Management of Special Populations

1
Management of Special Populations
2
Objectives

• Participants will be able to
• describe alcohol problems in adolescents
• describe alcohol problems associated with older
  adults
• describe alcohol problems associated with women

3
Adolescents

• Adolescence
• A time of rapid change and experimentation
• Nicotine, alcohol, and drug use frequently begins
• Nine out of ten high school seniors in the U.S.
  report lifetime experience with alcohol

4
Adolescents

• Definition of problematic alcohol and drug use
• Recurrent, compulsive use of any
• chemical substance which is causing
• negative consequences in some area
• of the adolescents life.
• Physical dependence with the development of
  withdrawal and tolerance is uncommon.

5
Adolescents

• Stage 1 Experimentation Stage
• First experience is often in elementary or junior
  high school
• Infrequent use
• Low tolerance
• Few consequences
• Parental role modeling is important influence

6
Adolescents

• Stage 2 Early Problematic Use
• Regular use (often only on weekends)
• Increased tolerance
• Increased rationalization regarding use
• Consequences

• School problems
• Truancy
• Hangovers

• Mood swings
• Loss of non-using friends

7
Adolescents

• Stage 3 Problematic Use
• Preoccupation with alcohol/drugs
• Use on weekdays and weekends
• Increased tolerance
• Maintenance of a supply of alcohol/drugs
• Withdrawal from family
• Consequences

• Stealing
• Fighting
• Injuries

• Blackouts
• Depression, overdose
• Legal problems

8
Adolescents

• Stage 4 Addiction
• Compulsive use
• Daily use/multiple drug use
• Use of alcohol/drugs to feel "normal"
• Consequences

• Criminal activity
• Selling drugs
• Paranoia

• Withdrawal symptoms
• Self hate
• Suicide attempts

9
Adolescents
Recognition of Risk Factors Warning Signs...

• Family history of addiction
• Family attitudes favorable toward smoking,
  drinking
• Friends who smoke, drink, use drugs
• Antisocial or criminal behavior
• Chronic family stress

• History of conduct or affective disorder
• Excessive parental discipline or permissiveness
• Physical or sexual abuse
• Low self-esteem
• Poor school performance

10
Adolescents

• Clinical Opportunities Screening...
• Health maintenance visits
• school physicals
• camp physicals
• Suggestive symptoms
• cough
• headaches
• Acute care visits for trauma
• Behavioral changes
• ANY hospital or office encounter

• sports physicals

• indigestion
• palpitations

• fatigue

11
Screening Questions for Adolescents

• Relax - Use to relax?
• Alone - Use alone?
• Family - Use with family?
• Friends - Use with friends?
• Trouble - Had any problems related to
  alcohol or drug use?

12
Adolescents

• Approach
• Be sincere
• Be respectful
• Emphasize confidentiality
• Establish trust

13
Adolescents

• Developing a Treatment Plan
• Get consent to talk with parents and school
  personnel
• Refer to a chemical dependency specialist for
  assessment
• Appropriate treatment should be based on
• Stage of use/problem
• Degree of disruption

• Coexisting psychiatric illness
• Availability of treatment facilities

14
Women

• Alcohol and drug problems have always been
  viewed as primarily male-related diseases, but...
• 24 of US women smoke cigarettes
• Lung cancer is the 1 cause of cancer mortality
  in women
• 60 of women drink alcohol
• 10 of women between 18 and 65 are
  at-risk/hazardous drinkers (more than 14/week or
  binge)
• Current alcohol dependence among women is 3-5

15
12-Month Prevalence (Females, Primary Care)
At-risk Drinkers 13
Problem Drinkers 6
Alcohol Dependent 3
Low-risk Drinkers 34
Abstainers 44
Manwell, et al, 1997
16
Women
Women become intoxicated on less alcohol than
men.

• Possible Mechanisms
• Women have lower total body water content which
  results in higher concentrations of alcohol in
  the blood
• Women have decreased levels of alcohol
  dehydrogenase in their gastric mucosa which
  causes 30 more alcohol to be absorbed into the
  blood
• Gonadal hormone levels during the menstrual cycle
  may affect the rate of alcohol metabolism
  increasing vulnerability to physiological
  consequences of drinking

17
Women

• Medical Consequences "Telescoping of Symptoms"
• Women are MORE prone to medical consequences of
  drinking than men
• 1. Increased severity and progression of
• Hypertension Anemia Polyneuropathies
• Malnutrition Gastrointestinal
  hemorrhage Depression
• Liver damage Seizures Suicidal ideation
• 2. Female alcoholics have death rates 50-100
  higher
• 3. Women experience more deaths from suicide,
  alcohol- related accidents, circulatory
  problems, and cirrhosis
• Female alcoholics are more vulnerable to assault
  than other women

18
Women

• Recognition and Identification
• Barriers
• - Physicians are reluctant to screen
• - Family members shield from detection
• - Social stigma
• Signs
• - Depression - Self mutilation
• - Insomnia - Anxiety/panic disorders
• - Amenorrhea - Suicidal thoughts

19
Women

• Treatment Options
• Brief Advice Women in primary care clinics who
  were drinking at hazardous levels reduced their
  drinking by 20-30 with brief advice
  counseling (Fleming et al, 1997)
• Cognitive Behavioral Therapy Good responses
  have been documented based on cognitive
  behavioral therapy models (4-10 one-hour
  sessions)
• Abstinence-Based AA Model Both inpatient and
  out- patient treatment models have been
  successful. AA model programs for women should
  address violence, safety, mood disorders, child
  care issues, and social support.

20
Older Adults

• Use of mood altering chemicals in persons over 65
  is an important medical concern with a wide range
  of consequences
• Most people in this age group visit a doctor
  regularly
• A brief physical, brief advice, and social
  support can be particularly effective in reducing
  nicotine, alcohol, and other medication/drug
  problems

21
Older Adults

• National Surveys/Research Indicate
• Older adults are less motivated to quit smoking
• Benefits of quitting smoking occur at any age
• Older adults suffer increased mortality from
  alcohol abuse

22
Older Adults Prevalence in a Primary Care
Population (Adams et al, 1996)
12--20
23
Older Adults
Prescription Drugs

• 85 of older adults take at least one medication
  per day
• Older adults consume 30 of all prescriptions
  written
• Prescription use increases with age
• less than 45 years old, 4-6 prescriptions/year
• 75 years and older, 6-9 prescriptions/year

24
Older Adults
Non-Prescription Drugs

• More than 500,000 over-the-counter products are
  available
• Older adults purchase 70 of all over-the-counter
  medications
• 85 of older adults do not properly follow
  directions written on over-the-counter containers

25
Older Adults

• Two Types of Older Adult Problem Drinkers
• Survivors Early onset disorder
• Includes two-thirds of older adults with a
  drinking problem
• Easiest type to identify in the office
• Numerous medical problems
• Late onset or reactive disorders
• Account for one-third of alcohol disorders in
  older adults
• Problematic alcohol use in response to stresses
  or losses
• Fewer classic consequences than seen in younger
  patients

26
Older Adults
Coping response can be positive or negative
27
Older Adults

• Physiological Response to Alcohol and Other Drugs
  with Aging
• Increased sensitivity to alcohol,
  over-the-counter drugs, and other medications
• Dysphoric reaction to alcohol
• Age-related decrease in lean body mass increases
  the total distribution of alcohol and other mood
  altering chemicals
• Liver enzymes are less efficient
• Hepatic blood flow is decreased
• Increased central nervous system sensitivity

28
Older Adults

• Physiological Consequences
• Cardiovascular system
• Pulmonary system
• Gastrointestinal system
• Neuromuscular system
• Sexual function

29
Older Adults
Identification Potential Warning Signs

• Anxiety
• Blackouts, dizziness
• Depression
• Disorientation, confusion
• Excessive mood swings
• Falls, bruises, burns
• Incontinence
• Headaches

• Memory loss
• New difficulty in decision-making
• Poor hygiene
• Poor nutrition
• Social isolation
• Suicidal thoughts
• Unusual response to medication

30
Older Adults

• Screening
• Place questions in a medical context
• Use gentle persistence
• Show mutual respect
• Be patient
• Ask for information from family/other caregivers
• Utilize the "brown bag" approach for checking
  medications
• Ask questions similar to those used in the CHARM

31
Screening in Older Adults

• Cut down on your drinking?
• How do you use alcohol?
• Anyone concerned about your drinking?
• Relief use?
• More than intended?

32
Older Adults

• Treatment Options
• Brief intervention including
• Adverse effects
• Warning signs
• Contract for drinking limits or abstinence
• Education
• Specialized Treatment
• Inpatient or outpatient

33
Older Adults

• Barriers to treatment
• Reluctance to turn to outsiders
• Reluctance to enter a treatment program
• Won't seek help unless medical problems arise
• Treatment approaches need
• A strong social support component
• Good news!!
• Older adults who enter some form of treatment are
  more likely to stay and do well!

34
Project GOAL Summary

• Randomized trial
• Community-based practices
• Effective blinding procedures
• High follow-up rates ( gt92.4 at one year)
• Research procedures generalizable to primary care
  settings

(Fleming et al, 1998)
35
Project GOAL Summary

• At 12 months in the intervention group
• 36 reduction in weekly alcohol consumption
• 48 reduction in proportion of individuals who
  drank excessively
• 37 reduction in levels of binge drinking

(Fleming et al, 1998)
36
Project GOAL Results
(Fleming et al, 1998)
Alcohol Consumption at Baseline Follow-up
37
Project GOAL Results
(Fleming et al, 1998)
Alcohol Consumption at Baseline Follow-up
Treatment Control
n78 n67 Mean of binge
drinking episodes in previous 30
days mean
(sd) mean (sd) t-score p-value Baseline
3.38 (7.05) 4.15 (8.47) 0.58 n.s.
Three months 2.05 (7.01) 4.61 (9.0
8) 1.88 lt .05 Six months 2.47 (
6.96) 4.79 (9.36) 1.67 lt .05 Twelve
months 1.83 (5.94) 5.36 (9.25) 2.6
8 lt .005 change (clinical effect) differe
nce between groups Base to 3 months -39
.39 11.15 50.55 Base to 6
months -26.89 15.47 42.36 Ba
se to 12 months -45.83 29.14
74.97