Substance Use Among Older Adults: Ethical Issues

By 2030, one in five Americans is projected to be 65 years or older, representing more than 20% of U.S. residents. As the “baby boomer” population ages, the age structure of the total U.S. population will shift toward increased old-age dependency, with a larger proportion of older adults compared with working-age adults (1). Life expectancy for older adults has increased, which means that Americans are living longer with chronic conditions, including substance use disorders (2).

Older adults are misusing alcohol and prescription drugs at rates higher than those of previous generations, posing a major challenge for physicians in identifying and addressing problematic substance use (3). A national survey in 2015 showed an estimated 2.3% of adults older than 65 years old met criteria for an alcohol use disorder within the previous 12 months, with a lifetime prevalence in this age cohort of 13.4% (4). Additionally, 25% of older adults are prescribed potentially addictive psychoactive medications (3), with benzodiazepines and other sedative/hypnotics being the most prevalent medication prescribed to this age group (2). However, substance use problems among older adults often go unrecognized or undertreated because of several factors: for example, generational stigma by older adults and their adult children, who may be in denial or may be ashamed of the problem and choose to ignore it; a general reluctance to seek out treatment; or an incorrect assumption by providers that treatment of older adults for substance misuse is not worth it. Because of biomedical changes associated with aging, older adults may experience accelerated declines in physiologic functioning contributing to increased morbidity and mortality, highlighting the importance of screening, early intervention, and treatment of substance misuse among older adults (2).

A prevailing ethical principle in addressing problematic substance use among older adults is autonomy, as older adults may be more sensitive to perceived threats to their personal autonomy when a physician expresses concern about harmful patterns of alcohol use or misuse of psychoactive prescriptions. Providing information to the older adult patient about age-related changes in alcohol and prescription drug metabolism and potential medication interactions may be less confrontational than engaging in a discussion about problematic alcohol and substance use behaviors (5). Although the presence of multiple medical and psychiatric comorbidities may make interactions with this population challenging, providers may be persuasive in encouraging reduction in use or engagement in substance use disorder treatment by consulting with the patient; allowing the patient to decide which changes he or she is able to make; and being sensitive to how information is presented, recorded, and disclosed (2).

In cases where there may be fluctuating levels of capacity or when the patient clearly is not able to fully participate in a decision-making process, an ethical dilemma arises for the provider who strives to maintain patient autonomy while also minimizing harm. If a health care proxy or a durable power of attorney has been named, that person may make decisions on behalf of the patient (2). Enlisting the help of family members or close friends identified by the patient, with the patient’s consent, may be necessary to help the patient reduce harm. For example, a family member may restrict access to alcohol and prescription drug use (e.g., managing medications, confiscating the patient’s driver’s license, removing access to alcohol, discussing living arrangements). Although all attempts should be made to maximize patient autonomy whenever possible, when patients are not able to fully grasp the information presented to them, act on that information, appreciate the implications of treatment alternatives, or make a decision that aligns with their best interests and values; the ethical principles of nonmaleficence and beneficence may supersede patient autonomy.

Case Illustration 1

Mr. Peters is an 80-year-old man with previous diagnoses of insomnia, sleep apnea, hypertension, type 2 diabetes, and peripheral neuropathy. His family has brought him to the emergency room after an accidental overdose. Mr. Peters reports a long history of insomnia for which he has been prescribed zolpidem. His primary care physician expressed some concern about Mr. Peters’ use of zolpidem, as the patient has intermittently taken higher doses of zolpidem than prescribed. Mr. Peters also admitted to drinking one to two shots of bourbon in the evenings to help him fall asleep when the zolpidem does not work: “I don’t even like the taste of alcohol, but it’s the only thing that works!” On the night of Mr. Peters’ presentation to the emergency room, he states that he was having difficulty falling asleep after his usual measures, so he got up to go to the medicine cabinet and took an unknown amount of gabapentin to help him fall asleep again. He was later found slumped on the floor by family members and appeared confused. He was held for observation and monitored in the emergency room; later, he was discharged and sent home after his mental status improved. Mr. Peters denied having thoughts or an intent to hurt himself, stating, “I just wanted to fall asleep.”

After this emergency room presentation, Mr. Peters’ family expressed their concern about Mr. Peters’ current medication regimen to the primary care doctor. They have noticed that Mr. Peters appears to be less steady on his feet, has been more forgetful than usual, and has continued to drink alcohol every evening despite his recent emergency room visit. They are concerned that Mr. Peters may have another bad fall or other adverse health consequences related to the combination of his medications and his alcohol use.

Mr. Peters’ wife asks the primary care physician for a printout of the patient’s current medication list so that she can get a second opinion about the patient’s care. The primary care physician states that she cannot provide this information without the patient’s consent but encourages her to discuss her concerns with Mr. Peters and consider accompanying Mr. Peters to a follow-up visit.

• 1. Which set of ethical principles governed the primary care physician’s response to this request for Mr. Peters’ medical records?

  1. Fidelity and veracity

  2. Altruism and nonmaleficence

  3. Autonomy and confidentiality

  4. Justice and compassion

  5. Respect for the law and compassion

After meeting with Mr. Peters and his wife for a follow-up visit and reviewing the patient’s medical history and risk factors, as well as concerns voiced by the patient’s family, Mr. Peters’ primary care physician recommends a tapering off zolpidem and a trial of another nonsedative/hypnotic medication to help address his insomnia.

• 2. Which ethical principle guided Mr. Peters’ primary care physician in the recommendation to taper off zolpidem in response to concerns about Mr. Peters’ current medication regimen?

  1. Beneficence

  2. Nonmaleficence

  3. Autonomy

  4. Fidelity

  5. Justice

Although Mr. Peters does not agree with his family that he is exhibiting signs of impairment related to his medication regimen, he agrees to try tapering off zolpidem as long as the primary care doctor prescribes him another medication to help him with his sleep. He also agrees to a referral to an addiction psychiatrist for medication recommendations and to explore how his current pattern of alcohol use may be affecting his problems with sleep.

• Mr. Peters attends an initial consultation with a psychia-trist. Match the following actions by the addiction psychiatrist with the most appropriate term (each term may be used once, more than once, or not at all):

  1. Autonomy

  2. Beneficence

  3. Nonmaleficence

  4. Confidentiality

  5. Respect for the law

  6. Justice

  7. Veracity

• 3. The psychiatrist explains expectations and limits of confidentiality to the patient at the start of the visit.

• 4. The psychiatrist documents aspects of the patient’s medical, psychiatric, and substance use history accurately in the electronic medical record.

• 5. The psychiatrist speaks to Mr. Peters alone during the clinical interview but also allows time to speak with Mr. Peters’ wife with the patient’s consent.

• 6. The psychiatrist elicits Mr. Peters’ thoughts about how his alcohol use may be affecting his sleep and provides information about age-related changes to metabolism of alcohol and prescription medications.

• 7. The psychiatrist engages the patient in a discussion of alternative non-habit-forming medication options to help with sleep and assesses the patient’s motivation and confidence level in his ability to make changes to his current pattern of alcohol use.

Case Illustration 2

Ms. Smith is a 73-year-old divorced woman who comes in for a follow-up visit with her psychiatrist, accompanied by her adult daughter who is concerned about her mother’s drinking. Ms. Smith has several medical conditions, including hypertension, poorly controlled type 2 diabetes, and peripheral neuropathy. She often wears thick socks instead of shoes to office visits because of the discomfort to her feet caused by lower-extremity edema. She is currently retired but volunteers 3 days a week as a teacher’s aide for a second-grade class. During her days off, she spends most of her time at home alone. Over the past couple of months, Ms. Smith’s daughter has become increasingly concerned about Ms. Smith’s memory and worries that her mother may be drinking too much. Although Ms. Smith admits to having an “occasional drink” on her days off, she is unable to quantify how much she drinks. Her daughter often finds one to two empty wine bottles every morning when she stops by to check in on Ms. Smith. She has also noticed that the medications laid out in a weekly pill box are not always gone when she comes over to help Ms. Smith manage her medications and reports that the patient has not been keeping up with her basic hygiene.

When the primary care doctor asks Ms. Smith about her thoughts on what her daughter has shared, Ms. Smith states that she does not recall drinking as much as her daughter reports, but she admits to sometimes forgetting to take her medications daily. Ms. Smith also admits to feeling a bit unsteady on her feet when trying to take a shower because of her neuropathy. Ms. Smith’s daughter mentions a medication that she has heard about that causes a person to get sick if they drink and asks whether this would be a good option for Ms. Smith, since the patient lives on her own and she has found it difficult to monitor the patient’s drinking.

The patient states that she does not want to start any new medication because she feels that she is already taking too many medications. On hearing this response, her daughter turns to the psychiatrist and says in a hushed tone, “Can you just order this medication, and I’ll make sure she takes it?” The psychiatrist declines to prescribe the disulfiram that the patient’s daughter has requested.

• 8. The psychiatrist’s decision to not prescribe this medication to Ms. Smith despite her daughter’s wishes is governed primarily by which of the following pairs of ethics principles?

  1. Compassion and veracity

  2. Respect for the law and justice

  3. Nonmaleficence and confidentiality

  4. Beneficence and veracity

  5. Autonomy and fidelity

Two weeks later, Ms. Smith returns to the office with her daughter. Her daughter reports that attempts to keep alcohol from the patient have been unsuccessful, as Ms. Smith has found ways to purchase or find other people to bring her alcohol. Ms. Smith was recently admitted to the hospital with an orbital fracture after she fell at home. Her blood alcohol level was measured to be 129 (blood alcohol concentration=0.13) on admission. Ms. Smith’s daughter is concerned about the patient’s safety living alone and has met with the hospital social worker to review options for assisted living. While in the hospital, Ms. Smith at times presents alert and oriented, whereas at other times she presents confused and agitated. After 5 days in the hospital, Ms. Smith appears to be closer to baseline but continues to have moments of forgetfulness. A family meeting has been arranged with providers to discuss discharge planning and possible transition from living alone to moving into an assisted living facility.

• 9. In cases of diminishing or fluctuating capacity in older adults, how can providers maximize patient autonomy in the decision-making process?

  1. Decisions should be made for the patient by the providing physician on behalf of the patient because of her fluctuating mental status.

  2. Providers should encourage the patient’s daughter to file for guardianship immediately.

  3. Providers can maximize the patient’s decision-making process by providing information clearly, to allow the patient to absorb information gradually, and restate information as necessary to help summarize information already covered at regular intervals.

  4. Providers should refer the patient to psychiatry for inpatient hospitalization because of danger to self.

  5. Providers should discuss decisions only with family members, since the patient is not able to participate in the decision-making process.

Answers

1. The answer is C. Autonomy and confidentiality. Although Mr. Peters’ wife requested information about his medical history on the basis of genuine concern for her husband’s well-being, this request would constitute an intrusion on Mr. Peters’ autonomy and privacy. Furthermore, if Mr. Peters was having problems with his wife, divulging information about his medical history without his consent may have a negative effect on the resolution of those problems and adversely affect his relationship with his wife and family members.

2. The answer is B. Nonmaleficence. In this scenario, the primary care physician should be concerned about the development of tolerance and dependence to zolpidem, as Mr. Peters has required higher doses of this medication without improvement in efficacy. Furthermore, Mr. Peters’ use of alcohol and recent emergency room presentation put him at high risk for future adverse effects related to coingestion of zolpidem and alcohol. A slow tapering off zolpidem would be in the patient’s best interest to avoid additional harm to the patient.

3. The answer is D. Confidentiality. Respect for the patient’s confidentiality is paramount to developing trust between a psychiatrist and patient. Patients should be informed of the limitations of confidentiality, including those regarding suicidal or homicidal ideations and child or elder abuse.

4. The answer is G. Veracity. Accurate documentation of the patient’s medical, psychiatric, and substance use history is reflective of the ethical principle of veracity.

5. The answer is D and E. Confidentiality and respect for the law. Patients with harmful patterns of substance use may be subject to discrimination and stigma, thus deterring them from seeking and entering treatment. This concern was the impetus for the U.S. Department of Health and Human Services to set a guide of regulations to protect patient information pertaining to substance use. 42 CFR Part 2 (Volume 42 of the Code of Federal Regulations, Part 2) is a federal law that restricts communication of sensitive patient information by providers who specialize in providing substance use diagnosis, treatment, and/or referral for treatment. Although primary care physicians and general psychiatrists may not be subject to these regulations, any health care practice or social service organization that employs an addiction psychiatrist or addiction medicine physician must comply with this federal law and implement procedures for protecting information pertaining to patients who may have substance abuse problems. Before the provider attempts to gather collateral information from other sources about a patient with substance abuse problems, he or she should ask the patient’s permission to do so. Unauthorized disclosures may be grounds for disciplinary action, fines, and license revocation.

6. The answer is A and G. Autonomy and veracity. It can be a challenge for providers to raise the concern about problematic alcohol or prescription drug use without triggering a defensive response from the patient, who may be in denial about the harmful effects of their substance use. Providers can respect patient autonomy by engaging patients in discussion about how their substance use may be affecting their physical or mental health and well-being and by providing information about age-related changes to their metabolism of alcohol and prescription drugs. Respecting patient autonomy (the right to make decisions about their care) and providing truthful medical information (i.e., veracity) are helpful strategies for encouraging patients to explore alternative treatments and consider making changes to their harmful use behaviors.

7. The answer is A. Motivational interviewing techniques may help the provider identify the patient’s readiness and motivation for change (stages of change: precontemplative, contemplative, preparation, action, and maintenance) and engage the patient in discussions on how his or her problematic substance or prescription drug use may be affecting his or her physical and mental health and quality of life. Emphasizing patient autonomy and highlighting self-efficacy are central to encouraging healthy lifestyle changes.

8. The answer is E. Autonomy and fidelity. Ms. Smith’s daughter was referring to a medication called disulfiram, a medication with approval from the Food and Drug Administration for treatment in alcohol abuse disorders. Disulfiram works by blocking aldehyde dehydrogenase, which inhibits the metabolism of alcohol and increases the toxic metabolite acetaldehyde, which is responsible for the short-lived drug–ethanol reaction (e.g., nausea, flushing, abdominal discomfort, sweating, dizziness, heart palpitations, and blurred vision) (6). Patients who are prescribed disulfiram should provide informed consent, indicating that they understand the risks associated with ingestion of alcohol while on this medication. In this case, Ms. Smith stated that she did not want to start a new medication; furthermore, reports of possible cognitive impairment would put her at risk of unintended adverse effects should this medication be given to her without her expressed consent. The ethical principle of autonomy requires that the physician respect the patient’s choice not to start a new medication; and the principle of fidelity prevails as the ethical obligation of the physician to serve the patient faithfully, despite conflicts that may arise from the patient’s family members who may be advocating for treatment for which the patient has not provided informed consent.

9. The answer is C. Providers should maximize patient autonomy whenever possible. This can be done by providing information in a clear way that will allow the patient to absorb information gradually and restate information as necessary to help summarize information already covered at regular intervals, enlisting the help of a trusted friend or family member identified by the patient to assist in decision making, referral to a geriatric or mental health professional for consultation, or utilization of a durable power of attorney or health care proxy previously identified by the patient in the case of the possibility of incapacity. A guardian is a court-appointed person who has been granted the authority to manage some or all of another person’s life based on the legal finding that the person is disabled in some way and that this disability prohibits the person from managing aspects of their own life. Rules for guardianship proceedings may vary state to state, with different standards of disability applied to different life skills. Petitioning the court for guardianship would effectively remove autonomy from the patient and may end up being an extensive and expensive legal process. For these reasons, it is often considered a last resort for family members.