Prescription Drug Nonmedical Use and Abuse in Older

Prescription Drug Nonmedical Use and Abuse in Older Women Drug abuse in the 21 st century: what lies ahead for the baby boomers? Linda Simoni-Wastila, Ph. D. University of Maryland, Baltimore School of Pharmacy National Institute on Drug Abuse Bethesda, Maryland September 16 -17, 2004 1

Introduction n Purpose: To review the evidence of illicit drug use among aging women Focus: prescription drug misuse and abuse u The Hidden Problem: u « Under-recognized « Under-screened « Under-treated 2

Today’s Discussion n n n Context: Older women and risk Substance use in older adults Prescription drugs with potential for misuse and abuse Continuum and extent of prescription drug use abuse Risk and protective factors Gaps in knowledge Conclusions - Implications for research 3

Older Women and Risk n Mature women may be particularly at risk for Rx misuse and abuse u u u n Greater likelihood for exposure Biology: body size; hormones; body fat; metabolic differences Propensity for care seeking propensity for treatment Consequences of Rx misuse and abuse u Cognitive impairment and increased sedation falls/injury; depression; suicide; interactions w/ alcohol and other drugs 4

Substance Abuse in Older Adults n n n Nearly 2. 8 M people aged 50 and older – or 3. 5% – have used 1 or more illicit substances in the past year Of these past-year users, 16. 0% (446, 844) may have illicit drug abuse or dependence problems u 262, 032 are male (58. 6%) u 184, 812 are female (41. 4%) Two substances of choice: u Prescription drugs u Marijuana (2002 NSDUH) 5

Substance Use - Type by Gender – 50 and Older (2002 NSDUH) 6

Substance Use in Older Adults n Alcohol use is also high in 50+ population – 2. 3 Million, or 14. 1%, meet criteria for alcohol abuse/dependency u 1. 84 Million are male (80. 0%) u 459, 000 are female (20. 0%) (2002 NSDUH) 7

Rx Drugs With Potential for Misuse and Abuse n Interest is only on those Rx drugs with abuse potential, a la CSA u Opioid analgesics (morphine, Dilaudid, Oxy. Contin, Darvon, Percocet) CNS stimulants (Ritalin, amphetamine) u Minor tranquilizers (Valium, Ativan, u Librium) u Sedative-hypnotics (Seconal, amobarbital, Noctec) 8

Continuum of Rx Use in Older Adults n Proper Use n Misuse (by patient and/or provider) n Abuse n Dependence (APA, DSM-IV, 1994) 9

Prescription Drug Misuse n n Any Rx drug can be “misused” Misuse = “Non-medical use” = Any use that is outside of medically prescribed regimen, eg: u u u Non-compliance Taking different dose Sharing Obtaining from non-medical source Taking for psychoactive effects Use with alcohol 10

Prescription Drug Abuse n Abuse = use resulting in Decline in work, school, or home performance u Legal problems u Use in risky situations u Continued use despite social/personal consequences (APA, DSM-IV, 1994) u 11

Prescription Drug Dependency n Dependency = use resulting in u u u u Tolerance Withdrawal sx Decline in normal activities Unsuccessful attempts to cut down or control use Use for longer period or larger amounts than intended Use consumes lot of time to acquire and/or recover from effects Continued use despite knowledge that it caused physical and/or psychological problems (APA, DSM-IV, 1994) 12

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Extent of the Problem: Medical Exposure n General US population 1 Women = 20. 0% u Men = 12. 5% u n Among elders aged 65 and older, 21. 7%, or 7. 22 M, receive at least 1 abusable Rx annually 2 Women = 24. 6% u Men = 17. 7% u 1 Simoni-Wastila et al, Sub Use and 2 Simoni-Wastila et al, under review, Misuse, 2004 14

Medical Exposure to Abusable Rx Drugs by Gender and Age Simoni-Wastila et al, under review, 2004 15

Extent of the Problem: Misuse n General population: 4. 0%, or 8. 27 M, misuse Rx drugs annually u u Opioids – 2. 4% (4. 84 M) Tranquilizers – 1. 5% (2. 98 M) Stimulants – 1. 1% (2. 35 M) Sedatives – 0. 9% (1. 84 M) Simoni-Wastila and Strickler, Am J Pub Health 2004 n Estimates of elder Rx misuse ranges from 0. 6% of elders (300 k) to >5. 0% (2. 8 M) 16

Extent of the Problem: Abuse and Dependency n General population: 0. 6 -0. 9%, or 1. 3 -2. 1 M individuals may be abusing Rx drugs u u Opioids: 0. 2 -0. 6% (1. 5 M) Tranquilizers: 0. 2% (509 k) Stimulants: 0. 2% (437 k) Sedatives: 0. 1% (155 k) Simoni-Wastila and Strickler, Am J Pub Health; 2002 NSDUH, SAMHSA n The elderly: ? 17

Risk Factors for Prescription Drug Misuse and Abuse General Population n Most consistent correlates in the general population for Rx misuse and addiction u u u u Female gender Young age Older age White race High SES Poor physical health Mental illness 18

Role of Gender in Rx Drug Misuse and Abuse n Females 1. 43 X more likely than males to misuse any Rx drug (95% CI 1. 19 -1. 69) u Driven by opioid analgesics (OR 1. 41) and minor tranquilizers (OR 1. 54) u Stat significance disappears when do not control for daily ETOH and illicit drug use Simoni-Wastila et al, Sub Use Misuse 2004 n Females 1. 49 X more likely than males to have abuse/dependency on Rx drugs (95% CI 1. 06 -2. 08) u Driven by opioid analgesics (OR 2. 00) and minor tranquilizers (2. 00) Simoni-Wastila and Strickler, AJPH 2004 n Gender NOT statistically significant predictor of stimulant or sedative-hypnotic misuse or abuse/dependency 19

Risk Factors for Rx Misuse and Abuse in Older Women n Among older women, possible risk factors include: u Social isolation u Lower SES and education u Poor health u Current or history of behavioral health problems u Loss of economic and social support u HC system factors 20

Social Isolation and Health Status Characteristic Annual Prevalence of Abusable Rx E+ Widowed/Divorced/Separated Married 24. 6% 19. 9% Lives Alone Lives w/ Spouse 23. 8% 20. 0% Poor/Fair Health Good/Excellent Health 34. 2% 18. 0% 0 ADLs 1 -2 ADLs 3 -4 ADLs 5 -6 ADLs 17. 1% 31. 0% 39. 0% 40. 7% Simoni-Wastila et al, under review, 2004 21

Baby Boomers “Come of Age” n n Current Problem: lack of knowledge of substance use in elders Substance use in elders will be a huge problem in < 20 years b/c boomers: u Accepting of alcohol and drug use Used more in youth « Use more NOW « u u Use more psychoactive Rx drugs now 3 -4 x more emotional disorders 22

Adults 50 and Older in Population and Needing Treatment (in millions) Gfroerer et al. , SAMHSA, 2003 23

Research Gaps n Data inadequacies u Lack of data sources u Small number of elders u Cross-sectional data u Lack of medical information n Definitional issues of misuse and abuse in elders 24

Diagnosis and Treatment Gaps n n n No screening/assessment tools specific to Rx drugs Dx and tx strategies not age- or gender-sensitive Efficacy of treatment modalities not tested in elders, women Absence of clinical guidelines Problems in organization and financing of health care 25

Conclusions n We need to better understand elder Rx misuse and abuse u u n Prevalence Diagnosis Prevention Treatment Older women are at special risk for Rx misuse and abuse u Gender- and age- specific risk and protective factors 26