Substance Use in Older Adults: Screening and Treatment Intervention - PowerPoint PPT Presentation

Barriers to Diagnosis Screening instruments for alcohol problems  not well-validated in older adults (except MAST-G, CARET - not endorsed by DMH) No screening instruments validated in older  adults for psychoactive drug misuse or tobacco Clinical symptoms of substance use disorders  may mimic, overlap, and exacerbate effects of prescribed medications and/or common medical and psychiatric symptoms 30

Alcohol Misuse among Older Women Older women may be at greater risk for  alcohol problems due to potential loneliness and depression from outliving spouse, other losses Physiologically at greater risk as they age  Alcohol use recommendations lower than  those set for older men and younger women Screening and brief intervention  useful

The Spectrum of Interventions for Older Adults Prevention/ Education Brief Advice Brief Interventions Pre-Treatment Intervention Formal Specialized Treatments 32

What is SBIRT? SBIRT is a comprehensive , integrated , public health approach to the delivery of early intervention and treatment services  For persons with substance use disorders  Those who are at risk of developing these disorders Primary care centers, mental health agencies, and other community settings provide opportunities for early intervention with at-risk substance users Before more severe consequences occur 33

SBIRT Goals Increase access to care for persons with  substance use disorders and those at risk of substance use disorders Foster a continuum of care by integrating  prevention, intervention, and treatment services Improve linkages between health care  services and alcohol/drug treatment services 34

Public Health Challenge Conclusion: The vast majority of people with a diagnosable illicit drug or alcohol 35 disorder are unaware of the problem or do not feel they need help. Source: SAMHSA, 2005 National Survey on Drug Use and Health (September 2006).

Screening and Brief Interventions in Mental Health and Healthcare Settings Work Substance abuse SBI may reduce alcohol and other drug use significantly Morbidity and mortality SBI reduces accidents, injuries, trauma, emergency dept visits, depression Health care costs Studies have indicated that SBI for alcohol saves $2 - $4 for each $1.00 expended Other outcomes SBI may reduce work-impairment and DUI 36

SBI Can Have a Major Impact on Public Health There are grounds for thinking SBI may: identify those at risk of abusing alcohol/drugs. stem progression to dependence. improve medical conditions exacerbated by substance abuse. prevent medical conditions resulting from substance abuse or dependence. reduce drug-related infections and infectious diseases . have positive influence on social function . 37

What does research say about older adults and substance abuse treatment? 38

Empirical Support for Brief Interventions with Older Adults Project GOAL (Guiding Older Adult Lifestyles)  focused on physician advice for older adult at- risk drinkers: Physician advice led to reduced consumption at 12 months (University of Wisconsin; N=156; 35-40% change) Health Profile Project: Preliminary findings  indicate that an elder-specific motivational enhancement session conducted in-home reduced at-risk drinking at 12 months (University of Michigan; N=454) 39

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 40

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  41

Age-Specific Treatment Elements (continued) 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  42

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

Alcohol Metabolism – Race as a Factor The most common pathways of metabolism  involve 2 enzymes: Alcohol Dehydrogenase (ADH)  Aldehyde Dehydrogenase (ALDH)  H 2 O ALDH ADH Alcohol Acetaldehyde Acetate CO 2 Different people carry different variations of  the ADH & ALDH enzymes. Variations in these enzymes affect how much  people drink and their risk for alcoholism. 44

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.  45 (Source: NIH/NIAAA, 2007)

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? 46

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

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 IV  Number of Prescriptions Collected  Annually: 21 million Number of Controlled Substance  Dispensers: 155,000 Website: http://ag.ca.gov/bne/cures.php  48 SOURCE: State of California Department of Justice, Office of the Attorney General.

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

Screening to Identify Consumers at risk for Substance Use Problems How do we conduct the screening?

Substance Use Problems Among Mental Health Populations SBI RT SBI RT 51

How do we define risk? Federal Guidelines* Source: NIAAA, 1995 *Average rates for general population without additional risk factors 52

What is the Difference between… What’s Going On in These Pictures? Screening Assessment 53

Screening Conducted with large numbers  of people to identify the potential that a problem exists Screening is intended to be broad scale  and produce false positives Screening leads to more in-depth  assessment and intervention for people identified with a potential problem 54

Why screen in Mental Health? Those with a Co-Occurring MH and SUD are more  likely to enter the system through a MH door. Research supports the application of screening and  brief intervention in primary care and mental health Consumers expect providers to:  Provide lifestyle advice  Ask about their use of alcohol and other drugs  55

Before Asking Screening Questions I am going to ask you some personal  questions about alcohol (and other drugs) that I ask all of the people that I work with. Your responses will be confidential .   These questions help me to provide the best possible care . You do not have to answer them if you  are uncomfortable. 56

Include prescription 57 misuse

Interviewing for interconnected problems e M s U e n e t a c n l H a t e s a b l u t h S Medical 58

Los Angeles DMH Assessment Medical Mental Health Considerations Considerations Cirrhosis Depression Gastroenteritis Anxiety Abscess Anhedonia Diabetes Psychotic Thinking High Blood Pressure Trauma/PTSD HIV/HCV Confusion Cardiac Problems Memory Issues TB … … 59

Los Angeles DMH Assessment SUD Mental Health 60

The need to screen for illicit drug use. An increasing trend among older adults? 61

Beware… The Baby Boomers are getting older! 62

Medication Use: BRITE Interview Items Takes more than one type of prescribed medication • Difficulty remembering how many meds to take • Prescriptions from two or more doctors • Felt worse soon after taking meds • Taking meds (or alcohol) to help sleep • Uses up meds too fast • Takes meds (or alcohol) for nervousness or anxiety • Doctor/nurse expressed concern about use of meds (or alcohol) • Take pain relieving meds • Take pills (or drink) to deal with loneliness, sadness • Saving old medications for future use • Chooses between cost of meds (or alcohol) and other necessities • A family member reminds them to take pills • Uses dispenser or other method to help remind • Fails to take meds supposed to • Borrow someone else's meds • Feel groggy after taking certain medications • 63

Medication Misuse Interviewer's impressions after asking about prescriptions: 1. Does not correctly recall the purpose of one or more medications 2. Reports the wrong dose/amount of one or more medications 3. Takes one or more medications for the wrong reasons or symptoms 4. Needs education and/or assistance on proper medication use 64

OTC Medication Use – BRITE Interview Items Do you frequently take aspirin, Tylenol, Advil, or other non- 1. prescription pills for pain? Do you ever tell your physician about the type of non- 2. prescription pills you buy? Do you use herbal pills such as Ginkgo, Saw Palmetto, St. 3. John's Wort? Do you take non-prescription pills or remedies for improving your 4. memory? Have you ever felt worse soon after taking over-the counter 5. remedies? Are you taking medications to help you sleep? 6. Do any of the non-prescription pills you take make you feel 7. groggy? Do you use plants or herbs to make your own remedies such as 8. garlic, or aloe? 65

Florida BRITE Project Screening: Prescription Medications 18% were referred for prescription misuse  16% reported wrong amount for one or more  medication 11% could not recall purpose of one or more  medications 17% need education and/or assistance on  proper medication use 4% took prescription medications for wrong  reasons or symptoms 66

Effecting Change through the Use of Motivational Interviewing

Putting Best Practices into Practice Order from http://www.samhsa.gov/ 68

Ambivalence (2) 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 69

Ambivalence (3) Ambivalence is normal  Consumers usually enter treatment with  fluctuating and conflicting motivations They “want to change and don’t want to  change” “Working with ambivalence is working  with the heart of the problem” 70

Brief Intervention Effect Brief interventions can trigger change  1 or 2 sessions can yield much greater  change than no counseling A little counseling can lead to significant  change Brief interventions can yield outcomes  that are similar to those of longer treatments 71

A consumer-centered directive method for consumer-centered directive method enhancing intrinsic motivation to change by exploring and resolving ambivalence exploring and resolving ambivalence. 72

Stages of Change Prochaska & DiClemente 73

Some Ways to Raise Awareness in the Precontemplation Stage Offer factual information  Explore the meaning of events that  brought the person in and the results of previous efforts Explore pros and cons of targeted  behaviors 74

Possible Ways to Help the Consumer in the Contemplation Stage Talk about the person’s sense of self-  efficacy and expectations regarding what the change will entail Summarize self-motivational statements  Continue exploration of pros and cons  75

Possible Ways to Help the Consumer in the Determination Stage Offer a menu of options for change or  treatment Help consumer identify pros and cons  of various treatment or change options Identify and lower barriers to change  Help person enlist social support  Encourage person to publicly  announce plans to change 76

Possible Ways to Help the Consumer in the Action Stage Support a realistic view of change  through small steps Help person identify high-risk  situations and develop appropriate coping strategies Assist person in finding new  reinforcers of positive change Help access family and social support  77

Possible Ways to Help the Consumer in the Maintenance Stage Help consumer identify and try  alternative behaviors (drug-free sources of pleasure) Maintain supportive contact  Encourage person to develop escape  plan Work to set new short and long term  goals 78

Strategies for Helping the Consumer Who Has Experienced a Recurrence Frame recurrence as a learning opportunity;  recurrence does not equal failure! Explore possible behavioral, psychological,  social antecedents to the recurrence/relapse Help person develop alternative coping  strategies Explain Stages of Change and encourage  him/her to stay in the process Maintain supportive contact  79

“People are better persuaded by the reasons they themselves discovered than those that come into the minds of others” Blaise Pascal

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) 81

SUD Family Medical Issues fusion Con- SUD Pain

Conducting the Brief Intervention FLO

84 Avoid Warnings! (that’s it) W Warn O Options Explored The 3 Tasks of a BI L Listen & Understand F Feedback

How does it all fit together? 85

How does it all fit together? 86

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) 87

How you talk to the consumer matters You are singing off key if you find yourself… • Challenging • Shaming • Warning • Labeling • Finger-wagging • Confronting • Moralizing • Being Sarcastic • Giving unwanted • Playing expert advice 88

The 3 Tasks of a BI F L O Feedback Listen & Understand Options Explored 89

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…  90

The First Task: Feedback Handling resistance… Look, I don’t have a drug problem  My brother was an alcoholic; I’m not like him  I can quit using anytime I want to  I just like the taste  At my age I do what I want to do  What would you say? 91

The First Task: Feedback To avoid this… LET GO!!! 92

The First Task: Feedback 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….  93

SUD SUD Hypertension Diabetes Cancer Pain Family Con ‐ fusion Medical Issue

Feedback: Content Areas for Older Adults Alcohol Use  Illicit Drug Use  Prescription Medication Use  OTC Medication Use  Always ask this question: “What role, if any, do you think (substance) played in (problem) ? 95

The First Task: Feedback Let’s practice F: Role Play Giving Feedback Using Completed Screening Tools  Focus the conversation  Get the ball rolling  Gauge where the consumer is  Hear their side of the story 96

The 3 Tasks of a BI F L O Feedback Listen & Understand Options Explored 97

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. 98

The Second Task: Listen and Understand Listen for the change talk… Maybe drinking did play a role in what happened If I wasn’t drinking this would never have happened Using doesn’t really make me feel happier I don’t want to be in this mess again The last thing I want to do is hurt someone else I know I can quit because I’ve stopped before Summarize, so they hear it twice! 99

The Second Task: Listen and Understand 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? 100