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336 Substance Use in Older Adults
Polypharmacy (continued)
definition, 39, 105–106
prescription cascades, 106
Prescribing practices, safe, 87–116
for anxiety and insomnia, 98
assessment tools, 88, 91
Brown Bag Medicine Review
strategy,
deprescribing, 108–114
antipsychotics, 113–114
benzodiazepines, 111–112
cognitive enhancers, 114
opioids, 109–111
stimulants, 112–113
drug–drug interactions, 100–105,
101
medication reconciliation and
re
misuse or dependence, risk of,
99–100
for pain, 98–99
physiological changes related to
aging, 87–88, 89–90
polypharmacy, 105–107, 107
safety concerns
benzodiazepines, 102–104
buprenorphine, 101–102
cannabis, 104
coprescription of benzo-
herbal/nutritional supple-
methadone, 102
opioids, 100–102
OTC medications, 104–105
z-drugs, 104
start low, go slow mantra, 88
summary, 92
Prescription cascades, 106
Prescription drug monitoring
progra
197
Prevalence of substance use in older
adults, 4, 10–11
Prison, 310–311, 314
91, 116
view, 91–97, 94
diazepines and opioids,
103–104
ments, 104–105
ms (PDMPs), 40, 91, 196–
Privacy protections, 64–65
Problematic opioid use, 188, 188–189,
190, 196, 208
Project ECHO, 199
Protective factors
for SUDs, 38
for suicide, 43, 44–45
Psychiatric comorbidity, 41–43, 42, 68
opioid use disorder, 193, 199
sedative, hypnotic, or anxiolytic
use disorder, 229–230
Psychoeducation
opioid use disorder, 197–198
sedative, hypnotic, or anxiolytic
use disorder,
stimulant use disorder,
tobacco use, 170, 171
trauma symptoms, normalizing,
76
Psychological factors, 8–9, 15
Psychosis
case example, 245–246
cocaine, 248
methamphetamine use, 245–246,
252
Psychosocial factors, 8–9, 15
Psychosocial interventions, 65–67
alcohol use disorder, 144–147
cannabis use disorder, 289
opioid use disorder, 204–205
overview of interventions, 59–60
sedative, hypnotic, or anxiolytic
use disorder, 226–227
stimulant use disorder, 254–256
tobacco use, 170–172
Psychostimulants, for methamphet-
amine use disorder, 257
Psychotherapeutic interventions
opioid use disorder, 204–205
sedative, hypnotic, or anxiolytic
use disorder, 226–227
tobacco use, 170–172
Psychotropic medications, safely
prescribing, 87–116
PTSD, 8, 13, 41, 102, 110, 225, 229–230
226
254
Index 337
Public health impact, 3–5
Public health interventions
opioid use disorder, 205–207, 206
sedative, hypnotic, or anxiolytic
use disor
tobacco use, 176
QT prolongation, 102, 200–201
Quitlines, 176, 178
Racial disparities in treatment, 302–
304, 314
Racism, structural, 303
Recreational marijuana, 276–277, 282,
285
Referral, 56
Reinforcement, conditioned, 5–6
REMS (risk evaluation and mitigation
strategy) program,
Required Organizational Practices of
Ac
creditation Canada, 93
Residential treatment facilities, 311–
312
Retraumatization, avoiding, 76–78
Reward
circuit/pathway, 6, 15–16, 254
contingency management
incentives, 204
dopamine-mediated, 6, 140
noncontingent, 256
for tobacco use cessation, 170, 171
Risk factors
for SUDs, 38
for suicide, 43, 44–45
Routines, establishing trust with, 75
SAD PERSONS scale, 46
Safety, managing threats to, 69–72
driving safety, 70–71
falls, 71–72
suicidality, 69–70, 71
Safety plan, for suicide risk
reduction, 70
SAMHSA. See Substance Abuse and
Mental Health Services
der, 231–232
202
SAMI, 33
Satisfaction With Life Scale, 194–195
SBIRT (screening, brief intervention,
and re
ferral to treatment), 4, 15,
79
alcohol use and use disorder,
144–145
BRITE, 61–62, 68
medication use disorder, 225
opioid use and use disorder, 198,
208
overview, 61–62
psychiatric comorbidities, 41–43,
42
SBI, 61
suicide risk assessment, 43–46,
44–45
Screen of Drug Use, 249
Screening
alcohol use disorder, 136–137
background, 26–27
barriers to identification, 27–30
28–29
cannabis use, 285–287, 286, 288
definition, 26
opioid use disorder, 196–197
recommendations, 26–27
sedative, hypnotic, or anxiolytic
use disorder, 225–226
stimulant use disorder, 249–252,
253
tobacco use, 165–168, 165–169
Screening Tool of Older People’s
Prescriptions (STOPP), 88, 91
Screening Tool to Alert Doctors to
Right Treatment (START), 88, 91
Sedative, hypnotic, and anxiolytic
use, 213–234
complications in older adults,
218–220
drug classes and medications,
215
epidemiology, 214–216
indications for use in older
adults, 216–218
,
338 Substance Use in Older Adults
Sedative, hypnotic, and anxiolytic
use (continued)
misuse, 220
overview of interventions, 60
resources, 233–234
safe prescribing practices, 98
Sedative, hypnotic, or anxiolytic use
disorder, 220–232
case examples, 223–224, 229–230
diagnostic criteria, 221–222
management, 226–231
complementary and alter-
native medicine, 231
pharmacological interventions,
227–229
psychoeducation, 226
psychotherapeutic and psy-
chosocial interventions,
226–227
overview, 220–224
prevalence, 216
psychiatric comorbidity, 229–230
public health interventions, 231–
232
screening and assessment, 225–
226
withdrawal, 214, 217–219, 222,
223–225, 227–228, 231, 233
Self-Management and Recovery
Training (SMART Recovery),
146, 205
Self-reflexivity, 299–300
Serotonin, 6, 243, 246
Serotonin syndrome, 100–101, 105
Sertraline
for cocaine use disorder, 258–259
for methamphetamine use
er, 256–257
disord
Short Michigan Alcoholism
Screening Test–Geriatric Version
(SMAST-G), 33, 137
Signposting, 30
Sleep aids, 215
Sleep disorders, complementary and
alternative medicine for, 176
Sleep hygiene, 98, 227
Sleep quality, 39
SLUMS (St. Louis University Mental
Status), 96
SMART Recovery (Self-Management
and Recovery T
205
SMAST-G, 33, 137
Smoking. See Tobac c o use
Smoking cessation, 7, 14, 68, 164–176,
173
Social capital, 301
Social determinants
of health, 9–10
of substance abuse, 301–302
Social history, 35–36
Social isolation, 8–9
130, 164, 171, 176, 214, 222, 301
Social support, in opioid use
disor
der, 204–205
St. John’s wort, 105
St. Louis University Mental Status
(SLUMS), 96, 225
Stages of change, 65, 66
Standard drink, 126, 127
START (Screening Tool to Alert
Doctors to Right Treatment), 88,
91
Start low, go slow approach, 88, 172,
279, 290
Stigma
alcohol use, 125
barrier to care, 57, 68, 226
barrier to SUD identification, 27,
28
language to reduce/avoid, 2–3, 3,
15, 17–18, 30
opioid use, 110, 206
structural effects on, 300
Stimulant use
cravings, 246–247, 250–251, 253,
261, 264
deprescribing, 112–113
overview of interventions, 60
withdrawal, 112, 246–247, 251,
253, 263–264
raining), 146,
, 28,
57, 70, 126,
Index 339
Stimulant use disorder, 241–265
clinical presentation, complica-
tions, and course, 243–249
cocaine, 246–248, 250
methamphetamine, 243–246,
244, 250
diagnostic criteria, 249, 249–251
epidemiology, 242–243
management, 252–263
overview, 252–253
pharmacological interven-
tions, 256–263
psychoeducation, 254
psychosocial interventions,
254–256
mechanism of action, 243
overview, 241–242
pharmacological interventions,
256–263
cocaine use disorder, 258–263
methamphetamine use
disorder, 256–258
resources, 264–265
screening and assessment, 249–
252, 253
Stop system, 6
STOPP (Screening Tool of Older
People’s Prescriptions), 88, 91
Structural competence, 300, 313
Structural factors in substance use, 9–
10
Structural racism, 303
Substance abuse, 2, 16
Substance Abuse and Mental Health
Services (SAMHSA)
on alcohol use, 127–128, 138–140,
149
Find Treatment, 81, 208
helpline, 50, 149, 209, 234, 265,
315
Treatment Improvement Protocol
(TIP), 4, 18, 82, 149–150, 196
Substance use disorder (SUD)
assessment, 25–51
terminology, 2
See also specific disorders
Suicidality, 69–70, 71
amphetamine use, 243
benzodiazepine use, 219
cannabis use, 276
cocaine use, 248
risk and protective factors, 70
risk reduction strategies, 70, 71
Suicide and Crisis Lifeline (988), 70, 81
43–46
69–70
SUPPORT for Patients and
i
Communit
Suvorexant, 220
Ta pe ri n g. See Deprescribing; specific
medications
TAPS (Tobacco, Alcohol, Prescription
Medication, and Other
Substance
285
Teach-back method, 76
Telephone counseling, 167, 176–177,
204
Temazepam, 103, 215
Terminology, 2–3
Tetrahydrocannabinol (THC), 7–8,
41, 277–279, 281, 283, 289–290
Thiamine, 63, 132, 139
Timed Up and Go (TUG) Test, 36,
71
Tobacco, Alcohol, Prescription
Medication, and Other
Substance Use (TAPS), 167, 177,
249, 285
Tobacco use and use disorder, 159–
178
clinical presentation, course, and
complications, 163–165
comorbidities, 13, 40
dementia risk, 14
dependence, 162–163, 169, 171,
175
diagnostic criteria, 162, 162–163
epidemiology, 160–161
epigenetic modifications, 7
es Act (2018), 5
Use), 167, 177, 249,
, 4
4–45,
340 Substance Use in Older Adults
Tobacco use and use disorder
(contiued)
management, 169–176
complementary and alterna-
tive medicine, 176
overview, 169–170
pharmacotherapy, 172–175,
173
psychoeducation, 170, 171
psychotherapeutic and psy-
chosocial interventions,
170–172
natural history of, 164
overview of interventions, 59
pharmacotherapy, 172–175,
173
bupropion/antidepressants,
173, 174
electronic cigarettes, 175
nicotine replacement therapy
(NRT), 172–174, 173
recommendations, 175
varenicline, 173, 174–175
prevalence, 10, 160–161
public health interventions,
176
resources, 177–178
screening and assessment, 165–
169, 167–168
terminology, 162
withdrawal, 162–165, 172, 174
To le ra nce
alcohol use, 134, 134–135
cannabis use, 283, 286
opioid use, 189, 190, 311–312
sedative, hypnotic, or anxiolytic
221
use,
stimulant use, 244–245, 251
tobacco use, 162–163, 163, 171
vulnerability of older adults, 12,
16, 63
To pi ra m at e
alcohol use disorder, 141, 143
for cocaine use disorder, 261
for methamphetamine use
disorder, 257
Tramadol, 100–101
Tr au ma
adverse childhood experiences,
8, 15, 72
overview, 72–73
Trauma-informed care, 72–79
aspects of, 74–78
case study, 73–74, 78–79
impact of trauma, realizing
widespre
integrating knowledge into
practice, 75–76
retraumatization, avoiding, 76–
78
screening tools, 74
signs and symptoms,
recognizing, 74–75
treatment modalities, 76
Trazodone, 112
Trea tme nt
cognitive-behavioral therapy
(CBT), 66–67
involuntary, 305–309
levels of specialty care, 64
medication interventions, 67
motivational interviewing, 61,
65–66
mutual-help groups, 67
in older adults, 64–67, 65
persuasion versus coercion, 309–
310
principles of effective, 58
privacy protections, 64–65
psychosocial interventions, 65–
67
recommendations, 64–65, 65
stages of change, 65, 66
start low, go slow approach, 88,
172, 279, 290
See also Management;
treatment modalities
Tr us t
steps for rebuilding, 75–76
trauma and violation of, 75
ad, 74
specific
Index 341
TSF (12-Step Facilitation)
interventions, 146
TUG (Timed Up and Go) Test, 36,
71
Unhealthy drug use, definition, 26
Urine drug test
cannabis use, 287
false-positive results, 34, 35, 252,
253
fentanyl and cocaine
co-occurrence, 249
methamphetamine use, 252, 253
sedative, hypnotic, or anxiolytic
use disorder, 225
Valerian, 215, 231
Valproate, 113, 228, 289
Va re ni c li ne , 173, 174–175, 262
Venlafaxine
for cocaine use disorder, 259
use in case example, 223–224
Veterans Crisis Line, 81
Vigabatrin, for cocaine use disorder,
260–261
Wernicke encephalopathy, 14, 37, 63,
132
WHO (World Health Organization),
93, 101–102, 106, 137, 301
Withdrawal
cannabis use, 275, 283, 284, 287,
289, 291
consequences in older adults,
12
decision-making capacity, short-
term, 305
managing, 63–64
nicotine, 164–165, 174
opioid, 63–64, 142
opioid use disorder, 189, 190–191,
195, 197–198, 200–201, 203,
205, 208
overview of interventions, 59–60
sedative, hypnotic, or anxiolytic
use, 214, 217–219, 222, 223–
225, 227–228, 231, 233
stimulant,
tobacco use, 162–165, 172, 174
World Health Organization (WHO),
93, 101–102, 106, 137, 301
Zaleplon, 104
Z-drugs
complications of use, 218–219
safety concerns, 98, 104
withdrawal, 112
Zolpidem, 104
for insomnia, 215, 220, 289
misuse/abuse, 99, 220
use in case examples, 223, 229–
withdrawal, 112
112, 246–247, 251, 253,
263–264
230
By 2050, estimates suggest that 85.7 million Americans will be age
65 or older, a gure that will inevitably include individuals struggling
with substance use disorders. It is essential, then, that clinicians understand how to screen for, assess, and manage substance use disorders in
older adults.
In this new volume, more than 20 contributors translate real-world experience in geriatric psychiatry into an accessible, evidence-based guide
that examines not only the etiology and epidemiology of substance use
in older patients but also its comorbidities and management.
Readers will nd detailed information on the problematic use of specic
substances—including alcohol, opioids, stimulants, and cannabinoids—
as well as guidance on safe prescribing practices for older adults and
the cultural and ethical issues that may arise when working with this
patient population.
Filled with case examples that illustrate key points in clinical practice;
easily referenced tables with information on comorbidities, screening
frameworks, and interventions for specic substances; and exhaustive
listings of additional resources for clinicians, Substance Use in Older
Adults also features resources for patients and their families—strength-
ening the partnership between clinician and patient.
Art Walaszek, M.D., is a Professor at the University of Wisconsin
School of Medicine and Public Health in Madison, Wisconsin.
WWW.APPI.ORG
Cover design: Rick A. Prather
Cover image: © ivabalk
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