Hot topic in geriatric medicineSystematic and narrative review of treatment for older people with substance problems
Introduction
The proportion of the population over 65 years old will increase in the next 20 years. Projection studies have estimated that the number of adults over the age of 50 with substance use disorder will double, from 2.8 million in 2002–2006 to 5.7 million in 2020 [1]. In 1995, 49% of the “baby-boom” cohort, then aged 31–49, had used illicit drugs during their lifetime, compared to 11% of those over 50 [2]. In the United States, the lifetime prevalence rates for dependence on illegal substances are 17% for 18–29-year-olds, 4% for 30–59-year-olds and 1% for the over-60's [3]. This picture is mirrored in the British Crime Survey of England and Wales [4].
In the UK in 2006/2007, 18% of 55–59-year-olds and 23% of 45–54-year-olds reported lifetime use of drugs, 1.7% and 3.0% respectively reported use within the previous year, and 0.8% and 1.6% reported use in the previous month [5]. National statistics for treatment in the UK in 2007 showed that 4% of those who had received treatment in the previous 12 months were aged over 50 [6], though this proportion is increasing with time and is higher in London (14%). The number of drug misusers aged 40+ increased as a proportion of all adult drug misusers in treatment from 13% in 2004/2005 to just above 16% in 2006/2007, according to the National Drug Treatment Monitoring System [7]. Hospital Episode Statistics report increasing numbers of patients aged over 45 with primary or secondary drug-related disorders, including poisoning. As a result there will be an increased demand for specialist drug treatment services to cater for the needs of these elderly patients in the future.
Older people are particularly at risk from the harmful effects of substances, due to altered metabolism [8] and polypharmacy [3]. The presentation of such problems can be subtle and under-diagnosis and under-reporting may, therefore, have contributed to unreliable estimates of the level of problems associated with substance use [9]. An Australian study found low levels of detection and appropriate onward referral to specialist services of older problematic substance misusers by medical staff, some of whom believed that “to give up established habits is inappropriate” [10].
That these attitudes need to be challenged is characterised by the issue of smoking. Smoking tobacco is the largest cause of premature death in the UK, causing 106,000 deaths every year [11] and it has been shown that people who are well into middle age when they quit smoking can still avoid more than 90% of smoking-related lung cancer risk [12]. Forty-four percent of smokers aged 50 or over want to quit [13], but some older smokers think that they cannot stop or that they have already caused so much damage that quitting would not be beneficial to their health [14]. Strikingly, the number of deaths in the UK linked to alcohol has more than doubled, from 4144 in 1991 to 8386 in 2005, with the highest death rates found in men and in those aged 55–74 [15]. Illicit drug use also results in mortality – cohort studies have demonstrated between 12–22 times greater mortality rate in drug users compared with in the general population and older drug misusers are between two and six times more likely to die from a drug-related death [16], [17], [18]. The Office for National Statistics also reports increased deaths from drug misuse for over-40–69-year-olds from 1993–2005 [19].
To further complicate matters, older people obtain prescription drugs (e.g. codeine-based medications for pain or coughs and benzodiazepine tranquillisers or hypnotics for affective and anxiety disorders) from GPs or over-the-counter and, since they may not adhere to the instructions, they experience a wide range of adverse effects [20], including tolerance, withdrawal symptoms and compulsive use in the long-term [21].
While it is acknowledged that the prevalence of substance misuse in this age group varies according to the definitions of “elderly” (usually over 65 years in the UK, but often as low as 50) and “substance misuse” used [22], there are considerable grounds for concern that there are unmet needs within communities and that problems will increase. In the case of opiate misusers, over the age of 40 is regarded as “older” [7]. Definitions of substance misuse and dependence often used as the gold standard are derived from the DSM-IV [23] or the ICD-10 [24], but there is some debate as to whether these can be applied to older people.
There is a vast literature on the pharmacological and psychological treatments for adult substance misusers, from which evidence-based guidance and consensus statements have resulted [25]. There is no published guidance by the National Institute for Health and Clinical Excellence (NICE) on the treatment of older substance misusing patients or, in particular, older opiate dependent patients [26], [27], [28], [29]. The studies on which the recommendations are based exclude those over 65 (sometimes even over 50-year-olds), as well as those with physical and psychiatric comorbidities. The Department of Health recently produced revised management guidelines, which include a brief section on older addicts, where the older patient is defined as 40+ years [7]. The National Service Framework for the care of the elderly does not discuss addictions and substance misuse [30].
Given the rising numbers of older people with substance problems and the potential for effective treatment, exploration of the evidence base in the elderly population to date was undertaken to evaluate the interventions carried out. As far as we are aware, this is the first systematic review of studies on the treatment of alcohol, tobacco, illicit drug and prescription medication misuse in the older population.
Section snippets
Objectives
To determine whether there is evidence to support the treatment of substance misusing by older people and to discover which treatments, if any, are appropriate for this population.
Inclusion criteria
For the purposes of this study, older people were defined as those aged 50 years old or older. Trials were included if they looked specifically at older people, or if older people were part of a wider age range and the results for the older population were clearly described. Both pharmacological and psychological
Results
The information from each of the 16 studies was summarised and listed in order of date of publication and by the substance with which it was concerned. For the purposes of discussion, the two papers concerned with alcohol and drug abuse were included amongst the studies on alcohol and highlighted as such in the tables and Appendix A, as it was found that the majority of older patients in these studies only had an alcohol dependence problem. Eleven studies [32], [33], [34], [35], [36], [37], [38]
Discussion
Based on the limited evidence available, there is no indication that older people do worse than younger people in terms of outcomes after treatment for substance dependence and, in some cases, they may even do better. Whether this is related to a less serious degree of dependence, fewer associated problems, more supportive social networks, better treatment adherence, a longer time in treatment with older age, or to age itself, requires further investigation. It is possible that the patients who
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
Acknowledgements
We would like to thank Marion Riley and Corrina Knight for their secretarial assistance in this project.
References (47)
- et al.
Substance abuse treatment need among older adults in 2020: the impact of the aging baby-boom cohort
Drug Alcohol Depend
(2003) - et al.
The older smoker: status, challenges and opportunities for intervention
Chest
(1990) - et al.
Smoking cessation in the elderly
Clin Geriatr Med
(2003) - et al.
Drug-related deaths by region, sex and age group per 100 injecting drug users in Scotland, 2000–01
Lancet
(2003) - et al.
Older adult treatment outcome following elder-specific inpatient alcoholism treatment
J Subst Abuse Treat
(2000) - et al.
Outcomes at 1 and 5 years for older patients with alcohol use disorders
J Subst Abuse Treat
(2003) - et al.
Treatment outcomes for alcohol dependence among middle-aged and older adults
Addict Behav
(2005) - et al.
Reaching midlife and older smokers: tailored interventions for routine medical care
Prev Med
(1996) - et al.
Characteristics and treatment outcome of older methadone maintenance patients
Am J Geriatr Psychiatry
(2004) - et al.
Substance use disorder among older adults in the United States in 2020
Addiction
(2009)