Substance Use in Older Adults: Brief Intervention Advanced Skill Building.

Substance Use in Older Adults:

Brief Intervention Advanced

Skill Building

Learning Objectives

Review of at-risk drinking, problem drinking, and alcohol dependence in older adults

Review signs and symptoms of alcohol problems and medication misuse in older adults

Review Brief Interventions with older adultsPractice all steps of the F.L.O. Brief

InterventionApply F.L.O. Brief Intervention to Case StudyDiscuss and trouble-shoot implementation

issues

2

Review: Is it really a problem?

Prevalence of problematic alcohol and other substance use

Moderate or Low Risk Drinking*

Under age 65Men: up to 2 drinks per day on averageWomen: 1 drink per day on average

65 and over: Men and Women: no more than 1 drink

per day on average.Never more than 2 drinks on any

drinking day (binge drinking)

(Source: USDHHS)

4*Average rates for general population without additional risk factors

Potential Comorbidities withAlcohol Use

Interference with metabolizing medications

Increased side effects from medicationSleep disordersPsychiatric conditions

(e.g. depression, anxiety)Increased risk of suicideDementia

Past Month Use of Any Illicit Drug or Alcohol by Age Group: 2000

15

.9

56

.8

37

.8

12

.8

7.8

58

.3

30

.3

7.6

4.9

53

.0

21

.1

5.3

1.0

37

.5

9.4

2.3

0

10

20

30

40

50

60

70

Any IllicitDrug Use

Any AlcoholUse

"Binge"Alcohol use

HeavyAlcohol Use

18 to 25

26 to 34

35 to 54

55 or Older

Per

cen

t R

epo

rtin

g U

se i

n P

ast

Mo

nth

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Review: Issues Unique to Older Adults

Loss (people, vocation, status)

Social Isolation and loneliness

Major financial problems

Changes in housing Family concerns Burden of time

management

Complex medical problems

Multiple medications Sensory deficits Reduced mobility Cognitive impairment

or loss Impaired self-care

Age-Related Factors that Increase Risks from Alcohol & Psychoactive Drugs in Older Persons

Physiological factors ratio body fat to lean muscle mass

blood alcohol levels clearance rate benzodiazepines

susceptibility to psychomotor effects (e.g. sedation, confusion, falls)

Other concomitants of aging morbidity medication use

8

Barriers to Diagnosis

Criteria used for dx abuse (DSM-IV) less pertinent in older adultsFailure to fulfill major obligations at work, school or homeSubstance-related legal problems

Ageism Denial Access—financial, cultural, functioning

Time constraints Medication use causing or confusing

symptoms

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The Spectrum of Interventions for Older Adults

Prevention/Education

Formal Specialized Treatments

Pre-Treatment Intervention

Brief Advice

Brief Interventions

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Age-Specific Treatment Elements

Attention paid to age-related issues (e.g. illness, depression, loss)

Consistent linkage with medical services Staff with geriatric training Create a “culture of respect” for older

consumers Broad, holistic approach recognizing

age-specific psychological, social & health aspects

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Age-Specific Treatment Elements (continued)

Less confrontation and probing for “private” information

Accommodate sensory and cognitive declines in educational components

Groups are especially helpful in reducing shame and improving social network

Preparation for AA is important due to high level of confrontation

Less use of self-help jargon

12

Less clinical distance/warmer relationships using appropriate self-disclosure

Attention to calming fears regarding confidentiality

Assistance from social services/family in medication monitoring

More family involvement Home visitation

Age-Specific Treatment Elements (continued)

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Cultural Adaptations of Interventions

Provide care in settings that consumers are more likely to use and feel safe.

Provide care in consumers’ preferred language.

Match ethnicity of consumer and therapist or train therapists in cultural competence.

Incorporate cultural knowledge, attitudes and behavior.

(Sources: Field & Caetano, 2010; Miranda et al., 2005; Munoz & Mendelson, 2005) 14

Alcohol Metabolism – Race as a Factor

The most common pathways of metabolism involve 2 enzymes: Alcohol Dehydrogenase (ADH) Aldehyde Dehydrogenase (ALDH)

Different people carry different variations of the ADH & ALDH enzymes.

Variations in these enzymes affect how much people drink and their risk for alcoholism.

Alcohol Acetaldehyde Acetate

H2O

CO2

ADH ALDH

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Alcohol Metabolism - Race as a Factor

A very efficient version of ADH is common in people of Chinese, Japanese and Korean descent but is rare in people of European and African descent.

Research suggests there is no difference in the rates of alcohol metabolism and enzyme patterns between Native Americans and Whites.

Environment still plays a large role.

(Source: NIH/NIAAA, 2007) 16

Small Group Discussion—Culture

What other cultural factors influence our activities with clients?How does the consumer’s culture

impact what we do?How does the consumer’s culture

impact how what we do is received?

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Role of Prescription Drug Monitoring Program Community

Collection and analysis of controlled substance data

Identification and investigation of illegal prescribing, dispensing and procurement

Prescribers access can help decrease extent of “doctor shopping”

SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.18

CURES: CA’s Prescription Drug Monitoring Program

Name: Controlled Substance Utilization Review and Evaluation System (CURES)

Overseen by: CA Dept of Justice, Bureau of Narcotic Enforcement

Schedules Monitored: II, III, and IVNumber of Prescriptions Collected Annually:

21 millionNumber of Controlled Substance

Dispensers: 155,000Website: http://ag.ca.gov/bne/cures.php

SOURCE: State of California Department of Justice, Office of the Attorney General.SOURCE: State of California Department of Justice, Office of the Attorney General.

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Real-Time Statewide Prescription Drug Monitoring Program

Internet-based technology to stop “drug seekers” Contains more than 100 million entries Instant access to patients’ controlled-substance

records (vs. fax/mail system) 7,500 pharmacies and 158,000 prescribers Goals:

Reduce drug trafficking and abuse of dangerous prescription medications

Lower the number of ER visits due to Rx drug overdose and misuse

Reduce healthcare costs

SOURCE: State of California Department of Justice, Office of the Attorney General.SOURCE: State of California Department of Justice, Office of the Attorney General.

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Screening to Identify Consumers at risk for Substance Use Problems

How do we conduct the screening?

Substance Use Problems Among Mental Health Populations

SBIRT

SBIRT

22

23

Include prescription

misuse

Interviewing for interconnected problems

Medical

Substa

nce

Use Mental Health

*24

Review: LAC DMH Assessment

Mental Health Considerations

DepressionAnxiety

AnhedoniaPsychotic Thinking

Trauma/PTSDConfusion

Memory Issues…

Medical Considerations

CirrhosisGastroenteritis

AbscessDiabetes

High Blood PressureHIV/HCV

Cardiac ProblemsTB…

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Review: LAC DMH Assessment

SUD Mental Health

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Effecting Change through the Use of Motivational Interviewing

28

Ambivalence

Ambivalence: Feeling two (or more) ways about something.

All change contains an element of ambivalence.

Resolving ambivalence in the direction of change is a key element of motivational interviewing

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Stages of ChangeProchaska & DiClemente

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Reflective Listening Key-Concepts

Listen to both what the person says and to what the person means

Check out assumptions Create an environment of empathy

(nonjudgmental) You do not have to agree Be aware of intonation (statement, not

question)

SUD

Family

Con-fusion Medical

Issues

Pain

SUD

Conducting the Brief Intervention

FLO

The 3 Tasks of a BI

Avoid Warnings!

F L O WFeed

back

Listen

& U

nd

erstand

Warn

Op

tion

s Exp

lored

(that’s it)

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How does it all fit together?

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36

Providing Feedback

Elicit (ask for permission)

Give feedback or advice

Elicit again (the person’s view of how the advice will work for him/her)

The 3 Tasks of a BI

F L OFeed

back

Listen

& U

nd

erstand

Op

tion

s Exp

lored

37

The First Task: Feedback

Your job in F is only to deliver the feedback!

Let the consumer decide where to go with it.

Ask for Permission explicitly There’s something that concerns me. Would it be ok if I shared my concerns with you?

Provide direct feedback The results of your screening form suggest that…

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To avoid this…

LET GO!!!


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Easy Ways to Let Go… I’m not going to push you to change anything you

don’t want to change… I’m not hear to convince you that you’re an

alcoholic… I’d just like to give you some information... I’d really like to hear your thoughts about… What you do is up to you….

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Hyp

erte

nsio

nD

iabe

tes

Canc

er

SUD

Family

Pain

Con-fusion Medical

Issue

SUD

Feedback: Content Areas for Older Adults

Alcohol UseIllicit Drug UsePrescription Medication UseOTC Medication Use

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Always ask this question: “What role, if any, do you think

(substance) played in (problem) ?


Let’s practice F: Role Play Giving Feedback Using

Completed Screening Tools

Focus the conversationGet the ball rollingGauge where the consumer is Hear their side of the story

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The 3 Tasks of a BI

F L OFeed

back

Listen

& U

nd

erstand

Op

tion

s Exp

lored

44

The Second Task: Listen and Understand

Change Talk

•DESIRE: I want to do it.

•ABILITY: I can do it.

•REASON: I can’t fall down again.

•NEED: I have to do it.

•COMMITMENT!!! I WILL DO IT.

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Dig for change talk…

•I’d like to hear your opinions about…

•What are some things that bother you about your use?

•What role do you think drugs/alcohol played in your injury?

•How would you like your drinking to be 5 years from now?

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Tools for Change Talk

• Pros and Cons

• Importance & Confidence Scales

• Readiness Ruler

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Strategies for weighing the pros and cons…•“What do you like about drinking?”•“What do you see as the downside of drinking?”•“What Else?”

Summarize both pros and cons…

“On the one hand you said..,and on the other you said….

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Importance/Confidence/Readiness

On a scale of 1–10… • How important is it for you to change your

drinking?• How confident are you that you can change your

drinking?• How ready are you to change your drinking?

For each ask…• Why didn’t you give it a lower number?• What would it take to raise that number?

1 2 3 4 5 6 7 8 9 10 49

The Second Task: Listen & Understand

Let’s practice L: Role Play Listen & Understand

Using Completed Screening Tools Pros and Cons Importance/Confidence/Readiness ScalesDevelop DiscrepancyDig for ChangeCreate movement in Consumer’s Stage of

Readiness for Change50

The 3 Tasks of a BI

F L OFeed

back

Listen

& U

nd

erstand

Op

tion

s Exp

lored

51

What now?

What do you think you will do?

What changes are you thinking about making?

What do you see as your options?

Where do we go from here?

What happens next?

The Third Task: Options for Change

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Offer a Menu of Options

• Manage drinking/use (cut down to low-risk limits)

• Eliminate your drinking/drug use (quit)

• Never drink and drive (reduce harm)

• Utterly nothing (no change)

• Seek help (refer to treatment)

• Set up appointment with prescribing physician


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During MENUS You can also explore previous strengths, resources and successes

•“Have you stopped drinking/using drugs before?”

•“What personal strengths allowed you to do it?”

•“Who helped you and what did you do?”

•“Have you made other kinds of changes successfully in the past?”

•“How did you accomplish these things?”


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Giving Advice Without Telling Someone What to Do

Ask for Permission explicitlyThere’s something that concerns me.Would it be ok if I shared my concerns with

you?Preface advice with permission to disagree

This may or may not be helpful to you

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Giving Advice Without Telling Someone What to Do

Provide Clear Information or FeedbackWhat happens to some people is that…My recommendation would be that…

Elicit their reactionWhat do you think?What are your thoughts?

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Closing the Conversation

S E W

Summarize consumers’ views (especially the pro)

Encourage them to share their viewsWhat agreement was reached (repeat it)

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Putting it all together

Feedback

Range

Pros and ConsImportance/Confidence/Readiness Scales

Summary

Options Explored

Listen and Understand

Menu of Options58

Case Study 1: Mr. Jackson

Anthony Jackson is a 67-year old man living alone in an apartment in a mixed-age housing project. For the past month he has been seen by a visiting nurse from your agency. The nurse was assigned upon his discharge from the hospital where he spent 4 days. He had a fall in the middle of the night prior to the hospitalization , was a bit confused on admission, and was also diagnosed of anemia in the hospital. The nurse noted the smell of alcohol during two of his visits, but Mr. Jackson did not ever appear intoxicated.

When the nurse asked him about his drinking, he said, “Oh, I don’t drink very much, really. I just seem so tired all the time and a little drink now and then makes me feel better”. He has complained about difficulty sleeping at night and was prescribed medication for sleep 6 months ago.

A homemaker is assigned to his case and visits two times/week. In addition, he has one friend who visits almost every day. Not counting his stay in the hospital, he has been confined to his apartment for the last two months.

The nurse asked you to see Mr. Jackson to assess his alcohol problems and determine what additional services are needed. 59

Role Play for Mr. Jackson

Provide FeedbackWhat would he identify as THE problem

Listen and UnderstandExplore readiness for change

Explore OptionWhat is he willing and able to do right now?

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Case Study 2: Mrs. Alvarez

Maria Alvarez is a 70 year old who is depressed and uses a sedative (lorazepam 1mg) most nights

Sometimes she takes two pills Osteoarthitis of knees and uses acetaminophen

and codeine Has fallen twice in last month Widowed for 3 months Wants to get more lorazepam to help her sleep

better

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Role Play for Mrs. Alvarez

Provide FeedbackWhat would he identify as THE problem

Listen and UnderstandExplore readiness for change

Explore OptionWhat is he willing and able to do right now?

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Important Internet Sites

[email protected]://sbirt.samhsa.gov/about.htmhttp://sbirt.samhsa.gov/trauma.htmhttp://www.saem.org/SAEMDNN/Portals/

0/IGroups/PublicHealth/sbirt2008/SBIRTResourceManual051608.doc

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Substance Use in Older Adults: Brief Intervention Advanced Skill Building.

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