Substance Abuse in the Elderly – An Overview. Timothy P. Condon, Ph.D. Deputy Director, National Institute on Drug Abuse National Institutes of Health Department of Health and Human Services. Drug Abuse in the 21st Century - What Problems Lie Ahead for the Baby Boomers? Bethesda, Maryland
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Substance Abuse in the Elderly – An Overview Timothy P. Condon, Ph.D. Deputy Director, National Institute on Drug Abuse National Institutes of Health Department of Health and Human Services Drug Abuse in the 21st Century - What Problems Lie Ahead for the Baby Boomers? Bethesda, Maryland Thursday, September 16, 2004
Past Year Illicit Drug Use, by Age: 2002 Source: 2002 National Survey on Drug Use & Health (SAMHSA)
What is a Baby Boomer? • Those born between (and including) 1946 and 1964 (40-58 yrs old) • Currently represent 29% of the U.S. population
Changing Demographics: More Elderly Source: A Profile of Older Americans: 2003, Administration on Aging, HHS
Inpatient Hospital Charges ($10.1 Billion) Medicare - $8.5 Billion Medicaid - $338 Million Private insurers/individuals - $1.3 Billion Nursing Home Expenses ($12.2 Billion) Medicare - $1.4 Billion Medicaid - $5.8 Billion Private insurers/individuals - $5 Billion Estimated Cost of the Consequences of Substance Abuse Among Mature Women in 1998 - $22.3 Billion* *Does not include outpatient hospital visits, physician office visits and home health care. Only 2% was spent to treat the substance abuse problem itself. Source: CASA, Under the Rug: Substance Abuse and The Mature Woman, June 1998.
What are the cultural/societal factors that may impact differences in drug use and abuse in this generation as compared to the previous generation?
Birth cohorts that experience high rates of illicit drug use in youth or young adulthood have subsequently shown higher rates of use as they age, relative to other cohorts. Source: The NHSDA Report, Substance Use Among Older Adults; Nov 2001
Americans are Living Longer *Projected Sources: US Census Bureau and Centers for Disease Control and Prevention
Mid-Life Crises – Distress Over Getting Older • “50 is the new 30” • Physical impairments • Losses • Kids leaving house • Decreased physical prowess • Retirement
“Quick Fix” Society • More Treatment Options Available • Increased Availability of Medications • Less Stigma Associated • Advertising
Just a Click Away - Drug Advertising is Ubiquitous Source: IMS Health and Competitive Media Reporting, Inc
30% of Americans talked to their doctor about medicine they saw advertised.Of these, 44% received the prescription drug they asked about Source: Kaiser Family Foundation Understanding the Effects of Direct-to-Consumer Prescription Drug Advertising, November 2001
24000 prescriptions emergency 18000 12000 prescriptions ED Mentions emergency 6000 0 As Prescriptions Increase Emergency Room Visits For Non-Medical Abuse Have Also Increased Hydrocodone 80000 70000 Number of Prescriptions (in 1000s) 60000 50000 Oxycodone 40000 30000 20000 10000 0 1994 1995 1996 1997 1999 2000 2001 1998 Source: SAMHSA, DAWN, 2002
Availability on the Internet Delivered in the Privacy of your Home “Some reasons why you should consider using this pharmacy” No prescription required!
Brain Changes Across the Lifespan Sowell et al, Nature Neuroscience v 6,3 p 309, 2003
Dopamine Pathways Serotonin Pathways striatum frontal cortex hippocampus • Functions • mood • memory • processing • sleep • cognition substantia nigra/VTA • Functions • reward (motivation) • pleasure,euphoria • motor function • (fine tuning) • compulsion • perseveration nucleus accumbens raphe
[11C]Raclopride 6.0 r = 0.69, p < 0.0001 5.5 (n = 25) 5.0 4.5 4.0 DV(BG) / DV (CB) 3.5 3.0 2.5 2.0 10 20 30 40 50 60 70 80 Age Age-related reductions in D2 receptor binding in striatum 24 years 44 years 86 years Source: Volkow, N.D. et al., BrookhavenNational Laboratory.
Age-related decline in dopamine transporter binding 24 years 44 years 86 years Source: Volkow, N.D. et al., Brookhaven National Laboratory.
Age-related Decreases in Serotonin Transporter Binding Source: Yamamoto M.. et al., Life Sciences, 71, pp. 751-757, July, 2002.
Will age-related changes in brain function affect susceptibility to reward or sensitivity to illicit substances?
Old Young Old (26-48 weeks) Young (6-10 weeks) EtOH Preference Cannabinoid Agonist Stimulated G-Protein Binding EtOH Intake (g/kg/day) Limbic Forebrain Amygdala Age-related declines in cannabinoid receptor function in mice are linked to age-related declines in alcohol preference Source: Wang, Lei et al. (2003) Proc. Natl. Acad. Sci. USA 100, 1393-1398
How does aging affect susceptibility to the toxic effects of drugs of abuse?
Age-related increases in methamphetamine-induced toxicity Modified from Miller et al., Annals of the New York Academy of Sciences 914 (1) 194, 2000
How does early exposure to drugs of abuse affect the aging process? What are the potential consequences?
Science Has Generated A Lot of Evidence Showing That… Prolonged Drug Use Changes the Brain In Fundamental and Long-Lasting Ways
Cocaine Alcohol Heroin Dopamine D2 Receptors are Lower in Addiction DA DA DA DA DA DA DA DA DA DA DA DA Reward Circuits Non-Drug Abuser DA D2 Receptor Availability DA DA DA DA DA DA Reward Circuits control addicted Drug Abuser
Increased white matter lesions in cocaine dependent subjects with age Source: Bartzokis, G. et al., American Journal of Neuroradiology, 20, pp. 1628-1635, October, 1999.
Rats Exposed to Nicotine in AdolescenceSelf-Administer More Nicotine Than Rats First Exposed as Adults Sources: Collins et al, 2004, Levin et al, 2003, NIDA Notes v19.2
Rats First Exposed to Nicotine in Adolescence Show Greater Sensitization to Cocaine Than Rats First Exposed as Adults *Activity level after cocaine administration was measured by counting the number of times in 10 minutes each rat crossed light beams projected in a grid across its cage. Sources: Collins et al, 2004, Levin et al, 2003, NIDA Notes v19.2
Medical Consequences: • Heart attacks • Cancer • Strokes • Psychiatric Disorders If in youth, drug addiction can cause serious medical complications… Consumption becomes compulsive, despite negative social and health consequences What might be the effect in the elderly?
Elderly persons use prescription medications approximately three times as frequently as the general population Source: Patterson, et al. Psychiatric Times, April 1999.
What are the consequences of drug interactions (e.g. between prescription drugs and illicit drugs)?
How does aging affect drug disposition/metabolism? • Pharmacokinetics change with aging • Reduction in renal drug elimination resulting in increased drug serum levels and the potential for adverse drug reactions. • Volume of drug distribution decreases resulting in higher plasma concentrations. • Pharmacodynamic effects with aging • Neurotransmitter receptor properties may change with age. • Reduction in homeostatic mechanisms resulting in more time required to regain steady-state following drug therapy
Psychiatric disorders Neurological disorders Cardiovascular disease Cancer Kidney Disease Liver disease Musculoskeletal disorders HIV What is the relationship between drug abuse and co-morbid conditions in the elderly?
Some relevant issues in developing prevention, detection/diagnosis, and treatment programs for the elderly • Age-related brain changes • Changes in drug sensitivity • Use of different drugs • Side effects more severe/more of an issue • Different access to the drugs • Different settings (i.e. nursing homes) • Age-specific screening instruments needed • Stigma • Need better education re. prescription drugs • Data systems to track prescription use
PHARMACOLOGICAL THERAPIESwith a Strong Base of Scientific Evidence – NOT TESTED ON ELDERLY • METHADONE • NALTREXONE • BUPROPION • NICOTINE REPLACEMENT THERAPY • BUPRENORPHINE
Future Research • Research on animal models • Expanding longitudinal epidemiological studies to examine drug abuse in the elderly • Behavioral and sociological studies in aging populations and substance abuse. • Developing age-specific prevention programs, screening tools, and treatments • Brain imaging over life course