Evidence-Based Reviews

Managing medication and alcohol misuse by your older patients

Current Psychiatry. 2010 February;9(2):21-41

References

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Older individuals are more sensitive than younger adults to the sedation and respiratory depression of opioids. Buprenorphine is the only opioid with a ceiling effect for respiratory depression, and it does not have an increased half-life in the elderly as do other opioids.²⁵

Other potential side effects of these medications include urinary retention—particularly in elderly males with prostatic hyperplasia—constipation, and movement disorders.

Despite potential side effects, we find that opioid dependence is more successfully treated with agonist or partial agonist therapy than with blocking agents. Buprenorphine and methadone address urges and cravings to use opioids, resulting in greater treatment retention and longer abstinence. Buprenorphine treatment is available in office-based practices of physicians who have received training and certification.

Smoking cessation. Pharmacotherapy and brief treatment interventions can be effective and should be offered to the older smoker. Nicotine replacement therapy, bupropion, varenicline, and nortriptyline help improve quit rates in younger adults, but studies of these agents in older adults are limited.

If monotherapy fails, try combining shorter-acting nicotine replacement therapy with longer-acting agents such as bupropion or varenicline. To our knowledge no dosing adjustment is necessary for the elderly, although we recommend low starting doses with gradual titration.

Some literature suggests nortriptyline as a second-line smoking cessation agent in the elderly. We do not recommend nortriptyline for smoking cessation in this population, however, because of tricyclic antidepressants’ cardiac effects.

Related resources

Schultz SK, Arndt S, Liesved J. Locations of facilities with special programs for older substance abuse clients in the U.S. Int J Geriatr Psychiatry. 2003;18(9):839-843.
National Association of Addiction Treatment Providers. www.naatp.org.
National Association of State Alcohol/Drug Abuse Directors. www.nasadad.org.
Substance Abuse and Mental Health Services Administration. www.samhsa.gov.
American Academy of Addiction Psychiatry. www.aaap.org.

Drug brand names

Acamprosate • Campral
Buprenorphine/naloxone • Suboxone
Bupropion • Zyban
Disulfiram • Antabuse
Methadone • Dolophine, Methadose
Naltrexone • ReVia
Nortriptyline • Aventyl, Pamelor
Oxycodone • OxyContin, Roxicodone, others
Topiramate • Topamax
Varenicline • Chantix

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.