Substance Abuse Treatment in the Elderly

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1 Substance Abuse Treatment in the Elderly Lawrence Schonfeld, Ph.D. Professor, Dept. of Aging & Mental Health Institute Florida Mental Health Institute

2

3 Admissions Age 55 or Older by Primary Substance at Admission (DASIS Report December 2001) Primary substances in 1999: 76.1% Alcohol 12.6% Opiates 4.5% Cocaine 1.3% Marijuana 0.7% Sedatives/Tranquilizers 0.6% Stimulants 4.1% Other Source: 1999 Treatment Episode Data System (TEDS)

4 Figure 1. Admissions Aged 55 or Older by Age Group: Source: 1999 Treatment Episode Data System (TEDS)

5 2002 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS) Schultz, Arndt, & Liesveld (2003) Survey of all treatment facilities in U.S. Question #16. Does this facility at this location offer a substance abuse treatment program or group specially designed for any of the following populations? (Seniors or Older/Adults) Received completed surveys from 13,416 treatment facilities 17.7% of facilities reported having elder-specific services

6 2002 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS) Schultz, Arndt, & Liesveld (2003) Elder-specific services were: Typically offered in facilities owned or operated by hospitals, psychiatric hospitals More common in programs operated for profit and those subsidized by federal & tribal governments Less often in state & private/not-for-profit facilities Less often in substance abuse specific facilities More often in programs offering specialized programs for other groups (dually diagnosed, adolescents, HIV/AIDS, pregnant women, etc.)

7 Older adults are disproportionally underserved

8 Florida s adult population (18 or older) Approx. 13 million adults (out of 17 million total residents) Ages 60 and Older 28.5% Ages % Source: U.S. Census Data

9 Proportion of Older Adults Treated in Publicly Funded Substance Abuse Treatment Services in Florida Fiscal Year Ages % Ages 60 and Older 2% Source: Policy & Services Research Data Center (2003) Louis de la Parte Florida Mental Health Institute

10 Thanks to our statewide Florida Coalition for Optimal Mental Health and Aging, and other state taskforces, recent changes in legislation in Florida have provided the impetus for change in treatment services: The Florida Dept. of Children and Families is now mandated to serve older adults as a separate target population for mental health and substance abuse services Includes older adults with identified SA problems as well as those at risk DCF must now account for proportion of services to elders The Florida Dept. of Elder Affairs is now mandated to screen older adults for mental health problems and substance abuse

11 Putting Best Practices into Practices

12 Treatment Recommendations (SAMHSA, 1998; Schonfeld & Dupree, 1997; 1998) 1. Age-specific, group treatment - supportive, not confrontive 2. Attend to negative emotions: depression, loneliness, overcoming losses 3. Teach skills to rebuild social support network 4. Employ staff experienced in working with elders 5. Link with aging, medical, and institutional settings 6. Slower pace & age-appropriate content 7. Create a culture of respect for older clients 8. Broad, holistic approach to treatment recognizing age-specific psychological, social & health aspects 9. Adapt treatment to address gender issues

13 Rationale for Age/Elder-Specific Approaches Kofoed et al. (1987) - Do older veterans in an age-specific treatment program have better outcomes than mixed-age treatment? Class of 45 - Portland VA Hospital Elder Specific group - Better treatment compliance, fewer relapses than those in mixed-age treatment When relapses did occur, longer periods between

14 Rationale for Age/Elder-Specific Approaches Kashner et al. (1992) 137 VA inpatients (ages 45+) randomly assigned to: Older Alcoholic Rehabilitation (OAR) program: Reminiscence therapy, goal of developing patient self-esteem and peer relationships Traditional care program - confrontation to focus on patients' past failures and present conflicts 12 Month follow-up: OAR patients twice as likely to report abstinence OAR patient care costs were 2.5 % lower Response to OAR was best for ages 60+

15 Age-Differences in Pre-treatment Substance Use Schonfeld, Dupree, & Rohrer (1995) Compared antecedents to substance use for older adults in our elder specific treatment younger adults in a state addictions program Both drank about as often prior to admission Older adults (n=109) more likely to: use alcohol only drink at home, alone drink in response to depression Younger adults (n=47) more likely to: drink until intoxicated (19 vs 11 days/month) use multiple substances use with other people, at bars or outdoors have a greater variety of intrapersonal & interpersonal antecedents

16 Elder Specific Treatment: A Relapse Prevention Approach

17 Gerontology Alcohol Project ( ) Dupree, Broskowski, & Schonfeld (1984) Targeted late life onset alcohol abusers Day treatment, Group format Self-management, CBT Curriculum: written, standardized with ratings, quizzes and other assessments included. Most drank in response to depression, loneliness, & other negative emotions Average consumption = 12.2 SECs on typical day Most were steady drinkers Over 12 month follow-up period: 75% of graduates maintained drinking goals No one returned to steady drinking Significant increase in social support networks

18 Replications: Substance Abuse Program for the Elderly (Schonfeld & Dupree, 1991) Continued the work of GAP All substance abusers ages 55+ Alcohol, medication misuse, illicit drugs GET SMART - West Los Angeles VA Partial components of the curriculum utilized in other programs in Florida and elsewhere

19 A Three Stage CBT/Self-Management Treatment Approach 1. Behavior analysis begin with a substance use profile to identify each client s antecedents and consequences for substance use. Create an individualized substance use behavior chain. 2. Teach client s 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.

20 A-B-C Approach to Treatment: The Substance Use Behavior Chain Antecedents Behavior Consequences Situations/ + Feelings + Cues + Urges Thoughts 1 st drink or Use of drug Immediate/ Short Term Conseq. + or - Long Term Consequences (always negative) Home/alone + bored and depressed + beer in refrigerator + A drink will help me forget my troubles. First sip of beer Feel happier Continue drinking, anger her children, and impair health

21 The GET SMART Program: A Replication of the GAP Approach Geriatric Evaluation Team: Substance Misuse/Abuse Recognition and Treatment West Los Angeles VA Medical Center Alcohol, prescriptions, illicit substances Veterans age 60+ recruited from medical or surgery wards, outpatient clinics, or community Must be cognitively intact enough to repeat a simple medication regimen All are voluntary admissions

22 A 16 session approach based on GAP Topics Introduction to Analysis of Behavior ( A- B-C s of Substance Abuse) # Sessions Social Pressure 2 At Home and Alone 1 Depression 2 Managing Anxiety & Tension 3 Managing Anger & Frustration 3 Controlling Cues 1 Coping with Urges 1 2 Preventing a Slip from Becoming A Relapse 1

23 Characteristics of 110 GET SMART Patients Schonfeld et al. (2000) Journal of Geriatric Psychiatry and Neurology Average Age yrs (sd=5.5) (range: 53-82) Average Educ yrs (sd= 2.7) Gender: 108 males, 2 females Marital Status: Married 21.1% Divorced 51.8% Widowed 10.5% Separated 8.8% Never Married 4.4%

24 GET SMART Patient Description Schonfeld et al. (2000) Journal of Geriatric Psychiatry and Neurology Race/Ethnicity Caucasian 50.8% African American 41.7% Latino 5.8% Asian 1.6% Percent Homeless 34.2% Percent living in a Domiciliary 19.8% In Which War Served? WW II 14.4% Korean 62.2% Vietnam 8.1% Percent Directly In Combat 32.4%

25 Most recent substances used prior to admission to GET SMART program. Alcohol Only 51.8% Street Drugs Only 9.1% Prescription Medications only 3.6% Alcohol and Street Drugs 26.4% Alcohol and Prescription Meds 5.5% Street Drugs + Prescription Meds 0.9% All three categories 1.8% Thus, prior to admission, 38.2% were using illicit drugs, mostly with alcohol Schonfeld et al. (2000) Journal of Geriatric Psychiatry and Neurology

26 GET SMART - Outcomes at Six Month Follow-up Outcome Completed Program n=49 (44.5%) Did Not Complete n=61 (55.5%) Remained Abstinent Abstinent at Follow-up, but had at least one slip Returned to fulltime alcohol use at follow-up Deceased at Follow-up 2 6 Couldn t be located 6 11 Couldn t follow-up for other reasons 0 14

27 Brief Interventions

28 Brief Intervention From 1 to 5 brief sessions targeting a specific health behavior Rely on use of screening techniques Offers advice, education, motivation enhancement approaches Goals: Reduce alcohol or substance use Motivate individual to change behavior Facilitate treatment entry

29 Elder Specific Brief Intervention Projects Project GOAL (Guiding Older Adult Lifestyles) (Fleming et al., 1999; University of Wisconsin) Brief physician advice for 156 adult at-risk drinkers Reduced consumption (35%-40%) at 12 months Health Profile Project Univ. of Michigan (Blow and Barry) In home, motivational enhancement session reduced at-risk drinking at 12 months (n=454) Staying Healthy Project American Society on Aging (California - Cullinane et al.) More than 4300 people screened About 6% drinking more than recommended Almost 40% reduction of alcohol use

30 The Florida BRITE Project: Brief Intervention & Brief Treatment for Elders

31 The Florida BRITE Project Agencies involved in the three counties Gulf Coast Community Care Coastal Behavioral HealthCare Broward County Elderly & Veterans Services

32 Florida BRITE Project Brief Intervention and Treatment For Elders An evidence-based approach to identifying older adults with substance abuse and related problems Recognizes that most elders with such problems are rarely served by the traditional systems of services Funded by the Florida Department of Children and Families Substance Abuse Program Office

33 The Florida BRITE Program Focus on helping underserved elders: Isolated, withdrawn individuals Minorities African American, Hispanic Low Income Work with non-traditional referral sources In-home screening & brief interventions Refer to more intensive treatment as needed Refer to external, aging and mental health service agencies based on screening info. Statewide Older Adult Workgroup advisory council

34 Screening by Pilot Programs Alcohol Abuse Short-MAST-Geriatric version (S-MAST-G) Brown Bag review - prescription & OTC medication use/misuse Illicit Drug Use Depression Short-Geriatric Depression Scale (GDS - 15 items) Suicide Risk 8 items developed at FMHI

35 The Florida BRITE Project: Conceptual Model

36 Pre-Screening by Nontraditional and other referral sources End Screening Re-contact at later date No Screening by SBIRT Pilot Program Client screens positive and agrees to be served. Yes Admit person for services appropriate to service plan Enter Screening Data on Tablet PC & upload to KIT Solutions Refer to external services as indicated in plan Brief Intervention Enter data into & upload to KIT Brief Treatment 2-4 weeks post Brief Intervention Re-screen client prior to discharge Completion of every six B.T. sessions Enter Data & upload to KIT

37 Florida BRITE Screening Tool Scales address alcohol, medications, drugs, depression, and suicide risk All components of the screen are in the public domain (no copyright infringement) Easy to administer and comprehend Translated into Spanish for BRITE Project Items include interviewer s impressions as well as client responses Next steps: to evaluate the program and validate screening tool

38 A Web-Based and Tablet PC Data System Providers interview clients in their own homes, senior centers, or other locations using a Tablet PC or laptop. They upload the recorded data to KIT Solutions Inc. KIT operates a stand alone data system for the BRITE project (separate from other DCF substance abuse data)

39 Resource for Pilot Program Participants: Health Promotion Workbook Barry, Oslin, & Blow (1999) (being modified to include drugs, medications, OTCs, depression and suicide risk)

40 Resource for Pilot Program Participants: Health Promotion Workbook Modifications will be made to address medications, OTCs, other domains 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

41 Resource for Pilot Program Participants: Substance Abuse Treatment for Older Adults: A Cognitive-Behavioral and Self-Management Approach A 16-session curriculum manual for conducting brief treatment Dupree & Schonfeld (in press, SAMHSA) Larry W. Dupree, Ph.D. and Lawrence Schonfeld, Ph.D. Department of Aging and Mental Health Louis de la Parte Florida Mental Health Institute University of South Florida Tampa, Florida Department of Aging & Mental Health Louis de la Parte Florida Mental Health Institute University of South Florida Tampa, FL 33612

42 Progress Within the Three Counties Broward County Elderly and Veterans Services Coastal Behavioral Health Care (Sarasota) Gulf Coast Community Care (Pinellas)

43 Conducted Local Needs Assessments Conducted Training For Staff and Stakeholders Implemented Brief Intervention and Brief Treatment for at least 95% who screen positive Developed their own Program Manual Program Description & Procedures Referral System Design & Referral Tools Enhance Curriculum Resource Manual Pilot Implementation Report

44 Early Results 83 Screenings 71% Caucasian, 14% Hispanic, 14% African American 76% Female, Ages Screening Sites Home Visit (Majority) Others: Senior Subsidized/Public Housing MediVan Project CCE Wait-list and CCE Active At Community, Health, Senior Fairs At Senior Centers 14 provided brief interventions 20 referred for substance abuse treatment

45 Early Results 6 (14%) Positive Screening Depression, Suicide Risk, Grief 6 Brief Intervention 5 with single sessions / one with 2 sessions Referrals Individual Counseling Referral to Depression Group Therapy Mental Health Case Management Follow-up with existing counselor and/or case manager Basic Case Management Assistance/Guidance

46 Behavioral Health Services in Sarasota County 100 individuals screened 12 screened positive of which 4 were for depression or other mental health disorder and referred to other programs 2 refused services. 6 have received intervention services

47 Elder Education Program (Pasco and Pinellas Counties) From March - July 2004: 90 screenings conducted at a variety of sites Health Fairs, Senior Residences, Senior Centers, and in-home Some received Brief Intervention during screenings 9 admissions 13 had depression and/or anxiety 6 alcohol problems received brief interventions 5 medication misuse received brief interventions

48 Services Provided: Medication Brown Bag Review Referrals for depression Educational materials (alcohol, prescription medications, diet and exercise) Food and linkages to other health promotion services Social Support (e.g. new resident integrating into new community)

49 Final Words Innovative methods are necessary to identify and treat older adults Providers must consider not only abuse, but risky behavior, given agerelated sensitivity to alcohol, medications, drugs, medications Unintentional medication misuse should be considered as different than substance abuse

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