# Presentation: 346038

## Substance Abuse Treatmentin the Elderly

- Lawrence Schonfeld, Ph.D.
- Professor, Dept. of Aging & Mental Health Institute
- Florida Mental Health Institute

## Slide 2

## 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)

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

- Source:  1999 Treatment Episode Data System (TEDS)

## 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, HIV/AIDS, pregnant women, etc.)

## Older adults are disproportionally underserved

## 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%**

- Source:  U.S. Census Data

## 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

## Putting Best Practices into Practices

## 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
- Employ staff experienced in working with elders
- Link with aging, medical, and institutional settings
- Slower pace & age-appropriate content
- Create a “culture of respect” for older clients
- Broad, holistic approach to treatment recognizing age-specific psychological, social & health aspects
- 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 periods between

## 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+

## 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

## Elder Specific Treatment:A Relapse Prevention Approach

## 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
- Significant increase in social support networks

## 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

- 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.”
- 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.
- 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.”**

**1****st****  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 Relapse | 1 |

## 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%
- Percent Directly In Combat		32.4%

## 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**

## 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 reasons | 0 | 14 |

## Brief Interventions

## 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 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

## The Florida BRITE Project:  

**Brief Intervention & **
**Brief Treatment for Elders**

## The Florida BRITE ProjectAgencies involved in the three counties

- Broward County Elderly & Veterans Services

- Gulf Coast Community Care

- Coastal Behavioral HealthCare

- The Florida BRITE ProjectAgencies involved in the three counties

## 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

## 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

## 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

## The Florida BRITE Project:Conceptual Model

## Brief

- 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

- Intervention

- 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

**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, other domains

## Resource for 

**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  33612**

- ©  Department of Aging & Mental Health
- Louis de la Parte Florida Mental Health Institute
- University of South Florida
- Tampa, FL 33612

**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 (Pinellas)**

## 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

- 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

## 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
- 20 referred for substance abuse treatment

## 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

- 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

- Early Results

## 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

- 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

**Behavioral Health Services in Sarasota County**

## 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

**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)

- 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