1. Prescription Drug Abuse and Misuse in the Elderly Thomas L. Patterson, Ph.D. Support for this work: NIMH Center Grants P30 MH49693 and MH45131, and by the Department of Veterans Affairs

2. Number of Americans >65 (Millions) U.S. Bureau of Census

3. Drug Problems in the Elderly Current State of Affairs Alcohol Illicit drugs Prescription/OTC

4. Prescription Drugs are consuming more health costs (Reinhardt et al., 2004)

5. Increased costs are related to use by elderly (Baugh et al. 2004)

6. Increased Spending primarily due to increased use (Reinhardt et al., 2004)

7. Age and gender effect number of Meds taken (Linjakurapu et al., 2002)

8. Past decade has seen increased use of virtually all classes of meds (Linjakurapu et al., 2002)

9. Estimated Numbers of People with Psychiatric Disorders in USA Age Group (Jeste et al., Arch Gen Psychiatry, 1999)

10. DAWN (2003)

11. Estimated Number (in thousands) of U.S. Residents (Age 12 and Older) Reporting Lifetime Non-Medical Use of Prescription Pain Relievers, 2003 *Prior to 2002, the NSDUH was known as the National Household Survey on Drug Abuse. Due to changes in the survey, estimates from the 2002 and 2003 NSDUHs should not be compared with estimates from the 2001 and earlier NHSDAs to assess changes over time. SOURCE: Adapted by CESAR from Substance Abuse and Mental Health Services Administration (SAMHSA), Overview of Findings from the 2003 National Survey on Drug Use and Health, 2004.

12. Large numbers of U.S. Population Misuse Prescription Drugs

14. Prescription Drug Abuse/Misuse Most drugs for medical conditions Psychoactive drugs (e.g., benzodiazepine) most often abused in elderly –Inpatient addiction program; 16% prescription Comorbidities –Prescription + alcohol –Psychiatric diagnoses Baby-Boomer impact unknown Problems identifying cases

15. Prescription drug abuse is probably underestimated by 20% Problems in Defining Drug Dependence in the Elderly (DSM-IV) Criteria: “Increased tolerance to effects of substance…” –changes in pharmacokinetics Criteria: “Report of adverse consequences…” (e.g., poor work performance, suspension from school etc.) –fails to consider lifespan changes

16. Abuse/Dependence in the Elderly Factors associated with abuse –Genetics –Stress –Co-morbidities –Metabolism Structural Problems –Research not consider aged –Dosage one size fits all Age related changes in abuse –“Maturing out” Theory Mortality Morbidity Maturational Factors Until problems emerge difficult to ID Access to prescription drugs is changing

17. Prescription Drug Abuse Prevalence affected by sampling –Increased in nursing homes and hospitalized –Less evidence for ambulatory aged Reason for misuse of meds –Difficulties reading and following prescription –Cognitive deficits –Cost –Complexity of drug treatment

18. Prescription Drug Use Types of misuse –Over dose –Under dose –Use for other than prescribed –Drug combinations

19. Antipsychotic Adherence Standardized Estimates of Annual Cost in Dollars Antipsychotic Adherence* HospitalOutpatientPharmacyTotal Nonadherent (.01 -.49) 3,413 (368) 3,464 (175) 1,542 (107) 8,168 (433) Partially Adherent (.5 -.8) 2,689 (412) 3,693 (208) 3,142 (110) 9,403 (542) Adherent (.8 – 1.1) 1,025 (95) 3,776 (151) 4,463 (161) 9,505 (289) Excess Filler ( > 1.1) 2,472 (272) 5,741 (312) 5,635 (188) 14,044 (561) Gilmer, et al 2004 *Cumulative Annual Possession Ratio

20. Medical Care Expenditures Increasing (Reinhardt et al., 2004)

21. Under-use of Medications May be increasing (Archives of Internal Medicine, 2004) Two-thirds of older patients reduce use of medications due to cost

22. 1197.pdf Inappropriate use of drugs effected by ethnic/cultural factors (Raji et al. 2003)

23. Meds may be purchased without prescription in Mexico and other countries.

24. The Internet is Becoming a Larger Source of Prescription Drugs “The internet has become a virtual wild west bazaar for “spam” emails and websites that sell controlled substances with little or no oversight..” DEA, 2004

25. General Information is available on many drugs (9/9/04)

26. There are many sites that sell prescription drugs (9/9/04)

27. Modified Swiss Cheese Model After James Reason ADVERSE EVENT Provider(s) Equipment & Tools Local Care Environment Organization Healthcare System EVENT TRAJECTORY Patient

28. Modified Swiss Cheese Model After James Reason ADVERSE EVENT Provider(s) Equipment & Tools Local Care Environment Organization Healthcare System EVENT TRAJECTORY Older Patient

29. Summary Scope of use –30% of prescription consumed by 12% of population >65 years –$15 billion/year in elderly (4x’s younger individuals) Abuse and misuse is a problem Estimates of scope of problem hindered by a number of factors Access to prescription drugs is easier than ever before

30. Specific Goals and Suggested Strategies Improve diagnostic criteria Focus research on compliance Standardize prescription labeling Develop treatment programs tailored to elderly Consider dual diagnosis (e.g., PTSD & drug use) Explicate age related changes in drug abuse Examine impact of internet/foreign purchase of med’s Examine ethnic and cultural differences