The AmericanJournal of Geriatric Pharmacotherapy L. Simoni-Wastilaand H.

IC Yang

Psychoactive Drug Abuse in Older Adults

Linda Simoni-Wastila, BSPharm, PhDI,2; and Huiwen KeriYang, MS2
ILon~term Care Initiative, Peter Lamy Center on Drug Therapy and Aging, School of Pharmacy, University of Maryland Baltimore, Baltimore, Maryland; and 2Department of Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland Baltimore, Baltimore, Maryland

ABSTRACT Background: Misuse and abuse of legal and illegal drugs constitute a growing problem among older adults. Objective: This article reviews the prevalence, risks and protective factors, and screening and diagnosis of drug
abuse in older adults. Treatment concerns and the consequences of drug problems arc examined briefly. Methods: MEDLINE and PsychInfo wcrc searched using the terms substance-related disorders, drug-use disorders, abuse, dependency, opioid-related disorders, stimulant-related disorders, cocaine-related disorders, marijuana-related disorders, and withdrawal syndrome. The review included articles published in English between January 1, 1990, and May 31, 2006. Results: Despite a wealth of information on the epidemiology and treatment of alcohol abuse in older adults, few comparable data are available on drug abuse in this population. The evidence suggests that although illegal drug use is relatively rare among older adults compared with younger adults and adolescents, there is a growing problem of the misuse and abuse of prescription drugs with abuse potential. It is estimated that up to 11% of older women misuse prescription drugs and that nonmedical use of prescription drugs among all adults aged >50 years will increase to 2.7 million by the year 2020. Factors associated with drug abuse in older adults include female sex, social isolation, history of a substance-use or mental health disorder, and medical exposure to prescription drugs with abuse potential. No validated screening or assessment instruments are available for identifying or diagnosing drug abuse in the older population. Special approaches may be necessary when treating substance-use disorders in older adults with multiple comorbidities and/or functional impairment, and the least intensive approaches should be considered first. Conclusions: Psychoactive medications with abuse potential are used by at least 1 in 4 older adults, and such use is likely to grow as the population ages. The treatment of disorders of prescription drug use in older adults may involve family and caretakers, and should take into account the unique physical, emotional, and cognitive factors of aging. Further research is needed on the epidemiologic, health services, and treatment aspects of drug abuse in older adults, as well as the development of appropriate screening and diagnostic tools. ( A m J Geriatr Pharmacother. 2006;4: 380-394) Copyright 2006 Excerpta Medica, Inc. Key words: abuse, drugs, prescription, geriatric, opioids, tranquilizers.

Accepted for publicationAugust 16, 2006.

Printed in the USA. Reproduction in whole or part is not permitied.

doi:l 0. 1016/j.amjopharm.2006.10.002 1543 5946/06/$19.00

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L. Simoni-Waa~tilaand H.IC Yang TheAmericanJournal of Geriatric Pharmacotherapy

INTRODUCTION

Thc potcntial for abusc of psychoactivc drugs among older adults is a recognized problem, and there is considcrablc concern that the use of abusablc drugs will grow as the baby-boom generation ages. Unlike the illegal drugs of abuse among adolescents and younger adults (cg, marijuana, cocaine, heroin), the substances abused by older adults are usually alcohol, nicotine, and prescription drugs. This article reviews the evidence for the abuse of prescription and illegal psychoactive drugs among older adults. Thc focus was on drugs with thc potcntial for abusc, dcpcndcncy, and/or addiction. Among lcgally available drugs, the emphasis was on controlled substances available by prescription only; use of tobacco, alcohol, and over-the-counter drugs wcrc excluded from thc rcvicw. Thc topics covcrcd includc thc currcnt and projected prevalence of drug abuse in the older population; screening for, evaluating, and diagnosing drug abusc; trcatmcnt conccrns spccific to oldcr adults; thc health care and economic consequences of drug abuse; and recommendations to providers and researchers.
MATERIALS AND METHODS

tions in books published during the time frame of the review were examined for relevant publications. Based on these procedures, 67 articles were identified that were considered relevant to this review. References to 35 other books, government monographs, and articles that did not otherwise meet our inclusion criteria were used for contextual and background information.
DEFINITIONS OF TERMS

MEDLINE and PsychInfo wcrc searched for articles published in English between January 1, 1990, and May 31, 2006. A scarch using thc tcrms substancerelated disorders, drug-use disorders, abuse, dependency, opioid-related disorders, stimulant-related disorders, cocaine-related disorders, marijuana-related disorders, and withdrawal syndrome identified 24,662 articles. Articles that concerned individuals aged _>50 years were selected, resulting in 624 articles. Abstracts of these papers were retrieved and examined for relevance (ie, they focused on or included subanalyses relevant to older adults and drugs ]rather than alcohol or nicotine only]). The relevant articles were then obtained, and additional publications were identified by examination of the reference lists of these articles. Articles relating to prevalence were limited to those pertaining to the United States. For other topical areas, such as screening and treatment, articles from other industrialized nations (eg, the United Kingdom, Australia, Canada) were included. Emphasis was placed on review articles, clinical trials, observational and epidemiologic studies, health services research studies, economic analyses, and studies describing screening and assessment instruments. Letters, commentaries, and articles that discussed only alcohol use or did not specifically concern older adults were excluded, as were books and book chapters. However, the reference cita-

For thc purposcs of this rcvicw, thc tcrm older adults included those aged _>50 years. Although 50 years is at thc lowcr cnd of thc rangc of oldcr adulthood, scvcral of the identified articles used this age as the lower limit; most studies, however, focused on individuals aged _>60 years. As used in this review, abuse was defined as problematic use of psychoactive drugs that could lead to such adverse consequences as diagnostically defined abuse or dependency, cognitive and/or physical impairment, limitations in social life and activities of daily living, or any other impairment of normal functioning. Whenever possible, as the literature allowed, it is specified when studies used published diagnostic criteria for abuse and dependency, such as those in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)) The DSM-IV definitions may be overly broad; however, no standard definition of psychoactive drug abuse in older adults emerged from the identified literature. Indeed, many of the studies reviewed did not define abuse or dependency or otherwise describe how they characterized problematic substance use. Finally, it is important to note that in this review, abuse is not necessarily synonymous with the concept of "inappropriate use" as applied in a medical context and defined by various published criteria (eg, those of Beers et al2,3 and others4,5).
DRUGS OF ABUSE AND DEPENDENCE

Like their younger counterparts, older adults may abuse both legal and illegal drugs (Table I). In general, use of illegal drugs by older adults is limited to a small group of aging criminals and long-term heroin addicts. 6 Legal drugs include those that can be obtained by prescription or over the counter. Based on research on the appropriate use of prescribed medicines in the elderly, psychoactive medications (many of which have addiction potential) are involved in much of what may be considered inappropriate use. 2,3,7 Older adults' inappropriate use of prescription drugs with addiction potential may range from sharing medications, using higher doses for longer durations than prescribed, and recreational use to persistent abuse and dependency.

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Table I. Illegal and prescription drugs that are subject to abuse and dependence in older adults.

Illegal drugs Marijuana and hashish Heroin Cocaine and crack cocaine Hallucinogens (lysergic acid diethylamide [LSD], Ecstasy(3,4 methylenedioxymethamphetamine) Prescription drugs Benzodiazepines Long acting: flurazepam, diazepam Short acting: alprazolam, Iorazepam, triazolam, temazepam Barbiturate and nonbarbiturate sedative hypnotics Pentobarbital, secobarbital, aprobarbital/secobarbital, chloral hydrate, ethchlorvynol, glutethimide Opioid analgesics Morphine, levorphanol, methadone, codeine, hydrocodone, oxycodone, propoxyphene, fentanyl, tramadol Central nervous system stimulants Methylphenidate, methamphetamine, dextroamphetamine, amphetamine dextroamphetamine

The 2 major classes of prescription drugs subject to abuse that are used by older adults are the benzodiazepine sedative-hypnotics and the opioid analgesics, although central nervous system stimulants and nonbenzodiazepine sedative-hypnotics also may be implicated. Benzodiazepines are used primarily for the treatment of anxiety and sleep disorders. As a dass, they have largely replaced such older drugs as the barbiturates and nonbarbiturate sedative-hypnotics because of their improved safety profile compared with the older products. 6,s Nevertheless, prolonged periods of benzodiazepine use (>4 months) and/or at high doses (>10 diazepam milligram equivalents/d) may be associated with development of dependency, particularly in the case of longacting benzodiazepines.6,9 11 In older adults, benzodiazepine dependency may manifest itself in the absence of apparent abuse. 12 It is important to recognize, however, that use of both long- and short-acting benzodiazepines can result in physiologic dependency, even when these drugs are taken at therapeutic doses and for as little as 2 months. 13 It is generally recommended that benzodiazepines with a longer half-life, such as flurazepam, be avoided in older adults because of residual sedative effects and an association with falls, motor vehicle accidents, and worsened memory.6,14 17 Benzodiazepines and other sedative-hypnotics should be used judiciously when prescribed for sleep disorders in older adults, particularly if use is prolonged. No studies were identified that evaluated the long-term (>30 days) effectiveness of these drugs for insomnia; for this reason, prescriptions for benzodiazepines and other sedativehypnotics should be for no more than a 30-day supply

of the lowest possible dose, and use should be limited to 7 to 10 days, with frequent monitoring and evaluation. 6 The most commonly prescribed benzodiazepine sedativehypnotics in older adults are oxazepam, temazepam, triazolam, and lorazepam, is Withdrawal from benzodiazepines and other sedativehypnotics should be monitored carefully. Symptoms of withdrawal include increased pulse, hand tremor, insomnia, nausea and/or vomiting, and rebound anxiety. Grand mal seizures may occur in 20% to 30% of all dependent persons whose withdrawal symptoms are untreated. 6,9 Another common adverse effect of untreated benzodiazepine withdrawal is hallucinations similar to those associated with alcoholic delirium tremens (DTs). 6,9 Both seizures and DTs can be life threatening in individuals undergoing either involuntary or medical benzodiazepine withdrawal. When used medically, opioid analgesics provide pain relief and anesthesia; when used nonmedically, however, they produce a sense of euphoria and well-being. As a result, opioid analgesics have the potential to produce physical and psychological dependency and sedation, and to impair cognitive and physical function, particularly when used long term. 1,6,19,2Abuse of illegal or prescription opioids has generally been considered rare in older adults, except among those with a history of abuse or in the presence of alcohol. 1<21 In addition to the rapid development of tolerance and physiologic dependency, other problems associated with the use of opioid analgesics (used medically or nonmedically) in older patients indude an increased risk for adverse events, such as increased sedation; impairment of motor coordination,

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particularly with weaker opioid analgesics such as codeine and propoxyphcnc; and substantial impairment of vision, attention, and motor coordination with stronger opioids (cg, oxycodonc, intramuscular mcpcridinc). 6,22,23 No rclation bctwccn incrcasing agc and scdation has bccn notcd in paticnts trcatcd with morphinc or pcntazocinc. 6,22,23 Although withdrawal from opioid analgesics is uncomfortablc, charactcrizcd by rcstlcssncss, nausca and/or vomiting, dysphoria, aching muscles, yawning and tearing, diarrhea, insomnia, and sometimes fever, it is not potentially life threatening or particularly dangerous compared with bcnzodiazcpinc withdrawal.
P R E V A L E N C E OF D R U G - U S E P R O B L E H S IN OLDER ADULTS

Illegal Drugs
Illcgal drug usc is rclativcly rarc among oldcr adults, although usc of thcsc substanccs is projcctcd to risc ovcr thc ncxt dccadc and bcyond as thc baby-boom population cntcrs rctircmcnt. In onc of thc fcw idcntificd national prcvalcncc rcports, thc Epidcmiologic Catchmcnt Arca Study,32 which analyzcd data from 1980-1985, found that thc lifctimc prcvalcncc of drug abuse and dependence was 0.12% for older men and 0.06% for older women. The lifctimc prevalence of illegal drug use among older men and women was 2.88% and 0.66%, respectively. Thcrc is a limitcd but growing litcraturc suggcsting that thc abusc of illcgal substanccs is bccoming morc common among oldcr adults sccking trcatmcnt for substance-use disorders and/or psychiatric conditions. Rcccipt of mcthadonc maintcnancc trcatmcnt is rclativcly uncommon among oldcr adults comparcd with youngcr adults, most likcly bccausc of thc initial rcgulations (now rcmovcd) that cappcd maintcnancc trcatmcnt at thc agc of 40 ycars and also bccausc of thc bclicf that hcroin addicts "maturc out" of addiction problcms oncc thcy pass thc agc of 40 ycars) 4 Also, mortality ratcs among hcroin uscrs arc quitc high; in onc 24-ycar follow-up study of hcroin addicts, >27% of the study subjects died) 3 In other words, older addicts may simply rcprcscnt youngcr addicts who havc survivcd thcir drug-usc disordcr and gottcn oldcr) 4

Unfortunately, little is known about the cpidcmiology of the misuse and abuse of psychoactive drugs in older adults. This is duc to notablc limitations in thc litcrature, including undersampling of older adults when collecting data on drug use, lack of standard definitions of abuse and dependency in this population, and prevalcncc cstimatcs bascd on a widc rangc of scttings and subpopulations (ranging from the community to longtcrm carc facilitics to thc cmcrgcncy dcpartmcnt lED] and inpatient substance-abuse treatment programs). The figure summarizes some of the available evidence for the prevalence of abuse of illegal and legal drugs among older adults.
4O 38.0

3O 26.0

8
16.0
sO-

13.0 10.2

11.4

20
Drug VA Patients with Dual
Diagnosis

II
(daily)

II
Drug

30

1.0

I Cocaine I Cocaine I Cocaine I

Substance

Any I Prescription' ,,,cit I Prescriptionl

Drugs Drugs Drugs
VA Inpatient Treatment

Abuse

(_>55 y)24

(_>60y)2S

Consult

(_>60y)26

ED Visits

Heroin/ VA Inpatient Cocaine Use Treatment

(_>50y)27

(_>60y)28

(_>65 y)29

Outpatient

Treatment (_>65 y)30

Hospital Admissions

forAIcohol (_>60y)31

Figure. Prevalence of drug abuse in older adults. BZDs = benzodiazepines; VA =Veterans Affairs; ED = emergency department.

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Among patients aged _>55 years with diagnoses of both psychiatric and substance-use disorders receiving services through the Department of Veterans Affairs, 26% had a drug-use disorder and 74% had an alcohol-use disorder. 24 Cocaine use by older individuals is not well documented in the literature. A study published in 2004 provided evidence concerning cocaine use in adults aged _>60 years presenting to a large urban ED over a 6-month period. 26 In 911 visits, the urine samples of 18 (2.0%) older patients tested positive for cocaine. Rates of older adults entering treatment for cocaine abuse are estimated at 0.2% among patients aged 61 to 65 years and 0.1% among those aged >65 years. 35 In a study of geriatric patients receiving a substance-abuse consultation, 10.2% reported cocaine use. 25 A study in 684 individuals aged _>50 years with a lifetime history of intravenous cocaine a n d / o r heroin use found that 13.0% were still actively using cocaine more than once daily.27 Another study found that 38% of older adults in a Veterans Affairs treatment program reported recent illcgal substancc usc. 2s A study of 565 gcriatric inpaticnts in thc Veterans Affairs system found that 1.0% had a disorder involving use of illegal drugs. 29

Prescription Drugs
Although Amcricans agcd >65 ycars rcprcscnt 13.0% of thc total US population, thcy account for 36.0% of total outpatient spcnding on prcscription mcdications. 36 Furthcrmorc, prcscription drug usc and spcnding among oldcr adults is incrcasing; onc study cstimatcd that drug spcnding among thc insurcd cldcrly had increased by >18% per year between 1997 and 2000. 37 In 2000, a typical oldcr citizen received >20 prcscriptions pcr ycar from a mcan of 4.7 different thcrapcutic classcs. 37

cal use encompass a wide range of behaviors, from a single incident of medical misuse or medically inappropriate use (eg, "borrowing" a product from a friend or relative to whom it has been prescribed) to periodic recreational use and physiologic addiction. 1,6 Other behaviors characteristic of misuse include taking higher-than-prescribed doses, using the drug for purposes other than the approved indication, hoarding drugs, and using the drug with other substances a n d / o r alcohol. Such behaviors can lead to addiction, which is marked by signs of tolerance, withdrawal, reduced participation in normal activities, and a decline in home a n d / o r work performance. 1 It is important to note that misuse, nonmedical use, and other potentially problematic drug-use behaviors can be promulgated by the patient, the provider (eg, by prescribing multiple drugs from the same therapeutic class, prescribing a drug at a higher dose a n d / o r for a longer duration than recommended, failing to determine whether the patient uses alcohol or other substances with abuse potential), or both. Thus, medical exposure to prescribed medications with dependency potential may be the single greatest risk factor for potentially problematic drug use by older men and women. Older adults can become physiologically dependent on prescription medications without meeting the criteria for dependence. Tolerance and physical dependence can develop when prescription medications such as benzodiazepines and opioid analgesics are taken at appropriate doses for even short periods of time. Thus, withdrawal symptoms or an abstinence syndrome can occur if the drug is abruptly discontinued. In older adults, iatrogenically induced physiologic dependence does not usually occur as a result of the patient intentionally increasing the dosage. 6,13

Mechanisms of Prescription Drug Abuse and Dependency In addition to differing from younger adults who misuse or abuse drugs, older adults who abuse or become dependent on prescription psychoactive drugs may be markedly different from their peers who intentionally abuse marijuana, cocaine, heroin, or other illegal substances. Problematic use of prescription drugs by older adults is usually unintentional. The use of prescription drugs with addiction potential is best described in terms of a continuum from appropriate use for medical or psychiatric conditions through nonmedical use or misuse to persistent abuse and dependence, as characterized by the D S M - I V . 1 Misuse and nonmedi-

Prevalence of Exposure to Prescription Drugs with Abuse Potential Although there is a growing body of literature that touches on thc prevalence of use of prescription drugs that arc inappropriate in community-dwelling oldcr adults,2,3,7,3842 little research has explicitly examined the prevalence of use of prescription drugs with abuse and dependency potential in this population. Thc most rcccnt rcscarch indicates that 7.2 million (21.7%) communitydwelling oldcr adults in the Unitcd States used >1 controlled prescription drug in 1999; 14.9% received >1 controlled opioid analgcsic, and 10.4% received >1 anxiolytic or scdativc-hypnotic.43 Other smdics have confirmed the prevalence of exposure to psychoactive prescription mcdications with abusc potcntial among community-dwelling

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older adults, with estimates ranging from 5% to 33%,7,8,21,4446 depending on the population sampled, the drugs classified as psychoactive, and the year of the estimate. Although 2 studies have noted that older adults are more likely to use psychoactive medications than their younger counterparts, 13,16 it should be noted that many studies do not differentiate between psychoactive drugs with dependency potential (eg, benzodiazepines, opioid analgesics) and those without dependency potential (eg, antidepressants, antipsychotics). Older adults residing in nursing homes, assisted living facilities, and other institutions, as well as those receiving care in hospitals, are often overlooked in examinations of substance-use disorders. Exposure to abusablc prescription medications is quite high in this particularly frail population; one study found that among nursing home residents in 878 facilities, 11% received an anxiolyric and 3% received a sedative-hypnotic. 47

Prevalence of Prescription Drug Abuse and Dependency There is considerably less information on the prevalence of prescription drug abuse and dependency among older adults than there is on the prevalence of exposure to these drugs. One study estimated that in 2001, 300,000 older adults aged >55 years had nonmedical use of >1 prescription drug in the past month. 4s Another estimated that 2.8 million (11.0%) US women aged >60 years misuse psychoactive prescription medications each year.49 There is limited information concerning older adults who seek treatment for abuse of any substance (excluding alcohol), including prescription drugs. The Drug Services Research Survey, 5 which was based on 2182 client records from drug-abuse treatment facilities, found that 10.1% of clients reported nonmedical use of >1 prescription drug in the 30 days before admission; 17.7% of these clients reported that prescription drugs were their drugs of choice. In a report on treatment episodes in 2001, 50,700 persons aged >55 years were admitted to publicly funded substance-abuse treatment facilities.4s Alcohol was the primary substance of abuse for 76% of these persons; legal and illegal opioid analgesics for 12.6%; and prescription sedatives, tranquilizers, and stimulants for 1.3%.
Projected Growth in Drug Abuse and Dependency A m o n g Older Adults There is reason to expect that older adults will constitute a growing proportion of the population treated for abuse and dependency. One study estimated that the

number of individuals aged >50 years who would need treatment for an illegal or prescription drug problem would increase from 147,000 in 1995 to 911,000 in 2020. 51 A follow-up analysis that used improved methods, definitions, and more current data estimated that the number of adults aged >50 years requiring treatment for a substance-use disorder would increase to 4.4 million in 2020, up from 1.7 million in 2001. 52 Of the 2.3% of older adults requiring treatment for substance-use disorders in 2001, 10.2% were dependent on or abusing drugs only, 4.0% were dependent on or abusing both drugs and alcohol, and the remaining 85.8% were dependent on or abusing alcohol only. Among the 244,000 older adults dependent on or abusing drugs, the most common drugs of abuse were marijuana (42%), cocaine (36%), pain relievers (25%), stimulants (18%), and sedatives (17%). 51 A recently published analysis estimated that the nonmedical use of psychoactive prescription drugs by adults aged >50 years would increase from 911,000 in 2001 to nearly 2.7 million in 2020. 53 The projections in these studies were based on an increase in the number of older adults, an associated increase in the rates of treatment that will be necessary, and the facts that the baby-boom cohort is larger than earlier cohorts (although succeeding groups are as large or larger) and that use of illegal and legal psychoactive drugs was quite common in this cohort. 52,53 FACTORS A S S O C I A T E D W I T H DRUG ABUSE Although mature adults are less likely than their younger counterparts to abuse psychoactive drugs, once exposed, they may be particularly vulnerable to the development of dependence. 54,55 This increased risk is the result of several factors associated with aging, including increased frailty, changes in body composition and drug metabolism, increased morbidity, and high utilization of prescription medications (including psychoactive medications with addiction potential). Collectively, these factors may place older adults at increased risk for iatrogenic complications, including dependency and abuse.

Illegal Drugs
There is a paucity of literature describing possible correlates or risk factors associated with the abuse of illegal drugs by older adults. In a small study of cocaine use by older adults presenting to an urban ED, 26 cocaine users were more likely than older adults not screened for cocaine use to be younger (66.4 vs 76.0 years, respectively), to be male (88.9% vs 46.6%), and to have a diagnosis of drug or alcohol abuse. Because late-life devel-

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opment of new psychoactive drug abuse is rare, it is likely that the most important correlate of abuse is previous abuse a n d / o r dependency.

Prescription Drugs
Although little is known about factors specific to older adults that may place them at risk for or protect them against prescription drug abuse, several variables have emerged as predictors in the general population that may be generalizable to older adults (Table II). Some of these factors include female sex, younger age (adolescent and young adult), older age (>60 years), white race, poor health status, residence in a rural area, and social isolation. 6,43,56"5s In a recent study that examined correlates of exposure to abusable prescription drugs in Medicare beneficiaries aged >65 years,43 those of female sex and white race, aged between 65 and 79 years, with >1 limitation in performance of activities of daily living, an increasing number of comorbid conditions, a large drug burden, and residing with nonspousal others were significantly more likely than others to have used >1 abusable prescription drug in the past year (P < 0.01). This study, however, did not examine prescription drug abuse or dependency, nor did it examine previous or current history of substance abuse or mental health conditions. Female sex may be among the most studied risk factors for problems associated with prescription drug use. Compared with older men, older women are prescribed and consume more psychoactive medications, particularly benzodiazepines, and are more likely to be longterm users of these substances. 6 Among older women, use of psychoactive drugs is associated with recent divorce and widowhood, lower educational level, lower income, poorer health status, and depression and anxiety disorders. 69 7s Szwab073 suggested that misuse of prescription drugs is a growing problem among older

Table II. Risk factors for prescription drug abuse in older adults. Female sex Social isolation (living alone or with nonspousal others) Poor health status Significant drug burden/polypharmacy Chronic physical illness/polymort~idity Previous and/or concurrent substance use disorder Previous and/or concurrent psychiatric illness

impoverished and minority women. It has been noted that women are more likely to report dependency within the past 12 months with increasing age; among those who have used an illegal substance by their midforties, more women than men meet the criteria for dependency. 74 Few studies have examined sex differences in substance use and dependency, including use of prescription drugs with addiction potential. In a study based on the 1 9 9 0 - 1 9 9 2 National Comorbidity Survey, Anthony et a169 found that the prevalence of lifetime dependence on anxiolytics and sedative-hypnotics in women aged 15 to 54 years was 12.3%, more than twice the lifetime prevalence in men of the same ages. This finding is in sharp contrast to the generally higher risk of lifetime dependence on alcohol and cannabis among men. To the extent that these patterns of earlier psychoactive drug use translate into use in later life, this information may be useful in predicting differences in the utilization of treatment resources among older men and women. It is likely that the reasons for drugspecific sex differences in dependence include men's preference for alcohol 75 and the possibility that women may be heavier medical and nonmedical users of psychotherapeutic drugs than men. Previous and concurrent substance abuse and psychiatric illness are additional important risk factors for the abuse of prescription drugs. 56,62,76 79 The Epidemiologic Catchment Area Survey reported that nearly 80% of persons with a psychoactive drug disorder also had a disorder involving alcohol or a mental comorbidity. 72 Both previous and current use a n d / o r abuse of other substances with abuse potential are associated with nonmedical use of prescription drugs. 56,57,59,68,78 81 Along with alcohol-related disorders, anxiety and affecrive disorders have been found to be highly associated with lifetime drug dependency. 76 In one study, rates of mental health conditions among 100 older adults hospitalized for prescription drug dependence included 32% with m o o d disorders, 28% with organic mental problems, 27% with personality disorders, 16% with somatoform disorders, and 12% with anxiety, s2 Although there is little research on older adults with substance-dependence disorders, the results of one study indicated that older addicts were more likely than younger addicts to have a dual diagnosis53 In this study, 85% of older drug-dependent patients had a dual diagnosis, compared with 36% of younger drugdependent patients. Although the likelihood of benzodiazepine abuse is generally low, M,76 it may be increased in those who are

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light to moderate users of alcohol; those with a history of sedative abuse, abuse of multiple drugs, or methadone maintenance treatment; and those with physiologic dependence on benzodiazepines after long-term use who experience acute withdrawal effects after abrupt discontinuation.1,x,76 Such individuals, however, prefer older anxiolytics and hypnotics such as methaqualone or meprobamate to benzodiazepines13; furthermore, individuals with none of these characteristics who have been successfully withdrawn from benzodiazepines do not exhibit a continued craving. 6 Also relevant are provider variables. In particular, physician specialty influences drug prescribing, with primary care physicians prescribing more psychotropics of all types, including opioid analgesics and minor tranquilizers, than specialists. 61 Several studies have suggested a link between medical opioid analgesic exposure and eventual abuse and dependency,1,6,19,73,s3 with those individuals who have chronic noncancer pain more likely to develop disorders associated with opioid use than those with acute or chronic cancer pain. s3,s4 Finally, there is some evidence that problematic use of prescription opioids may be differentiated from medically appropriate use based on the drug, dose, formulation, and dosage form. s5 s7
SCREENING AND ASSESSHENT

including dementia, is an important comorbid condition that makes screening for prescription drug abuse difficult. Furthermore, some of the symptoms of dementia, such as agitation, delirium, combativeness, and mood shifts, are also associated with prescription drug abuse. In this situation, in which an accurate response is unlikely to be obtained from the older adult, a nonconfrontational approach and the participation of family members or friends is recommended. 6 Numerous instruments are available to screen for disorders of alcohol and other substance use. The CAGE (Cut Down, Annoyed, Guilty, Eye-opener) and Michigan Alcoholism Screening Test-Geriatric Version are well-known screening instruments for alcohol problems whose use has been validated in older adults. 6,ss However, there are few validated screening instruments specific to problems related to the use of illegal or prescription psychoactive drugs in older adults. Thus, to screen for such problems in older adults, providers must ask about the drugs patients are using, any side effects experienced, where the prescriptions are filled, and the use of over-the-counter, supplemental, or alternative medications (including medical marijuana and other herbal substances). Additional warning signs of a potential problem that may emerge during patientprovider conversations include excessive worry about

The majority (87%) of older adults see physicians regularly; however, 40% of older adults who have or are at risk for development of substance-use disorders are unaware of this risk or do not seek services on their own. 21 Furthermore, they are unlikely to be recognized by their physicians as having a substance-use disorder, despite the frequency of provider contact. In one study of primary care physicians who were presented with patient scenarios involving older women with symptoms indicating potential substance-abuse problems, 49 only 1% accurately recognized the symptoms; the remainder suspected depression, anxiety, and/or stress. Misdiagnoses of this sort can be medically dangerous, as the treatment for anxiety and other related disorders is often a benzodiazepine or other potentially abusable prescription medication, the use of which would potentiate the drug-abuse problem. Common comorbid conditions that may complicate the diagnosis of prescription drug abuse in older adults are summarized in Table III. Many of these conditions may be antecedents or consequences of prescription drug abuse, either providing clinical warning signs of possible prescription drug abuse or masking symptoms of such abuse. For example, cognitive impairment,

Table III. Comorbid conditions that may complicate the diagnosis of prescription drug abuse in older adults.
Neuropsychological Psychiatric conditions (depression, anxiety, mood disorders, schizophrenia, or psychotic disorders) Cognitive impairment (eg, Alzheimer's disease, dementia Delirium Personalil7 changes Mood changes or swings (depression, agitation) Seizures Tremor Sleep complaints (insomnia or hypersomnia) Medical Chronic pain Gastrointestinal disorders Hepatic and/or renal disorders Functional Falls, fi-actures, or other trauma Functional decline Hygiene deterioration Motor vehicle accidents

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whether psychoactive medications are really working; detailed knowledge of and attachment to a particular psychoactive medication; excessive anxiety about the supply and timing of medications; continued use of or a request for a refill of medication when the medical condition for which it was prescribed should have resolved; complaints about physicians who refuse to write prescriptions for preferred drugs, who reduce or taper dosages, or who do not take symptoms seriously; excessive sleeping, particularly during the day; changes in personal grooming and hygiene; and withdrawal from family, friends, and normal social activities.6 Once an older adult has had a positive result on screening for a potential drug problem, assessment is needed to confirm the problem, characterize its dimensions, and develop an individualized treatment plan. 6 This is often accomplished through the use of D S M - I V criteria, which is necessary for reimbursement and insurance purposes, 1 although other relevant criteria may be used. The D S M - I V criteria for abuse include recurrent substance use resulting in failure to fulfill major role obligations at home, work, or school; putting oneself in physically hazardous situations; substance-related legal problems; and recurrent social or interpersonal problems. It is significant, however, that a number of these criteria do not pertain to older adults--most older adults do not work or attend school; many no longer drive or operate dangerous equipment, which may reduce the legal consequences associated with a druguse problem (eg, driving while impaired); and many older adults live alone a n d / o r have limited mobility, making substance-related interpersonal problems less apparent. 12 In general, detecting drug-use disorders in older adults using the currently accepted diagnostic criteria for substance abuse and dependency is problematic for a variety of reasons. This may be particularly true among older women. 12,73 The failure to detect problems in older women may be related to their lack of knowledge about the medication's common side effects, or because providers do not recognize that symptoms such as insomnia may be associated with drug misuse. 8 Furthermore, older adults who suspect that their drug use may be associated with a health or psychological complaint may be unwilling to admit it because of shame, guilt, or the possible stigma attached to drug use in their age cohort. 89,9 The lack of validated instruments for evaluating prescription drug problems in older adults is likely to lead to underestimation of the prevalence of such problems. In particular, problems of prescription drug use in older adult women, who are considered at particular

risk, may be missed because of the lack of specific instruments. 91 Because of this lack, health care professionals need to rely on their diagnostic skills. Early signs of misuse and abuse of sedatives and anxiolytics, for example, include such symptoms as decreased energy, weight loss, irritability, heartburn and other gastrointestinal distress, and insomnia. 6,12,49
TREATMENT

There is a large amount of evidence concerning effEctive approaches to the treatment of older adults with alcohol-use disorders, but relatively little information on the comparative efficacy of various approaches to the treatment of disorders of psychoactive drug use in older adults. A primary reason for the lack of clinical studies of treatment effectiveness in older adults is the relatively small number of these individuals who present with possible drug-use problems, making it difficult to enroll sufficient numbers of older adults) 4 The findings of 2 observational studies, however, suggest that older adults who are admitted for treatment of drug- a n d / o r alcohol-use problems generally have a favorable prognosis, with short- and long-term outcomes after treatment that are equivalent to or better than those for younger adults undergoing treatment for similar problems. 92,93 Older adults with a problem of drug use may require specialized approaches because of their age, the probability of more severe addiction, and the increased likelihood of comorbid conditions that intensify the risks associated with detoxification. 14 For example, in older adults, opioid detoxification often is conducted in a medical setting, and, although the choice of medication may not differ from that in younger adults, the dosage may differ because of the metabolic changes associated with aging. 14 In addition, clinicians should pay close attention to potential drug-drug interactions and drug-disease interactions in the older adult undergoing treatment for substance-related disorders. 14 Treatment of benzodiazcpine dependence involves very gradual tapering to avoid withdrawal symptoms. 1,11,23 Benzodiazepine withdrawal symptoms usually are different in older adults than in younger persons; in older adults, the symptoms include confusion and disorientation rather than anxiety, insomnia, and perceptual changes. 94 Withdrawal symptoms with gradual tapering also are usually less severe in older adults than in younger adults. 94 When considering the treatment options for older adults with a problem related to drug use of any kind, the least intensive options should be explored first. 6 An

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initial approach of this sort can function as either a pretreatment or treatment strategy. Table IV summarizes strategies to improve the treatment of older adults with problems of prescription drug abuse, in order of preference. 6 Brief interventions range from fairly unstructured counseling to structured approaches aimed at motivating behavioral change. Full interventions, on the other hand, generally involve the presence of family members and friends who, under the guidance of a counselor, confront the older adult with their perceptions of the patient's drug use. Motivational counseling considers drug abusers as being in 1 of 5 stages with respect to changing their drug use (precontemplation, contemplation, ready for action, action, and maintenance) and assumes that people at different stages may respond differently to recommendations. Based on this framework, motivational counseling is an intensive process that builds on an individual's recognition of the problem and implements interventions tailored to his/her readiness to change. 6 At all steps, provision of patient education is particularly important in helping older adults with problems of prescription drug abuse to identify problems and become motivated to obtain treatment. This includes identifying causes of noncompliance, informing patients about medication management and the importance of following dosing instructions, and describing the health and functional consequences of prescription drug abuse. The foregoing treatment strategies may be sufficient for many older adults. For others, use of more specialized treatment services, such as those provided by a 24-hour medical or psychiatric inpatient facility, may

be necessary. The available services include inpatient or outpatient detoxification, inpatient or outpatient rehabilitation, and other outpatient services. Because detoxification is generally considered riskier in older adults than in younger persons, 24-hour primary medical, psychiatric, and nursing care in managed intensivetreatment settings is generally advisable. 6 Once their condition has been stabilized and they return to the community, older adults may benefit from 12-step and other self-help programs, as well as individual and/or group counseling or psychotherapy.
CONSEQUENCES O F M I S U S E AND A B U S E

The misuse and abuse of illegal and prescription psychoactive drugs by older adults is associated with both medical and economic consequences. Clinical and functional problems include drowsiness, sedation, confusion, memory loss and other impairment of cognitive function, falls, and other accidents.6,12 Physical and cognitive impairment can, in turn, lead to the need for hospitalization and institutionalization.95 Central nervous system depressants are generally the most commonly implicated substances of abuse in older adults. The adverse consequences associated with misuse of these drugs are heightened when they are taken with alcohol, which is also a depressant. In fact, although older adults generally have lower rates of heaW drinking than do their younger counterparts, 31,96 many older adults still use alcohol in patterns that are contrary to current guidelines.96 The metabolic and physiologic changes associated with aging can mean that even an occasional drink may be problematic} 1

Table IV. Strategies to improve the treatment of prescription drug abuse in older adults. 6
Treatment Strategies Brief interventions Summary One or more counseling sessions involving direct feedback on screening questions', patient education', approaches to motivational and behavioral change', use of writien manuals and materials to reinforce message Counseling sessions with patient in the presence of family or friends to confront drug use problems Intensive meetings with counselor to understand patient's perspective on the situation, assess readiness to change behaviors, help patient shift perspective and consider alternative solutions Inpatient/outpatient detoxification, inpatient/outpatient rehabilitation, outpatient services Psychotherapy, individual and/or group counseling, selhelp and 12 step programs

Interventions Motivational counseling

Specialized treatment Maintenance treatment

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One study in older adult drinkers found that 12% reported use of a prescription sedative or narcotic.97 Nearly all drugs with abuse potential, particularly prescription drugs, tend to be cross-tolerant with alcohol (ie, they affect the body in a physiologically identical manner); thus, the central nervous system depressant effects of benzodiazepines, other sedative-hypnotics, and opioid analgesics tend to be markedly enhanced by the addition of even small amounts of alcohol, with consequences that can occasionally be lethal. 1,6 A recent study in older adults of low to moderate income enrolled in the Pennsylvania Pharmaceutical Assistance Contract for the Elderly program examined the potential for interactions between alcohol and prescription drugs, many of which had abuse potential. 98 The study found that 77.1% of all drug users were exposed to prescription medications that interact with alcohol and that 19.3% of these individuals reported concomitant alcohol use. Among users of narcotic analgesics, 16.7% reported concomitant alcohol use; 16.8% of users of anxiolytics and sedative-hypnotics reported concomitant alcohol use. The potential for interactions between psychotropic drugs and other drugs is an added concern, particularly in older adults, who tend to use more prescription and over-the-counter medications than do younger individuals. Continuing use of illegal and prescription psychoactive drugs may pose significant abuse and dependency problems in older adults, and these problems eventually bring patients to treatment facilities. Substance misuse and abuse add considerably to national health care expenditures. Although no published research to date has attempted to quantify the economic costs associated with drug-use disorders among older adults, the total annual costs associated with all substance-use disorders in 1995 were estimated at $276 billion. 99 It has been estimated that almost 20% of all Medicaid hospital costs and $1 in every $4 of Medicare hospital costs is associated with substance use (H. Harwood, unpublished data, 1995). One study reported that individuals with substance-use disorders make greater use of health care resources and incur higher health care costs than those without substance-use problems. 52 Hospitals and EDs are visited more frequently by such individuals, who may use these services in the hope of obtaining prescription drugs or because of adverse effects, such as overdose, associated with their misuse of prescription drugs. Illegal drug users make almost 530,000 costly ED visits per year for drug-related problems. 1 The Drug Abuse Warning Network, which reports ED episodes associated with substance use, found that vis-

its involving prescriptions for opioid analgesics increased markedly from 1994 to 2001, with visits involving oxycodone increasing by 352%, methadone by 230%, and morphine by 210%. 52 Furthermore, individuals visiting an ED often used >1 drug; multiple drugs were mentioned in 72% of all ED visits involving opioid analgesics.
CONCLUSIONS

Despite evidence that older adults are particularly vulnerable to misuse and abuse of psychoactive drugs, particularly those that have been prescribed by a physician, there is a scarcity of information on the factors associated with such abuse and its screening, assessment, diagnosis, and treatment. Although projected estimates provide some information on the number of older adults with disorders of psychoactive drug use and the types of drugs abused, current prevalence estimates are unavailable, largely because of a lack of data on the most frequently used drugs and failure to adequately sample this population. There is a need for more research on the patient, provider, socioeconomic, environmental, and clinical factors associated with psychoactive drug abuse and dependence in older adults to elucidate the progress from medical exposure to problematic use, as well as to document factors that may contribute to, or protect against, development of psychoactive drug abuse. Understanding such factors is necessary for the creation of prevention and education resources for patients and providers, as well as for the development of valid and reliable screening and assessment instruments tailored to older individuals and the drugs they abuse. Finally, there is a need for allocation of resources to identify and test treatment approaches in older adults with disorders of psychoactive drug use. Physicians, pharmacists, nurses, family members, and others involved in the care of older adults, both in the community and in other residential settings, should be aware of the potential for problems of psychoactive drug use in older adults. For physicians and other health care providers, this means being aware of the signs and symptoms of possible drug-use disorders and eliciting them in the course of conversation and the medical workup. Such symptoms include, but are not limited to, marked changes in demeanor and mood; increased use or seeking of psychoactive medications; complaints of insomnia, depression, and anxiety; changes in social activities; changes in functioning and ability to perform activities of daily living; and increasing cognitive and physical impairment. Evidence of falls, motor vehicle accidents, and other injury or trauma also should be

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reviewed for possible involvement o f psychoactive medications. Family members and other formal and informal caregivers should be attuned to the same concerns.
ACKNOWLEDGMENT

T h e authors thank Devadatta Tata, MS, a graduate student in the D e p a r t m e n t o f Pharmaceutical Health Services Research, School o f Pharmacy, University o f M a r y l a n d Baltimore, for assistance in identifying, retrieving, and organizing the relevant publications.
REFERENCES

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: APA; 1994. 2. Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med. 1997;157:1531-1536. 3. Beers MH, Ouslander JG, Rollingher I, et al, for the UCLA Division of Geriatric Medicine. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch InternMed. 1991;151:1825-1832. 4. Briesacher B, Limcangco R, Simoni-Wastila L, et al. Evaluation of nationally-mandated drug use reviews to improve patient safety in nursing homes: A natural experiment. J A m GeHatr Soc. 2005;53:991-996. 5. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis. 1987;40:373-383. 6. Blow FC. Substance abuse among older aduks treatment protocol (TIP). Rockville, Md: USDHSS/PHS/SAMHSA Center for Substance Abuse Treatment; June 2001. 7. Zhan C, Sangl J, Bierman AS, et al. Potentially inappropriate medication use in the community-dwelling elderly: Findings from the 1996 Medical Expenditure Panel Survey. JAMA. 2001;286:2823-2829. 8. Finlayson R. Misuse of prescription drugs. IntJAddict. 1995;30:1871-1901. 9. Salzman C. The APA Task Force report on benzodiazepine dependence, toxicity, and abuse. A m J Psychiatry. 1991;148:151-152. 10. Salzman C. Benzodiazepine treatment of panic and agoraphobic symptoms: Use, dependence, toxicity, abuse. JPsychiatr Res. 1993;27(Suppl 1):97-110. 11. Salzman C. Issues and controversies regarding benzodiazepine use. NIDA ResMonogr. 1993;131:68-88. 12. Finfgeld-Connett DL. Treatment of substance misuse in older women: Using a brief intervention model. J Gerontol Nuts. 2004;30:30-37.

13. Woods JH, Winger G. Current benzodiazepine issues. Psychopharmacology (Berl). 1995;118:107-115; discussion 118,120-121. 14. Menninger JA. Assessment and treatment of alcoholism and substance-related disorders in the elderly. Bull Menninger Clin. 2002;66:166-183. 15. Hanlon JT, Homer RD, Schmader KE, et al. Benzodiazepine use and cognitive fimction among communitydwelling elderly. Clin Pharrnacol Ther. 1998;64:684692. 16. Sheahan SL, Coons SJ, Robbins CA, et al. Psychoactive medication, alcohol use, and falls among older adults. JBehav Med. 1995;18:127-140. 17. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: A systematic review and meta-analysis: I. Psychotropic drugs. J A m Geriatr Soc. 1999;47:3039. 18. Fouts M, Rachow J. Choice of hypnotics in the elderly. P-T News. 1994;14:1M:. 19. Cowan CD. Coverage, sample design, and weighting in three federal surveys. ]Drug Issues. 2001;31:599-614. 20. Joranson DE, Ryan KM, Gilson AM, Dahl JL. Trends in medical use and abuse of opioid analgesics. JAMA. 2000;283:1710-1714. 21. Jinks MJ, Raschko RR. A profile of alcohol and prescription drug abuse in a high-risk community-based elderly population. DICP. 1990;24:971-975. 22. Ray WA, Thapa PB, Short RI. Medications and the older driver. Clin Geriatr Med. 1993;9:413M:38. 23. Solomon I(, Manapelli J, Ireland GA, Mahon GM. Alcoholism and prescription drug abuse in the elderly: St. Louis University grand rounds. J A m Geriatr Soc. 1993; 41:57-69. 24. Prigerson HG, Desai RA, Rosenheck RA. Older adult patients with both psychiatric and substance abuse disorders: Prevalence and health service use. Psychiatr Q. 2001; 72:1-18. 25. Weintraub E, Weintraub D, Dixon L, et al. Geriatric patients on a substance abuse consultation service. A m J Geriatr Psychiatry. 2002;10:337-342. 26. Rivers E, Shirazi E, Aurora T, et al. Cocaine use in elder patients presenting to an inner-city emergency department. Acad Emerg Med. 2004;11:874-877. 27. McBride DC, Inciardi JA, Chitwood DD, McCoy CB, for the National AIDS Research Consortium. Crack use and correlates of use in a national population of street heroin users. JPsychoactive Drugs. 1992;24:411M:16. 28. Schonfeld L, Dupree LW, Dickson-Euhrmaim E, et al. Cognitive-behavioral treatment of older veterans with substance abuse problems. J GeHatr Psychiatry Neurol. 2000;13:124-129.

391

The American Journal of Geriatric Pharmacotherapy

L. Simoni-Wastila and H.K. Tang

29. Edgell RC, Kunik ME, Molinari VA, et al. Nonalcoholrelated use disorders in geropsychiatric patients. J Geriatr Psychiatry Neurol. 2000;13:33-37. 30. Fulop G, Reinhardt J, Strain JJ, et al. Identification of alcoholism and depression in a geriatric medicine outpatient clinic. J A m GeHatr Soc. 1993;41:737-741. 31. Adams WL, Cox NS. EpideIniology of problem drinking among elderly people. IntJAddict. 1995;30:1693-1716. 32. Anthony JC, Helzer JE. Syndromes of drug abuse and dependence. In: Robins LN, Regier DA, eds. Psychiatric Disorders in America: The Epidemiologic Catchment Area Study. New York, NY: The Free Press; 1991:116-154. 33. Hser YI, Anglin D, Powers K. A 24-year follow-up of California narcotics addicts. Arch Gen Psychiatry. 1993; 50:577-584. 34. Oslin DW. Evidence-based treatment of geriatric substance abuse. Psychiatr Clinic North Am. 2005;28:897-911. 35. Substance Abuse and Mental Health Services Administration, ONce of Applied Studies. Treatment Episode Data Set (TEDS): 1994-1999. National Admissions to Substance Abuse Treatment Services. DASIS Series S-14. DHHS Publication (SMA) 01-3550. Rockville, Md: US Dept of Health and Human Services; 2001. 36. Cook AE. Strategies for containing drug costs: Implications for a Medicare benefit. Health Care Financ Rev. 1999;20:29-37. 37. Thomas CP, Ritter G, Wallack SS. Growth in prescription drug spending among insured elders. Health A f f (Millwood). 2001;20:265-277. 38. Stuart B, Kamal-Bahl S, Briesacher B, et al. Trends in the prescription of inappropriate drugs for the elderly between 1995 and 1999. A m J GeHatr Pharmacother. 2003;1:61-74. 39. Willcox SM, HiInmelstein DU, Woolhandler S. Inappropriate drug prescribing for the communitydwelling elderly. J A M A . 1994;272:292-296. 40. Zuckerman I. Inappropriate Medication Use and Transition to Nursing Home A m o n g CommunityDwelling Elders [dissertation]. Baltimore, Md: University of Maryland Baltimore School of Medicine; 2005. 41. ZuckerInan I, Byrns P, Baumgarten M, et al. Inappropriate medication use and transition to nursing home. Paper presented at: Annual Meeting of the Gerontological Society of America; November 19-21, 2005; Orlando, Fla. 42. Kamal-Bahl SJ, Doshi JA, Stuart BC, Briesacher BA. Propoxyphene use by community-dwelling and institutionalized elderly Medicare beneficiaries. J A m GeHatr Soc. 2003;51:1099-1104. 43. SiInoni-Wastila L, Zuckerman IH, Singhal PK, et al. National estimates of exposure to prescription drugs with

44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

54.

55.

56.

57.

58.

addiction potential in the community-dwelling elders. Subst Abus. 2005;26:33-42. Moxey ED, O'Connor JP, Novielli KD, et al. Prescription drug use in the elderly: A descriptive analysis. Health Care Financ Rev. 2003;24:127-141. Gleason PP, Schulz R, Smith NL, et al. Correlates and prevalence ofbenzodiazepine use in community-dwelling elderly. J Gen Intern Med. 1998;13:243-250. Blazer D, Hybels C, SiInonsick E, Hanlon JT. Sedative, hypnotic, and antianxiety medication use in an aging cohort over ten years: A racial comparison. J A m GeHatr Soc. 2000;48:1073-1079. Tobias D, Pulliam C. General and psychotherapeutic medication use in 878 nursing facilities. A 1997 national survey. ConsultPharm. 1997;12:1401-1408. Drug and Mcohol Services Information System. The DASIS Report. Older Adults in Substance Abuse Treatment: 2001. Rockville, Md: Office of Applied Statistics, Substance Abuse and Mental Health Service Administration; May 11, 2004. National Center on Addiction and Substance Abuse. Under the Rug: Substance Abuse and the Mature Woman. New York, NY: Columbia University; 1998. Batten HL, Prottas JM, Horgan CM, et al. Drug Services Research Survey Final Report: Phase II. Waltham, Mass: Brandeis University; 1992. Gffoerer JC, Epstein IF. Marijuana initiates and their impact on future drug abuse treatment need. Drug Alcohol Depend. 1999;54:229-237. Gfroerer J, Penne M, PeInberton M, FolsoIn R. Substance abuse treatment need among older adults in 2020: The impact of the aging baby-boom cohort. Drug Alcohol Depend. 2003;69:127-135. Colliver JD, CoInpton WM, Gffoerer JC, Condon T. Projecting drug use among aging baby boomers in 2020. A n n Epidemiol. 2006; 16:257-265. Patterson TL, Jeste DV. The potential impact of the baby-boom generation on substance abuse among elderly persons. Psychiatr Serv. 1999;50:1184-1188. Sheahan SL, Hendricks L, Coons SJ. Drug misuse among the elderly: A covert problem. Health Values. 1989;13:22-29. SiInoni-Wastila L, Strickler G. Risk factors associated with problem use of prescription drugs. A m J Public Health. 2004;94:266-268. SiInoni-Wastila L, Ritter G, Strickler G. Gender and other factors associated with the nonmedical use ofabusable prescription drugs. Subst Use Misuse. 2004;39:123. SiInoni-Wastila L. Gender and psychotropic drug use. Med Care. 1998;36:88-94.

392

L. Simoni-Waazilaand H.IC Tang

The AmericanJournal of Geriatric Pharmacotherapy

59. Simoni-Wastila L. The use of abusable prescription drugs: The role of gender. J Womens Health Gend Based Med. 2000;9:289-297. 60. Olfson M, Pincus HA. Use of benzodiazepines in the community. Arch Intern Med. 1994;154:1235-1240. 61. Hohmann AA, Larson DB, Thompson JW, Beardsley RS. Psychotropic medication prescription in US ambulatory medical care. DICP. 1991;25:85-89. 62. Takala J, Ryynanen OP, Lehtovirta E, Turakka H. The relationship between mental health and drug use. Acta Psychiatr &and. 1993;88:256-258. 63. Swartz M, Landerman R, George LK, et al. Benzodiazepine anti-anxiety agents: Prevalence and correlates of use in a southern community. A m J Public Health. 1991;81:592-596. 64. National Institute on Drug Abuse Research Report Series. Prescription Drugs: Abuse and Addiction. N I H Publication 05-4881. Bethesda, Md: US Dept of Health and Human Services, National Institutes of Health; 2005. 65. Substance Abuse and Mental Health Service Administration, Office of Applied Studies. Summary of Findings from the 1999 National Household Survey on Drug Abuse. NHSDA Series H-12. D H H S Publication (SMA) 00-3466. Rockville, Md: US Dept of Health and Human Services; 2000. 66. Johnston LD, O'Malley PM, Bachman JG. Monitoring the Future: National Survey Results on Drug Use, 1975-1999. Bethesda, Md: National Institute on Drug Abuse; 2000. 67. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Substance Use Among Women in the United States. SAMHSA Analytic Series A-3. DHHS Publication (SMA) 97-3162. Rockville, Md: US Dept of Health and Human Services; 1997. 68. Zickler P. NIDA scientific panel reports on prescription drug misuse and abuse. NIDA Notes Res News. 2001 : 16. 69. Anthony JC, Warner LA, Kessler RC. Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Exp Clin Psychopharmacol. 1994;2:244-268. 70. Gomberg ES. Older women and alcohol. Use and abuse. In: Galanter M, ed. Recent Developments in Alcoholism, Vol. 12. Alcoholism and Women. New York, NY: Plenum Press; 1995:61-79. 71. Closser MH, Blow FC. Recent advances in addictive disorders. Special populations. Women, ethnic minorities, and the dderly. Psychiatr Clin North Am. 1993;16:199-209. 72. Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse.

73. 74.

75.

76.

77.

78.

79.

80.

81.

82.

Results from the Epidemiologic Catchment Area (ECA) Study. JAMA. 1990;264:2511-2518. Szwabo PA. Substance abuse in older women. Clin GeHatr Med. 1993;9:197-208. Warner LA, Kessler RC, Hughes M, et al. Prevalence and correlates of drug use and dependence in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:219-229. Hilton ME. The demographic distribution of drinking patterns in 1984. In: Clark WB, Hilton ME, eds. Alcohol in America: DHnking Practices and Problems. Albany, NY: State University of New York Press; 1991:73-86. Bamas C, Rossmaim M, Roessler H, et al. Benzodiazepines and other psychotropic drugs abused by patients in a methadone maintenance program: Familiarity and preference. J Clin Psychopharmacol. 1992;12:3974:02. Golub A, Johnson BD. Variation in youthful risks of progression from alcohol and tobacco to marijuana and to hard drugs across generations. A m JPublic Health. 2001; 91:225-232. Kessler RC, Crum RM, Warner LA, et al. Lifetime cooccurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey. Arch Gen Psychiatry. 1997;54:313-321. Kessler RC, Nelson CB, McGonagle KA, et al. The epidemiology of co-occurring addictive and mental disorders: Implications for prevention and service utilization. A m J Orthopsychiatry. 1996;66:17-31. Dickey B, Normand SL, Weiss RD, et al. Medical morbidity, mental illness, and substance use disorders. Psychiatr Serv. 2002;53:861-867. Iguchi MY, Handelsman L, Bickel WK, Griffiths RK Benzodiazepine and sedative use/abuse by methadone maintenance clients. Drug Alcohol Depend. 1993;32:257-266. Finlayson RE, Davis LJ Jr. Prescription drug dependence in the elderly population: Demographic and clinical features of 100 inpatients. Mayo Clin Proc. 1994;69:
1137-1145.

83. Fishbain DA, RosomoffHL, Rosomoff RS. Drug abuse, dependence, and addiction in chronic pain patients. Clin JPain. 1992;8:77-85. 84. Harstall C, Ospina M. H o w prevalent is chronic pain? Pain Clin Updates. 2003;11:14:. 85. Zacny J, Bigelow G, Compton P, et al. College on Problems of Drug Dependence taskforce on prescription opioid non-medical use and abuse: Position statement. Drug Alcohol Depend. 2003;69:215-232. 86. Zacny JP. Characterizing the subjective, psychomotor, and physiological effects of a hydrocodone combination product (Hycodan) in non-drug-abusing volunteers. Psychopharmacology (Berl). 2003;165:146-156.

393

The American Journal of Geriatric Pharmacotherapy

L. Simoni-Wastila and H.K. Yang

87. Zacny JP, Gutuerrez S. Characterizing the subjective, psychomotor, and physiological effects of oral oxycodone in non-drug-abusing volunteers. Psychopharmacology (Bed). 2003;170:242-254. 88. Blow F, Brower K, Schulenberg J, et al. The Michigan Alcoholism Screening Test-Geriatric Version (MAST-G): A new elderly-specific screening instrument. Alcohol Clin Exp Res. 1992;16:372. 89. Kail B, DeLaRosa M. Challenges to treating the elderly Latino substance abuser: A not so hidden research agenda. J Gerontol Social Work. 1998;30:123-141. 90. Reid MC, Anderson PA. Geriatric substance use disorders. Med Clin North Am. 1997;81:999-1016. 91. Smith WB, Weisner C. Women and alcohol problems: A critical analysis of the literature and unanswered questions. Alcohol Clin Exp Res. 2000;24:1320-1321. 92. Satre DD, Mertens JR, Arean PA, Weisner C. Five-year alcohol and drug treatment outcomes of older adults versus middle-aged and younger adults in a managed care program. Addiction. 2004;99:1286-1297. 93. Satre DD, Mertens J, Arean PA, Weisner C. Contrasting outcomes of older versus middle-aged and younger adult chemical dependency patients in a managed care program. J Studies Alcohol. 2003;64:520-530.

94. I(ruse WH. Problems and pitfalls in the use of benzodiazepines in the elderly. Drug Saf. 1990;5:328-344. 95. Roy W, Griffin M. Prescribed medicines and the risk of falling. Top Geriatr Rehabil. 1990;5:12-20. 96. Liberto JG, Oslin DW, Ruskin PE. Alcoholism in older persons: A review of the literature. Hosp Community Psychiatry. 1992;43:975-984. 97. Fink A, Elliott MN, Tsai M, Beck JC. An evaluation of an intervention to assist primary care physicians in screening and educating older adults who use alcohol. JAMA. 2005;53:1937-1943. 98. Pringle KE, Ahem FM, Heller DA, et al. Potential for alcohol and prescription drug interactions in older people. J A m GeHatr Soc. 2005;53:1930-1936. 99. Harwood H, Fountain D, Livermore G. The Economic Costs of Alcohol and Drug Abuse in the United States. Report prepared for the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism. N I H Publication 98-4327. Rockville, Md: National Institutes of Health; 1998. 100. Substance Abuse and Mental Heakh Services Administration, Office of Applied Studies. Year-End 1998 Emergency Department Data from the Drug Abuse Warning Network. Rockville, Md: US Dept of Health and Human Services; 1999.

A d d r e s s c o r r e s p o n d e n c e to: Linda Simoni-Wastila, BSPharm, P h D , Associate Professor and Director, L o n g - t e r m Care Initiative, Peter L a m y Center on D r u g Therapy and Aging, University o f Maryland Baltimore, School o f Pharmacy, 220 Arch Street, 14th Floor, Baltimore, M D 2 1 2 0 1 . E-mail: lsimoniw@rx.umaryland.cdu

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