<v ->Hi, my name is Louis Trevisan.</v> I'm an Associate Professor, Adjunct at Yale University School of Medicine, Department of Psychiatry. And I'm here to talk about substance use disorders in older adults. Disclosures, I have no disclosures to reveal. I have no relevant financial relationships with ineligible companies to disclose. 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 the conclusion of this activity, participants should be able to, one, review the prevalence of substance use disorders in older people two, describe the signs and symptoms of substance use and misuse in older people, three, recognize the psychopharmacology of substance use disorders in older people, and four, assess the relevance and importance of psychotherapeutic intervention in old people. In this presentation, we will examine the case of a 75 year old Caucasian female who has been married to the same man for 50 years and has been recently complaining of feeling more anxious. She has asked her husband to help her with this. She has a history of anxiety not otherwise specified, and is prescribed clonazepam by her primary care physician. Her husband is retired and has a complex medical history, including chronic pain from peripheral neuropathy treated with extended-release oxycodone, 40 milligrams by mouth every 12 hours. She presents to the emergency room after she became confused, was unable to eat her dinner, and fell into a light sleep at the dinner table while out to dinner with her husband. We'll examine other aspects of this case later in the presentation. Basically, the nomenclature surrounding treating older people with substance use disorders is not uniform. Basically, we're looking at working with a group of people who are baby boomers, which means they were born between 1946 and 1964 and are between 58 and 76 years of age. This group will present with more substance use disorders and substance use treatment going forward. The use of greater than 65 years old definition to describe elderly adults may be somewhat arbitrary, perhaps a term like older adults may be more appropriate and has been used more often in the current literature. The information in this presentation is based on persons older than 50 to 55 years of age, and the terminology will vary. Everything that all aged adults use, they abuse tobacco, alcohol, opioids, including misuse of prescription medications and use of illicit drugs, to include heroin, fentanyl, and other synthetic opioids like carfentanyl, and at times xylazine as well, stimulants and cocaine, marijuana or cannabis and other sedatives and muscle relaxants. This is a slide taken from Ireland, believe it or not, between 2003 and 2019, separated in five years to show the consistency and slight downward trend as we go forward in terms of the prevalence of combustible cigarette smoking, these numbers are very close to the same types of numbers that you see in the United States. Older adults have had consistently lower rates of alcohol use, high-risk drinking, and alcohol use disorder over the past 40 years. Between 2001 and 2013, we've seen an increase in alcohol use by 22 1/2%, high-risk drinking by over 65%, alcohol use disorder by over 100%. These were all substantial and unprecedented relative to earlier surveys. Reports of increases since the onset of COVID-19 pandemic are also evident. This is a slide picture from the National Poll on Healthy Aging from the University of Michigan National Poll Unhealthy Aging, it's a snapshot of alcohol use in the past year among adults between the ages of 50 and 80 years, 67% of these folks drank alcohol. Among those who did drink, 10% reported drinking while using other drugs, 20% four times a week, 23% had more than three drinks on a typical drinking day, and 27% had six drinks on at least one occasion. So this is a large amount of alcohol misuse in this age group. It's been projected that, you know, the older American population will increase between 2010 and 2030 from 40 million to 80 million, and this could produce a substantial increase in the absolute number of older adults with high-risk drinking and of course alcohol use disorder. It may be exacerbated again by the onset COVID-19 pandemic lockdowns due to increased loneliness, lack of access to in-person medical care, screening, and SUD treatment. This is a slide that shows the projected increase in prescription psychotherapeutics between 2000, essentially in 2020, which we've already seen, and it shows that yes they are increasing. It was projected and we have increased the amount of prescription psychotherapeutics that older adults do use. This is a slide that shows the past year prescription psychotherapeutic users among people aged 12 and older in 2015, it's from SAMHSA, NSDUH data, National Survey of Drug Use and Households. It shows that the predominant psychotherapeutic medication that was used and people who used or had prescription psychotherapeutics were pain relievers and then tranquilizers and including stimulants and sedatives, notwithstanding. So almost 44 1/2% of all the people over age 12 were using some form of prescription psychotherapeutic medication. This is a look at the Centers for Disease Control and Prevention statistics on the number of overdose deaths and what they're attributable to. You can see from the blue line that synthetic opioids have other than methadone, primarily fentanyl and carfentanyl now have increased dramatically. The total number of deaths in 2021, I believe, overdose deaths was over 107,000. So in this case you can see that heroin and prescription opioids are actually contributing to a level amount of overdose deaths, whereas the psychostimulants, which also have carfentanyl in them and synthetic opioids with fentanyl are contributing to a large amount to the opioid overdose deaths. This is a slide again from the Centers for Disease Control and Prevention from 2017, which shows the groups of people from 55 to over 65 who were counted as overdose deaths in those years, and you can see that the group 55 to 64 in the green has gone up considerably quickly, almost as quickly as younger adults and middle-aged adults between 45 and 54, the over 65 group is also increasing, so this is something to really keep an eye on. I stumbled upon this slide while, you know, looking for other things and it shows the, you know, increase of opioid consumption in the G-7 countries, which are most of western Europe and Japan and the United States, and clearly, the United States in the red is an outlier though it looks like western Europe also is falling along the same types of lines as we have, and Canada looks like they had a spike and then they cut back, but clearly, this is a remarkable statistic. In some respects, you can see that there's a lot of opioid consumption in Western world. The older patient with prescription opioid use disorder, the things that most define these folks are multiple medical problems, a higher incidence of chronic pain, commonly they have mood disorders, whether it's from use of opioids, prescription opioids or from chronic pain or pre-existing, major depression is, hasn't been sorted out. Misunderstanding directions, again, misuse versus a use disorder. Misuse is a big problem in the older population. There are multiple prescribers, although you'll also hear from me like that most people get their medications from one prescriber and then give them to somebody else, so this is a controversial aspect. Rationalization and denial among family members and peers or caregivers is a barrier and that's also seen. Deficits presumed to be due to age are often mistaken for substance use disorders and and vice versa, and interaction with alcohol or benzodiazepines. The main thing that sticks out in some respects is that there is an overrepresentation of females in this group of older patients with prescription opioid use disorder. Clinical pearls, recognition of misuse of prescribed medications. Any symptom in an older adult should be considered a medication side effect until proven otherwise, falls, GI distress, incontinence, constipation, depression, anxiety, confusion, insomnia, all of these can be attributable to potential medications that older adults are taking in a prescribed fashion or illicitly or misused. So it's important when you see an older person that if they have these issues in an older adult that you consider substance use or misuse as a potential cause of those. Let's talk about medication misuse. This is basically taking extra doses of medication, taking four or five of your 0.25 Xanax instead of three per day as a doctor prescribes or missing doses, not filling prescriptions, not understanding directions or incorrect timing, taking the medication at the wrong time of day, these are all risk factors, they include being female, social isolation, polypharmacy or and multiple prescribers, prescribe drugs with abuse potential, chronic medical problems, and a history of substance use or psychiatric disorder. Past year illicit drug use among older adults. If you look closely at this slide, you can see that the amount, it looks pretty flat, but in general, there is an uptick in everybody over the age of 26. If you look at the table, table 10 below, you can see that it's a constantly increasing number of people using illicit drugs. So this is not a problem only of younger people or of people of middle age, but older people as well. This is a slide that may show it more clearly, it's the latest slide we can find, I can find of the NSDUH data from the survey year, it goes back to 2013. I haven't seen a newer slide from NSDUH on this, but you can see clearly that the rates of substance use illicits drug use has gone up, especially in the 50 to 54 year old range, and, you know, somewhat in the other two age ranges, 55 to 59 and 60 to 64. In the older adult population, the prevalence of past-year cannabis uses ranged from 4 to 5% based on NESARC and National Survey of Drug Use and Health surveys. The greatest increase in cannabis use was observed in the older adult population between 2006 and 2013. The past-year prevalence of marijuana use came among those 50 and older was significantly increased by 71%. Past-year cannabis use among those 50 to 64 year olds increased 10% annually, and among the 65 year olds and older increased by 15% annually. Of course, this was adjusted for sociodemographic factors, substance use, and risk factors. The prevalence is higher among cannabis users aged 50 to 64, but the largest increase in the use has been found among those 65 and older, and this may account for some of the illicit, increased illicit drug use that you saw on the previous slide, although that's at times questionable now because there are 19 or 20 states that have legalized cannabis and it may not be being counted as an illicit drug. Let's talk about alcohol. When people talk about alcohol, they talk about two different groups of people, early onset alcohol use disorder in older adults and then an older, you know, late-onset alcohol use disorder. The early onset alcohol use disorder problem defined as problem drinking onset before age 60. Most often these folks have started drinking in their early twenties, sometimes teenage, and they comprise 2/3 of the older people with alcohol use disorders. Other characteristics of a group include chronic alcohol-related medical problems, positive family history, serious psychiatric comorbidities, particularly major affective disorders and may require medically focused intensive treatment. And compared to those with later onset alcohol use disorder, older adults with early-onset AUD have been reported to have more social relationship problems, more antisocial characteristics, a chronic and complicated course, and more legal problems. If drinking began after 60, we would classify these folks as later onset. They may have fewer psychological consequences of disease, often begin alcohol misuse after a stress-related event, there's a loss of a spouse or a job or a home, retirement can cause it, they might be more emotionally stable, their better adherence to treatment, lower recidivism rate, more social support, and greater life satisfaction. The interesting thing that was found in earlier on in 2003 and 2004 by Drs. Oslin and Lemke and Satre was that, regardless of the onset age of alcohol use disorder and high-risk drinking, as people got older, they became more responsive to treatment that they were offered. Psychosocial stressors of aging. These are important factors to keep in mind when you're thinking about treating somebody who's an older adult or elderly and they are that there's a role or status change, especially retirement, this is a big step in people's lives, which I'm sure some people can relate to, others may not yet. It's a major change in your life that means that sometimes can cause adjustment problems. Income changes due to retirement, physical health decline just due to age or, you know, physical infirmities, cognitive changes, and these usually come along or can come along with, being elderly or being older adult, not always, but it's important to pay attention to these problems or possibilities. Widowhood is a big one, often when you've spent a really long time with another person, a partner, and if you lose that partner quickly it can be very devastating. Shrinking social networks and also loss of independence, these are also major stressors as one gets old. Older populations of patients are changing. We're basically increasing the age cutoffs to be considered older, but that doesn't mean we won't look at somebody who's a little younger and who has health problems or psychosocial factors as somebody who may be treated in the same way that somebody who's an older adult may be. So, you know, treating these folks is not merely defined by age, keep that in mind. Older adults usually have many different substances including alcohol, opioids, prescription medications, and illicit drugs. So keep all those in mind, don't be afraid to ask about them. Screening and evaluation, these are the three major categories of the barriers that you would find, physician factors, patient factors, and diagnostic factors. Physician factors are quite significant still. I work in a integrated care at the VA at this time and a collateral sort of situation, and there are still stereotypes about substance use disorder, not only among mental health providers and psychiatrists and nurse practitioners, but among primary care physicians, social workers, and they don't always want to deal with them and sometimes there's still some stigma available. There's also stereotypes about older adults, i.e. older adults don't abuse substances, how could grandma be drinking a bottle of Malbec every night or a bottle of Rose, and it's very possible. There's a lack of knowledge about treatment in the general healthcare sector as well, you know, what kind of treatments are appropriate, when to refer somebody for treatment. Patient factors include in this group of baby boomers denial and shame and guilt. And even though baby boomers took advantage of sex, drugs, and rock and roll, not necessarily in that order, we still had the upbringing that said, "This was bad, this is not good, it's a moral failing." And so denial was a easy way to deal with it, and shame and guilt come into play an important factor in these folks' lives. Diagnostic factors include comorbid medical conditions, which I've mentioned earlier, age-related changes including the aforementioned falls, anemia, neuropathy, altered cognition, fewer overt warning signs, and as you know, DSM criteria may be less applicable in older adults. I mean, they may not be out driving, they don't have a job to report to, so they don't have a lot of sick time that they're accumulating or huge family problems due to substance use. These are the four major tests that you can screen somebody with in terms of tobacco dependence or combustible cigarette dependence, and I would say they're hardly ever used in clinical practice. Basically, you know, in the old days in the baby boomer age, tobacco was the Marlboro Man, it didn't have the stigma that, you know, being an alcohol use disorder or being a addicted to a drug or having a substance use disorder had, so basically people didn't hide or tried to gloss over tobacco, and it becomes very evident if somebody's smoking tobacco, and it continues to be the number one public health problem in the United States and probably in the world. These are 1, 2, 3, 4, 5, 6, 7, 8 tests that you can use to screen people for alcohol use disorder in the geriatric population. The main ones I'm going to focus on are the AUDIT-C and the CAGE, and probably touch on the short version of the Michigan Alcohol Screening Test as well. This is the questions that are involved in the AUDIT-C, three questions, pretty straightforward. You can spend a little bit of time with somebody and ask them to do this or have them fill it out, and you can see that, you know, they ask for frequency of alcohol drinking, number of drinks on any drinking day, and the largest amount that you ever had in one sitting or on one occasion. And what this does is tell you that in an elder adult, if you have a score of three or more points on questions one through three or report of drinking four more drinks on one occasion, you need a more comprehensive evaluation, so that would be reason for a referral to a substance abuse specialist or to do a more general comprehensive intake yourself. Everybody has heard about the CAGE, I think, you know, have you cut down? Have you ever told you should cut down or tried to cut down? Have you been annoyed by other people critical of your drinking? Have you felt bad or guilty about your drinking? And have you ever had to have a drink first thing in the morning? You know, a la Jim Morrison, if I woke up this morning and I had a beer from a, I had a beer. This group of people have a long history of possible substance use disorders, especially alcohol, and an answer of one on these is reason for a more comprehensive screening or evaluation in an older adult. The AUDIT-C gives you a current assessment, and the CAGE gives you a historical data as well. There's one screening test that is validated in the elderly, and that is the Screening Tool of Older Persons' potential inappropriate prescriptions or STOPP, and this you can find online. Other screening tests are the ones that are mentioned here, including the SOAPP-R, the Current Opioid Misuse Measure, the Drug Assessments Screening Tool, which is like the Michigan Alcohol Screening Test, which is a person can do it on their own, it's a written assessment, and the NIDA TAPS TOOL, which is also very helpful. In summary, there are many usable screening instruments to help the clinician ascertain substance use in the older population, some are self-administered, others are clinician administered or a mix. The most important thing to remember is to ask about substance use in this population. It's not something they may, that they're going to bring up voluntarily unless they're really having a difficult time. Make sure that you ask older adults about substance use even if there's no indication that there is a problem. Substance abuse disorders in the older population, treatment, tobacco use disorder. So we have biological treatments including nicotine replacement therapy, patch and gum. We also have varenicline, but in this series, you'll be instructed about varenicline on a separate presentation. Just remember that if you're going to use a prescribed medication, that you start with a low dose and go slow, keep going as tolerated and monitor closely. This is a chart of the different forms or the most common forms of nicotine replacement therapy with the form listed on the left-hand side and the advantages and disadvantages laid out for you. The place where I work at the Veterans, VA Connecticut Healthcare System, we use primarily the transdermal patch, as it delivers a safe, steady level of nicotine, and the patient can't really adjust it. It should help with craving. The nicotine polacrilex gum and/or lozenge are what we use for craving, the patient can control the dose. It can be used as an oral substitute for cigarettes or combustible tobacco. It doesn't really mimic inhaled nicotine in terms of the pharmacokinetic aspects, but it mimics it to a lesser degree. Psychosocial treatments for tobacco use disorder, there are behavioral treatments, cognitive behavioral therapy, and brief interventions, social treatments including groups and using epidemiological larger groups to help with changing that. Alcohol use disorder, we have biological treatments including withdrawal management that is detoxification, and then treatment medications which include naltrexone, acamprosate, and disulfiram. Alcohol, treatment of withdrawal. Older patients at higher risk for delirium, prolonged fusion, and falls. This is clear, they don't have quite as robust of a withdrawal experience, but the onset is slower and can be more confusional and prolonged, tremor as the initial sign may not be there, which you'll see in younger populations. Inpatient treatment is often indicated if the history of severe withdrawal or a significant medical comorbidity is present, and if it's going to be a protracted withdrawal, it may warrant inpatient hospitalization as well. It's quite difficult to do an ambulatory detoxification with somebody who is intermittently confused, although it is possible if you have enough psychosocial supports. The post-acute phase, including periodic confusion may continue for weeks to months, So this is something to really consider when trying to do alcohol detox in the older adult. Historic slide from 1953 in the textbook by Victor and Adams to show you the usual timeline for alcohol withdrawal using the nomenclature of the 50s. I was a history major, I guess I like to see, you know, how things have progressed. The nomenclature is much different now, however, the symptoms and the syndrome of alcohol withdrawal delirium and acute alcohol withdrawal from alcohol intoxication are the same. This is an excellent slide to familiarize yourself with in terms of any time you're dealing with withdrawal from alcohol. This is medications for treatment of alcohol use disorder. And in the yellow banner up there you can see in quotation marks, I will be repeating this most likely again, start low with medications, increase the medications slowly, go slowly, keep going as tolerated, and monitor closely. So, you know, for alcohol we have naltrexone, acamprosate, and disulfiram You can see the relative doses and dosing regimens on the slide, you can refer to that later if need be. The important thing to remember about treating alcohol use disorder with naltrexone is that you must have an opioid-free period from seven to 10 days before starting either the oral or the injectable medication. And frankly, I would probably start them on an oral medication before I did an injectable medication anyway, just to make sure they didn't have a bad response. With the acamprosate, you can use that with somebody who's taking an opioid pain medication, but you really probably need to wait until they established abstinence. Whereas naltrexone, you can probably still give them when they're, when they continue drinking, and it should reduce craving. Disulfiram is, you have to use sparingly in the elderly, but can be used in healthy elderly, but again, with great care, and you want to be able to evaluate liver function and follow that closely for both naltrexone and disulfiram. This is a retention and treatment slide taken from Volpicelli's landmark treatment of alcohol use disorder with naltrexone, which was followed very, very closely by Stephanie O'Malley at Yale with the same result looking at the relapse rates of people on naltrexone versus placebo. This and many other repeat studies of this medication are what got its FDA approval for alcohol use disorder in terms of lowering, in terms of keeping people in treatment and reducing the amount of alcohol that somebody might drink, including abstinence, but the main thing to look at here is that the way they defined abstinence was by drinking report drinking five or more days in one week or less, reporting five or more drinks in a drinking occasion or coming to the treatment intoxicated at 0.1 grams per deciliter. In other words, it was fairly difficult to get out of this study, and it was ingenious in that respect in that it helped us find a medication that can help reduce alcohol intake without necessarily enforcing abstinence, which is very difficult for some people. At the behest of David Fiellin from my addiction medicine colleague, I've listed majority of the database from Cochrane through 2010 that shows the experimental favor of naltrexone in heavy drinking. So oftentimes this risk ratio shows that the experimental condition, which was now naltrexone, actually lowered, you know, heavy drinking, it may not have eliminated drinking, but it helped lower it, and this can be life-saving for many people. So it's an important slide to look at. You've heard this before, I'll say it again, age-specific treatments are more effective than drug-oriented or substance-oriented groups for older adults. Address issues of loss and isolation. Teach skills to rebuild social supports. Use a slower pace when you're doing your work with them. And be alert to cognitive changes. Sometimes minimal cognitive impairment is hard to detect, so it's important to listen closely to whether people have word-finding difficulties and that kind of thing, which may indicate some cognitive problems. This is a look at brief interventions for at-risk drinking in older persons. This is something that received a lot of attention earlier on in Project Guiding Older Adult Lifestyles where older adults who received a physician intervention demonstrated a significant reduction in seven-day alcohol use, episodes of binge drinking, and frequency of excessive drinking. This generally consists of two to three, 10 to 15-minute sessions, education assessment and feedback, use of motivational strategies, not confrontation, goal setting, behavior modification techniques. There were other trials as well as Project GOAL, including Healthy Profile Project, the ASSIST-Linked brief intervention for hazardous and harmful substance abuse, and all of these have shown effectiveness in decreasing alcohol consumption, which is a goal. This is an acronym for brief treatment intervention called F.R.A.M.E.S. It's to help you remember in the throws of the setting of me doing a brief intervention that you want to give people feedback about your assessment. You want to ask them to take responsibility for change. You want to give them some advice for change and menu for change options, like how would your life be better if you didn't drink as much? So get them to think about positive aspects and negative aspects of drinking or any drug use really. And then, of course, use an empathic counseling style. Please don't confront and just tell them no or to stop drinking, this hasn't worked in the past and it probably won't work in the future. So be empathic, try to understand, get them to come along slowly, and to really get invested in it. And then enhanced client self-efficacy and ongoing follow-up is really good. Many older adults really benefit from talking to an expert about their substance use more so than younger adults. Psychotherapeutic treatments in alcohol use disorder. Of course, these entail relapse prevention, motivational interviewing, motivational enhancement, individual psychotherapy. I believe it was the, I'm blanking on the name of the study, but it showed that meeting with the doctor and getting advice from the doctor on your alcohol was as effective sometimes as taking, in this study, as taking naltrexone or other medications. CBT, again, you can use cognitive behavioral therapy, and these have been, you know, evidence-based, it has been very good, 12-step facilitation is very good, but CBT should not be used in a documented cognitive, person with cognitive decline, that being said, I think that there have been a couple of studies that have come out that say, that have looked at minimal cognitive impairment and that CBT can be helpful in some instances with minimal cognitive impairment. Alcohol use disorder, social treatments, groups in the elderly or older adult are very effective. These groups should be age-related and not necessarily just all alcohol or all narcotics or all drug-related. 12-step groups have, some places have become very sophisticated and will have older groups, this can be very helpful as well. Rational recovery and family interventions. Family interventions may be as important in the older population as they are in the child and adolescent population. In the earlier 2000s, almost 5 to 6% of patients receiving methadone, maintenance were over 55. I can tell you from personal experience that the methadone mean age at VA Connecticut is older than that now. Older adults may do better in treatment than younger adults with methadone maintenance, even if they have more medical complexity. There is an increased risk of sedation with the polypharmacy, however, and there's an increased risk of QTC prolongation and torsades de pointes. So it's important to monitor heart function, liver function, and watch for constipation in this age group. As you all know, buprenorphine is a partial opioid agonist, it has a lower abuse potential than methadone, it does have a plateau effect, so at some point, it stops being an agonist and becomes an antagonist or at least holds the line. The half-life is not altered by impaired renal function, so that shouldn't be a problem. You may need to use a decreased dose or change to the mono-product in liver failure. So instead of using suboxone in liver failure, you would use straight buprenorphine and use a lower dose. It has poor bioavailability so it shouldn't be swallowed. It's a transmucosal, under the tongue or buccal absorption drug that, you know, absorbed through oral mucosa. If it's swallowed, it can cause problems and will not be available, and it may actually cause upset, and I've seen patients vomit when they swallow their saliva. The injection, there's a monthly subcutaneous formulation called Sublocade. This is a very useful, it has a slow dissociation rate and can be given every, the oral dose can be given every other day or every third day. I would definitely use an oral dose in older adults and regular-age adults before giving them a Sublocade injection. Who might benefit from naltrexone? Well, those who are willing and wanting to take it. So almost anybody with an opioid use disorder can benefit from taking naltrexone. The problem is that you need to remember, often challenging, how challenging it is to start naltrexone because generally, it requires 7 to 10 days of the subject being opioid-free, and, you know, this is hard for many people to do, and could potentially be dangerous when the person is actively using opioids. So it's kind of a tricky proposition but it's shown that once you get people on the naltrexone, they do very well. Pearls for dosing in older adults. Monitor liver and renal functioning, and always remember I would start with the oral product and start low, go slow but keep going if tolerated and monitor closely, monitor liver functions, and if they're stable you can use an injection but you have to be very careful with that. So in my review of substance use disorders in older adults, I got feedback from a group of geriatric psychiatrists and other substance use psychiatrists and pharmacists that showed me this assessment wheel which talks about polypharmacy and management in older adults. And, you know, this is really a big problem. I'm a geriatric psychiatrist as well as addiction and I can tell you that many geriatric or older patients are on multiple medications with nobody really taking the reins and monitoring why they're getting all those medications, they're added by different specialists, and it's sometimes overwhelming, it leads to a lot of medication misuse. So this wheel shows you the assessment of medications, you know, how to assess drug interactions and drug-disease interactions, identify non-beneficial therapy. There should be a course in medical school and nursing school on how to stop medications that patients don't need anymore, I'm not sure that there are that many of them, there may be some out there but it's clearly a problem, polypharmacy. Identify high-risk therapy and reconsider and then assess the patient as well. Do a medication reconciliation. Are all the medications necessary? Are you really taking all these medications as prescribed? You can clear up a lot of problems and perhaps potentially avoid substance use disorders by using this approach with your patients, no matter what age they are, but especially for elderly patients. There are treatments available for older adults with substance use disorders. Start low, go slow in older populations. Age-specific treatments appear to be more efficacious in general and should be combined with pharmacologic treatments when possible. Age-specific specific treatments include building relationships and relations and support. Use of less confrontation, I would say no confrontation. An older adult-only environment when talking about drugs, this will get you the greatest results. 75 year old Caucasian female who has been married to the same man for 50 years, and recently been complaining of feeling more anxious, and has asked her husband for help with this. She has a history of anxiety NOS and is prescribed clonazepam by her primary care physician. Her husband has retired and has a complex medical history including chronic pain from peripheral neuropathy treated with extended-release oxycodone, 40 milligrams every 12 hours. She presents to the emergency room after she became confused, was unable to eat her dinner, fell into a light sleep at the dinner table while out at dinner with her husband. Upon arrival to the emergency room, she has required intubation and is given naloxone IV. Her urine toxicology screen was positive for opioids and her breathalyzer was 0.4 grams per deciliter. She is stabilized and admitted and detoxified i.e. she's weaned off of her opioid pain medications with little problem. She is maintained on her clonazepam and transferred to the psychiatry inpatient unit. Older adults can and often do misuse prescription medications. Mixing alcohol, opioids, and benzodiazepines is never a good idea, and use of these medications should be scrutinized and monitored closely in the older adult. Even small amounts of alcohol levels that are sub-threshold for legal intoxication can be deadly in an elderly or medically compromised when combined with benzodiazepines and opioids. This listed references, references, references. The PCSS Mentoring Program is designed to offer general information to clinicians about evidence-based clinical practices and prescribing medications for opioid use disorder. You can see that there's a three-tiered approach which allows mentor-mentee relationship and that there's a great deal of evidence-based treatment, including medications for opioid use disorder, and it has no cost. The website is listed below. Have a clinical question? Ask a colleague, there's the website below. Feel free to ask me a question at any time. PCSS is a collaborative effort led by the American Academy of Addiction Psychiatry in Partnership with. Thank you very much.

substance use disorders

older adults

Louis Trevisan

PCSS

evidence-based practices

case study

treatment options

medication monitoring