Our Invisible Addicts

187 Pages·2017·7.6 MB·English

Our Invisible Addicts, 2nd edition

College report CR211
March 2018
Approved by: The Policy and Public Affairs Committee (PPAC) in January 2018
Due for revision: 2025
Front cover image:
Untitled, 2017, acrylic on paper 40 x 50 cm, Prof Ilana Crome
© 2018 The Royal College of Psychiatrists
College Reports constitute College policy. They have been sanctioned by the College via the Policy and Public Affairs Committee
(PPAC).
For full details of reports available and how to obtain them, contact the Book Sales Assistant at the Royal College of
Psychiatrists, 21 Prescot Street, London E1 8BB (tel. [phone]; fax [phone]) or visit the College website at:
www.rcpsych.ac.uk/publications/collegereports.aspx
The Royal College of Psychiatrists is a charity registered in England and Wales (228636) and in Scotland (SC038369).
Contents
Foreword 4
Acknowledgements 6
Working group 7
Executive summary 8
Key recommendations 15
Introduction 20
Notes and thoughts from a patient 23
Public health and substance misuse in older people 28
Assessment of substance misuse 43
Alcohol-related brain damage and physical
complications of substance misuse 61
Treatment 68
Service delivery and implementation 90
Education and training 115
Ethical and legal considerations for older people with
substance misuse 127
Research and development 147
Conclusion 152
References 158
Appendix 177
Abbreviations 179
Glossary 182
Models of service 184
College report CR211 3
Foreword
The publication of Our Invisible Addicts in 2011 represented an
important landmark in recognising the extent of substance-related
health problems amongst older people and that the special service
needs to deal with the complexity of such problems, which often
involve co-morbid mental and physical health problems, polypharmacy
and psychosocial adversity.
Since then, our knowledge concerning the clinical and public mental
health aspects of substance misuse in older people has continued to
advance but substance misuse amongst older people continues 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.
Given the further experience and knowledge we now have and the
growing need, it is now timely to readdress the issue and to review
and revise the original report and build on its recommendations. With
this revision, we seek to build on the progress made over the past
six years and to emphasise anew that including older people with
substance problems in national policies is imperative and that there
is a need for organisational reform to tackle this burgeoning issue.
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.
As a result, in this revision we consider and advocate the further
development of a clinical workforce with the appropriate knowledge,
skills and attitudes to provide identification, assessment, treatment,
and assist in recovery and referral for substance misuse in an older
population. In particular, we see a need to reverse the loss of multi-
professional specialist training in addictions that has taken place in
recent years.
We also explain how the problem can be best addressed though
an approach that is multi-professional, involving psychiatry, nursing,
pharmacy, occupational therapy, psychology, social work and the
voluntary sector (including peer support).
This report also addresses the important public mental health aspect.
The public is poorly informed about the relationship between drinking
and health risks in older people. There is also a need to improve
College report CR211 4
knowledge and awareness around the increasing use of illicit and
prescription drugs, as well as the harm caused by novel psychoactive
substances, substances acquired using the internet, and other
addictions accompanying substance misuse such as gambling.
Improving health and social outcomes for older people with substance-
related disorders requires a rigorous approach and this report collates
the most up-to-date information relevant to practising psychiatrists,
their teams and other colleagues.
There is a need for best practice to be implemented and extended to
all relevant settings including the criminal justice system and end of life
care. As we do so, we should continue to research the effectiveness of
the different approaches taken, using both qualitative and quantitative
measures to evaluate this.
This report, which has been developed with representation from
a patient, the Royal College of Psychiatrists, the Royal College of
General Practitioners and the British Geriatrics Society, provides the
latest milestone on the journey towards developing the best possible
response to this important problem.
Professor Wendy Burn, President
Professor Colin Drummond, Chair of the Faculty of Addictions
Dr Amanda Thompsell, Chair of the Faculty of Old Age Psychiatry
College report CR211 5
Acknowledgements
We would like to acknowledge the constant encouragement of the Faculty Chairs, Dr Amanda Thompsell
and Professor Colin Drummond.
Without the unstinting assistance of Kitti Kottasz, Committee Manager; Dr Adrian James, Registrar;
and Thomas Denning, Policy and Standards Manager, we would have found the process far more
demanding.
The commitment, patience, good humour and meticulous approach of Christine Goodair ensured that
we were able to meet a very tight deadline.
We would like to thank Dr Cheryl Kipping (Consultant Nurse for dual diagnosis, South London and
Maudsley NHS Foundation Trust) for sharing her expertise with the group and commenting on previous
drafts of this report.
Professor Peter Crome, Emeritus Professor of Geriatric Medicine, Keele University, contributed valuable
insights, and we are appreciative of the input of Dr Marc Mandell, Consultant Liaison Psychiatrist.
College report CR211 6
Working group
Professor Ilana Crome and Dr Tony Rao were responsible for co-editing the report, contributing to
individual chapters and coordinating its format, content and style, as well as checking for accuracy.
Professor Ilana Crome Royal College of Psychiatrists (Faculty of Addictions Psychiatry), Emeritus
(Co-Chair) Professor of Addiction Psychiatry, Keele University; Honorary Consultant
Psychiatrist, South Staffordshire and Shropshire Healthcare NHS
Foundation Trust; Honorary Professor, St George’s Hospital, University
of London
Dr Tony Rao Royal College of Psychiatrists (Faculty of Old Age Psychiatry),
(Co-Chair) Consultant in Old Age Psychiatry, South London and Maudsley
NHS Foundation Trust and Visiting Lecturer in Old Age Psychiatry,
Institute of Psychiatry, Psychology and Neuroscience, London

The following working group members contributed to writing individual chapters:
Dr Amit Arora British Geriatrics Society, Consultant Physician/Geriatrician, University
Hospitals of North Midlands NHS Trust and Honorary Clinical Lecturer,
Keele University
Dr Conor Barton Royal College of Psychiatrists (Faculty of Old Age Psychiatry) and
Consultant in Old Age Psychiatry, Belfast Health and Social Care Trust
and Honorary Lecturer at Queen’s University Belfast
Dr Ed Day Royal College of Psychiatrists (Faculty of Addictions Psychiatry),
Senior Clinical Lecturer in Addiction Psychiatry, Institute of Psychiatry,
Psychology and Neuroscience, London and Consultant in Addiction
Psychiatry, Birmingham & Solihull Mental Health NHS Foundation Trust
Dr Arun Dhandayudham Royal College of Psychiatrists (Faculty of Addictions Psychiatry),
Joint Chief Executive Officer and Medical Director, WDP
Mrs Christine Goodair Programmes Manager (Substance Misuse), Population Health Research
Institute, St George’s Hospital Medical School, University of London
Ms Diane Goslar Patient Representative, Royal College of Psychiatrists
Prof Steve Iliffe Royal College of General Practitioners and Emeritus Professor of Primary
Care for Older People, University College London
Dr Anand Ramakrishnan Royal College of Psychiatrists (Faculty of Old Age Psychiatry) and
Consultant in Old Age Psychiatry, Nottinghamshire Healthcare NHS Trust
College report CR211 7
Executive summary
Introduction Notes and thoughts from a
patient
This report has harnessed the collective z Public campaigning should be expanded
knowledge, skills and experience of health to reduce the stigma associated with
professionals and others with experience in alcohol problems.
the field of substance misuse. z There should be greater recognition of
the enormity of the problem – detailed
It presents an up-to-date and evidence- research and publication of statistics
based revision of Our Invisible Addicts, with should be widely marketed.
the following terms of reference:
z Early identification of the problem
z Portraying lived experience of substance should be keenly promoted through
misuse training of general practitioners.
z Examining public health aspects z There should be provision of more
alcohol treatment centres generally
z Emphasising the importance of
including those specifically for older
comprehensive assessment
people.
z Highlighting the relevance of alcohol
z There should be a substantial increase
related brain damage and physical
in provision of aftercare services.
complications
z More health professionals (including old
z Detailing the nature, range and benefits
age psychiatrists) should be trained to
of age-sensitive treatment approaches
deal specifically with alcohol problems,
z Exploring best practice in service
and there should be more addiction
delivery and implementation
psychiatrists.
z Developing education and training to
z Education at all levels should be
improve workforce competencies
developed.
z Suggesting future areas for research
z The economic impact of alcohol should
and development
be determined by detailed research
z Clarifying the role and relevance of
and publication of how it affects the
ethical and legal aspects of care.
economy, what revenues and what
expenses are affected and by how
much.
Executive summary 8
Public health and substance misuse in older people
z The proportion of older people with z Psychosocial factors such as social
substance misuse continues to rise more isolation, financial problems, retirement,
rapidly than can be explained by the rise life events, pain and insomnia have strong
in the proportion of older people in the UK. associations with alcohol misuse
z The “baby boomer” population born z There is strong evidence for the potential
between 1946–1964 (now aged between effectiveness of minimum unit pricing in
53 and 71 years old) is at the highest risk reducing alcohol-related harm, particularly
of substance misuse which is rising within in people with both harmful alcohol use
the older population. and socio-economic deprivation.
z The misuse of illicit drugs such as z Awareness of alcohol units among older
cannabis and amphetamines, prescription people is improving but there is a general
painkillers such as morphine and lack of health awareness around lower
buprenorphine, as well as gabapentinoid risk drinking limits among the public. This
drugs is now recognised as a growing also includes practitioners assessing older
public health problem. people with alcohol misuse.
z Substance misuse in older people is z There is large gap in evidence for both
associated with reduced life expectancy the prevention of alcohol misuse in older
and accelerated ageing, which is further people and evidence assessing the impact
compounded by socio-economic of public health interventions to reduce
deprivation cognitive decline or preventing dementia.
z Death rates in older people with substance z Prevention of alcohol misuse needs to be
misuse are higher than the general older balanced carefully against the role played
population. by alcohol in maintaining social cohesion
z Deaths related to poisoning from among older people.
substances in older people have more

than doubled over the past decade.
z Recent revision of lower risk drinking
guidelines for all age groups may still be
too high for some older people, especially
those who have accompanying physical
and mental disorders and who are
receiving medication.
z Older people with mental disorders such
as depression, anxiety, and personality
disorder have higher rates of substance
misuse than those without mental
disorders.
Executive summary 9
Assessment of substance Alcohol-related brain
misuse damage and physical
complications of substance
misuse
z When presenting to clinical services, z Current services are poorly equipped in
all older people should be screened the assessment, treatment and care of
for alcohol and tobacco misuse and be older people with alcohol-related brain
asked about other substance use and damage (ARBD).
misuse. z ARBD has a wide range of mechanisms
z Older people misusing substances involved in its development, with
should be offered a full assessment Wernicke-Korsakoff Syndrome and
of their substance misuse in mental alcohol-related dementia being the most
health services and offered referral to common clinical presentations.
specialist substance misuse services, if z Rising rates of hospital admissions
required. for ARBD has implications for clinical
z There should be user-friendly and service provision.
special consideration of older people’s z Assessment, diagnosis, harm reduction
distinctive needs, with assessment and recovery require specialist skills
considering the physical, psychological and involve a joint approach between
and social changes consequent on health and social care professionals, as
ageing. well as families, carers and Third Sector
z Assessment may need to be ongoing providers.
and frequently reviewed, and involve the z Reduction of, or abstinence from,
collaboration of health and social care harmful drinking may be associated with
professionals, families and carers over partial reversibility in cognitive function.
the longer term.
z Long-term care is not a substitute for
z Major life events, presentation appropriate rehabilitation.
with physical and psychological
z Substance misuse is associated with a
symptomatology (particularly if
wide range of physical complications
unexplained), and inconsistencies or
that require appropriate assessment,
contradictions in the presentation,
treatment and aftercare.
should prompt re-screening or
assessment.
z Although applying the standard criteria
for the diagnosis of dependence to
older people may be useful, this must be
undertaken thoughtfully as they may not
always be applicable.
Executive summary 10