# Presentation: 293521

## Prescription Drug Abuse and Misuse in the Elderly

**Thomas L. Patterson, Ph.D.**
- Support for this work: NIMH Center Grants P30 MH49693 and MH45131, and by the Department of Veterans Affairs

## Number of Americans >65 (Millions)

**Number of Americans >65 (Millions)**

**  **

**U.S. Bureau of Census**

## Drug Problems in the Elderly Current State of Affairs

**Alcohol**
**Illicit drugs**
**Prescription/OTC**

## Prescription Drugs are consuming more health costs (Reinhardt et al., 2004)

##  Increased  costs are related to use by elderly (Baugh et al. 2004)

**Notes:**
During the 1990s  Medicad drug payments for the aged increased from 1.5 to 5.4 billion dollars, an average incarese of 13.5%   Together the aged and disabled represeent 85% of total medicad spending in 2000

## Increased Spending primarily due to increased use

- (Reinhardt et al., 2004)

## Age and gender effect number of Meds taken (Linjakurapu et al., 2002)

## Past decade has seen increased use of virtually all classes of meds (Linjakurapu et al., 2002)

## Estimated Numbers of People with Psychiatric Disorders in USA

**Age Group**

**(Jeste et al., Arch Gen Psychiatry, 1999)**

## DAWN (2003)

## Estimated Number (in thousands) of U.S. Residents (Age 12 and Older) Reporting Lifetime Non-Medical Use of Prescription Pain Relievers, 2003

- *Prior to 2002, the NSDUH was known as the National Household Survey on Drug Abuse. Due to changes in the survey, estimates from the 2002 and 2003 NSDUHs should not be compared with estimates from the 2001 and earlier NHSDAs to assess changes over time.
- SOURCE:  Adapted by CESAR from Substance Abuse and Mental Health Services Administration (SAMHSA), *Overview of Findings from the 2003 National Survey on Drug Use and Health*, 2004.

## Large numbers of U.S. Population Misuse Prescription Drugs

## Slide 13

## Prescription Drug Abuse/Misuse

**Most drugs for medical conditions**
**Psychoactive drugs (e.g., benzodiazepine) most often abused in elderly**
**Inpatient addiction program; 16% prescription**
**Comorbidities**
**Prescription + alcohol**
**Psychiatric diagnoses**
**Baby-Boomer impact unknown**
**Problems identifying cases**

## Prescription drug abuse is probably underestimated by 20%Problems in Defining DrugDependence in the Elderly (DSM-IV)

**Criteria: “Increased tolerance to effects of substance...”**
**changes in pharmacokinetics**
**Criteria: “Report of adverse consequences...” (e.g., poor work performance, suspension from school etc.)**
**fails to consider lifespan changes**

## Abuse/Dependence in the Elderly

**Factors associated with abuse**
**Genetics**
**Stress**
**Co-morbidities**
**Metabolism**
**Structural Problems**
**Research not consider aged**
**Dosage one size fits all**
**Age related changes in abuse**
**“****Maturing out” Theory**
**Mortality**
**Morbidity**
**Maturational Factors**
**Until problems emerge difficult to ID**
**Access to prescription drugs is changing **

**Notes:**
Access could impact missuse and/or abuse of drugs

## Prescription Drug Abuse

**Prevalence affected by sampling**
**Increased in nursing homes and hospitalized**
**Less evidence for ambulatory aged**
**Reason for misuse of meds**
**Difficulties reading and following prescription**
**Cognitive deficits**
**Cost**
**Complexity of drug treatment**

## Prescription Drug Use

**Types of misuse**
**Over dose**
**Under dose**
**Use for other than prescribed**
**Drug combinations**

## Antipsychotic Adherence

| Standardized Estimates of Annual Cost in Dollars |  |  |  |  |
| --- | --- | --- | --- | --- |
| Antipsychotic Adherence* | Hospital | Outpatient  | Pharmacy  | Total  |
| Nonadherent
(.01 - .49) | 3,413
(368) | 3,464
(175) | 1,542
(107) | 8,168
(433) |
| Partially Adherent
(.5 -.8)  | 2,689
(412) | 3,693
(208) | 3,142
(110) | 9,403
(542) |
| Adherent
(.8 – 1.1) | 1,025
(95) | 3,776
(151) | 4,463
(161) | 9,505
(289) |
| Excess Filler
( > 1.1) | 2,472
(272) | 5,741
(312) | 5,635
(188) | 14,044
(561) |

- Gilmer, et al 2004

***Cumulative Annual Possession Ratio**

## Medical Care Expenditures Increasing

- (Reinhardt et al., 2004)

## Under-use of Medications May be increasing (Archives of Internal Medicine, 2004)

- Two-thirds of older patients reduce use of medications due to cost

## 1197.pdf

- Inappropriate use of drugs effected by ethnic/cultural factors (Raji et al. 2003)

**Notes:**
A study of older persons crossing Az border found 80% with prescription drugs.

## The Internet is Becoming a Larger Source of Prescription Drugs

- “The internet has become a virtual wild west bazaar for “spam” emails and websites that sell controlled substances with little or no oversight..” DEA, 2004

## General Information is available on many drugs(9/9/04)

## There are many sites that sell prescription drugs (9/9/04)

## Modified Swiss Cheese ModelAfter James Reason

- ADVERSE
- EVENT

*Provider(s)*

*Equipment*
*& Tools*

*Local Care*
*Environment*

*Organization*

*Healthcare*
*System*

- EVENT TRAJECTORY

*Patient*

**Notes:**
Point of Reason, not all problems (Holes) lead to an adverse event, He missed the patient. Holes in aging patient could be cognitive deficits, metabolic changes, poor eye sight. 

## Modified Swiss Cheese ModelAfter James Reason

- ADVERSE
- EVENT

*Provider(s)*

*Equipment*
*& Tools*

*Local Care*
*Environment*

*Organization*

*Healthcare*
*System*

- EVENT TRAJECTORY

*Older Patient*

**Notes:**
Point of Reason, not all problems (Holes) lead to an adverse event, He missed the patient. Holes in aging patient could be cognitive deficits, metabolic changes, poor eye sight, adherence problems, financial hardships, etc.

## Summary

**Scope of use**
**30% of prescription consumed by 12% of population >65 years**
**$15 billion/year in elderly (4x’s younger individuals)**
**Abuse and misuse is a problem**
**Estimates of scope of problem hindered by a number of factors**
**Access to prescription drugs is easier than ever before**

## Specific Goals and Suggested Strategies

**Improve diagnostic criteria**
**Focus research on compliance**
**Standardize prescription labeling**
**Develop treatment programs tailored to elderly**
**Consider dual diagnosis (e.g., PTSD & drug use)**
**Explicate age related changes in drug abuse**
**Examine impact of internet/foreign purchase of med’s**
**Examine ethnic and cultural differences**