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Helping elderly drug abusers.

The Department of Health and Human Services predicts that the number of seniors with substance abuse problems will rise by 150% by 2020. Because many of these patients are resistant to therapy, treating them can prove challenging. What strategies have you used in your practice that have proved effective with these patients?

Diagnosis Is a Big Problem

In our experience, the biggest problem in dealing with elderly drug abusers is the lack of diagnosis. For various reasons, including physicians' own biases, we either ignore or minimize this issue. If these disorders are not diagnosed, they will not be treated. Since the number of older adults with these problems has been increasing, psychiatrists need to be vigilant in their diagnosis and treatment of these disorders.

Another problem is the DSM-IV criteria for substance abuse in older adults. Often, the elderly have no employment, legal, or social problems because of substance abuse, but family members may shelter and minimize the elderly individual's substance use. By the time the patient is diagnosed, the substance use has worsened.

Many of these individuals have never been treated before, and they find it hard to acknowledge that their lifelong behavior is wrong and harmful. Motivational techniques that identify contradictions between what the patients are saying with what might be happening in their lives may be useful. Confrontation is not effective, and it may be counterproductive and drive them away. Grouping older adults with substance abusers who are younger and face different problems makes their connection with their peers and the program difficult, but an elderly group therapy session might be beneficial.

Assessment of these patients should include the reason for their use. Most alcohol- and drug-using patients can identify a particular reason for using, and once it is identified, it can often be treated with psychiatric medications.

Our experience suggests that older adults have underlying medical and psychiatric disorders that increase their substance abuse. Treatment of these underlying disorders promotes abstinence. Involvement of family members, restriction of their access to alcohol, restriction of their access to money, and referral to structured living facilities may be considered in extreme cases.

S. Pirzada Sattar, M.D.

Navdeep Baath, M.D.

Omaha, Neb.

Screening and Treatment Are Possible

According to one study, alcohol abuse and dependence occurs in 1%-3% of the U.S. population older than 65 years. Alcohol abuse and dependence among patients over 65 also occurs in about 5%-10% of primary care outpatient departments and 7%-22% of medical inpatients (J. Geriatr. Psychiatry Neurol. 2000;13:106-14). The 2000 National Health Interview Survey showed that 38% of men older than 55 years participated in moderate drinking, and 10% drank heavily. Of women over 65, 32% drank moderately, and 2% drank heavily (J. Stud. Alcohol 2003;64:884-92).

The CAGE questionnaire can be used to screen elderly patients for alcohol problems by asking only four questions:

* Have you ever felt you should cut down on your drinking?

* Have people annoyed you by criticizing your drinking?

* Have you felt bad or guilty about your drinking?

* Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

Besides developing a rapport with the substance-abusing patient, you may want to develop a relationship with his or her relatives and caregivers. They may be able to give you some insight.

Brief intervention strategies can be effective for substance abuse patients. At our Kaiser Permanente facility, we provide hospital detoxification, 30- to 60-day residential programs, and outpatient day and evening groups to provide education and counseling about the addictive disease process. Disulfiram (Antabuse), naltrexone (ReVia), and acamprosate (Campral) can be considered for older alcoholic patients, but they may already be on numerous medications, so a liver and renal function test should be ordered before prescribing.

Barry Solof, M.D.

West Covina, Calif.

Dr. Fink replies:

We usually think of the young as drug users and abusers, but drug and alcohol use spans the life cycle. Perhaps the stereotype relates to societal concern about children of 10 or 11 years who are introduced to marijuana, and our mental pictures of hippies and drop outs are of people in their teens or 20s.

A person who becomes addicted is often trapped in a vicious cycle of self-destructive behavior, attempts to become sober, treatment in rehabilitation centers, and a return to drugs. Addiction is a trap from which it is very difficult to escape. Addicts are usually great deniers, and drugs and alcohol are often used to help control severe anxiety or depression. The road to hell is clearly paved with good intentions, and an addict often finds it much easier to give in to the craving than to fight it.

All this is background to help us look at and understand the reality that addiction is a lifetime disease. Alcoholism is the most prevalent and perhaps the most vicious of the addictive disorders because it is legal and socially acceptable, and because a person who drinks goes into a stuporous state slowly and perhaps after everyone stops paying attention. Most older alcoholics start young, blame someone else for their addiction, and fill the air with meaningless promises of sobriety.

I know of one woman who was a heavy drinker all her life and wrought a great deal of damage on her children and her husband. She was in her 70s when her son came for treatment and told me how he would try to get from the front door to his room after school very quietly in the hope that Mom, who was drinking every day, would not emerge from her room to harass him or hurt him. He also hid from me that he was seriously addicted to alcohol, and at 40 years old he was well on his way to a life identical to his mother's.

Most big cities have eliminated their "skid row" but have not been able to rid themselves of the many homeless men and women who become street people or beggars. Often, psychiatrists skip over the drug and alcohol questions on intake because they automatically assume that there is a problem.

In many ways, what I have written applies to marijuana. Many people "dropped out" in the 60s and 70s to live a different lifestyle. Most of these individuals returned to society, but even though they may marry and succeed in business, they do not give up the nightly joint, which is rationalized in the same way as alcohol: "You enjoy your martini every night; I use marijuana instead." They are hooked, like every other addict using denial and rationalization to cover their trail.

I have seen a significant number of late adolescents and young adults who develop an amotivational syndrome, which is common and, to me, the most difficult symptom of marijuana addiction. They drop out and often cannot be retrieved.

Another devastating addictive substance is cocaine. It shows up at many "sophisticated" parties where those who "need" it indulge and try to persuade those who will not participate to do so. They may not even know they are addicted, but it is clear that the need is real and just covered with sophisticated talk to try to make it acceptable. Sigmund Freud and Sir Arthur Conan Doyle were both addicted for a period of time and attested to the control this drug had over them. I have no experience with elderly cocaine users, so I can not comment on a clinical case of a 60- or 70-year-old cocaine abuser.

The final drug category to mention is the opiates. This may be the most difficult habit for a user to break, and it is not confined to the young, although many heroin addicts die before they get a chance to reach old age as overdoses, deterioration in physical health, and violence reduce the population.

Drug addiction in any period of a person's life must have a long-term effect. The recognition of self-loathing that comes with being unable to stop are serious bariers. The inner sense of worthlessness is profound once you scratch the surface of a long-term addict and begin to see either the deep depression or the profound anxiety that emerges when the patient can be kept sober for a period of time.

Sometimes people will stop using under threat, such as a spouse threatening to leave and take the children. This could cause an individual to be more highly motivated to change, but a good psychiatrist must recognize the exquisite vulnerability that addicts have to insult or criticism. They can be crushed and run back to their substance, driven by a word or phrase that wounds them.

I believe age is irrelevant in efforts to get patients to reach sobriety. A family history of substance abuse is a major deterrent.

There is no doubt that life is tough. Escape is a self-destructive way of avoiding the pain of the hand we are dealt. No one is immune to marital strife, business reverses, serious illnesses, and loved ones getting sick and/or dying, but a tendency to develop psychiatric symptoms and a world that encourages the use of habit-forming substances make many in our society vulnerable. We often concentrate on adolescent abusers, but now we must carefully examine the use of drugs and alcohol throughout the life cycle.

Finally, consider a 51-year-old man who smoked marijuana from adolescence until recently. He used a lot of alcohol as well. All his four sons became addicted to marijuana, with one smoking himself into psychosis and another developing amotivational syndrome and "dropping out." Not only does this patient have the daily reality of his terrible situation but also the guilt related to his own behavior, from which he will never be able to escape.


DR. FINK is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia.

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The USA Network series called "Monk" showcases the investigative talents of a modern-day Sherlock Holmes whose OCD becomes more pronounced after the murder of his wife. The character's psychiatrist has used therapy and medication as treatment, to no avail.

For Discussion: Is this an accurate portrayal of OCD? Can trauma exacerbate the illness? Have you tried using cognitive-behavioral therapy as an intervention for your OCD patients?

Deadline: March 14, 2005

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Title Annotation:FINK! STILL AT LARGE
Author:Fink, Paul J.
Publication:Clinical Psychiatry News
Geographic Code:1USA
Date:Mar 1, 2005
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