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Professor Ilana Crome Keele University 21 March 2013 Thanks to colleagues and friends Prof Peter Crome Dr Tony Rao Dr Martin Frisher Dr Roger Bloor Dr Alex Baldacchino Drs Ishbel Moy & Harvinder Sidhu, our future! And many other collaborators… Professor Ilana Crome Dr Karim Dar Dr Stefan Janikiewicz Dr Tony Rao Dr Andrew Tarbuck OVERVIEW Why is it important What current research tells us How do we deal with it now The future Peter’s contributions Peter’s Principles Style - Non judgemental, non confrontational Demystify and destigmatise What’s special and distinctive? Proactive and positive Evidence and uncertainties Chronic disease - resilience but vulnerability Dignity, integrity, (e)quality and compassion Substance misuse is: WHY IS IT IMPORTANT? WHY IS IT IMPORTANT? Scale of the problem Burden of disease Lifespan issue Mortality Financial costs Societal impact CONTEXT Older people will constitute ~25% of the UK population by 2020; currently 18% over 65s Overall increase in older people using alcohol and illicit substances over past decade National surveys of alcohol, illicit drugs, prescription drugs, presentations to Accident and emergency units, presentations to specialist services, hospital admissions (poisoning, drug related mental disorders, alcohol related physical disorders) Prediction: set to double in the next 2 decades How much do older people use? 13% men,12% women over 60 still smoke Smoking largest cause of premature death 45% NHS prescriptions for over 65s, twice Alcohol consumption above adult ‘safe limits’: 20% in men, 10% in women over 65 Highest alcohol death rate in aged 55-74 5% over 45s used any illicit drug over the previous year, 0.7% used a Class A drug Increasing over 40s coming into treatment – 17% in drug treatment units are over 40 EUROPEAN DISEASE BURDEN ATTRIBUTABLE TO SELECTED LEADING RISK FACTORS (2000) Blood pressure Tobacco Alcohol Cholesterol High Body Mass Index Fruit and vegetable intake Physical inactivity Illicit drugs 0 5000 10000 15000 20000 Number of Disability-Adjusted Life Years (000s) Most difficult to give up (among those who consume in previous year) 50 40 30 20 10 0 tobacco alcohol cannabis heroin ecstasy LSD NIGHT LIFE AND RECREATIVE DRUG USE IN EUROPE A study in 10 European Cities 1998 Lifespan perspective Early life difficulties – maltreatment, distress – associated with substance use disorder and psychiatric comorbidity 90% people who use substances problematically have started before the age of 19 Addiction can be a life long problem Cannabis case grandmother is spared prison Peter’s contribution NO LONGER ONLY A YOUNG MAN’S DISEASE ILLICIT DRUGS May 2011 POISONING - ANTIDEPRESSANTS May 2011 POISONING - PARACETAMOL May 2011 PERSPICACITY May 2011 SOURCE: British Beer and Pub Association 2008 Year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 Alcohol Consumption in the UK in litres per head Per capita alcohol consumption in the UK, 1984-2008 9.5 9 8.5 8 7.5 7 Alcohol-related mortality per 100,000 in the UK from 1984 – 2008 trebled 15 14 13 Mortality per 100,000 12 11 10 9 8 7 6 Year SOURCE: UK Office of National statistics, the Scottish Government and the Northern Ireland Department of Health. 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 4 1984 5 Harms and costs ALCOHOL - all time high DRUGS 3rd leading cause of death Increased for a decade £15 billion per annum £21 billion per annum 300,000 children 1 million children 3% - £ 0.5 bn – NHS £2.7 billion - health ~£7 billion crime-related 6% - £1bn - deaths 90% is due to crime £6.4 bn - workplace Family, friends and wider communities - not quantified – child protection, divorce, homeless COSTS – GREATER FOR OLDER More than 10 times -The cost of alcoholrelated inpatient admissions in England for 55 to 74 year olds was £825.6m compared to £63.8m for 16 to 24 year olds in 2010/11. 8 times as many 55 to 74 year olds (454,317) were admitted as inpatients compared to 16 to 24 year olds (54,682). The cost of alcohol-related inpatient admission was £1,993.57m, over 3 times greater than the cost of A&E admissions, £636.30m. The cost of alcohol-related inpatient admissions for men was £1,278.4m, just under double the cost for women, £715.1m. PRICING AND POLICY HARMS Distinctive issues Substance use decreases with age, but can be more dangerous Older people are at increased risk of the adverse physical effects as substances accumulate due to decreased metabolism Brain sensitivity to drugs may be increased Women metabolise faster; more severe effects earlier, present later; more comorbidity May not have dependence eg withdrawal Distinctive issues INTERACTIONS AND MISTAKES Physical and mental health problems – eg sleep, anxiety, pain - hypnotics, anxiolytics and analgesics with abuse potential Complexity, long term chronic disorders Self management in partnership – embedded in preventative, communities and team based, continuity, responsive, flexible coordinated and integrated Precipitants and complications Self harm a serious risk Psychiatric problems associated with substance use eg intoxication, withdrawal, dependence, anxiety, depression, psychosis, cognitive dysfunction Psychosocial factors eg bereavement (spouse, friends, family), retirement, boredom, loneliness, homelessness, loss of income, Alcohol with symptoms PETER HAS SEEN ALCOHOL PROBLEMS IN MEMORY CLINIC Memory problems 22.5% Sleeping problems 38.5% Feeling sad or blue 16.8% Tripping, falling 17.8% Gastrointestinal 24.1% Physicians should notice alcohol use complications Hypertension Depression Gout Diabetes Ulcer disease Liver condition Pancreatitis 30% 12% 7.6% 5.2% 4.1% 3.5% 0.6% Alcohol with medications Antihypertensives Ulcer medications NSAID Antiplatelet Non-prescription Antidepressants Sedatives Opioids Nitrates Warfarin Seizure 31.7% 18.2% 17.9% 17.3% 12.7% 11.9% 10.1% 6.7% 4.3% 4.4% 0.6% BARRIERS TO DETECTION – AND HOW TO RESPOND Training – competence, screening tools Stigma, moral weakness – non-judgmental, non-confrontational Under-reporting – comprehensive history Mis-attribution of symptoms, underdiagnosis – awareness of subtle presentations, high index of suspicion Ageism – ‘that is all she has left’ Stereotyping – older, higher social class, more educated, women DETECTION - AWARENESS Altered/erratic behaviour or symptoms Poor response to treatment for medical illness, request for prescription drugs, sharing, storing Past personal history/family history of substance misuse & legacy of personal, legal, occupational deficits Illegal activities THE 5 A’s ASK – all drugs, dependence, ambivalence, non-judgemental ASSESS – motivation, goals, complications ADVISE – ‘brief intervention’ – feedback, information, self help material ASSIST – coping strategies, hope, self esteem ARRANGE – admission – severe addiction, polysubstance, social, comorbidity, relapse DAPA-PC Drug and Alcohol Problem Assessment for Primary Care (Blazer) Computerized screening system quickly identifies substance problems in primary care Can be used by psychiatrists as well DAPA-PC is self administered, internet based, automatic scoring Generates patient profile for medical reference Presents unique motivational messages and advice for the patient Information technology Save clinicians’ time Patients to be screened in the waiting room Clinician to follow-up with a patient only when prompted by the results of screen Computerized screening may lend itself to a more honest revelation regarding drug use compared with face-to-face discussions. Acceptability of computers by the elderly will only increase.’ Peter has been interested in this for a long time CURRENT RESEARCH WHAT DOES IT TELL US? Alcohol dependence was last among 30 medical conditions in proportion of care received as evidence would recommend Senile cataract Breast cancer Prenatal care Hypertension Asthma Diabetes Mellitus Urinary Tract Infection Atrial Fibrillation Alcohol Dependence 78.7% 75.7% 73.0% 64.7% 53.5% 45.4% 40.7% 24.7% 10.5% Source: McGlynn E., et al., (2003). The quality of health care delivered to adults in In the United States. New England Journal of Medicine, 348. Trials and guidelines Usually dictated by clinical trials Complex patients excluded ie unrepresentative samples eg older, substance users, comorbidity Combined treatments rarely studied Guidelines are not for older people May 2011 May 2011 Peter’s first randomised clinical trial! May 2011 Pharmacological treatment Medication Licensed Age limits Specific old age Diazepam Alcohol withdrawal Not in children <half adult dose In anxiety Chlordiazepoxide Alcohol withdrawal Not in children < half adult dose for anxiety Disulfiram Alcohol deterrent Not in children None Methadone Opiate addiction Not in children Caution Subutex Opiate addiction >16 years None Lofexidine Opiate detox’n Not in children Caution NRT Nicotine withdrawal > 18 years None Bupropion Smoking cessation > 18 years Caution Pharmacological treatments Need to diagnose dependence Management of withdrawal symptoms Maintenance of abstinence eg methadone, buprenorphine;nicotine replacement, bupropion Prevention of complications Relapse prevention Psychiatric conditions eg depression Physical conditions eg diabetes Ishbel Moy Martin Frisher Peter Crome Ilana Crome Overview of Study Findings Myths dispelled Value in treating older adults Physicians can help Brief Advice and Motivational Enhancement are equally successful for both older and adult population Respond positively Have the capacity to change Number achieving follow-up goal is at least as good as compared with younger adults Effective treatment in elder-specific or adult programme – could do even better Overview of Study Findings Good outcomes in substance use, mental and physical health, and social function Both older men and women are capable of achieving abstinence if given access to alcohol abuse programs Should be encouraged to seek treatment for substance dependence Recovery prospects encouraging, long-term management further research Older age should not be a barrier to addressing drinking problems - something Peter has done Addiction Research Unit Comprehensive assessment Single detailed counselling session Follow up to check on progress Basic treatment scheme of 3 hours of assessment and advice is effective in reducing alcohol problems in moderately dependent drinkers Motivational interviewing/enhancement Non-confrontational principles and style Increase effectiveness of more extensive psychosocial treatments Could be effective as preparation for more intensive treatments Potentially more cost effective COST EFFECTIVENESS benefits – saving of £5 for every £1 invested Social benefits also Alcohol interventions are highly cost effective in comparison with other health care interventions Economic ‘Safe’ limits No such thing as a safe limit Adult safe limits may not apply For some healthy older people, 1 US (14 gm alcohol) drink a day, and no more than 7 a week (UK unit = 8 gm IE 1.5 units daily) More than 3 US drinks a day is harmful Should not drink and drive, swim, use machinery. Should eat before drinking Drink more slowly ie over two hours For those with comorbid conditions, on medications, no alcohol may be appropriate Under review by the Chief Medical Officer Key Issues for Doctors Prevention of disease of later life Prevention of functional decline Early identification of disease with rapid response Supporting participation Application of evidence-based approaches Ageing, multiple pathology, vulnerability and resilience Key Issues for Older People Finance Housing Food Warmth Family Work Health Participation and functional status Cognitive decline TRAINING – ROLE MODEL, KNOWLEDGE, SKILLS, ATTITUDES May 2011 Training Not an optional extra – improve attitudes, reduce stigma, reverse therapeutic nihilism Royal Medical Colleges - Undergraduate, specialist post graduate, continuing professional development - competencies Multidisciplinary specialists - Old age psychiatrists, geriatricians, addiction specialists, nursing, psychology, social care and other allied professionals The future – not only baby boomers! A UK based research programme on older substance misusers Prescription drug use Any particular intervention, specific programme, service model can be recommended - over long term Policy implementation RCPsychiatrists Information Guide – Peter is contributing A question of values? Dignity, integrity, compassion and (e)quality Health eg mental illness, cognitive impairment Life circumstance eg poverty, in prison, family conflict, social isolation Behaviour eg substance misuse, crime Status eg older, victim of abuse, refugee, immigrant Personal quality eg low self esteem, impaired functional life skills 19 March 2013 Guardian