1. Substance Abuse/Misuse and Older Adults Cori Robin, LCSW Health and Aging Rush University Medical Center Illinois Elder Rights Conference July 12, 2012 Session T14

2. We thank Retirement Research Foundation’s generous support for this project for two program years. 2 Presenter Disclosures

3. 3 Gain knowledge of current findings and prevalence of substance use/misuse in older adults Understand risk factors that may influence this population’s use/abuse/misuse Understand physiological differences with aging Learn about potential treatment efforts to imbed in current workplace environment Objectives

4. Rise in Older Adults 13% of current U.S. population age 60 and older Expected to increase up to 20 % by 2030 Each year more than 3.5 million Boomers turn 55 Individuals aged 85 and older are the fastest growing segment of the population. www.census.gov 4

5. The Need for Change Social and human services are going to be overwhelmed with increase in older adults Increased need for age-sensitive substance abuse and mental health prevention and treatment Demand for Substance Abuse and Mental Health services is likely to increase because the Baby Boom cohort tends to: – use these services more frequently than current older adult cohort – be less stigmatized by seeking services. Blow & Barry, 2011 5

6. Substance Use in Older Adults #1 Most common: Nicotine (~18-22%) #2 Alcohol (~2-18%) #3 Psychoactive Prescription Medications (~2-4%) #4 Other Illegal Drugs (marijuana, cocaine, narcotics) (<1%) Blow & Barry, 2011 6

7. Levels of Drinking World Health Organization Standards: Harmful drinking: Use of alcohol that causes complications (includes abuse and dependence) Hazardous drinking: Use of alcohol that increases risk for complications Non-hazardous drinking: Use of alcohol without clear risk of complications (includes beneficial use) 7

8. Drinking in Older Adults 66% of men, 65% of women used alcohol 3% met full criteria for an alcohol use disorder At-risk drinking was reported in: – 17% of men, 11% of women ages 50+ – 19% of all respondents ages 50-64 – 13% of all respondents ages 65+ Binge drinking was reported in: – 20% of men, 6% of women ages 50+ – 23% of all respondents ages 50-64 – 15% of all respondents ages 65+ Blazer & Wu, 2009a 65+ age group binge on alcohol more frequently than any other age group CDC, January 2012 8

9. Substance Use in Older Adults Estimated one in five older adults may be affected by combined difficulties with alcohol and medication misuse. More patients 60 & older are admitted to hospitals for alcohol connected problems than for heart attacks About 1/4 of nursing home admissions occur because the patient is unable to manage their medications. Psychoactive medication use indirectly causes up to 14% of hip fractures in older adults 60+ Hazlett and Schonfeld, 2011 9

10. Prescription Medication Use Older Adults are the largest consumers of psychoactive medications 85% of older adults take a prescription medication 76% use more than one medication daily Older adults constitute 13% of the population & use 1/3 of the prescriptions 20% use tranquilizers daily Factors associated with prescription drug abuse in older adults: – female sex, social isolation, history of a substance-use or mental health disorder, and medical exposure to prescription drugs with abuse potential Simoni-Wastila & Yang, 2006; Blow & Barry, 2011 10

11. At least 1 in 4 older adults use psychoactive medications with abuse potential By 2020, non-medical use of prescription drugs among adults age 50 and over will increase dramatically Older adults average 2-3 serious medication errors per month An estimated 125,000 older adults’ deaths can be attributed to medication noncompliance at a cost of $100 billion in the US alone Wolstenholme, 2011; Simoni-Wastila & Yang, 2006 11 Prescription Medication Use (Cont)

12. Interactions: Medication and Alcohol Medications with significant alcohol interactions Benzodiazepines Other sedatives Opiate/Opioid Analgesics Some anticonvulsants Some psychotropics Some antidepressants Some barbiturates Blow & Barry, 2011; NIAAA, 1998 12

13. Physiological Aging Decrease in percent of body weight composed of water Changes in digestion Changes in liver function Changes in kidney function Other medical factors associated with aging (multiple medications, sensory issues) Barry & Blow, 2004 13

14. Medical Risks 1 or More Drinks per Day Gastritis, ulcers, liver and pancreas problems 2 or More Drinks per Day Depression, gout, GERD, breast cancer, insomnia, memory problems, falls 3 or More Drinks per Day Hypertension, stroke, diabetes, gastrointestinal diseases, cancer of many varieties Blow & Barry, 2011 14

15. Signs/Symptoms Anxiety Blackouts Dizziness Depression Disorientation Mood swings Falls, bruises, burns Family problems Financial problems Headaches Incontinence Increased tolerance to alcohol Blow & Barry, 2011 15 Legal difficulties Memory Loss Problems in decision making Poor hygiene Seizures Sleep problems Social isolation Unusual response to medications

16. Medical & Psychosocial Issues with Aging Loss (loved ones, employment, driving, social or economic status) Financial problems Transitions in housing Social isolation Caregiving for loved ones Complex medical problems Multiple medications Reduced mobility Cognitive impairment or loss Sensory deficits Blow, 2007 16 Unique Aspects with Older Adults

17. Risk for Psychiatric Illness Older adults are three times as likely to develop a mental illness with a lifetime diagnosis of alcohol abuse. Common “Dual Diagnoses” include: Depression (20-30%) Cognitive loss (10-40%) Anxiety disorders (10-20%) Blow & Barry, 2011 17

18. Assumptions with age Lack of awareness Difficulty in recognizing symptoms Symptoms attributed to other causes Cultural/social context Many do not self-refer or seek help Hazlett and Schonfeld, 2011 18 Barriers to Identification

19. Recommended Drinking Limits Centers for Disease Control and Prevention: Drinking Limits: no more than one drink per day on average for older men or less than one drink per day on average for older women Binge drinking: drinking four or more drinks during a single occasion (drinking day) for men or three or more drinks during a single occasion for women CDC, 2011 19

20. Standard Drink 20

21. Intervention to identify non-dependent substance use or prescription medication issues and to provide effective service strategies prior to their need for more extensive or specialized substance abuse treatment Prescreen quickly identifies older adults who use alcohol and/or the psychoactive medications targeted for this intervention (opioid analgesics for pain and sedative hypnotics: benzodiazepines and barbiturates for sleep, anxiety, nerves, agitation) Screening quickly assesses the severity of substance use and identifies the appropriate level of education and/or treatment needed for the individual (primary prevention). Brief intervention focuses on increasing insight and awareness regarding substance use and motivation for behavioral change (secondary prevention). Referral to Treatment provides access to specialty substance abuse assessment and care, if needed. Six Month Follow-up uses same screening questionnaire and can help determine if clients have changed their alcohol and/or psychoactive medication use, or need additional assistance with their alcohol and/or psychoactive medication use. 21 SBIRT Intervention

22. 1) In general, would you say your health is: __ Excellent __ Very Good___ Good__ Fair__ Poor 2) Do you visit your primary care physician at least one time per year? __Yes __No 3) Please review the list of medications on back of this page. During the past 3 months, have you used any of these prescription medications for pain for problems like back pain, muscle pain, headaches, arthritis, fibromyalgia, etc.? __Yes __No 4) During the past 3 months, have you used any prescription medications to help you fall asleep or for anxiety or for your nerves or feeling agitated? __Yes __No 5) In the last 3 months, have you felt you should: a. lose some weight:___No___Sometimes___Quite Often___Very Often b. cut down or stop smoking: ___No___Sometimes___Quite Often___Very Often c. cut down or stop drinking: ___No___Sometimes___Quite Often___Very Often d. do more to keep fit: ___No___Sometimes___Quite Often___Very Often e. better manage medications: ___No___Sometimes___Quite Often___Very Often 6) In the past 3 months, have you fallen or had a fear of falling? __Yes __No 7) In the past 3 months, have you had anything to drink containing alcohol (beer, wine, wine cooler sherry, gin, vodka or other hard liquor)? __Yes __No 8) In the past 3 months, have you thought about changing any other things about your health? Prescreen Questions

23. Screening Instruments – Substance Consumption – Substance Consequences CAGE, AUDIT, MAST, SMAST Older Adult Specific: MAST-G; SMAST-G – Health Screening Survey Universal (not systematic) Screening Techniques 23 Screening

24. After a positive identification of at-risk status, Brief Intervention is conducted: 1.Identify future goals (related to physical/mental health, social life/relationships, finances, etc) 2.Summary of health habits 3.Psycho-education on standard drinks, level of consumption and physical changes with aging and substances 4.Types of older drinkers in U.S. 5.Psycho-education on interaction of alcohol and medications 6.Consequences of at-risk drinking or medication misuse (discuss positive and negative effects) 7.Reasons to quit or cut down 8.Agreed-upon plan 9.Handling risky situations or triggers 10.Visit summary Barry, Blow & Schonfeld, 2004 24 Brief Intervention

25. Motivational Interviewing Principles Express empathy Roll with resistance Support self-efficacy Develop discrepancy Miller & Rollnick, 2002 25 Techniques of BI

26. Avoid labels (i.e. addict, alcoholic) Avoid confrontation or anger Create a culture of respect Acknowledge difficulty of behavior change Create a safe environment Avoid shaming language Be non-judgmental Focus on re-building coping skills and increasing support network Connect use and symptoms Connect behaviors and participants’ emotional responses Relate alcohol and drug use-abuse issues to how it can effect health 26 When Intervening with Older Adults…

27. 27 Sources Barry, K.L., Blow, F.C. & Schonfeld, L. (2004). Health promotion workbook for older adults (adapted to include medication misuse). Blazer, D.G. & Wu, L.T. (2009). The epidemiology of at-risk and binge drinking among middle-aged and elderly community adults: National survey on drug use and health. American Journal of Psychiatry, 166, 1162-1169. Blow, F.C. (2007). Substance abuse screening and interventions for older adults: Evidence-Based Approaches. Presented at American Society on Aging, San Francisco, CA: June 21, 2007. Blow, F.C. & Barry, K.L. (2011). Substance use disorders among older adults. Presented at SAMHSA/Substance Abuse Prevention Older Americans Technical Assistance Center Training, Chicago, IL. Get Connected! Toolkit: Linking Older Adults With Medication, Alcohol, and Mental Health Resources: http://www.samhsa.gov/Aging/docs/GetConnectedToolkit.pdf Hazlett, RW. & Schonfeld, L. (2011). The use and abuse of alcohol, drugs and prescription medication in vulnerable adults. 2011 Florida Conference on Aging. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people to change addictive behavior (2nd ed.). New York: Guilford Press. Older Americans Substance Abuse and Mental Health Technical Assistance Center: http://www.samhsa.gov/OlderAdultsTAC/index.aspx Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. (1998). Substance Abuse Among Older Adults: A Guide for Social Service Providers. Treatment Improvement Protocol (TIP) Series 26. Department of Health and Human Services Publication No. (SMA) 98-3179. Rockville, MD Simoni-Wastila, L., & Yang, H. K. (2006) Psychoactive drug abuse in older adults. American Journal of Geriatric Pharmacothery, 4: 380–394. Wolstenholme, B. (2011). Medication-related problems in geriatric pharmacology. Aging Well, 4(3), 8..

28. Cori Robin, LCSW Rush University Medical Center (312) 942-6087 Cori_B_Robin@rush.edu 28 Contact Information