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309

CHAPTER 12

Substance Abuse

NOELL L. ROWAN and ANNA C. FAUL

HE POPULATION OF

the United States is aging, as evidenced by the increase

in the older adult population from 3.1 million in 1900 to 35 million in 2000.

The U.S. Census Bureau (He, Sengupta, Velkoff, & DeBarros, 2005) projects

that a substantial increase in the number of older people (age 65 and older) will

occur between 2010 and 2030. It is estimated that the older population will grow

from 35 million in 2000 to 72 million in 2030—nearly 20% of the total U.S. popu-

lation. The median age in the United States in 2000 was 35.3, 12.4 years older

than in 1900, with a projected median age in 2030 of 39 years (He et al., 2005). It

is predicted that the number of adults over 65 will grow by an average of 2.8% an-

nually between 2010 and 2030 (Blow, 2000; Center for Substance Abuse Treat-

ment [CSAT], 1998).

Alcohol and drug abuse and misuse among older adults are one of the

fastest growing public health problems in the United States. The current aging

population has more liberal attitudes toward substance use than older adults

from a generation or two ago, resulting in expectations that the drug abuse

problem will increase in the years to come (Shibusawa, 2006). Evidence is

starting to grow showing that this new generation of older adults will have

high levels of substance-related health problems. The use of alcohol, combined

with the inappropriate use of medications, is nationally reported as the lead-

ing problem for admission of older adults to substance abuse treatment facili-

ties (Ray, 2002).

Despite the fact that alcohol and drug misuse affects as many as 17% of older

adults, the problem does not receive enough prominence in the literature, prob-

ably due to substance use being more common among younger adults (ages 18 to

49) than among older adults (50 and older; Blow, 2000; CSAT, 1998; Shibusawa,

2006). In this chapter, the incidence and prevalence of substance abuse among

the elderly is discussed, as well as evidence-based approaches to assessment and

intervention.

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TRENDS AND INCIDENCE

Substance abuse among the elderly includes not only alcohol and illicit drug use,

but also prescription and over-the-counter drug abuse. The separation between

alcohol use and drug use is becoming blurred, mainly due to the inappropriate

use of prescription and over-the-counter medications (Ray, 2002). More and more

older adults are now also using illicit drugs, casting doubt on the “maturing-out

theory,” which claims that people age out of illicit drug use or die prematurely

from abuse (Shibusawa, 2006).

The following sections address alcohol abuse, misuse of prescription and

over-the-counter medications, and illicit drug abuse. In an effort to clarify the

trends and incidents associated with alcohol and other drugs, each is discussed

separately.

LCOHOL

BUSE

Many older people associate alcohol use with socialization and use alcohol in

moderation. However, there are a growing number of older adults who use alco-

hol as a way to cope with some life events and to help them relax (Hooyman &

Kiyak, 2002).

The overall prevalence of drinking is relatively low among people 65 and older

(National Center for Health Statistics [NCHS], 2000). In 2000, about 50% of the

population ages 18 to 44 were regular consumers of alcohol, compared with 46%

of adults ages 45 to 64 and 29% of older adults (He et al., 2005).

Despite the lower prevalence of alcohol consumption by older adults, alcohol

abuse and misuse is the major substance abuse problem in this population. In

each year from 1995 to 2002, alcohol was the most frequently reported primary

substance of abuse among those admitted to a treatment facility (The DASIS Re-

port, 2005). It is estimated that 4% to 20% of community-dwelling older adults

abuse alcohol (Shibusawa, 2006). These percentages translate to an estimated 2.5

million older adults with problems related to alcohol (Blow, 2000; CSAT, 1998). In

health care settings, 6% to 11% of older adults exhibit symptoms of alcoholism; in

psychiatric settings, 20% of older adults exhibit similar symptoms; and in emer-

gency rooms, 14% (Shibusawa, 2006). Rates for alcohol-related hospitalizations

among older adults are similar to those for heart attacks. Forty-nine percent of

older nursing home residents show signs of alcoholism, some of whom may be

using nursing homes for short-term rehabilitation (Blow, 2000; CSAT, 1998).

The National Institute of Alcohol Abuse and Alcoholism recommends that older

adults drink no more than one alcoholic drink per day because of age-related phys-

ical changes. The central nervous system, liver, and kidneys become less tolerant of

alcohol with age because of the physiological changes taking place due to the aging

process. Despite this recommendation, studies have shown that 20% of residents

in retirement communities have two or more drinks per day (Gurnack, 1997;

Hooyman & Kiyak, 2002; Shibusawa, 2006).

In 2000, 40.7% of White men over 65 were current regular alcohol users (at least

12 drinks in a week), with lower percentages reported by Hispanic men (35.6%)

and African American men (23.7%; NCHS, 2000). Despite the elevated regular

usage of alcohol by White men, African American and Hispanic older men

demonstrate the highest prevalence of alcohol dependence (Shibusawa, 2006).

Overall, alcohol abuse is 4 times more common in older men than women.

Substance Abuse 311

Despite these alarming figures, they still represent an underestimation of

the true problem. It is difficult to obtain accurate statistics on the prevalence of

alcoholism in older adults, due mainly to the stigma associated with this condi-

tion among older adults, nonspecific symptoms for older adults, and inade-

quate screening methods specific for older adults (He et al., 2005; Hooyman &

Kiyak, 2002).

ISUSE AND

BUSE OF

RESCRIPTION AND

VER

THE

-C

OUNTER

EDICATION

Adults over 65 consume more prescribed and over-the-counter medications than

any other age group in the United States (Blow, 2000; CSAT, 1998). Older adults

spend $15 billion a year on prescription drugs, four times the amount spent by

younger populations. Prescriptions filled by older adults represent approxi-

mately 30% of prescription expenditures (Hooyman & Kiyak, 2002). An average

older patient takes 5.3 prescription medicines per day. Over-the-counter medica-

tions commonly used by older adults are pain relievers, sleeping aids, cold reme-

dies, antacids, laxatives, and vitamins (Shibusawa, 2006). A large amount of

prescriptions for older adults are for psychoactive, mood-changing drugs that

have the potential for misuse, abuse, or dependency (Blow, 2000; CSAT, 1998).

The literature distinguishes between misuse and abuse of prescription and

over-the-counter medication. Misuse refers to the inappropriate use of medica-

tions that can be caused by difficulties with reading and following prescription

labels, keeping track of medications, and taking inappropriate dosages. Vision

and hearing loss can increase the misuse of prescription and over-the-counter

medications among older adults. Physicians can also cause misuse by inappropri-

ate prescribing of medications. Problems with drugs generally fall into the mis-

use category and are unintentional (Blow, 2000; CSAT, 1998; Shibusawa, 2006).

Abuse, on the other hand, refers to the use of medication in a way that is non-

therapeutic and not for its intended purposes. A typical form of abuse occurs

when older adults use prescription or over-the-counter medications as a form of

self-medication. Unintentional misuse can progress into abuse if an older adult

continues to use a medication nontherapeutically for the desirable effects it pro-

vides (Blow, 2000; CSAT, 1998; Shibusawa, 2006).

The most commonly prescribed psychoactive medications for older adults

(with potential for abuse) are benzodiazepines, antidepressants, and opiate/opi-

oid analgesics. Benzodiazepines, which are prescribed for conditions such as in-

somnia, anxiety, and chronic pain, are prescribed widely among older adults.

Studies report that 17% to 23% of drugs prescribed to older adults in North

America are benzodiazepines (Blow, 2000; CSAT, 1998; Shibusawa, 2006). The

drug-taking patterns of psychoactive prescription drug users can be described on

a continuum that ranges from appropriate use for medical or psychiatric indica-

tions through misuse to persistent abuse and dependence (Blow, 2000; CSAT,

1998; Shibusawa, 2006). Older women are more likely than men to receive psy-

choactive drugs, and drug dependence is more common among older women than

men (Shibusawa, 2006).

LLICIT

RUG

BUSE AND

EPENDENCE

According to the 2000 National Household Survey on Drug Abuse, 568,000 adults

age 55 or older (1% of all older adults in the United States), reported using illicit

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drugs in 2000 (Substance Abuse and Mental Health Administration, 2001). The

Epidemiologic Catchment Area Study indicates a lifetime prevalence of illegal

drug use of 1.6% of persons over 65 (Patterson & Jeste, 1999). Data gathered

through surveys of homeless individuals and drug arrest data indicate that illicit

drug use in the elderly population is not very common (Atkinson, Ganzini, &

Bernstein, 1992).

The general belief is that most older adults who use or are dependent on illegal

drugs start using these drugs early on in their lives (Blow, Oslin, & Barry, 2002).

The popular maturing-out theory suggests that people age out of illicit drug use

or die prematurely from abuse. However, methadone treatment and needle ex-

change programs have added to the longevity of heroin and injection drug users.

Also, the number of older adults who start using crack cocaine for the first time

after age 50 is slowly on the increase (Shibusawa, 2006).

The National Survey on Drug Abuse provides one of the few nationwide longi-

tudinal studies that allow examination of drug use trends over time in specific

age cohorts. In 1979, overall, 27% of younger baby boomers (born between 1946

and 1964), ages 21 to 33—almost 14 million people—reported using any illicit

drug during the past month. The prevalence rate has remained stable but higher

than for age-matched cohorts from previous generations. These data suggest that

some baby boomers have continued to use illicit drugs as they age. Marijuana is

the most commonly used illicit drug by older adults, at a rate of 1.1% (National

Survey on Drug Use and Health, 2005). Due to large numbers of baby boomers, it

can be expected that larger numbers of current drug users will reach age 65 and

have a potential impact on treatment programs and other resources (Patterson &

Jeste, 1999).

ETIOLOGY AND PROGNOSIS

At all ages, women drink less than men (Fingerhood, 2000). It is therefore under-

standable that older men are much more likely than older women to have alcohol-

related problems, mainly due to a longer history of problem drinking than

women (Blow, 2000). Older women are less likely to drink and less likely to drink

heavily, although they are more likely than men to start drinking heavily later in

life (Menninger, 2002). Gomberg (1995) found that men reported a mean age at

onset of 27.0 years, whereas women reported 46.2 years.

A specific distinction must be made between chronic alcoholics or early-onset

drinkers and situational alcoholics or late-onset drinkers. About two thirds of el-

derly individuals with alcoholism problems are early-onset drinkers (Benshoff &

Harrawood, 2003). Throughout their lives, they have turned to alcohol to cope

with a range of psychosocial or medical problems. Drinking has become an over-

learned, maladaptive coping response. Psychiatric comorbidity is common among

this group, particularly major affective disorders and thought disorders. Alcohol-

related physical complications like cirrhosis are common for chronic alcoholics

(Blow, 2000; Hanson & Gutheil, 2004). More men than women are classified into

the early-onset drinking group.

Late-onset drinkers or situational alcoholics are more likely to have begun or

to have increased drinking in response to a negative life situation or event such as

retirement, divorce, death of a spouse, decline in status in the community, or

health setbacks (Benshoff & Harrawood, 2003; McInnis-Dittrich, 2005). About one

Substance Abuse 313

third of older adults with drinking problems are late-onset abusers, with more

women identified in this category (Hanson & Gutheil, 2004; McInnis-Dittrich,

2005). Alcohol abuse is more prevalent among older adults who have been sepa-

rated or divorced and among men who have been widowed. Varied disorders may

be triggered in older men when their wife dies: depression, development of alco-

hol problems, and suicide (National Institute on Alcohol Abuse and Alcoholism,

1988). Other losses of family members may also trigger alcohol abuse. When older

adults retire, they may lose significant income as well as job-related social sup-

port systems and the structure of self-esteem that work provides. Other losses in-

clude diminished mobility, impaired sensory capabilities, and declining health

due to chronic illnesses. All of these losses may trigger isolation and alcohol

abuse. Some researchers suggest that increased amounts of free time and lessen-

ing of role responsibilities may serve as an etiological factor for why women start

drinking later in their lives (Blow, 2000). Moving to a retirement community may

also trigger overdrinking, when the social activities provide more opportunities

to drink (Abrams, 2002).

Drinking patterns in late-onset abusers have created fewer cumulative nega-

tive stressors on family and friends. They may also lead to fewer physical and

mental health problems and stronger societal connections; late-onset abusers are

less likely to have ever been in an alcohol treatment program. This group there-

fore has a better prognosis for recovery because they have not suffered the physi-

cally and psychologically devastating effects of long-term alcohol and drug

problems (Benshoff & Harrawood, 2003).

A strong relationship exists between developing a substance use disorder ear-

lier in life and experiencing a recurrence in later life. Some recovering alcoholics

with long periods of sobriety undergo a recurrence of alcoholic drinking as a re-

sult of major losses or an excess of free time. A previous drinking problem is the

strongest indicator of a problem in later life. Genetic factors are also important in

alcohol-related behaviors. Studies provide strong evidence that drinking behav-

iors are greatly influenced by genetics throughout the life span (Blow, 2000).

A variety of factors influence the use and potential for misuse of psychoactive

prescription drugs and over-the-counter medications by older adults. Old age,

poor physical health, and female sex are most consistently correlated with psy-

choactive prescription drug use in the literature (Blow, 2000). The Epidemiologi-

cal Catchment Area (ECA) study reports that benzodiazepine use was predicted

by being elderly, White, female, less educated, and separated or divorced, by hav-

ing experienced a greater number of negative life events, and by having a psychi-

atric diagnosis (Patterson & Jeste, 1999).

Among older women, use of psychoactive drugs is correlated with late-life di-

vorce, widowhood, less education, poorer health, and more depression and anxi-

ety. Older women are nearly twice as likely as older men to develop a diagnosable

anxiety disorder. Bereavement often precipitates anxiety. Anxiety is also com-

mon after a severe traumatic event (Blow, 2000).

Many mature women use prescription and over-the-counter medications ap-

propriately. Unfortunately, there are some older women who dangerously over-

use the drugs or mix them with alcohol. This inappropriate use can lead to

chronic abuse or addiction; mixing sedating psychoactive drugs with alcohol usu-

ally accelerates the development of a dependence on the drug because the alcohol

magnifies the drug’s effect (Abrams, 2002).

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A variety of health care system-related factors place older adult users of psy-

choactive prescription drugs at risk for misuse, abuse, or dependence. Potentially

dangerous prescribing practices include ordering medications without a clear di-

agnosis, prescribing them without medical monitoring for too long a period of

time, selecting drugs with a high risk for side effects in older adults at the doses

given, ordering drugs without checking whether they interact adversely with

other medications the older adult is taking, and failure to provide instructions for

patients regarding how and when to take medications and what side effects to ex-

pect (Blow, 2000).

The medical consequences of acute alcohol intoxication are more severe in the

elderly than in other age groups. Due to the human aging process, physiological

changes occur in the older adult that account for the development of problems sec-

ondary to alcohol use even when the older adult did not increase the amount of al-

cohol intake over the years. One of the major problems for older adults is the

decreased absorption rate in the gastrointestinal system, occurring as a result of

decreased blood flow to that system. Drugs and alcohol therefore remain in the

body longer and at higher rates of concentration. Reduced hepatic blood flow and

decreased enzyme efficiency diminish the liver’s functional capacity to metabo-

lize drugs and alcohol. Older adults therefore keep an increased amount of drugs

in their body for longer periods of time. The mortality rate for cirrhotic liver dis-

ease in older adults is about twice the mortality rate for the general population

(Benshoff & Harrawood, 2003; Menninger, 2002).

Aging decreases the proportion of body water and increases the proportion of

body fat. Therefore, the concentration of alcohol and the sensitivity to alcohol is

increased because alcohol is a water-soluble substance. Concentration of lipid sol-

uble drugs, particularly benzodiazepines, increases and prolongs their effects.

For many older adults, the decrease in body mass is so significant that the typical

adult dose of a medication, particularly a sedative-hypnotic medication, may be

far too high (Benshoff & Harrawood, 2003).

Many medications used by the elderly have the potential for inducing toler-

ance, withdrawal syndromes, and harmful medical consequences such as cogni-

tive changes, renal disease, and liver disease. Illness and mortality rates

associated with misusing prescription and nonprescription medications are on

the increase (Blow et al., 2002; Fingerhood, 2000).

The consequences of substance abuse are numerous and tend to mimic other

problems that are common among older adults. Vague symptoms such as irritabil-

ity, stomach upset, weight loss, malnutrition, depression, and insomnia may be

the first signs of a problem. Later, evidence of liver, kidney, and heart disease, os-

teoporosis, incontinence, and pancreatitis may become evident. Problems associ-

ated with the misuse of benzodiazepines overlap with those of alcohol abuse and

may include drowsiness, sedation, confusion, memory loss, falls, and other types

of accidents. When used in combination, the adverse effects of alcohol and benzo-

diazepines may be severe (Finfgeld-Connett, 2004).

The most common causes of death in older substance abusers are cirrhosis of

the liver; cancers of the mouth, esophagus, pharynx, lung, and liver; breast can-

cer in women; and trauma. Gastrointestinal and liver diseases are the main com-

plications of alcohol use among older adults. Esophagitis, ulcer disease, and

gastritis are all more common in the older drinker; aspirin and other nons-

teroidal anti-inflammatory drugs commonly taken by older people add to the

Substance Abuse 315

risk of these alcohol-related problems. Alcohol may lead to malabsorption of vi-

tamins and cause chronic diarrhea. Alcohol is also the second leading cause of

acute pancreatitis in older people, after gallstone disease, and is the cause of

chronic pancreatitis in many cases. The complications associated with alcohol

use in older adults are no different than in younger people. However, the compli-

cations may be more severe and occur at lower levels of alcohol consumption

than in younger people (Fingerhood, 2000).

Despite the severe effects of substance abuse in older adults, several barriers

exist that make proper identification of substance abusers difficult. Problem use

of alcohol and other drugs in older adults does not necessarily meet the criteria

for substance abuse or dependence as defined by the Diagnostic and Statistical

Manual of Mental Disorders, fourth edition (DSM-IV-TR; American Psychiatric As-

sociation, 2000). The criteria for problematic abuse or dependence do provide for

common communication among service providers in terms of an operational defi-

nition and subsequent treatment. However, these criteria (see Table 12.1) may

present challenges when applying them to older adults.

The criterion of tolerance for substance dependence may not apply to older

adults with alcoholism due to the high sensitivity and higher blood levels at

lower consumption amounts. Because older persons are more sensitive to the ef-

fects of alcohol and other medications, their consumption of lower quantities of

alcohol may not meet the criterion of spending a great deal of time in activities

related to substance use. Menninger (2002) reports that the criteria for physiolog-

ical dependence with withdrawal may not be detected in older people with late-

onset alcoholism. However, cognitive dysfunction may interfere with older

persons’ ability to monitor their drinking.

Another concern with the DSM-IV-TR criteria for substance abuse and depend-

ence in older adults is the criterion of failure to fulfill major role obligations at

work, as this may have changed with retirement or isolation from regular social

interaction. These concerns, along with denial of chemical abuse and depend-

ence, make screening, assessment, and diagnosis challenging with older adult

clients.

Menninger (2002) identified several barriers to being able to identify alcohol and

other drug misuse in older adults. As illustrated in Table 12.2, these barriers make it

easier to see why older adults have been underidentified and underdiagnosed.

EVIDENCE-BASED INTERVENTIONS

CREENING AND

SSESSMENT

Before health professionals can intervene, it is important to know the common

signs and symptoms of substance abuse in older adults and to effectively screen

for any problems with alcohol or other drugs. A careful and thorough history

must be compiled to include a history of first chemical use, regular using pat-

terns, heavy using patterns (including a question about frequency and amount as

well as any related consequences with all chemicals such as tobacco, alcohol, anx-

iolytics, hypnotics, and prescribed, borrowed, over-the-counter, and street

drugs). This history should also include the current patterns of use of chemicals,

attitudes toward aging and drinking alcohol and using other drugs, and a nutri-

tional and current diet status.