David Oslin, MD
Professor of Psychiatry, Philadelphia Veterans Affairs Medical Center and the University of Pennsylvania Medical Center
Dr. Oslin has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CATR: Let’s start with diagnosis. Are there specific challenges in diagnosing substance use disorder (SUD) in older adults? Dr. Oslin: There definitely are, and DSM criteria can be hard to apply. Older adults are more likely to drink at home, much more likely to have medical problems, and may have interpersonal issues, but they will likely have fewer work-related problems as many are retired. They’re also more sensitive to the effects of substances, so their tolerance may go down.
CATR: Are there screening tools we can use to make sure we don’t miss SUDs in this population? Dr. Oslin: There is a questionnaire specific to older adults called the Michigan Alcoholism Screening Test—Geriatric Version (MAST-G) (https://www.the-alcoholism-guide.org/michigan-alcohol-screening-test.html), but this is a long instrument. The Alcohol Use Disorders Identification Test (AUDIT-C) is just as sensitive and has only 3 items (https://www.integration.samhsa.gov/images/res/tool_auditc.pdf). Then there’s the National Institute on Alcohol Abuse and Alcoholism single-item screen based on number of drinks (see Dr. Jordan’s article in this issue), which I would recommend for most practices. The key issue is for providers to feel more comfortable broaching the topic and not to assume their older patients don’t drink. Many providers—both in primary care and psychiatry—are too hesitant to ask about this.
CATR: Why do you think clinicians are so reluctant to ask? Dr. Oslin: There’s the idea that they don’t see substance use as frequently as in younger adults, so it’s not as evident; there’s an overall anxiety related to asking older adults about substance use, because providers think it’s somehow disrespectful; and then there’s the ageist belief that there is no need to intervene in an older adult if the person has been using a substance for many years.
CATR: Let’s unpack the first reason you mentioned. Is it actually true that people give up using substances as they age? Dr. Oslin: Yes, the prevalence rates of SUDs clearly go down with age. When you get past about 80, you’re talking about alcohol and tobacco for the most part, and alcohol is dramatically decreased after age 80 (Vasilenko SA et al, Drug Alcohol Depend 2017;180:260–264).
CATR: What do you think are the reasons for this? Dr. Oslin: One factor is biological. Dopamine is the one neurotransmitter that most consistently decreases as we age, so there may be less reward circuitry driving addiction as we get older. Another factor is illness. Older people accumulate illnesses like hypertension and diabetes, and this is a strong motivator for behavior change. And unfortunately, some people may not survive into older age as a result of their substance use.
CATR: Can the opposite be true for some people? We do hear about late-onset SUDs. Dr. Oslin: Well, on the flip side, there are a lot of people in their 60s and early 70s who markedly increase their consumption of different substances once they retire. Many patients in their 60s are relatively healthy—60 is the new 40—and as they retire they have a lot of free time and sometimes increase their drinking.
CATR: What about illicit substances—do you see much use of those in older adults? Dr. Oslin: Historically, illicit substances such as cocaine, ecstasy, and LSD have not been all that prevalent. For older adults, if they want a stimulant, they’ll go to a provider and get Ritalin. If they want an opiate, they’ll go to a provider and possibly get a prescription for that too. You don’t have to go far to get these substances if you have a health care provider. Yet, it’s true that over the last 20 years there has been an increase in illicit substance use, mostly in people in their 60s and to an extent into their 70s—the baby boomers that are now reaching that age (https://www.drugabuse.gov/publications/drugfacts/nationwide-trends).
CATR: What about problems related to the use of prescription drugs, like benzodiazepines and opiates? Dr. Oslin: Yes, that can be an issue. Older adults are the largest consumers of any pharmaceuticals, and they are clearly the largest consumers of opiates and benzos in this country. So when these substances are prescribed, it is often easy to miss a developing opioid or benzo use disorder. Just because the patient has a prescription for it doesn’t mean it’s not a problem.
CATR: Do you have practical advice for how to distinguish appropriate use vs misuse of these agents? Dr. Oslin: Of course, we should not be prescribing pharmaceuticals that are not benefitting patients. That’s a blanket statement, and it applies to anyone. The issue is that we are not very good about taking away medications, even when we’re not sure if they are helping the patient. As prescribers, we need to do a better job of demonstrating the continued value for prescribing any meds and discontinuing them when they offer no benefit.
CATR: This is often a difficult discussion to have with patients. What’s a good way to broach the topic? Dr. Oslin: I will start by saying, “I don’t think this has gotten you better, and here’s the evidence for it: You’re not sleeping any better and you’re not less anxious. We need to think about a different treatment.”
CATR: So some of it comes down to measuring what we’re doing and discussing that with the patient. Dr. Oslin: Right. If you give a benzodiazepine for sleep and then don’t rate that person’s sleep, how can you possibly know if the medication worked? If you are going to prescribe these medicines, you should be measuring and documenting the outcomes for the target symptoms. And if the meds are not working, then taper them down and get rid of them.
CATR: Let’s talk a bit about older adults’ vulnerabilities to the effects of substance use, such as the risk of falls and cognitive problems. Dr. Oslin: As we age, we are more vulnerable to a lot of things—the same amount of alcohol or the same amount of any of these substances is going to cause more impairment in an older person vs a younger one. As an example, our stability and gait can worsen as we get older, so any substance that affects gait or balance will have a larger effect. Reaction time also decreases with age. So there’s more pronounced impairment while driving under the influence of most of these substances as we get older.
CATR: And there’s also the issues of interactions with prescribed medications. Dr. Oslin: Exactly. The other large vulnerability is that the average older adult is taking 5 prescribed medications, and alcohol has the most drug-drug interactions of any substance. For example, it can affect changes in metabolism, which is why if you have a patient on something like warfarin (Coumadin), you have to be careful as alcohol dramatically affects its metabolism and the dose required for appropriate anticoagulation. Alcohol can change target responsivity, which is why you shouldn’t drink and be on an antidepressant—the alcohol will lower the antidepressant’s effectiveness (Qato DM et al, J Am Geriatr Soc 2015;63(11)2324–2331). Alcohol counters the effects of antidepressants not from a metabolic perspective, but just from hitting the system from two different directions—an antidepressant and a depressant.
CATR: Let’s shift and talk about psychosocial factors. Are there stressors that can specifically impact substance use in older adults? Dr. Oslin: The things that are relevant for a 70-year-old are very different than those relevant for a 30-year-old. The big struggles later in life are generativity: What am I doing with my life? How am I contributing to society? What’s my role? Of course, there are the external losses: the grief that people go through as they age when people around them are dying. And then there is the overall change in social fabric. For most of our adulthood, our social lives are centered around our employment (plus other activities to an extent, like church). But in older adulthood, you are no longer occupied for the 8 hours a day or 60 hours a week that you used to put into work.
CATR: So grief, isolation, and boredom can become big issues. Oslin: Yes. Some people are successful at navigating that and some people are not. And then there’s loss of function: difficulty driving at night, pain, arthritis, sleep disruption, changes in sexual function. There’s a loss of independence from no longer being able to do things that you could do when you were 40.
CATR: How can this knowledge guide our psychosocial interventions in treating older adults? Dr. Oslin: The big issue for older adults is the time and effort needed to work a recovery program. If you are 62, it may not be a big deal to do 90 meetings in 90 days, but if you are 72, going to a meeting every day is probably not going to be as easy depending on how healthy you are. We published a paper a couple of years ago demonstrating that older adults were much less likely to engage in traditional group-oriented activities such as AA (Oslin DW et al, Addict Behav 2005;30(7):1431–1436). It can also be tougher to relate to others. If a person is 70 and lives in a small town, and the only local AA meeting has members that are younger and have different issues and comorbidities, then the person might not want to go to that group. So those are things that we need to be cognizant of.
CATR: What about formal outpatient treatment, like an intensive outpatient program (IOP)? Dr. Oslin: That’s challenging as well. It’s really hard for an older adult to sit through 4 hours of programming a day or to get to an IOP 4 or 5 days a week. Most older adults would much prefer individual treatment; that comes out over and over again in most studies (http://www.aa.org/assets/en_US/p-48_membershipsurvey.pdf). Individual treatment is not the mainstay of what we deliver, but it is the preferred method for most people.
CATR: What about older adults who may not have a full SUD, but are using here and there or drinking more than is healthy—the so-called at-risk users? Dr. Oslin: The most effective treatment for older people who are at-risk drinkers is brief intervention. The key factor here is giving direct advice that’s relevant to the patient. For many patients, reducing the drinking isn’t the important thing; it’s getting better control of their diabetes or hypertension, etc. So this brief intervention is a way to show that the substance use is tied to the domains that are important to the person. Then we can help form strategies to reduce or change that behavior.
CATR: That’s interesting. Patients don’t commonly make these connections to their general health. Dr. Oslin: Correct. What we run into all the time with older adults is they have no idea that their glass of wine, for instance, interferes with their antihypertensives or their antibiotics. Just learning and having that direct conversation helps them realize that they need to not drink.
CATR: And again, you are relating to the at-risk population that may not even have a bona-fide SUD, correct? Dr. Oslin: Exactly. It is education in a way, but it includes very direct advice to connect with patients’ goals. Most patients are not coming to us and saying, “Oh, I’m worried about my glass of wine at night and whether I should change that behavior.” It would be very rare for a provider to hear that kind of question. So tying it to something that’s relevant to the patient is really important.
CATR: Thank you very much for your time, Dr. Oslin.