1321 Duke Street
Background
Older adults are particularly vulnerable to misuse and abuse of prescription medications.
• Persons ages 65 and older make up less than 15 percent of the population but they consume about one-third of all prescription medications.1
• Many prescriptions for older adults are for psychoactive drugs with high abuse and addiction liability.2
• One in four older adults has used psychoactive medications with abuse potential, and such use is likely to grow as the population ages.3
Although illicit drug use is relatively rare among older adults compared to younger adults and adolescents, there is increasing evidence that prescription drug misuse and abuse is a growing problem in the older population. The prevalence of prescription drug misuse and abuse in older adults may be as high as 11%.3
Definitions
For our purposes, prescription drug misuse is the use of a medication other than as directed or indicated, including taking too little or too much of a drug, taking it too often, or taking it for too long, whether harm results or not.4
• Prescription drug misuse can be either willful or accidental.
• Non-adherence with a medication regimen is a broad category of prescription drug misuse. Prescription drug abuse refers to intentionally taking medications that are not medically necessary, or for the experience or feeling a drug causes.4
The pathway from appropriate medication use, through misuse to abuse can result from patient behavior, prescriber behavior, or both.3
PRESCRIPTION DRUG MISUSE
Increased medication use affords the opportunity for older adults to accidentally or intentionally misuse prescription medications.
Patient Behaviors
Prescription drug misuse by older adults can take many forms:3, 5
• Taking more of a drug than prescribed • Missing doses
• Not following instructions • Using drugs that have expired • Not knowing about side effects • Sharing or borrowing drugs • Taking the wrong drugs
• Using a drug for other than the prescribed reason • Combining drugs with alcohol or other
substances.
Prescriber Behaviors
Prescriber-related factors also place older adults at risk for prescription drug misuse, serious adverse effects, or abuse and dependence. Prescribing practices that are potentially dangerous include:3, 5
• ordering medications without adequate diagnoses or other indications for use,
• failure to consider the influence of aging on the effects of drugs in the body,
• prescribing multiple drugs from the same therapeutic class,
• prescribing a drug at a higher dose and/or for a longer duration than recommended,
• prescribing for too long a duration without appropriate monitoring of drug reactions and patient adherence with the prescribed regimen, • selecting drugs known to have a high risk for side
effects or that are potentially inappropriate for use in older adults,
• ordering drugs without knowing or reviewing whether they interact adversely with other medications the patient is taking,
• failing to determine whether the patient uses alcohol or other substances with abuse potential, and
• failing to provide adequate instructions for regarding how and when to take medications and what side effects to expect and report Consequences of Prescription Drug Misuse Prescription drug misuse can lead to:
• treatment failure6
• increased health resource utilization
• preventable emergency room visits and hospital admissions7, 8
• Increased health care costs8
• death9
Prescription drug abuse may proceed on a continuum from appropriate use for medical or psychiatric conditions through nonmedical use or misuse, to persistent abuse and dependence.
Risk of Prescription Drug Misuse
Most prescription drug misuse by older adults is unintentional and there are many factors that contribute to or increase the risk of misuse:5, 10
• The use of numerous medications for chronic conditions, frequently with uncoordinated care between multiple prescribers.
• Inappropriate prescribing (e.g., prescribing the wrong medication or an inappropriate dose). • Instructions and package inserts written in small
print or confusing language.
• Limited English language proficiency and low health literacy.
• Memory problems making it difficult to keep track of medication schedules.
• Hearing or vision problems that interfere with the ability to take medications correctly.
• Failure to tell the doctor about over-the-counter medications, vitamins and herbals.
• Willingness of doctors to prescribe drugs for sleeplessness, anxiety and depression without investigating and treating the root cause of these problems.
PRESCRIPTION DRUG ABUSE
The non-medical use of prescription medications in older adults is estimated to increase from 1.2 percent in 2001 (911,000 persons) to 2.4 percent in 2020 (2.7 million persons) - a 100% increase.13 This is related to
the growth in size of the baby boomer population, as well as to this group’s acceptance of and experience with both prescription drugs and illicit drugs.13
Data from the National Survey on Drug Use and Health indicate that nonmedical use of prescription medications is second only to alcohol abuse among adults older than 55.11
The Drug Abuse Warning Network (DAWN), which monitors emergency rooms across the nation, reported that emergency department (ED) visits involving drug misuse and abuse by adults aged 50 or older more than doubled between 2004 and 2008.12
• One-fifth of ED visits were made by persons aged 70 or older.
• Among all drug-related ED visits made by older adults, pain relievers were most commonly involved (43.5%), with narcotics being the most popular type, followed by drugs used to treat anxiety or insomnia (31.%) and antidepressants (8.6%).
• More than one-third of drug-related ED visits made by older adults misusing or abusing
pharmaceuticals resulted in a hospital admission; of these, nearly a quarter resulted in an
admission to the intensive care unit.
Nonmedical use of psychotherapeutic drugs among adults aged 50 years and older is projected to double over two decades, to 2.7 million by the year 2020,13, 14 with 4.4 million in need of substance abuse
Commonly Abused Medications
The most common prescription medications abused by people of any age are11
• Opioids—bind to opioid receptors in the central nervous system (CNS), resulting in inhibition of pain pathways;
• CNS depressants—decrease CNS activity
resulting in drowsiness, sedation, and hypnosis; and
• Stimulants— promote the release of dopamine and norepinephrine (primarily) from presynaptic nerve terminals causing CNS excitation.
Common Opioid Prescription Medications5, 12
Common drugs with abuse potential prescribed to older adults include benzodiazepines prescribed to treat insomnia and anxiety, opioid analgesics to manage pain related to arthritis and hip fractures, as well as alcohol. Misuse and abuse of over-the-counter medications without physician monitoring is also common.12 Many of these drugs can result in
dependence in the older adult. Using lower doses may decrease the risk of abuse or dependence. However, fear of addiction, both by the patient and their doctor often results in inadequate treatment of anxiety, insomnia and pain and opens the door to self-management and prescription drug misuse or abuse.3, 5
Commonly Prescribed Depressants5, 12
Consequences of Prescription Drug Abuse
Compared to younger adults, older adults who abuse medications can develop health problems due to increased sensitivity to medications, slower metabolism, a decrease in volume of distribution, and possible cognitive impairment, which makes self-monitoring of medication use and following directions from health care providers difficult. The misuse and abuse of psychoactive drugs by older adults can result in drowsiness, sedation, confusion, memory loss and other impairment of cognitive function16, which in turn may lead to falls and other
accidents17.
Organ systems can be damaged by prescription drug abuse and there may be a profound impact on the social and economic spheres of the older adult’s life, with negative impact on self-esteem, coping skills and relationships, adding to other cumulative life losses.
Generic Name Brand Name
morphine MS Contin®, Kadian®, Avinza® codeine Tylenol with Codeine®, Robitussin
AC®
hydrocodone Vicodin®, Lortab®, Zydone®
oxycodone OxyContin®, Percodan®, Percocet®, Tylox®, Roxicet® fentanyl Duragesic® Brand Name Benzodiazepines alprazolam clonazepam Valium® Xanax® Klonopin® Non-benzodiazepine sleep medications zolpidem eszopiclone zaleplon Ambien® Lunesta® Sonata® Barbiturates secobarbital mephobarbital pentobarbital Seconal® Mebaral® Nembutal
Once exposed to psychoactive drugs, older adults may be at greater risk for the development of dependence than their younger counterparts due to factors associated with aging.3 For instance,
with age the liver becomes less efficient at filtering out medications from the body. This slowed drug metabolism and elimination may cause an increase in medication sensitivity with smaller amounts of medication.19 Also, aging brains are more sensitive to
the effects of drugs that act on the central nervous system.
Risk Factors for Prescription Drug Abuse in Older Adults
Older women have been found to be at greater risk for prescription drug abuse than older men or younger women. Compared with older men, older women take more psychoactive drugs, especially benzodiazepines, and are more likely to be long-term users of these medications.5
Social isolation or loss of social supports, factors related to the provider and health care system, depression, and history of mental health problems or substance abuse may increase vulnerability for abusing prescribed medications.3, 5 Exposure
or access to prescribed medications with abuse potential may be the single greatest risk factor for prescription drug abuse by older adults.3
Families and caregivers may be able to help prevent abuse by being alert to the symptoms and early warning signs, and knowledgeable about the abuse potential of certain medications.11
Recognizing Prescription Drug Abuse
The older adult does not fit the typical drug abuser profile, and the signs of prescription drug abuse are less obvious in older adults than in younger people. Symptoms of drug abuse and dependence can be difficult to assess. Traditional signs of abuse (e.g. missed time from work, legal problems, etc.) are not as common in the older adult.
There are currently no validated screening instruments for identifying and diagnosing
drug abuse in the geriatric population,3 and the
guidelines and screening tests used are often designed for younger people and may not be easily applied to older adults.18
Many of the diseases caused by substance abuse – such as high blood pressure, stroke, dementia, or ulcers – are common disorders in later life, so health care providers and family members may not think of drug abuse as a cause.18
Many of the symptoms of prescription drug abuse mirror common signs associated with aging, such as shaky hands, mood swings, balance issues, confusion and memory loss, thus making it even harder to subjectively detect in older adults.10 Some
warning signs – such as sleep problems, falls, anxiety, depression, and memory problems – can also be signs of other health conditions. As a result, doctors and family members often do not realize that the person has a problem, and people may not get the help they need.
There are however, some very specific behaviors suggestive of drug abuse. Here are some warning signs to look for if you suspect an older adult has a drug problem:20, 21
• Excessive worry about whether mood-altering drugs are “really working”.
• Worrying about having “enough” medication on hand.
• Giving excuses as to why they need the pills. • Frequent requests for refills of certain medicines. • Self-medicating by increasing doses of
prescribed drugs that “aren’t helping anymore” or supplementing prescribed drugs with over-the counter drugs.
• Complaints about doctors who refuse to write prescriptions for medications they want. • “Doctor shopping” – moving from provider to
provider in an effort to get several prescriptions for the same medication.
• Paying for medications out-of-pocket rather than using prescription drug insurance.
• Behavior or mood change.
lifelong social practices.
• Sleeping during the day or signs of sleep disturbances.
• Falls or other unexplained injuries, which might be a result of excessive sedation.
• Changes in personal grooming and hygiene. • Remorse or concern about taking pills.
• Receiving the same medication from more than one physician or pharmacy at approximately the same time.
• Annoyance or discomfort when others talk about their use of medications.
• Sneaking or hiding pills.
Seniors who abuse medications acquire them in the same way as younger drug abusers, including forging or altering prescriptions, impersonating physicians on the phone, seeking out prescribers with a reputation for writing prescriptions under dubious circumstances, doctor shopping to obtain prescriptions from multiple prescribers, filling prescriptions at different pharmacies to evade detection, ordering medications from illegitimate internet pharmacies, frequent visits to the emergency department for vague complaints with the hopes of obtaining pain or anti-anxiety medications, and sharing or borrowing prescription drugs from family and friends.10, 11
PREVENTING PRESCRIPTION DRUG MISUSE AND ABUSE
A primary reason for continued escalation of prescription drug misuse and abuse is lack of
education among all segments, including physicians, pharmacists, and the public.22 For the older adult
population, addressing the factors related to willful and inadvertent misuse of prescription medication is a necessary part of prevention and early
intervention.10
With one-fifth of ED visits by older adults involving pharmaceutical misuse or abuse occurring among adults aged 70 or older, caregivers (e.g., adult children of aging parents) may be able to help prevent abuse by being alert to the symptoms and dangers. Education for caregivers about the abuse
potential of certain medications and the early warning signs of abuse may be needed.12
Tactics to prevent medication misuse and abuse include:10, 22, 24
• Improving medication adherence.
• Making sure that older adults understand how to take medications and what to avoid when taking a prescription medication.
• Encouraging older adults to share concerns and ask questions about their medication.
• Encouraging older adults to inform health care providers of all medications they take regularly. • Encouraging older adults to keep a current
medication list, including prescription drugs, OTC products, supplements and herbals AND provide it to all their health care providers.
• Providing aids, such as medication tracking charts and personal drug records.
• Addressing communication barriers, including low health literacy, vision and hearing
impairments and language barriers.
• Community informational and interventional support programs.
• Educating prescribers and other health care providers about the severity of the problem concerning prescription misuse and abuse. • Adequate treatment by health care providers
of the underlying medical problems that yield symptoms (e.g. insomnia, pain and anxiety) rather than just symptom management.
• Standardized screening protocols for physicians to assess for drug misuse or abuse.
• Transitional care programs and home-based medication reviews.
There is another, often overlooked, serious unintended consequence from prescription drug misuse. Older adults who keep large supplies of “leftover” medications in their medicine cabinets contribute to the risk for accidental poisoning of children who can access these drugs and provide a source of drugs for others to abuse. A majority of abused prescription drugs are obtained from family and friends,25 including from the home medicine
Questions to Ask23
Asking some simple questions can also uncover a substance abuse problem. For example, the CAGE questionnaire, originally developed for alcohol, has been modified to include drug use and has been tested in older adults with some success. CAGE includes four basic questions, with the modified version asking about drinking and drug use:
1. Have you felt you ought to cut down on your drinking or drug use?
2. Have people annoyed you by criticizing your drinking or drug use?
3. Have you felt bad or guilty about your drinking or drug use?
4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves, get rid of a hangover or, get the day started (as an eye-opener)?
Research suggests that answering yes to just one of these questions can identify a potential problem with substance use.
REFERENCES
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