Prescription medication misuse and abuse are growing public health problems among older adults; these problems are associated with many serious consequences, and often go unrecognized.
Misuse of prescription medications, also referred to as non-medical use of prescription drugs. This problem is growing because of the size of the baby boom population as well as the boomers greater acceptance of and experiences with using prescription medications and illicit drugs. One indicator of this growth is emergency department (ED) visits involving medication misuse and abuse; from 2004 to 2008, there was a 121 percent increase in ED visits involving prescription medication misuse by older Americans.
Problematic prescription medication use by older adults is usually unintentional, and most misused medications are obtained legally through prescriptions. However, unintentional prescription medication misuse can progress to abuse if an older adult continues to use a medication for the desirable effects it provides. Furthermore, tolerance and physical dependence can develop in some older adults when certain psychoactive medications, such as benzodiazepines, are taken regularly at the therapeutic appropriate dose for brief periods.
Nature of the Problem
Older adults are among those most vulnerable to medication misuse and abuse because they use more prescription and over-the-counter (OTC) medications than other age groups. They are likely to experience more problems with relatively small amounts of medications because of increased medication sensitivity as well as slower metabolism and elimination.
Older adults are at high risk for medication misuse due to conditions like pain, sleep disorders/insomnia, and anxiety that commonly occur in this population. They are, therefore, more likely to receive prescriptions for psychoactive medications with misuse and abuse potential, such as opioid analgesics for pain and central nervous system depressants like benzodiazepines for sleep disorders and anxiety.
Approximately 25 percent of older adults use prescription psychoactive medications that have a potential to be misused and abused. Older adults are more likely to use psychoactive medications for longer periods than younger adults. Longer periods of use increases the risk of misuse and abuse. In addition to concerns regarding misuse of medications alone, the combination of alcohol and medication misuse has been estimated to affect up to 19 percent of older Americans.
Definitions of Proper Use, Misuse, Abuse, and Dependence
The Diagnostic and Statistical Manual of Mental Disorders has defined the continuum of use of psychoactive prescription medications as follows:
- Proper use—Taking only medications that have been prescribed, for the reasons the medications are prescribed, in the correct dosage, and for the correct duration
- Misuse (by patient)
- Dose level more than prescribed
- Longer duration than prescribed
- Use for purposes other than prescribed
- Use in conjunction with other medications or alcohol
- Skipping doses/hoarding drug
- Misuse (by practitioner)
- Prescription for inappropriate indication
- Prescription for unnecessary high dose
- Failure to monitor or fully explain appropriate use
- Abuse (by patient)
- Use resulting in declining physical or social function
- Use in risky situations (hazardous use)
- Continued use despite adverse social or personal consequences
- Use resulting in tolerance or withdrawal symptoms
- Unsuccessful attempts to stop or control use
- Preoccupation with attaining or using the drug
Misuse and abuse are distinct from medication mismanagement problems, such as forgetting to take medications, and confusion or lack of understanding about proper use. Medication mismanagement problems can also have serious consequences for older adults, but they have different risk factors and typically require different types of interventions.
What Are Psychoactive Medications?
Psychoactive substances act primarily on the central nervous system, where they affect brain function resulting in changes in mood, cognition, behavior, and consciousness as well as block the perception of pain. Some psychoactive substances also produce euphoric effects by acting on the pleasure center of the brain. The two classes of psychoactive prescription medications that are most problematic among older adults are opioid analgesics (also known as narcotic analgesics) used for the treatment of pain and benzodiazepines (also referred to as sedatives or tranquilizers) used primarily for the treatment of anxiety/nervousness and insomnia. Listed below are common opioid analgesics and benzodiazepines. These medications are frequently prescribed to older adults, have a high dependence and abuse potential, and interact with alcohol leading to many negative consequences. Pain relievers were the type of medication most commonly involved (43.5 percent) in older adults’ ED visits involving medication misuse, followed by medications for anxiety and insomnia (31.8 percent).
Common Benzodiazepines for anxiety, nervousness, and insomnia
- Alprazolam (Xanax®)
- Clorazepate (Tranxene®)
- Diazepam (Valium®)
- Estazolam (ProSom®)
- Flurazepam (Dalmane®)
- Lorazepam (Ativan®)
- Oxazepam (Serax®)
- Quazepam (Doral®)
- Temazepam (Restoril®)
- Triazolam (Halcion®)
Common Opioid Analgesics for pain
- Codeine (Tylenol #3®, Empirin® and Fiorinol® with codeine, Robitussin A-C®)
- Oxycodone (OxyContin®, Percocet®, Percodan®)
- Hydrocodone (Vicodin®, Lortab®, Lorcet®, Tussionex®)
- Morphine (MS Contin®, Roxanol®, Kadian®, Avinza®)
- Meperidine (Demerol®)
- Hydromorphone (Dilaudid®)
- Fentanyl (Duragesic®, Actiq®)
- Tramadol (Ultram®)
Who is at Risk for Psychoactive Prescription Medication Misuse and Abuse?
A number of factors have been associated with an increased risk of psychoactive prescription medication misuse/abuse among older adults:
- Female gender
- Social isolation
- History of substance abuse
- A mental health disorder, particularly depression
Older women are at higher risk because they are more likely to use psychoactive medications, especially benzodiazepines. This use may be associated with divorce, widowhood, lower income, poorer health status, depression, and/or anxiety.
Preventing psychoactive prescription medication misuse and abuse requires a coordinated system of care that integrates medical/ physical health, behavioral health, and the aging services networks to fully address this growing problem. Older adults and their caregivers also play important roles in preventing the misuse of, abuse of, and dependence on psychoactive prescription medications.
Key Actions for Older Adults and Caregivers
- Carefully follow the directions for medication use; use the correct dose and only for as long as prescribed; ask about possible side effects and when to report these effects; read all medication-related information provided by doctors and pharmacists before starting a new medication.
- Inform doctors and pharmacists about all medications, including all OTC medications, that are being taken as well as alcohol use.
- Never use another person’s prescription medication.
- Inform the doctor if you believe a medication is not working. This is particularly important for pain management; older adults may take opioid analgesic medication in greater doses than prescribed if they are not getting adequate pain relief, which can potentially lead to misuse and abuse. Other medications or non-pharmaceutical approaches may be more appropriate before opioid analgesic doses are increased.