Our invisible addicts
Our Invisible Addicts is the slightly outdated sounding title of a new (7 March 2018) report from the Royal College of Psychiatrists into the extent of substance-related health problems amongst older people and the special services needed to deal with the complexity of such problems, which often involve “co-morbid mental and physical health problems, polypharmacy and psychosocial adversity”.
The report is an updated version of the original Our Invisible Addicts report published in 2011 which wasd an important landmark in recognising the extent of substance-related health problems amongst older people.
Since then, substance misuse amongst older people has continued to grow as the population of “baby boomers” ages, increasing both the number of older people and the percentage of the older population with experience of substance misuse.
The complex constellation of risks that older people with addictions face and create can result in presentation to a variety of services such as older people’s mental health, addictions, primary care, acute hospital settings, social care, housing, criminal justice and the voluntary sector. In many cases the staff in these settings have little specialist knowledge of how to deal with such complexity.
Key public health messages
The report sets out a number of key public health message about substance misuse in older people:
The proportion of older people with substance misuse continues to rise more rapidly than can be explained by the rise in the proportion of older people in the UK.
- The “baby boomer” population born between 1946-1964 (now aged between 53 and 71 years old) is at highest risk of rising substance misuse in the older population.
- The misuse of illicit drugs such as cannabis and amphetamines, prescription painkillers such as morphine and buprenorphine, as well as gabapentinoid drugs is now recognised as a growing public health problem.
- Substance misuse in older people is associated with reduced life expectancy and accelerated ageing, which is further compounded by socio-economic deprivation.
- Death rates in older people with substance misuse are higher than in the general older population.
- Deaths related to poisoning from substances in older people have more than doubled over the past decade.
- Recent revision of lower risk drinking guidelines for all age groups may still be too high for some older people, especially for those who have accompanying physical and mental disorders and who are receiving medication.
- Older people with mental disorders such as depression, anxiety, and personality disorder have higher rates of substance misuse than those without mental disorders.
- Psychosocial factors such as social isolation, financial problems, retirement, life events, pain and insomnia have strong associations with alcohol misuse.
- There is strong evidence for the potential effectiveness of minimum pricing in reducing alcohol-related harm, particularly in people with both harmful alcohol use and socio-economic deprivation.
- Awareness of alcohol units among older people is improving but there is a general lack of health awareness around lower risk drinking limits among the public. This also includes practitioners assessing older people with alcohol misuse.
- There is a large gap in evidence for both the prevention of alcohol misuse in older people and evidence assessing the impact of public health interventions to reduce cognitive decline or preventing dementia.
- Prevention of alcohol misuse needs to be balanced carefully against the role played by alcohol in maintaining social cohesion among older people.
Service delivery & implementation
The RCP advocates that older people should be screened for drug, alcohol & tobacco use when presenting to any sort of clinical service and that this should be a specialist assessment which takes into consideration the physical, psychological and social changes associated with ageing.
The report highlights that there is a paucity of UK-based research and evidence for treatment interventions and services relating to the management of substance use disorders in older people. However, it asserts that the evidence to date indicates that many older people with substance misuse want to abstain and have the capacity to change.
Where part of the response is a pharmacological intervention, the RCP notes that there is need for a better understanding of how to provide this since many service users will already be receiving a range of other medications.
It presents its key recommendations:
- Ensure that all services are user-friendly and non-judgemental, flexible and consider the individual needs of older people at all points of the treatment journey.
- Improve access to and the availability of services – age should not be a bar to receiving high quality care for substance misuse.
- Improve collaboration, communication and cooperation between health and social care professional teams, families and carers at all stages of treatment and recovery.
- Develop care pathways for substance misuse within mental health services for older people and mental health treatment for older people within substance misuse services.
- Specify operational definition(s) of integrated care and models of care.
- Review addiction psychiatry and old age psychiatry services to formulate a plan for change.
- Ensure ‘mainstreaming’ of skills in the management of substance misuse within mental health services for older people.
- Encourage the development of innovative models of service delivery for older substance misusers.
- Improve public and professional education about the need for, and role of, the specialist through education, training and workforce development.
This is an authoritative and comprehensive (187 page) report whose core message is that we must apply the same rigour and investment in research to develop best practice in helping older people with substance misue problems as we do with any other age group.