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) medications  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 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) 70

12% of 55+ age group are either binge or heavy alcohol users

60 50

18 to 25 26 to 34 35 to 54 55 or Older

40 30 20 10 0

Any Illicit Drug Use Any Alcohol Use "Binge" Alcohol use Heavy 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: 76.1% 12.6% Alcohol Opiates 4.5% 1.3% 0.7% 0.6% 4.1% Cocaine Marijuana Sedatives/Tranquilizers Stimulants Other

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 28.5%  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 98%

People age 60+ are only 2% of all adults in treatment Source: Policy & Services Research Data Center (2003) Louis de la Parte Florida Mental Health Institute

Expert panel recommendations for screening and treating the older adult: SAMHSA/CSAT Treatment Improvement Protocol (TIP) #26

TIP#26 Expert Panel Recommendations

1. Age-specific, group treatment that is supportive, not confrontive.

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 issues

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, weddings) • Somewhat lower limits for women.

Treating Older Adults with Alcohol Problems

   Outcomes are generally better than younger adults 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 (1979-1981) (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? WW II Korean Vietnam 34.2% 19.8% 14.4% 62.2% 8.1%

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 51.8% 9.1% 3.6% 26.4% 5.5% 0.9% 1.8%  Thus, prior to admission, 38.2% were using illicit drugs, mostly in conjunction with alcohol

GET SMART - Outcomes at Six Month Follow-up Outcome

Remained Abstinent

Completed Program (n=49 or 44.5%) 27 Did Not Complete (n=61 or 55.5%) 10 13 1

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 reasons

1 2 6 0 19 6 11 14

Screening & Brief Intervention

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What is the best way to identify older adults with alcohol or other substance use problems?

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What are alternatives to traditional substance abuse treatment?

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Focusing on primary care practice patients…

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 elders 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

S-MAST-G

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 tremors?

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?

CAGE

1. Have you ever felt you should Cut down on your drinking? 2. Have people Annoyed you by criticizing your drinking? 3. Have you ever felt bad or Guilty about your drinking? 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

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Primary Care Patients:

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SAMHSA funded “Primary Care Research in Substance Abuse and Mental Health Services for the Elderly” (PRISM-E)

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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 problems).  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 use.

 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 consumption

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 California - 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 BR

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The Florida BRITE Project

BRief Intervention & Treatment for Elders

Gulf Coast Community Care Coastal Behavioral HealthCare

Orlando

Center for Drug Free Living – added in 2005 Broward County Elderly & Veterans Services

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 services  Older adults have the highest rate of suicides among all age-groups.

End Screening Re-contact at later date Brief Intervention Re-Assess at Discharge, 30 and 90 days post discharge Pre-Screening by Nontraditional and other referral sources Screening by BRITE Pilot Program No Client screens positive and agrees to be served.

Yes Admit person for services appropriate to service plan Enter data into ETIPS & upload Enter Screening Data on Tablet PC & upload to KIT Solutions Refer to external services as indicated in plan Brief Treatment Re-screen client prior to discharge Completion of every six B.T. sessions, discharge, 30 & 90 days Enter Data & upload to KIT

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 regardless 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 prescriptions:

1. Does not correctly recall the purpose of one or more medications 2. Reports the wrong dose/amount of one or more medications 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 non prescription 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

Scoring: 1. Are you basically satisfied with your life? 2. Have you dropped many of your activities and interests?

3. Do you feel that your life is empty? 5-9 = mild to moderate depression 10+ = serious levels of 4. Do you often get bored?

5. Are you in good spirits most of the time?

depression 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 *

1. Has anyone in your family ever committed suicide? 2. If yes, who in your family committed suicide?

3. Have you ever thought about taking your life?

4. How recently have you thought about killing yourself?

5. Do you have a plan for doing this? (response selected from list of plans provided) 6. Have you ever been in the care of psychiatrist, psychologist, or other professional because of severe depression or mental problems?

7. Do you keep firearms in the house?

8. 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 Program Participants: Health Promotion Workbook Barry, Oslin, & Blow (1999) (modified to include drugs, medications, OTCs, depression and suicide risk)

Resource for Pilot Program Participants: Health Promotion Workbook  Workbook Topics: Identify future goals for physical and emotional health, activities, finances.

 Summarize health habits:  Exercise, tobacco, alcohol, nutrition  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 Program Participants: Health Promotion Workbook  Workbook Topics (continued): Medication misuse  Reasons for taking wrong   dose Things to tell your doctor Do’s and Don’ts for taking  medications Potential problems with OTC Medications  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 Workplace Even within the Substance Abuse Treatment Program!

Brief Treatment

A 16-session curriculum manual for conducting brief treatment

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 Social Pressure Loneliness Depression Anxiety Anger/Frustration Cues Urges Slips Skills Taught Drink Refusal Rebuild Social Network Cognitive Restructuring Thought-stopping Relaxation, Problem solving Thought-stopping 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 = 1,411 • Gulfcoast Community Care (Pinellas) = 365 • Coastal Behav. Health Care (Sarasota) = 186 • Ctr. for Drug Free living (Orange)* = 28 * began in August 2005 • Most (67%) are identified through BRITE outreach, presentations to the public, visits to senior centers, etc.

Demographics

 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 symptoms.

Florida BRITE Project Screening: Prescription Medications

  18% were referred for prescription misuse 16% reported wrong amount for one or more medication  11% could not recall purpose of one or more medications  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: Depression

  71% of all 1,990 were referred for depression Screening these with the Short-GDS:  20% of those referred had moderate depression   Another 7% with serious depression Similar proportions for those not referred specifically for depression

Florida BRITE Project Screening: Suicide Risk

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Only 0.6% referred for suicide risk Yet, 14% of all referrals indicated that they contemplated suicide at some time

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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)

Conclusions

    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.

Beware… The Baby Boomers are getting older!