Martin J. Jinks

A Profile of Alcohol and Prescription Drug Abuse in a High-Risk Community-Based Elderly Population

Substance abuse among the elderly is relatively common but often remains undetected or ignored by health and social workers. Psychosocial and health factors related to the aging process are the major contributors to alcoholism and other drug abuse. It is estimated that between two and ten percent of individuals over the age of 60 suffer from alcoholism. This article profiles alcohol and prescription drug abuse among the geriatric clientele of Elderly Services of Spokane (ESS), a division of the Spokane (Washington) Community Mental Health Center. In addition to traditional channels, ESS uses a unique gatekeeper network to identify high-risk, community-based elderly. Elderly persons referred by gatekeepers are regarded as “hidden” elderly and at highest risk; notably, 37 percent of ESS clients are referred via this mechanism. Case management records of 1668 ESS clients were reviewed for a history of alcoholism, and a total of 161 persons (9.6 percent) were diagnosed with either primary or secondary alcohol abuse. Fifty subjects (about five percent of the average active ESS caseload) were referred for prescription drug abuse. Misused prescription drug classes were sedative-hypnotics, antianxiety agents, and analgesics. Diazepam, codeine, meprobamate, and flurazepam were the top four agents, and 92 percent of the subjects were found to have a duration of prescription drug abuse in excess of five years. A 60 percent correlation between prescription drug abuse and previous or active alcoholism was found. Additional characteristics of the geriatric study population are discussed in detail, including specific psychosocial factors, source of referral, age, gender, living situation, marital status, psychiatric history, and presence of polypharmacy.

Counseling the Hearing-Impaired Older Adult:

Older adults use more prescription medication than any other segment of our society. They consume about 1/4 of all prescription drugs while comprising only 1/10 of the general population.23 This widespread use of medications, while perhaps increasing longevity and improving the quality of life of older adults, also subjects these patients to a wide array of adverse drug reactions which often may be more serious than the illness for which the medication was prescribed. It has been documented that the risk of adverse reactions nearly doubles in the aged compared to younger adults.21 One report found that 60 percent of an elderly outpatient population made errors in self-medication, and more than 25 percent of these committed potentially serious errors.25 An alarming number of older adults are admitted to hospitals as a direct result of preventable drug reactions.26 As noted earlier, presbycusis afflicts nearly 14 million (60 percent) of the individuals over age 65, and these older adults are particularly vulnerable to drug-use problems. A significant number have difficulty taking their medication in the manner intended by the physician because of inadequate instruction and poor comprehension of directions resulting from hearing-impairment. An understanding of the social and medical implications of hearing impairment in the older adult and the use of the basic communication techniques described in this paper will assist the pharmacist to improve his counseling efforts in the hearing-impaired older adult. ≃

Mail-Order Pharmacy: A Challenge to Pharmacy Practitioners and Educators

As a pharmacy student, I have a growing concern on the impact of mail-order pharmacy. Many pharmacists and pharmacy students may be wondering “if mail-order pharmacies are becoming increasingly popular, then why did I spend 6-7 hard-working years in school learning everything there is to know about drugs and how to implement that learning to patient care?” Knowing the value of my services it is a concern not only for my career, but also for the patients that are affected. For this reason, I will discuss the reasons for mail-order pharmacies, laws and regulations, advantages/disadvantages. Surveys were conducted to find out how pharmacists and patients really feel about mail-order pharmacies. Survey results will also be discussed.

Book Review: Prescribing for the Elderly

This book contains the proceedings of the International Conference on Drug Absorption, held in Edinburgh, September 26-28, 1979. The 34 contributions were written by 67 authors. The purpose of the conference was to bring together scientists from the areas of clinical practice, pharmacy, pharmacology, toxicology, and drug development who are experts in their fields, and who have special interest and experience, to discuss the status of drug absorption. Emphasis was given to absorption from the gastrointestinal tract and a detailed discussion of factors influencing absorption, such as physiological and pharmaceutical (physiochemical properties of drugs and drug products) factors, food and fluid intake, pathological factors (diseases), other drugs administered concomitantly, and new drug delivery systems. Also, practical aspects of bioavailability assessment and regulatory agency requirements were discussed. The book is divided into ten chapters representing the sessions held. Session I deals with limitations of classical theories of drug absorption, gastrointestinal drug absorption: anatomical and physiological considerations, and gastric emptying and drug absorption. Session II is concerned with absorption of polar acids and bases, rate-limiting steps and factors in drug absorption, and rectal absorption: portal or systemic. Session III addresses the topics of drug metabolism by intestinal flora, drug metabolism by the gastrointestinal mucosa: clinical aspects, and drug metabolism by the gastrointestinal flora. In Session IV, the following aspects are considered: presystemic hepatic metabolism: practical and pathophysiological aspects, presystemic hepatic metabolism: interaction with ethanol, first-pass effects in health and disease: pharmacokinetic studies on propoxyphene, and drug absorption and toxicity. Session V is concerned with important formulation factors influencing drug absorption, absorption screening and new drug development, and novel drug delivery systems. In Session VI, prodrugs: principles and practice, transdermal therapeutic systems, and advances in controlled gastrointestinal absorption are discussed. Session VII covers the aspects of drug formulation to minimize gastrointestinal toxicity, slow-release preparations in clinical practice, drug absorption interactions, and effects of food and drink on drug absorption in man. The influence of age on drug absorption, gastrointestinal disease and drug absorption, and drug absorption in other disease states are addressed in Session VIII. Session IX deals with assessment of drug absorption: pharmacokinetic interpretation and limitations, in vitro and in vivo bioavailability correlations, practical problems in the assessment of drug absorption in man, and bioavailability: are regulatory agency requirements justified? The last session (X) deals with general aspects related to absorption drug absorption and bioavailability: the 1980s, drug regulatory agency attitudes to bioavailability studies, clinical pharmacology, and the view from the pharmaceutical industry. Considering the large number of authors addressing the problem of absorption, one might assume a considerable amount of overlapping and repetition, but this is not the case. The editors and organizers of the conference are to be congratulated for careful editing, as documented by the homogeneous appearance of each chapter. The book is a treasure box for all concerned with or interested in absorption, regardless of whether one is interested in practical or research information. All contributions are well referenced. This book should be a valuable asset to the handbook library of clinicians, biopharmaceuticists and pharmacokineticists.

Magnifying the Impact of Clinical Practice by Automated Drug Reviews

About ten percent of total Medicaid expenditures are for drugs. Because a growing share of drug costs, and the consequences of their misuse, are being derived from tax dollars, those in government are seeking methods to hold drug-related expenditures down. The problems of high drug costs and drug misutilization have been clearly documented and indicate a need for effective drug utilization review (DUR). This need is especially acute in ambulatory patient populations, which suffer from a lack of good drug use control due to a general inability to reliably track ambulatory drug use patterns. The advent of government reimbursed drug benefits, which require compilation of all recipient drug claims regardless of the number of pharmacist or physician providers involved, and the pressures of drug cost control and drug use problems, have led to the creation and growth of a new health industry, the fiscal intermediary (FI). The FI combines expertise in electronic data processing (EDP) with knowledge of the drug delivery system. In this business milieu, new and unique opportunities have emerged for the clinically-trained pharmacist. This paper reviews the various levels of drug utilization review (DUR) employed by FIs, from elementary quantitative computer screens to highly sophisticated professional and peer review functions. The potential role of the clinically trained pharmacist in assuring the practice of optimal therapeutics across broad, ambulatory patient populations is illustrated. Specifically, the clinical pharmacists functions in DUR problem identification, drug use criteria setting, DUR criteria evaluation, and as drug information resource person to the peer review networks, are discussed.