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The consultant pharmacist

Case Study
The Psychedelic 1960s,
Hippies in Their 60s:
Substance Abuse in the Elderly

August 2009 was the 40th anniversary of theWoodstock music concert, a cultural touchstone for the late 1960s and widely seen as the height of the“counterculture” known, in part, for illicit—often psychedelic—drug use. Those who identified with this counterculture were known as “hippies” or “flower children.” Then in their twenties and thirties, Individuals who at ended the famous Woodstock concert— ex-hippies are now in their sixties and seventies, and known col ectively as hippies—were part of the “counter - they may still be using illicit drugs. How long did culture” of the late 1960s and wel known for their use of today’s seniors continue their substance abuse and il icit, sometimes psychedelic, drugs. Did they and other how are they presenting now? This case gave us an former hippies, who are now in their sixties and seventies, opportunity to be reminded of the music, culture, continue their substance abuse, and how are they present- and, of course, the substance abuse of a now aging ing now? This case evaluates a 77-year-old man who was population. It also illustrates the need to conduct a referred to the geriatric assessment clinic for evaluation complete medication history, including substance of worsening cognition. This case il ustrates the need to conduct a complete medication history, including sub- A 77-year-old man was referred to the geriatric assess- stance abuse and dietary supplements, in elderly patients.
ment clinic for evaluation of worsening cognition. A Consultant pharmacists with knowledge of alcohol and pharmacist’s interview of the caregiver identified that substance abuse and the influence of this abuse on a the patient had a long history of illicit drug use and was patient’s drug regimen can make improved quality-of-life currently misusing herbal and dietary supplements. After recommendations for appropriate dosage adjustments discontinuing some of his supplements and modifying his prescription medications, he had slight improvementin mental status.
Key words: Alcohol, Elderly, Herbal supplements,
As the population ages, the risk of alcohol and sub- stance abuse use and its complications will have a signifi- Abbreviations: ADL = Activities of daily living, ALT/AST =
cant impact on health care. As a consultant pharmacist, Alanine aminotransferase/aspartate aminotransferase, being able to recognize the potential for substance abuse CBC = Complete blood count, CK = Creatine kinase, and knowing what resources are available locally are CrCl = Creatinine clearance, IADL = Instrumental activities of daily living, SAMHSA = Substance Abuse and MentalHealth Services Agency.
Janice Hoffman, PharmD, is assistant professor of pharmacy practice and
administration, Western University of Health Sciences, Pomona, California.
Acknowledgements: Special thanks to David Stern, MD; Dan Osterweil,
MD, and Joy Fruth, program director and staff, Specialized Ambulatory
Geriatric Evaluation (S+AGETM),Sherman Oaks, California.
For correspondence: Janice Hoffman, PharmD, Western University of
Health Sciences, 309 East Second Street, Pomona, CA 91766; Phone:
909-706-3510; Fax: 909-469-5539; E-mail: [email protected]
Disclosure: No funding was received for the development of this manu-
script. The author reports no potential conflicts of interest.
2010 American Society of Consultant Pharmacists, Inc. All rights reserved.
THE CONSULTANT PHARMACIST SEPTEMBER 2010 VOL. 25. NO. 9 Case Study: The Psychedelic 1960s, Hippies in Their 60s—Substance Abuse in the Elderly
Based on the government office of Applied Studies, a possibility of normal-pressure hydrocephalus and was Substance Abuse and Mental Health Services Admin - scheduled for a trial shunt to see if it would improve his istration (SAMHSA), the National Drug Use and Health cognition and behavior. Additionally, the patient has Survey, done in 2002 to 2003 among adults older than gone from being a balanced and successful real estate 65 years of age, 1.4 million (1.8%) used an illicit drug agent for the past 10 years to a person with extreme during the past month.1 Marijuana was the most com- challenges who cannot operate a telephone, or even monly used illicit drug (used by 1.1% of older adults), remember his address. He has an elderly sister with a followed by prescription-type drugs used nonmedically (0.7%), and cocaine (0.2%).1 In comparison, according He presents to the clinic with history of the following to the same survey, 13.7 million persons 50 years of age diagnoses: Alzheimer’s dementia (from primary care or older (17.1%) smoked cigarettes and 36 million physician); coronary artery disease, with a history of (45.5%) drank alcohol during the past month.1 myocardial infarction (MI) and angiography (with stents); Additionally, 12.2% of older adults reported binge bradycardia, hypertension, dyslipidemia; gait and balance alcohol use (five or more drinks on the same day), issues, with a history of falls; and urinary frequency, and 3.2% reported heavy alcohol use.1,2 With the associated with incontinence and depression.
increasing prevalence of substance abuse in the elderly, The physician took a lifestyle history, which included there are very limited alcohol and substance abuse extensive alcohol use in the 1970s (the patient says he programs that will treat a patient older than 65 years rarely drinks alcohol at present), and cigarette smoking of age. There are many safety risk factors for the elderly (but he quit 30 years ago). He goes to the gym and does in the treatment of substance abuse—including the an elliptical machine for cardiovascular (CV) training and risk of a fall—in addition to complicated, comorbid lifts free weights for strength building. Hobbies include disease states that require a higher level of care. These sculpting, cooking, and reading, all of which he can no risk factors limit the available programs that are willing to provide the quality and high level of care needed for an elderly oriented substance-abuse program.
Medical History
Alcohol and substance abuse can contribute to a decline in cognitive function as well as affect the pharma- General appearance: Ambulates without assistance,
cokinetics of other prescription medications. Assessment with a lumbering gait. No clear-cut gait instability, of elderly patients for substance abuse is difficult since well-groomed. Overall health is fair.
there are limited tools designed to evaluate elderly Eyes: Pupils equal, round, and reactive to light and
patients for such abuse. Consultant pharmacists with accommodation. Extraocular muscle movements intact.
knowledge of alcohol and substance abuse, and the influ- ence of this abuse on a patient’s drug regimen, can make Mouth: Dry buccal mucosa. Tongue midline. No den-
recommendations for improving quality of life including appropriate dosage adjustments, as needed.
Pharynx: Benign.
Ears: Pinnae are intact. Tympanic membranes clear.
Case Presentation
Neck: Supple carotids are full equal without bruits.
A 77-year-old, married Caucasian male was referred by No venous detention. Trachea midline. No thyromegaly.
the Alzheimer’s Association of the San Fernando Valley, California to our geriatric assessment clinic, in spring Cardiac: Past history of myocardial infarction. Regular
2009, with few medical records. He was experiencing sinus rhythm. Grade 1 or 2/6 systolic murmur across progressive difficulties over the past couple of years precordium. Heart is in the fifth intercostals space (time frame not reliable) with word-finding, disorienta- tion, agitation, and irritability. In addition, he was under Vascular: Carotid, radial, femoral, and doralis pedis
stress because his family had to sell their home for finan- cial reasons. The patient recently had an MRI suggesting Chest: Full chest-wall expansion.
VOL. 25. NO. 9 SEPTEMBER 2010 THE CONSULTANT PHARMACIST Case Study: The Psychedelic 1960s, Hippies in Their 60s—Substance Abuse in the Elderly
Pulmonary: Clear without rales, rhonchi, or rub.
Medication History
Rheumatologic: Arthritis with pain involving
Patient was referred to the consultant pharmacist for a complete medication history. There were no Skin: No rash or petechaie. Warm and dry.
pharmacy records because the patient had used multi- Endocrine: No diabetes or thyroid.
ple pharmacies over the years, and no medical records Genitourinary: Urinary frequency and incontinence.
were available that would have shed a history of start- Gastrointestinal: Heartburn. Past history of hepatitis.
stop dates for medications. The patient and family Soft, nontender. No hepatosplenomegaly, discrete mass- were unreliable in giving medication dates for previous es, or bruits. Bowel sounds active. Evidence to suggest medication, but the patient was able to provide his current medication regimen. Medication history
Rectal: Deferred.
included that he was allergic to penicillin. We deter- Extremities: Large and small venous varicosities
mined that his daily prescription regimen as of April 1, extending to the knees. History of venous ligation. Ankle and leg edema bilaterally. Onchomycosis noted. No calf tenderness but complains of occasional leg cramps.
Neuropsychiatric: Cranial nerves II through XII intact.
Motor function 5/5 in upper and lower extremities.
n Niacin extended-release 500 mg: one tablet daily Cerebellar function intact, with ataxia. Sensory function n Triamterene/hydrochlorothiazide 37.5/25 mg: is grossly intact. Position-sense intact. Pathologic reflex not evident—toes are downward in response to plantar stimulation. No signs of resting tremor, cogwheel rigidity.
No signs of bradykinesia. Note patient has significant n Memantine 10 mg: one tablet two times a day word-finding difficulty. Thought content normal.
Further questioning by the pharmacist noted that Dementia disorder, depression, insomnia. Some gait dis- he was currently on quite a few dietary and herbal turbance and episodes of falling. Gait and balance disorder supplements for “years” which were as follows: with MRI in 2007. Moderate cerebral atrophy consistent with possible normal pressure hydrocephalus with recur- rent falls. Gait speed 0.847 m/sec. History of spine n Omega-3 fatty acid 1 g three times daily surgery with rod implantation in 2001.
n Core Complex daily (vitamins A, E, B6, B12, Cognitive status: Folstein Mini-Mental State Exam
fish oil, phytosterol esters, omega-3, krill oil, alpha- (MMSE) with a total score of 15/30 with orientation lipoic acid, medium chain triglycerides, quercetin, only 3/10, registration 1/3, and he needed three tries to get the three words. Attention and calculation was n CardioHealth daily (vitamin E, fish oil, omega-3) 1/5 and recall was 2/3. There was no evidence of visual- spatial deficit. The clock drawing was abnormal; in fact, he could not draw a clock. Executive control dysfunction was evident. Patient Health Questionnaire 9 (PHQ-9) for depression screening was done with a score of 1 (greater than 3 would be significant for depression).
Functional status: Assessment of activities of daily living
(ADL) was 6/6 but Instrumental activities of daily living n Calcium complex daily (vitamin D, calcium, (IADL) was 4/8 where he is unable to cook, do his own magnesium, zinc, copper, manganese, boron herbal finances, drive, or use a telephone independently.
Vital signs: Blood pressure = 154/68 mmHg, Pulse =
n Triple Berry Complex twice daily (cranberry 43 bpm (standing), Respiratory rate = 12, Temperature powder, bilberry extract, blueberry powder) = afebrile, Weight = 169 lbs, Height = 68 inches.
n Schizandra Plus twice daily (vitamins A, C, E, B6, THE CONSULTANT PHARMACIST SEPTEMBER 2010 VOL. 25. NO. 9 Case Study: The Psychedelic 1960s, Hippies in Their 60s—Substance Abuse in the Elderly
pantothenic acid, calcium sulfate, selenium, exclusive questioned the accuracy of this; probably more alcohol blend schizandra, L-cysteine, L-phenylalanine) n Mega Garlic Plus tablets three times daily n Caffeine intake of tea multiple times per day, n Garden 7 phytonutrients (vitamins A, C, B12, calci- quantity not consistent (used to drink coffee one to um carbonate, garlic powder, cranberry extract, carrot powder, broccoli extract, hesperidin [from orange fruit n Wife stated that when he was heavily drinking and bioflavonoids], quercetin, grape skin extract, spinach using drugs he sometimes had difficulty with words, did powder, glucosinolate [from broccoli extract], allicin not know where he was, and his behaviors were aggres- [from garlic powder], lycopene, lutein, zeaxanthin) sive and agitated at times. However, he never hit her.
n Rose OX 500 mg daily (calcium, exclusive herbal Laboratory findings that were out of normal range blend, dried rosemary extract, cruciferous vegetable concentrate [broccoli, cauliflower, cabbage, carrots], dried turmeric extract from root, tomato concentrate, n Creatine kinase, 737 units/L (50-200 units/L) n Vitamin B12, > 1200 pg/mL (200-900 pg/mL) n Joint support (MSM, glucosamine, turmeric, n Folate > 20.0 ng/mL (3.1-17.5 ng/mL) n Aspartate aminotransferase (AST), 87 units/L n Cell Activator daily (potassium magnesium aspartate, Alanine aminotransferase (ALT) 95 units/L (< 40 citric acid, malic acid, fumaric acid, aspartic acid, units/L) was slightly elevated. Electrolytes, TSH, glutamic acid, succinic acid, inositol, chlorella, shiitake CBC were within normal limit. Calculated creatinine mushroom, L-glutamine, dried cordyceps extract, clearance (CrCl) was estimated at 36.4 mL/min using dried rhodiola extract, cayenne powder, dries reishi mushroom, dried pine bark extract [pycnogenol]) n NiteWorks (nitric oxide, L-taurine, L-arginine, Pharmacist’s Assessment
L-citrulline, vitamin C, vitamin E, lemon balm extract, There are several concerns with this patient. First, was this patient’s ability to clear any medications, because of his renal and hepatic function, compromised? (CrCl His wife told us that he has some flushing when he decreased, and creatine kinase [CK], and ALT/AST were took the niacin, but was able to tolerate it most days, all elevated). Second, was the amount of herbal supple- but there were days that he refused the niacin.
mentation with many products resulting in duplicate When questioning this patient on his cognitive ability, ingredients affecting cognition and liver function. Third, the patient agreed to have his wife present most of the is the cognitive decline actual brain damage from the history; he agreed with most of the information, and substance abuse or is it truly Alzheimer’s-type dementia? provided some additional information. The pharmacistasked about lifestyle practices, and found additional Pharmacist’s Intervention
information that was not disclosed to the physician: The pharmacist worked on convincing the family that n Use of marijuana multiple times a day, from 1968 some of the supplements being taken by the patient were duplications, and they were not beneficial for the patient.
n Use of cocaine multiple times a day, from 1968 Duplicate ingredients can, for example, have added toxici- ties on the liver and kidneys. Of particular concern for n Cigarette smoking 1-2 packs per day, but stopped this patient were the multiple fat-soluble vitamins A, D, and E, the folate and vitamin B12 as well as the minerals n Heavy alcohol use of one pint of vodka, tequila, (e.g., selenium). Also the side effect profile of some of the and/or a bottle of wine daily, from 1960s; continues cur- agents such as the valerian root may affect liver function, rently, but has tapered (one to two glasses of wine or one which may further compromise this patient. The pharma- ounce hard liquor daily with dinner) (but the pharmacist cist recommended that the following be discontinued: VOL. 25. NO. 9 SEPTEMBER 2010 THE CONSULTANT PHARMACIST Case Study: The Psychedelic 1960s, Hippies in Their 60s—Substance Abuse in the Elderly
use and no marijuana use (she told us that the marijuana had stopped, but on the follow-up visit explained that there was occasional use). It is uncertain how much the herbal agents were contributing to the cognitive issues.
The recommended PET scan was not done because the insurance would not cover it. The source of memory loss was inconclusive at this time. The wife wanted the donepezil restarted because she feared the progression of memory loss. The pharmacist discussed a potential trial of rivastigmine patch in the future because of fewer drug interactions and topical administration. Furosemide will be considered if changes in blood pressure or The consultant pharmacist recommended that the edema occur. The pravastatin was placed on hold and patient take the aspirin with dinner and the niacin 30 minutes later to reduce the possibility of flushing.
Additionally, the pharmacist recommended that the Discussion
B-complex, vitamin B12, and folate be discontinued In the elderly, illicit, prescription drug, and nonprescrip- because the blood levels were above normal range. Also, tion drug use is often missed in medical assessments, the pharmacist recommended that the physician assess if leading to what some might refer to as a hidden or pravastatin was contributing to the elevated CK and liver “closet” epidemic of substance abuse. The 1960s hippies function tests and if the statin should be discontinued.
are now in their sixties and seventies, and a number have There was concern over effectiveness of the meman- continued their illicit drug use, which can contribute to tine and donepezil with the possibility of brain injury acute and chronic comorbidities. Additionally, elderly from the long-standing illicit drug use, and we referred patients with chronic pain (for example, pain associated the patient for a PET scan. In the interim, because of the with arthritis) have good access to opiate medications, patient’s loss of appetite and decreased heart rate, use and those patients who have a tendency for abuse can of the donepezil was placed on hold. As a result of the easily get their choice of agents. An elderly patient may decreased kidney function, the pharmacist also advised a not seek help for the alcohol or substance abuse issue reduction in memantine to 10 mg daily. The pharmacist until secondary comorbid disease states such as depres- advocated that sertraline be moved to the morning to sion and anxiety arise.16 Normal physiologic changes of aging combined with a substance-abuse history can On the follow-up visit a change from triamterene/ potentially lead to significant medical complications hydrochlorothiazide to a loop diuretic will be considered including liver, renal, and CV dysfunction. Increased because so many discontinuations and changes were geriatric hospital admissions related to substance abuse being made this visit. No significant drug interactions will likely become a public health concern. For example, were present to change medications; however, several Adams et al. presented a study in 1989 that showed were present that should be monitored. For example, charges to Medicare associated with the primary alcohol- Sertaline and omega-3 fish oils can prolong bleeding time related issues totaling $233,543,500.4 The number of with aspirin. The patient was instructed to return for adults 50 years of age and older with substance-abuse problems is projected to reach more than 4.4 million by On return to clinic, his cognition was slightly improved the year 2020, having a significant impact in the health from previous (MMSE 17/30) and in IADL (able to care system for substance-abuse treatment as well as cook a bit). The wife did stop all of the herbal products recommended, but was reluctant to share which ones According to SAMHSA, in 2005 there were 11,300 were continued; however, she said she is working on hospital admissions of individuals 65 years of age and stopping all of them. His spouse reported less alcohol older to substance-abuse treatment programs.3 Adults THE CONSULTANT PHARMACIST SEPTEMBER 2010 VOL. 25. NO. 9 Case Study: The Psychedelic 1960s, Hippies in Their 60s—Substance Abuse in the Elderly
65 to 69 years of age made up the largest part of the 2. Have people Annoyed you by criticizing your substance-abuse treatment population, increasing from 56% from 1995 to 59% in 2005.3 In each year between 3. Have you ever felt bad or Guilty about your 1995 and 2005, alcohol was the most frequently report- ed substance used on admission to treatment programs, 4. Have you ever taken a drink first thing in the while reported opiate use increased from 6.6% to morning (Eye opener) to steady your nerves or to get The “baby boomer” generation grew up in a time After detection of a condition related to substance marked by drug and alcohol experimentation, and abuse, a common question is where can the patient and alcohol can significantly affect the concurrent medical family be referred? Currently there are limited programs conditions in a geriatric patient.16 Alcohol-related health that specifically address the needs of the elderly with problems for elderly patients include: falls with frac- a history of substance abuse. The best referral is to a tures, insomnia, confusion, delirium, dehydration and geriatric psychiatrist. There are self-help groups such malnutrition, hypoglycemia, electrolyte imbalances, as Alcoholics Anonymous, Al-Anon, and many others late-onset seizure disorder, hypertension, congestive available, but they may not have the capacity for the heart failure, gastrointestinal disorders, and inconti- special needs of the elderly. A good referral source is nence, to name a few.5,7 Additionally, with the number of the SAMHSA Web site, which can help with finding a medications being taken by geriatric patients, alcohol can treatment center at www.findtreatment.samhsa.gov.
contribute to substantial drug interactions. Detection of There will need to be many more treatment programs any alcohol or other drugs of abuse problem is a critical for substance abuse geared toward the elderly to first step toward minimizing medical complications.
accommodate this growing sector of the population.
There are several screening tools to use if substance Long-term effects of substance abuse can contribute to abuse is suspected. However, there is no one validated medical complications. With marijuana abuse, heart rate screening tool appropriate for the elderly.16 The impor- can be increased by 20% to 100% after smoking, and last tance of asking the general questions of “How often do up to three hours.12 It is estimated that marijuana users you drink alcohol?” and “Have you used any drugs for have a 4.8-fold increase in the risk of a myocardial infarc- recreational use?” is a good place to start a substance- tion during the first hour of smoking, and this may be abuse assessment. Positive answers to these questions greater the older the user is, especially if comorbid car- will lead to more advanced questions. The CAGE8 diac disease is present.13 Marijuana smoke contains 50% questionnaire, and the Michigan Alcoholism Screening to 70% more carcinogens than tobacco smoke, and mari- Test—Geriatric Version (MAST-G),9 are geared toward juana users generally inhale more deeply and hold their detecting alcohol abuse, and the Drug Abuse Screening breath longer than tobacco smokers, increasing lung Test (DAST)10 is for other drugs of abuse; however, exposure.12 High-dose users of marijuana can experience although useful, the DAST and CAGE are not specific an acute psychotic reaction. Long-term marijuana use has been studied in mice to cause changes in the activity The CAGE is the most widely used assessment for of nerve cells containing dopamine.14 Neurons involved alcohol abuse as it is a simple “Yes or No” four-item in the regulation of motivation and reward are mediated questionnaire that can be incorporated into any medical by dopamine. Additionally, marijuana use can affect interview by all health care professionals. The MAST-G memory, learning, and problem-solving ability.
is a 24-item questionnaire in dichotomous format that Common adverse effects of cocaine include: blood- was developed to target specific geriatric-related issues vessel constriction, dilated pupils, and increased body for alcohol use.16 However, it can be too long for some temperature, heart rate, and blood pressure, as well as headaches, abdominal pain, and nausea. Cocaine also can decrease appetite, so long-term users can become 1. Have you ever felt you should Cut down on your malnourished.15 However, effects of cocaine use vary depending on the route of administration. Long-term VOL. 25. NO. 9 SEPTEMBER 2010 THE CONSULTANT PHARMACIST Case Study: The Psychedelic 1960s, Hippies in Their 60s—Substance Abuse in the Elderly
intranasal use (snorting) of cocaine can lead to loss of Clinical Pearls
sense of smell, nosebleeds, problems with swallowing, n Don’t assume older patients don’t partake in hoarseness, and a chronically runny nose.15 Oral inges- tion of cocaine can cause severe bowel gangrene as a n It is becoming more critical to ask patients about result of reduced blood flow.15 Injecting cocaine can cause severe allergic reactions, and sharing needles can n Illicit drug use during early adulthood may increase the risk for HIV and other blood-borne diseases contribute to medical conditions in older adults such as hepatitis.15 Mental adverse effects of cocaine use include severe paranoia with auditory or tactile hallucinations, anxiety, irritability, and restlessness.15 References
1. Bartels SJ, Blow FC, Brockmann LM et al. Substance Abuse and Mental
Regardless of the route of administration, cocaine users Health Among Older Americans: The State of the Knowledge and Future are at higher risk for emergent complications of seizures, Directions. Rockville, MD: Older Adult Technical Assistance Center, Substance Abuse and Mental Health Administration; August 11, 2005.
2. Office of Applied Studies, Substance Abuse and Mental Health Services For this patient, the dysphagia and CV disease states may (SAMHSA). Substance Abuse Among Older Adults: 2002 and 2003 Update.
be related to cocaine use, and the memory issues could be Washington, DC: Department of Health and Human Services; April 22, related to the substance abuse, but this is uncertain.
2005. Available at http://www.oas.samsha.gov.
In addition, for this patient there is the concern of the 3. Office of Applied Studies, Substance Abuse and Mental Health Services(SAMHSA). The DASIS Report. May 31, 2007. Available at http://www.
multiple herbal substances, which can affect cognitive function. For example, valerian root is an anxiolytic simi- 4. Adams WL, Yuan Z, Barboriak J et al. Alcohol-related hospitalizations of lar in action to benzodiazepines; an increase in gamma- elderly people: prevalence and geographic variation in the United States.
JAMA 1993;270:122-5.
aminobutyric acid, the inhibitory neurotransmitter, may 5. Widlitz M, Marin DB. Substance abuse in older adults: an overview.
contribute to confusion. Lemon-balm extract has mild sedative properties that may also contribute to decline 6. Office of Applied Studies, Substance Abuse and Mental Health Services(SAMHSA). The DASIS Report of cognitive function. The glutamate is an activating . November 8, 2007. http://oas.samhsa.gov.
7. Holbert KR, Tueth MJ. Alcohol abuse and dependence: a clinical update neurotransmitter to the brain cells, and mushroom on alcoholism in the older population. Geriatrics 2004;58:38-40.
products can increase dopamine, which many contribute 8. Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA to hallucinations. Herbals also should be considered in 1984;252:1905-7.
9. Fingerhood M. Substance abuse in older people. J Am Geriatr Soc the assessment of cognitive decline; while natural, they 10. Gavin DR, Ross HE, Skinner HA. Diagnostic validity of the Drug AbuseScreening Test in the assessment of DSM-III drug disorders. Br J Addict1989;84:301-7.
11. Mayfield D, McLeod G, Hall P. The CAGE questionnaire validation of a The “flower children” of the psychedelic 1960s and their new alcohol screening instrument. Am J Psychiatry 1974;131:1121-3.
experimentation with illicit drugs are now blossoming 12. National Institute of Drug Abuse (NIDA) Infofacts: Marijuana. Availableat www.nida.nih.gov/infofacts/marijuana.html. Accessed October 26, into our fast-growing elderly population with medical complications of their substance abuse. When assessing 13. Mittleman MA, Lewis RA, Maclure M et al. Triggering myocardial any geriatric patient, all health care providers—especial- infarction by marijuana. Circulation 2001;103:2805-9.
ly the pharmacist—should ask questions related to 14. Diana M, Melis M, Muntoni AL et al. Mesolimbic dopaminergic declineafter cannabinoid withdrawal. Proc Natl Acad Sci USA 1998;95:10269-73.
drug- and substance abuse. Knowing what questions to 15. National Institute of Drug Abuse (NIDA) Infofacts: Crack and Cocaine.
ask a patient and what to look for in assessing substance Available at www.nida.nih.gov/infofacts/cocaine.html. Accessed October abuse as well as knowing local resources for referral 26, 2009.
16. Dole EJ, Gupchp GV. A review of the problems associated with screen- including self-help, treatment programs, and geriatric ing instruments used for alcohol use disorders in the elderly. Consult Pharm psychiatrists is a critical first step in an intervention.

Source: http://ws.westernu.edu/WesternU-News/docs/TCP10-9_Hoffman.pdf

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