CHAPTER 39—ALCOHOL AND DRUG ABUSE
DEFINITIONS OF SUBSTANCE ABUSE
RISKS AND BENEFITS OF SUBSTANCE USE
IDENTIFYING SUBSTANCE-USE DISORDERS
The abuse and misuse of alcohol, psychoactive medications, illicit drugs, and nicotine have become significant public health concerns for the growing population of elderly people. This concern is highlighted by the growth in the literature demonstrating that substance abuse and dependence among older people is common. Moreover, elderly adults are particularly vulnerable to the cognitive and physical effects of these substances. Clinicians and researchers therefore may need to change their thinking about the risks of use in this segment of the population. Typically, substance-use problems are thought to occur only in those persons who use substances in high quantities and at regular intervals. Among elderly persons, however, negative health consequences have been demonstrated at consumption levels previously thought of as light to moderate, and certainly not in the amounts usually associated with a diagnosis of substance dependence. A growing number of effective treatments for these problems lead not only to reductions in substance use but also to improvement in general health. Taken together, both the risks and the emergence of new treatments underscore the need to identify problems and provide appropriate treatment for those older adults suffering from the effects of substance misuse.
Establishing valid criteria for determining which older adults would benefit from reducing or eliminating their substance use is the first step in successful intervention. Substance dependence has been defined by the medical community as any use that imparts significant disability and warrants treatment. Many older adults are not recognized as having problems that are related to their substance use, partly because the diagnostic criteria are difficult to interpret and to apply consistently to older adults. For instance, many older people drink at home by themselves; thus, they are less likely than younger drinkers to be arrested, to get into arguments, or to have difficulties in employment. Moreover, because many of the diseases caused or affected by substance misuse (eg, hypertension, stroke, and peptic ulcer disease) are common disorders in late life, the clinician may overlook the effects of substance use on the older patient who presents with these disorders. The literature indicates that older problem drinkers are identified less often by clinicians and are less often referred for treatment than are their younger counterparts.
Because of the difficulties in assessing older adults for substance dependence, many of the experts have advocated screening to identify persons who are at risk for problem behaviors or who have at-risk or problem use. At-risk use is defined as any use of a substance at a quantity or frequency greater than a recommended level. The level of use is often determined empirically on the basis of association with significant disability. For instance, the recommended upper limit of alcohol consumption for elderly adults has been established as no more than seven standard drinks per week with no more than two episodes of binge drinking (four or more drinks in a day) during a period of 3 months. Problem substance use is defined as the consumption of any amount of an abusable substance that results in at least one problem related to this use. For example, the use of benzodiazepines by a patient who has an unsteady gait would be considered problem use.
On the other end of the spectrum, abstinence refers to drinking no alcohol in the previous year. Approximately 60% to 70% of older adults are abstinent. If an older patient is abstinent, it is useful to ascertain why alcohol is not used. Some individuals are abstinent because of a previous history of alcohol problems. For this reason, it is particularly important to obtain a history of both current and past use. Some are abstinent because of recent illness; others have lifelong patterns of low-risk use or abstinence. Patients who have a previous history of alcohol problems may require preventive monitoring to determine if any new stresses could exacerbate an old pattern. In addition, a previous history of at-risk drinking or alcohol dependence increases the risk for developing other mental health problems in late life, such as depressive disorders or cognitive problems, and may limit treatment response because of brain damage.
Low-risk or moderate use of alcohol is that which falls within the recommended guidelines for consumption and is not associated with problems. Older adults in this category not only consume amounts that fall within recommended drinking guidelines but are also able to employ reasonable limits on alcohol consumption, that is, they do not drink when driving a motor vehicle or boat, or when using contraindicated medications. It is important to note, however, that a change in physical health or change in prescription medications may elevate even low-risk use to a problem level.
The most practical method for identifying persons who could benefit from intervention is to determine the quantity and frequency of their use of abusable substances. This method has advantages over formal diagnostic interviews because of its brevity, easily interpretable results, and absence of stigmatizing language, such as “addiction,” “alcoholism,” “alcoholic” or “alcohol dependence.” For more on screening, see the section below on identifying substance-use disorders.
Little is known about the epidemiology of substance-use disorders among elderly persons other than alcoholism. The general belief is that older drug addicts are only younger addicts grown old and that few older adults initiate drug use in their later years. The Epidemiologic Catchment Area study provides perhaps the only community study of the prevalence of drug abuse and dependence among elderly adults. Using the Diagnostic Interview Schedule to determine prevalence rates for psychiatric diagnoses as defined by the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), the study found the lifetime prevalence rates of drug abuse and dependence to be 0.12% for elderly men and 0.06% for elderly women. The lifetime history of illicit drug use was found to be 2.88% for men and 0.66% for women. No active cases were reported in either gender. In contrast, a more recent study of an elder-specific drug program in a veteran population found that one quarter had either a primary drug problem or concurrent drug and alcohol problems. This study may be a reflection of the growing number of elderly persons who used drugs during a time of expanded drug experimentation in the United States in the 1960s. Recent increases in hepatitis C among patients aged 60 and over may reflect both a history of intravenous drug use as well as increased risk of nosocomial infection with advanced age. Other studies to determine the prevalence and incidence of substance-use disorders involving nicotine, caffeine, benzodiazepines, marijuana, and opiates (in later life) are needed.
Perhaps a unique problem with the elderly age group is the misuse or inappropriate use of prescription and over-the-counter medications. This problem includes the misuse of substances such as sedatives, hypnotics, narcotic and non-narcotic analgesics, diet aids, decongestants, and a wide variety of over-the-counter medications. Community surveys have found that 60% of elderly persons are taking an analgesic, 22% are taking a central nervous system medication, and 11% are taking a benzodiazepine. Many medications used by elderly persons have the potential for inducing tolerance, withdrawal syndromes, and harmful medical consequences, such as cognitive changes, kidney disease, falls, and liver disease. There is a growing body of literature demonstrating a concerning increase in morbidity and mortality associated with the misuse of prescription and nonprescription medications, even though this is not considered as a disorder by DSM-IV.
Medication use by all elderly patients needs to be monitored carefully; it is important to avoid prescribing potentially hazardous combinations of drugs, medications with a high risk for adverse effects, and ineffective or unnecessary medications. (See Pharmacotherapy.) A practical approach to monitoring psychoactive medications is to reevaluate the older patient’s use every 3 to 6 months. Continue on maintenance treatment only those patients with specific target symptoms and a documented response to the treatment. Reevaluate to consider the appropriate diagnosis and further care of patients without a response or partial response. In such cases, consultation with a geriatric mental health professional could be advantageous. (See also Depression and Other Mood Disorders; Anxiety Disorders; Psychotic Disorders; and Personality and Somatoform Disorders.)
Community-based epidemiologic studies define the extent and nature of alcohol use in the older population by reporting percentages of abstainers, heavy drinkers, and daily drinkers. Abstention from alcohol ranges from 31% to 58%, and daily drinking ranges from 10% to 22% in samples of older patients. “Heavy” drinking, defined as a minimum of 12 to 21 drinks per week, is present in 3% to 9% of the older population; alcohol abuse, as defined clinically, is present in approximately 2% to 4%.
Longitudinally designed community studies give valuable insight regarding the natural course of drinking patterns in elderly age groups. Studies that examined longitudinal alcohol use indicate an incidence of heavy drinking of 0.2% to 4% of older persons per year. It is also important to keep in mind that most of the literature on drinking indicates that although elderly persons are likely to decrease the quantity of alcohol consumed on a given day, the frequency of use or pattern of use changes very little over time.
Numerous studies have shown that the prevalence of alcohol use and alcohol-related problems among older persons is much higher for men than for women. Among younger adults, however, the ratio of men to women drinkers has changed over the past several decades, with the result that more women present for treatment. These changes are likely to continue to be reflected in the next generation of older women. Similar patterns by gender are seen with illicit drug use, except that benzodiazepines are much more commonly used by older women than by older men.
Conclusions are less clear from the few studies addressing differences among various ethnic groups. Depending on the study, older black Americans and older Hispanic Americans have been found to consume amounts of alcohol similar to or lower than the amounts consumed by older white Americans. The Epidemiologic Catchment Area data demonstrated nonsignificant differences in the 1-year diagnosis of alcohol abuse and dependence among black Americans (2.93% among men, 0.60% among women), white Americans (2.85% among men and 0.47% among women), and Hispanic Americans (6.57% among men and 0.0% among women). More relevant risk factors than race or ethnicity for alcohol consumption among elderly persons are increased leisure time and higher disposable income.
Elderly people constitute the majority of admissions to acute-care facilities and are frequent users of outpatient medical services, including primary care. The prevalence rates for alcohol problems among hospital populations are substantially higher than for community dwellers. High prevalence rates for problems related to drinking are also becoming more common in retirement communities. Data from a survey of a Veterans Affairs nursing home has demonstrated that 35% of the patients interviewed had a lifetime diagnosis of alcohol abuse. A significant number of patients seen in outpatient clinics also have been found to have an active alcohol-use disorder. The high prevalence of alcohol-related problems in both hospital and outpatient populations underscores the need for thorough screening of older patients in medical settings.
Moderate alcohol consumption among otherwise healthy older adults has been promoted as having significant beneficial effects, especially with regard to cardiovascular disease and mortality. The findings from the cardiovascular literature have led to a host of articles in the popular press espousing the benefits of alcohol use.
Alcohol in moderate amounts may promote relaxation and reduce social anxiety. However, even though there are benefits of moderate drinking, the practice of recommending drinking to people who currently do not drink is not advocated. Many older adults do not drink because of past problems with drinking, family problems with drinking, the expense related to drinking, and the adverse effects of intoxication. There is no evidence to support a therapeutic effect of alcohol for heart disease or any other condition in persons who previously did not drink.
Substance abuse has clear and profound effects on the health and well-being of elderly people in all spheres of life. Older persons are prone to the toxic effects of substances on many different organ systems. The social and economic impact is also tremendous. Substance abuse has adverse effects on self-esteem, coping skills, and interpersonal relationships, which may be compounded by losses that are common in the late stages of life. Elderly adults are particularly prone to these toxic effects because of both the physiologic changes associated with aging and the changes associated with other illnesses common in late life.
Levels of alcohol consumption above seven drinks per week, so called at-risk drinking, have been associated with a number of health problems, including an increased risk of stroke caused by bleeding, impaired driving skills, and an increased rate of injuries, such as falls and fractures. The risk of breast cancer in women who consume three to nine drinks per week has been shown to be increased by approximately 50% over that of women who drink fewer than three drinks per week. Of particular importance to older persons are the potential harmful interactions between alcohol and both prescribed and over-the-counter medications, especially psychoactive medications such as benzodiazepines and antidepressants. Alcohol is also known to interfere with the metabolism of many medications, including digoxin and warfarin.
Older adults who consume more than an average of four drinks per day or whose drinking has led to a diagnosis of alcohol dependence are at greatest risk for excess physical disability and physical illness that are related to the drinking. The most common problems associated with alcohol dependence are alcoholic liver disease, chronic obstructive pulmonary disease, peptic ulcer disease, and psoriasis. Moreover, unexplained multisystem disease should alert the clinician to probe more closely for alcohol use. With smoking, the risks are much clearer, including increased rates of pulmonary disease, especially cancer. Medications such as benzodiazepines are also associated with excess physical disability, with increased rates of falls, and driving-related impairment. Research is beginning to demonstrate that the disability associated with these problems is also reversible with reductions in substance use.
Substance use can be a significant factor in the course and prognosis of nearly all mental health problems of late life. Alcohol, benzodiazepine, opioid, and cigarette use have all been demonstrated to be related etiologically to mood disturbances, but they also complicate the treatment of concurrent mood disorders. Persons with both alcoholism and depression have been shown to have a more complicated clinical course of depression with an increased risk of suicide and more social dysfunction than nondepressed persons with alcoholism. Overall, elderly persons with alcohol abuse or dependence are nearly three times more likely to have a lifetime diagnosis of another mental disorder. Alcoholism has been implicated in mood disorders, suicide, dementia, anxiety disorders, and sleep disturbances.
As might be expected, patients with alcohol-related dementia who become abstinent do not show a progression in cognitive impairment comparable to that of persons with Alzheimer’s disease. The complex role of alcoholism in the development of Alzheimer’s disease is not fully understood, but certainly alcoholism is known to lead to a syndrome of dementia independently. Interesting new hypotheses implicate glutamatergic toxicity, but overall, the mechanisms are not well understood. The criteria for alcohol-related dementia are as follows:
Clinical features supporting the diagnosis include end-organ damage (eg, liver disease), cognitive stabilization or improvement after abstinence, and evidence of cerebellar atrophy in brain imaging. Further research is greatly needed to understand the potential benefits of long-term abstinence in this condition. Similarly, those with comorbid depression and alcohol use are likely to have better depression outcomes if abstinence is achieved. Moderate alcohol use has also been demonstrated to have negative effects on the treatment of late-life depression, further underscoring the need for reducing moderate use in the context of chronic health problems in older adults.
Although clinical examination remains the most valuable tool for identifying substance-use problems, screening instruments help increase the sensitivity and efficiency of the diagnosis of various disorders. Several instruments have been developed for identifying alcohol-use disorders, including self-administered questionnaires and laboratory studies. Self-administered questionnaires provide the busy physician with a rapid, sensitive, and inexpensive method of screening for alcohol problems. Two questionnaires—the Michigan Alcoholism Screening Test (MAST) and the CAGE (see Table 39.1)—have been developed with these principles in mind. Both of these instruments have high sensitivity and specificity for identifying alcohol-use disorders in young and middle-aged persons.
Biologic markers of substance use can be useful in managing patients with known substance-use disorders, but they have proved less valuable in detecting illness. These markers include γ-glutamyl transferase, which has a low sensitivity and a moderate specificity for diagnosing an alcohol-use disorder; mean corpuscular volume, which has a low sensitivity but a high specificity; and carbohydrate-deficient transferrin, which has a low sensitivity and low specificity. These markers require further research, but clinically any combination of macrocytic anemia, thrombocytopenia, and elevated γ-glutamyl transferase should flag the need for further screening. Urine drug screens are an effective method for screening for or identifying illicit drug use as well as prescription drug use.
Older persons with a substance-use problem often present with a variety of treatment needs. It is therefore important to have an array of services available for older adults that can be tailored to these individual needs and to have the flexibility to adapt to changing needs over time. The most important aspect to treating an older adult who is misusing a substance is to engage the patient in the intervention. Older adults engaged in treatment have been shown to have very robust improvement, especially in comparison with younger cohorts. The spectrum of interventions for alcohol abuse in older adults range from prevention and education for persons who are abstinent or low-risk drinkers, to minimal advice or brief structured interventions for at-risk or problem drinkers, and formalized alcoholism treatment for drinkers who meet criteria for abuse or dependence. The array of formal treatment options available includes psychotherapy, education, rehabilitative and residential care, and psychopharmacologic agents. An example of the necessity to tailor care is the contrast between the at-risk drinker or benzodiazepine user and the severely dependent patient. It is unlikely that the at-risk user will need the intensity of services required for the severely dependent patient. Indeed, requiring the at-risk drinker to accept a set of rigorous services may be more detrimental than helpful.
Dependency on medications such as benzodiazepines is managed by placing the patient on a 24-hour equivalent of the dosage of the drug on which the patient is dependent, tapering the dosage by 10% every three half- lives, and by providing supportive counseling via groups, psychosocial support, and 12-step programs. Symptoms of withdrawal from narcotics can be controlled when necessary with oral clonidine. Assuring that the patient enters a long-term treatment program increases the likelihood of long-term success. For smoking cessation, it is important to prepare the patient for quitting by discussing management strategies before quitting, setting a quit date, and implementing a monitoring plan for maintaining success.
The assessment of any substance abuser starts with a thorough history, physical, and laboratory examination. Included in the initial assessment is an assessment of the patient’s potential to suffer acute withdrawal. Severe withdrawal such as that from alcohol use can be life threatening and warrants careful attention. Patients with severe symptoms of dependency or withdrawal potential and patients with significant medical or psychiatric comorbidity may require inpatient hospitalization for acute stabilization prior to implementing an outpatient management strategy. Detoxification is achieved by placing the patient on the minimum amount of drug that suppresses withdrawal symptoms and then decreasing the dosage by 10% every three half-lives. In general, longer acting formulations of the drug being abused are preferred to shorter acting formulations, but many clinicians find that prescribing the specific drug that a patient was abusing makes the process more acceptable to the patient and minimizes the time needed to determine the initial dose.
For the patient hospitalized for an elective surgery or condition unrelated to the substance problem, it is extremely important to be vigilant for any evidence of withdrawal. Unrecognized alcohol withdrawal can result in serious morbidity and mortality for the elderly patient. Early symptoms include tachycardia, diaphoresis, tremulousness, and hypertension. These symptoms may progress to overt delirium, psychosis, and seizures. Intravenous lorazepamOL is most expedient intervention in this scenario, followed by an oral taper.
Traditionally, outpatient substance-abuse treatment has been reserved for specialized clinics focused on substance abuse. It is becoming increasingly apparent that this model is inadequate in addressing the broader public health demand, and there is a need to involve a variety of clinicians and clinical settings to deliver substance-abuse treatment. This is particularly important for older adults, who frequently seek medical services but rarely seek specialized addiction services. The traditional addiction clinic is focused on supportive group psychotherapy and encouragement to attend regular self-help group meetings such as Alcoholics Anonymous, Alcoholics Victorious, Rational Recovery, or Narcotics Anonymous. For older adults, peer-specific group activities are considered superior to mixed-age group activities. Outpatient rehabilitation, in addition to focusing on active addiction issues, usually needs to address issues of time management. Abstinence reduces the time spent in maintaining the substance-use disorder. The management of this time, which is often the greater part of a patient’s day, is critical to the prognosis of treatment. Clinicians should be wary of focusing on abstinence as the only positive outcome of treatment and should commend patients for making progress in cutting down on use as well as stopping. This may be particularly relevant for medications misuse such as benzodiazepines, as it may be more difficult to eliminate the use. For benzodiazepines, remember that the risks of adverse events such as falls are greater with higher doses and medications with a longer half-life such as diazepam or clonazepam. Therefore, using medications with a half-life of 6 to 12 hours reduces the risks for that patient. If benzodiazepines seem to be indicated for an anxiety condition and treatment is initiated for the first time, it is best to avoid the long-acting preparations in favor of shorter-acting agents that do not have active metabolites (eg, lorazepam). However, for patients already receiving long-acting benzodiazepines (eg, 50 mg or more per day of diazepam), there is an increased risk for withdrawal complications, and dose reductions should therefore be made very gradually. If the daily dose is greater than the equivalent of 100 mg of diazepam, then the patient should be hospitalized to initiate withdrawal. Ultimately, a transition to shorter-acting agents is ideal, but this should be initiated very carefully and should involve an equivalent dose initially before any reductions are considered. The use of resources such as day programs and senior centers can be beneficial, especially for cognitively impaired patients. Social services such as financial support are often needed to stabilize the patient in early recovery. Supervised living arrangements, such as halfway houses, group homes, nursing homes, and residing with relatives, should also be considered.
Low-intensity, brief interventions have been suggested as cost-effective and practical techniques that can be used as an initial approach to at-risk and problem drinkers in primary care settings. Studies of brief intervention have been conducted in a wide range of health care settings, from hospitals and primary health care locations to mental health clinics. Two trials of brief alcohol intervention with older adults have been reported. Both studies were randomized trials of brief intervention to reduce hazardous drinking by older adults, and both used advice protocols in primary care settings. These studies have shown that older adults can be engaged in brief intervention protocols, that the protocols are acceptable in this population, and that there is a substantial reduction in drinking among the at-risk drinkers receiving the interventions in comparison with a control group.
The use of medications to support abstinence may be of benefit, but it is not well studied. Small-scale studies have demonstrated that naltrexone is well tolerated and efficacious in older patients. Studies are currently under way using various antidepressants, including the selective serotonin-reuptake inhibitors. Some of the general principles used in treating younger patients should be applied to older drinkers as well. For example, benzodiazepines are important in the treatment of alcohol detoxification, but they have no clinical place in maintaining long-term abstinence because of their abuse potential and the potential for fostering further alcohol or benzodiazepine abuse. Disulfiram may benefit some well-motivated patients, but cardiac and hepatic disease limits the use of this agent by the older person who abuses alcohol. The use of methadone maintenance has proven efficacy in opioid dependence. Older patients can be initiated and maintained on methadone, following the same principles of use as in younger patients. Comorbid medical and psychiatric disorders must be identified and properly treated, and they may necessitate the need for referral to, or consultation with, a psychiatrist with expertise in these areas. Buprenorphine and buprenorphine with naloxone have been approved for outpatient treatment of opioid dependence. However, given the complexity of the treatment of this condition, systematic training, practice, monitoring, regulation, and evaluation are necessary in a multidisciplinary treatment setting to optimize outcomes. Guidelines for developing treatment programs using buprenorphine are available on the Web site of the Substance Abuse and Mental Health Services Administration (see http://buprenorphine.samhsa.gov/index.html).
Establishing abstinence from nicotine follows the same principles as that from other addicting substances. Initially, pharmacologic substitution with either nicotine gum or patch is followed by a gradual decrease in dosage. Several trials demonstrated that antidepressant medications improve rates of continued abstinence, but only bupropion has been approved for this purpose by the U.S. Food and Drug Administration. As with other abstinence regimens, psychotherapy plus pharmacotherapy is better than pharmacotherapy alone. See also Respiratory Diseases and Disorders.
■ Blow FC, Brower KJ, Schulenberg JE, et al. The Michigan Alcoholism Screening Test–Geriatric Version (MAST-G). Alcohol Clin Exp Res. 1992;16:372.
The geriatric version of the MAST (MAST–G), which asks questions relevant to an aging cohort, has been found to be 95% sensitive and 78% specific for identifying older persons with alcohol problems. Other widely used questionnaires include the Alcohol Use Disorders Identification Test (AUDIT) and the Drinking Problems Index. For information about a number of screens for alcohol problems, see http://www.niaaa.nih.gov/publications/ (accessed October 2005) or the AGS Clinical Practice Committee guidelines (see below).
■ Fleming MF, Manwell LB, Barry KL, et al. Brief physician advice for alcohol problems in older adults: a randomized community-based trial. J Fam Pract. 1999;48(5):378–384.
This study demonstrates the efficacy of a brief alcohol intervention among older patients attending primary care. Results from the intervention group were compared with those in usual care in similar primary care practices, and the intervention group showed a 62% greater reduction than the control group by those who were drinking more than 21 drinks per week.
■ Helzer JE, Burnam A, McEvoy LT. Alcohol abuse and dependence. In: Robins LN, Reiger DA, eds. Psychiatric Disorders in America: The Epidemiologic Catchment Area Study. New York: The Free Press; 1991.
This chapter reviews the epidemiology of alcohol use, abuse, and dependence from the Epidemiologic Catchment Area (ECA) study. The remainder of the book is also relevant and includes discussion of drug use, abuse, and dependence. The ECA study was a sampling of community residents from five sites representing urban and rural populations. Persons who were sampled were then interviewed with the Diagnostic Interview Schedule for mental health problems. Thus, the results published are broad-based epidemiologic data on all mental health conditions. The alcohol chapter includes analyses of demographic information on age and race.
■ Korper SP, Council CL, eds. Substance Use by Older Adults: Estimates of Future Impact on the Treatment System (DHHS Publication No. SMA 03-3763, Analytic Series A-21). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies; 2002.
This report extensively documents the projected demand for substance abuse treatment services for older Americans over the next three decades. This report highlights the importance of recognizing the relatively greater use of alcohol and illicit substances by the baby-boomer generation than by earlier generations. Electronic access to this report may be obtained via http://www.samhsa.gov (accessed October 2005).
■ Moore AA, and the American Geriatrics Society Clinical Practice Committee. Clinical guidelines for alcohol use disorders in older adults. Updated November 2003. Available at: http://www.americangeriatrics.org./products/positionpapers/alcohol.shtml (accessed October 2005).
The AGS guideline, which updates Substance Abuse among Older Adults, Treatment Improvement Protocol Series 26 of the Substance Abuse and Mental Health Services Administration, addresses screening recommendations for older adults and age-related physiologic changes that may occur with late-life alcoholism. Medications that may interact adversely with alcohol are outlined, and chronic conditions that may be triggered or worsened by alcohol use are noted. To assist the clinician in early detection, the risk factors for alcoholism in late life are summarized; guidelines for inquiring about alcoholism and specific laboratory values that may be abnormal are also provided. Different risk levels are outlined, and definitions for abuse and dependence are provided. Various interpersonal and pharmacologic intervention strategies are discussed and supplemented by a link to the following resource: http://findtreatment.samhsa.gov (accessed October 2005).
■ Oslin DW, Pettinati HP, Volpicelli JR. Alcoholism treatment adherence: older age predicts better adherence and drinking outcomes. Am J Geriatr Psychiatry. 2002:10(6);740–747.
This study, conducted in younger and older adults with alcohol dependence, was a double-blind, randomized controlled trial of naltrexone 100 mg versus placebo. The results of the trial demonstrated that naltrexone is well tolerated by older adults, but more importantly, that older adults are more adherent to treatment and have better treatment outcomes.
David W. Oslin, MD