Transcript schonfeld

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
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 60 and
Older 28.5%
Ages 18-59
71.5%
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
Ages 60 and
Older 2%
98%
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
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
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)
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•
•
•
•
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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
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
Antecedents
Situations/ + Feelings + Cues + Urges
Thoughts

Behavior
1st drink or

Use of drug

Consequences

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
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
Introduction to Analysis of Behavior (“AB-C’s” of Substance Abuse)
Social Pressure
# Sessions
2
2
At Home and Alone
Depression
1
2
Managing Anxiety & Tension
Managing Anger & Frustration
Controlling Cues
3
3
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
(range: 53-82)
• Average Educ.
• Gender:
• Marital Status:
Married
Divorced
Widowed
Separated
Never Married
64.71 yrs (sd=5.5)
12.94 yrs (sd= 2.7)
108 males, 2 females
21.1%
51.8%
10.5%
8.8%
4.4%
GET SMART Patient Description
Schonfeld et al. (2000) Journal of Geriatric Psychiatry and Neurology
• Race/Ethnicity
 Caucasian
 African American
 Latino
 Asian
• Percent Homeless
• Percent living in a Domiciliary
• In Which War Served?
 WW II
 Korean
 Vietnam
• Percent Directly In Combat
50.8%
41.7%
5.8%
1.6%
34.2%
19.8%
14.4%
62.2%
8.1%
32.4%
Most recent substances used prior to
admission to GET SMART program.
•
•
•
•
•
•
•
Alcohol Only
Street Drugs Only
Prescription Medications only
Alcohol and Street Drugs
Alcohol and Prescription Meds
Street Drugs + Prescription Meds
All three categories
51.8%
9.1%
3.6%
26.4%
5.5%
0.9%
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
Completed
Program
Did Not
Complete
n=49 (44.5%)
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
Outcome
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
Gulf Coast
Community
Care
Coastal
Behavioral
HealthCare
Broward
County Elderly
& Veterans
Services
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
Pre-Screening by Nontraditional
and other referral sources
Screening by SBIRT
Pilot Program
End Screening
Re-contact at
later date
No
Enter Screening
Data on Tablet PC &
upload to KIT Solutions
Client screens positive
and agrees to be served.
Yes
Admit person for services
appropriate to service plan
Brief
Intervention
2-4 weeks post
Brief Intervention
Enter data into &
upload to KIT
Re-screen client prior
to discharge
Enter Data & upload to KIT
Refer to external
services as
indicated in plan
Brief
Treatment
Completion of every six
B.T. sessions
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
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
S u b sta n ce A b u se T r e a tm en t
fo r O ld e r A d u lts:
Resource for
Pilot Program
Participants:
A 16-session
curriculum manual
for conducting brief
treatment
A C o g n itiv e -B eh a v io r a l a n d
S elf-M a n a g em en t A p p ro a ch
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
Dupree & Schonfeld
(in press, SAMHSA)
© Department of Aging & Mental Health
Louis de la Parte Florida Mental Health Institute
University of South Florida
Tampa, FL 33612
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
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
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
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
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 agerelated sensitivity to alcohol,
medications, drugs, medications
• Unintentional medication misuse
should be considered as different than
substance abuse