CGPR: Please tell us about yourself and the patients you see.

Dr. Bogunovic: I work at McLean Hospital as the medical director of ambulatory services in the Division of Drugs and Alcohol. I see patients in the outpatient clinic and work with a multidisciplinary team. My subspecialties are benzodiazepine use disorders and tapers in the outpatient setting, as well as older patients who struggle with substance use disorders (SUDs).

CGPR: SUDs are often undiagnosed and underestimated in older adults. How serious is this problem?

Dr. Bogunovic: Although the prevalence of SUDs in older adults is lower than in the younger adult population, it is rising, in part because the baby boomer generation is aging. This cohort grew up with more substance use and experimentation than prior generations, and many older adults continue these patterns as they age. They may have used alcohol and cannabis for quite some time; they’re aware of hallucinogens and other drugs. The two main areas of concern in older adults are alcohol use and prescription medication misuse. Illicit substance use continues to be lower in older adults but is expected to increase. The prevalence of opioid use disorder (OUD) in older adults is around 1% (Shoff C et al, Am J Prev Med 2021;60(6):850–855).

CGPR: How common is problematic alcohol use among older adults?

Dr. Bogunovic: Alcohol is the most commonly used substance in older adults. Alcohol use disorder (AUD) affects about 1%–3% of older adults, although it may be 10 times more frequent in treatment settings (Fagbemi M, Cleve Clin J Med 2021;88(8):434–439). Up to a third of older adults with alcohol use disorder (AUD) develop drinking problems in later life (Taylor C et al, Int Psychogeriatr 2014;26(11):1755–1766). Alcohol use has been rising: Between 2001 and 2013, past-year alcohol use in older adults increased 22%, high-risk drinking increased 65%, and the diagnosis of AUD increased by over 100% (Han BH et al, J Am Geriatr Soc 2019;67(10):2139–2144). An estimated 10.6% of older adults are current binge drinkers (Han et al, 2019).

CGPR: That’s a huge jump. What are the trends in alcohol use among older adults over the past couple years?

Dr. Bogunovic: According to the 2021 National Poll on Healthy Aging, 67% of adults between ages 50 and 80 drank alcohol in the past year, 10% drank while using other drugs, 20% drank four times a week or more, 23% had three drinks on a typical drinking day, and 27% had six drinks on at least one occasion (www.tinyurl.com/3saeksb2). Recently, the increase in alcohol use among older adults has been ascribed to COVID-19 pandemic isolation, especially as senior centers closed. When the social activities stopped, people turned to alcohol (and to illicit drugs).

CGPR: Older adults are also using cannabis to help with sleep, anxiety, and depression. What do the data show here?

Dr. Bogunovic: In the US (as of 2022), cannabis is legal for medicinal purposes in 37 states, and it’s legal for recreational use in 19 states. From 2006 to 2016, the prevalence of past-year cannabis use increased seven-fold (from 0.4% to 2.9%) in adults over the age of 65 (Han BH and Palamar JJ, Drug Alcohol Depend 2018;191:374–381). The prevalence of past-year use increased further to 4.2% in 2018, with significant increases in women, racial minorities, people with higher incomes, and people with mental illnesses (Han BH and Palamar JJ, JAMA Intern Med 2020;180(4):609–611). This is partly due to the legalization of cannabis products, but also because this generation of older adults has more familiarity with cannabis use than previous generations, for whom alcohol was the primary problem.

CGPR: How do early-onset SUDs differ from late-onset SUDs?

Dr. Bogunovic: The early-onset SUDs are much more severe and are more likely to be accompanied by psychiatric comorbidities. Late-onset SUDs may be precipitated or perpetuated by stressors like partner loss, chronic medical conditions, social isolation, or a decrease in independence or functional ability. In late-onset SUDs, comorbid psychiatric disorders are actually more responsive to treatment.

CGPR: Can you walk us through a brief intervention to help older adults engage in SUD treatment?

Dr. Bogunovic: I use motivational interviewing, which means meeting the patients where they are and engaging them in treatment (Purath J et al, Geriatr Nurs 2014;35(3):219–224). I help patients assess how they’re doing and give them feedback. For example, I may ask older adults why they use alcohol, and they may tell me that it helps them with insomnia. I often discuss the benefits of addressing their SUD in terms of their overall health. Even if they do not meet the criteria for SUDs, they may be at a higher risk for complications because of their medical comorbidities. I let patients know that once they address their SUDs, their medical conditions may improve. For example, if a patient has uncontrolled hypertension and stops using alcohol, their blood pressure improves. I use an empathic counseling style and try to enhance a patient’s self-efficacy. I have patients take personal responsibility for their change. And then I provide them a menu of change options, such as “You can try not drinking every night as you’re watching the evening news and instead substitute with seltzer water or M&Ms.” I let my patients know they are doing a good job, which helps keep them motivated.

CGPR: Do you make any changes to medication treatment recommendations in older adults?

Dr. Bogunovic: I use the same medications, except that I’m very cautious about using disulfiram (Antabuse) in older adults with AUD. I use the standard medication-assisted treatments for OUD—either buprenorphine or methadone maintenance. I taper benzodiazepines very, very slowly based on the potential severity of withdrawal symptoms, usually decreasing the dose by 1/8 every couple of weeks. I generally do not switch to a longer-acting benzodiazepine in older adults. If an older adult has a comorbid anxiety disorder, I prefer treating with mirtazapine due to its tolerability, minimal drug interactions, and ability to help with insomnia (Crocco EA et al, Curr Treat Options Psychiatry 2017;4(1):33–46). For intolerable anxiety, and for immediate and faster relief, I may use gabapentin. I tend to avoid topiramate in older adults because of its effects on cognition (Mula M, Ther Adv Drug Saf 2012;3(6):279–289).

CGPR: Are you more likely to recommend hospitalization for detox in older adults?

Dr. Bogunovic: If the patient struggles with the outpatient taper or doesn’t have supports such as family, I explore inpatient options. Most detox settings do a very fast taper, a couple of days to a week. I prefer to admit older adults who are really struggling to a geriatric unit and then complete a slower taper while addressing other psychiatric conditions, which are highly comorbid. Patients often benefit from additional assessments to address functioning after hospital discharge.

CGPR: What resources do you recommend if patients are thinking about change?

Dr. Bogunovic: It’s important to refer patients for an initial assessment by an individual clinician rather than immediately referring them to a medically supervised detox, residential program, or partial program. An individual assessment provides a patient-centered approach, which includes providing resources available for the treatment of SUDs. Older adults respond best to age-specific programming, such as group therapy. The problems that they encounter are different from the problems that younger adults encounter; for example, older adults are more likely to experience multiple chronic health problems and may have experienced more loss. Studies show that if we match older adults to a cohort group that addresses their needs, they’re much more likely to be successful in treatment (Choi NG et al, Drug Alcohol Depend 2014;145:113–120). Studies also show that once older adults overcome shame and guilt, and once they engage in treatment, their success rate is much higher compared to the younger population (Rothrauff TC et al, Subst Abus 2011;32(1):7–15).

CGPR: Are there any resources specific to older adults that help them connect?

Dr. Bogunovic: There are a few age-specific programs for older adults with SUDs across the United States, and more programs are in development. I generally start by referring patients to senior centers and self-help groups. At McLean, we run a group for “mature adults” affected by SUDs. Back when we were meeting in person, older adults would always come earlier, and they would have a pre-group and post-group meeting. They never missed meetings—even during a snow day they would call to ensure that the groups were not cancelled. During the pandemic, they became pretty savvy with using Zoom. It’s nice to see a cohort that cares about each other. If a group member is suffering, the other members independently reach out to that person—which helps with group ­cohesiveness.

CGPR: When an older adult is not ready for abstinence, how do you discuss harm reduction?

Dr. Bogunovic: We have to meet patients where they are. It is important to continually engage patients in treatment rather than abandoning them. At some point, I hope that the skillful use of motivational interviewing will help patients come around. I work around a patient’s values, what is considered very important for them, and I try to engage them. Patients may not want to discontinue or decrease substance use for themselves, but they may value their relationship with their children or grandchildren and see the effects of substance use on their relationships. I tend to support the patient regardless of the path they choose. This allows the patient to learn, but it also helps us understand the nature of relapse and the values that help guide patients to their desired outcome. Although many patients engage in treatment, it’s difficult for them to grasp the model of permanent abstinence. They often want to try to see if they can cut down to be social drinkers, for instance.

CGPR: Can you walk us through an example of this approach?

Dr. Bogunovic: I have a patient who is now five years sober. Initially he came to treatment because AUD was eroding other parts of his life. His wife was unhappy and his grandkids saw him once when he was intoxicated. He engaged in treatment, which included a partial hospital level of care. However, he was not sure about long-term abstinence. After a period of abstinence, he decided to engage in social drinking, which escalated quickly. We kept on working together. He re-engaged in a second partial hospitalization. At that point we were also able to address his mood and anxiety disorder. After a second period of abstinence, he realized its benefits. He was able to significantly reduce his drinking and stopped drinking around his grandkids altogether; he was fully engaged in life and present in the lives of his grandchildren.

CGPR: What psychoeducation do you provide?

Dr. Bogunovic: I explain that a patient’s illness is chronic and that we expect exacerbations of the illness. We talk about the effects of substance use on their physical health and about their values and what they will achieve with long-term abstinence. If I provide psychoeducation about medications such as benzodiazepines, I discuss their effects on cognition and increased risk of falls. I may mention that there have been inconclusive studies about the role of benzodiazepines in dementia. I also talk about tolerance and the risk of abuse.

CGPR: Thank you for your time, Dr. Bogunovic.