The Promise of Substance Use Disorder Treatment in an Aging Population

February 24, 2017

Advances in Psychiatry - February 2017

NewYork-Presbyterian blends the rigor of two top-tier academic institutions, Columbia University Medical Center and Weill Cornell Medicine, with world-class psychiatry and addiction expertise to bring novel approaches to substance use disorders, one of the fastest growing health problems in the United States. Attuned to a shifting medical landscape marked by an increasingly older and sicker patient population, Frances Rudnick Levin, MD at NewYork-Presbyterian/Columbia University Medical Center and Nabil Kotbi, MD at NewYork-Presbyterian/Weill Cornell Medicine are spearheading clinical, research and educational initiatives designed to combat substance use disorders across diverse cultures and the lifespan.

“Over the past couple of decades we have made significant advances in our understanding of the neurobiology of addiction and are placing more emphasis on empirically-based treatments, yet there are significant barriers to widespread prescribing,” says Dr. Levin, the Kennedy-Leavy Professor of Psychiatry at Columbia University Medical Center and Chief of the Division on Substance Use Disorders at the New York State Psychiatry Institute. “Our goal is to get the word out so that physicians recognize substance use disorders in their patients, become more knowledgeable about available treatments, and learn how to do brief interventions or appropriately refer patients for treatment.”

“As the ‘silver tsunami’ approaches, substance use disorders in the elderly are expected to more than triple by 2020,” says Dr. Kotbi, Associate Professor of Psychiatry at Weill Cornell Medicine, Unit Chief of The Haven and Addiction Recovery Services at New York-Presbyterian/Westchester Division who is board-certified in Psychiatry, Psychosomatic Medicine, Addiction Medicine and Geriatric Psychiatry. “One of our primary goals is to identify and target substance use behaviors in the elderly and better understand the cognitive compromises that result from substance use in the context of aging. Cognitive dysfunction may impede patient engagement in traditional interventions, necessitating novel means of delivering treatment.”

Evidence-Based and Culturally Sensitive Approaches to Care

NewYork-Presbyterian provides comprehensive, individualized care for patients with cocaine, opioid, cannabis and alcohol use disorders. Inpatient and outpatient services are provided across three New York City campuses and in Westchester at the Westchester Division by substance use disorder experts who are distinguished by their culturally sensitive approach to every phase of care, from evaluation through treatment and into recovery. Treatments encompass a complete range of evidence-based psychopharmacologic therapies, cognitive behavioral therapies, individual therapies, problem-solving therapies, motivational enhancement therapies and relapse prevention therapies.

At these campuses, researcher-clinicians bring groundbreaking research in neurobiology and genomics from bench to bedside in order rapidly translate findings into novel, evidence-based treatment approaches.

“Here at Columbia we are renowned for our clinical trials program, which provides patients with access to the most cutting-edge treatments for substance use disorders,” says Dr. Levin, who serves as Director of Clinical and Educational Activities of the Substance Treatment and Research Service of Columbia University, a program that offers patients free and confidential substance use disorder evaluation and treatment in a clinical trial setting. Some of the most exciting clinical trials, notes Dr. Levin, include explorations of the utility of rapid induction onto long-acting injectable naltrexone for those with opioid use disorders; the use of ketamine infusions for adults with cocaine use and cannabis use disorder; understanding the neurobehavioral mechanisms underlying treatment response in adults with alcohol use disorders; and novel treatment approaches for patients with cocaine use disorders and adults with substance use disorders and attention-deficit hyperactivity disorder or other psychiatric illnesses.

At NewYork-Presbyterian/Westchester Division, Dr. Kotbi and his colleagues apply their extensive expertise in psychiatry, addiction medicine and geriatrics to patients with complex psychiatric, neurological, medical and substance use disorder co-morbidities. “Our team is keenly adept at addressing the cultural impacts that are often associated with substance use disorders,” says Dr. Kotbi. “For instance, there are many assumptions regarding cannabinoids. The fact that cannabis has been legalized in some states and used for medicinal purposes gives people the false impression that synthetic cannabinoids, e.g. “spice” and “K2,” are safe, when in fact they are highly dangerous, much more potent than cannabis and highly addictive.”

“From another perspective,” adds Dr. Kotbi, “elderly patients who are addicted to alcohol, painkillers or marijuana may find it taboo to admit to their addiction.”

Keeping a Keen Eye on the ‘Silver Tsunami’: The Importance of Recognizing and Treating Substance Use Disorders in Elderly Patients

Dr. Kotbi and Dr. Levin are concerned about the rise of substance use disorders in older patients. “We have seen a significant rise of marijuana, alcohol and sedative use disorders in patients over age 50, yet physicians often do not consider this to be an issue,” says Dr. Levin, who leads several educational programs that train residents, medical students and dental students in substance use disorder identification and intervention. “Physicians should have the potential problem of substance use disorder on their radars when they are evaluating older patients.”

“It takes a keen clinician to recognize addiction in an elderly patient, and it is especially important to detect it in elderly patients who are medically compromised,” says Dr. Kotbi. “Our alliance with the Weill Cornell Institute of Geriatric Psychiatry, right here on the Westchester campus, puts us way ahead of the curve in the identification and treatment of geriatric substance use disorders. We treat our patients rapidly and efficiently, which is important for this older and sicker patient population.”

“In this shifting medical landscape, it is more important than ever for physicians and the public to understand that addiction is a medical disease, and that the consequences of addiction have major social, cultural and economic implications,” adds Dr. Kotbi. “Our hope is to normalize substance use disorders and advocate on behalf of our patients to give them the best chance for successful treatment, longevity and quality of life.”