Probleme älterer Patienten in Substitutionsbehandlung

Zusammenfassung

Aufgrund der Wirksamkeit von Substitutionsbehandlungen zeichnet sich zukünftig eine deutliche Zunahme von älteren Patienten ab. Viele Substitutionspatienten scheinen infolge ihres langjährigen Drogenkonsums und der damit assoziierten Risiken „vorgealtert“ und häufig leiden sie bereits frühzeitig an Mobilitätseinschränkungen und altersbedingten chronischen Erkrankungen. Dazu gesellen sich bei vielen von ihnen psychische Störungen, die das Problem der Polypharmazie verschärfen. Neurokognitive Funktionseinbußen, die erhebliche Auswirkungen auf die Compliance und die Behandlungsplanung haben können, treten in dieser Population auch häufig früh auf. Alterungsbedingte physiologische Veränderungen beeinflussen zudem die Wirkung von Medikamenten, was pharmakotherapeutisch zu berücksichtigen ist. Bislang mangelt es an Studien zum Gesundheitszustand und zur bedürfnisgerechten Behandlung älterer Substitutionspatienten, und vielerorts bestehen noch Mängel und Widerstände im Versorgungssystem. Dennoch sind ältere Substitutionspa­tienten wie alle anderen Personen ihrem Alter und ihren gesundheitlichen Problemen entsprechend zu behandeln, und das Substitut sollte vorbehaltlos als Medikament für ihr Wohlbefinden betrachtet werden.

Abstract

The population of older maintenance patients continues to grow rapidly, which is largely due to the effectiveness of opioid maintenance treatment. Many of them have aged prematurely as a result of their drug use history and associated risk factors, and they often suffer early from reduced mobility and age-related chronic diseases. A high proportion of them have co-occurring mental conditions which aggravates the issue of polypharmacy. Neurocognitive functions in this population may also be impaired at an early age, which may compromise compliance and have implications for treatment planning. Furthermore, aging induces physiological changes that affect drug action which must be considered in pharmacotherapy. However, research addressing the health problems and the treatment needs of older maintenance patients is still sparse. And, within the health care system there are many shortcomings and resistance. However, older maintenance patients should be accorded treatment appropriate to their age and health problems, just like any other patients – meaning opioids should be considered as a medication for the well-being of these patients without any undue restrictions.

Schlüsselwörter

Alterung - altersbedingte Erkrankungen - neurokognitive Einbußen - Polypharmazie - physiologische ­Veränderungen

Key words

aging - age-related diseases - neurocognitive impairment - polypharmacy - physiological changes

• Literatur

• 1 Van den Brink W, Haasen C. Evidenced-based treatment of opioid-dependent patients. Can J Psychiatry 2006; 51: 635-646
• 2 Dürsteler-MacFarland KM, Kowalewski R, Bloch N et al. Patients on injectable diacetylmorphine maintenance have low bone mass. Drug Alcohol Rev 2011; 30: 577-582
• 3 European Monitoring Centre for Drugs and Drug Addiction . Treatment and care for older drug users. In Luxembourg: EMCDDA; 2010
• 4 Beynon CM, McVeigh J, Hurst A et al. Older and sicker: Changing mortality of drug users in treatment in the North West of England. Int J Drug Policy 2010; 21: 429-431
• 5 Hser YI, Gelberg L, Hoffman V et al. Health conditions among aging narcotics addicts: medical examination results. J Behav Med 2004; 27: 607-622
• 6 Lofwall MR, Brooner RK, Bigelow GE et al. Characteristics of older opioid maintenance patients. J Subst Abuse Treat 2005; 28: 265-272
• 7 Rajaratnam R, Sivesind D, Todman M et al. The aging methadone maintenance patient: treatment adjustment, long-term success, and quality of life. J Opioid Manag 2009; 5: 27-37
• 8 Rosen D, Smith ML, Reynolds CF. The prevalence of mental and physical health disorders among older methadone patients. Am J Geriatr Psychiatry 2008; 16: 488-497
• 9 Firoz S, Carlson G. Characteristics and treatment outcome of older methadone-maintenance patients. Am J Geriatr Psychiatry 2004; 12: 539-541
• 10 Anderson JF, Warren LD. Client retention in the British Columbia Methadone Program, 1996–1999. Can J Public Health 2004; 95: 104-109
• 11 Burns L, Randall D, Hall WD et al. Opioid agonist pharmacotherapy in New South Wales from 1985 to 2006: patient characteristics and patterns and predictors of treatment retention. Addiction 2009; 104: 1363-1372
• 12 Davstad I, Stenbacka M, Leifman A et al. Patterns of illicit drug use and retention in a methadone program: a longitudinal study. J Opioid Manag 2007; 3: 27-34
• 13 Mancino M, Curran G, Han X et al. Predictors of attrition from a na­tional sample of methadone maintenance patients. Am J Drug Alcohol Abuse 2010; 36: 155-160
• 14 Gurnack AM, Atkinson RM, Osgood NJ. Treating alcohol and drug abuse in the elderly. New York: Springer Pub; 2001
• 15 Hiltunen AJ, Lafolie P, Martel J et al. Subjective and objective symptoms in relation to plasma methadone concentration in methadone patients. Psychopharmacology (Berl) 1995; 118: 122-126
• 16 Miller NS, Belkin BM, Gold MS. Alcohol and drug dependence among the elderly: epidemiology, diagnosis, and treatment. Compr Psychiatry 1991; 32: 153-165
• 17 Beynon CM, Roe B, Duffy P et al. Self reported health status, and health service contact, of illicit drug users aged 50 and over: a qualitative interview study in Merseyside, United Kingdom. BMC Geriatr 2009;
• 18 Fareed A, Casarella J, Amar R et al. Benefits of retention in methadone maintenance and chronic medical conditions as risk factors for premature death among older heroin addicts. J Psychiatr Pract 2009; 15: 227-234
• 19 Reece AS. Chronic immune stimulation as a contributing cause of chronic disease in opiate addiction including multi-system ageing. Med Hypotheses 2010; 75: 613-619
• 20 Vogt I. Alter und Alkohol, Zigaretten, Cannabisprodukte und andere illegale Drogen: Herauswachsen aus der Sucht, Weitermachen wie gewohnt oder Hineinwachsen in die Sucht?. Verhaltenstherapie und psychosoziale Versorgung 2010; 42: 593-609
• 21 O’Toole J, Hambly R, Cox AM et al. Methadone-maintained patients in primary care have higher rates of chronic disease and multimorbidity, and use health services more intensively than matched controls. Eur J Gen Pract 2014;
• 22 Maruyama A, Macdonald S, Borycki E et al. Hypertension, chronic obstructive pulmonary disease, diabetes and depression among older methadone maintenance patients in British Columbia. Drug Alcohol Rev 2013; 32: 412-418
• 23 Kim TW, Alford DP, Malabanan A et al. Low bone density in patients receiving methadone maintenance treatment. Drug and Alcohol Dependence 2006; 85: 258-262
• 24 Weiner DK, Hanlon JT, Studenski SA. Effects of central nervous system polypharmacy on falls liability in community-dwelling elderly. Gerontology 1998; 44: 217-221
• 25 Vestergaard P, Rejnmark L, Mosekilde L. Fracture risk associated with the use of morphine and opiates. J Intern Med 2006; 260: 76-87
• 26 Brooner RK, King VL, Kidorf M et al. Psychiatric and substance use comorbidity among treatment-seeking opioid abusers. Arch Gen Psychiatry 1997; 54: 71-80
• 27 Callaly T, Trauer T, Munro L et al. Prevalence of psychiatric disorder in a methadone maintenance population. Aust N Z J Psychiatry 2001; 35: 601-605
• 28 Morse JQ, Lynch TR. Personality disorders in late life. Curr Psychiatry Rep 2000; 2: 24-31
• 29 Abrams RC, Horowitz SV. Personality disorders after age 50: a meta-analytic review of the literature. In: Rosowsky E, Abrams RC, Zweig R. Hrsg Personality Disorders in Older Adults: Emerging Issues in Diagnosis and Treatment. Mahwah, NJ: Lawrence Erlbaum Associates; 1999: 55-68
• 30 Soyka M, Apelt SM, Wittchen HU. Insufficient involvement of psychiatrists in substitution treatment. Nervenarzt 2006; 77: 1368-1372
• 31 Vogel M, Petitjean S, Borgwardt S et al. Therapie der Opioidabhängigkeit – ein Update. Schweizer Archiv für Neurologie und Psychiatrie 2010; 161: 5-13
• 32 Stohler R, Dürsteler-MacFarland KM. Cocaine and opiate related disorders. Ther Umsch 2003; 60: 329-333
• 33 Miller WR, Rollnick S. Motivational Interviewing, Second Edition: Preparing People for Change. New York: Guiford Press; 2002
• 34 Dürsteler-MacFarland KM, Schmid O, Strasser J et al. Therapiemanual Kokainabhängigkeit: Grundlagen und Arbeitsmaterialien zur kognitiv-verhaltenstherapeutischen Behandlung. Stuttgart: Kohlhammer; 2010
• 35 Stitzer M, Petry N. Contingency management for treatment of substance abuse. Annu Rev Clin Psychol 2006; 2: 411-434
• 36 Stitzer ML, Peirce J, Petry NM et al. Abstinence-based incentives in methadone maintenance: interaction with intake stimulant test results. Exp Clin Psychopharmacol 2007; 15: 344-350
• 37 Tegeder I, Lotsch J, Geisslinger G. Pharmacokinetics of opioids in liver disease. Clin Pharmacokinet 1999; 37: 17-40
• 38 Smith HS, Passik SD. Pain and chemical dependency. Oxford: Oxford University Press; 2008
• 39 Davies G, Kingswood C, Street M. Pharmacokinetics of opioids in renal dysfunction. Clin Pharmacokinet 1996; 31: 410-422
• 40 Goldberg RJ, Grabowski R. Methadone maintenance: its future in skilled nursing facilities. J Am Med Dir Assoc 2003; 4: 98-100
• 41 Paterniti S, Dufouil C, Alperovitch A. Long-term benzodiazepine use and cognitive decline in the elderly: the Epidemiology of Vascular Aging Study. J Clin Psychopharmacol 2002; 22: 285-293
• 42 Woolcott JC, Richardson KJ, Wiens MO et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 2009; 169: 1952-1960
• 43 Stewart SA. The effects of benzodiazepines on cognition. J Clin Psychiatry 2005; 66: 9-13
• 44 Dowling GJ, Weiss SR, Condon TP. Drugs of abuse and the aging brain. Neuropsychopharmacology 2008; 33: 209-218
• 45 Ersche KD, Jones PS, Williams GB et al. Cocaine dependence: a fast-track for brain ageing?. Mol Psychiatry 2013; 18: 134-135
• 46 Dürsteler-MacFarland KM, Herot Cereghetti K, Wiesbeck GA. Neurocognitive impairment: an underdiagnosed comorbid entity in the treatment of substance use disorders?. In: Stohler R, Rössler W. Hrsg Dual Diagnosis – the evolving conceptual framework. Basel: Karger; 2005: 115-136
• 47 Yucel M, Lubman DI, Solowij N et al. Understanding drug addiction: a neuropsychological perspective. Aust N Z J Psychiatry 2007; 41: 957-968
• 48 Gonzalez R, Cherner M. Co-factors in HIV neurobehavioural disturbances: substance abuse, hepatitis C and aging. Int Rev Psychiatry 2008; 20: 49-60
• 49 Woods SP, Moore DJ, Weber E et al. Cognitive neuropsychology of HIV-associated neurocognitive disorders. Neuropsychol Rev 2009; 19: 152-168
• 50 Bates ME, Convit A. Neuropsychology and neuroimaging of alcohol and drug abuse. In: Calev A. Hrsg Neuropsychological functions in psychiatric disorders. Washington, DC: American Psychiatric Press; 1999: 342-375
• 51 Wolter DK. Drogenabhängigkeit und Demenz. In: Vogt I. Hrsg Auch Süchtige altern. Frankfurt: Fachholchschulverlag; 2011
• 52 Teichner G, Horner MD, Roitzsch JC et al. Substance abuse treatment outcomes for cognitively impaired and intact outpatients. Addict Behav 2002; 27: 751-763
• 53 Vogt I. Auch Süchtige altern: Probleme und Versorgung älterer Drogenabhängiger. Frankfurt am Main: Fachhochschulverlag; 2011