Managing medication and alcohol misuse by your older patients
Age-appropriate screening and in-office interventions are sufficient in many cases
Several brief intervention trials—including Project Guiding Older Adult Lifestyles (GOAL), the Health Profile Project, and the Staying Healthy Project—found that brief intervention results in significantly decreased alcohol consumption, sometimes even at 12-month follow-up.18 These trials were conducted in primary care settings, but brief interventions likely would be effective in psychiatric practice as well. Project GOAL included two 10- to 15-minute sessions with a physician scheduled 1 month apart and a follow-up phone call 2 weeks after each visit. The Health Profile Project consisted of a single motivational enhancement session.19
When to refer. Severe cases may require evaluation by a substance abuse specialist of the need for detoxification from alcohol, benzodiazepines, or opioids. Referral is appropriate if the patient has:
- a history of complicated withdrawal, including withdrawal seizures or delirium tremens
- complicated underlying medical conditions, such as severe coronary artery disease, uncontrolled hypertension, or uncontrolled diabetes.
Because of age-related physiologic changes, the older population is at risk for a more protracted withdrawal with more severe symptoms, compared with younger patients.20 Specialized care may include detoxification (outpatient or inpatient, depending on withdrawal symptom severity), day hospital program, or—in the case of a patient with a long history of substance use and multiple relapses—a longer-term residential program.
Table 4
Recommended treatments for substance use disorders in the elderly
| Disorder | Treatment |
|---|---|
| Hazardous use | Assess for withdrawal symptoms; brief intervention |
| Alcohol dependence | Assess for withdrawal symptoms; Alcoholics Anonymous; use of BRENDA model ( Table 5 ); pharmacotherapy (naltrexone, acamprosate); structured rehabilitation program with age-appropriate programming |
| Prescription medication misuse* | Assess for withdrawal symptoms; taper off medication (slowly and gradually); buprenorphine detoxification; brief intervention |
| Opioid dependence | Appropriate detoxification; drug-free trial; harm reduction approach with methadone or buprenorphine; age-appropriate psychosocial groups; Narcotics Anonymous |
| *Sedative-hypnotic and opioid pain medications (such as oxycodone HCl) | |
Table 5
The BRENDA model:
A brief psychosocial intervention for alcohol use disorders*
| Biopsychosocial evaluation |
| Reporting the assessment to the patient |
| Empathy |
| Needs identification |
| Direct advice |
| Assessment of patient reaction to the advice |
| *Any trained health care staff member can administer this model, which is standardized with a comprehensive manual |
| Source: Reference 17 |
Pharmacotherapy
Pharmacotherapy is an important component in the treatment of older adults with SUDs. Other elements include psychosocial interventions, brief interventions, cognitive-behavioral therapies, and supportive programs such as Alcoholics Anonymous or Narcotics Anonymous. Randomized controlled trials on the use of medications for SUDs in older patients are limited. As with any other medication trial in the elderly, start with the lowest possible dose and titrate slowly to treatment effect.
Alcohol use disorders. In our experience, naltrexone—an opioid antagonist—is the first-line agent to consider for alcohol dependence in older patients ( Table 4 ). Oslin et al21 found naltrexone, 50 mg/d, to be well-tolerated and effective in decreasing rates of relapse to heavy drinking in older adults.
Because of its potential hepatotoxic effects, use naltrexone with caution in patients with hepatic impairment. We recommend baseline liver function tests, with repeat testing in 3 to 6 months. Severe liver disease would be a contraindication for naltrexone, but consider risk vs benefit in individual patients.
Acamprosate—a glutamatergic medication—has been studied and approved for treating alcohol dependence in adults, although no study has specifically examined its use in elderly patients. Acamprosate may offer an alternative for patients with severe liver disease or those who can’t tolerate naltrexone.
Disulfiram is rarely used in the elderly because of potential risks of hypotension and cardiovascular adverse effects in a disulfiram-ethanol reaction. Topiramate—an anticonvulsant that potentiates gamma-aminobutyric acid—has shown benefit in treating initiation of abstinence from alcohol.22 It is an incompatible treatment for the elderly, however, because it may cause cognitive impairment.
Sedative-hypnotic misuse. The goal in treating patients who misuse sedatives or hypnotics is detoxification, which usually is addressed with a gradual and slow taper under controlled supervision in the outpatient setting.
Opioid dependence. Treatment options for opioid dependence are the same whether older patients are misusing prescription opioids or illicit ones such as heroin. Naltrexone, methadone, and buprenorphine/naloxone have been widely studied and used in younger adults but only minimally in the elderly.
Studies conducted in methadone maintenance clinics have found positive results when older patients are treated for opioid dependence:
