Substance Abuse and Older Adults - Carter

Substance Abuse
and Older Adults
Lawrence Schonfeld, PhD
Department of Aging & Mental Health
Florida Mental Health Institute
University of South Florida
[email protected]
Substance Use:
Issues of Concern for Older Adults
 Alcohol – primary focus of
today’s presentation
 Tobacco – a well established
health risk
 Prescription Medication Misuse
 Over-the-Counter (OTCs)
 Illicit Drug Use
Prevalence Rates – Ages 65+
 Alcohol problems among older adults:
 2%-10% of community-based
 6% to 11% of hospital admissions
 14% in Emergency Departments
 Tobacco: About 10% are current users (similar
rates for older men and older women)
 Prescription Drugs
 17% of hospitalizations of older adults are
related to an adverse drug reaction – a rate
6 times greater than for entire population.
 OTC Products: Adults ages 65+ consume more
OTC medications than any other age group.
 Illicit drug use – Low rate, but increasing trend?
This 2001 report from the National Household Survey
suggested that illicit drug use, binge drinking and heavy
drinking among adults ages 55+ was higher than previously
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
What does the research tell us about older
adults and substance abuse treatment?
Substance Abuse Treatment Program
Admissions Age 55 or Older
by Primary Substance at Admission
(DASIS Report December 2001)
Primary substances in 1999:
Source: 1999 Treatment Episode Data System (TEDS)
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, among adults in treatment for
substance abuse problems, only 2%
are age 60+
Few older adults are treated in Florida’s
substance abuse treatment programs
Fiscal Year 2001-2002
Ages 18-59
People age
60+ are only
2% of all
adults in
Source: Policy & Services Research Data Center (2003)
Louis de la Parte Florida Mental Health Institute
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
NIAAA (1995) recommended for individuals over the
age of 65, "no more than one drink per day"
TIP#26 refinement:
• Maximum of 2
drinks on any
drinking occasion
(New Year's Eve,
• Somewhat lower
limits for women.
Treating Older Adults with Alcohol
 Outcomes are generally better than younger
 Late-onset may have the best outcomes
 Early studies involving group treatment have
demonstrated several important points:
 Depression, boredom and loneliness are
frequent triggers to drinking
 Those entering treatment often consume
greater quantities than one might expect.
Gerontology Alcohol Project
(Dupree, Broskowski & Schonfeld, 1984)
 “GAP” was a day treatment program for late
onset alcohol abusers ages 55+
 Onset of problem after age 50
 Curriculum manual provided scripted,
cognitive-behavioral and self-management
skills to prevent relapse
 Group treatment format
 Average alcohol consumption prior to
admission was 12.2 SECs on a typical drinking
day (equivalent to 12 drinks/day)
 Depression, loneliness reported in about 80%
of cases as the antecedents to drinking.
Gerontology Alcohol Project: Alcohol consumption at
admission, discharge & follow-ups for Program completers
GAP - Replications
• Substance Abuse Program for the Elderly 1986-94
(Schonfeld & Dupree, 1991, J. of Studies on Alcohol)
• Age of onset not restricted
• Alcohol, medications, drugs targeted
• Used the GAP approaches
• GET SMART Program at West Los Angeles VA
(Schonfeld et al. 2000, J. of Geriatric Psychiatry & Neurology)
• Modified GAP to a 16 session curriculum
• Use with VA outpatients
• Older Adult Services Substance Abuse Program –
Tennessee – community-based project from
Centerstone Mental Health Center
Characteristics of 110 GET SMART Patients
(Schonfeld et al. 2000, Journal of Geriatric Psychiatry & Neurology)
• Average Age 64.71 yrs (sd=5.5) (range: 53-82)
• Diverse group:
• 50.8% Caucasian, 41.7% African American
• 5.8% Latino; 1.6% Asian
• Percent Homeless
• Percent living in a Domiciliary
• In Which War Served?
Most recent substances used prior to
admission to GET SMART program.
Alcohol Only
Street Drugs Only
Prescription Medications only
Alcohol and Street Drugs
Alcohol and Prescription Meds
Street Drugs + Prescription Meds
All three categories
 Thus, prior to admission, 38.2% were using illicit
drugs, mostly in conjunction with alcohol
GET SMART - Outcomes at Six Month Follow-up
Did Not
(n=49 or 44.5%)
(n=61 or 55.5%)
Remained Abstinent
Abstinent at follow-up, but
had had at least one slip
Returned to fulltime alcohol
use at follow-up
Deceased at Follow-up
Couldn’t be located
Couldn’t follow-up for other
Screening & Brief Intervention
 What is the best way to identify
older adults with alcohol or other
substance use problems?
 What are alternatives to traditional
substance abuse treatment?
 Focusing on primary care practice
Screening Instruments that have been
used with older primary care patients
 S-MAST-G: Short-Michigan Alcoholism
Screening Test- Geriatric Version (10
items; Yes/No format)
 AUDIT (Alcohol Use Disorders
Identification Test – Recommended for
screening in ethnic minorities.
 CAGE (4 item scale) – CAGE may lack
specificity (too many false positives).
Should be enhanced with questions on
Quantity/Frequency of alcohol use.
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?
1. Have you ever felt you should Cut down on
your drinking?
2. Have people Annoyed you by criticizing your
3. Have you ever felt bad or Guilty about your
4. Have you ever had a drink first thing in the
morning to steady your nerves or to get rid of
a hangover ( Eye opener)?
Scoring: Score 0 for "no" and 1 for "yes" answers.
Higher scores indicate alcohol problems. A total
score of 2 or greater is considered clinically
significant. (Ewing, 1984).
Examples of Large Scale
Screening of Older Adults
 Primary Care Patients:
 SAMHSA funded “Primary Care
Research in Substance Abuse
and Mental Health Services for
the Elderly” (PRISM-E)
 Project GOAL
 Project Healthy Lifestyles
PRISM-E Screening Results
(Levkoff et al. 2004)
Ages 65+; screened at 10 sites across the U.S.
 34 primary care practices & 22 MH facilities
 Represented managed care, community health
clinics, VA facilities, & group practices
Assessed at baseline, and 3 and 6 months
Research assistants screened 23,828:
 14% with depression and/or anxiety (more likely
to be younger, female, and ethnic minorities)
 6% with at-risk alcohol consumption (more
likely to be younger, whites, males)
Patients with MH/SA problems randomly assigned:
 Integrated model = MH & SA brief intervention
co-located with PCP
 Enhanced referral model (MH & SA provider is
separate) models of MH/SA care
 Results still being analyzed and in-press.
Project GOAL:
Guiding Older Adult Lifestyles Screening
(Fleming, Manwell, Barry, Adams, & Stauffacher 1999)
 At-risk drinkers age 65+ in primary care practice
settings involving 43 family physicians in 24 sites
in 10 Wisconsin counties
 Men and women ages 65-85 seeking routine care
in community primary care clinics
 11% of 6,000 screened positive. Inclusion criteria:
 Males had to consume 11 or more drinks/week
 or 2 or more positive responses on the CAGE
or be a binge drinker
 Females: 8 drinks or more per week, etc.
 Eligible patients agreeing to participate were
randomly assigned to brief intervention (n= 87) or
usual care (n= 71)
Project GOAL: Brief Advice - Method
(Fleming et al. 1999)
 In Brief Intervention, the physician:
 States his/her concern
 Provides specific feedback to patients on how
their drinking is affecting them (e.g., elevated
blood pressure, liver function problems, family
 Gives a clear recommendation about changing
their alcohol use.
 Negotiates a drinking contract.
 Provides a self-help (Health Promotion) booklet
 Establishes follow-up procedures.
 Brief Intervention = 2 physician-delivered
15-min face-to-face visits (one month apart)
 Follow-up: by a nurse via telephone at 2
weeks, 3, 6, and 12 months.
Project GOAL: Results
(Fleming et al. 1999)
 Results:
 34% reduction in seven-day alcohol
 74% reduction in mean number of
binge drinking episodes.
 62% reduction in percentage of older
adults who had consumed more than
20 drinks per week at the beginning.
 Further research extended follow-up to
two years, also with positive outcomes.
Extending Brief
Interventions Beyond the
Physician’s Office
Health Profiles Project (Michigan)
• Largest randomized trial of brief alcohol
advice to at-risk drinkers 60+ in primary
care settings.
• 14,060 patients screened
• 454 entered randomized trial
• Outcome: (preliminary results)
• Over 12 months: 30% decrease in
experimental group and 20%
decrease in control group alcohol
In-Home Brief Intervention for older primary
care patients with alcohol problems
 Staying Healthy Project (Cullinane, Blow,
Barry, et al. – in progress)
- Screened 4,300+ older adults in
- 166 people entered randomized trials
- 39% decrease in Experimental
- 28% decrease in Control
• Decline in drinking in both groups suggests
that bringing attention to drinking may result
in decrease.
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
 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
The Florida BRITE Project - Goals
 Implement evidence-based/best practice
approach based on CSAT’s Treatment
Improvement Protocols (TIP)
 Substance Abuse & Older Adults TIP #26
 Brief Intervention & Brief Therapies TIP #34
 Develop referral networks, screening and
services appropriate for older adults in order
to reach greater numbers of elders.
 Follow SAMHSA’s model of Screening, Brief
Intervention, Referral and Treatment (SBIRT)
The Florida BRITE Project’s Criteria:
• Focus is on helping underserved elders:
• Minorities
• Low Income
• Isolated, withdrawn individuals
• “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
• Brief Interventions in home or on-site
• Brief Treatment if needed (CBT/Self-Mgt.)
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
BRITE Screening Tool
 All screens in the public domain (no
copyright infringement, free to use)
 Easy to administer by staff member
 Easy for older adults to comprehend
 Translated into Spanish for BRITE Project
 Includes both client self-report and the
interviewer’s impressions
 Includes questions on substance use
history and treatment
Alcohol Screening
Ever consumed alcohol?
Recent use of alcohol
Quantity consumed on typical day
10 item screen S-MAST-G
administered only if the individual
indicates recent use of alcohol.
Medication Misuse –
“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 Use: Client Interview Items
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 – Client Interview Items
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?
The need to
screen for
illicit drug use.
An increasing
trend among
older adults?
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.
Florida BRITE Project:
Brief Intervention
Resource for Pilot
Health Promotion
Barry, Oslin, & Blow (1999)
(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
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
Even within the Substance Abuse
Treatment Program!
Brief Treatment
A 16-session
curriculum manual
for conducting brief
Dupree & Schonfeld
(CSAT, 2005)
A Three Stage CBT/Self-Management
Treatment Approach
(Dupree & Schonfeld, CSAT 2005)
1. For each person in treatment, begin by
conducting an analysis of the antecedents and
consequences for substance use to create an
individualized “substance use behavior chain”
- 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.
* Manual designed for group treatment. Includes complete
word-for-word curriculum, exercises, assessments,
homework assignments, and more.
Self-Management Skills for Older Alcohol Abusers
High Risk Situation
Skills Taught
Social Pressure
Drink Refusal
Rebuild Social Network
Cognitive Restructuring
Relaxation, Problem solving
Assertiveness Training
How to dispose, avoid, rearrange
Thought-stopping, Learn to Delay
Relapse Training
BRITE – Screenings from
March 2004 through Jan. 2006
• 1,990 screened by 4 agencies:
Broward Co. Elderly & Veterans Serv =
Gulfcoast Community Care (Pinellas) =
Coastal Behav. Health Care (Sarasota) = 186
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:
 56% alone
 22% with spouse
 8% in group setting (e.g., ALF)
 69% were women
 Median age = 76
 Race
 76% Caucasian
 17% African Amer.
 6.7% multiracial
 Hispanic 14%
Florida BRITE Project Screening:
Alcohol Problems
 8.5% of those referred to BRITE were for
potential alcohol problems
 39% of all 1,990 screened were drinkers
 16% of drinkers consumed 3 or more
drinks on a drinking day
 68% of referrals for alcohol problems and
5% of those referred for other reasons
scored 2 or more on the S-MAST-G.
 292 clients provided services – mostly brief
intervention. Many of these showed other
Florida BRITE Project Screening:
Prescription Medications
 18% were referred for prescription misuse
 16% reported wrong amount for one or more
 11% could not recall purpose of one or more
 17% need education and/or assistance on
proper medication use
 4% took prescription medications for wrong
reasons or symptoms
Florida BRITE Project Screening:
Over-the-Counter Medications
• 2.4% referred for potential OTC misuse
Illicit Drug Use
 < 1% referred to BRITE for illicit drug use
Florida BRITE Project Screening:
 71% of all 1,990 were referred for
 Screening these with the Short-GDS:
 20% of those referred had moderate
 Another 7% 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
 49% 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 156 of
the 161 people screened (p<.001)
 Significant improvement in S-MAST-G
(alcohol screening) at discharge for 69
people receiving re-screening (p<.001)
 Screening older adults for substance misuse
should focus on “at-risk” behaviors as well as
more serious problems (involving dependence
and tolerance)
 Screening should be addressed in:
 Primary care
 Aging services, senior centers, etc.
 Health clinics
 Likely to see signs of depression associated with
substance misuse
 Difficult to identify medication misuse, since it is a
nebulous construct and requires review of patient
characteristics and prescribing practices.
The Baby Boomers are getting older!

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