Substance Abuse and Older Adults

The Florida BRITE Project:
BRief Intervention and Treatment for Elders
Lawrence Schonfeld, PhD
Department of Aging & Mental Health
Florida Mental Health Institute
University of South Florida
[email protected]
History of Florida DCF’s Efforts on
Substance Abuse among Older Adults
 Legislative budget requests
 2002 SAMHSA Grant proposal
 Screening, Brief Intervention,
Referral and Treatment (SBIRT)
 Older Adult Workgroup on
Substance Abuse
 SBIRT concept funded by DCF in
2004 – later renamed as the Florida
BRITE Project
Categories of Substance Misuse
among Older Adults
 Alcohol Abuse – the primary
concern for substance abuse
 Other substances:
 Medication Misuse – usually
unintentional misuse; related to
patient errors, difficulties with
regimen, & prescribing practices
 Over-the-Counter (OTCs)
 Illicit Drugs – an increasing
This 2001 report suggests that illicit drug use, binge
drinking and heavy drinking among adults ages 55 and older
is higher than previously thought.
Percentage of Adults Aged 18 or Older Reporting Past Month Use of
Any Illicit Drug or Alcohol by Age Group: 2000. (source NHSDA, 2001)
12% of 55+ age group are either
binge or heavy alcohol users
18 to 25
26 to 34
35 to 54
55 or Older
Percent Reporting Use in Past Month
Any Illicit
Drug Use
Any Alcohol
Alcohol use
Alcohol Use
Admissions Age 55 or Older by Primary
Substance at Admission: 1994-1999
(DASIS Report December 2001)
Primary substances in 1999:
Source: 1999 Treatment Episode Data System (TEDS)
Expert panel
for screening and
treating the older
Protocol (TIP) #26
TIP#26 Expert Panel Recommendations
1. Age-specific, group treatment that is supportive, not
2. Attend to depression, loneliness; address losses.
3. Teach skills to rebuild social support network
4. Employ staff experienced in working with elders
5. Link with aging, medical, institutional settings
6. Content should be age-appropriate and offered at a
slower pace.
7. Create a “culture of respect” for older clients
8. Broad, holistic approach recognizing age-specific
psychological, social & health aspects.
9. Adapt treatment as needed to address gender
Florida’s Elder Population
 Total population - about 17 million
 22% are age 60 or older
 Among the adult population ages 18
and older, elders ages 60+ represent
 However, in 2000, among adults in
Florida’s treatment for substance abuse
problems, only 2% were ages 60+
The FMHI Model: Relapse prevention,
group treatment using cognitive-behavioral
interventions and self-management skills
• Gerontology Alcohol Project (1979-1981)
• Substance Abuse Program for Elderly (1986-1994)
• Replications:
• Chelsea Arbor Older Adult Recovery Center in
Ann Arbor, Michigan (1990’s)
• GET SMART Program (West Los Angeles VA
Hospital; 2000)
• Older Adult Substance Abuse Treatment
Program – Tennessee (2005 - present)
• Zablocki VA Medical Center (Milwaukee, 2006 present)
The alternative: Brief Intervention
 Project GOAL (“Guiding Older Adult Lifestyles”)
Fleming et al. (1999) focused on at-risk drinkers
age 65+ in community-based primary care received
2 15 minute sessions of brief physician advice.
 Health Profiles Project (Blow, Barry, et al.) – the
largest randomized trial of brief alcohol advice to atrisk drinkers 60+ (N=454). Provided in-home brief
 Later Used with aging services’ providers: Staying
Healthy Project (Cullinane, Blow, Barry, et al.)
- Screened 4,300+ older adults in California
- 166 people entered randomized trials
- 39% decrease in Experimental & 28% in Control
groups’ drinking
The Florida BRITE Project
funded by the Florida Dept. of Children and Families
Intervention and
Treatment for
The Florida BRITE Project
BRief Intervention & Treatment for Elders
Gulf Coast
Center for
Drug Free
Living – added
in 2005
County Elderly
& Veterans
The Florida BRITE Project - Goals
 Implement screening, brief intervention,
referral and treatment (SBIRT) relying on
CSAT’s Treatment Improvement Protocols
 Substance Abuse & Older Adults TIP #26
 Brief Intervention & Brief Therapies TIP #34
 CSAT manual: Relapse Prevention for
Older Substance Abusers (Dupree & Schonfeld)
 Develop referral networks, screening and
services appropriate for older adults in order
to reach greater numbers of elders.
The Florida BRITE Project - Goals
 Reach more older Floridians than previously served
 Screen older adults (ages 60+) considered:
 At risk for substance misuse, or
 Demonstrating problems with substances
 Reach elders unlikely to be served by “traditional”
types of services:
 Low-income elders
 Minorities
 Isolated, withdrawn
 Florida BRITE Project must remain flexible!
 Modified based on formative evaluation, system
changes and needs.
BRITE differs from usual services
• “Non-traditional” substance abuse referral
sources to identify hidden abusers
• Screen where elders are more likely to be
found or interviewed:
• In their own homes
• Elder-specific living, centers
• Exemption from Florida’s standard
admission and assessment protocols
• Brief Interventions in home or on-site
• Brief Treatment if needed (CBT/Self-Mgt.)
The Florida BRITE Project
 BRITE identifies older adults who misuse or are at
risk for misusing:
 Alcohol
 Prescription medications
 Over-the-counter (OTC) medications
 Illicit drugs
 Depression and suicide risk are also being
screened by BRITE providers since:
 Depression is the most frequent antecedent to
substance abuse in elders
 Few older adults participate in behavioral health
 Older adults have the highest rate of suicides
among all age-groups.
Pre-Screening by Nontraditional
and other referral sources
Screening by BRITE
Pilot Program
End Screening
Re-contact at
later date
Enter Screening
Data on Tablet PC &
upload to KIT Solutions
Client screens positive
and agrees to be served.
Admit person for services
appropriate to service plan
Re-Assess at
Discharge, 30
and 90 days
post discharge
Enter data into
ETIPS & upload
Re-screen client prior
to discharge
Enter Data & upload to KIT
Refer to external
services as
indicated in plan
Completion of every six
B.T. sessions,
discharge, 30 & 90 days
Pre-Screening for BRITE
• Prescreening through “traditional” referral
sources for substance abuse services may
not be appropriate for elders.
• Link with agencies that more likely to serve
older adults with problems:
• Aging Services (AAA, County Aging)
• Protective services
• Visiting Nurses
• Geriatric physicians
• Assisted living facilities
• Mental health centers
• Health clinics
Pre-Screening for BRITE
• To date, much of the referral efforts have
involved outreach efforts by BRITE
providers through:
• Presentations at senior housing, health
fairs, other group settings
• The more efficient method we are trying to
establish is to build a community agency
referral network in which BRITE providers
• Identify local aging, social, & healthcare
services who frequently serve elders
• Educate these services about BRITE
• Develop schedule of regular contact
 BRITE Screening Tool consists of scales that
separately address the required domains of alcohol,
medications, drugs, depression, suicide risk
 Alcohol, Depression screens already valid
 All screens in the public domain (no copyright
infringement, free to use)
 Easy to administer and comprehend
 Translated into Spanish for BRITE Project
 Includes interviewer’s impressions
 Includes questions on substance use history and
Short - Michigan Alcoholism Screening
Test - Geriatric Version (SMAST-G)
 A 10 item screen
 Includes risk factors appropriate to
 YES/NO response format
 Scoring: 2 or more "YES" responses
are indicative of an alcohol problem.
Source: Frederic C. Blow, Ph.D., University of Michigan Alcohol
Research Center, Ann Arbor, MI
1. When talking with others, do you ever underestimate how
much you actually drink?
2. After a few drinks, have you sometimes not eaten or been
able to skip a meal because you didn't feel hungry?
3. Does having a few drinks help decrease your shakiness or
4. Does alcohol sometimes make it hard for you to remember
parts of the day or night?
5. Do you usually take a drink to relax or calm your nerves?
6. Do you drink to take your mind off your problems?
7. Have you ever increased your drinking after experiencing a
loss in your life?
8. Has a doctor or nurse ever said they were worried or
concerned about your drinking?
9. Have you ever made rules to manage your drinking?
10. When you feel lonely, does having a drink help?
Begin with a “Brown Bag” Review
Interviewer's impressions of the person
after completing the "Brown Bag Review" of
1. Does not correctly recall the purpose of one or
more medications
2. Reports the wrong dose/amount of one or more
3. Takes one or more medications for the wrong
reasons or symptoms
4. Needs education and/or assistance on proper
medication use
Medication Misuse High Risk Behaviors?
Takes more than one type of prescribed medication
Difficulty remembering how many meds to take
Prescriptions from two or more doctors
Felt worse soon after taking meds
Taking meds to help sleep
Uses up meds too fast
Takes meds for nervousness or anxiety
Doctor/nurse expressed concern about use of meds
Take pain relieving meds
Take pills to deal with loneliness, sadness
Saving old medications for future use
Chooses between cost of meds and other necessities
A family member reminds them to take pills
Uses dispenser or other method to help remind
Fails to take meds supposed to
Borrow someone else's meds
Feel groggy after taking certain medications
OTC Medication Use and Misuse - Risks
1. Do you frequently take aspirin, Tylenol, Advil, or other
non-prescription pills for pain?
2. Do you ever tell your physician about the type of nonprescription pills you buy?
3. Do you use herbal pills such as Ginkgo, Saw Palmetto,
St. John's Wort?
4. Do you take non-prescription pills or remedies for
improving your memory?
5. Have you ever felt worse soon after taking over-the
counter remedies?
6. Are you taking medications to help you sleep?
7. Do any of the non-prescription pills you take make you
feel groggy?
8. Do you use plants or herbs to make your own remedies
such as garlic, or aloe?
Drug Use
Use of any of the following in past year:
1. Marijuana?
2. Cocaine?
3. Crack?
4. Heroin?
5. Hallucinogens (such as LSD, PCP)?
6. Substances - sniffed or inhaled?
Recorded by interviewer - YES/NO
format. Any YES responses results
in a Flag for further assessment.
Short - Geriatric Depression Scale
1. Are you basically satisfied with your life?
5-9 = mild to moderate
2. Have you dropped many of your activities
and interests?
3. Do you feel that your life is empty?
10+ = serious levels of
4. Do you often get bored?
5. Are you in good spirits most of the time?
6. Are you afraid that something bad is going to happen to you?
7. Do you feel happy most of the time?
8. Do you often feel helpless?
9. Do you prefer to stay at home, rather than going out and
doing new things?
10. Do you feel you have more problems with memory than most?
11. Do you think it is wonderful to be alive now?
12. Do you feel pretty worthless the way you are now?
13. Do you feel full of energy?
14. Do you feel that your situation is hopeless?
15. Do you think that most people are better off than you are?
Suicide Risk Items *
Has anyone in your family ever committed suicide?
If yes, who in your family committed suicide?
Have you ever thought about taking your life?
How recently have you thought about killing
Do you have a plan for doing this?
(response selected from list of plans provided)
Have you ever been in the care of psychiatrist,
psychologist, or other professional because of
severe depression or mental problems?
Do you keep firearms in the house?
If yes, ask how many guns are in the house?
Adapted from Brown & Bongar (2004) Assessing risk for completed suicide in
elderly patients: Psychologists' views of critical risk factors. Professional
Psychology: Research and Practice.
Following Screening
 Older adults who screen positive for
substance abuse can be offered one of two
types of services
 Brief Intervention
 1 to 5 sessions of brief advice, education
about substance use
 Health Promotion Workbook
 Brief Treatment
 Up to 16 sessions using the Relapse
Prevention Curriculum (CSAT, 2005)
Brief Interventions can be delivered
where older adults can be found
In the elder’s home
Senior center, congregate meal sites
Home Health Care
Physician’s office
ER’s or Hospital rooms
Florida BRITE
Health Promotion
Barry, Oslin, & Blow (1999)
and CSAT TIP #26 (1998)
(modified to include drugs,
medications, OTCs,
depression and suicide risk)
Resource for Pilot
Health Promotion
Workbook Topics:
 Identify future goals for physical
and emotional health, activities,
 Summarize health habits:
 Exercise, tobacco, alcohol,
 Alcohol use
 What is a standard drink
 Types of older drinkers
 Consequences of drinking
 Reasons to quit or cut down
 Drinking agreement
 Drinking diary card
 Handling risky situations
 Visit summary
Resource for Pilot
Health Promotion
Workbook Topics (continued):
 Medication misuse
 Reasons for taking wrong
 Things to tell your doctor
 Do’s and Don’ts for taking
 Potential problems with OTC
 Visit summary
Alternative to Brief Intervention is
“Brief Treatment”
 BRITE providers have the option to use
the 16 session Relapse Prevention
curriculum if:
 The client’s problem requires more
 The client requires more sessions
 The client does not succeed during
Brief Intervention
A Three Stage CBT/Self-Management
Treatment Approach
(Dupree & Schonfeld, SAMHSA/CSAT manual, 2005)
1. For each person begin by identifying
his/her antecedents and consequences
for substance use to create an
individualized “substance use behavior
chain” using the Substance Abuse
Profile for the Elderly
2. Teach the person how to identify the
components of that chain so that he or
she can understand the high risk
situations for alcohol or drug use.
3. Teach specific skills to address these
high risk situations to prevent relapse.
Relapse Prevention Curriculum
 Each topic is presented as a module,
with specific instructions to the leader
regarding the theme of the lecture,
materials needed, and exercises.
 Instructions to the group leader to:
 prompt discussion among clients
 use diagrams or visual aids
 lead rehearsals/role plays
 provide homework/assignments
Teaching Relapse Prevention Skills
 Each topic is presented as a module,
with specific instructions to the leader
regarding the theme of the lecture,
materials needed, and exercises.
 Instructions to the group leader to:
 prompt discussion among clients
 use diagrams or visual aids
 lead rehearsals/role plays
 provide homework/assignments
The Result:
A 16-session
curriculum manual
for conducting brief
(Dupree & Schonfeld,
CSAT, 2005)
BRITE – Screenings from
March 2004 – October 17th 2006
• 2,945 screened by 4 agencies:
Broward Co. Elderly & Veterans Serv =
Gulfcoast Community Care (Pinellas) =
Coastal Behav. Health Care (Sarasota) =
Ctr. for Drug Free living (Orange)* =
* began in August 2005
• Most (67%) are identified through BRITE
outreach, presentations to the public, visits
to senior centers, etc.
 Living arrangements:
 54% alone
 20% with spouse
 8% in group setting (e.g., ALF)
 70% were women
 Median age = 75
 Race
 75% Caucasian
 18% African American
 6% multiracial
 Hispanic 15%
Florida BRITE Project Screening:
Alcohol Problems
 8.4% of those referred to BRITE were for
potential alcohol problems
 75% of all 2,945 screened were drinkers
 17% of drinkers consumed 3 or more
drinks on a drinking day
 81% of referrals for alcohol problems and
14% of those referred for other reasons
scored 2 or more on the S-MAST-G.
 483 clients provided services – mostly brief
intervention. Many of these showed other
Florida BRITE Project Screening:
Prescription Medications
 25% were referred for prescription misuse
 Of this group:
 9% reported wrong amount for one or
more medication
 13% could not recall purpose of one or
more medications
 20% need education and/or assistance on
proper medication use
 7% took prescription medications for
wrong reasons or symptoms
Florida BRITE Project Screening:
Over-the-Counter Medications
• 8% referred for potential OTC misuse
Illicit Drug Use
 < 1% referred to BRITE for illicit drug use
Florida BRITE Project Screening:
 67% of all 2,945 were referred for
 Screening these with the Short-GDS:
 24% of those referred had moderate
 Another 9.6% with serious depression
 Similar proportions for those not referred
specifically for depression
Florida BRITE Project Screening:
Suicide Risk
 Only 0.6% referred for suicide risk
 Yet, 14% of all referrals indicated that
they contemplated suicide at some time
 23% of these within the past year
Services Provided based on the
limited data entered:
 Preliminary Outcomes:
 Significant improvement in Geriatric
Depression Scores (S-GDS) for 270 of
the 273 people screened (p<.001)
 Significant improvement in S-MAST-G
(alcohol screening) at discharge for
116 people receiving re-screening
The new SBIRT Grant
Screening, Brief Intervention,
Referral and Treatment
(funded by SAMHSA’s Center for
Substance Abuse Treatment)
 Florida was recently awarded a $14 million SBIRT
grant (Oct. 2006- Sept. 2011)
 Most of the funding goes to direct services
 The new funding added to current funding will
increase BRITE to a total of 12 sites
 Additional counties include: Charlotte, Duval,
Hillsborough, Miami-Dade, Palm Beach, and
 An RFP process will be used for selecting and
awarding contracts to providers
 The new grant will involve both “generalist” providers
(e.g., physicians; aging services) and “specialist”
providers (substance abuse treatment agencies).
 Best or promising practices and curricula are
available, yet few elder-specific programs exist.
 Identifying older adults with substance abuse,
misuse, or “at-risk” behavior remains a difficult
 Especially true for medication misuse
 Depression is often associated with use and
misuse among older adults, yet remains a
challenge for substance abuse providers.
 The new SBIRT Grant received by Florida aims
to address many of these issues.

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