1. First Responders: Drug Abuse and Drug Misuse Among Older Adults Rhode Island Elder Mental Health and Addiction Coalition and Rhode Island Elderly and Addiction Recovery Taskforce October 26, 2011 1

2. Officer Sandra Marinucci West Warwick Police Department Elderly Affairs Advocate Janet Spinelli, RN, PCNS RI Division of Behavioral HealthCare 2

3. Why is the Problem Getting Worse? 20% of the population is expected to be 65 or older by 2030. 66% of men and 65% of women use alcohol (Blazer & Wu, 2009). Seventy six % of adults 60 and over use two or more prescription drugs and 37% use five or more (Gu, et al., 2010). One in four older adults may use prescription medication with abusive potential (Blow, 2011). 1 3

4. Why is the problem getting worse? (cont.) Why is the problem getting worse? (cont.) By 2020, non-medical use of prescription drugs among adults 50 and over will increase dramatically (Simoni-Wastila & Yang, 2006). One in five older adults may be affected with difficulties from alcohol and medication misuse (Blow, 2011). 1 Non-medical use of prescription drugs was as common as marijuana use among adults aged 60 or over (NSDUH, 2007-2009). 2 Aging Baby Boomers are predicted to triple marijuana use among persons aged 50 or over between 1999/2001 and 2020 1 (NSDUH, 2007-2009). 2 Source: 1 Blow, F., 2011. Substance Use Disorders Among Older Adults. Available at: http://www.nattc.org 2 Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (September 1, 2011). The National Survey on Drug Use and Health Report. Illicit Drug Use among Older Adults. Rockville, MD. 4

5. Why is the Problem So Serious? 2006-Overall deaths caused by overdose of pharmaceuticals has exceeded deaths from traffic accidents. (T. Prough, DEA from CDC June 18, 2010). Overdose deaths in RI-9 th in US: Average 2-3 per week (T. Green, 2011). Older adults present unique challenges; requiring different strategies for problem recognition (NSDUH 2007-2009). Education is needed to can change perception of the problem. 5

6. Early Intervention & Treatment Early Intervention & Treatment Early intervention works! Early intervention can prevent unintentional drug poisoning. Early intervention may improve medical care for the many health conditions associated with drug abuse (NSDUH 2007-2009). Treatment can reduce ER visits, hospitalization, institutionalization, overdose, and death associated with illicit drug and pharmaceutical use. 6

7. Police and Fire First Responder 7

8. How were you dispatched? Who is the caller? 911 Lifeline Concerned family member, friend or neighbor What is the nature of the call? Medical Well being check Self initiated Wandering 8

9. Common Situations Wandering Unusual or Risky behaviors Not making sense Mood changes Environmental risk Falls/Injuries Requesting help with personal care Intoxication Complaints with neighbors 9

10. Potential Impairments Hearing deficit Visual deficit Speech deficits Language issues Specialized communication needs Cognitive impairment Intellectual special needs Medical issues/Medication reaction issues Drug and Alcohol intoxication issues 10

11. Initial Contact Try to establish rapport and trust. Respect personal space. Follow their lead, try not to rush the situation. Use slow, even, and low speech. Avoid talking down to the individual. Use a “sit and chat” scenarios when possible. Do not argue, use listening. 11

12. Recognizing Substance Abuse Communication o What difficulties are you having? o What concerns do you have? o How can we help you? Can they hold a conversation? o Use short sentences. o Use non-verbal communication. Can they talk about current events? Look for common signs of drug abuse. 12

13. Responding: Elder’s Home Look around the home. o Are there fire hazards? Are windows or doorways blocked? o Are there building violations? Are wires exposed? Smoke detectors? Deplorable conditions? o Dog, cat, human feces on the floor o Bugs Is there food? When was the last time they ate? Check the refrigerator Is this person able to care for themselves? o If the answer is No, they need to go to the hospital Document everything. Police and Fire: Take photos. 13

14. Fire &Police First Responder and Hospital Collaboration If time prevails, respond to the hospital. Talking to triage: o Locate the charge nurse, social services and/or the doctor. Give them the history and data on living conditions. o Report anything of importance. o Be descriptive and give details. o Recognize and report repetitive incidences. o Address discharge planning, if appropriate. Consider recidivism and related history. 14

15. Coordination with Social Services Mandatory Reporting: DEA – fax a copy to them ASAP 401-462-0545 The Point 211/www.DEA.RI.GOV ER card Case management agencies o West Bay Community Action– West Warwick, Coventry, Warwick, East Greenwich, West Greenwich (401-732-4660) o Child & Family Services of Newport (401-845-2270) o East Bay Community Action (401-437-1000) o Tri-Town Community Action Southern RI (401-789-3016 x7) Providence & Northern RI (401-349-5760 x3) 15

16. First Response: Integration with Treatment 16

17. How can we Partner to Address Substance Misuse? Screen: Scan the Environment Recognize Signs of Health and Safety Risk Develop Opportunities to use Motivation, Education, and Other Brief Interventions Balance Privacy vs. Health Concerns Refer to Treatment 17

18. Recognizing Common Scenarios Elders with Substance Use Issues Self Neglect Environmental & Community Safety Issues Abusive Caregiver Elder Victims of Abuse or Neglect from Substance Abusing Caregivers 18

19. Possible Signs of Drug Use Physical or Emotional Indicators: Smell of alcohol or marijuana on clothes Burned fingers, lips, or needle track marks Slurs speech, stutters, or incoherent Dilated or constricted pupils Tremors of hands or eyelids Hyperactive or overly energetic Lethargic or falls asleep easily Impaired coordination, staggering, off balance Speaks rapidly or slowly Mood swings, fearful or anxious Impatient, agitated, irritable, angry or defiant Behavioral Indicators: Impulsive or inappropriate Denies, lies or covers up; breaks or bends rules 19

20. Recognizing Possible Signs (Cont.) Cognitive Indicators: Difficulty concentrating, focusing, attending to task Appears distracted or disoriented Makes inappropriate or unreasonable choices Difficulty making decisions Memory loss, or black outs Makes frequent errors, or needs repeated directions Difficulty recalling known details Needs repeated assistance completing ordinary paperwork Adapted from: SAMHSA Tips for First Responders: Possible Alcohol and Substance Abuse Indicators. Publication # NMH05-0212. Available at www.samhsa.gov 20

21. Signs of Neglect in the Home Absence of necessities including food, water, heat Inadequate living environment evidenced by lack of utilities, sufficient space, and ventilation Animal or insect infestations Signs of medication mismanagement, including empty or unmarked bottles or outdated prescriptions Housing is unsafe as a result of disrepair, faulty wiring, inadequate sanitation, substandard cleanliness, or architectural barriers Source: National Committee for the Prevention of Elder Abuse (NCPEA) March 2003. 21

22. Signs of Neglect in the Home (Cont.) Physical indicators Poor personal hygiene including soiled clothing, dirty nails and skin, matted or lice infested hair, odors, and the presence of feces or urine Unclothed, or improperly clothed for weather Decubiti (bedsores) or skin rashes Dehydration, evidenced by low urinary output, dry fragile skin, dry sore mouth, apathy, lack of energy, and mental confusion Worsening dementia 22

23. Signs of Neglect in the Home (Cont.) Physical Indicators (cont.) Untreated medical or mental conditions including infections, soiled bandages, and unattended fractures Absence of needed dentures, eyeglasses, hearing aids, walkers, wheelchairs, braces, or commodes Exacerbation of chronic diseases despite a care plan Source: National Committee for the Prevention of Elder Abuse (NCPEA) March 2003. 23

24. Signs of Caregiver Abuse in the Home Indicators for caregiver abuser Expresses anger, frustration, or exhaustion Isolates the elder from the outside world, friends, or relatives Obviously lacks care giving skills Is unreasonably critical and/or dissatisfied with social and health care providers and changes providers frequently Refuses to apply for economic aid or services for the elder and resists outside help Source: National Committee for the Prevention of Elder Abuse (NCPEA) March 2003. 24

25. Signs of Abuse Indicators observed in Abuse Victim Exhibits emotional distress such as crying, depression, or despair Has nightmares or difficulty sleeping Has had a sudden loss of appetite that is unrelated to a medical condition Is confused and disoriented (this may be the result of malnutrition) Is emotionally numb, withdrawn, or detached Exhibits regressive behavior Exhibits self-destructive behavior Exhibits fear toward the caregiver Expresses unrealistic expectations about their care Source: National Committee for the Prevention of Elder Abuse (NCPEA) March 2003. 25

26. Specialized Interventions with Older Adults 26

27. Use Specialized Techniques LINK Concerns with Interview Questions. Ask DIRECT questions about identified concerns. PREFACE questions with link to medical, health or safety concerns. Use non-judgmental approach; avoid stigmatizing terms. Adapted from: F. Blow. (2011) Substance Use Disorders Among Older Adults. Available at: http://www.nattc.org 27

28. Screening leads to Treatment Ask about what drugs are used? o alcohol, misuse/use of prescription drugs, marijuana, cocaine, inhalants, hallucinogens, or heroin How much? When? o Identify recent intake, binge use, quantity and frequency What are the health conditions, functional issues and risks? o Identify comorbid risks. 28

29. Brief Intervention: Motivation using the 4 “R’s” Relevance to the Older Adult Risks of Continued Use Rewards of Quitting Repetition at Each Encounter Source Blow, F. (2011) Substance Use Disorders Among Older Adults. Available at: http://www.nattc.org 29

30. Health Education Works A non judgmental and empathic educational approach can highlight personal responsibility and capacity for behavior change. Alcohol Issues: Alcohol interacts with prescription drugs; and affects balance, appetite, sleep, nutrition, blood glucose levels, memory, and cognition. Health risks: Identify needs vs. adequate supports for medical, behavioral health and/or environmental issues. Education on Social Drinking : Choosing drinks with lower alcohol content and mixing with non alcoholic beverages may reduce the risk of dangerous consumption. 30

31. Health Education Works Prevention of Medication Misuse Use Only One Pharmacy. Ask your Health Care Provider or Pharmacist about potential side effects or drug interactions. Have a health care advocate. Report changes in health status to Health Care Providers.

32. Other Specialized Strategies Establish Strength Based Approach for Consumer Directed Goal Setting. Engage in Brief Interventions for Problem Solving, Coping with Losses and Changes in Health Status. Support Self Care Management and Skill Development. Establish Social Connection; Rebuild Social Supports. Promote Meaningful Day Activities. 32

33. Resources Rhode Island Council on Alcoholism and Other Drug Dependence http://www.ricaodd.org/http://www.ricaodd.org/ RI Department of Behavioral Healthcare, Developmental Disabilities and Hospitals http://www.bhddh.ri.gov/ http://www.bhddh.ri.gov/ Substance Abuse and Mental Health Service Administration (SAMHSA) http://www.samhsa.gov/http://www.samhsa.gov/ Addiction Technology Transfer Center (ATTC) Network http://www.nattc.orghttp://www.nattc.org Alcohol Screening: The Short Michigan Alcoholism Screening Test- Geriatric Version (SMAST-G); AUDIT- C, CAGE, MAST-Geriatric Version. The Drug Abuse Screening Test: DAST 33