1. Addictive and Co-Occurring Disorders in Late Life David W. Oslin, M.D. University of Pennsylvania, School of Medicine And Philadelphia, VAMC Hazelden Research Co-Chair on Late Life Addictions

2. Translating Positive findings in Aging to Younger Adults

3. Disclosures  NIMH  K08 Award  ACSIR  NIDA  Center for Studies on Addiction  NIAAA  R01  VA  Merit Early Entry  MIRECC  HSRD Merit Award  Industry Support  DuPont Pharma  Forest Labs  Hazelden Foundation  Pfizer

4. Relevance of comorbidity to an aging population  Cohort changes in exposure – we will see more elderly patients using illicit substances (current and past abuse)  Consequences may be greater in older adults  Direct toxicity / withdrawal  Indirect interactions with medications or other illnesses  Comorbidity is a significant issue perhaps uniquely so for the elderly  Cognition  Minor depression  Suicide  Anxiety and personality problems  Changing environment  Social isolation  Limited resources  Limited access to care

5. Comorbidity and Drug/Alcohol Dependence  Higher than expect rates in representative community samples  Markedly higher rates in treatment seeking samples  Increased morbidity and mortality particularly suicide  Presents diagnostic difficulties  Poor prognostic factor  Call for integrated care system

6. Suicide  Highest rates of suicide occur in late life among men.  Depression causes a 5.8 fold increase in risk of suicide compared to death from other causes  Heavy drinking (3+ drinks/day) causes a 8.9 fold increase in risk of suicide compared to death from other causes  Moderate drinking (1-2 drinks/day) causes a 10.6 fold increase in risk of suicide compared to death from other causes Grabble, et al. 1997

7. The difficulty  Extremely limited research  Drug and alcohol dependence are exclusions to most geriatric trials  Age >65 is almost always an exclusion for drug and alcohol trials

8. What is the Extent of the Issues? In the Community Current / Last 12 months Alcohol Dependence2 - 4 % Medication misuse? Overall Chronic Benzodiazepine use 5 – 20% Nicotine dependence10 - 15 % Illicit Substance dependence< 1 % Pathological Gambling1 – 2 %

9. Baby Boomers Aging 91 – 9201 – 02Percent Increase 18-296.57.08% 30-443.06.0100% 45 – 641.43.5150% 65+0.31.2300% Grant, et. al. Drug and Alcohol Dependence 2004

10. Veterans (Age 60 and Over) in Addiction Treatment Alcohol Only51.8% Street Drugs Only 9.1% Prescription Medications only 3.6% Alcohol and Street Drugs26.4% Alcohol and Prescription Medications 5.5% Street Drugs and Prescription Medications 0.9% All three categories of substances 1.8% Missing data 0.9% Schonfeld et al. 1990 Sample of 110 subjects in a special geri-addiction program

11. Past History of Heavy drinking/alcoholism  Many older adults especially those of the “Woodstock” generation will enter late life with a past history of alcohol or drug abuse  5 fold increase in late life mental disorders (depression and dementia)  Treatment of late life depression (3-5 yr outcomes)  88% of those without an alcohol history significantly improved  57% of those with an alcohol history significantly improved Saunders et al. 1991, Cook et al. 1991

12. Behavioral Health Laboratory (BHL): Links To Primary Care

13. Research to Practice: Behavioral Health Laboratory  The BHL is an automated telephone assessment and triage service for patients identified by primary care providers as having depressive symptoms or at-risk drinking.  The depression and alcohol clinical reminder system generates a consultation request to the BHL.  The BHL conducts a brief telephone (20-30 minutes) assessment generating a report for the PCP including diagnosis, severity, and general treatment recommendations.

14. Drug Use Among Primary Care Patients with Minor or Major Depression <50 Years50-64 years65 + years n=205n=323n=112 Use in past year24.420.72.7 Past history of use20.520.41.8

15. Types of Substance Use Among Older Adults (50+) Use in Past Year Only a past history n=70n=22 Cocaine54.336.4 Heroin7.10 Marijuana58.677.3 Amphetamines1.49.0 LSD1.44.5 Inhalants1.40 Barbiturates1.40

16. Drug Use Among Older Patients with Minor or Major Depression No Hx of Drug use Only a past Hx Use in the past year Diff (by column) n=342n=22n=70 Nicotine use36.568.268.6c>a, b>a At-risk drinker10.531.827.1c>a, b>a Cognitive screen4.2 (4.2)6.6 (4.8)4.8 (4.0)b>a Suicide12.513.628.6c>a Manic symptoms7.00.018.6c>a Psychotic symptoms9.99.121.4c>a PTSD27.018.237.1

17. Treatment

18. Depression Alcohol Aging Trial  Hypotheses  Among older adults with major depression and comorbid alcoholism, naltrexone combined with sertraline improves the outcomes of both drinking and mood.  Reduction in alcohol consumption will be associated with improved mood regardless of randomization.  Naltrexone will lead to a reduction in alcohol consumption independent of changes in mood.

19. Concurrent Treatment of Depression Complicated by Alcohol Dependence  Current depressive syndrome  Current alcohol dependence  Age 55 and over  10 sessions of compliance enhancement therapy  1/2 of subjects are randomly assigned to receive naltrexone 50 mg  All subjects receive sertraline 100 mg  Outcomes at 3 months (Oslin, 2004 )

20. Pre-Treatment Clinical Characteristics PlaceboNaltrexonep value HDRS Score23.4 (5.0)20.1 (5.7)0.011 Percent Days Heavy Drinking-75.8 (29.1)59.2 (35.6)0.032 Percent Days Drinking82.4 (24.5)75.5 (29.3)0.270 Drinks/ Drinking Day10.2 (6.8)6.5 (3.9)0.006 ASI-Alcohol Score0.67 (0.18)0.64 (0.17)0.433 PCS43.8 (8.5)46.1 (10.3)0.325 MCS33.2 (9.6)38.1 (11.5)0.061 % with Primary Depression68.665.70.799

21. Relationship between heavy drinking during the trial and depression outcomes No RelapseRelapsep Completed Research (%)83.784.00.886 Depression Remitted63.332.00.011 HDRS – end of trial8.8 (6.7)12.7 (8.2)0.013

22. Overall Treatment Outcomes

23. Substance Induced Depression in the elderly?  Less than 50% resolution of symptoms early in treatment  No relationship between clinical impression of primary vs. secondary depression and early response

24. Not just Dependence  Moving beyond DSM in conceptualizing risk

25. Disease and Behavior  Substance dependence  Follows the biomedical model of an illness  At-risk use  Public health model  Recognizes risks (health, economic, etc.) associated with use in individuals not suffering with the “disease”  Most relevant for alcohol, medications, marijuana and nicotine.

26. What about moderate or abusive drinking (non-dependent drinking)  Most common pattern of drinking among those with depression  May be beneficial for heart disease  Safety concerns may be less with newer medications (SSRIs) than older meds (TCAs)

27. Response to Standard Depression Care Among the Elderly  PROSPECT study  Remission of depression (men only)  Non-drinkers – 41 %  Moderate drinkers – 18.2%  PRISM-E study (preliminary)  Remission of depression (men only)  Non-drinkers – 33.8 %  Moderate drinkers – 6.3 % (Personal Communication, 2002)

28. Telephone Disease Management for Depression and At-Risk Drinking  To develop a method for delivering high quality depression and alcoholism treatment in Primary Care, CBOCs, and other clinics in which there are significant transportation, staff resource, or other impediments to the delivery of face-to-face MH/SA care.  To develop methods for translating effects demonstrated in randomized clinical trials to clinic populations.

29. Treatments  Telephone Disease Management is algorithm driven care delivered by a Behavioral Health Specialist.  Enhanced Usual care. The PCP can monitor, treat, and/or refer. The PCP is provided a diagnosis and references for treatment options.

30. Improvements with TDM Oslin, et. al. 2003

31. Is Sedative/Hypnotic Use a Co- Occurring Problem?  Association with falls  Association with memory impairment  ?Association with treatment of depression

32. How to Define Inappropriate Benzodiazepine Use  Chronic Use (>3 months)  Use of long-acting agents  Undocumented response  Lowest effective dose (harm reduction)

33. Sedative/Hypnotic Use A Disappearing Problem? M:W p= 0.0393, Positive: Negative p=0.002

34. Types of Sedative/Hypnotics Used Percent Xanax32.7 Ativan24.1 Restoril13.1 Klonopin11.1 Valium10.6 Librium6.0 Tranxene4.5 Barbituates2.0 Serax2.0 Dalmane1.0