# Presentation: 239306

## Addictive and Co-Occurring Disorders in Late Life 

**David W. Oslin, M.D.**
**University of Pennsylvania, School of Medicine**
**And**
**Philadelphia, VAMC**

**Hazelden Research Co-Chair on Late Life Addictions**

## Translating Positive findings in Aging to Younger Adults

## Disclosures

**NIMH**
**K08 Award**
**ACSIR**
**NIDA **
**Center for Studies on Addiction**
**NIAAA **
** ****R01**
**VA**
**Merit Early Entry**
**MIRECC**
**HSRD Merit Award**
**Industry Support**
**DuPont Pharma **
**Forest Labs **
**Hazelden Foundation**
**Pfizer **

## Relevance of comorbidity to an aging population

**Cohort changes in exposure – we will see more elderly patients using illicit substances (current and past abuse)**
**Consequences may be greater in older adults**
**Direct toxicity / withdrawal**
**Indirect interactions with medications or other illnesses**
**Comorbidity is a significant issue perhaps uniquely so for the elderly**
**Cognition**
**Minor depression**
**Suicide**
**Anxiety and personality problems**
**Changing environment**
**Social isolation**
**Limited resources**
**Limited access to care**

## Comorbidity and Drug/Alcohol Dependence

**Higher than expect rates in representative community samples**
**Markedly higher rates in treatment seeking samples**
**Increased morbidity and mortality particularly suicide**
**Presents diagnostic difficulties**
**Poor prognostic factor**
**Call for integrated care system**

## Suicide

**Highest rates of suicide occur in late life among men.**
**Depression causes a 5.8 fold increase in risk of suicide compared to death from other causes **
**Heavy drinking (3+ drinks/day) causes a 8.9 fold increase in risk of suicide compared to death from other causes**
**Moderate drinking (1-2 drinks/day) causes a 10.6 fold increase in risk of suicide compared to death from other causes**

**Grabble, et al. 1997**

## The difficulty

**Extremely limited research**
**Drug and alcohol dependence are exclusions to most geriatric trials**
**Age >65 is almost always an exclusion for drug and alcohol trials**

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

|  | Current / Last 12 months |
| --- | --- |
| Alcohol Dependence | 2 - 4 % |
| Medication misuse | ? Overall
Chronic Benzodiazepine use 5 – 20% |
| Nicotine dependence | 10 - 15 % |
| Illicit Substance dependence | < 1 % |
| Pathological Gambling | 1 – 2 % |

**Notes:**
Drinking was categorized during the last year.
Most older adults don’t drink. Abstinence is defined as drinking on no more than 2 occasions in the last year and no binge drinking. Moderate drinking is defined as drinking within the NIAAA recommended guidelines – see slide 5
Drinking is more common in men than women and more common in Caucasians than African Americans.  Drinking among other ethnic minority elderly is even less common.
 At-risk drinking is common and a target for treatment
 Alcohol dependence is relatively uncommon in the general population but is more common in hospitals and clinics
 The major difference in epidemiology of late life drinking with younger adults is a greater proportion of abstinence and a smaller group of moderate drinkers. Reasons for high rates abstinence include poor health, prior problems with alcohol, and cohort differences compared with current generations.

## Baby Boomers Aging

|  | 91 – 92 | 01 – 02 | Percent Increase |
| --- | --- | --- | --- |
| 18-29 | 6.5 | 7.0 | 8% |
| 30-44 | 3.0 | 6.0 | 100% |
| 45 – 64 | 1.4 | 3.5 | 150% |
| 65+ | 0.3 | 1.2 | 300% |

**Grant, et. al. Drug and Alcohol Dependence 2004**

## Veterans (Age 60 and Over) in Addiction Treatment

**Alcohol Only****	****	****	****	****	****	****51.8%**
**Street Drugs Only****	****	****	****	****	****  9.1%**
**Prescription Medications only ****	****	**** ****	****  3.6%**
**Alcohol and Street Drugs****	****	****	****	****26.4%**
**Alcohol and Prescription Medications****	****	****  5.5%**
**Street Drugs and Prescription Medications****	**** ****	****  0.9%**
**All three categories of substances****	****	****  ****	****  1.8%**
**Missing data****	****	****	****	****	****	****  0.9%**

**Schonfeld et al. 1990**

**Sample of 110 subjects in a special geri-addiction program**

## Past History of Heavy drinking/alcoholism

- Many older adults especially those of the “Woodstock” generation will enter late life with a past history of alcohol or drug abuse
- 5 fold increase in late life mental disorders (depression and dementia)
- Treatment of late life depression (3-5 yr outcomes)
- 88% of those without an alcohol history significantly improved
- 57% of those with an alcohol history significantly improved

**Saunders et al. 1991, Cook et al. 1991**

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

## Research to Practice:Behavioral Health Laboratory

**The BHL is an automated telephone assessment and triage service for patients identified by primary care providers as having depressive symptoms or at-risk drinking.**
**The depression and alcohol clinical reminder system generates a consultation request to the BHL.**
**The BHL conducts a brief telephone (20-30 minutes) assessment generating a report for the PCP including diagnosis, severity, and general treatment recommendations.**

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

|  | <50 Years | 50-64 years | 65 + years |
| --- | --- | --- | --- |
|  | n=205 | n=323 | n=112 |
| 
Use in past year | 
24.4 | 
20.7 | 
2.7 |
| Past history of use | 20.5 | 20.4 | 1.8 |

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

|  | Use in Past Year | Only a past history |
| --- | --- | --- |
|  | n=70 | n=22 |
| Cocaine | 54.3 | 36.4 |
| Heroin | 7.1 | 0 |
| Marijuana | 58.6 | 77.3 |
| Amphetamines | 1.4 | 9.0 |
| LSD | 1.4 | 4.5 |
| Inhalants | 1.4 | 0 |
| Barbiturates | 1.4 | 0 |

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

|  | No Hx of Drug use | Only a past Hx | Use in the past year | Diff             (by column) |
| --- | --- | --- | --- | --- |
|  | n=342 | n=22 | n=70 |  |
| 
Nicotine use | 
36.5 | 
68.2 | 
68.6 | 
c>a, b>a |
| At-risk drinker | 10.5 | 31.8 | 27.1 | c>a, b>a |
| Cognitive screen | 4.2 (4.2) | 6.6 (4.8) | 4.8 (4.0) | b>a |
| Suicide | 12.5 | 13.6 | 28.6 | c>a |
| Manic symptoms | 7.0 | 0.0 | 18.6 | c>a |
| Psychotic symptoms | 9.9 | 9.1 | 21.4 | c>a |
| PTSD | 27.0 | 18.2 | 37.1 |  |

## Treatment

## Depression Alcohol Aging Trial

**Hypotheses**
**Among older adults with major depression and comorbid alcoholism, naltrexone combined with sertraline improves the outcomes of both drinking and mood.**
**Reduction in alcohol consumption will be associated with improved mood regardless of randomization.**
**Naltrexone will lead to a reduction in alcohol consumption independent of changes in mood.**

## Concurrent Treatment of Depression Complicated by Alcohol Dependence

- Current depressive syndrome
- Current alcohol dependence
- Age 55 and over
- 10 sessions of compliance enhancement therapy
- 1/2 of subjects are randomly assigned to receive naltrexone 50 mg
- All subjects receive sertraline 100 mg
- Outcomes at 3 months

**(Oslin, 2004****)**

## Pre-Treatment Clinical Characteristics

|  | Placebo | Naltrexone | p value |
| --- | --- | --- | --- |
| HDRS Score  | 23.4 (5.0)  | 20.1 (5.7) | 0.011 |
| Percent Days Heavy Drinking- | 75.8 (29.1) | 59.2 (35.6) | 0.032 |
| Percent Days Drinking  | 82.4 (24.5) | 75.5 (29.3) | 0.270  |
| Drinks/ Drinking Day | 10.2 (6.8) | 6.5 (3.9) | 0.006  |
| ASI-Alcohol Score | 0.67 (0.18) | 0.64 (0.17) | 0.433 |
| PCS	 | 43.8 (8.5) | 46.1 (10.3) | 0.325 |
| MCS | 33.2 (9.6) | 38.1 (11.5) | 0.061 |
| % with Primary Depression | 68.6 | 65.7 | 0.799  |

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

|  | No Relapse | Relapse | p |
| --- | --- | --- | --- |
| Completed Research (%) | 83.7 | 84.0 | 0.886 |
| Depression Remitted | 63.3 | 32.0 | 0.011 |
| HDRS – end of trial | 8.8 (6.7) | 12.7 (8.2) | 0.013 |

## Overall Treatment Outcomes

**Overall Treatment Outcomes**

**Notes:**
David W. Oslin, M.D.
CME 2001 Key West

## Substance Induced Depression in the  elderly?

- Less than 50% resolution of symptoms early in treatment
- No relationship between clinical impression of primary vs. secondary depression and early response

## Not just Dependence

**Moving beyond DSM in conceptualizing risk**

## Disease and Behavior

**Substance dependence**
**Follows the biomedical model of an illness**
**At-risk use**
**Public health model**
**Recognizes risks (health, economic, etc.) associated with use in individuals not suffering with the “disease”**
**Most relevant for alcohol, medications, marijuana and nicotine.**

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

- Most common pattern of drinking among those with depression
- May be beneficial for heart disease
- Safety concerns may be less with newer medications (SSRIs) than older meds (TCAs)

## Response to Standard Depression Care Among the Elderly

- PROSPECT study
- Remission of depression (men only)
- Non-drinkers – 41 %
- Moderate drinkers – 18.2%
- PRISM-E study (preliminary)
- Remission of depression (men only)
- Non-drinkers – 33.8 %
- Moderate drinkers – 6.3 %

**(Personal Communication, 2002)**

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

**To develop a method for delivering high quality depression and alcoholism treatment in Primary Care, CBOCs, and other clinics in which there are significant transportation, staff resource, or other impediments to the delivery of face-to-face MH/SA care.**
**To develop methods for translating effects demonstrated in randomized clinical trials to clinic populations.**

## Treatments

**Telephone Disease Management is algorithm driven care delivered by a Behavioral Health Specialist.  **
**Enhanced Usual care.  The PCP can monitor, treat, and/or refer. The PCP is provided a diagnosis and references for treatment options.**

## Improvements with TDM

**Oslin, et. al.  2003**

**Notes:**
These results represent a randomized trial of Telephone Disease Management (TDM) vs. usual care among veterans in primary care identified by screening 

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

- Association with falls
- Association with memory impairment
- ?Association with treatment of depression

## How to Define Inappropriate Benzodiazepine Use

- Chronic Use (>3 months)
- Use of long-acting agents
- Undocumented response
- Lowest effective dose (harm reduction)

## Sedative/Hypnotic UseA Disappearing Problem?

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

## Types of Sedative/Hypnotics Used

|  | Percent |
| --- | --- |
| Xanax | 32.7 |
| Ativan | 24.1 |
| Restoril | 13.1 |
| Klonopin | 11.1 |
| Valium | 10.6 |
| Librium | 6.0 |
| Tranxene | 4.5 |
| Barbituates | 2.0 |
| Serax | 2.0 |
| Dalmane | 1.0 |