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326 Substance Use in Older Adults
Benzodiazepines (continued)
overdose, 102–103, 216, 218–219,
228
paradoxical reactions to, 102, 218
polypharmacy, 106
prevalence of use, 11, 214
public health interventions, 231–
232
risks associated with, 40
safe prescribing practices, 98
safety concerns, 102–104
tapering, 229
time course of use, 217–218
use disorder, 220, 225–226
withdrawal, 63, 111, 217–219,
227–228, 233
Benzoylecgonine, 252
Bereavement, treatment of, 217
Best possible medication history
(BPMH), 93, 94, 115
Binge drinking, 10, 40, 61, 70, 127,
129, 137, 147
Blood alcohol concentration, 127
BPMH (best possible medication
history), 93, 94, 115
BPSD (behavioral and psychological
symptoms of dementia), 280
Brief Intervention and Treatment of
Elders (BRITE), 61–62, 68
Brief interventions
alcohol use disorder, 144–145
overview, 58, 61–62
See also SBIRT (screening, brief
intervention, and referral to
treatment)
Brown Bag Medicine Review
strategy, 91, 116
Buprenorphine
cocaine use disorder, 262
disparities in access, 302–303
dosing, 202
formulations, 201
naltrexone compared, 203
opioid use disorder, 200–202, 201,
207–208
pain management, 312
safety concerns, 101–102
use in case examples, 191, 194–
196
use with benzodiazepines, 104
Bupropion
for cocaine use disorder, 259,
for methamphetamine use
disorder,
for smoking cessation, 173, 174
Buspirone, 261
CAGE (cutting back, annoyance,
guilt, eye-opener), 31, 136–137
CAGE-AID, 31, 33, 34
Canadian Coalition for Seniors’
Mental Health (CCSMH), 127,
149
Cancer
heavy drinking associated with,
132
tobacco-related, 161, 165, 168
Cannabidiol (CBD), 41, 277–281
Cannabinoids, 275–292
FDA-approved uses, 279
medical use in older adults, 277–
281
preparations and their
physiological effects, 277–279
safety concerns with medical use,
280–281
See also Cannabis
Cannabis hyperemesis syndrome
(CHS), 62, 275, 283–285, 284, 291
Cannabis use
alcohol use with, 276
cannabis hyperemesis syndrome
(CHS), 62, 275, 283–285, 284,
291
cognition effects, 14
comorbidities, 13
epidemiology, 276–277
interventions, overview of, 60
intoxication, 62, 275, 281–282,
284, 291
257–258
260
Index 327
medical marijuana, 276–277, 279–
281, 286, 290
prevalence, 11, 104, 160
resources, 291–292
routes of administration, 277
safety concerns, 104
screening and assessment, 285–
287, 286, 288
temporal patterns, 276
withdrawal, 275, 283, 284, 287,
289, 291
Cannabis use disorder
clinical presentation, 281–285,
284
diagnostic criteria, 285, 285–287
epidemiology, 276
management, 287, 289–290
screening and assessment, 285–
287, 286, 288
Cannabis Use Disorder Identification
Te
st-Revised (CUDIT-R), 33, 287,
288
Cannabis–medication interactions,
41
Capacity, decision-making, 304–305,
314–315
Carceral settings, 310–311, 314
Cardiovascular disease
alcohol use, 133
cocaine use, 246
methamphetamine use, 243–244
smoking association, 161, 165
Caregiver
addressing concerns of, 37, 222
as barrier to SUD identification,
15, 28
communication with, 93, 94, 95,
113, 204, 289
involvement in management of
SUD treatment, 57, 107, 109,
115, 226
Case example
alcohol use disorder, 130–131
cocaine use, 247–248
cultural assessment, 296, 298–299
medication reconciliation and
review
, 95–97
methamphetamine use and
psychosis,
opioid use disorder, 190–191,
193–196
palliative care, 313
persuasion to begin treatment,
309–310
sedative, hypnotic, or anxiolytic
use disorder, 223–224, 229–230
self-reflexivity, 300
trauma-informed care, 73–74,
78–79
Cathinones, 241
CBD (cannabidiol), 41, 277–281
CBT. See Cognitive-behavioral
therapy (CBT)
CCSMH (Canadian Coalition for
Seniors’ M
Centers for Disease Control and
Preventio
CFI (Cultural Formulation
Intervie
Chamomile, 231
Change, stages of, 65, 66
Checklist for clinicians, 80
Cholinesterase inhibitors, 106, 114
CHS (cannabis hyperemesis
syndrome), 62, 275, 283–285, 284,
291
Civil commitment, 305–309
Clinical Institute Withdrawal
Assessment for Alcohol
protocol,
Clonazepam, 103, 285
alprazolam switched to, 224, 228
case example use of, 96–97, 224,
229–230
tapering case example, 229–230
Cocaine
crack, 242–243, 247, 261, 263
mechanism of action, 243
methamphetamine compared, 250
source, 242, 263
245–246
ental Health), 127, 149
n, 100, 178, 206, 291
w), 296, 297–298, 298
139
328 Substance Use in Older Adults
Cocaine use
case example, 247–248
clinical presentation,
complications, and course,
246–248, 250
comorbidities, 13
epidemiology, 242–243
opioid use comorbidity, 194
prevalence, 11, 242–243
Cocaine use disorder
pharmacological interventions,
258–263
antipsychotics, 259
anxiolytics, 261
cognitive-enhancing drugs,
261
dopamine agonists, 259
muscle relaxants and anticon-
vulsants, 260–261
opiate agonists, 262
psychostimulants, 259–260
prevalence, 243
See also Stimulant use disorder
Coercion, 309
Cognitive impairment, 14
alcohol use, 133
cannabis use, 279–282
comorbid neurocognitive
disorders, 68–69
sedative, hypnotic, or anxiolytic
use, 218–220
stimulant misuse, 249
topiramate associated with, 143
See also Neurocognitive disorders
Cognitive screening tools, 42, 43
Cognitive-behavioral therapy (CBT),
66–67
alcohol use disorder, 145
anxiety management, 231
cannabis use disorder, 289
for insomnia, 227
opioid use disorder, 204–205
sedative, hypnotic, or anxiolytic
use disorder, 227
stimulant use disorder, 254–256
Cognitive-enhancing drugs
cocaine use disorder, 261
deprescribing, 114
Columbia Suicide Severity Rating
Scale (C-SSRS), 46, 69
Commitment, 305–309
Community reinforcement, for
stimulant use disorder
Comorbidities
alcohol use disorder, 131–132
assessing, 38–43, 42
management, 68–69
neurocognitive disorders, 68–69
opioid use disorder, 192–196
overview, 12–13, 13t
psychiatric, 41–43, 42
psychiatric disorders, 68
Competence, 299
Complementary and alternative
ine
medic
opioid use disorder, 205
sedative, hypnotic, or anxiolytic
use disorder, 231
tobacco cessation interventions,
176
Complications of substance use, 11–12
Compulsivity, 6, 8
Conditioned reinforcement, 5–6
Confusion, new-onset, 63, 80
Consequences of substance use, 11–
12
Contingency management, 67
cannabis use disorder, 289
opioid use disorder, 204
stimulant use disorder, 254–256
Crack cocaine, 242–243, 247, 261, 263
Craving(s)
in addiction stages, 6
cannabis, 285, 287
stimulant, 246–247, 250–251, 253,
261, 264
strategies for handling, 66
tobacco, 162–164, 163, 171
C-SSRS (Columbia Suicide Severity
Rating Scale), 46, 69
, 16, 249
, 254–256
Index 329
CUDIT-R, 33, 287, 288
Cues, reducing, 66
Cultural assessment, 296–300, 313–
314
Cultural competence, 299
Cultural concordance, 304
Cultural Formulation Interview
(CFI), 296, 297–298, 298
Cultural humility, 299, 313
CYP2C9, 41, 280–281
CYP2D6, 100, 101, 281
CYP3A4, 100, 101, 103–104, 200, 280–
281
Cytochrome P450 (CYP450) iso-
enzymes, 100, 101, 103–104, 130,
174, 200, 280–281
DAST-10 (Drug Abuse Screening
Test, 10-item), 249
Decision-making capacity, 304–305,
314–315
Defense mechanisms, 29, 29
Delirium, 48, 111, 132, 165, 198, 218, 223
Delirium tremens (DTs), 14, 139, 233
Dementia
alcohol use relationship, 14, 133
Alzheimer’s, 114, 133, 165, 219,
249
behavioral and psychological
symptoms of dementia
(BPSD), 280
benzodiazepine use, 14, 217, 219
cannabinoids for, 280
deprescribing antipsychotics, 113
deprescribing cognitive
enhancers, 114
polypharmacy, 106
risk increase with methamphet-
amine misuse, 249
risk increase with smoking, 14,
165
vascular, 165, 249
Denial, 8, 15, 28, 29
Dentition, methamphetamine use
effect on, 244, 246, 263
Dependence, 2, 16
nicotine, 162–163
risk, 99–100
tobacco use, 162–163, 169, 171,
175
Deprescribing, 108–114
antipsychotics, 113–114
benzodiazepines, 111–112
cognitive enhancers, 114
decision support systems, 108
goals of, 108
guidelines, 108
opioids, 109–111
stimulants, 112–113
Depression
opioid use comorbidity, 194
screening for substance use
com
orbidity, 41, 42
Detoxification
alcohol, 63, 138–139, 142, 144
benzodiazepines, 63, 228
enzymes necessary for, 7
opioid, 56, 193, 198–199
Dexamphetamine, 257, 260
Diabetes, as opioid use comorbidity,
194
Diagnosis
detailed history, obtaining, 46–47
differential, 48
DSM-5-TR criteria, applying, 47–
48
making, 46–48
Diazepam, 99, 103, 112, 199, 215
Dietary supplements, safety concer ns
with, 104–105
Differential diagnosis, 48
Diphenhydramine, 215
Discussing substance use, 30–31
Disparities in treatment, 302–304, 314
Disulfiram, 141, 142–143, 261
Donepezil, 69
Dopamine
agonists, 144, 259
reward system, 6,
stimulant effects on, 243, 246, 250
140
330 Substance Use in Older Adults
Doxepin, 96–97
Driving safety, 70–71, 282
Driving under the influence (DUI),
70, 131, 282
Dronabinol, 278–281, 283, 289
Drug Abuse Screening Test, 10-item
(DAST-
10), 249
Drug holidays, 112
Drug testing, 34, 35
Drug–drug interactions, 100–105,
101
Drug–medication interactions, 38–41
DSM-5-TR criteria, applying, 47–48
DTs (delirium tremens), 14, 139, 233
Early-onset substance use, 29, 56
Elder abuse, screening for, 43
Elder Abuse Suspicion Index (EASI),
43
Electronic cigarettes (e-cigarettes),
160, 175
Endocannabinoid system, 6, 283
End-of-life care, 312–313
Epidemiology, 10–11
Epidiolex, 279
Epigenetics, 7, 15, 17
Epinephrine, 243
Escitalopram, 96–97
Eszopiclone, 104
Ethnic disparities in treatment, 302–
304, 314
Ethyl glucuronide, 37
Etiology, 5–10
neurobiology and physiology,
5–8
psychosocial, psychological, and
personality factors, 8–9
social determinants and
structural factors, 9–10
Evidence-based treatment, 27, 55, 79
Faces and Voices of Recovery, 208
Faces Pain Scale, 36
Fall risk assessment, 36
Falls, 71–72
False-positive results on urine drug
test,
34, 35
Familismo, 304
Family history, 36
Family support, 254, 304
Fentanyl, 10, 100, 202–203, 248–249
in case examples, 191, 193, 195, 310
concurrent substance use, 249, 264
safety concerns, 101
Flumazenil, 228
FRAMES model of motivational
interviewing, 61
Functional assessment, 36
Gabapentin
alcohol use disorder, 141, 143
cannabis use disorder, 289
case example use of, 96–97
cocaine use disorder, 260
complications of use, 219–220
methamphetamine use disorder,
257
polypharmacy, 106
Garlic, 105
GAS (Geriatric Anxiety Scale), 225
Generalized anxiety disorder
benzodiazepines for, 217
case example, 223–224
(GAD-7),
Genetics, 7, 15, 36, 72, 254
Geriatric Anxiety Scale (GAS), 225
Geriatric Depression Scale, 225
Geriatric Evaluation Team: Substance
Misused Abuse Recognition and
Treatment (GET SMART), 145
Gingko biloba, 105
Ginseng, 105
Go system, 6
Goals of treatment, meaningful, 30–31
Grief, treatment of, 217
Hallucinogen intoxication, 62–63
Health Insurance Portability and
Accountability Act (HIPAA), 64
225
Index 331
Helpline
National Alliance on Mental
Illness (NAMI), 233, 265
Substance Abuse and Mental
Health Services (SAMHSA),
50, 149, 209, 234, 265, 315
Hemp, 278
Herbal/nutritional supplements
safety concerns, 104–105
sleep aids, 215
History, obtaining detailed substance
use, 46–47
Hyperemesis, 62, 275, 283–285, 284,
291
Hyperthermia, cocaine-induced, 247
Hypnotics
tapering off, 228
See also Sedative, hypnotic, or
anxiolytic use dis
Hypothalamic-pituitary-adrenal
A) axis, 6
(HP
Ibuprofen-induced acute kidney
injury, 96
Identity, 296
Incentive salience, 5–6
Insomnia
alcohol use, 132
antipsychotics use, 113–114
benzodiazepines for, 215
cognitive-behavioral therapy
(CBT) for, 227
orexin antagonists, 220
safely addressing, 98
tapering benzodiazepines, 111–
112
zolpidem for, 289
Institute for Healthcare
Improvement, 93
Instrumental activities of daily living
(IADLs), 36
Interventions
brief (see Brief interventions)
medication, 67
overview, 59–60
order
psychosocial, 65–67
serving minoritized groups
better, 303–304
See also specific substance use
diso
rders
Intoxication
cannabis use, 275, 281–282, 284,
291
decision-making capacity, short-
term, 305
managing, 62–63
overview of interventions, 59–60
Involuntary treatment
commitment, 305–309
effectiveness, 307–308, 314
Iowa Pain Thermometer-revised
(IPT-R), 36
Korsakoff syndrome, 14, 43, 63, 132
Laboratory investigations
alcohol use assessment, 136
overview, 37
See also Urine drug test
Language
as barrier to care, 303
to reduce/avoid stigma, 2–3
15, 17–18, 30
Late-onset substance use, 29, 56
Levamisole, 248
Lithium, 113, 289
Loneliness, 8, 15, 73–74, 164, 171
Long-term-care facilities, 311
Lorazepam, 62, 99, 102–103, 139, 215,
230
Lung disease
crack lung, 247
tobacco smoking-associated, 165
Management, 55–82
alcohol use disorder, 138–147, 141
brief interventions, 58, 61, 61–62
cannabis use disorder, 287, 289–
290
checklist for clinicians, 80
, 3,
332 Substance Use in Older Adults
Management (continued)
ocmorbidities, 68–69
neurocognitive disorders, 68–69
psychiatric disorders, 68
FRAMES model of motivational
inte
rviewing, 61
of intoxication, 62–63
opioid use disorder, 197–205
overview, 56–57, 59, 60
principles of effective treatment,
58
sedative, hypnotic, or anxiolytic
use disorder, 226–231
stimulant use disorder, 252–263
threats to safety, 69–72
driving safety, 70–71
falls, 71–72
suicidality, 69–70, 71
tobacco use, 169–176
trauma-informed care, 72–79
aspects of, 74–78
case study, 73–74, 78–79
retraumatization, avoiding,
76–78
treatment of SUDs in older
adults, 64–67, 65
cognitive-behavioral therapy
(CBT), 66–67
effective care, 65
medication interventions, 67
motivational interviewing, 61,
65–66
mutual-help groups, 67
psychosocial interventions, 65–
67
stages of change, 65, 66
of withdrawal, 63–64
Mandated treatment, 305–308
Marchman Act, 305
Marijuana
medical, 276–277, 279–281, 286, 290
recreational, 276–277, 282, 285
See also Cannabis
MAST-G, 33, 137
MAT (medication-assisted
treatment), for OUD, 188, 191,
196, 199–200, 204
Mazindol, 260
Medical history, 36
Medical marijuana, 276–277, 279–
281, 286, 290
Medicare, 5, 280
Medication access, 302
Medication Appropriateness Index, 88
Medication interventions, 67
Medication reconciliation (MedRec),
93–95,
94
case example, 95–97
errors, 95
steps, 93, 94
Medication reconciliation and
review, 91–97, 94
Medication review (MedRev), 93, 95
Medication-assisted treatment
(MAT), for OUD, 188, 191, 196,
199–200, 204
Medications
fall risks, 71–72
interaction with substances of
abuse, 38–41
safe prescribing practices, 87–116
See also Polypharmacy
Medications for OUD (MOUD), 198–
199, 207–209
access in carceral settings, 310, 314
access in long-term-care facilities,
311, 314
disparities in access, 302, 304,
314
Melatonin, 112, 215, 231
Memantine, 114, 261
Mental Health Parity and Addiction
Equity Act (2008), 5
MEOS (microsomal ethanol-
oxidizing system), 129–130
Meperidine and drug–drug
interactions, 99–101
MET (motivational enhancement
therapy), 226–227, 289
Metabolism
age-related changes, 11, 16, 138,
213, 218, 233
Index 333
alcohol, 7, 129–130, 147
benzodiazepine, 103
cannabis, 41, 278
opioid, 100
Methadone, 200
cocaine use disorder, 262
disparities in access, 302–303
pain management, 312
safety concerns, 101, 102
use with benzodiazepines, 104
Methadone maintenance treatment
(MMT), 194–195
Methadone maintenance treatment
programs (MMTPs), 200
Methamphetamine
cocaine compared, 250
mechanism of action, 243
Methamphetamine use
acute effects of, 243, 244
case example, 245–246
clinical presentation,
complications, and course,
243–246, 244, 250
epidemiology, 242
overdose, 242
prevalence, 11, 242
Methamphetamine use disorder
pharmacological interventions,
256–258
antidepressants, 256–257
antipsychotics, 257
muscle relaxants and anticon-
vulsants, 257
naltrexone, 257–258
psychostimulants, 257
prevalence, 242
See also Stimulant use disorder
Methylphenidate, 257
Michigan Alcoholism Screening
Test–Geriatric Version (MAST-
G), 33, 137
Microaggressions, 76–78
Microsomal ethanol-oxidizing
system (MEOS), 129–130
Mindfulness, 231
Mirtazapine
for cocaine use disorder, 259
for methamphetamine use
der, 257
disor
Misuse
definition, 220
of medications, 99–100
MMT (methadone maintenance
treatment),
MMTPs (methadone maintenance
treatment pr
Modafinil, 257, 260
Montreal Cognitive Assessment
(MoC
Mood stabilizers, 113
Morphine, safety concerns with, 100–
101
Motivational enhancement therapy
(MET), 226–227, 289
Motivational interviewing, 58, 65–
66
alcohol use disorder, 145
cannabis use disorder, 289
FRAMES model of,
opioid use disorder, 204–205
persuasion to begin treatment,
309–310
sedative, hypnotic, or anxiolytic
use disorder, 226–227
stimulant use disorder, 253–255
Motivations, of older adults, 66
MOUD (medications for OUD), 198–
199, 207–209, 302, 304, 309–311,
314
Muscle relaxants
cocaine use disorder, 260–261
methamphetamine use disorder,
257
Mutual-help groups, 67, 79
alcohol use disorder, 146
opioid use disorder, 205
Nabilone, 278–280, 283, 289
Nabiximols, 279, 289
Naloxone, 111
194–195
ograms), 200
A), 131, 225
61
334 Substance Use in Older Adults
Naltrexone
alcohol use disorder, 140, 141,
142
cocaine use disorder, 262
disparities in access, 302–303
methamphetamine use disorder,
257–258
opioid use disorder, 202–204
NAMCS (National Ambulatory
Medical Care Survey), 106
Narcotics Anonymous, 205
National Alliance on Mental Illness
(NAMI) helpline, 50, 149, 209,
233–234, 265, 315
National Ambulatory Medical Care
Survey (NAMCS), 106
National Behavioral Health
Network, 178
National Cancer Institute, 177–178
National Council on Aging, 82
National Institute on Alcohol Abuse
and Alcoholism (NIAAA)
18, 81, 127, 148–149
National Institute on Drug Abuse
(NIDA), 17–18, 265, 291, 315
National Patient Safety Goals of the
Joint Commission, 93
Negative affect, 5–6, 16, 66
Neuroadaptation, 5–6
Neurobiology of SUDs, 5–8
Neurocognitive disorders
driving safety, 70–71
screening for, 41, 42, 43
substance use and, 14
as SUD comorbidities, 68–69
See also Dementia
Neuroimaging, 37
Neurotransmitters, 6–7, 243, 247
Nicotine
addiction, 169
dependence, 162–163
sources of, 160
terminology of use, 162
withdrawal, 164–165, 174
See also Toba cco u se
, 17–
Nicotine replacement therapy (NRT),
163, 169, 172–174, 173, 177
NIDA Quick Screen, 225
Nortriptyline, 174
Nussbaum, Abraham, 308–309
Olanzapine, 245–246
Opiate agonists, for cocaine use
der, 262
disor
Opioid crisis, 301, 313
Opioid use disorder (OUD), 187–209
case examples, 190–191, 193–196
clinical presentation and course,
188–196
comorbidities, 192–196
complications, 192
definition, 190
diagnostic criteria, 188–190, 190,
196
disparities in treatment, 302–304
involuntary treatment, 306, 308
in long-term-care facilities, 311
management, 197–205
complementary and alterna-
tive medicine, 205
detoxification, 198–199
pharmacological interventions,
199–204, 201
psychoeducation, 197–198
pyschotherapeutic and psy-
chosocial interventions,
204–205
medication-assisted treatment
(MAT), 188, 191, 196, 199–200,
204
overview of interventions, 59
pharmacological interventions,
199–204, 201
buprenorphine, 200–202, 201
naltrexone, 202–204
in prison population, 310–311, 314
problematic opioid use, 188, 188–
189, 190, 196, 208
public health interventions, 205–
207, 206
Index 335
in residential treatment facilities,
311–312
resources, 208–209
SBIRT (screening, brief inter-
vention, and referral to
treatment),
screening and assessment, 196–
197
withdrawal, 189, 190–191, 195,
197–198, 200–201, 203, 205,
208
Opioids
as cocaine adulterants, 248–249
coprescription of
benzodiazepines and
opioids, 103–104, 216, 226
deprescribing, 109–111
detoxification, 56, 193, 198–199
dosing in older adults, 99
drug–drug interactions, 100–101,
101
overdose, 99–100, 103, 110–111,
188, 192, 197, 199, 201, 207–
208, 242, 306, 309–311
polypharmacy, 106
prevalence of use, 10
problematic opioid use, 188, 188–
189, 190, 196, 208
problematic use, 188, 190
safe prescribing practices, 99
safety concerns, 100–102
withdrawal, 63–64, 109, 142
Orexin antagonists, 215, 220
OTC medications
drug–medication interactions, 40
hypnotics, safe use of, 98
safety concerns, 104–105
sleep aids, 215
OUD. See Opioid use disorder
Overdose
benzodiazepines, 102–103, 216,
218–219, 228
deprescribing medications, 108
110–111
methamphetamines, 242
198, 208
opioids, 99–100, 103, 110–111, 188,
192, 197, 199, 201, 207–208,
242, 306, 309–311
PDMP to identify risk, 40
predictors of, 301
sedative, hypnotic, or anxiolytic
use, 218–219, 224, 228
Oxazepam, 139
Oxycodone, 100, 193, 215, 313
Pain
assessment, 36
comorbidity to substance use, 39
deprescribing opioids, 109–111
medical marijuana for, 280
opioid use disorder, 192–193
palliative care, 312–313
problematic opioid use, 188
safely addressing, 98–99
Palliative care, 312–313
Patient Health Questionnaire-9
(PHQ-9), 225
PDMPs (prescription drug
monitoring pr
196–197
Personal Well-Being Index, 194–195
Personality disorder, 13
Personality factors, 8–9
Persuasion, 309
Pharmacotherapy
alcohol use disorder, 139–144, 141
opioid use disorder, 199–204, 201
overview of maintenance
interventions, 59–60
sedative, hypnotic, or anxiolytic
use disorder, 227–229
tobacco use, 172–175, 173
Physical examination,
comprehensive, 36
Physiological changes related to
aging, 38, 87–88, 89–90, 129–130
Physiology of SUDs, 5–8
Polypharmacy, 38–39, 87, 114–115
,
addressing, 105–107, 107
antipsychotics, 113
ograms), 40, 91,
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