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

What do we know?

0

5

10

15

20

25

30

35

40 "Gen X & Y"

"Baby Boomers"

"Greatest Generation"

Past Year Illicit Drug Use, by Age: 2002

Source: 2002 National Survey on Drug Use & Health (SAMHSA)

What do we anticipate seeing from the aging baby boomer generation?

What is a Baby Boomer?

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

3.1 4.99

16.7

25.731.2 35

40.2

54.6

71.5

0

10

20

30

40

50

60

70

80

num

ber

in m

illi

ons

1900 1920 1940 1960 1980 1990 2000 2010 2020 2030

Year (as of July 1)

Number of Persons 65+, 1900-2030

Source: A Profile of Older Americans: 2003, Administration on Aging, HHS

Changing Demographics: More ElderlyChanging Demographics: More Elderly

Estimated Cost of the Consequences of Substance Abuse Among Mature Women in

1998 - $22.3 Billion*

• 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

Only 2% was spent to treat the substance abuse problem itself.

*Does not include outpatient hospital visits, physician office visits and home health care.

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

What are some of the behavioral and sociological factors?

Americans are Living Longer

8481

7775.473.770.869.768.2

47.34045505560657075808590

1900 1950 1960 1970 1980 1990 2000 2025* 2050*

Year of Birth

Lif

e E

xpec

tanc

y at

Bir

th

*Projected

Sources: US Census Bureau and Centers for Disease Control and Prevention

Sex, Drugs & Rock ‘N Roll

Disposable Income

Fewer Family Responsibilities

Americans Are Living Better?

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

Source: IMS Health and Competitive Media Reporting, Inc

Just a Click Away - Drug Advertising is Ubiquitous

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

As Prescriptions Increase Emergency Room Visits For Non-Medical Abuse

Have Also Increased

Num

ber

of P

resc

ript

ions

(in

100

0s)

0

10000

20000

30000

40000

50000

60000

70000

80000

1994

1995

1996

1997

1998

1999

2000

2001

Source: SAMHSA, DAWN, 2002

Hydrocodone

Oxycodone

prescriptions

prescriptions

0

6000

12000

18000

24000E

D M

enti ons

emergency

emergency

Availability on the Internet Delivered in the Privacy of your Home

“Some reasons why you should

consider using this pharmacy”

No prescription required!

Are There Biological Factors to Consider?

How Does the Brain Change with Age?

Brain Changes Across the Lifespan

Sowell et al, Nature Neuroscience v 6,3 p 309, 2003

How Does Aging Affect the Pathways Associated with Substance Abuse?

Dopamine Pathways

Functions•reward (motivation)•pleasure,euphoria•motor function (fine tuning)•compulsion•perseveration

Serotonin Pathways

Functions•mood•memory processing•sleep•cognition

nucleusaccumbens

hippocampus

striatum

frontalcortex

substantianigra/VTA

raphe

Age-related reductions in D2 receptor binding in striatum

Source: Volkow, N.D. et al., Brookhaven National Laboratory.

2.0

2.5

3.0

3.5

4.0

4.5

5.0

5.5

6.0

10 20 30 40 50 60 70 80D

V(B

G)

/ D

V (

CB

)Age

r = 0.69, p < 0.0001(n = 25)

[11C]Raclopride24 years24 years

44 years44 years

86 years86 years

Age-related decline in dopamine transporter binding

2.0

2.3

2.5

2.8

3.1

3.4

10 20 30 40 50 60 70 80

DV

(BG

) /

DV

(CB

)

Age

r = 0.70, p < 0.0002

[11C]d-Threo Methylphenidate24 years24 years

44 years44 years

86 years86 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 Will age-related changes in brain function affect susceptibility to function affect susceptibility to reward or sensitivity to illicit reward or sensitivity to illicit

substances?substances?

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

Young Old

EtO

H I

nta

ke

(g/k

g/d

ay)

EtO

H P

refe

ren

ce

Can

nabi

noid

Ago

nist

Stim

ulat

ed

G-P

rote

in B

indi

ng

AmygdalaAmygdala

Old (26-48 weeks)

Young (6-10 weeks)

Limbic Limbic ForebrainForebrain

How does aging affect susceptibility to the toxic effects of drugs of abuse?

Modified from Miller et al., Annals of the New York Academy of Sciences 914 (1) 194, 2000

Age-related increases in methamphetamine-induced toxicity

How does early exposure to drugs of abuse affect the aging process?

What are the potential consequences?

Prolonged Drug Use ChangesProlonged Drug Use Changesthe Brain In Fundamentalthe Brain In Fundamentaland Long-Lasting Waysand Long-Lasting Ways

Science Has Generated A Lot ofEvidence Showing That…

Dopamine D2 Receptors are Lower in Addiction

DA

D2

Rec

epto

r A

vaila

bili

tycontrol addicted

Cocaine

Heroin

Alcohol

DA

DA

DA

DA DA DA

DA

Reward Circuits

DA DA DA DA

DA

Reward Circuits

DA

DA

DA

DA DA

DA

Drug Abuser

Non-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 Rats First Exposed to Nicotine in Adolescence Show Greater Sensitization to Cocaine Than Rats First Exposed as AdultsSensitization to Cocaine Than Rats First Exposed as Adults

Sources: Collins et al, 2004, Levin et al, 2003, NIDA Notes v19.2

*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.

Medical Consequences: Heart attacks Strokes

Cancer Psychiatric Disorders

Consumption becomes compulsive, despite negativesocial and health consequences

If in youth, drug addiction can cause serious medical complications…

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

What is the relationship between drug abuse and co-morbid conditions in the

elderly?

• Psychiatric disorders

• Neurological disorders

• Cardiovascular disease

• Cancer

• Kidney Disease

• Liver disease

• Musculoskeletal disorders

• HIV

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 THERAPIES with 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