Download Substance Abuse Practice - PowerPoint Slides

Substance Abuse
in Later Life
Center for Mental Health and
Aging
School of Social Welfare
University at Albany
Substance Abuse Module
 Developed by the MAC Project Team
School of Social Welfare
University At Albany, 2007
Overview of Presentation
 Prevalence
 Risk and Protective Factors
 Co-Morbidity and the Older Adult
 Screening Tools
 Dependence/Abuse/ and Onset of Addictions
 Treatment Interventions
 Approaches to Treatment
 Ethnic Sensitive Practice
Prevalence in Older Adults
 13% (men) and 2% (women) consume more than 1
ounce of alcohol /day
a
 9% of older adults report “binge use” (>5 drinks on the
same occasion for at least 1 day in the past 30 days)
b
 2% report heavy alcohol use (5 days or more in past 30
days)
b
 15%-20% with major depression have an alcohol
disorder
c
 Under-detected and under-screened
 Few older adults with alcohol abuse or dependence seek
help in addiction treatment settings
A Adams, W. (1995). Int. J of Addictons,30,1693-1716
B Devanand, D. (2002). Biological Psychiatry,52,236-242
C Sattar, S. Petty, F., Burke, W. (2003). Clinical Geriatric Medicine, 19
Population Demographics
Total Population age 50+ In the United States
= 85.2 Million U.S.
Total Population age 50+ In New York State
= 5.7 Million NYS
National Survey on Drug Use and Health (averages of 2004, 2005,
2006)
SAMHSA (March, 2007: Dr. James Colliver, Division of Population
Surveys, Office of Applied Studies)
Aging In America
25
20
% of Total 15
U.S.
Population 10
Age 65+
Age 85+
5
0
248.8 275.3 299.9
Mill
Mill
Mill
1990 2000 2010
324.9 351.1 377.4
Mill
Mill
Mill
2020 2030 2040
www.census.gov (Dr. Bartels)
Population Demographics: MICA
Total Population 50+ In U.S. (85.2 Million) Vs. 50+ Population
New York State (5.7 Million)
United
States
New York
State
Serious
Psychological
Substance Use
Disorder
Serious
Psychological
Distress And
Substance Use
Disorder in Past
Yr.
Distress in Past
Year
In Past Year
= 7.0 % (SE= 0.23)
= 3.5% (SE =0.17)
= .7% (SE=0.07)
= 6 Million (SE= 196,000)
= 3 Million (SE= 141,000)
= 563,000 (SE= 57,000)
= 6.8% (SE= 0.86)
= 2.7% (SE= 0.53)
= .5% (SE= 0.21)
= 391,000 (SE= 49,000)
= 157,000 (SE= 30,000)
= 29,000 (SE= 12,000)
Serious Psychological Distress and Substance Use Disorders in Past Year among persons Aged 50 or older in the
United States and in New York State: Percentages and Standard Errors of Percentages, Average of 2004,
2005, and 2006.
Note: Dependence or Abuse based on criteria from the Diagnostic and Statistical Manual 4th Edition
Source: SAMHSA, Office of Applied Studies, 2004-2006 National Surveys on Drug Use and Health.
Prevalence of the Problem
OASAS: NYS
According to OASAS Survey Data for the 55+ Population:
The substance abuse disorder (SUD) prevalence estimate for
NYS residents is 4.9%.
Based on the 2006 U.S. Census estimates for this population
is approximately 223,000 people.
Prevalence: of Alcohol & Drug Problems: For those 55 and
over, estimates of problem use range from 2% to 17%.
(OASAS)
Source: 2006 New York State Household Survey
Risk Factors in Older Adults
1.Gender (male)
2.Loss of spouse
3.Early onset of alcoholism
4.Co-morbidity
5.Significant losses
6.Loss of physical wellness
7.Family history
Substance Abuse Among Older Adults: TIPS 26
Center for Substance Abuse Treatment, 1998
Protective Factors
-Supportive family
-Other social supports
-Screening - primary care physician
-Early intervention and access to
services
Barriers to Treating Older
Adults
 Stigma, negative bias to older persons
 Elderly reluctant to report
 Certain minority group members/lack of
culturally competent tools & intervention
 Co-morbid physical illnesses
 Lack of awareness by health/human services
 Elderly mask presentation via somatic
symptoms
NIAAA (Revised 3/04)
Co-Morbidity & the Older Adult
 Co-morbidity occurs when an
individual struggles with more than
one diagnosis
 By the year 2030 the number of our
elderly who will be suffering from
substance abuse or mental illness is
estimated at 15 million.
(Blow, F; Bartels, S.; Brockmann, L. &
Van Citters, A., 2005)
Co-morbid Conditions
 Depression and Anxiety
disorders: most common among
older adults (Bartels, S. et. al.; 2006)
 Alzheimer’s disease, other
dementia
 Sleep disorders, gambling, sexual
addictions
©2002 Microsoft
Corporation
NIAAA, 3/04
Age Matters: How Alcohol/Drugs
Impacts the Brain
 As we age our ability to metabolize alcohol and other
drugs changes:
 Impact of alcohol on aging brain is significant.
 There is a difference between what younger adults
can tolerate with alcohol consumption vs. older adults
 Increased sensitivity to alcohol & prescriptive
medications. Important that older adults have
decreased consumption compared to younger adults.
(Oslin, 2004)
 “ The NIAAA and CSAT protocol recommend that
persons 65+ consume no more than one standard
drink a day or 7 drinks per week” (Blow & Barry, 2002, p. 311)
Older Adults and Alcohol Use
 Increased risk of:
Stroke (with overuse)
Impaired motor skills
(e.g., driving) at low
level use
Injury (falls,
accidents)
Sleep disorders
Suicide
Interaction with
dementia symptoms
(NIAAA, 3/04)
Older Adults and Use
(continued)
Other Effects:
Higher blood alcohol
concentrations (BAC) from dose
More impairment from BAC
Medication effects:
Potential interactions
Increased side effects
Compromised metabolizing
(especially psychoactive
medications, benzodiazepines,
barbiturates, antidepressants,
digoxin, warfarin)
©2002 Microsoft
Corporation
(NIAAA, 3/04)
Older Adults and Prescriptive
Drug Abuse
Older patients are prescribed benzodiazepines more than any other
age group, and North American studies demonstrate that 17 to 23
percent of drugs prescribed to older adults are benzodiazepines
(D’Archangelo, 1993). The dangers associated with these
prescription drugs include problematic effects due to age-related
changes in drug metabolism, interactions among prescriptions, and
interactions with alcohol (SAMHSA TIP 26). The nonmedical use of
prescriptive drugs among adults 50 and over will increase to 2.7
million by the year 2020 (Simoni-Wastila, L., et al., 2006).
Screening Tools: Assessing the
Older Addicted Adult
 Know DSM IV diagnostic criteria for
Abuse/Dependence.
 Complete a thorough biopsychsocial as an
important part of the initial meeting.
 Screening instruments will provide you with
techniques to determine if there is an addiction
problem.
Drinking Guidelines
 Recommended Drinking Limits for Older Adults
 No more than 1 standard drink per day.
 No more than 2 drinks on any drinking day
 Limits for older women should be somewhat less
then for
older men (Merrick, E. et al., 2008).
 Lower limits for older adults because:

Greater use of contraindicated medications

Less efficient liver metabolism

Increased alcohol sensitivity with age

Less body mass/fat increases circulating levels
(Source: NIAAA, 3/04; Dufour & Fuller, 1995)
Drinking Guidelines
Standard Drink Sizes
(Source: NIAAA, 3/04;
Dufour & Fuller, 1995)
(Source: NIAAA, 3/04;
Dufour & Fuller, 1995)
Screening Instruments
 Michigan Alcohol Screening Test-Geriatric
Version and Short Mast- G (Short G-MAST)
 CAGE
 Cut down,
 Annoyed by others
 feel Guilty
 need Eye opener)
Short MAST-G and CAGE adapted from NIAAA Social Work Module 10C
Dependence vs. Abuse
Alcohol Abuse: a maladaptive pattern of
use leading to one or more of the
following during the past twelve
months but not meeting criteria for
dependence: use of alcohol despite
negative impact on major life roles,
legal difficulties, physical impact, and
social consequences.
(DSM, 2000)
Dependence vs. Abuse
Alcohol Dependence: a medical condition which is
characterized by use of the substance leading to
impairment and the presentation of at least
three of the following within the last twelve
months:
 tolerance
 withdrawal
 increased use
 desire to cut down
 a great deal of time devoted to use
 loss of major role functions
 continued use despite having knowledge of the adverse
consequences of the substance on ones life
(DSM, 2000)
Early Onset vs. Late Onset
 Early Onset:
use began <40 yrs
have used services for years
have basic understanding
 Late Onset:
Use began >40 yrs
Usually healthier mentally and
physically
have begun using services later in life
(Blow, Tip, 1998)
Treatment Approaches
 Cognitive Behavioral Therapy
 Suggested treatment approach
 Address negative cognitions & selfdestructive behaviors
 Practice new coping strategies
 Group- based counseling
 Increased social support
 Normalizing experiences
 Provide addiction education
(NIAAA, 3/2004)
Treatment Approaches (cont.)
 Harm Reduction
 Reduce negative consequences
associated with substance use w/o
requiring abstinence
 Case Management
 Access to entitlements
 Facilitating additional services
(psychiatric, medical, etc.)
Treatment Approaches (cont.)
 Family Support
 Multiple generations affected by older adult
addiction
 Wish to heal and improve family relationships
 Education on the disease of addiction
 Family Interventions
Treatment Approaches (cont.)
 Medical/psychiatric approaches
 Detoxification
 Inpatient Rehabilitation
 Residential Services
 Day Treatment
 Outpatient Treatment (Mixed Age
Group)
 Age-Specific Outpatient Treatment
Brief Protocols: Working with
Older Adults
Brief intervention/motivational enhancements
are effective approaches:
 Accepted well by older adults
 Can be conducted at home or in the clinic
 Reduces alcohol use & alcohol related harm
 Reduces health care utilization
(NIAAA, 3/04)
Brief Protocols: Ten Components
 1: Identify future goals (health, activities, etc.)
 2: Customize feedback
 3: Define drinking patterns
 4:
Discuss pros/cons of drinking (motivation to change)
 5: Discuss consequences of heavy drinking
(NIAAA, 3/04)
Brief Protocols: Ten Components
Continued
 6: Identify reasons to cut down or quit
 7: Setting sensible limits, devising strategies
 8: Develop a drinking agreement
 9: Anticipate a plan for risky situations
 10: Summary of the brief session
(NIAAA, 3/04)
Detoxification
 Most intensive level of care.
 Appropriate for patient who is having:
withdrawal symptoms and needs 24
hour care and supervision from medical
staff.
 Withdrawal symptoms from ETOH can
include: shakes, delirium tremens,
headaches, and vomiting.
 Brief stay 23 hrs to a week
Inpatient Rehabilitation
 Longer term stay at an inpatient facility
 Offers 24 hour care and supervision
 Usually from 2-4 week stay
 Services offered include: medication management,
group support, case management services, family
interventions, and individual counseling.
 Referral: Some patients enter Inpatient Rehab from a
Detoxification. Others enter from outpatient facilities.
Residential Treatment
 Older addicted adult resides at a
residential location longer term.
 The treatment services and housing
are combined to offer greater support
to the individual who struggles with
‘people, places, and things.’
 Allows for a clean and sober
environment.
 Usually lasts for six months to over a
year.
Day Treatment
 Considered an outpatient intensive service.
 Certain patients need a half day service.
 Patients engage in several structured
outpatient groups.
 Patients receive individual and family
support.
 Helps structure their day so that they are
not tempted to use during that time.
Outpatient Mixed-Age Group
 This type of service is more readily available
across NYS for Older addicted adults.
 It includes less intensive support such as a
few groups and individuals weekly.
 Additionally case management services and
family support is available.
 Older adults are mixed in with younger
patients.
 Time in treatment varies up to a year approx.
Outpatient Same-Age Group
 Offers a non-intensive support program for
50+ population that suffer from addictions.
 Groups are custom tailored to meet the
needs of older adults.
 Very few Age-Specific Clinics.
Advantages to Same-Age Treatment
 Age-specific group treatment: Recent movement is away
from generic treatment approaches to more specific
tailored programs to meet the need. (Cummings, S.;
Bride, B.; & Rawlins-Shaw, A., 2006)
Topic specific support: grief & Loss, retirement,
depression, social isolation
Help with increased social supports –sober networks
A Slower pace of individual and group support to help
older adult
Linking client to services for medical and case
management needs.
(Substance Abuse Among Older Adults: TIPS 26 Center for Substance
Abuse Treatment, 1998)
Ethnic Sensitive Practice
 Social Workers need to be aware of the
differences in gender, ethnicity, sexual
practices, and cultural viewpoints of those that
they treat.
 Development of a trusting therapeutic alliance
and family involvement can assist with this
approach.
 There is a limited body of research on older
addicted minorities. Further research is
needed in this area. (Oslin, 2004)
Group Discussion: Case Study
 Divide Class into groups for review of
Case Study.
 Review of Case Study Questions by
class.
 Discussion of responses from each
group.
Film
Alcohol and Other Drugs
Problems Among Older Adults
Frederic C. Blow, Ph.D.
http://preventionpathways.samhsa.gov/videos/fred_bl
ow_01.mov
To Instructor: Consider giving this short online video
as part of the required reading for the module. It
provides an overview of the initial slides in this
module.