Prescription Drug Abuse and Misuse in the Elderly

Thomas L. Patterson, Ph.D.

Support for this work: NIMH Center Grants P30 MH49693 and MH45131, and by the Department of Veterans Affairs

Number of Americans >65 (Millions)

70 60 50 40 30 20 10 0 1900 1920 1940 1960 1980 2000 2010 2020 2030 9 3 5 17 26 39 35 53 69

U.S. Bureau of Census

Drug Problems in the Elderly Current State of Affairs

Alcohol Illicit drugs Prescription/OTC

Prescription Drugs are consuming more health costs (Reinhardt et al., 2004)

Increased costs are related to use by elderly (Baugh et al. 2004)

Increased Spending primarily due to increased use

(Reinhardt et al., 2004)

Age and gender effect number of Meds taken (Linjakurapu et al., 2002)

Past decade has seen increased use of virtually all classes of meds (Linjakurapu et al., 2002)

Estimated Numbers of People with Psychiatric Disorders in USA

16 14 12 10
Millions

Age Group
>65 Years 30-44 Years

8 6 4 2 0 1970 1990 2010 2030

(Jeste et al., Arch Gen Psychiatry, 1999)

DAWN (2003)

Estimated Number (in thousands) of U.S. Residents (Age 12 and Older) Reporting Lifetime Non-Medical Use of Prescription Pain Relievers, 2003
Any Prescription Pain Reliever Darvocet, Darvon, or Tylenol with Codeine Vicodin , Lortab or Lorcet , Percocet, Percodan, or Tylox Codeine Hydrocodone Demerol Oxycontin Morphine Ultram Dilaudid 0 6,985 5,716 2,986 2,832 2,060 1,105 914
Estimated Number of Users (in Thousands)

31,207 19,672 15,717 10,811

5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000

*Prior to 2002, the NSDUH was known as the National Household Survey on Drug Abuse. Due to changes in the survey, estimates from the 2002 and 2003 NSDUHs should not be compared with estimates from the 2001 and earlier NHSDAs to assess changes over time. SOURCE: Adapted by CESAR from Substance Abuse and Mental Health Services Administration (SAMHSA), Overview of Findings from the 2003 National Survey on Drug Use and Health, 2004.

Large numbers of U.S. Population Misuse Prescription Drugs

Prescription Drug Abuse/Misuse

Most drugs for medical conditions Psychoactive drugs (e.g., benzodiazepine) most often abused in elderly
Inpatient addiction program; 16% prescription

Comorbidities
Prescription + alcohol Psychiatric diagnoses

Baby-Boomer impact unknown Problems identifying cases

Prescription drug abuse is probably underestimated by 20%

Problems in Defining Drug Dependence in the Elderly (DSM-IV) Criteria: Increased tolerance to effects of substance
changes in pharmacokinetics

Criteria: Report of adverse consequences (e.g., poor work performance, suspension from school etc.)
fails to consider lifespan changes

Abuse/Dependence in the Elderly

Factors associated with abuse
Genetics Stress Co-morbidities Metabolism

Structural Problems
Research not consider aged Dosage one size fits all

Age related changes in abuse

Maturing out Theory
Mortality Morbidity Maturational Factors

Until problems emerge difficult to ID Access to prescription drugs is changing

Prescription Drug Abuse

Prevalence affected by sampling
Increased in nursing homes and hospitalized Less evidence for ambulatory aged

Reason for misuse of meds

Difficulties reading and following prescription Cognitive deficits Cost Complexity of drug treatment

Prescription Drug Use

Types of misuse
Over dose Under dose Use for other than prescribed Drug combinations

Antipsychotic Adherence
Standardized Estimates of Annual Cost in Dollars Antipsychotic Adherence* Nonadherent (.01 - .49) Partially Adherent (.5 -.8) Adherent (.8 1.1) Excess Filler ( > 1.1) Hospital 3,413 (368) 2,689 (412) 1,025 (95) 2,472 (272) Outpatient 3,464 (175) 3,693 (208) 3,776 (151) 5,741 (312) Pharmacy 1,542 (107) 3,142 (110) 4,463 (161) 5,635 (188) Total 8,168 (433) 9,403 (542) 9,505 (289) 14,044 (561)

Gilmer, et al 2004

*Cumulative Annual Possession Ratio

Medical Care Expenditures Increasing

Under-use of Medications May be increasing (Archives of Internal Medicine, 2004)

Two-thirds of older patients reduce use of medications due to cost

Inappropriate use of 1197.pdf drugs effected by ethnic/cultural factors (Raji et al. 2003)

Meds may be purchased without prescription in Mexico and other countries.

The Internet is Becoming a Larger Source of Prescription Drugs

The internet has become a virtual wild west bazaar for spam emails and websites that sell controlled substances with little or no oversight.. DEA, 2004

General Information is available on many drugs (9/9/04)

There are many sites that sell prescription drugs (9/9/04)

Modified Swiss Cheese Model After James Reason

Healthcare System

Organization Local Care Environment Equipment & Tools

ADVERSE EVENT
Provider(s) Patient

EVENT TRAJECTORY

Modified Swiss Cheese Model After James Reason

Healthcare System

Organization Local Care Environment Equipment & Tools

ADVERSE EVENT
Provider(s) Older Patient

EVENT TRAJECTORY

Summary
Scope of use
30% of prescription consumed by 12% of population >65 years $15 billion/year in elderly (4xs younger individuals)

Abuse and misuse is a problem Estimates of scope of problem hindered by a number of factors Access to prescription drugs is easier than ever before

Specific Goals and Suggested Strategies

Improve diagnostic criteria Focus research on compliance Standardize prescription labeling Develop treatment programs tailored to elderly Consider dual diagnosis (e.g., PTSD & drug use) Explicate age related changes in drug abuse Examine impact of internet/foreign purchase of meds Examine ethnic and cultural differences