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Substance use disorder among older adults in the United States in 2020
Abstract
This study aimed to project the number of people aged 50 years or older with substance use disorder (alcohol/illicit drug dependence or abuse) in the United States in 2020.
Logistic regression models were applied to estimate parameters predicting past-year substance use disorder using the 2002-06 National Survey on Drug Use and Health data. We applied these parameters to the projected US 2020 population to estimate the number of adults aged 50 or older with substance use disorder in 2020.
Non-institutionalized US residences.
Representative sample of the US civilian, non-institutionalized population.
Substance use disorder is classified based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition.
Due to the large population size and high substance use rate of the baby-boom cohort, the number of adults aged 50 or older with substance use disorder is projected to double from 2.8 million (annual average) in 2002-06 to 5.7 million in 2020. Increases are projected for all examined gender, race/ethnicity and age groups.
Our estimates provide critical information for policymakers to allocate resources and develop prevention and treatment approaches to address future needs of the US older adult population with substance use disorder.
... Las tendencias internacionales demuestran que un gran número de consumidores de opioides viven más tiempo. Es probable que esto se deba a una serie de factores: (i) cambios demográficos y aumento de la esperanza de vida en la población general, (ii) cohortes que envejecen durante el baby boom y después del baby boom (grupo de 50 años o más) que experimentaron niveles crecientes disponibilidad de drogas a lo largo del tiempo junto con tasas más altas de uso de drogas ilícitas durante la juventud, (iii) avances en el acceso a la atención médica y un mejor acceso a los servicios de atención médica, reducción de daños y tratamiento de drogas que conducen a una mayor longevidad entre los consumidores de drogas (4,6,10, [16][17][18][19] . ...
... La prevalencia de consumo problemático de sustancias de abuso encontrada en este estudio tiende a ser menor que la descrita en encuestas realizadas con la población en general y menor que los hallazgos internacionales (2,3,5,7,8,(10)(11)(12)14,(16)(17)(18)25) . Esta diferencia puede estar relacionada con las características socioculturales de la muestra y el hecho de que los pacientes evaluados ya están en contacto con un servicio de salud mental, siendo monitoreados regularmente. ...
... Cabe destacar que la sensibilidad de los adultos mayores aumenta con los años, lo que hace que sientan los efectos inducidos por el uso de sustancias psicoactivas con menor consumo, lo que significa que no necesitan consumir tanto como antes para obtener el mismo efecto (5) . Simultáneamente, con el uso de medicamentos para controlar, entre otros, la presión arterial, tales medicamentos, por regla general, interactúan negativamente con el consumo de sustancias psicoactivas (18) , anulando o potenciando sus efectos, favoreciendo la muerte. Esto explica que las personas mayores que abusan de sustancias tienden a morir antes que la población general (54) . ...
El uso de drogas por los ancianos se caracteriza por ser un grave problema de salud pública. El número de usuarios de mayor edad ha aumentado a nivel internacional durante los últimos 40 años, pero el tema sigue siendo descuidado. Este estudio se centra en pacientes ancianos con síntomas de enfermedades mentales concomitantes. Así, se investigó el tiempo de uso, patrones de consumo de sustancias de abuso y el perfil sociodemográfico de los pacientes atendidos en los Centros de Atención Psicosocial por Alcohol y Drogas (CAPS-AD), ubicados en la ciudad de Río de Janeiro. Se trata de un estudio observacional descriptivo con un diseño cuantitativo transversal sobre la frecuencia de abuso de sustancias en la población mencionada. Las prevalencias obtenidas en este estudio son inferiores a las encontradas en la población general y a las reportadas en estudios internacionales. Esta diferencia puede estar relacionada con las características socioculturales de la muestra y el hecho de que los pacientes ya están en contacto con un servicio de salud mental, lo que puede indicar la importancia del contacto regular con los servicios de salud como factor protector y espacio de ayuda.
... As such, the aging of this group will significantly affect the size and characteristics of the geriatric population, including patterns of substance use [5]. Therefore, with an estimated 5.7 million older adults in the United States requiring addiction treatment in 2020 [6][7][8], the number of older adults with substance use disorders is expected to continue to rise over the next decade. ...
... Opioid use as well as substance use in general is a common occurrence in older adults, though often overlooked and undertreated [1,2,88]. Available evidence suggests that the number of older adults with substance use disorders is likely to increase with the aging of the population [6][7][8]. Previous estimates have predicted a doubling in the number of individuals aged of > 50 years with substance use disorders in the United States, from 2.8 million in 2006 to 5.7 million in 2020 [8]. A proportion of this increase will likely be due to OUD. ...
... Available evidence suggests that the number of older adults with substance use disorders is likely to increase with the aging of the population [6][7][8]. Previous estimates have predicted a doubling in the number of individuals aged of > 50 years with substance use disorders in the United States, from 2.8 million in 2006 to 5.7 million in 2020 [8]. A proportion of this increase will likely be due to OUD. ...
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.
... Alcohol use, drug use, and the prevalence of substance use disorders have grown substantially among adults in recent years, particularly among older adults (those 65 and older). Alcohol use among this age group is notably higher than in previous generations, [1][2][3][4][5] and rates of excessive alcohol use among adults 65 and older increased by 65% between 2001-2002 and 2012-2013. 6 Although the prevalence of alcohol use disorders (AUDs) among older adults (estimated at about 3%) is low compared to other age groups, the prevalence is growing rapidly with an estimated increase of over 100% in that same time period. ...
... The number of quarterly OUD hospitalizations was small for Latino, Asian, and Native American older adults (<25/quarter), and the number of OUD hospitalization records with "Unknown" and "Other" for race/ethnicity is in some cases similar or larger than the number of hospitalizations with Latino, Asian, and Native American race/ethnicity (See Supplemental Appendix Figure 1). 5 The results of the regression analyses showed that the overall trend was positive and statistically significant for OUD quarterly hospitalization rates (Coeff = 2.14 (95% CI = 1.86-2.43), P < .001). ...
Background
The prevalence of substance use disorders (SUDs) among adults ages 65 and older has been increasing at a notably high rate in recent years, yet little information exists on hospitalizations for SUDs among this age group. In this study we examined trends in hospitalizations for alcohol use disorders (AUDs) and opioid use disorders (OUDs) among adults 65 and older in the United States, including differences by gender and race/ethnicity.
Methods
We used Medicare claims data for years 2007-2014 from beneficiaries ages 65 and older. We abstracted hospitalization records with an ICD-9 diagnostic code for an AUD or OUD. Hospitalization rates were calculated using population estimates from the United States Census. We examined trends in quarterly hospitalization rates for hospitalizations with AUD/OUD as primary diagnoses, and separately for those with these disorders as secondary diagnoses. We also examined comorbidities for those with a primary diagnosis of AUD/OUD. Analyses were conducted for all hospitalizations with AUD/OUD diagnoses, and separately by gender and race/ethnicity.
Results
Between the last quarter of 2007 and the third quarter of 2014, AUD hospitalization rates increased from 485 to 579 per million (19%), and OUD hospitalization rates from 46 to 101 per million (120%) and varied by gender (for AUD) and race/ethnicity (for both AUD and OUD). Hospitalization rates were particularly high for Black older adults, as was the increase in hospitalization rates. The increase in hospitalization rates was substantially higher for hospitalizations with AUD (84%) and OUD (269%) as secondary diagnoses.
Conclusions
Hospitalizations for AUDs and OUDs among older adults increased at an alarming rate during the observation period, and disparities existed in hospitalization rates for these conditions. Interventions focusing on the needs of older adults with AUD and/or OUD are needed, particularly to address the needs of a growing racially/ethnically diverse older adult population.
... Updated estimates of smoking and alcohol misuse rates among Canadian older adults are not available. However, it is estimated that more American older adults would suffer from substance use disorders in the next decade, especially among "baby boomers" (Han, Gfroerer, Colliver, & Penne, 2009;Wu & Blazer, 2014). ...
... Associations between sleep and substance use have also been observed in other large samples of older adults, with evidence from the Canadian Alcohol, Tobacco, and Drugs survey indicating that smoking and alcohol use frequency peaks in the 65 to 74 year age group, and is three times higher than in those aged 15 to 54 years (CTADS, 2017). Moreover, current estimates indicate this prevalence will only increase with the aging "baby boomer" generation (Han et al., 2009;Wu & Blazer, 2014). Studies conducted among community-dwelling adults have shown that aging seems to moderate the association between alcohol use and sleep, with older adults who used alcohol for longer and more frequently showing greatest decreases in both sleep efficiency and subjective sleep satisfaction (McHugh et al., 2018). ...
Poor sleep is associated with chronic health conditions among older adults. As substance use rates increase in this population, age-related physiological and cognitive declines may exacerbate its detrimental consequences, including sleep problems. We analyzed cross-sectional associations between sleep patterns, smoking, and alcohol use using baseline data from 30,097 community-dwelling Canadian adults aged 45-85 years from the Canadian Longitudinal Study on Aging. Insomnia symptoms(difficulties falling/staying asleep), sleep duration(short:<6h; long:>8h), and sleep satisfaction(dissatisfied/neutral/satisfied) were measured. Smoking and alcohol-use frequency(past 12 months), average daily amount(past 30 days), and binge drinking(past 12 months) were self-reported, and associations were examined using modified Poisson regression. Approximately 23% of participants had insomnia symptoms, and 26% reported sleep dissatisfaction. 91% of participants were current non-smokers, whereas 7% reported smoking daily. Over 50% drank ≤2 drinks daily, and 3% reported binge drinking. There was a higher adjusted prevalence of insomnia among daily smokers(PR=1.10, 95%CI=1.00-1.21) and binge drinkers(PR=1.21, 95%CI=1.02-1.43). Odds of short sleep duration were lower among regular drinkers(COR=0.71, 95%CI=0.56-0.90) and higher among daily smokers(COR=1.19, 95%CI=1.01-1.40). Heavy and frequent smoking and alcohol use are associated with both insomnia symptoms and sleep dissatisfaction, but not consistently with sleep duration. Further longitudinal investigation of this relationship in aging populations is needed in clinical and public health settings to infer the extent of causality and design effective public health interventions in this vulnerable population.
... Individuals in the 1945-65 and subsequent birth cohorts initiated illicit drug use, including injecting drug use, at higher rates than previous generations [9][10][11][12]. For some members of this group, drug use remains a persistent behaviour throughout the life-course, including into older age [13,14]. ...
... This includes 14 editorials or commentaries calling for additional research in this area, the earliest of which were published in the 1970s [52,53], but continuing into the 2010s [54][55][56]. Demographic trends towards an ageing of people using drugs [4,5,57] as well as people seeking drug treatment [6,8,53,58] were noted, occasionally attributed to the greater prevalence of drug use in the 'baby boom' birth cohort [9][10][11]. Publications also noted the especially OAT, to better serve older adults [26,77,78]. ...
Aims:
To provide an overview of research literature on aging 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 aging 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.
... In the present study, women, who have a longer life average expectancy than men, emerged as being at particular risk of developing prescription opioid dependence condition. 40,41 Although data regarding comorbid mental health illnesses at intake were unfortunately not available here, one could argue that women may be at a higher risk of developing both chronic pain-related medical conditions and psychological distress/depression. [42][43][44][45] Consistent with findings in the literature, 6,39-46 data from the present study showed a non-negligible level of concurrent dependence on hypnotics, tranquilizers, and sedatives (e.g. benzodiazepines and Z-drugs). ...
... This is cause for concern, as these pharmacological interactions may be associated with a decline in cognitive function, 47 psychomotor abnormalities, and excessive central nervous system depressant side-effects, 3 with a dose-dependent risk of falls and hip fractures. 3,6,41,48,49 Furthermore, as advised by the 2015 American Geriatrics Society Beers Criteria, potential drug-drug interactions, especially if involving opioids, should be avoided, and prescription of three or more central nervous system agents should be considered inappropriate prescribing. 50 The synthetic compound tilidine appeared here to be the most reported opioid analgesic. ...
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.
... 2015;Kuerbis et al. 2017). Indeed, other age-related conditions have similar physiological and psychological consequences, making screening complicated (Maynard et al. 2016). In Europe and the USA, projections indicate that the number of OA over 65 years of age requiring treatment for problematic AU is expected to triple by 2050 (Bobak et al. 2016;B. Han et al. 2009). Today, treatments implemented to treat AUD are not specific to OA (Bhatia et al. 2015;I. B. Crome & Crome, 2018). International research on treatments for UAU in OA (Moy et al. 2011) and evidence-based preventive practices and effective policies are scarce (Anderson et al. 2012;Veerbeek et al. 2019). ...
Alcohol use among older adults, often denied, is a real public health problem in view of the harmful consequences it induces. The objective of this systematic review was to identify articles on the biopsychosocial factors, assessment tools, and treatment options that have proved useful for the early detection and management of alcohol use among older adults. With a view to producing a narrative synthesis from several databases, 66 articles were identified and studied, of which 45.4% (n = 30) were published between 2015 and 2020. The review is reported according to PRISMA guidelines. Although differences appear to exist between the samples studied, the analyses show that biopsychosocial factors such as quality of life, well-being, emotions, perceived stress, coping strategies, and mood disorders are associated with unhealthy alcohol use. Psychosocial factors such as strong social support appear to be correlated with low levels of alcohol use and abstinence. In general, the tools used to screen for alcohol use are AUDIT, CAGE, DPI, CARET, and SMAST-G. Interventions to prevent and manage alcohol use in older adults include CBT and brief interventions. This review of the literature provides a better understanding of which assessment tools should be used for screening. Emphasis should be placed on process-oriented scientific studies, which to date do not exist. Psychological processes mediated by biopsychosocial factors would enable the development of effective prevention interventions to be conducted in order to improve the quality of life of older adults.
... The current study indicates that marriage may be a particularly important mechanism of problem-drinking reduction in young adulthood relative to later periods of the adult life span. However, given the ongoing increases in older adult problem drinking that coincide with aging of the "baby boomer" generation (Han et al., 2009), future research should continue to examine other possible mechanisms that may be important in later periods of adulthood. ...
While prior literature has largely focused on marriage effects during young adulthood, it is less clear whether these effects are as strong in middle adulthood. Thus, we investigated age differences in marriage effects on problem-drinking reduction. We employed parallel analyses with two independent samples (analytic-sample N s of 577 and 441, respectively). Both are high-risk samples by design, with about 50% of participants having a parent with lifetime alcohol use disorder. Both samples have been assessed longitudinally from early young adulthood to the mid-to-late 30s. Separate parallel analyses with these two samples allowed evaluation of the reproducibility of results. Growth models of problem drinking tested marriage as a time-varying predictor and thereby assessed age differences in marriage effects. For both samples, results consistently showed marriage effects to be strongest in early young adulthood and to decrease somewhat monotonically thereafter with age, reaching very small (and nonsignificant) magnitudes by the 30s. Results may reflect that role transitions like marriage have more impact on problem drinking in earlier versus later adulthood, thereby highlighting the importance of life span developmental research for understanding problem-drinking desistance. Our findings can inform intervention strategies aimed at reducing problem drinking by jumpstarting or amplifying natural processes of adult role adaptation.
... Moreover, elderly people, especially older women, are particularly vulnerable to the adverse effects of alcohol and, alcohol use disorders in this subgroup, are often overlooked or misdiagnosed [13]. It is expected, that in the coming years, the absolute number of elderlies with problems related to alcohol will rise, further increasing the number of cognitive and physiologically impaired elderly [14][15][16]. Each of these substantial neuropsychiatric morbidities are often accompanied with behavioral manifestations. ...
The increasing trend of life-expectancy is becoming a significant demographic, societal and economic challenge. Currently, global number of people above sixty years of age is 900 million, while United Nations expect this number to rise to over 1.4 billion in 2030 and over 2.5 billion by 2050. Concordant to this trend, numerous physiological changes are associated with aging and brain-related ones are associated with neuropsychiatric diseases. The main goal of this chapter is to identify the most important neuropsychiatric diseases to assess in older patients to help to promote health and prevent diseases and complications associated with chronic illness, as these changes are progressive and require important psychological and setting-related social adjustments. Findings identify several health-aspects highly present in elderly: stroke, white matter lesions, dementia rise with age, changes in levels of neurotransmitters and hormones, depression as well as the bereavement following loss of the loved one, and the most common neurodegenerative disease—Alzheimer’s disease and Parkinson’s. In conclusion, studying the aging process should include all developmental, circumstantial, and individual aspects of aging. This offers opportunities to improve the health of elderly by using a wide range of skills and knowledge. Thus, further studies are necessary to elucidate what can be done do to improve the aging process and health of elderly in the future.
... Illicit and prescription unhealthy drug use is associated with significant global morbidity, mortality, and economic and social costs. 1 Unhealthy drug use is any hazardous use of non-alcohol substances beyond legal and medical guidelines, 2 which may signify a substance use disorder (SUD). 1 Globally, about 5% of adults use illicit drugs and 0.4% fit criteria for an SUD. 1 However, only about 10% fitting an SUD criteria actually receive treatment. 3,4 This 90% disparity is known as the treatment gap. The treatment gap led to the development of screening and brief intervention (SBI) programs in outpatient medical settings to identify and treat or provide referrals to non-treatment-seeking patients. ...
Background:
The efficacy of brief intervention (BI) for unhealthy drug use in outpatient medical care has not been sufficiently substantiated through meta-analysis despite its ongoing global delivery. This study aims to determine the efficacy of BI for unhealthy drug use and the expected length of effects, and describe subgroup analyses by outpatient setting.
Methods:
Trials comparing BI with usual care controls were retrieved through four databases up to January 13, 2021. Two reviewers independently screened, selected, and extracted data. Primary outcomes included drug use frequency (days used) and severity on validated scales at 4-8 months and were analyzed using random-effects model meta-analysis.
Results:
In total, 20 studies with 9182 randomized patients were included. There was insufficient evidence to support the efficacy of BI for unhealthy drug use among all outpatient medical care settings for use frequency (SMD = -0.07, 95% CI = -0.17, 0.02, p = 0.12, I2 = 37%, high certainty of evidence) and severity (SMD = -0.27, 95% CI = -0.78, 0.24, p = 0.30, I2 = 98%, low certainty of evidence). However, post hoc subgroup analyses uncovered significant effects for use frequency by setting (interaction p = 0.02), with significant small effects only in emergency departments (SMD = -0.15, 95% CI = -0.25, -0.04, p < 0.01). Primary care, student health, women's health, and HIV primary care subgroups were nonsignificant. Primary care BI revealed nonsignificant greater average use in the treatment group compared to usual care.
Discussion:
BI for unhealthy drug use lacks evidence of efficacy among all outpatient medical settings. However, small effects found in emergency departments may indicate incremental benefits for some patients. Clinical decisions for SBI or specialty treatment program referrals should be carefully considered accounting for these small effects in emergency departments.
Registration:
PROSPERO (CRD42020157733).
... Broadly, the proportion of older adults aged 50 to 64 years who used illicit drugs in the past month has increased from 4.1% in 2008 to 5.8% in 2013 (SAMHSA, 2014) and researchers predicted the number of US adults aged 50 and older with substance use disorder would exceed 5.6 million in 2020 (Han et al., 2009). According to case records from one state, nearly 81% of adults aged 55 years and older who were incarcerated had substance use issues (Haugebrook et al., 2010) and authors of a recent review detailed that between 5% and 80% of older adults who were incarcerated had substance use problems (Haesen et al., 2019). ...
The targeted use of standardized outcome measures (SOMs) of mental health in research with older adults who are incarcerated promotes a common language that enables interdisciplinary dialogue, contributes to the identification of disparities and supports data harmonization and subsequent synthesis. This paper aims to provide researchers with rationale for using "gold-standard" measures used in research with community-dwelling older adults, reporting associated study sample psychometric indexes, and detailing alterations in the approach or measure.
Keywords: Incarceration; Measurement; Mental health; Older adults; Outcomes; Standardized measures.
... The scoping review by Zolopa and colleagues highlights that the majority of research on opioid and/or stimulant use in older adults is gleaned from medical records or national surveys to assess clinical correlates and trends in older adults seeking treatment over time [1][2][3]. While these studies are informative and necessary, Zolopa et al. [3] note that very few studies apply conceptual frameworks that seek to explain why older individuals might have opioid use disorder (OUD) and/or stimulant use disorder (StimUD) that persists throughout the life-span (sometimes termed 'drug use careers') [4], and why some older individuals develop OUD/StimUD later in life. ...
... In contrast, and similar to the general population ( Fang et al., 2020 ;Gasmi et al., 2021 ;Izcovich et al., 2020 ), non-psychiatric comorbidities, especially hypertension and cardiovascular disease, were more prevalent in patients with OUD and COVID-19. Such a finding is relevant as the population with OUD is aging ( Armstrong, 2007 ;Khatri and Perrone, 2020 ;Han et al., 2020 ); and has a high prevalence of chronic medical diseases ( Maruyama et al., 2013 ) highlighting the need to prioritize COVID-19 vaccination for individuals with OUD and comorbidities ( Iversen et al., 2021 ). ...
Introduction
: During the COVID-19 pandemic, limited access to health care augmented COVID-19 risk in subjects with opioid use disorder (OUD). The aim of the study was to compare COVID-19 incidence in individuals with OUD receiving continuous clinical care with that of the general population.
Methods
: A prospective cohort study was carried out from March 2020 to March 2021 comparing COVID-19 cumulative incidence of individuals presenting an OUD receiving integrated clinical care with that of an age-reference general population, in three public outpatient treatment centers for addiction in Barcelona, Spain.
Results
: Over the study period, 366 individuals received clinical care. Mean age: 48.2±8.9 years, 280 (76.5%) were men and 283 (77.3%) native Spanish. All subjects were on opioid agonist therapy. Prevalence of communicable diseases were: HIV infection in 109 (29.8%) and hepatitis C in 46 (12.6%). Psychiatric comorbidity was present in 207 (56.6%), and 119 (32.5%) had >1 chronic medical disease.
COVID-19 was diagnosed in 10 patients
: a cumulative incidence of 2,732 casesx100,000 people/year (C.I.95%: 1,318–4,967). There were no differences compared to the age-general population: 2,856 casesx100,000 people/year (C.I.95%: 2,830–2,880) (p=0.81). In the bivariate analysis, hypertension (5[50.0%] vs. 53[14.9%], p=0.01) and cardiovascular chronic diseases (2 [20.0%] vs. 8 [2.2%], p=0.03) were more prevalent in patients with OUD and COVID-19.
Conclusions
: Individuals with OUD who received integrated clinical care had a COVID-19 incidence comparable to the general population. Ensuring comprehensive healthcare is essential to prevent the clinical impact of COVID-19 on individuals with OUD.
... 15 23 24 The overall increased risks of the majority somatic diseases in patients with AUD aged 36-65 years could be due to more psychiatric comorbidities compared with the general population, and relatively higher utilisation of healthcare services compared with older adult patients with AUD. 25 However, underdiagnoses or under treatment of AUD 26 and a higher mortality rate in the older age group may contribute to underestimations of risks of somatic diseases. 27 It could also relate to age differences in the frequency and quantity of alcohol drinking, where both the frequency of heavy episodic drinking and the quantities reported to be drunk decrease by age. 28 Furthermore, we found that most somatic diseases do not significantly vary between females and males with AUD, except for pulmonary heart diseases, metabolic Open access disorders and viral hepatitis. ...
Objective
This study aimed to examine how age and gender moderate the associations between alcohol use disorders (AUD) and several somatic diseases.
Design and setting
We performed a retrospective, register-based cohort study with 6-year follow-up of patients with AUD and the general population. Data were acquired from the Norwegian Patient Registry. Cox regressions were used to estimate HRs of somatic diseases.
Participants
Patients with AUD (17 023; 0.4%) were compared with the population without AUD (4 271 559; 99.6%), with adults aged 18 years or older who were registered residents of Norway on 1 January 2008.
Main outcomes
Dichotomous variables of 12 specific somatic diseases (cardiovascular diseases, endocrine, nutritional, and metabolic diseases, cancer, and infectious diseases) were assessed. Diagnoses were set in specialist healthcare services.
Results
Patients with AUD, compared with a population without AUD, experienced a significantly greater burden of all studied somatic diseases. Middle-aged adults with AUD had increased risks (p<0.05) for hypertension; ischaemic diseases; pulmonary diseases; cerebrovascular diseases; malnutrition; metabolic disorders; cancer; and influenza and pneumonia than younger and older adults with AUD. For most somatic diseases, we found no differences between younger versus older adults with AUD, and between females versus males with AUD (p>0.05). Males with AUD had significantly higher risks for pulmonary heart diseases (HR=3.9, 95% CI 3.3 to 4.6) and metabolic disorders (HR 4.7, 95% CI 4.5 to 5.0), while females with AUD had a significantly higher risk for viral hepatitis (HR=4.4, 95% CI 3.8 to 5.1).
Conclusions
Age moderated the associations between AUD and most somatic diseases, with middle-aged adults with AUD having a greater increased risk of somatic diseases compared with younger and older adults with AUD. Gender only moderated associations between AUD and pulmonary heart diseases, metabolic disorders and viral hepatitis. This has implications for the prioritisation of somatic resources among patients with AUD.
... This trend suggests that incidences of SUDs among older adults could increase even further when paired with expected population growth. Consequently, substance misuse among older adults is an existing and growing public health problem that requires professional attention (Han et al., 2017(Han et al., , 2009Yarnell et al., 2020). Older adults with SUDs, or those who are engaging in risky substance use, have been under-identified in healthcare settings and under-represented in research and treatment, which may reflect deficiencies in current screening and assessment processes (Quinn, 2020;Rosen et al., 2017;Yarnell et al., 2020). ...
The older adult population in the United States is projected to grow significantly due to improvements in healthcare and sustained population growth. Adults aged 65 and older experience unique risks for, and consequences of, substance misuse. This Endpage applies recovery capital theory to outline the distinctive physical, social, human, and community and cultural forms of recovery capital for older adults. Based on this conceptualization, we provide directions for examining recovery from substance use disorders among older adults.
... Significantly more adults ≥65 will likely need substance use disorder treatment in the coming years, given significant increases in both past-year cannabis use and cannabis use disorders found in multiple general population studies and across multiple demographic subgroups (e.g., Blacks and Whites) (Wu and Blazer 2011). A study using projections of NSDUH data similarly predicted that rates of substance use disorder will double from 2.8 million in 2002-2006 to 5.7 in 2020 among adults 50 and older in the USA because of the baby-boom cohort's large size and high rates of substance use (Han et al. 2009). ...
Background
The US national surveys and data from legal adult use cannabis states show increases in the prevalence of cannabis use among older adults, though little is known about their manner of cannabis consumption. Here, we examine cannabis use frequency, routes of cannabis administration, and co-use with alcohol, focusing on adults aged 50–64 and ≥65.
Methods
Data come from a general population survey conducted January 2014–October 2016 (N=5492) in Washington state. We first estimate prevalence and trends in cannabis frequency, routes of administration, and co-use with alcohol in gender by age groups (18–29, 30–49, 50–64, ≥ 65). To test associations between cannabis frequency, route of administration, and co-use with alcohol, we then use sample-weighted multinomial regression adjusted for gender, race/ethnicity, marital status, education, employment, and survey year. Sampling weights are used so results better represent the Washington state population. Regressions focus on the 50–64 and ≥65 age groups.
Results
Among men and women 50–64, the prevalence of no cannabis use in the past 12 months decreased significantly (84.2% in 2014 to 75.1% in 2016 for women, 76.8% in 2014 to 62.4% in 2016 for men). Among those who report past-year cannabis use, oral administration and vaping and other routes of administration increased by 70% and 94%, respectively each year. Almost one-third of women aged 50–64 and one-fifth of women aged ≥65 who use cannabis reported daily/near daily use, and more than one-third of men who use cannabis in all age groups reported daily/near daily use, including 41.9% of those ≥65. Among men, the prevalence of edibles, drinks, and other oral forms of cannabis administration went up significantly with age (6.6% among 18–29, 21.5% among ≥65). Vaping and other administration are more strongly related to regular and daily/near daily use than infrequent use among those ≥65. The pattern of associations between cannabis frequency and co-use with alcohol differed for women vs. men.
Conclusions
In a general population representative sample of adults living in a state with legal adult use cannabis, the prevalence of cannabis use increased among those aged 50–64 between 2014 and 2016, the prevalence of daily use is substantial, and oral administration and vaping are increasing.
... In addition to the socioeconomic factors, substance use disorder may have a marked effect on the mental well-being of people [71,72]. To adjust for the effect of substance use, the age and sex standardized rate of substance use disorders (both sexes, 0+ age, and per 1000 population) was retrieved from the Ontario Community Health Profiles Partnership database [9,45] and added as a potential confounder in the Bayesian models. ...
Considerable debate exists on whether exposure to vegetation cover is associated with better mental health outcomes. Past studies could not accurately capture people's exposure to surrounding vegetation and heavily relied on non-spatial models, where the spatial autocorrelation and latent covariates could not be adjusted. Therefore, a suite of five different vegetation measures was used to separately analyze the association between vegetation cover and the number of psychotic and non-psychotic disorder cases in the neighborhoods of Toronto, Canada. Three satellite-based and two area-based vegetation measures were used to analyze these associations using Pois-son lognormal models under a Bayesian framework. Healthy vegetation cover was found to be negatively associated with both psychotic and non-psychotic disorders. Results suggest that the satellite based indices, which can measure both the density and health of vegetation cover and are also adjusted for urban and environmental perturbations, could be better alternatives to simple ratio-and area-based measures for understanding the effect of vegetation on mental health. A strong dominance of spatially structured latent covariates was found in the models, highlighting the importance of adopting a spatial approach. This study can provide critical guidelines for selecting appropriate vegetation measures and developing spatial models for future population-based epidemiological research.
... They are characterised by an impulsive and uncontrolled desire for psychoactive substances and intake behaviour, notwithstanding the clinical implications and social consequences (Ross, et al., 1988; Le Moal & Koob, 2007). In 2014, the WHO revealed that more than 15 million people were diagnosed with Substance Use Disorders (SUD), highlighting the evidence of this dramatic worldwide situation (Han, et al., 2009;Hone-Blanchet, et al., 2014). In addition to several forms of substance-related addiction, excessive reward-seeking behaviours have been claimed as healthy and social problem in modern societies, mirroring canonical addiction (Albrecht, et al., 2007). ...
... Illicit and prescription unhealthy drug use is associated with significant global morbidity, mortality, and economic and social costs. 1 Unhealthy drug use is any hazardous use of non-alcohol substances beyond legal and medical guidelines, 2 which may signify a substance use disorder (SUD). 1 Globally, about 5% of adults use illicit drugs and 0.4% fit criteria for an SUD. 1 However, only about 10% fitting an SUD criteria actually receive treatment. 3,4 This 90% disparity is known as the treatment gap. The treatment gap led to the development of screening and brief intervention (SBI) programs in outpatient medical settings to identify and treat or provide referrals to non-treatment-seeking patients. ...
... As the baby boomer cohort started to reach age 55 years and above from 2010 in Germany, the share of older age groups-which have been underrepresented in addiction care so far-is anticipated to rise as projected in other countries [19][20][21]. Considering the size, the relatively high life expectancy and the specific substance-related use patterns of this cohort, the baby boomers are an important target group in addiction care, especially when it comes to the older age group. Hence, to facilitate addiction care planning, knowledge about baby boomers and the developments they will set off in the addiction care system is required. ...
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.
... En d'autres termes, le vieillissement des générations du baby-boom dont la part s'accroît parmi les populations âgées s'opère chez des personnes qui ont eu leur vie durant des facilités d'accès et des habitudes de consommation de substances psychoactives inconnues des générations antérieures (2,3) . Cela aboutit à une diffusion des troubles de l'usage de substances et des conduites addictives parmi les aînés, dans une évolution annoncée dès les années 2000, mais redoutée bien avant (4) . Dans le même temps, la plupart des recherches en addictologie excluent les plus âgés (5,6) , quand la recherche en gériatrie ou gérontologie ne concerne que rarement les addictions. ...
Les troubles de l'usage de substances existent chez des sujets âgés, avec une prévalence qui ne décroît que peu avec l'âge. Ils adoptent différentes présentations peu symptomatiques, rarement typiques, allant de la surconsommation, au mésusage (avec ou sans dépendance), à des conduites addictives. Ces addictions peuvent concerner des substances psychoactives ou des comportements, adoptant des spécificités d'âge, surtout avec l'alcool, les médicaments psychotropes ou opioïdes, le tabac, les jeux de hasard et d'argent, les achats, et des substances illicites pour une part émergente. Les spécificités gérontologiques de l'addiction nécessitent de prendre en compte les particularités de chaque situation, du repérage à l'évaluation précise de la conduite, des comorbidités physiques psychiques, cognitives ou addictives dans une approche diagnostique globale, avant de formuler une proposition de soin. Les soins sont d'autant plus utiles que leur pronostic est aussi bon ou meilleur qu'à de plus jeunes âges. Ils ciblent la réduction des souffrances induites, l'amélioration de la qualité de vie, conditionnées par des modifications des consommations ou des pratiques. ABSTRACT Substance use disorders exist among older adults, with a prevalence that only slightly decreases with age. They display more tenuous and atypical symptoms, ranging from overuse to misuse, with or without dependence. These addictions can relate either to psychoactive substances or behaviors, with age specificities, in particular regarding alcohol, psychotropic or opioid drugs, tobacco, gambling, purchases and, illegal substances for an emerging part. The gerontological specificities of addiction require considering the peculiarities of each situation, from the screening phase to a precise assessment of the behavior, of physical, psychic, cognitive or addictive comorbidities, in a global diagnostic approach before formulating a treatment proposal. The treatment is all the more useful as their prognosis often better, relative to that of younger subjects. Treatment strategies aim to reduce pain and psychological distress, and to improve quality of life, through progressive changes in consumption or practices.
... As the baby boomer cohort started to reach age 55 years and above from 2010 in Germany, the share of older age groups-which have been underrepresented in addiction care so far-is anticipated to rise as projected in other countries [19][20][21]. Considering the size, the relatively high life expectancy and the specific substance-related use patterns of this cohort, the baby boomers are an important target group in addiction care, especially when it comes to the older age group. Hence, to facilitate addiction care planning, knowledge about baby boomers and the developments they will set off in the addiction care system is required. ...
Background
The aging of baby boomers is expected to confront addiction care with new challenges. This study aims to investigate if German addiction care is confronted with a sustained change in its clientele that was 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 older (n = 6524) as well as a younger cohort (n = 15677). To isolate cohort effects, two-level random-intercept regression models were applied in the overlapping age groups of the baby boomer cohort with each other cohort.
Results
Compared to the older cohort, alcohol use disorder lost importance while illicit substances use disorder gained importance in the baby boomers. Baby boomers presented a higher number of comorbid substance use disorders than the older cohort. Comparing baby boomers with the younger cohort, these relationships pointed in the opposite direction.
Conclusions
Outpatient addiction care faces a sustained change to more illicit and comorbid substance use disorders. The addiction care system ought to adapt its services to address the changing needs of its clientele.
Key messages
Baby boomers differed in comparison to the older cohort regarding type of substance use disorder and comorbid substance use disorders. The changes set off by the baby boomers continued in the younger cohort.
... Changes in dopamine-rich brain regions have long been associated with HIV infection within the CNS, and although these effects are often subtler in the ART era, they still persist (Larsson et al. 1991;Aylward et al. 1993;Hestad et al. 1993;Wiley et al. 1998;Berger and Arendt 2000;Bell et al. 2006;Gelman et al. 2006;Scheller et al. 2010;Becker et al. 2011a;Kumar et al. 2011;Wright et al. 2016;Deren et al. 2019). Defining more precisely the dopamine-associated impact of both legal and illicit drugs on the development of HIV associated comorbidities is a critical need, as the number of HIV-infected individuals with substance use disorder (SUD) continues to increase, particularly among older individuals, the fastest growing segment of the infected population (Grabar et al. 2006;Han et al. 2009;Kirk and Goetz 2009;Skalski et al. 2013;Deren et al. 2019). Additionally, the specific interactions between SUD and ART, and the pathological consequences of those interactions, must also be addressed, and understanding the interplay between ART and substances of abuse will be essential to improving HIV treatment in vulnerable populations. ...
Antiretroviral therapy (ART) has transformed HIV into a chronic condition, lengthening and improving the lives of individuals living with this virus. Despite successful suppression of HIV replication, people living with HIV (PLWH) are susceptible to a growing number of comorbidities, including neuroHIV that results from infection of the central nervous system (CNS). Alterations in the dopaminergic system have long been associated with HIV infection of the CNS. Studies indicate that changes in dopamine concentrations not only alter neurotransmission, but also significantly impact the function of immune cells, contributing to neuroinflammation and neuronal dysfunction. Monocytes/macrophages, which are a major target for HIV in the CNS, are responsive to dopamine. Therefore, defining more precisely the mechanisms by which dopamine acts on these cells, and the changes in cellular function elicited by this neurotransmitter are necessary to develop therapeutic strategies to treat neuroHIV. This is especially important for vulnerable populations of PLWH with chemically altered dopamine concentrations, such as individuals with substance use disorder (SUD), or aging individuals using dopamine-altering medications. The specific neuropathologic and neurocognitive consequences of increased CNS dopamine remain unclear. This is due to the complex nature of HIV neuropathogenesis, and logistical and technical challenges that contribute to inconsistencies among cohort studies, animal models and in vitro studies, as well as lack of demographic data and access to human CNS samples and cells. This review summarizes current understanding of the impact of dopamine on HIV neuropathogenesis, and proposes new experimental approaches to examine the role of dopamine in CNS HIV infection. [Figure not available: see fulltext.] © 2020, Springer Science+Business Media, LLC, part of Springer Nature.
The older adult population in the United States is projected to grow significantly due to improvements in healthcare and sustained population growth. Adults aged 65 and older experience unique risks for, and consequences of, substance misuse. This End Page applies recovery capital theory to outline the distinctive physical, social, human, and community and cultural forms of recovery capital for older adults. Based on this conceptualization, we provide directions for examining recovery from substance use disorders among older adults.
Objectives
The drug overdose crisis with shifting patterns from primarily opioid to polysubstance uses and COVID-19 infections are two concurrent public health crises in the United States, affecting the population of sizes in different magnitudes (approximately <10 million for substance use disorder (SUD) and drug overdoses vs. 80 million for COVID-19 within two years of the pandemic). Our objective is to compare the relative scale of disease burden for the two crises within a common framework, which could help inform policymakers with resource allocation and prioritization strategies.
Methods
We calculated disability-adjusted life years (DALYs) for SUD (including opioids and stimulants) and COVID-19 infections, respectively. We collected estimates for SUD prevalence, overdose deaths, COVID-19 cases and deaths, disability weights, and life expectancy from multiple publicly available sources. We then compared age distributions of estimated DALYs.
Results
We estimated a total burden of 13.83 million DALYs for SUD and drug overdoses and 15.03 million DALYs for COVID-19 in two years since March 2020. COVID-19 burden was dominated by the fatal burden (>95% of total DALYs), whereas SUD burden was attributed to both fatal (53%) and non-fatal burdens (47%). The highest disease burden was among individuals aged 30-39 for SUD (27%) and 50-64 for COVID-19 (31%).
Conclusions
Despite the smaller size of the affected population, SUD and drug overdoses resulted in comparable disease burden to the COVID-19 pandemic. Additional resources supporting evidence-based interventions in prevention and treatment may be warranted to ameliorate SUD and drug overdoses during both the pandemic and post-pandemic recovery.
Substance use is a perennial public health concern with associated health risks and economic impacts on society. In this article, we present a selective review of the epidemiological and clinical literatures on alcohol and substance use from a lifespan developmental perspective. We compare and contrast risk factors for the initiation of use and the development of a substance use disorder in adolescence, young adulthood, middle-age and later life. During adolescence, alcohol use experimentation is at its peak. Specific risk factors have been identified including trauma and parenting style that can increase the risk of substance use for teenagers. Emerging adults and college students are likely to experiment with other substances in addition to alcohol such as nicotine, marijuana, cocaine, and prescription medication such as Adderall. Middle-age and older adults with alcohol and substance use in their developmental histories may have an undiagnosed alcohol use disorder. Others will develop a late-onset substance use disorder in older age, possibly due to a dearth of social support, coping with bereavement, and medical complication. Based on Social Cognitive Theory, the roles of expectancies and self-efficacy are hypothesized to impact substance use and the risk of substance use disorder across the lifespan. Implications of the present review for future research on age-specific risk factors in alcohol use in relation to underlying developmental processes are considered.
Introduction
Substance use is one of the most important global issues that have become a worldwide psychological, social, and familial problem among older adults, but epidemiologic studies remain sparse especially in developing countries. The current study aims to examine the prevalence and related factors for substance use among older adults in Tehran, Iran.
Methods
The sample consisted of 1280 community-dwelling individuals aged over 60 years. A linear logistic regression model and bivariate analyses were done to test the relationship between substance use and related explanatory variable.
Results
The prevalence of current substance use (past 30 days) was 11.3% (95% CI: 10.98, 11.61); such a way that opium was the most commonly used drug (74.3%), followed by alcohol (20.83%). The main reason for substance use was pain relief (66.01%). Substance use was more among men, the most elderly, those with low educational levels, and those who have musculoskeletal disorders. In addition, there was a significant relationship between social networks, perceived health status, and income level with substance use.
Discussion
Policies aimed to improve access to health and rehabilitation services, re-building support networks, and developing health literacy can lead to a reduced rate of substance use among older adults.
Introduction:
Cardiovascular disease is a health concern in ageing population with opioid use disorders (OUD). The study aims to analyse the cardiovascular risk factors in individuals with OUD.
Methods:
An observational study was carried out to compare cardiovascular risk factors of adults >50 years with OUD on methadone therapy from public outpatient drug treatment centres, with that of an age- and gender-matched sample (ratio of 1:5) of subjects from a sample of the Spanish population (REGICOR cohort). High cardiovascular risk (HCVR) at 10 years was defined according to Framingham-REGICOR and SCORE risk functions.
Results:
The individuals studied included 94 people with OUD and 495 from the general population; the mean age was 55.7 ± 4.8 years and 432 (72.7%) were men. Obesity (21.2% vs. 35.2%), hypertension (26.3% vs. 42.1%), total cholesterol (30.3% vs. 65.4%) and LDL-cholesterol ≥130 mg/dL (27.2% vs. 59.3%) were significantly more prevalent in the general population group, while tobacco smoking (96.0% vs. 25.9%), low HDL-cholesterol (46.5% vs. 21.2%), hypertriglyceridaemia (39.4% vs. 18.8%) and atherogenic dyslipidaemia (30.3% vs. 10.5%) were significantly higher in individuals with OUD. Differences in abdominal obesity (62.6% vs. 65.3%) were not significant. HCVR was more prevalent in patients with OUD: 15.2% versus 5.8% (Framingham-REGICOR function) and 21.2% versus 11.3% (SCORE function).
Discussion and conclusions:
Older adults with OUD on methadone therapy have a different prevalence of cardiovascular risk factors and HCVR than the general population. Preventive measures, particularly tobacco smoking cessation and weight control, should be included in the routine care of individuals with OUD.
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 = 2168) 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.
There is an increased incidence of substance use in adults aged 65 or older. Substance use is often underdiagnosed and rarely screened for in older adults. However, ongoing substance use can lead to medical and psychiatric complications and require treatment in the forms of both psychopharmacology as well as talk therapy. This chapter describes different substance use disorders in older adults, screening for the same, symptoms present, and treatment which focuses on both talk therapy and pharmacology.
Virtual reality (VR) is an emerging evidence-based intervention approach that has been successfully used to address substance use disorders (SUDs) and manage chronic pain in young and middle age adults. However, the safe and effective use of VR-based interventions with older adults living with SUDs has not been established. This article outlines considerations for researchers wishing to develop and test VR-based intervention approaches for older adults impacted by substance misuse. An overview of older adult substance misuse and treatment needs will be provided, followed by a review of ethics and general safety related considerations for using VR based intervention approaches with an older adult population.
This study explored the impact of the Hispanic cultural value of familismo (a focus on, and passionate commitment to, one’s family) on the injection heroin use patterns of a cohort of aging Mexican-American men. An ecological ethnographic approach was applied to 26 in-depth interviews of these men in recovery to determine the influence of familismo on initiation and cessation of heroin use. Iterative analysis revealed that in regard to interpersonal relationships with men, familismo functioned as a risk factor for heroin initiation and continued use. Conversely familismo functioned dialectically as both a risk factor for continued use, and protective factor contributing to recovery, in regard to relationships with women. A better understanding of the gendered impact of familismo on substance use patterns can provide valuable insight to inform the development of culturally grounded or adapted interventions for Hispanics/Latinos.
O objetivo do presente estudo foi discutir acerca dos fatores de risco e proteção para o consumo de drogas, considerando evidências da literatura brasileira e internacional. Inicialmente, são apresentados os conceitos de fatores de risco e fatores de proteção, bem como sua importância no contexto do consumo de drogas. A partir disso, são discutidos os fatores de risco/proteção já conhecidos para esse comportamento de acordo com a literatura. Finalmente, são refletidas as limitações do presente estudo. Destaca-se a importância do estudo dos aspectos psicossociais envolvidos no consumo de drogas no contexto da saúde coletiva e da promoção de bem-estar.
This study aimed to discuss risk and protective factors for drug use, considering evidence from the Brazilian and international literature. Initially, the concepts of risk factors and protective factors are presented, as well as their importance in the context of drug consumption. From this, the risk/protection factors already known for this behavior are discussed. Finally, the limitations of the present study are reflected. The importance of studying the psychosocial aspects involved in drug use in the context of collective health and the promotion of well-being is highlighted.
As our elderly population represents an increasing percentage of the overall population, more healthcare resources are spent treating this population. One of the overlooked issues is substance use in this population and its complications. This population is often not forthcoming with psychoactive medical issues, yet many of them came into adulthood in a time when substance use was widespread. This article will discuss the epidemiology of this population, a case of substance-induced persecutory delusion and the availability of screening methods and treatment options.
Research that explores the role of substance use treatment among older individuals is scarce. This paper offers a historical investigation of admissions and discharges for treatment episodes over the past two decades across race, ethnicity, gender, and age. Our results suggest that although older individuals are not typically associated with risky behavior, they are increasingly seeking treatment for substance use disorders. We find that substance use treatment admissions for people aged 50 and older have persistently increased over our sample period. Our findings also indicate that, on average, Black (relative to white) admissions across all ages are less likely to complete treatment and more likely to have their treatment terminated by a treatment facility. We also find some evidence that Hispanic admissions are relatively less likely to complete treatment across all age groups. Hispanics over 50 years old are also more likely to terminate treatment. Interestingly, among younger individuals in the most recent years of our sample, the disparity between minority completion rates has improved. Lastly, we find that males (relative to females) are more likely to complete a substance use treatment program but no more likely to have their treatment terminated by a substance use treatment facility.
Das Kapitel gibt einen Überblick über Störungen im Zusammenhang mit dem Gebrauch psychotroper Substanzen und vergleichbarer Störungen ohne Substanzbezug, vor allem der Störung durch Glücksspielen. Themenschwerpunkte in dieser Einführung sind wichtige Definitionen sowie bedeutsame gemeinsame und unterschiedliche Merkmale der verschiedenen Störungen bei Klassifikation und Diagnostik, Ätiologie, Therapie und Prävention, während die spezifischen Aspekte in den nachfolgenden Kapiteln (Drogenkonsumstörungen, Alkoholkonsumstörungen, Tabakkonsumstörungen und Störung durch Glücksspielen) behandelt werden. Zur sprachlichen Vereinfachung wird in diesem Kapitel der Oberbegriff Abhängigkeitsstörungen verwendet. Weiterhin stehen aufgrund der klinisch-psychologischen Schwerpunksetzung die Störungen durch Substanzkonsum nach DSM-5 (auch Substanzkonsumstörungen; ICD-10: schädlicher Gebrauch und Abhängigkeit) im Vordergrund.
Background
Most research on prescription drug misuse (PDM) focuses on the misuse of specific classes of psychoactive prescription drugs among adolescents or young adults. The current research addressed important gaps in the literature by assessing poly-prescription drug misuse (poly-PDM), the misuse of more than one class of psychoactive prescription drug, across different adult age cohorts.
Methods
We used the 2015–2018 National Survey on Drug Use and Health to examine the prevalence of past-year poly-PDM and specific combinations of PDM. Multinomial logistic regression was used to identify demographic, health-related factors, and substance use behaviors that were significantly associated with poly-PDM.
Results
The prevalence of poly-PDM decreases with age and is common among individuals who engage in PDM. Slightly more than one in four respondents in age cohorts 18–25 (31.66%, 95% CI = 30.35, 33.00) and 26–34 (29.92%, 95% CI = 25.82, 30.12) who engage in PDM, misused more than one class of prescription drug. Additionally, poly-PDM was identified as a high-risk type of PDM as roughly 60% of adults younger than 65 who endorse poly-PDM reported having a substance use disorder (SUD). While certain characteristics (i.e., race/ethnicity, marital status, depression, suicidal ideation, illegal drug use, and SUD) were consistently associated with poly-PDM across age cohorts, other characteristics (i.e., sexual identity, income, and justice involvement) varied across age cohorts. Finally, a comparison of poly-PDM to single PDM showed, in all age cohorts, that having an SUD was associated with an increased likelihood of poly-PDM, while Black adults were less likely than whites to report poly-PDM.
Conclusions
By identifying prevalence and correlates of poly-PDM across adult age cohorts, the current research has significant implications. Understanding stability and heterogeneity in the characteristics associated with poly-PDM should inform interventions, identify at-risk groups, and shape public health approaches to dealing with high-risk substance use behavior.
Background
People with substance use disorders are considered at increased risk of COVID-19 and its more serious complications, however data on the impact of COVID-19 are lacking. The study aimed to describe the clinical characteristics and outcomes of COVID-19 on people with substance use disorders.
Methods
an observational study was carried out including patients aged ≥ years with COVID-19 pneumonia admitted to an urban hospital during March 12 to June 21,2020.
Results
Among 2078 patients admitted, 27 (1.3%) were people with substance use disorders: 23(85.2%) were men with a median age of 56.1 + 10.3 years and. The main SUD were alcohol in 18(66.7%) patients, heroine in 6(22.2%) and cocaine in 3(11.1%) and 24(88.8%) patients were on ongoing substance use disorder treatment. One or more comorbidities associated to COVID-19 risk were observed in 18(66.6%) of patients. During a median length of stay of 10 days (IQR:7-19), severe pneumonia developed in 7(25.9%) patients, acute respiratory distress syndrome in 5 (18.5%) and none died.
Conclusion
Larger sample sizes and sero-epidemiological studies are needed to confirm the low incidence of severe COVID-19 on patients with SUD.
Objectives:
The objective of this study was to review the significant differences of MMT outcomes related to drug use behavior, health status, and social behavioral functioning between genders.
Materials and methods:
A search of publication was conducted in PubMed/MEDLINE, Embase, CINAHL, PsycINFO, and Scopus database. Two reviewers independently screened the titles, abstracts, and keyword use for the search. Inclusion of studies was based on randomized controlled trials (RCTs) or observational studies that report the difference of opioid addiction treatment outcomes between genders. Any conflict between the two reviewers was resolved through discussion and consensus. The systematic review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines and was registered in PROSPERO with a registration number CRD42019116261.
Results:
A total of 25 studies were evaluated as part of qualitative synthesis. The review resulted in three main themes, which are (1) improving well-being and methadone-related outcome (five subthemes), (2) impact on social and behavioral (four subthemes), and (3) illicit drug use pattern-related behavior (four subthemes).
Conclusion:
This review will highlight how men and women differ in methadone treatment outcomes for further application and improvement in the clinical setting.
Chronic pain and addiction are common comorbidities. Some pain medications can increase the risk of developing addiction to the medication taken and as well as other medications and substances. In addition, use of certain potentially addictive medications and substances such as benzodiazepines, alcohol, or marijuana can increase the risk of falls, sleep disturbance, and memory difficulties, which can increase the risk of chronic pain and decrease response to therapy. In addition to the unifying qualities of these treatments to impact the reward center and learning, understanding their unique properties can also be helpful when caring for all patients. As our understanding of the impact of these drugs continues to grow, this chapter will highlight the general concepts related to pain and addiction as well as the special characteristics of commonly used medications and substances.
Introduction:
Drug misuse is associated with significant global morbidity, mortality, economic costs and social costs. Many primary care facilities have integrated drug misuse screening and brief intervention (BI) into their usual care delivery. However, the efficacy of BI for drug misuse in primary care has not been substantiated through meta-analysis. The aim of this systematic review and meta-analysis is to determine the efficacy of BI for drug misuse in primary care settings.
Methods and analysis:
We will include all randomised controlled trials comparing primary care-delivered BI for drug misuse with no intervention or minimal screening/assessment and usual care. Primary outcomes are (1) drug use frequency scores and (2) severity scores at intermediate follow-up (4-8 months). We will retrieve all studies through searches in CENTRAL, Embase, MEDLINE and PsycINFO until 31 May 2020. The reference list will be supplemented with searches in trial registries (eg, www.clinicaltrials.gov) and through relevant existing study reference lists identified in the literature. We will conduct a random-effect pairwise meta-analysis for primary and secondary outcomes. We will assess statistical heterogeneity though visual inspection of a forest plot and calculate I2 statistics. We will assess risk of bias using the Cochrane Risk of Bias Tool V.2 and evaluate the certainty of evidence through the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Sensitivity analyses will account for studies with control group variations and studies with a high risk of bias. If heterogeneity is present, subgroup analyses will consider patient variables of age, sex/gender, race/ethnicity, per cent insured, baseline severity and primary drug misused.
Ethics and dissemination:
This study will use published aggregate data and will not require ethical approval. Findings will be disseminated in a peer-reviewed journal.
Background
As the United States' population ages, the health care system will experience overall change. This study aims to identify factors in the older adult that may contribute to involuntary hold status in the ED.
Methods
This study is a retrospective review conducted at a suburban acute-care hospital ED of adult patients evaluated while on involuntary hold from January 1, 2014, through November 30, 2015. Older adults (patients born on or before 06/31/1964) were compared to younger adults (born on or after 07/01/1964) according to demographic and clinical variables including medical comorbidity, ED length of stay, reason for involuntary hold, psychiatric disorder, suicide attempt, substance use disorder, serum alcohol level, urine drug testing, medical comorbidity, violence in the ED, 30-day ED readmission, and 30-day mortality.
Results
Of 251 patients, 90 (35.9%) were older adults. The most common reason for involuntary hold in both cohorts was suicidal ideation. Medical comorbidities were more prevalent in older adults [60 (66.7%) vs. 64 (39.8%), P ≤.0001]. Older adults were less likely to report current drug abuse [31 (34.4%) vs. 77 (47.8%), P = .04]. The most commonly misused substance in both groups was alcohol; however, despite similar rates, blood alcohol levels (BAC) and urine drug screen (UDS) were performed less often in older adults. Cohorts were not significantly different with respect to sex, race, violence in the ED, psychiatric diagnosis, and ED LOS.
Conclusions
Involuntary older adult patients present with medical comorbidities that impact mental health. In the ED, they are less likely report substance use, and drug screening may be underutilized. Medical needs make their care unique and may present challenges in transfer of care to inpatient psychiatric facilities.
Background
To assess the association between the implementation of Medicare Part D and the use of outpatient prescription opioids.
Methods
Nationally representative data on community-dwelling adults aged 61–69 came from the 2000−2015 Medical Expenditure Panel Survey (MEPS) (N = 26,545). A difference-in-differences approach was used to compare opioid use between Medicare eligible (ages 66−69) and Medicare ineligible (ages 61−64) adults before and after the introduction of Part D in 2006, while controlling for socio-demographic characteristics, risk factors for opioid use, and secular trends.
Results
Medicare Part D was associated with a small and statistically non-significant increase in the number of outpatient prescription opioids filled in a year (coefficient, 0.03; 95% CI, -0.08 to 0.13), in the amount of morphine milligrams equivalents (coefficient, 113.23; 95% CI, -25.47–251.93), and in the odds of using any prescription opioid (OR, 1.03; 95% CI, 0.85–1.26). There was no evidence for a heterogeneous effect of Part D across subgroups. The results were robust to the impacts of the 2007−2009 recession, the spillover effect of the Affordable Care Act, and the anticipation effect of Part D.
Discussion
Although policymakers suggested that gaining access to medical care as a result of insurance expansion might have fueled the opioid epidemic, this paper found limited evidence to support this claim. While Part D took effect more than a decade ago, its long-term implication for opioid use is still relevant for the recent opioid epidemic and future health insurance expansions such as the proposed Medicare-for-all initiative.
Introduction to the Logistic Regression Model Multiple Logistic Regression Interpretation of the Fitted Logistic Regression Model Model-Building Strategies and Methods for Logistic Regression Assessing the Fit of the Model Application of Logistic Regression with Different Sampling Models Logistic Regression for Matched Case-Control Studies Special Topics References Index.
This study sought to describe patterns of initiation, persistence, and cessation in drug use in individuals from their late 20s to their mid-30s, within a broad perspective that spans 19 years from adolescence to adulthood.
A fourth wave of personal interviews was conducted at ages 34-35 with a cohort of men and women (n = 1160) representative of adolescents formerly enrolled in New York State public secondary high schools. A school survey was administered at ages 15-16, and personal interviews with participants and school absentees were conducted at ages 24-25 and 28-29. Retrospective continuous histories of 12 drug classes were obtained at each follow-up.
There was no initiation into alcohol and cigarettes and hardly any initiation into illicit drugs after age 29, the age at which most use ceased. The largest proportion of new users was observed for prescribed psychoactives. Periods of highest use since adolescence based on relative and absolute criteria were delineated. Among daily users, the proportions of heavy users declined for alcohol and marijuana but not for cigarettes.
Cigarettes are the most persistent of any drug used. Drug-focused interventions must target adolescents and young adults.
In order to answer the question whether older alcoholics form a distinct group among problem drinkers and within their age cohort, drinking histories of male, older (over 50 years of age) alcoholics in treatment (n = 52) are compared to those of younger alcoholics (n = 55), and to those of older social drinkers (n = 46). Within the older alcoholics category, comparisons are made by age of onset. Changes in consumption volume and onset and remission of heavy drinking, morning drinking and solitary drinking are related to events in other spheres of life.
In face-to-face interviews, respondents were asked to report drinking behavior in subsequent drinking phases, from the beginning of regular drinking to the present. Events that marked a transition to a new drinking phase, as well as the impact that these events had on the general well-being of the respondents, were assessed using a semistructured interview format.
Compared to younger alcoholics, older alcoholics were older when they started drinking regularly, and they report later age at onset of heavy drinking. Older alcoholics and social drinkers were similar with respect to the first years of their drinking career. Older alcoholics with onset of heavy drinking before the age of 35 were similar to younger alcoholics, while older alcoholics with later onset of heavy drinking resembled social drinkers with respect to their earlier drinking history. Alcoholics with later onset more often reported onset in connection with events such as marital disruption.
Among older alcoholics, a distinct group can be distinguished that may benefit from specific prevention and treatment measures.
Illicit drug use and dependence often are associated with premature death, but available evidence comes mainly from clinical samples. The present paper examines drug-related mortality experience over 14 years in a United States community sample.
Following probability sampling, 3,481 adult community household residents were recruited for the 1981 NIMH Baltimore Epidemiologic Catchment Area survey. Follow-up occurred in 1993-1996.
Survival analyses were used to estimate median age at death and relative risk of dying in relation to drug use and dependence as assessed in 1981 using the Diagnostic Interview Schedule (DIS).
Cases with DIS "drug dependence" were more likely to have died and to have a younger median age at death (p < .05), with and without statistical adjustment for confounding variables. Higher levels of drug involvement also were associated with increased age-adjusted mortality.
The evidence favors the hypothesis that DIS-elicited "drug dependence," as well as subthreshold drug use, help to account for premature death in this community sample.
Evidence is provided about the association between "alcohol-use disorders" and the 14-year risk of death in a community sample. Most prior descriptions of this association come from treatment samples.
3,481 adult household residents were recruited into the NIMB Baltimore Epidemiologic Catchment Area survey and interviewed in 1981. The Diagnostic Interview Schedule (DIS) was employed to assess alcohol drinking and other drug-taking behaviors, and to determine fulfillment of DSM-III criteria for "alcohol abuse" and/or "dependence" diagnoses. Participants were followed-up in 1993-1996, by which time 24% of the sample had died. Median age of death was estimated for persons with and without alcohol disorders, and for "heavy" and "nonheavy" drinkers. Cox proportional hazards models adjusted for the influence of age, sex, race, "drug-use disorders," and tobacco smoking.
"Alcohol abuse" and/or "dependence" was associated with a higher risk of death and a younger median age of death (adjusted relative risk = 1.3, p = .016). "Heavy" alcohol consumption was also associated with a significantly elevated risk of death. The DIS diagnosis of "alcohol use disorder" helped predict mortality over and above a prediction based solely upon "heavy drinking" (p < .01).
These findings indicate that the observed increased risk of death associated with "alcohol dependence" is not limited to cases severe enough to have been treated but is also present among cases in the household population.
The effects of drug dependence on social systems has helped shape the generally held view that drug dependence is primarily a social problem, not a health problem. In turn, medical approaches to prevention and treatment are lacking. We examined evidence that drug (including alcohol) dependence is a chronic medical illness. A literature review compared the diagnoses, heritability, etiology (genetic and environmental factors), pathophysiology, and response to treatments (adherence and relapse) of drug dependence vs type 2 diabetes mellitus, hypertension, and asthma. Genetic heritability, personal choice, and environmental factors are comparably involved in the etiology and course of all of these disorders. Drug dependence produces significant and lasting changes in brain chemistry and function. Effective medications are available for treating nicotine, alcohol, and opiate dependence but not stimulant or marijuana dependence. Medication adherence and relapse rates are similar across these illnesses. Drug dependence generally has been treated as if it were an acute illness. Review results suggest that long-term care strategies of medication management and continued monitoring produce lasting benefits. Drug dependence should be insured, treated, and evaluated like other chronic illnesses. JAMA. 2000;284:1689-1695.
Greater rates of lifetime drug use among the baby-boom generation, combined with the size of that generation, suggest that the number of elderly persons using drugs will increase in the next two decades. Given the potential public health demands implied by increasing numbers of elderly drug users, the goal is to project the numbers of current drug users aged 50 years and older in 2020.
Using the modeling and projection methods of Gfroerer et al (2003) applied to data from the 1999 to 2001 National Household Surveys on Drug Abuse, projections were developed for the use of marijuana, nonmedical use of any prescription-type psychotherapeutic drug, and any illicit drug use.
From 1999 to 2001 to 2020, past-year marijuana use in persons 50 years and older is forecast to increase from 1.0% to 2.9%. The number of users is expected to increase from 719,000 to almost 3.3 million, reflecting the combined effects of the increase in rate of use and a projected 51.9% increase in the civilian noninstitutionalized population in this age group. Use of any illicit drug will increase from 2.2% (1.6 million) to 3.1% (3.5 million), and nonmedical use of psychotherapeutic drugs will increase from 1.2% (911,000) to 2.4% (almost 2.7 million).
These projections call attention to changes to be considered in planning and to the need for improved knowledge of the biomedical and psychosocial effects of nonmedical drug use on aging and elderly individuals.
Over the past 40 years the rate of illicit drug use worldwide has risen dramatically, and with it the number of deaths reported among drug-using populations. What are the clinical, ethical and psychopathological implications of these deaths? In this book, Shane Darke and his team provide the first full, synthetic review of the epidemiology, causes, prevalence, demography, and associated risk factors of illicit-drug-related mortality. In addition, they examine and evaluate interventions to reduce these deaths. The major causes of death among illicit drug users are overdose, disease, suicide and trauma. Each is independently examined. This is an important book for all clinicians and policy makers involved in issues relating to illicit drug use.
From the reviews of the First Edition."An interesting, useful, and well-written book on logistic regression models . . . Hosmer and Lemeshow have used very little mathematics, have presented difficult concepts heuristically and through illustrative examples, and have included references."—Choice"Well written, clearly organized, and comprehensive . . . the authors carefully walk the reader through the estimation of interpretation of coefficients from a wide variety of logistic regression models . . . their careful explication of the quantitative re-expression of coefficients from these various models is excellent."—Contemporary Sociology"An extremely well-written book that will certainly prove an invaluable acquisition to the practicing statistician who finds other literature on analysis of discrete data hard to follow or heavily theoretical."—The StatisticianIn this revised and updated edition of their popular book, David Hosmer and Stanley Lemeshow continue to provide an amazingly accessible introduction to the logistic regression model while incorporating advances of the last decade, including a variety of software packages for the analysis of data sets. Hosmer and Lemeshow extend the discussion from biostatistics and epidemiology to cutting-edge applications in data mining and machine learning, guiding readers step-by-step through the use of modeling techniques for dichotomous data in diverse fields. Ample new topics and expanded discussions of existing material are accompanied by a wealth of real-world examples-with extensive data sets available over the Internet.
Aims: Illicit drug use and dependence often are associated with premature death, but available evidence comes mainly from clinical samples. The present paper examines drug-related mortality experience over 14 years in a United States community sample. Participants: Following probability sampling, 3,481 adult community household residents were recruited for the 1981 NIMH Baltimore Epidemiologic Catchment Area survey. Follow-up occurred in 1993-1996. Methods: Survival analyses were used to estimate median age at death and relative risk of dying in relation to drug use and dependence as assessed in 1981 using the Diagnostic Interview Schedule (DIS). Findings: Cases with DIS “drug dependence” were more likely to have died and to have a younger median age at death (p. 05), with and without statistical adjustment for confounding variables. Higher levels of drug involvement also were associated with increased age-adjusted mortality. Conclusions: The evidence favors the hypothesis that DIS-elicited “drug dependence” as well as subthreshold drug use. help to account for premature death in this community sample.
Little is known about the broad-scale demographic characteristics of low income or indigent alcoholics in public hospital systems. The purpose of the study was to examine issues relative to age, race/ethnicity, and marital status for a large group (n = 62,829) of alcoholic men receiving inpatient care in Department of Veterans Affairs (VA) medical centers nationally. Subjects were VA inpatients completing alcoholism treatment (n = 27,562), in brief alcohol detoxification or short intervention (n = 9,322), or hospitalized for primary diagnoses other than alcoholism but with a secondary diagnosis of alcohol dependence syndrome (n = 25,945). Minority alcoholics were significantly younger than Caucasian alcoholics. Hispanic and African-American men, as well as older alcoholics, were significantly less likely to complete treatment or attend detoxification and more likely to be hospitalized for other primary diagnoses. Native Americans, however, were most likely to complete alcoholism treatment. Results suggest that members of some minority groups and elderly alcoholics seek inpatient care for diagnoses other than alcoholism and that, as a result, such individuals may need targeted interventions to encourage them to seek alcohol-specific care.
Low Medicare reimbursement rates are already causing some mental health professionals to turn away elderly patients, restricting access to care. Where will funds come from to pay for the mental health needs of older adults in the year 2020, when 80 million baby boomers pass age 65? This cohort, in contrast to elders today, have high rates of psychiatric illness, and are also much more likely than older adults to seek mental health services. Seemingly oblivious to these trends, plans are being made to cut, rather than expand, the Medicare budget. We are projecting an increasing gap over the next 25 years between need and availability of geriatric mental health services.
We conducted a retrospective chart review of older (n = 48; mean age = 69) and younger (n = 36; mean age = 30) patients who were admitted to residential/inpatient treatment for alcohol withdrawal and dependence. Although the two age groups did not differ in terms of recent drinking history, the elderly group had significantly more withdrawal symptoms for a longer duration than the younger group. The elderly group also had more symptoms of cognitive impairment, daytime sleepiness, weakness, and high blood pressure. Finally, no significant differences were found between age groups in either the dosage or number of days of detoxification medication, although a trend was found for more days of medication in the elderly. We conclude that alcohol withdrawal may be more severe in elderly than in younger persons. Accordingly, treatment may take longer and should target the specific profile of symptoms that characterize alcohol withdrawal in the elderly.
Alcoholism occurs in 10 to 15% of the population over age 65 and may be difficult to diagnose. The diagnosis is based on a history aimed at detecting behavioral problems associated with drinking, administering an in-office screening instrument, and conducting tests of liver function and/or mean corpuscular volume. The most effective treatment approach in this population focuses on the stresses of aging and co-existing depression, rather than on alcohol use itself. This approach has been found equally effective in long-standing alcoholics and those who develop a drinking problem in late life. Generally, older alcoholics are very responsive to treatment.
AUDs are increasingly recognized as common problems among older adults. The magnitude of this problem is likely to increase over ensuing decades as baby boomers reach retirement age with drinking habits that are significantly different from current cohorts of older adults. Barriers to detection are numerous and include nonspecificity of alcohol-related presentations, patient denial, and clinicians' unwillingness to recognize that patients can and do develop alcohol problems in later life. Despite the limitations of current screening and diagnostic instruments, the authors recommend use of the CAGE as a formal screening tool for older patients because of its brevity, demonstrated efficacy, and convenience. In patients who answer affirmatively to any CAGE question, diagnostic certainty can be increased by use of follow-up questions or referral to an alcohol treatment specialist. Referral of patients with established alcohol abuse or dependence is essential for definitive treatment, and successful outcomes can be expected and are gratifying once achieved. In patients with less severe AUDs, brief interventions with frequent follow-up are recommended. Age-specific screening and diagnostic instruments for older AUD patients, once fully developed and validated, will facilitate identification. Much less is known about other substance use disorders in older adults. Psychoactive drug use is not uncommon in this patient population and may result in adverse health outcomes. Treatment interventions proposed for AUDs are advocated for older adults found to have other substance use disorders as well and are likely to yield improved outcomes. Future investigations that better define the epidemiology, detection, and treatment of other substance use disorders in older populations are clearly warranted at this time.
Brief interventions to change alcohol use have proven effective in different primary care settings. Current data show decreases in consumption as well as a decreased utilization of some health resources and decreased mortality. The process of changing drinking or substance abuse behavior requires a series of predictable steps. The key to changing behavior is ambivalence about current behavior. Understanding the stages of behavioral change and assessing the patient's readiness to change are important for effective interventions. Brief interventions include giving the patient feedback about a behavior, clearly recommending a change in behavior, presenting options to achieve this change, checking and responding to the patient's reaction, and providing follow-up care. Effective interventions help develop the patient's sense of motivation and self-efficacy for behavioral change. In approaching a patient with a substance abuse problem, using techniques of motivational enhancement is more effective than a confrontational approach.
The purpose of this article is to review screening for substance use disorders in health care settings. The epidemiology of alcohol and other drug abuse is briefly reviewed, followed by a discussion of the principles underlying whether or not screening is warranted. Different screening instruments and strategies are then described. Finally, current recommendations for screening for alcohol and other drug abuse are discussed.
It will be some time before known effective practices on behalf of patients with ATOD problems are integrated into the mainstream of medical care. Ironically, much of the medical literature centers on the medical and psychiatric complications of substance abuse and on physician attitudes regarding treatment of these patients. Rather the focus should be on the ways in which physicians can intervene early and effectively to treat the substance abuse problem itself. Much of this issue serves to correct the imbalance.
Measuring levels and patterns of illicit drug use, their correlates, and related behaviors requires the use of self-report methods. However, the validity of self-reported data on sensitive and highly stigmatized behaviors such as drug use has been questioned. The goal of this monograph is to review current and cutting-edge research on the validity of self-reported drug use and to describe methodological advances designed to reduce total error in estimates of drug use and quantify sources of nonsampling error. This monograph reviews a number of studies that use some presumably more accurate measure of drug use to validate self-reported use. In addition, evolving methods to improve a wide variety of procedures used in survey designs are explored, including computer-assisted interviewing, predictors of response propensity, measurement error models, and improved prevalence estimation techniques. Experimental manipulations of various survey conditions and situational factors also show promise in improving the validity of drug prevalence estimates in self-report surveys.
This study examined recent trends in initiation of psychoactive drug use.
Data from the 1991 through 1993 National Household Surveys on Drug Abuse were used to compare the percentages of US cohorts born from 1919 through 1975 who began using drugs before the ages of 15, 21, and 35.
Initiation of cigarette smoking by males peaked in the 1941-1945 cohort, then declined steadily. For females, early smoking initiation rose through the 1951-1955 cohort and then stabilized. Initiation of alcohol use was less common than smoking for pre1950 cohorts but increased steadily, approaching cigarette use for cohorts born in the early 1970s. Only 2% of teenagers born in 1930-1940 tried marijuana; half the teenagers born in 1956-1965 did so. The percentage initiating marijuana use declined in the 1980s, more so among young adults than among teenagers. The use of cocaine and other illicit drugs echoed the rise of marijuana use but peaked later and showed less evidence of subsequent decline. Sex differences declined over time for every drug.
Cohorts born since World War II have had much higher rates of illicit drug use initiation, but trends have varied by drug type, possibly reflecting changes in relative prices.
This paper presents estimates of the number of people who will need treatment for illicit drug abuse problems for the years 2000 through 2020. The methodology employs logistic regression models, with treatment need as a dependent variable, using data from lifetime marijuana users included in the National Household Survey on Drug Abuse. Age at first use of marijuana was found to be the most important predictor in these models. Other variables included in the models were age, gender, and race/ethnicity. By generating estimates under alternative assumptions about future rates of initiation, it was projected that if current rates of initiation continue, treatment need will increase by 57% by 2020, and that the need for treatment will remain high even if initiation rates decrease dramatically, because of the aging baby boom cohort.
Little attention has been paid to substance use disorders in the elderly population. Currently available diagnostic criteria are likely to significantly underestimate the prevalence of substance abuse among elderly persons because they were developed and validated in younger samples. As baby boomers age, the number of elderly persons who misuse or abuse illicit drugs and alcohol may increase because this age cohort has higher rates of use of these substances than previous cohorts. Abuse and misuse of prescription and over-the-counter drugs may also increase due to the larger numbers of baby boomers. Few studies have addressed treatment issues that may be unique to elderly substance abuse patients. Some evidence suggests that substance abuse treatment outcomes are poorer among individuals with cognitive impairment, and special treatment strategies are needed for elderly persons with dementia. To identify the magnitude of the problem, diagnostic criteria should be modified and national survey data should be analyzed to provide more accurate estimates of substance abuse and dependence among baby boomers.
This study examined multidimensional 6-month outcomes of elder-specific inpatient alcoholism treatment for 90 participants over the age of 55. At baseline, physical health functioning was similar to that reported by seriously medically ill inpatients in other studies while psychosocial functioning was worse, and nearly one third of the sample had comorbid psychiatric disorders. Based on 6-month outcomes, participants were classified into the following groups: Abstainers, Non-Binge Drinkers, and Binge Drinkers. The groups did not differ on any baseline measures (demographics, drinking history, alcohol symptoms and age of onset, comorbidity, or length of treatment). General health improved between baseline and follow-up for all groups. Psychological distress decreased for Abstainers and Non-Binge Drinkers, but did not change for Binge Drinkers. Results suggest that a large percentage of older adults who receive elder-specific treatment attain positive outcomes across a range of outcome measures.
The authors describe two case histories of patients served by the GET SMART program that provide a glimpse of typical client substance abuse histories and their remarkable journeys of change. An age-specific outpatient program for older veterans with illicit drug and alcohol dependence, the GET SMART program uses individualized and group treatment interventions in an environment of collaboration, respect, and hope. The program employs the stages of change framework and a clinical framework that includes cognitive-behavioral and motivational interviewing approaches.
The authors describe the initial cohort of participants in the GET SMART program, an age-specific, outpatient program for older veterans with substance abuse problems. Chief among the program's services is a relapse-prevention intervention consisting of 16 weekly group sessions using cognitive-behavioral (CB) and self-management approaches. Group sessions begin with analysis of substance use behavior to determine high-risk situations for alcohol or drug use, followed by a series of modules to teach coping skills for coping with social pressure, being at home and alone, feelings of depression and loneliness, anxiety and tension, anger and frustration, cues for substance use, urges (self-statements), and slips or relapses. Of the first 110 admissions, more than one-third were homeless, which is indicative of the severity of psychosocial distress of the patients, and more than one-third used illicit drugs. A total of 49 patients completed CB treatment groups and 61 dropped out of treatment. At 6-month follow-up, program completers demonstrated much higher rates of abstinence compared to noncompleters. The results suggest that CB approaches work well with older veterans with significant medical, social, and drug use problems.
The prevalence of medical disorders is high among substance abuse patients, yet medical services are seldom provided in coordination with substance abuse treatment.
To examine differences in treatment outcomes and costs between integrated and independent models of medical and substance abuse care as well as the effect of integrated care in a subgroup of patients with substance abuse-related medical conditions (SAMCs).
Randomized controlled trial conducted between April 1997 and December 1998.
Adult men and women (n = 592) who were admitted to a large health maintenance organization chemical dependency program in Sacramento, Calif.
Patients were randomly assigned to receive treatment through an integrated model, in which primary health care was included within the addiction treatment program (n = 285), or an independent treatment-as-usual model, in which primary care and substance abuse treatment were provided separately (n = 307). Both programs were group based and lasted 8 weeks, with 10 months of aftercare available.
Abstinence outcomes, treatment utilization, and costs 6 months after randomization.
Both groups showed improvement on all drug and alcohol measures. Overall, there were no differences in total abstinence rates between the integrated care and independent care groups (68% vs 63%, P =.18). For patients without SAMCs, there were also no differences in abstinence rates (integrated care, 66% vs independent care, 73%; P =.23) and there was a slight but nonsignificant trend of higher costs for the integrated care group ($367.96 vs $324.09, P =.19). However, patients with SAMCs (n = 341) were more likely to be abstinent in the integrated care group than the independent care group (69% vs 55%, P =.006; odds ratio [OR], 1.90; 95% confidence interval [CI], 1.22-2.97). This was true for both those with medical (OR, 3.38; 95% CI, 1.68-6.80) and psychiatric (OR, 2.10; 95% CI, 1.04-4.25) SAMCs. Patients with SAMCs had a slight but nonsignificant trend of higher costs in the integrated care group ($470.81 vs $427.95, P =.14). The incremental cost-effectiveness ratio per additional abstinent patient with an SAMC in the integrated care group was $1581.
Individuals with SAMCs benefit from integrated medical and substance abuse treatment, and such an approach can be cost-effective. These findings are relevant given the high prevalence and cost of medical conditions among substance abuse patients, new developments in medications for addiction, and recent legislation on parity of substance abuse with other medical benefits.
Increased alcohol consumption is associated with substantial morbidity and mortality in young and middle-aged adult populations, but its effects on the health of older adults have received less attention. The objective of the study was to review published studies that assessed the effects of alcohol on falls or fall injuries, functional impairment, cognitive impairment, and all-cause mortality among older adults. MEDLINE database and bibliographies of selected citations were searched for English language studies published between 1966 and 1998 that examined the relationship between alcohol and one or more of the above outcomes. Also a study was analyzed if it included participants 60 years of age or older, or a broader age range of participants and reported results for older subgroups, or predominantly older participants as evidenced by a mean age of 65 years of age or above. Information on studies' sample sizes, exposure and outcome measures, and risk estimates were extracted, and articles were evaluated for methodologic quality using predetermined criteria. Eighty-four studies were identified that examined 91 potential exposure-outcome associations including falls or fall injuries (n = 26); functional impairment (n = 13); cognitive impairment (n = 32); and all-cause mortality (n = 20). The percentage of studies demonstrating harm, no association, or benefit by outcome included falls (15% vs. 81% vs. 4%); functional disability (38% vs. 46% vs. 16%); cognitive impairment (31% vs. 66% vs. 3%); and all-cause mortality (15% vs. 65% vs. 20%). Studies (n = 84) inconsistently adhered to methodologic standards. Although 90% provided eligibility criteria; 61% cited participation rates; and 73% described the methods used to measure alcohol exposure; only 44% adjusted for potentially important confounding factors; and 26% distinguished former drinkers from nondrinkers. Of the cohort studies (n = 47), 30% assessed for change in participants' exposure status over time, and 17% determined whether losses to follow-up varied by exposure status. The magnitude of risk posed by alcohol use for falls or fall injuries, functional disability, cognitive impairment, and all-cause mortality among older adults remains uncertain. Prospective studies are needed to better define the health-related effects of alcohol use in older populations.
To examine whether the availability of primary medical care on-site at addiction treatment programs or off-site by referral improves patients' addiction severity and medical outcomes, compared to programs that offer no primary care.
Secondary analysis of a prospective cohort study of patients admitted to a purposive national sample of substance abuse treatment programs.
Substance abuse treatment programs in major U.S. metropolitan areas eligible for demonstration grant funding from the federal Substance Abuse and Mental Health Services Administration.
Administrators at 52 substance abuse treatment programs, and 2,878 of their patients who completed treatment intake, discharge, and follow-up interviews.
Program administrators reported whether the program had primary medical care available on-site, only off-site, or not at all. Patients responded to multiple questions regarding their addiction and medical status in intake and 12-month follow-up interviews. These items were combined into multi-item composite scores of addiction and medical severity. The addiction severity score includes items measuring alcohol and drug use, employment, illegal activities, legal supervision, family and other social support, housing, physical conditions, and psychiatric status. The medical severity score includes measures of perceived health, functional limitations, and comorbid physical conditions.
After controlling for treatment modality, geographic region, and multiple patient-level characteristics, patients who attended programs with on-site primary medical care experienced significantly less addiction severity at 12-month follow-up (regression coefficient, -25.9; 95% confidence interval [95% CI], -43.2 to -8.5), compared with patients who attended programs with no primary medical care. However, on-site care did not significantly influence medical severity at follow-up (coefficient, -0.28; 95% CI, -0.69 to 0.14). Referral to off-site primary care exerted no detectable effects on either addiction severity (coefficient, -9.0; 95% CI, -26.5 to 8.5) or medical severity (coefficient, -0.03; 95% CI, -0.37 to 0.44).
On-site primary medical care improves substance abuse treatment patients' addiction-related outcomes, but not necessarily their health-related outcomes. Further study is needed to discern the mechanism through which on-site primary care might improve the addiction-related outcomes of substance abuse treatment.
There is concern that as the baby boom population ages in the US, there will be a substantial increase in the number of older adults needing treatment for substance abuse problems. To address this concern, projections of future treatment need for older adults (defined as age 50 and older) were made.
Using data from the National Household Survey on Drug Abuse, regression models including predictors of treatment need in 2000 and 2001 were developed. Treatment need was defined as having a DSM-IV alcohol or illicit drug use disorder in the past year. Regression parameters from these models were applied to the projected 2020 population to obtain estimates of the number of older adults needing treatment in 2020.
The number of older adults in need of substance abuse treatment is estimated to increase from 1.7 million in 2000 and 2001 to 4.4 million in 2020. This is due to a 50 percent increase in the number of older adults and a 70 percent increase in the rate of treatment need among older adults.
The aging baby boom cohort will place increasing demands on the substance abuse treatment system in the next two decades, requiring a shift in focus to address the special needs of an older population of substance abusers. There is also a need to develop improved tools for measuring substance use and abuse among older adults.
For the subgroups indicated, a few questions/issues are relevant to all three (women, elderly, minorities):
1.
Heterogeneity of the special populations, for example, Hispanic-Americans are from different countries with different cultures. Women and the elderly vary by age, education, income, social class, health status, etc., to say nothing of ethnicity/color/religion.
2.
Of therapy modalities, professional and indigenous, which are more efficacious?
3.
Are group-specific therapies needed, or will sensitivity to a particular group work as well?
In Australia people aged 65 years or older currently comprise 12.1% of the population. This has been estimated to rise to 24.2% by 2051. Until recently there has been relatively little research on alcohol and other drug use disorders among these individuals but, given the ageing population, this issue is likely to become of increasing importance and prominence. Epidemiological research shows a strong age-related decline in the prevalence of alcohol and other drug use disorders with age. Possible reasons for this include: age-related declines in the use and misuse of alcohol and other drugs; increased mortality among those with a lifetime history of alcohol and other drug use disorders; historical differences in exposure to and use of alcohol and other drugs. Despite the age-related decline in the prevalence of these disorders, they do still occur among those aged 65 years or older and, given historical changes in exposure to and use of illicit drugs, it likely that the prevalence of these disorders among older-aged individuals will rise. Specific issues faced by older-aged individuals with alcohol and other drug use problems are discussed. These include: interactions with prescribed medications, under-recognition and treatment of alcohol and drug problems, unintentional injury and social isolation. Finally, a brief discussion of treatment issues is provided.
Aims As part of a larger study to estimate the global burden of disease attributable to alcohol:
Design, methods, setting Systematic literature reviews were used to select diseases related to alcohol consumption. Meta-analyses of the relationship between alcohol consumption and disease and multi-level analyses of aggregate data to fill alcohol–disease relationships not currently covered by individual-level data were used to determine the risk relationships between alcohol and disease. AAFs were estimated as a function of prevalence of exposure and relative risk, or from combining the aggregate multi-level analyses with prevalence data.
Findings Average volume of alcohol consumption was found to increase risk for the following major chronic diseases: mouth and oropharyngeal cancer; oesophageal cancer; liver cancer; breast cancer; unipolar major depression; epilepsy; alcohol use disorders; hypertensive disease; hemorrhagic stroke; and cirrhosis of the liver. Coronary heart disease (CHD), unintentional and intentional injuries were found to depend on patterns of drinking in addition to average volume of alcohol consumption. Most effects of alcohol on disease were detrimental, but for certain patterns of drinking, a beneficial influence on CHD, stroke and diabetes mellitus was observed.
Conclusions Alcohol is related to many major disease outcomes, mainly in a detrimental fashion. While average volume of consumption was related to all disease and injury categories under consideration, pattern of drinking was found to be an additional influencing factor for CHD and injury. The influence of patterns of drinking may be underestimated because pattern measures have not been included in many epidemiologic studies. Generalizability of the results is limited by methodological problems of the underlying studies used in the present analyses. Future studies need to address these methodological issues in order to obtain more accurate risk estimates.
The nature and extent of treated health problems in patients with problems related to the use of alcohol and drugs (including both licit and illicit drugs) were compared with the morbidity levels of all patients treated for all conditions in Canada. The morbidity experience of all patients with alcohol or drug (A/D) diagnoses treated as inpatients (n = 52,200 cases) in all Ontario hospitals in 1985-1986 (based on Hospital Medical Records Institute [HMRI] data) was compared with that of the total population of all inpatients treated in all Canadian hospitals using age-sex standardized morbidity ratios (SMR) and adjusting for multiple diagnoses. Of A/D cases, 32% were admitted with a primary A/D diagnosis and 68% with a secondary A/D diagnosis; 17% of A/D cases had multiple A/D diagnosis. On average, cases with a primary A/D diagnosis had 29% more diagnoses per case than all cases treated in Ontario. SMRs were highest for cases with diagnoses relating to the use or misuse of licit drugs (SMR = 13.32 and 3.51 for those with primary and secondary drug diagnoses, respectively), intermediate for illicit drug cases (SMR = 8.87 vs. 4.74 for primary and secondary diagnoses, respectively), and lowest for patients with alcohol diagnoses (SMR = 6.68 and 4.12 for primary and secondary diagnoses, respectively). Excess morbidity for alcohol cases affected more diagnostic categories and body systems, being at a higher level than for drug cases. Alcohol or drug cases had particularly high SMRs for mental disorders, infectious and parasitic conditions, and injury and poisoning diagnoses. Alcohol or drug cases had reduced reproductive morbidity: for complications of pregnancy, childbirth, and the puerperium, SMR = 0.04 to 0.24 for cases with primary A/D diagnoses and SMR = 0.12 to 0.89 for those with secondary A/D diagnoses. Cases with drug diagnoses had a considerable reduction in SMR for certain conditions originating in the perinatal period: SMR = 0.0 for cases with primary drug diagnoses and SMR = 0.0 for secondary illicit drug diagnoses cases and SMR = 0.18 for secondary licit drug diagnoses cases.
Treatment of alcohol dependence among older alcoholic patients should be multidimensional to address as many potential relapse factors as possible. As the literature suggests, alcohol-related disorders often are under diagnosed and under treated. More efforts are needed to identify and improve diagnosis of these disorders in older alcoholic patients. For better outcomes, age-specific programs should be implemented. Furthermore, when treating elderly patients, basic therapeutic principles like respect for privacy and a respectful attitude should be adopted. Adequate medical, pharmacologic, and psychiatric treatment should be provided when appropriate. Medication to reduce cravings should be considered in patients without contraindications to its use. Participation in individual, group, and family therapy and attendance at self-help group meetings such as AA should be encouraged (Table 8). Despite the lack of empiric testing to validate these recommendations in an elderly population, clinical experience suggests that adherence to these recommendations will benefit elderly patients just as it has the general adult population. Research is necessary to explore the benefits of alcohol treatments in elderly patients. Until then, adherence to these recommendations should be the best available approach.
Modifiable behavioral risk factors are leading causes of mortality in the United States. Quantifying these will provide insight into the effects of recent trends and the implications of missed prevention opportunities.
To identify and quantify the leading causes of mortality in the United States.
Comprehensive MEDLINE search of English-language articles that identified epidemiological, clinical, and laboratory studies linking risk behaviors and mortality. The search was initially restricted to articles published during or after 1990, but we later included relevant articles published in 1980 to December 31, 2002. Prevalence and relative risk were identified during the literature search. We used 2000 mortality data reported to the Centers for Disease Control and Prevention to identify the causes and number of deaths. The estimates of cause of death were computed by multiplying estimates of the cause-attributable fraction of preventable deaths with the total mortality data.
Actual causes of death.
The leading causes of death in 2000 were tobacco (435 000 deaths; 18.1% of total US deaths), poor diet and physical inactivity (365 000 deaths; 15.2%) [corrected], and alcohol consumption (85 000 deaths; 3.5%). Other actual causes of death were microbial agents (75 000), toxic agents (55 000), motor vehicle crashes (43 000), incidents involving firearms (29 000), sexual behaviors (20 000), and illicit use of drugs (17 000).
These analyses show that smoking remains the leading cause of mortality. However, poor diet and physical inactivity may soon overtake tobacco as the leading cause of death. These findings, along with escalating health care costs and aging population, argue persuasively that the need to establish a more preventive orientation in the US health care and public health systems has become more urgent.