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:
76.1%
Alcohol
12.6%
Opiates
4.5%
Cocaine
1.3%
Marijuana
0.7%
Sedatives/Tranquilizers
0.6%
Stimulants
4.1%
Other
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
services
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
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
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
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
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
(1979-1981)
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
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
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
community
– 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
•
Goals:
–
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 reducedat-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
No
Yes
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
Program
Participants:
Health Promotion
Workbook
Barry, Oslin, & Blow (1999)
(being 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
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
treatment
Dupree & Schonfeld (in press, SAMHSA)
Progress Within
the Three Counties
•
Broward County Elderly and
Veterans Services
•
Coastal Behavioral Health Care
(Sarasota)
•
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
screenings
• 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
services
• 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