing and time since first heroin/cocaine use on cause-specific mortality risk and age disparities in excess mortality among heroin (HUs) and cocaine users (CUs) in Spain.

METHODS

A cohort of 15,305 HUs and 11,905 CUs aged 15-49 starting drug treatment during 1997-2007 in Madrid and Barcelona was followed until December 2008. Effects of ageing and time since first heroin/cocaine use were estimated using a competing risk Cox model and the relative and absolute excess mortality compared to the general population through directly age-sex standardized rate ratios (SRRs) and differences (SRDs), respectively.

RESULTS

Mortality risk from natural causes increased with time since first heroin use, whereas that from overdose declined after having peaked in the first quinquennium. Significant effects of time since first cocaine use were not identified, although fatal overdose risk seemed higher in CUs after five years. Mortality risk from natural causes (HUs and CUs), injuries (HUs), and overdoses (CUs) increased with age, the latter without reaching statistical significance. Crude mortality rates from overdoses and injuries remained very high at age 40-59 among both HUs (595 and 217 deaths/100,000 person-years, respectively) and CUs (191 and 88 deaths/100,000 person-years). SRDs from all and natural causes were much higher at age 40-59 than 15-29 in both HUs (2134 vs. 834 deaths/100,000 person-years) and CUs (927 vs. 221 deaths/100,000 person-years), while the opposite occurred with SRRs.

CONCLUSION

The high mortality risk among HUs and CUs at all ages from both external and natural causes, and increased SRDs with ageing, suggest that high-level healthcare and harm reduction services should be established early and maintained throughout the lifetime of these populations.

Alcohol and other drug use in older adults: results from a community needs assessment

BACKGROUND

With the "Baby Boomer" generation reaching older adulthood, substance abuse treatment providers find themselves needing to address the unique needs of this population. Heavy drinking in adults ages 65 and over is strongly correlated with depression, anxiety, decreased social support, and poor health. However, while alcohol misuse has been shown to be predictive of a lower quality of life in older adults, the generalizability of these findings to urban dwelling, lower socioeconomic status individuals remains unclear.

AIMS

To identify potential treatment needs of this population, a city-funded needs assessment was conducted.

METHODS

Subjects were 249 individuals (44% male) who voluntarily completed measures of quality of life (QOL), depression, and substance abuse. Measures used included the Psychological General Well-Being Schedule, the Geriatric Depression Scale-15, and the Alcohol Use Disorders Identification Test (AUDIT).

RESULTS

Alcohol or substance abuse was reported by over 20% of respondents, with 3.4% of respondents engaged in maladaptive alcohol use. Scores on the AUDIT were predictive of increased depression (r = - .209, p = .01), anxiety (r = - .201, p = .002), lower general well-being (r = - .154, p = .019), and decreased self-control (r = - .157, p = .017).

DISCUSSION

A substantial percentage of the sample reported alcohol and substance misuse. Alcohol use was predictive of depression, global psychological distress, and decreased quality of life.

CONCLUSIONS

This needs assessment reinforces findings from previous studies and addresses the added dimension of examining this in an urban, lower socioeconomic population.

Long QTc During Methadone Maintenance: Contributors and Interventions Over 4 Years

Our goal consisted of describing the 4-year prevalence, contributors, and interventions for long QTc's in methadone maintenance treatment. Cardiologists' diagnosis of long QTc defined case-ness in 62 patients. Long QTc categories, drawn from epidemiological reports, encompassed 440 to 469 (borderline), 470 to 499 (moderate), and 500+ milliseconds (severe). Data collection included electrocardiograms, demographic characteristics, contributors to long QTc, and interventions-plus-outcomes (defined by resolution of long QTc). Of 62 patients, 21 had 39 long QTc episodes-a 4-year case prevalence of 34%, and an annual episode incidence of 15.7 per 100. Contributing factors identified in 36 of 39 episodes consisted of medication management (n = 19), illicit drug use (n = 11), and other factors (n = 6). Long QTc reverted to normal in 38 of 39 episodes. Of 21 patients, 12 (57%) experienced one or two recurrences. Methadone maintenance treatment physicians normalized most episodes as outpatients, often in collaboration with patients' primary care physicians. One fifth of episodes required hospitalization and other specialty care. Lack of timely QTc normalization may have accounted for one sudden death.

Trends in substance use admissions among older adults

BACKGROUND

Substance abuse is a growing, but mostly silent, epidemic among older adults. We sought to analyze the trends in admissions for substance abuse treatment among older adults (aged 55 and older).

METHODS

Treatment Episode Data Set - Admissions (TEDS-A) for period between 2000 and 2012 was used. The trends in admission for primary substances, demographic attributes, characteristics of substance abused and type of admission were analyzed.

RESULTS

While total number of substance abuse treatment admissions between 2000 and 2012 changed slightly, proportion attributable to older adults increased from 3.4% to 7.0%. Substantial changes in the demographic, substance use pattern, and treatment characteristics for the older adult admissions were noted. Majority of the admissions were for alcohol as the primary substance. However there was a decreasing trend in this proportion (77% to 64%). The proportion of admissions for following primary substances showed increase: cocaine/crack, marijuana/hashish, heroin, non-prescription methadone, and other opiates and synthetics. Also, admissions for older adults increased between 2000 and 2012 for African Americans (21% to 28%), females (20% to 24%), high school graduates (63% to 75%), homeless (15% to 19%), unemployed (77% to 84%), and those with psychiatric problems (17% to 32%).The proportion of admissions with prior history of substance abuse treatment increased from 39% to 46% and there was an increase in the admissions where more than one problem substance was reported. Ambulatory setting continued to be the most frequent treatment setting, and individual (including self-referral) was the most common referral source. The use of medication assisted therapy remained low over the years (7% - 9%).

CONCLUSIONS

The changing demographic and substance use pattern of older adults implies that a wide array of psychological, social, and physiological needs will arise. Integrated, multidisciplinary and tailored policies for prevention and treatment are necessary to address the growing epidemic of substance abuse in older adults.

Cognition and adaptive functioning in older people attending drug and alcohol services

BACKGROUND

Substance use disorders in older adults are expected to increase dramatically in the coming years. Given the increased susceptibility to cognitive deficits in older substance users (defined here as aged 50+ years due to the accelerated health decline observed in this population), it is important to consider the functional correlates of cognitive impairment in these older adults. This study details the cognitive status of older individuals attending outpatient drug and alcohol (D&A) treatment services and seeks to determine of the association of cognitive impairment to self-reported daily functioning.

METHODS

Ninety nine clients aged 50 years or over attending outpatient D&A treatment services in Sydney, Australia participated. Cognition was assessed using the Addenbrooke's Cognitive Examination - Revised (ACE-R). Recent substance use (Australian Treatment Outcome Profile), physical and mental health (SF12, Geriatric Depression Scale), social isolation (Lubben Social Network Scale), and activities of daily living (Bayer ADL Scale) were also assessed.

RESULTS

Nearly two-thirds of participants screened positive for cognitive impairment on the ACE-R; 41% and 65% of clients met the cut-off scores for mild cognitive impairment (MCI) and more severe cognitive impairment, respectively. Self-reported seizure history was a predictor of cognitive impairment.

CONCLUSIONS

The results suggest that cognitive impairment in this group is common. The assessment of cognitive status for this older group of patients should not only include the identification of cognitive impairment but also encompass mental health and social functioning. A greater understanding of the needs of this cohort will also enable better co-ordination with other health and welfare services tailored to this population.