Substance Abuse Treatment in the Elderly







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Substance Abuse Treatment

in the Elderly

Lawrence Schonfeld, Ph.D.

Professor, Dept. of Aging & Mental Health Institute Florida Mental Health Institute


Admissions Age 55 or Older by

Primary Substance at Admission

(DASIS Report December 2001)

Primary substances in 1999:
















Figure 1. Admissions Aged 55 or Older by Age Group: 1994 - 1999


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



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,


Older adults are


Florida’s adult population (18 or older)

Approx. 13 million adults

(out of 17 million total residents)

Ages 18-59 71.5%

Ages 60 and Older 28.5%


Proportion of Older Adults Treated in Publicly Funded Substance Abuse Treatment Services in Florida

Fiscal Year 2001-2002

Ages 18-59 98%

Ages 60 and Older 2%

Source: Policy & Services Research Data Center (2003) Louis de la Parte Florida Mental Health Institute


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


Treatment Recommendations

(SAMHSA, 1998; Schonfeld & Dupree, 1997; 1998)

1. Age-specific, group treatment - supportive, not


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


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


“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


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


OAR patient care costs were 2.5 % lower


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 &


Elder Specific Treatment:


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



• 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



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.


“A-B-C” Approach to Treatment:

The Substance Use Behavior Chain

Behavior Antecedents Long Term Consequences (always negative)

Situations/ + Feelings + Cues + Urges Thoughts Consequences First sip of beer Feel happier Home/alone + bored and depressed +

beer in refrigerator + “A drink will help me forget my troubles.” 1st drink or Use of drug Immediate/ Short Term Conseq. + or - Continue drinking, anger her children, and impair health


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


– Must be cognitively intact enough to repeat a simple medication regimen – All are voluntary admissions


A 16 session approach based on GAP

Topics # Sessions

Introduction to Analysis of Behavior

(“A-B-C’s” of Substance Abuse) 2

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

Preventing a Slip from Becoming A


Characteristics of 110 GET SMART Patients

Schonfeld et al. (2000)

Journal of Geriatric Psychiatry and Neurology

• Average Age 64.71 yrs (sd=5.5) (range: 53-82)

• Average Educ. 12.94 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%


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%


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


GET SMART - Outcomes at Six Month Follow-up Outcome Completed Program n=49 (44.5%) Did Not Complete n=61 (55.5%) Remained Abstinent 27 10

Abstinent at Follow-up, but had

at least one slip 13 1

Returned to fulltime alcohol use

at follow-up 1 19

Deceased at Follow-up 2 6

Couldn’t be located 6 11

Couldn’t follow-up for other


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


Reduce alcohol or substance use

Motivate individual to change behavior

Facilitate treatment entry


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


The Florida BRITE Project:

Brief Intervention &


Broward County Elderly & Veterans Services Gulf Coast Community Care Coastal Behavioral HealthCare

The Florida BRITE Project


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


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


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


The Florida BRITE Project:

Conceptual Model




Pre-Screening by Nontraditional and other referral sources

Screening by SBIRT Pilot Program

Client screens positive and agrees to be served. End Screening

Re-contact at later date

Admit person for services appropriate to service plan

Brief Intervention Brief Treatment Refer to external services as indicated in plan

Re-screen client prior to discharge

Completion of every six B.T. sessions

2-4 weeks post Brief Intervention

Enter Data & upload to KIT

Enter Screening Data on Tablet PC & upload to KIT Solutions

Enter data into & upload to KIT


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


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)


Resource for Pilot



Health Promotion


Barry, Oslin, & Blow (1999)

(being 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, 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

Modifications will

be made to address

medications, OTCs,


Larry W. Dupree, Ph.D. and Lawrence Schonfeld, Ph.D.

Department of Aging and Mental Health Louis de la Parte Florida Mental Health Institute

Univ ersity of South Florida Tampa, Florida 33612

© Department of Aging & Mental Health Louis de la Parte Florida Mental Health Institute

University of South Florida Tampa, FL 33612

Su bstance A buse T re atm ent for O lder A dults:

A C ognitive-B ehavioral and Self-M a nagem ent A pproach

Resource for Pilot Program

Participants: A 16-session

curriculum manual for conducting brief


Dupree & Schonfeld (in press, SAMHSA)


Progress Within

the Three Counties

Broward County Elderly and

Veterans Services

Coastal Behavioral Health Care


Gulf Coast Community Care


• 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


Early Results

• 83 Screenings

71% Caucasian, 14% Hispanic, 14% African American

76% Female, Ages 60 – 95 • 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


• 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


• 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


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


• 9 admissions

• 13 had depression and/or anxiety

• 6 alcohol problems received brief interventions

• 5 medication misuse received brief interventions


Services Provided:

• Medication “ Brown Bag” Review

• Referrals for depression

• Educational materials (alcohol, prescription

medications, diet and exercise)

• Food and linkages to other health promotion


• Social Support (e.g. new resident integrating

into new community)


Final Words

• Innovative methods are necessary to

identify and treat older adults

• Providers must consider not only

abuse, but risky behavior, given

age-related sensitivity to alcohol,

medications, drugs, medications

• Unintentional medication misuse

should be considered as different than

substance abuse





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