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 Table of Contents  
EDITORIAL
Year : 2020  |  Volume : 36  |  Issue : 4  |  Page : 267-269

Substance abuse in the elderly: A hidden behemoth


1 Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
2 Department of Psychiatry and NDDTC, AIIMS, New Delhi, India

Date of Submission31-Oct-2020
Date of Acceptance17-Nov-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Subhash Das
Department of Psychiatry, Block D, Level V, Government Medical College and Hospital, Chandigarh - 160 030
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_394_20

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How to cite this article:
Das S, Sarkar S. Substance abuse in the elderly: A hidden behemoth. Indian J Soc Psychiatry 2020;36:267-9

How to cite this URL:
Das S, Sarkar S. Substance abuse in the elderly: A hidden behemoth. Indian J Soc Psychiatry [serial online] 2020 [cited 2021 Jan 18];36:267-9. Available from: https://www.indjsp.org/text.asp?2020/36/4/267/305948



India's elderly population is gradually on the rise and is expected to increase to 19% of the population in the year 2050 from the current proportion of about 8%.[1] Concurrently, the plethora of mental health issues in the elderly is also expected to rise. Disorders such as depression, anxiety, and dementia are quite common in the elderly.[2] However, there remains a constellation of other mental health issues in the elderly that may go unaddressed. The problem of substance abuse in the elderly is one such issue that may be overlooked. This can happen due to various reasons, that is, substance use being conceptualized mostly as a problem of the younger generation,[3] inadequate training which may lead to hesitation on the interviewer's part to explore the substance use problem in the elderly,[4] and underrecognition of substance use among the elderly due to denial on the part of the user who may not perceive substance use as a problem leading onto gross underreporting.[3] Some of the common substances of abuse in the elderly are alcohol, tobacco, opioid, and benzodiazepines.[5]

Benzodiazepines are commonly used medications in the elderly population. Benzodiazepines, mainly in the form of alprazolam and clonazepam, are commonly prescribed for insomnia and anxiety. These medications seem to have a good safety profile, a large therapeutic window, good efficacy in reducing the symptoms, and fast onset of action. However, tolerance develops to their effect over a period of time, leading to gradually escalating doses. The use of benzodiazepines typically starts as infrequent use of prescribed benzodiazepines, gradually increasing to daily usage, and then usage in increasing doses due to tolerance. A tussle may ensue between a physician who would like to reduce the dose, and the patient resisting a change as he/she experiences significant comfort with it. And the use continues, sometimes, with the accumulation of several prescriptions. Two side effects of benzodiazepines, that is, cognitive impairment and falls, are particularly problematic in the elderly population. Many of the elderly have age-related cognitive impairment or mild cognitive impairment or dementia, and use of benzodiazepines is likely to worsen it further. In addition, use of benzodiazepines may lead to lack of clarity in diagnosis when evaluation for cognitive impairment is being done. Abrupt cessation in the situations of medical ailments can result in withdrawal symptoms in the form of anxiety, sympathetic arousal, insomnia, and sometimes tremors.[6] In clinical populations, dependence may be difficult to establish as pharmacological tolerance may be there, but elderly users seldom report “deriving pleasure” as the motivating factor for continuing benzodiazepine use.

Opioid is another category of substances whose use in the elderly is linked often to medical comorbidities, at least in the Western world. Opioids are excellent pain-relieving agents, and their side effect profile, which is devoid of gastritis and nephropathy that are major issues with nonsteroidal anti-inflammatory drugs, makes these medications an attractive proposition to be used for severe and intense pain. However, the use of opioid medications has been rather constrained in developing countries like India, where underuse of opioid is more prominent than overuse. Physician caution, clinical practices, regulatory framework, and lack of demand from patients are some of the reasons of less frequent use of opioid. However, India does seem to have a cohort of opioid users, who have been using natural opioid (raw opium and poppy husk) for decades.[7] Before heroin became the dominant form of opioids being used in the country, raw opium and poppy husk (afeem and bhukki) were the common forms in which opioids were used in the region. The use of opium was socially sanctified in some situations, though some individuals did become dependent users and continued limited doses of opium for decades together. However, the dysfunction attributable to these natural opioids has been minimal, and has been mainly so in the form of financial burden accrued. As the supply of these “illicit” products waned, many of the elderly have been left in the lurch to get treated with pharmacological opioids to manage their withdrawal symptoms and function in their daily life. Detoxification is a considerable challenge in such patients as withdrawal symptoms cause intense discomfort. Opioid agonists seem to work as maintenance treatment in elderly patients with opioid dependence.[8],[9]

Alcohol and tobacco are two other commonly used substances whose use continues in the elderly.[10] Initiation of use of these substances generally begins in adolescence or adulthood. The use continues in the elderly age groups as well. However, the adverse consequences of alcohol and tobacco use are quite prominent in the elderly. Many of the chronic medical health conditions faced by the elderly such as coronary artery disease, chronic obstructive pulmonary disease, hypertension, neoplasms, and cerebrovascular diseases have alcohol and/or tobacco as their contributing factors. Alcohol and tobacco dependence generally run a chronic course with several remissions and relapses. Many of the elderly quit alcohol or tobacco use, at least temporarily, on the advice of the health-care professionals. However, many elderly individuals resume these substances again after a period of cessation, leading to worsening of the health condition.[11] Furthermore, agism often plays a role in the suggestions given to the elderly. It has been seen that many a times, the health-care professionals are concerned about the possible futility of making attempt to change tobacco- or alcohol-related behaviors in the elderly, thinking that it may not work, or may not make much difference to the overall outcome. However, addressing alcohol and/or tobacco dependence in the elderly may improve the quality of life and the course of some of the medical health conditions.

The problem of substance abuse in the elderly does exist and is generally hidden. What we see could be the tip of the iceberg. However, this problem is being gradually identified in the elderly population. Attempts have been made to curtail prescription misuse of drugs such as benzodiazepines. Guidelines suggest to limit the prescription of benzodiazepines in the elderly, using these medications for short periods only.[4] Serious attempts at de-prescribing of benzodiazepines should be made. Psycho-educating the users, who many a times have apprehension regarding stopping benzodiazepines, could be useful. Algorithm about such de-prescribing approach exists,[12] and could be followed even in the elderly. Misuse of prescription may also happen due to factors such as error in reading the prescription by the elderly, associated cognitive deficits, or frank dependence. Thus, thorough history taking, involving the caregivers, and writing legible prescription with simple instruction could help in such situations. In the elderly with dependence on benzodiazepines and similar drugs, the principles of management are more or less similar to that of the younger population, but more vigorous monitoring is required along with liaison for possible comorbid conditions. Various psychosocial interventions have been studied for cessation of benzodiazepines in the elderly, including cognitive behavioral therapy (CBT) and taper, motivational interviewing, advice by general practitioners, letters to patients, relaxation exercises, and electronically delivered counseling.[13] Among them, CBT with taper seems to show promising results over the initial 3-month period. As with benzodiazepines, de-prescribing has also been suggested for opioids, and found to be successful in many cases.[14] Assessment of pain and exploration of alternative interventions for management of pain, such as CBT, acupuncture, and other complementary and alternative medicine-based approaches, may reduce the quantum of opioids that are required by the elderly.

To manage the problem of alcohol withdrawal syndrome in the elderly is challenging; there is limited evidence on the efficacy of the various medications used. As the elderly are vulnerable to sedation and fall due to the use of benzodiazepines, these drugs should be used with caution and careful monitoring. Preferably, the short-acting benzodiazepines such as lorazepam and oxazepam should be used.[15] To control features such as agitation, if benzodiazepines are not enough, then haloperidol may be used with caution. During the maintenance phase to prevent relapse, drugs such as naltrexone, acamprosate, baclofen, and topiramate have been tried with varied level of success. Particularly, naltrexone is safe and useful for the elderly in the prevention of relapse.[15] In addition to pharmacotherapy, other measures such as psycho-education, motivational interviewing, and involvement with alcoholics anonymous are also useful in helping the older people overcome their problem of alcohol misuse, in clinical as well as settings like old-age homes.[15],[16]

Realizing that tobacco use results in serious health hazards in India, legislations have been passed from time to time. Smoking in public places has been banned; advertisement of tobacco products has been prohibited; and other measures have been taken to reduce the promotion, sale, and consumption of tobacco.[17] Despite this, the problem of tobacco use is rampant. Apart from the policymaking at public level, to tackle the menace at individual level, therapists can refer to the “Clinical Guideline: Treating Tobacco Use and Dependence” by the US Public Health Services. The “5 As” approach, “Ask” (to find out about the nature of the problem); “Assess” (to analyze the depth of the problem and find out about the motivation of the user); “Advise” (give proper instruction with clarity; often individualized); “Assist” (setting realistic goals and negotiating with the user to achieve it, using behavioral therapy, enhancing coping strategies, pharmaco-therapy–nicotine gum/lozenges, bupropion, etc.); and “Arrange” (follow-up, prevention of relapse), is quite useful in decreasing tobacco use.[17],[18]

Service delivery for elderly substance-using population is a challenge that needs to be handled. Limited mobility, dependence on others for material means, frailty and problems in organizing, and using transport may be some of the issues that are faced by the elderly. Two approaches can be particularly helpful in addressing these pragmatic challenges faced by the elderly population. One is integration treatment or intervention for addiction-related problems in the general medical setting and providing such services along with medical care for comorbidities such as diabetes and hypertension. Another approach can be to provide home-based care for elderly patients. Elderly individuals experience multiple treatment barriers which may deter them from seeking treatment. Providing home-based care may help to ameliorate many such treatment barriers. In clinical settings as well, accommodating elderly patients in ways possible and feasible, including minimizing appointment delays and wait times, dispensing medications for longer times, and providing counseling interventions on the bedside, would probably help provide better care for them. Elderly substance users are a hidden population, who might be better served by targeted identification and culturally responsive professional intervention to improve their overall health outcomes. Such intervention is likely to make the elderly have a positive and meaningful approach to life and would surely make them socially productive and capable of independent living, with lesser chances of being homeless, indulging in domestic violence, running into debt, and legal hassles.



 
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