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Narcotics

This information on depression is for health and mental health professionals including:

  • psychologists
  • psychiatrists
  • psychotherapists
  • physicians
  • psychiatric nurses
  • clinical social workers

This information is for reference only.  Actual recommendations will depend on the needs of individual patients and resources available.

Prevelance
Risk Factors and Symptoms
Diagnosis
Management

Prevelance

  • There is a lack of data on narcotic use and abuse by older adults. It is thought that older adults who abuse narcotics in late life are simply younger addicts grown old, because very few older adults initiate narcotic drug use in their later years.
  • The number of emergency room visits for heroin or morphine abuse in persons older than 55 in the United States has doubled in the past 10 years, from 1.8% to 3.6%.
  • Older women are more likely than older men to have problems with prescription drug abuse and dependence because they are more likely to visit physicians and receive prescriptions.

Finlayson RE, Davis LJ. Prescription drug dependence in the elderly population: demographic and clinical features of 100 inpatients. Mayo Clinic Proceedings 1994; 69:1137-1145.

Juergens SM. Prescription drug dependence among elderly persons. Mayo Clinic Proceedings 1994; 69:1215-1217.

National Institute of Drug Abuse (NIDA). Annual medical examiner data 2002: data from the Drug Abuse Warning Network (DAWN). (Online) http://www.samhsa.gov

The National Center on Addiction and Substance Abuse at Columbia University. Under the Rug: Substance Abuse and The Mature Woman. (Online) http://www.casacolumbia.org/publications1456/publications

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Risk Factors and Symptoms


Risk Factors for Abuse

  • Other primary psychiatric diagnoses (particularly depression)
  • Chronic medical illness
  • Cognitive impairment/li>
  • Social isolation

Reasons for Misuse/Abuse

  • Lack of judgment or misconceptions about drugs
  • Inability to manage medications because of confusion or cognitive impairment
  • Insufficient resources for purchasing or storing medications
  • Self-medication for reasons other than those prescribed; e.g., to:
    • Sleep
    • Relax
    • Alleviate depression or anxiety

Symptoms of Abuse

  • Sleep disturbances
  • Impaired cognition
  • Diminished ability to perform activities of daily living
  • Irritability
  • Delusions
  • Violent behavior
  • Falls
  • Constipation

Juergens SM. Prescription drug dependence among elderly persons. Mayo Clinic Proceedings 1994; 69:1215-1217.

Ozdemir V, Fourie J, Busto U, Naranjo CA. Pharmacokinetic changes in the elderly: do they contribute to drug abuse and dependence? Clinical Pharmacokinetics 1996; 31:372-385.

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Diagnosis


DSM-IV diagnostic criteria

No specific diagnostic criteria for narcotics abuse and dependence exist in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). However, the general criteria for substance abuse and substance dependence from the DSM can be applied:

Substance Abuse

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12--month period:

  1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance re-lated to substance use; substance-related absences, suspensions, or neglect of children or household)
  2. Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  3. Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
  4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights). The symptoms have never met the criteria for Substance Dependence for this class of substance.

Substance Dependence

A maladaptive pattern of substance use, leading to clinically significant impair-ment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

  1. Tolerance, as defined by either of the following:
    1. A need for markedly increased amounts of the substance to achieve in-toxication or desired effect
    2. Markedly diminished effect with continued use of the same amount of the substance
  2. Withdrawal, as manifested by either of the following:
    1. The characteristic withdrawal syndrome for the substance
    2. The same (or a closely related) substance is taken to relieve or avoid with-drawal symptoms
  3. The substance is often taken in larger amounts or over a longer period than was intended
  4. There is a persistent desire or there are unsuccessful efforts to cut down or control sub-stance use
  5. A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance, or recover from its effects
  6. Important social, occupational, or recreational activities are given up or re-duced because of substance use
  7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

DSM-IV TR criteria: five axes

Evaluate patients using all five axes in the DSM-IV TR criteria:

  1. Axis I: Clinical Disorders, other conditions that may be a focus of clinical attention
  2. Axis II: Personality Disorders, borderline intellectual functioning or mental retardation
  3. Axis III: General Medical Conditions
  4. Axis IV: Psychosocial and Environmental Problems
  5. Axis V: Global Assessment of Functioning

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Washington, DC, 1994.

More specialized assessments

Some patients also require evaluation for:

  • Medical problems
  • Psychological issues
  • Substance abuse

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Management

Older patients who are addicted to prescription narcotics should be referred early for appropriate psychiatric, addiction, and pain management services.

Education

It is important to educate patients that narcotics can be “habit-forming.” Once educated about this fact, many older patients will request discontinuation and medication use can be gradually decreased.

Medication

To treat withdrawal symptoms, combination therapy may include:

  • Benzodiazepines to treat anxiety, tremors, and insomnia
  • Antihistamines to treat rhinorrhea, watery eyes, and pruritis
  • Belladonna alkaloid antispasmodics to treat diarrhea and cramping

Other medications:

  • Methadone
  • Naloxone
  • Naltrexone
  • Buprenorphine

Psychotherapy

    Immediately refer patients to a psychiatrist if they abuse narcotics and have any of the following conditions:

    • Severe anxiety or anorexia
    • Significant psychomotor agitation or retardation
    • Psychosis or mania
    • Suicidal or homicidal thinking

    Consider referring patients to a psychiatrist if they abuse narcotics and have any of the following disorders:

    • Depression
    • Eating disorders
    • Post-traumatic stress or abuse
    • Obsessive compulsive disorders or personality disorders

    Substance Abuse and Mental Health Services Administration (SAMHSA). Substance abuse among aging adults: a literature review. National Evaluation Data Services, Center for Substance Abuse Treatment: Fairfax, VA. 2002.