Special Populations in Addiction Psychiatry: The Elderly and Women

CONFERENCE COVERAGE

We are pleased to present this Q&A with Dr Louis Trevisan, who is part of a comprehensive review course titled “Addictions and Their Treatment” at this year’s American Academy of Addiction Psychiatry (AAAP) annual meeting.

Dr Trevisan is Associate Clinical Professor in the Department of Psychiatry at the Yale School of Medicine in New Haven, Connecticut. He is the Acting Chief of Psychiatry at VA Connecticut Healthcare System. He is certified in addiction and geriatric psychiatry and teaches in both the addiction and geriatric psychiatry fellowships at Yale University.

Q&A

Psychiatric Times (PT): What topic did you select for the AAAP meeting and why?

Louis Trevisan, MD (LT): I chose to lecture about elderly substance abuse and women and substance abuse because both groups are large and underserved in addictions. These two groups are part of our AAAP review course for the Addiction Boards, and I have been doing a form of this lecture for about five years now. I think that these two special populations are very important because they are usually unrecognized, underserved, and in general overlooked by the general psychiatrist, as well as the average addiction psychiatrist and geriatric psychiatrist.

Information about special populations can also be used by general practitioners/internists, advanced practice nurse practitioners, and allied health practitioners. If I can help spread the word that there is a problem in general with treating these patients and help practitioners recognize, assess and treat or appropriately refer these patients to a qualified clinician, then I have succeeded to a degree.

PT: What aspects of addiction do you plan to cover?

LT: I will cover the epidemiology, recognition, assessment, and treatment of substance  use disorder in the elderly and in women. I will talk about these populations in general terms and in specific terms with emphasis on tobacco, marijuana misuse, alcohol use disorders, and prescribed medication misuse, as well as other illicit drugs.

Prescribed medication misuse is a huge problem in this country, and women and the elderly are not exempt. It is therefore essential that psychiatrists conduct proper screening for use and misuse of alcohol and prescribed opioid and sedative medications. Screening will be covered, as well as a discussion on instruments and techniques that clinicians can use to screen and assess the need for treatment. Methods to engage the elderly and women in appropriate treatments will be discussed. Evidence-based pharmacological treatments and evidence-based therapies as well as 12-step programs are efficacious in these two special populations. Additionally, this is a theme that will pervade the entire course.

PT: Some who consider themselves “medication management only” psychiatrists may wonder how addiction psychiatry is relevant to them. Can you tell us about that?

LT: I think that most “medication management” psychiatrists would agree that when you are prescribing medications, it is very important to know if someone is using or misusing medications or illicit drugs, alcohol or tobacco, or has a significant history of abusing prescribed medications, alcohol, tobacco, or illicit drugs. I think the day psychiatrists take a narrow view of their patients has long departed.

Many people out there are being prescribed all types of medications. We are a pill-oriented society and it is never more evident than in the growing cohort of older Americans in “baby boomer generation.” They have been exposed to more medications, alcohol, marijuana, and other illicit drugs than any previous cohort.

We are seeing baby boomer aged patients in increasingly greater numbers. They have pain problems, they are aging, and additionally they are driven to extend their productive life span and are living longer than any other generation to date. They continue to be exposed to opioid medications for chronic pain, as controversial as this is. So it is of the utmost importance that all physicians and allied health professionals learn about substance abuse, its prevalence, how to screen for it and at least how to refer to an appropriate clinician for further assessment and treatment.

PT: Why should adult psychiatrists be informed about special populations in addiction psychiatry?

LT: We go through profound biological and psychosocial changes as we age, and we often experience many life-altering changes, including: retirement, loss of a spouse, and the development of perhaps chronic medical problems. Women are unique and have special needs in many health-related aspects, not to mention specifically in terms of substance use and abuse. In the cases of the elderly and women, the guidelines for the consumption of alcohol changes as we age.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) suggests that after the age of 65, moderate use of alcohol is characterized by one drink per day or no more than 7 drinks per week for both men and women.1 Consuming more alcohol than this may be termed “hazardous consumption.” This is a decrease for men, but not for women.

Many men do not adapt to this and with retirement continue or increase their drinking. Women seem to be more susceptible to the use of alcohol, as they do not metabolize alcohol in the same way that men do. Their volume of distribution is smaller, and therefore, they have more of an alcohol effect for a smaller amount consumed.

Women appear to have decreased oxygenation of ethanol (decrease ADH activity) in their gastric lining, therefore allowing a greater amount of alcohol to reach the blood prior to a first pass effect of the liver. Consequently, women seem to be much more susceptible to the ravages of prolonged alcohol use or misuse and their course can “telescope.”

Our country is fast becoming and has really always been a melting pot of different ethnic groups, some of whom have acculturated easily and others who are more marginalized and underserved. Ethnic groups with different unique cultural overlays have different biological interactions with as well as personal and group approaches to substance use and abuse. For example, Native Americans, Asian Americans, African Americans, and Hispanic Americans do not seek treatment or respond to treatment in the same way as Caucasian Americans.

These are just a few of the issues that are relevant to adult general psychiatrists as well as primary care clinicians. Another group that is important is LGBT. These issues are also discussed in “Addictions and Their Treatment” by a psychiatrist who is expert in this topic, Petros Levounis, MD.

In summary, obtaining a history that is informed by age, gender, sexual orientation, and cultural/ethnic history and attempting to understand the patient within the context of their special population will be critical to screening for drug-related problems and developing a successful, tailored alcohol or drug referral strategy and treatment plan.

Suggested Readings:

Offsay J. Treatment of alcohol-related problems in the elderly. Ann Long Term Care. 2007;15:39-44.

Oslin DW. Treatment of late-life depression complicated by alcohol dependence. Am. J Geriatr Psychiatry. 2005;13:491-500.

Liberto JG, Oslin DW. Early versus late onset of alcoholism in the elderly. Int J Addict. 1995;30:1799-1818.

O’Connell H, Chin AV, Hamilton F, et al. A systematic review of the utility of self-report alcohol screening instruments in the elderly. Int J Geriatr Psychiatry. 2004;19:1074-1086.

Walitzer KS1, Dearing RL. Gender differences in alcohol and substance use relapse. Clin Psychol Rev. 2006;26:128-48.

References:

1. Sobell LC, Sobell MB. Alcohol Consumption Measures. National Institute on Alcohol Abuse and Alcoholism. August 2004. http://pubs.niaaa.nih.gov/publications/AssessingAlcohol/measures.htm. Accessed November 20, 2014.