At Any Age, It Does Matter:
Substance Abuse and Older Adults (for Professionals)

Module 5: Recognizing Other Forms of Substance Abuse - Page 7 of 31

Psychoactive Drugs

Studies of older populations conducted over the past 20 years have generally found that most adults who take psychoactive medications do not intend to abuse them. Psychoactive drugs are primarily used to treat a physical condition or to alleviate symptoms of emotional stress.33,34

Psychoactive drugs usually are obtained with an appropriate prescription from a primary care physician for a specific health-related purpose. In fact, there has been a steady improvement in prescribing practices and safe and appropriate medication use in the last 25 years.

Misuse and abuse of prescription drugs have dwindled over time for several reasons:

  1. Pharmaceutical companies are constantly developing safer drugs with fewer undesirable side effects, especially for common health and mental health problems.
  2. Ever-changing Federal and State regulations (e.g., Food and Drug Administration regulations) seek to protect consumers from hazardous substances and to restrict undesirable provider practices.
  3. Guidelines and protocols recommending best practices are being developed and disseminated to health care providers.
  4. More physicians are receiving training relevant to the care of older patients from geriatric research, education, and clinical centers.
  5. Physicians and other health care providers, pharmacists, and various media sources are educating consumers about the dangers of drug interactions and the importance of medication compliance.

Trends in Use

Changes in drugs over time have helped reduce misuse and abuse. Specifically, benzodiazepines with lower addiction potential and fewer adverse interactions with other medications have replaced many of the older barbiturates, bromides, meprobamate (Miltown), and neuroleptics. These drugs are used to manage anxiety, especially acute situational anxiety, generalized anxiety disorder, and associated transient insomnia.

Similarly, in the 1960s, the benzodiazepine flurazepam (Dalmane) replaced many of the barbiturates and nonbarbiturates routinely used for sleep disorders and insomnia complaints. Displaced drugs included:

Sales reports and pharmacy prescription audits reflect the overall decline in the numbers of stimulant and barbiturate prescriptions. Minor tranquilizers and sedatives have exceeded other classes since the 1980s.37 Prescriptions for the popular anxiolytic benzodiazepines have more recently shifted from diazepam (Valium) to shorter acting compounds, particularly alprazolam (Xanax) and lorazepam (Ativan).

Additional changes include replacing the earlier long-acting hypnotic benzodiazepine flurazepam (Dalmane) with the shorter acting triazolam (Halcion) and temazepam (Restoril). Overall, sales of benzodiazepine anxiolytics have decreased. However, use of benzodiazepines as sleep-inducing hypnotics has increased or remained stable.11,38

In 1997, the top 10 drugs prescribed in nursing homes included three selective serotonin reuptake inhibitors (SSRIs), sertraline (Zoloft), fluoxetine (Prozac), and paroxetine (Paxil). Another popular drug is the nonbenzodiazepine anxiolytic buspirone (BuSpar). This represents a decrease from 1970, when 8 of the top 10 nursing home prescriptions were for psychoactive drugs.39

Furthermore, chronic pain from conditions such as arthritis is more frequently treated with nonsteroidal anti-inflammatory agents. These have replaced opiate-containing drugs such as acetaminophen with codeine.40

Even though fewer prescriptions for psychoactive drugs are being written for older adults, many patients prescribed these drugs still misuse and abuse them. Also, some health care providers’ prescribing and monitoring practices reflect a lack of understanding of the issues regarding older adults.

Patterns of Use

The drug-taking patterns of psychoactive prescription drug users can be described as a continuum. This continuum ranges from appropriate use for medical or psychiatric indications to persistent abuse and dependence. Abuse and dependence are defined by the American Psychiatric Association’s criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).41

Because older adults are less likely to use psychoactive medications nontherapeutically, problems with drugs generally fall into the misuse category and are unintentional. For example, older patients are more likely to misunderstand directions for appropriate use.

Problems are compounded by the multiple prescriptions older adults receive, often from multiple physicians unaware of a colleague’s treatments. In these circumstances, overdose, additive effects, and adverse reactions from combining drugs are more likely to occur. Unintentional misuse can, however, progress into abuse if an older adult continues to use a medication nontherapeutically for the desirable effects it provides.

Adults can become physiologically dependent on psychoactive medications without meeting dependence criteria. Tolerance and physical dependence can develop when some psychoactive medications (e.g., benzodiazepines, opioids) are taken regularly at the therapeutically appropriate dose for relatively brief periods. An abstinence syndrome or withdrawal effects may occur if the drug is stopped abruptly.

Patients with medically induced physiological dependence do not usually escalate dosage during or after medically supervised withdrawal, experience cravings after discontinuation, or subsequently continue use or addictive behavior.11,42 In other words, adults can become dependent on psychoactive medications without realizing it.

Adverse Effects

The chronic administration of psychoactive substances to older adults, even at therapeutic doses, has been associated with a variety of adverse central nervous system effects, including:

Psychoactive medications have been implicated in 23 percent of adverse drug reactions among nursing home residents.43 Side effects from these drugs can include: However, all undesirable reactions may be more serious in frail older adults and in those with multiple chronic diseases and cannot be ignored.44,45

Although older adults use various types of drugs, three categories present problems in terms of potential for abuse.

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