Hello, everyone, and thank you for joining. My name is Andrew Saxon, and on behalf of the American Psychiatric Association, welcome to today's webinar, Substance Use Disorders in Late Life. Today's activity is presented on behalf of the SAMHSA-funded Providers Clinical Support System, a program operated collaboratively by 19 medical specialty organizations, including the APA, which is presenting today's webinar. Please note that following today's presentation, you will receive a follow-up email within one hour of the webinar. This email will contain the instructions to claim your one credit hour for attending. This activity offers CE credit for physicians, nurses, nurse practitioners, pharmacists, physician assistants, and social workers. Next slide, please. Please feel free to submit your questions throughout the webinar by typing them into the questionnaire you found in the attendee control panel, as depicted on this slide. That would be the Q&A area, and we'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Although the slide says 20 to 30 minutes, it's going to actually be more like 15 minutes. Next slide. Now I would like to introduce the faculty for today's webinar, Drs. Roberto Sanchez and Ali Abbas Asghar Ali. Dr. Asghar Ali is an associate professor at the Baylor College of Medicine and a staff psychiatrist at the Michael E. DeBakey VA Medical Center. Dr. Roberto Sanchez is an addiction psychiatry fellow at the Yale School of Medicine. Next. The overarching goal of PCSS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications, as well as for the prevention and treatment of substance use disorders. At this point, I will turn it over to Drs. Sanchez and Asghar Ali to do their presentation. Welcome. Thank you. Thank you to APA for inviting us and covering this really important topic that both of us feel really passionate about, from two different angles coming together to help care for older adults with substance use disorders. Here are disclosures, and I'll let people read them. Okay, and then moving on to our objectives, covering a topic that has a lot of information, we did ask and thank you for allowing us to have more than 60 minutes, because we really wanted to make sure that we were able to cover the gamut of information that would be helpful for clinicians and physicians to be able to understand the problem, as well as then address the problem with information that they have in this presentation. You'll see the objectives go all the way from gaining some knowledge, as well as applying that knowledge in your practice. Before any talk, I think getting a little introduction to terminology and language is really important, especially in an area that is as stigmatized as substance use disorders. While these won't be all the terms that we use, I wanted to just bring to attention two commonly used terms, the first being substance misuse, and that's the use of a substance for a purpose not consistent with legal or medical guidelines. It could include both prescribed and non-prescribed substances. On the other hand, at risk or hazardous use is substance use that increases the chances that one may develop future problems, including physical or mental problems and complications. This is not necessarily consistent or the same as substance misuse, but does put a person at risk. The other part of the presentation that I want to highlight is that we will do our best, and I've tried to make sure that our slides reflect that, but using person-first language. We really want to make sure that we de-stigmatize and don't continue to use language that may make people feel ashamed, embarrassed, or create barriers to seek care. Finally, stigmatizing language within members of the healthcare team can impact the care of individuals they're caring for. Thinking about even beyond this presentation about how we can remember to use language that is respectful of the people with whom we're providing care. Remember that as we talk to our healthcare team, we're using the same kind of language, so that becomes part of our unconscious practice as well. Let's start with some background. We'll start with prevalence, historical factors, and then talk about our current trends. We'll see that these are all differing and changing as we speak. For the most part, adults above the age of 65 are referred to as older adults. However, due to limited literature and prevalence data, studies often define older adults as 55 years or older, and those will be considered in many of the studies that we used in creating this presentation. This group is more than 30% of the US population at this time. Specifically, people over 65 and older include members of the baby boomer generation. Those, of course, are people born between 1946 all the way to 1964. Once all of them are old enough, they will be the largest group of older adults in US history. We've never had such a large population of older adults before. As a member of that generation ages, more presentations and complications of substance use will be seen as well as increasing hospitals' admissions. Let's talk a little bit more about older adults in this age group. The number of older adults is projected to be about 72 million by 2030, so very large. Members of the baby boomer generation have the highest rates of early life substance use and are more likely to continue substance use into later life. We have this unique circumstance, unique in our history, where we have a group of people who were most likely to have used any substances when they were younger and now are using them even as older adults. Of course, our legal definitions and prohibitions about substance use are also changing. The rates of substance use disorders in older individuals has more than doubled in the last 15 years or so. The rate of substance use disorders in current group of older adults is higher than any previous cohort of older adults. Finally, the number of older adults needing treatment for substance use disorders is increasing across all genders and all racial and ethnic groups. To point that out so that this is not simply an issue of a certain group of people, but is affecting all genders and racial and ethnic groups. How about substance use in older adults and its impact? Certainly higher rates of medical comorbidities are present, hypertension, hepatic illness, and chronic pain. We have to remember that even low doses of substances can exacerbate physical and mental health illnesses due to diminished physiologic reserve. Certainly, as people might be working with patients who might be in their 50s or 60s, and then you might be working with them 10 years later, 60s, 70s, 80s, just keeping in mind that use that might have been tolerated that may not have caused as many problems may now start to have manifestations that they did not before. Finally, hospital admissions related to opioids, particularly heroin, stimulants, including cocaine, amphetamines, and cannabis have increased in older adults. Cocaine and heroin are among the most frequently reported in those admissions. How does substance use affect older adults and why is this different? Why talk about substance use in older adults differently? We have to remember that older adults are more vulnerable to the effects of substances as a result of physiologic changes. What are so many of these changes that might be impacting them? First is decreased percentage of lean body mass. What that means is that the amount of fat to lean body mass is increasing and therefore storage can increase. Decreased total body water, that means that the amount of substance diluted is less. Increased blood-brain barrier permeability, drugs can enter the brain more easily before they can even be washed out by liver or kidneys. The metabolism and excretion may be slower. Both the liver and the kidney function might affect the way in which and how long the drug is in the system. We have altered pharmacodynamics. So far I've been talking about some pharmacokinetics but thinking about just the impact that these have on a molecular level on an older adult. An older adult's brain could be different. Then finally, once they affect the brain, the impact of the drug on the brain might be affected by age-related changes in the brain. Whether these are microvascular events, whether this is because of a distant TBI, any presence of even pathologic changes such as dementia. So how does substance use disorders affect older adults differently? There are much greater risk for mood and anxiety disorders, particularly depression and PTSD, more likely to be affected by sleep disorders, more cognitive impairment. Many people I've worked with over the years, their substance use has not increased and in fact it may have declined but now it's causing them a increased and in fact it may have declined but now it's causing them a great more problem especially related to cognitive impairment. Drug interactions, slower metabolism and lower body fat again contribute to that. Greater physical disability, it might be that now the substances are affecting different kinds of body systems because of the presence of liver disease, cardiomyopathy and falls. They can have more severe withdrawal and then the drugs can have interactions with medications. In younger adults, it is much less likely to be on one or two or three medications. Older adults can be on as many as 10 or more and the likelihood that now these medications are interacting with the drugs can make it even more dangerous. This is in the context of cultural changes over time. Let's just think about how these may have changed older adults' views of addiction over the years. There are a diverse range of opinions and attitudes and we're going to summarize them and obviously putting millions of people in a very narrow definition but overall, before World War II, there was more moralistic attitudes towards substance use. That generation had lived through both prohibition and temperance and benefit more from screening and brief intervention that is part of the overall assessment. Now, members of the baby boomer generation may see substance use as more culturally acceptable. Again, remembering that they were people who were most likely to have used in early life. At the same time, they're more willing to seek treatment. Of course, screening and brief intervention are important for them too but the good news is that they may be even more inclined to seek treatment on their own or as a result of the screening and assessment processes. Why is it that we might also be seeing a greater number of people diagnosed with substance use disorders in older life? Well, the first is just increased life expectancy. The longer people live, the more number of years they might have to use. We're more likely to then see that or catch that. There's a heightened desire for personal gratification among many in baby boomer generation. Again, a large generalization of a statement but consistent with what people may have made people start the substance use in the beginning. Again, the higher use at younger age means that they have more exposure and also higher risk of relapse. Changes in culture and shifting attitudes, remembering that the phrase sex drugs and rock and roll was coined by the baby boomer generation and also really represented a large shift in attitudes towards substance use. Thinking more specifically about epidemiology, substance use disorders are underestimated, under-identified, under-diagnosed and under-treated right across. Of course, we know how those are all related. If we don't think it's a problem, it's underestimated. We don't look for the problem often so we under-identify it, which then of course feeds our belief that they're not as common. If we just don't identify them, then we don't diagnose them. If we don't talk about them, ask about them, we don't learn enough about the person's use to be able to diagnose. What we don't diagnose or identify, we're not likely to treat. We may also overlook these when we're taking care of people with hypertension, diabetes, not thinking about other factors that might be relating into less control over those chronic and medical illnesses. Why is there potentially a large variability in use? The first is, of course, that the prevalence varies greatly based on the substance. As Dr. Sanchez will go over, each substance has its own prevalence as it does also in younger adults and affects our older adults very differently. There's lack of consensus around nomenclature, screening, and diagnosis. For example, the older terms of abuse versus dependence, misuse, is it a use disorder? Are these screenings appropriate for older adults? Again, we hope to offer you some guidance on screening mechanisms that are more tailored to older adults. Lack of research on the topic. In general, while we don't have a tremendous amount of research in substance use, there could be even more understanding. In older adults, this is especially lacking. Ageism, which then reduces our index of suspicion. For many people, substance use is a young person's illness. It's something that you do when you're young and you're taking risks. However, again, to remember that our culture has shifted. People who were younger in the 60s and 70s were more likely to use. As we know, if you're likely to use as a younger adult, you're much more likely to use as an older adult. It is not just about acquiring a new onset substance use disorder in older adults, but we have a situation in which a large number of our older adults were using even previously. Alternatively, and additionally, we don't always think about older adults starting to use in their life. That is also increasingly common. Again, part of it being, even if they didn't use before, they may have had friends and family members who used and were exposed to it and have different attitudes towards substance use than perhaps a person who was 70 years old about 30 years ago. Then finally, denial by caregivers and family members. If it's something that we don't think is happening, then it's not happening. We also, because in older adults, especially the dynamics between adult children and older adults can be such that they may be less inclined to identify, to confront, to even advocate for their older adult parent or family member may lead to this not being as, may not be brought to the attention of healthcare professionals or any intervention being sought. Hopefully we're seeing why, especially in older adults, there are a whole host of different reasons and different from younger adults and certainly adolescents and children that might make it harder to identify substance use disorders and certainly then treat and intervene. Here's some data about just the number of people who have been affected and this data are required. We have a pretty good sense and getting a longitudinal perspective over 20 years. The percentage of older adults admissions increased from about 9% in 2008 to 15%. These are just again, to substance use disorder facilities. Referrals to treatment from self about 40% and healthcare systems about 11%. Underscoring that, does this now represent some degree of lost opportunities? Most people are coming in because they're referring themselves, yet could we as a healthcare system be identifying more and referring more often and appropriately? The increase in admissions continued all throughout that timeframe, of course, and illicit substances, notably heroin and methamphetamines, surpassed alcohol use as primary reason for admission. Doesn't mean that those are more common than alcohol use, but certainly as far as the causes of admission and the reason for admission, they were more common than alcohol use disorder. At that point, I'm going to now shift over and let Dr. Sanchez take over. Thank you. There were so many important points mentioned there. We're going to switch gears slightly and talk about specific substances along with their treatments, screening and statistics surrounding their use. As Dr. Ali mentioned, especially it seems to be with alcohol, there's varying nomenclature. I think when we go back and read some of the studies, we'll see things like problem drinking, heavy drinking, hazardous use, risky use, and then of course, alcohol use disorder or substance use disorder. When we're hearing these other terms in general, we're referring to use that's above the recommended guidelines by NIAAA or CDC, and maybe before an alcohol use disorder. When we have the data to say that this is particularly surrounding an alcohol use disorder or substance use disorder, we do say that. Just something I wanted to mention, because when you look at screening, oftentimes some of the major screening tools are ending at 26 years old and older and such, and we don't often get specific data about 55 years and older, 65 years and older. We're trying to find the data that we can based on what we have right now. Hopefully, we can present some of that. We can go on to the next slide. This is just some considerations for a late life diagnosis of a substance use disorder. We all become familiar with the DSM-5 criteria, but in an older adult, that might not be as applicable depending on where they are in life, their stage in life. I know this is somewhat of a busy slide, but there's a couple of things I wanted to highlight. That first point on the right where it says an older adult may be impaired using the same amount taken when younger, Dr. Ali referenced these physiologic changes with age. That might mean that in an older adult, they might not need more of a substance to get the effects of it. Because of these physiologic changes, decreased metabolism, a lower total body water volume, they may become intoxicated with the lower amount. They may feel some of the effects or side effects at lower amounts. They may not need to use more of a substance to get the effect. If they've been using most of their life, and it's been consistent, and it's just now starting to cause health problems, and despite the health problems they continue to use, they may not see it as big of a problem if it didn't cause social or occupational impairment in the past. The role impairment may be less pertinent if they're retired, if they're homeless in the day. If they're not participating in many activities, you may not see as easily that their substance use is impairing their roles or obligations. It may be less obvious again, like as we mentioned, depending on how much they're doing or how much they're seeing family or friends. And that last point, I kind of touched on this already, the two last points is the tolerance might not be exactly the same based on their changes in metabolism. But again, they may be using for a long period of time, they may be using the same amounts. And so it requires a little bit further questioning, clarifying, understanding, and maybe even getting information from family or friends to understand how this might be impacting their life. So we want to make sure that we ask some additional questions, because just our general criteria for going down the list might not totally capture everything we're seeing. Okay, go to the next slide. So late life risk factors and protective factors for substance use disorders. There's several here, there's a couple that I'd like to really highlight. But for risk factors, you know, a previous history of a substance use disorder, they may be in sustained remission or early remission. But this history, of course, puts them at risk for returning to use, especially in the context of stressors, major role changes. We bolded here retirement that is not voluntary. So thinking about the pandemic, the last couple of years, people that were, you know, maybe forced to retire, they were in a position where they couldn't come into work. And maybe that was a continued requirement. But because of the dangers of COVID, and not wanting to put themselves at risk, they had to stay home. And now they've retired earlier than they desired to. And that's a major change in their life that came earlier than anticipated. That can be really stressful and can lead to substance use, again, especially if they have a history of a substance use disorder. Loss is a major factor. As we age, you know, there's a higher risk of losing those around us that we care about that we love. And that can significantly contribute to substance use. Worse than physical health, especially pain, male gender, bolded here, chronic physical illnesses or pain, again, that can be a major risk factor for substance use, especially if those things aren't being adequately addressed or treated right now. And then some of the protective factors late life onset. So in general, if they didn't have a history of a substance use disorder, they may have more support later in life, there may be less of a genetic component to their substance use. And they tend to respond to treatment pretty well. And good social support, you know, the better the social support, the more people around them that can sort of motivate them and be a protective factor, the better. Of course, resiliency, if they've been through a lot in their life and has continued to move forward and do what they need to do, it's great. Yeah, okay, next. So going over some substances specifically, we're starting off with alcohol. As we mentioned before, there's some varying nomenclature, and we'll kind of touch on this as we go. Next. Alcohol. Yeah. So most common substance misuse, misuse in older adults. And again, when we're using the term misuse here, we're saying, you know, there's certain guidelines as to what's recommended as being moderate use. And use beyond that can be considered misuse, problematic use, risky use. And there's been an increase in alcohol consumption in those over the age of 50. In comparison to younger age groups, greater than 10% of adults age 65 and older binge drink, and we'll go over exactly what that means on the next slide. But 65% of people greater than 65 years old reported high risk drinking at least weekly over the previous year. So again, beyond what's recommended. And then an estimated 4% of older adults struggle with alcohol use disorder. One point I want to make here really quickly is we know that one standard drink of alcohol is 14 grams. And I'm sure most people have seen at least a similar illustration to what's on this slide as to, you know, you can find 14 grams of alcohol and one 12 ounce beer, and one five fluid ounce glass of wine, or an ounce and a half of distilled spirits, things like whiskey or vodka. But I challenge everybody, I think to take it a little bit further. I think oftentimes our patients might say something like I'm having a pint a day. But what does that really mean? I mean, how much is a pint? Do we know? And a pint itself is about eight and a half standard drinks, right? It's about 12.7 ounces, you divide that by 1.5. So we'll go over this a little bit further in the presentation as far as a brief intervention. But if you can relay this information back to your patient, if you can say, I understand you having a pint a day, you've been doing this for a while, it doesn't feel like a lot. But it is still eight and a half standard drinks. And over the course of a week, if you're having a pint, Monday through Sunday, that can be about 60 drinks in one week. And sometimes hearing that number and comparing it to what the recommendations are can be therapeutic in and of itself. And there's others. I mean, sometimes people say I have a couple of nips. A nip is kind of like a shot, and it's a little bit more than a standard drink. A fifth might be about 16 standard drinks, and a handle can be up to 40 drinks. But when we really kind of take apart what it is that they're drinking, how much they're drinking, it can be really helpful in providing information and counseling and education. Okay, next. So looking at what the current recommendations are, and this is from NIAAA and the CDC, moderate alcohol use is one drink per day for women or two drinks per day for men, and those above the age of 65. And this is per day, this is not an average. So we might look at for men, 14 drinks in a week, or for women, seven in a week. But again, it shouldn't be necessarily considered as an average. It should be per day. More than three standard drinks, so four or more drinks in an older adult is considered a binge drinking or a heavy drinking day in comparison to five standard drinks in younger male adults, and the same as in younger female adults. And this amount is, you know, if you drink a particular amount within two hours, and that brings your blood alcohol concentration to 0.08%, that is what is considered heavy drinking. So in older adults, greater than three standard drinks, we know bring somebody to a blood alcohol concentration at 0.08%. Knowing this information, we know that somebody is at a higher risk for developing an alcohol use disorder if they're having episodes of heavy drinking or binge drinking. So this guides our counseling, our clinical decision making, but also our education for our patients. And per SAMHSA, 10% of all adults age 65 and older are reported having at least one binge drinking episode over the previous month. And those with dementia or sleep disorders, even one to two drinks might not be safe, right? I mean, there's, these are guidelines, but this really varies on a variety of factors. I mean, if somebody has an alcohol use disorder, we're probably, and they're in remission, they've been doing really well, you know, this isn't necessarily the recommendation we're going to give them. We're going to encourage that they continue their sustained remission of their alcohol use disorder. If somebody has cognitive impairment or dementia or other medical conditions that we know can be worsened by alcohol use, then our recommendation is probably going to be no alcohol. And, you know, I think there's new information coming out lately, but even low amounts of alcohol, even maybe one standard drink can increase our risks of a variety of conditions, high blood pressure, heart disease, stroke, liver disease, cancers like breast cancer, colon cancer, esophageal cancer. And I think because these are, this is a legal substance, oftentimes our patients can feel I'm just having one drink. And maybe they remember when we, I used to often say that maybe a glass of wine a day could be healthy and they kind of hold onto that. But the reality is that even a low amount has health consequences and it's important that we educate on that. Okay, next. So some important considerations, young adults, as Dr. Lee mentioned, you know, metabolism changes with age. Young adults, their liver metabolizes roughly one serving of alcohol per hour. Slower metabolism of alcohol, less lean body mass, less total body water, and older adults can lead to a higher blood alcohol level, maybe by about 20%. And blood alcohol level can stay higher longer. 78% of older adults in the US who drink alcohol are taking medications that interact with alcohol. So again, the education is important. And this could be a person that maybe no alcohol use is the safest and best option. And that note about it sort of lingering and having more effects quicker. I mean, that can change the way that we view withdrawal. If somebody presents to the ER, maybe they're not in alcohol withdrawal yet, but we know that they've been drinking a handle a day or a fifth a day. This might occur a little bit later. And on the flip side, you know, like we discussed earlier, they may tell us that they're only drinking a certain amount. But if they're 78 years old, we know that that amount may not sound as significant as the previous patient we saw that was 26 and drinking much more. Because of these body changes with age, these effects are much more pronounced, and we should take them seriously. Next. So looking at early versus late onset of alcohol use disorder, and we kind of discussed or touched on this briefly when we were talking about risk factors. But early onset, referring to less than 60 years old, it's associated with poor outcomes and a more severe course. They've likely been, you know, in this case, they've been drinking for longer, and they're taking this into the older age. This accounts for about 67% of late life problem drinkers. And again, when we read studies, and we hear things like problem drinkers, we're referring to people that are drinking more than what is recommended and might be causing problems in their life now. Due to the length of use, there are more alcohol related problems, medical problems, legal problems, there might be less social support as a result of their substance use. And they're more likely to have a family history or a genetic component to their substance use. Late onset on the other side, it's associated with better outcomes, there's fewer physiologic consequences of the illness, because there's been a shorter use, there's been less sort of exposure to the substance. And onset is often after a loss or a stressful event. We talked earlier a little bit about forced retirement and the pandemic, that could be a major life change, especially if you've really found your sort of sense of self and purpose in your work and your job. And now suddenly that's changed in your home. That can certainly be a stressful factor that can lead to substance use. And onset, I'm sorry, generally, these patients are more emotionally stable, they may not carry comorbid anxiety or depressive disorders as much as people who developed an alcohol use disorder before the age of 60. And they might have more social support as well. Okay, moving on to the next. So risk factors for alcohol misuse in late life, physical factors, chronic pain, physical disabilities, a change in living situation, maybe moving into a retirement home, overall poor health status, maybe if they have multiple chronic health conditions and health might be sort of deteriorating, chronic physical illness. One point I want to make here in regards to chronic pain, you know, alcohol may be used to, we sometimes hear people say that they might use alcohol to numb pain. But at the same time, we understand that alcohol withdrawal causes an increase in pain sensitivity. So one may continue to drink in order to get rid of this worsened pain that they experienced in withdrawal. So they may feel stuck as well. So chronic pain can significantly exacerbate use in multiple ways. Mental risk factors, so avoidant coping style, maybe using alcohol as a way to cope. As previously mentioned, a history of alcohol misuse in the past, previous substance use disorders, even if it's maybe an opioid use disorder or a different substance use disorder, past or current co-occurring mental illness, anxiety, depression, PTSD, and social factors. So financial stressors, bereavement, and as we've mentioned, unexpected or forced retirement, and maybe a lack of social support, especially if they have used through much of their life and maybe don't have the same support that they had when they were younger. Next. So signs and symptoms of alcohol use disorder in late life. So anxiety, depression, emotional lability, new social isolation. So maybe they used to go out and see friends or spend more time with family and now they're staying home more often. Disorientation, memory loss, difficulties with decision-making. And this is really tricky because I think, you know, if you're in a busy clinic and you're seeing somebody who comes in who's 78 and they have a history of strokes, a history of MI, multiple metabolic risk factors, and a lot of other things going on, it may be easy to attribute some of these symptoms to other sort of diagnoses and they're problemless and miss alcohol use and how that might be contributing and we may not screen for it or address it in the way that we should. So idiopathic seizures, especially if they don't have a history of epilepsy or other seizures, and this occurs later in life. And some physical health signs, poor hygiene, falls, bruises. Of course, we have to rule out any mistreatment or abuse. Poor nutrition, new incontinence, new sleep problems. We know alcohol really affects sleep architecture. And even when in remission, those symptoms can linger for months to years. And, you know, we sometimes refer to it as post-acute withdrawal syndrome. And alcohol and medications, we touched on this a few times, but increased alcohol tolerance is something we often refer to, but really important to note that in older adults, they may not need to drink more to get a particular effect because of their changes in metabolism. Next. And so some screening tools, and there's a couple here that I'm sure sound familiar. CAGE is one that I think we've all been sort of trained in through medical school and through training and things. The audit is sometimes built into our electronic medical record. And these are, of course, several screening tools. But one thing we wanted to note is that out of this list, there are only two that are listed that are specific for older adults. And that's the MASS-G and then the shortened version of it. And we'll go into some more detail in a second. But these are the only two. And as we previously mentioned, the diagnosis of a substance use disorder in late life can differ from just sort of the normal criteria that we see in the DSM. The MASS-G is 22 items, yes or no. And the shortened version is just 10 questions. It might be less sensitive and specific than the MASS-G, but it could be useful when time is limited. And one thing, so there's a couple of questions that I just wanted to highlight that were present on the MASS-G. Again, it's a fairly long questionnaire and it's easily accessible online. But our goal here is identifying alcohol use in a person where role obligations might not be as obvious, where they may be retired, they may be at home, and they're also facing a different stage in their life with different stressors and different risks. But a couple of the questions that stood out to me on this MASS-G was, did you find your drinking increased after someone close to you died? So again, unfortunately at this older age group, this population might be exposed to losing more family members or friends, and that is a significant risk factor for alcohol use. And so that's a really important factor. Similarly, have you ever increased your drinking after experiencing a loss in your life? And another question, when you feel lonely, does having a drink help? So loneliness is a significant risk factor in this patient population, and that's something we want to ask about and address. Briefly, I know this isn't mentioned on this list, but there is one other screening tool called Senior Alcohol Misuse Indicator Tool, sometimes just abbreviated as SAMI. And that really was built to emphasize nonjudgmental and sort of careful questioning. I think if somebody has drank a significant or a certain amount over their life, and maybe it's now starting to cause problems, it can be hard to sort of look at that and say, okay, this is a problem. They may feel like I've done this my whole life. It's never been a problem. Why do I need to do something about it now? And that tool can say things like, you mentioned you have difficulties with sleep. I'm wondering if you think that the wine that you're having might be connected. And so it's phrased in this sort of MI standpoint that might be a little bit easier of a way to approach things in this patient population. So just wanted to mention that. Next slide. And I think I've probably covered a couple of these now, but the Michigan Alcohol Screening Test, the MassG, 24 yes or no questions. And as I mentioned, the couple that I read here, it's trying to incorporate changes in employment and also social circumstances for somebody in late life. And the abbreviated version takes some of those really important questions and still incorporates it as far as 10 or yes or no questions. On the MassG, a score of five or more raises concern for an alcohol use disorder. But again, we need to ask further questions to really see if this meets criteria. Yeah. And one thing worth mentioning, if you're doing the audit or you're doing a different screening that may be built in to your electronic medical record, and that's something that you're already doing, you can add on these questions. I mean, we want to make sure that we're asking these things. And if you want to add on things like how has loneliness affected you, how has your alcohol use gotten worse after you had a significant loss in your life, after you had to retire, after you moved, we want to incorporate those questions in our overall interview regardless. Okay. Next slide. Okay. So kind of switching gears now to some of the pharmacologic treatments, and this is specifically now for alcohol withdrawal. Benzodiazepines, all of them are listed on the VAERS criteria for potentially inappropriate medications for use in older adults, but that doesn't mean that they shouldn't be used in particular circumstances, and especially alcohol withdrawal. This is something that we don't want to miss in an older adult, especially in somebody who maybe has a history of DTUs, alcoholic leucinosis, or other severe symptoms of withdrawal. We still want to treat this and make sure that we're taking care of them. Undertreating things like this can lead people to leave the ER, to leave treatment, and unfortunately, maybe return to use to sort of self-treat their own symptoms at home. But looking at the treatment of alcohol withdrawal, especially in older adults, we want to use shorter-acting agents when we can. We want to use things like Ativan that doesn't linger or build up or have these active metabolites that stay around. Ativan is available in a P-O-I-M-I-V form. It's part of the lot groups. It's not hepatically metabolized. In somebody that has a severe alcohol use disorder and may have cirrhosis, this is, of course, important. It has linear kinetics, and it's well-absorbed. So it's typically the one that we reach for in older adults. There are, of course, some other shorter-acting agents, but because of the various forms and availabilities, this is the one that we go for most often. But of course, there's still longer-acting agents like chlorodiazepoxide, but this is hepatically metabolized. It does have active metabolites. It may take a little bit longer to start treating the withdrawal symptoms. And if we keep giving additional doses because somebody is still having withdrawal symptoms, they could experience stacking or all of the effects sort of occur at once, and they have respiratory depression or other things that are dangerous. And so chlorodiazepoxide or diazepam medications that last a little bit longer, we tend to maybe use a second line and go for shorter-acting agents first. And of course, if the patient presents to you and they're still intoxicated on alcohol, and maybe they're experiencing agitation, this isn't somebody that we'd want to give benzodiazepine for their agitation while they're actively intoxicated, because the respiratory depression from the benzodiazepine and alcohol together can be really dangerous in somebody in older age. Next slide. So now, you know, we touched on withdrawal treatment, but looking at maintenance treatment. So what can we offer somebody to reduce cravings, to reduce heavy drinking days, and to help them gain their goal for recovery. So naltrexone is one of our first-line FDA-approved agents for alcohol use disorder. We dose it at 50 milligrams daily. It, of course, comes in a long-acting injectable version, which can be 380 milligrams every month. And this can be discussed with your patient. You know, of course, we know that sometimes long-acting injectables, there's better adherence, and as a result, you know, better outcomes. But some people just really don't like taking medication every day and prefer to just get an injection once a month. It's a competitive antagonist of the opioid receptor. Some side effects that we hear about, most commonly some dizziness, headaches, GI distress. And, you know, this should be used with caution in decreased liver function. It is hepatically metabolized. We want to check transaminases before starting treatment and after. But this is something that's been shown to decrease relapse, increase days before relapse, and decrease heavy drinking days. So if somebody's still drinking while they're taking the medication, they tend to drink far less. And you may have read about some of the protocols where some people actually take it just before they plan on drinking, and they tend to drink a lot less. So maybe if somebody's just really drinking on Friday nights and they really hate taking medication, they might just take it on Friday and it seems to have some benefits, although we prefer daily dosing. So in older adults, some considerations, there's no change from adult dosing. We still do 50 milligrams. Of course, just like in younger adults, if an individual has been on opioid therapy, you want to avoid for about seven or 14 days after their last use, depending on what they were taking. Avoid with acute liver failure or if there's a concern for hepatotoxicity. But there's some data, some recent data, suggesting that naltrexone is safe to use in compensated cirrhosis. Although this is probably something, this person should be seeing a hepatologist and it would be something you'd want to discuss with them just to make sure that everybody's on the same page and in agreement. Next. A camprosade. So another first-line FDA-approved agent for alcohol use disorder and reducing cravings. The dose is anywhere from 333 to 666 milligrams three times a day. Sometimes in older adults, we might start at the lower end, 333 milligrams, make sure it's well-tolerated and then move up. The mechanism is reduces glutamatergic transmission and increases GABA transmission. So almost working like an artificial alcohol. We know that this sort of change as an adaptation to the amount of alcohol somebody is consuming, it's something that lingers after somebody stops and that can result in irritability, anxiety, trouble sleeping. And this medication can help reduce some of those symptoms so that hopefully they don't return to use. Potential side effects, diarrhea, nausea, and some geriatric considerations. So dosing is the same as adults. You know, I hear oftentimes like, oh, it's a pain to have to take medication three times a day. But there are a variety of other medications that we prescribe fairly often where it seems like people don't have as much you know, they don't feel as worried about taking it three times a day, maybe such as GABA-Pentan. So, you know, we encourage people to give it a shot, to try it, and if it works really well, then it's great. It's not hepatically metabolized, so it can be used in people with severe liver disease. But we wanna be cautious if in chronic kidney disease, if somebody has a creatinine clearance of 30 to 50 milliliters a minute, you know, we'll use with caution and kind of collaborate with their nephrologist. But it's contraindicated if their creatinine clearance is less than 30. So we might reach for something like naltrexone. And then lastly, as far as the medications for FDA-approved medications for alcohol use disorders, disulfiram. So the dose here is 250 to 500 milligrams a day. This is an aldehyde dehydrogenase inhibitor. So if somebody drinks while they're taking this medication, they have a disulfiram reaction. This looks like tachycardia, diaphoresis, nausea, vomiting, if drinking. There's some potential side effects, like dermatitis, drowsiness, metallic fates. And then there's a thought that disulfiram can inhibit beta-hydroxylase, and that results in an increase in dopamine. So if there's a history of psychosis especially, this could worsen that. It doesn't seem to be as common of a side effect, but something to watch out for. And per the package insert, you should not start for at least 12 hours after the last drink. Although in our older folks, we might want to start waiting until maybe 24 hours after the last drink. So start at a lower dose, use with caution. If somebody has a history of cardiac disease, severe liver disease, or cognitive impairment, this might not be our first choice. It could be dangerous, especially with cardiac disease. And so this is kind of on a case-by-case basis. If somebody's taken this and they felt like it worked really well and they knew that they wouldn't drink if they took this, it might be a good choice. But otherwise, it's probably something in this patient population that we reach for after naltrexone and akimbose. Next. Okay, so that was, I know alcohol was a fairly big topic. We're gonna move on to a couple more substances. And substance misuse, just in general, older adults are vulnerable to misusing prescription medications. They may take something for reasons other than they were prescribed, or they may take more of it if they feel like they're still having anxiety or still having pain. Misuse is common with medications prescribed to address sleep difficulties, pain, and anxiety. Prevalence of substance misuse, including benzodiazepines and cannabis, is unknown. And again, we don't have as much data from screening and research as we'd like. With a higher prevalence of chronic pain in older adults, opioid misuse is a concern. You know, we don't doubt that people are still experiencing pain and they want relief, and so they may take more than prescribed in order to get relief. A 2019 study showed that the most misused medication were pain relievers. And currently, there's no validated screening to assess for over-the-counter medication misuse. But again, these are questions that we should be asking. Next. Okay, so moving on to nicotine and tobacco. You know, we know that tobacco is a major cause of death, a major cause of health-related problems, including lung cancer, diabetes, osteoporosis, heart attacks, and worsening of mental health conditions. You know, working in the addiction setting, it seems like it's oftentimes the substance that's sort of the last to be given up. You know, maybe somebody is in sustained remission of their opiate use disorder or their alcohol use disorder, but they're still smoking, and they kind of feel like that's the one that they're holding onto a little bit. But, you know, it's the second most common substance used in adults above the age of 65, about 14.1% or 30% in those between the ages of 50 and 64. There are approximately about 300,000 deaths related to smoking a year in those above the age of 65. Yeah, so as I was mentioning, you know, I think it's a substance that has sort of this insidious course, right? And it's unfortunate that I, you know, at times we might not become more aggressive about treatment until somebody's had a stroke or somebody's had a heart attack. But this is something that we have effective treatment for. We can intervene and reduce tobacco use or stop tobacco use, and that can have really immediate beneficial sort of effects for somebody. This last bullet point is really important. Tobacco use is associated with an increased risk of suicide up to 2.5 times. And so, you know, screening should be a component of the suicide risk assessment as well, knowing this statistic. Next. Okay, so looking now, of course, at some of the pharmacologic treatments, and this is not to ignore everything else that goes into it, that there's so many resources online. There's Quitline. People can put in their phone number and they can receive text messages that sort of motivate them to continue reducing their use or stopping. There's so much to do within motivational interviewing and therapy, especially unpairing tobacco with certain parts of their lives. If somebody wakes up and has a cigarette with coffee, you know, that association is really strong and we need to weaken it. And so, separating tobacco use with other activities is incredibly important. But looking at some of the pharmacologic treatments, the gum and the patch, of course, are some of the ones that we refer to the most, right? It's one, I think, that we hear about most often, but there are other options. The gum comes in a two and a four milligram dosage per the package insert. You should start at four milligrams if the first cigarette is within 30 minutes upon waking. And the potential side effects with the gum, buccal mucus irritation, nicotine-related GI distress, headaches, and palpitations. And one thing I want to mention is we want to make sure that our patients are using this correctly. If it's their first time using it, we need to let them know that they should chew the gum until they feel the tingling or they feel the nicotine sensation. And then they would park the gum between their gums and their cheek to let the nicotine be absorbed. And once that goes away, then they can chew again and sort of repeat the process. But some considerations in older age, we want to avoid the gum in poor dentition, TMJ disorders, if they have dental appliances. I've sometimes heard some patients say that it pulled the filling from their teeth and so they really didn't like it. And so in this case, we'll want to reach for one of the other short-acting agents. But the gum, the lozenge, the nasal spray, these are all good for breakthrough cravings. And this should be for sort of optimal effect. If we can come up with this plan with our patient, it should be used in combination with the patch. I've sometimes heard this referred to as almost like a basal bolus thing with insulin. But the patch can be used all day. They put their patch on their arm and they have this on throughout the day. And if they have breakthrough cravings, then they can reach for something shorter acting like the gum, the nasal spray, or the lozenge. But the patch comes in seven milligram, 14 milligram, and 21 milligram doses. And based on the amount of cigarettes they're having a day, we'll determine how high of a dose you would use. So greater than 10 cigarettes, a 21 milligram patch, less than 10, 14 milligram patch. Potential side effects, skin irritation, vivid dreams or nightmares. And if that occurs, they can remove the patch at bedtime. But otherwise, no specific changes for older adults as far as the patch goes. But again, most effective if we're using the patch with the short-acting agent like the gum and lozenge. And one other thing I just want to mention before I move on to the other short-acting agents is that when you look at sort of the instructions and the package inserts for all of these, it generally says that the treatment course is 12 weeks. And so at the end of 12 weeks, you might start to taper the dose and reduce and stop. But if you're reducing the dose or you're stopping it and they start to have a significant urge to smoke tobacco or to chew tobacco, then this is something to discuss with your patient. I mean, this might be somebody who would benefit from longer treatment if the alternative is them returning to tobacco use. Next. Again, so some of the additional short-acting agents, the lozenge, also in two milligrams and four milligrams. The good thing about it is that if somebody has dentures or dental appliances, a poor dentition, they don't have to chew it. They can just park it between their gum and their cheek and they can move it around every once in a while to sort of reduce any irritation, but they can get the absorption of the nicotine that way without having to chew. But it still has a risk of irritating the buccal mucosa, GI distress, headaches, and palpitations. And as I mentioned, this might be a better choice than somebody with poor dentition. The inhaler and the nasal spray may be less commonly used, but are available. The inhaler comes in a 10 milligram cartridge and again, 12 weeks of treatment. There's no studies beyond 12 weeks. Some potential side effects are sore throat, oral irritation, and headaches. And some consideration in older adults is you want to avoid it in those with bronchospastic disease for which this could worsen. And the nasal spray also comes in a 10 milligram. You do take about one to two doses an hour with no more than five doses or 10 sprays in an hour, and also not studied beyond 12 weeks of treatment. Potential side effects, nasal discomfort, rhinitis, dyspepsia. And you want to avoid it in those with chronic nasal disorders like sinusitis. You know, the spray, I think sometimes people can be concerned about using the spray in public. They, you know, might feel embarrassed or things. And that's just a conversation to have to see who would feel most comfortable with doing it, or if they're homeless at the time and they feel like this works better for them. Yeah. So the spray itself seemed to have the highest sort of peak in nicotine concentration, the quickest. It doesn't necessarily compare to a cigarette itself, but worth noting in case, you know, we reach for that one. Next. Oh, we can go to the next slide. Oh, sweet. Okay. And then, so we hear often about Chantix, right? And bupropion, looking at both and really all medications. I mean, there was a large trial looking at all medications that we have for the treatment of tobacco use disorder. And they were all better than placebo, right? But you have to find what works best for the patient. And if they've tried nicotine replacement therapy and that didn't seem to work the best for them, then we might work or reach for one of these other agents. Varenicline is a medication that's been around for a long time. It is an alpha-4 beta-2 nicotinic acetylcholine receptor partial agonist. I know it's kind of a mouthful, but it treats withdrawal symptoms of nicotine withdrawal. And dosing on days one through three, do 0.5 milligrams a day. Day four through seven, 0.5 twice a day. And day eight on, do one milligram twice a day. Potential side effects, nightmares, GI upset, behavioral disturbances. Of course, we want to monitor for mood, new onset, suicidal ideation. These are questions that we want to discuss with the patient and make sure that they're aware of. There's no dose adjustment needed for older adults unless there's a history of renal impairment. And that's outlined here. So creatinine clearance less than 30, you'd want to initiate with 0.5 milligrams daily, but maintenance would stay at 0.5 milligrams twice a day. So you wouldn't move on to the one milligram DID. And if there's a history of end-stage renal disease, then the maximum dose we would set would just be 0.5 milligrams daily. Bupropion, we use it oftentimes for mood, right? But it is approved for tobacco cessation. The mechanism is weak inhibition of dopamine reuptake. And the dose here, day one through day, would be 150 milligrams daily. And this is a sustained release formulation. And then on day four, we would go up to 150 milligrams twice a day. And we'd want them to pick a quit date that would be seven to 14 days after they start medication. So this medication can assist with them having that quit date and then staying in remission afterwards. Potential side effects, increased anxiety, sometimes irritability, although this is typically seen with higher doses, and it's been shown to be effective in older adults. Before moving on from this, I just want to mention, there's been some question about whether we should use some of these agents in combination with nicotine replacement therapy, varenicline especially. And there's some studies that show that there's an increased risk of some adverse effects, although mild, drowsiness, upset stomach, headaches, but this should be a discussion that you have with the patient. If you felt like nicotine replacement therapy was very helpful and they don't want to stop it, we might be able to do the two together, but this is on a case-by-case basis. Next. Moving on to opioids now. We can go on to the next slide. So we've heard a lot about the opioid crisis, right? We know that in 2021, there was over 100,000 overdose deaths, which were in large part due to synthetic opioids. And the factors, or I'm sorry, this presence and knowing this, of course, is relevant for our older adults, especially many of which have been on opioid therapy for chronic pain. Chronic pain is one of the most common contributors for misuse and potential opioid use disorder in late life. 49% of older adults are prescribed opioids for pain. Multimodal treatment options aren't always available. So we'd love to have this opportunity where our patient is engaged in physical therapy, aqua therapy, acupuncture. They maybe see a chiropractor. They're also maybe on an SNRI, if it's safe for them. They're in CBT for chronic pain. You know, we'd love if they could do all those things and treat this in this multidisciplinary way, but that's not always available. So we need to work with what we have. Risk of serious side effects increases with age, particularly when opioids are combined with alcohol or benzodiazepines. So combining opioids with any other downer, of course, can be dangerous and we need to provide education to our patients and to other members of the healthcare team about this. And looking, you know, between 2013 and 2015, there was significant increase in the diagnosis of OUD in older adults. And older adults may be less inclined to accept OUD as a diagnosis when there's co-occurring chronic pain. So if they've been in chronic pain for many years and, you know, they've been prescribed opioids for this pain and it has developed now to what we're concerned about being an opiate use disorder, because they still have severe pain, they feel like it's justified, you know, the amount that they're taking or the measures that they're taking to get substances. And so, you know, it might be a little bit more of a cautious discussion and it may take time to sort of build that rapport and understanding of why we're careful about this. Okay, next. So common characteristics of an older adult with opiate use disorder. Multiple medical comorbidities. As we mentioned, chronic pain, mood and anxiety disorders and trauma-related disorders, MBD, GAD, PTSD. History of misuse in the past. So history of opiate misuse or other substance misuse. Multiple prescribing clinicians. So of course we have to check the prescription monitoring program. We find that maybe they're receiving multiple substances or multiple prescriptions from different areas. Having family members who rationalize or deny the individual's use. And again, you know, it's really hard for a family member to see their loved one in severe pain and not being able to do the things that they wanna do or maybe being stuck at home. And it can be hard to accept that an opiate use disorder may have developed. Emergency room visits for sedation, especially if it's being combined with other substances. And from some of the limited data that we have, we may see that women can be more affected or more diagnosed often than men. Next slide. So screening. Unfortunately, there's no screening specific for opiate use disorder in older adults. There's several that are listed here like screening and opioid assessment for patients with pain, current opioid misuse measure, drug assessment screening tool. There are various that we can use, but none of these are necessarily specific for older adults. So we have to ask the questions that we've been referring to, you know, recognizing maybe major physical impairments that have led to them no longer being able to be social or golf or do some of the things that they enjoy doing and how is that impacting their substance use. And this last bullet point here, the Beers Criteria Medication List is an important tool. Obviously, we wanna safely prescribe to patients in older age. And next slide. I'm gonna elaborate a little bit further on that. So the American Geriatric Society has the Beers Criteria that we know about, but this is updated in 2019 with the recommendation to avoid opioids for chronic pain. So we know that opioids are effective for acute severe pain, especially after, you know, a fracture or an accident, but this is what they should be reserved for. We know that chronic pain is not effectively treated with full agonist opioid treatment and attempts to have higher mortality, like more side effects, more risks and benefits. And this is really difficult for somebody who's been on this medication, maybe let's say OxyContin for 20 years to hear. I mean, they've been on it, they're still in severe pain with it and they feel like pain is gonna be so much worse if they come off of it. And so it's a difficult topic. Some of you may have seen recently, the DOD released these guidelines about, if somebody is on a full agonist for opioids, buprenorphine, a partial agonist is a much safer option. And a review of opioid related deaths from 2001 to 2016 found that older adults constituted the largest relative increase during this period. So between the ages of 55 and 64, there was a 754% increase. And again, we're looking at a review of opioid related deaths. In age 65, there was a 635% increase. So this is really significant. And although maybe earlier in life, the full agonist opioid that somebody was on was not causing problems, but now they're having falls, now they're having respiratory depression, and now they're having cognitive impairment. It's our job to act and have them on something safer. Next. So looking at some of the pharmacologic treatments for opioid use disorder. So there's three, and methadone of course has been around the longest, approved in 1972. Dose is gonna vary. The absolute most that you can give in a day is 40 milligrams, but this is a 30 milligram dose. And if this is somebody who's monitored for hours and is exhibiting withdrawal symptoms, then you can give an additional 10 milligram dose and you have to document that this was because they were still experiencing withdrawal. And older adults were likely to start at lower doses, 10 or 20 milligrams. But I wanna stress that we shouldn't undertreat, especially if somebody has a long history of an opioid use disorder, undertreating and then still experiencing symptoms of withdrawal because they haven't been on enough of the dose can lead to them not returning to treatment. And we wanna minimize any risk for overdose or return to use. But this is a full agonist at the new opioid receptor, potential side effects include constipation, restlessness, nausea, vomiting, shallow breathing, sexual dysfunction, hallucinations, erectile dysfunction, all things to monitor for. Geriatric considerations. Older adults may do better in treatment than younger individuals, especially as we mentioned, if it's a late onset diagnosis. There's an increased risk of sedation with polypharmacy and orthostatic hypertension. So we wanna make sure these medications aren't interacting with some of the others on their list. There's an increased risk for falls and of course we have to monitor EKG and look at the QTC. If there's QTC prolongation, we wanna be more conscious, use a lower dose and monitor the EKG more regularly. And we wanna make sure they're on a bowel regimen that's working well for them. Naloxone has been shown to be safe and effective. And of course we should prescribe naloxone to any person with a history of opioid use disorder despite age, because this is a life-saving medication. Next. Buprenorphine, often used in combination with naloxone. The dose depends on the formulation, but for opiate use disorder reason, often the film or the tablet, before milligrams, eight milligrams, 12 milligrams. The mechanism here is a partial agonist of the medial opioid receptor. So that's where it differentiates a bit from a full agonist methadone. Potential side effects, constipation, headaches, trouble concentrating. In general, this is thought to be safer than methadone in older adults. Although methadone may be required depending on the amount of substance use, especially if somebody has been primarily maybe using larger amounts of fentanyl. Half-life is not altered with impaired renal or hepatic function. It can be as effective as methadone for a moderate use disorder, especially at doses between 16 and 24 milligrams. And this is a medication that's also approved for chronic pain. I don't want those last two bullet points to be misleading, but the other formulations for chronic pain can be really effective, especially when somebody's been on a full agonist, like OxyContin for 20 years, and maybe they have analgesic tolerance now. So if somebody has an opiate use disorder and chronic pain, this can still be a really effective and safe medication. And one study of low-dose buprenorphine in older adults with depression found that the medication can be safe and well-tolerated. Next slide. So Vivitrol, now Trexone, the long-acting injectable version of it is the one that's approved for opiate use disorder. So not the oral version, but the long-acting injectable version of the 380 milligram injection once every 28 days works best in the highly motivated individual, maybe in somebody who has recently detoxed from methadone maintenance, or buprenorphine maintenance are not eligible for methadone maintenance, maybe if they have a prolonged QTC, maybe if they're scared about having a controlled substance on their PMP. And also if somebody has been in recovery for a year and they don't wanna start a new physiologic dependence on something like methadone or buprenorphine, now Trexone might be a good option for them. Next slide. Dr. Sanchez, I'm sorry to interrupt, but I'd ask you to wind up in the next three or four minutes so we do have some time for questions, which we promised everyone. Yes, sir, sounds good. So just a brief mention on a few other substances, alcohol, cannabis, I'm sorry, alcohol, opiates, and tobacco were the ones that we spent the most time on, but cannabis is something that we should review with our patients. We know that there's a significant amount of individuals that use, especially now with legalization, we may gain a better understanding of how much people are using. And this also applies for cocaine, inhalants, methamphetamine, things that we might believe are less common. We now know that there are many first-time hospitalizations related to methamphetamine and other substances, so we should still be screening and offering treatment for this. Next. And just a brief mention of sedative hypnotics in older life, we know that benzodiazepines increase the risk for falls, cognitive impairment, and this may be regardless of how long it was used, motor vehicle accidents, and there's, of course, interactions with other respiratory depressants like alcohol and opiates. Next. And in cannabis use, as we mentioned, we know that use is increasing, legalization changes things, so hopefully we'll have more data in the future. But we still have to monitor for cognitive impairment, psychomotor slowing, side effects like psychosis, increased anxiety, or even things as serious as MI. And we know that THC concentration is increasing maybe up to 30% in some individuals, so we should be very careful with that. Okay, next. And there's no specific screening tool in older age for cannabis use, but I just wanted to mention this as a tool that we can use for everyone. So, next. Okay, Dr. Ali, I know I didn't leave you a whole lot of time there. I apologize for that. Dr. Saxon, is it okay if I just spend two minutes? Yes, two or three minutes would be fine. I think we're good. Yes, two or three minutes would be fine. Okay, thank you. So, I won't go into detail, but we would be remiss if we did not underscore that psychosocial interventions are important. Next slide, please, Ben. And there is a role for them in older adults. And like many things, we just want to remember that older adults benefit from treatments that are tailored to their needs, whether it be their physical needs, their mental health conditions. And next slide. They're starting off with kind of the same approach as you would with many younger adults using SBIRT. And this has been adopted and been shown to be helpful. Next slide. In this particular version, which is known as BRITE and tried out in Florida, we have this here just to remind people that we can use psychosocial treatments with older adults. We should use psychosocial treatments with older adults, and they have, at least some of them, have been tested and proven to be helpful with older adults. Next slide. When we're thinking about appropriate environments, think about having things in daytime hours, assisted transportation. And some of these things people may not ask about, so if you don't have them available and you go, well, we just don't get many older adults at our program, so we haven't seen the need to create these services or offer these services, it's one of those chicken egg. Well, when people visit their website or perhaps are calling and they learn that these are not available, they may not even seek care. And remember age-specific topics like grief and loss, isolation, life stage and role transitions. Next slide. And as we're thinking about a suitable environment, stronger therapeutic alliance leads to greater retention and engagement. So think about hiring and having people who will be able to work with older adults, think about their values and preferences. In older adult kind of vernacular, it would be thinking about what matters most, which is one of the four Ms of older adult care. Next slide. One thing that's really important is, especially if you have younger adult treatment centers as well, hiring and training staff members who have skills in and are committed to serving older adults. Older adult care does require different sort of approach, interest and interaction. And so the ways of engaging and talking with someone who's in their teens, 20s, 30s, 40s, may be very different from what you may want for an older adult. Next slide. And we just wanna remember that older adults come in a variety of kind of dimensions. We have thought of them as a single entity. We reduce them in many ways to generations, but there's intersectionality, including the concern about ageism, different ethnicities, races, LGBTQIA, identification. So when we're thinking about care for older adults, again, while we did give a lot of information about different kinds of considerations, we also wanna be thinking about their unique cultural needs as well. Next slide. And of course, we won't go into all of these, but just think about healthcare system factors, what we may be as a system bringing into disparities and how to address these so that equitable care is provided to older adults as well, especially stigma and ageism. So one more minute to finish up. Yeah, last slide. Reminders, just be supportive and non-confrontational during your evaluation, assessment, and treatment. Provide flexibility, making telehealth or in-home services available. Be culturally responsive to the needs of people with intersecting kind of identities, and then adapt to accommodate change in individuals' physical and cognitive functioning. I know on more than one occasion, an older adult has not been able to attend or be at certain facilities because of physical limitations, because the whole area is not set up for someone to fully participate in their treatment program. All right, next slide, thanks. Thank you so much. Thank you, Drs. Ashgar, Ali, and Sanchez for a very informative presentation. We'll now try and address some of the questions, and I apologize in advance. There have been some really excellent, both questions and comments put in, and we obviously won't have time to get to them all, but we'll try and cover some of them. So the first question I wanna ask you relates to what you were kind of finishing up with. This is a question from Allison Jones, and Allison asks, what motivational interviewing strategies have been found to be most effective in older adults who have cognitive deficits that limit their processing? So, you know, there's definitely, there's a lot of good literature on how to do psychotherapy with older adults. Mild cognitive impairment plus mild dementia allows for cognitive, or sorry, psychotherapies to be helpful and engaged. And now each individual is gonna be different, and I don't wanna go off on a tangent, but depending on what the impairment is, you know, if the impairment is primarily visuospatial, then of course, maybe not. If it's memory, then perhaps having more reinforcing information built into the therapy is really helpful. If it's language, then maybe having, again, this is where the staff is gonna be helpful, using short, simple directions, using behavioral interventions so that they're not language-based. And then all of this, one thing that was on our slides, but I didn't mention, was including caregivers, family members. Again, that's not always very typical in many forms of treatment, but with older adults, especially if there is a need for, and they identify and are consenting for participation from other people, including them is gonna be very helpful. Thank you. We're gonna go back to a more biomedical question. So this is from Bhavna Bali. If liver function tests are above four to five times the upper limit of normal, oftentimes naltrexone is not recommended. Do you recommend considering lower liver function test number cutoffs in older adults? That's a great question. I don't think we have specific literature to answer it confidently. I, you know, my hope is that in somebody who has liver disease, that they're engaged with primary care and maybe with hepatology, and we can sort of discuss it in like this collaborative effort where if they felt like that was a medication that was really helpful for them to definitely reduce alcohol use, the benefits of the medication likely outweigh the risks in terms of, you know, if they weren't on the medication and they were drinking more and this was more severe on the liver, then it might be the right medication for them, even if transaminases are slightly elevated. But of course, if they have hepatotoxicity or acute liver disease or damage, then it's something we'd wanna avoid. So I can't necessarily comment on the exact maybe numbers that we have, but it would have to be sort of on a case-by-case basis and hopefully a kind of collaborative approach with the patient's other clinicians. Thank you. I'm sorry, I'm gonna just add and much closer monitoring. So not relying on six monthly labs or maybe even weekly as the medication is initiated. Yeah. Yeah. And especially as transaminases may be transiently sort of elevated. And so we get a better picture of maybe it did elevate and now it's back down. Those are helpful comments. Sticking with the alcohol, can we compare and contrast inpatient versus outpatient care versus naltrexone versus acamprosate? Are there any recommended protocols? Great question. I'm not aware of any specific protocols in over time. I do know, it seems that most inpatient facilities when somebody is admitted for alcohol intoxication or withdraw that they are often started on bivigabapentin. And as they are no longer intoxicated maybe they're offered things like naltrexone or acamprosate. Never been some studies to suggest that maybe the combination of naltrexone and gabapentin together might be more beneficial than either alone. And so this is something that could be started on the inpatient basis, but then continued outpatient. But again, we have to be careful in individualized treatment because gabapentin I believe is also something that was added to the Pierce criteria. And there is some concern about, somebody has an opioid use disorder as well that maybe taking gabapentin may not be safe. And so it really depends on the individual. But in general, I think that there's a big push to start treatment for alcohol use disorder on the inpatient unit. I think a lot of facilities now are having addiction consult teams where they're starting naltrexone or acamprosate or doing even in the case of OUD, buprenorphine inductions in the hospital because this increases the chance that they will make their outpatient appointments and sort of remain in treatment. So yeah, I'm not aware of any specific protocols, but from what I understand, a lot of these consult services that are being built, they're really starting the same treatments that we often start on the outpatient basis, inpatient in hopes that it will sort of bridge that gap and help somebody stay in treatment if we can initiate them on treatment faster. Thank you. Someone asked also, how do you make a decision whether to use oral naltrexone versus long-acting injection naltrexone for alcohol use disorder? Great question. If a patient has significant difficulties getting to the clinic, like driving to the clinic, oftentimes, or maybe we're seeing them through video every two weeks because it's hard to drive here, but they can come once a month, the injection may be a better option for them. Oftentimes, I speak to them and I talk to them about both options. And if they really prefer having the injection and they feel like they're more likely to stay on the medication that way, then that's great. I think sometimes, I have heard people say that the injection was painful and that they did have like an injection site reaction afterwards. And it's on the gluteal region and if they have trouble sitting afterwards and they really didn't like it, then whatever is gonna make them more comfortable and more likely to stay on the medication is what I'll reach for. While Vivitrol tends to be, you know, it seems to be easier if it is making some people uncomfortable, then the oral option is just as fine. I didn't necessarily have the time to talk about this, but sometimes there's been some notes about people using oral medication the last week, they feel like the shot kind of wears off in the third week and then they're using oral medication after. So there's a lot of ways that we can approach it based on the patient. Okay, so finally, just related to that same topic, there was one comment that you may or may not wanna react to, if only Medicare would pay for long-acting naltrexone injection. Yeah, yeah, yeah, I know. It's, you know, and I didn't get to comment on sublocate either, but that's another long-acting injectable version of, you know, buprenorphine that can be effective. And one thing, if I may, I just wanted to mention, I briefly scanned the questions and one thing I just wanted to make sure I emphasize because I did go through it fairly quickly, but when I was talking about methadone and I was saying, you know, 40 milligrams is the max, but in older adults, we may start lower, but of course we don't wanna undertreat. That is referring specifically to outpatient on the first day of treatment. So older adults may certainly get up to 120 milligrams or higher. And again, it depends on the person, if they're reusing synthetic opioids like fentanyl and a variety of other factors. But on day one, we wanna make sure we address it appropriately to keep them engaged in care and not having them return to use. Okay, I'm sorry we have to cut it off here, but I've got a few more comments before we close. Next slide. Thank you all for participating in today's session. Please visit www.pcssnow.org and see the variety of helpful resources that are offered, including the free PCSS Mentor Program, which offers general information to clinicians about evidence-based clinical practice and prescribing medications for opioid use disorder. Next. PCS mentors have expertise in medication for substance use treatment and clinical education. You can also find the PCSS discussion forum, a simple and direct way to receive an answer related to medication for substance use treatment. Next. Today's activity was presented on behalf of the SAMHSA-funded Providers Clinical Support System, a program operated collaboratively by 19 medical specialty organizations, including the American Psychiatric Association. Next. Again, thank you for joining us today. We hope to see you soon at our next presentation. Thanks to our presenters. Goodbye, everyone.

substance use disorders

older adults

screening

diagnosis

alcohol use disorders

risk factors

protective factors

moderate alcohol use

CAGE questionnaire

pharmacologic treatments

psychosocial interventions

medications