Alcohol, Drugs, and Aging: 21st Century Challenges A New Frontier in Addictions Treatment and Prevention

1
Alcohol, Drugs, and Aging 21st Century
ChallengesA New Frontierin Addictions
Treatment and Prevention

• Darwin Shane Koch Rh.D, CRC, CSADC, AADC
• Associate Professor and Director of Addiction
  Studies
• Rehabilitation Institute- SIUC
• With the support of the SIASATF and the Koch
  Research Team

2
Goals

• Identify the population
• Identify the challenges
• Identify the solutions / Hopes (Embedded)
• Transform you all into local heroes!

3
Invisible Epidemic

• AODA among older adults has been called an
  invisible epidemic since it is often under
  diagnosed, under treated, and/or misdiagnosed
  (Benshoff, Koch, Harrawood, 2003)
• http//www.nationalrehab.org/website/pubs/vol69no2
  .html
• "We are only beginning to realize the
  pervasiveness of substance abuse among older
  adults," SAMHSA Administrator Charles Curie said.
  "We have made older adults a priority at SAMHSA
  and we are working to advance understanding of
  the relationship between aging and substance
  abuse, and to provide practical information for
  incorporating our understanding into treatment
  services.
• http//www.seniorjournal.com/NEWS/Features/5-05-05
  SubstanceAbuse.htm
• Unidentified --- Underserved ---- Inappropriately
  Served --- Excluded

4
Why is this population at risk?

• Generational trends
• Iatrogenic Effects, the medical model and
  advertising
• Onset of disabilities (including co-occurring
  disorders)
• Ageism
• Stigma
• Expectations
• Stereotypes
• Isolation

5
(No Transcript)
6
(No Transcript)
7
National Trends

• The need for substance abuse treatment for older
  adults is expected to TRIPLE by the year 2020
  (SAMHSA, 2003)
• http//www.oas.samhsa.gov/Aging/chap5.htm
• Healthcare costs associated with AODA-among all
  individuals (Gunter and Arndt, 2004)
• 11 of hospital admissions
• 20 of psychiatric admissions
• 16 of emergency room visits
• Older Adults represent a classic at-risk
  population for AODA (Alcohol and Other Drug Abuse)

8
AODA Treatment for Older Adults in Illinois

• DASA DARTS Data 2003-2005
• Funded by the Substance Abuse and Aging Seed
  Grant-SIUC
• With help from Gajef McNeil at DASA and the
  SIASATF

9
Important Trends

• Numbers Served
• 2003 - 4108
• 2005 - 6,087
• Many cases are from age 55-65 (2409/2519)
• Gender Male Female
• 76 24
  
• 73 27
• Important note What, not why

10
What we would expect in terms of drugs of choice

• Alcohol - number 1?
• Prescriptions - number 1?
• Illicit drugs - very limited?

11
2003 Drug of Choice

• Alcohol 49
• Heroin 31
• Crack 8
• Cocaine 3
• Cannabis 1 (61)
• Opioids 1 (42)
• Benzos lt1 (7)

12
2005 DOC

• Heroin 44
• Alcohol 36
• Crack 9
• Cocaine 4
• Cannabis 1.5 (89)
• RX Opioids 1 (82)
• Benzos lt1 (9)

13
Understanding Levels of Care

• Impact of the least restrictive environment
• Right consumer in the right program at the right
  time
• What would we expect for older adults?
• Co-occurring disorders
• Co-existing disabilities
• Severe progression?
• Multiple medications?
• Should we expect to see older adults in more
  restrictive levels of care?

14
Level of Care - 2005

• 5,879 Persons received outpatient treatment
• 208 Persons received inpatient treatment (!)
• .this is not what we expected
• .why is it occurring?
• Models Managed Care

15
Rural Southern Illinois

• 18 Counties in Southern Illinois
• Total population of 55 and older
• 104,284
• Over the years 2003-2005
• 700 individuals received any kind of treatment
• .67
• SAMHSA Need, Want, Numbers Served
• What would we expect need rates to be?
• In Need of Treatment 5200 (SUD DEP)
• In Need of Treatment 10,400 (SUD SA)

16
Focus Group and Aging Task Force

• Predicted Drug Use
• Alcohol
• Benzodiazepines
• Other RX issues
• Lack of Screening
• Inaccessibility / Inappropriateness of Services
• Lack of education/preparation across allied
  health professions (Annapolis)
• The ABCs of TCE
• A Significance
• B Models
• C - Intervention (how do we do it?
• D - Staffing
• E - Evaluation

17
Hypotheses

• Older adults are an underserved population
• Older adults get into treatment when they fit
  into priority populations
• Persons over the age of sixty may not get
  treatment due to ageism/access
• Older persons and their families are not
  recognizing the potential for Rx dependence
  and/or are not seeking treatment
• Our current system is not working Screening,
  Assessment Treatment

18

• Specific Challenges or Why the c keeps me up
  at night.

19
Why special populations do not get AODA services

• Ask the APE
• Attitudes
• Programs
• Environments

20
Attitudes and Ageism

• Ageism consists of a negative bias or stereotypic
  attitude toward aging and the aged. It is
  maintained in the form of primarily negative
  stereotypes and myths concerning the older adult.
  
• Traxler (1980) outlines four factors that have
  contributed to this negative image of aging.

21
Four Factors

• Existential Anxiety
• Emphasis on Youth
• Productivity Culture
• Early research focused on the medically frail

22
Challenge Screening

• Ageism
• Lack of appropriate screens?
• Lack of willingness to screen?
• Lack of resources to screen?
• Most allied health professionals are focused in
  their specialized areas
• Physician discomfort with substance abuse topic
• - 46.6 of primary care physicians found it
  difficult to discuss prescription drug abuse
  with their patients
• - Most PCPs were unable to diagnose AODA
• - Most PCPs felt that treatment doesnt work
• (CASA, 2000)

23
Symptom Confusion

• Warning signs can be confused with or masked by
  concurrent illnesses and chronic conditions, or
  attributed to aging
• Sleep problems associated with chronic
  conditions, particularly cardiovascular disease
  and pain
• Falls attributed to poor lower body strength,
  poor balance, or vision limitations
• Anxiety attributed to psychosocial concerns
• Confusion/memory problems associated with
  Alzheimers disease or other dementias

24
Screening Instruments

• - CAGE for drug abuse
• Examined for older populations (50 and over)
• Excellent sensitivity, poor specificity
• (Hinkin et al., 2001)
• - Conjoint two-item screen
• "In the past year, have you ever drunk or used
  drugs more than you meant to?"
• "Have you felt you wanted or needed to cut down
  on your drinking or drug use in the past year?"
• Ages 50-59 Sensitivity 73.9, Specificity 84.8
• (Brown et al., 2001)
• - Drug Abuse Screening Test (DAST-10, 20, 28)

25
Solution

• Need for development of Appropriate Screening
  strategies
• Who screens?
• How do they screen?
• When do they screen?
• Need for development of Appropriate screening
  instruments
• What tools do they use?
• How do they interpret the data?

26
What is appropriate?

• Every person over 60 SHOULD be screened for
  alcohol and drug abuse as part of regular
  physical examination
• Screen or re-screen if certain physical symptoms
  are present or if the older person is undergoing
  major life transitions
• -Fred Blow
• Medical intervention has been repeatedly shown to
  be effective
• -Fingerhood, 2000

27
AODA perceptions about screening and Assessment

• Screening Could their be a problem?
  (Diagnosis)
• Assessment what is the exact nature of the
  problem (diagnosis)
• You have a role in both aspects of this process
• Someone has to screen
• Someone has to provide accurate data for
  assessments
• Someone who understands aging has to help to
  overcome the limitations in the DSM IV diagnostic
  criteria

28
Applying DSM-IV Criteria to Older Adults
Tolerance Even low intake may cause problems due to body changes
Withdrawal May not develop physiological dependence
Use in larger amounts or for longer than intended Cognitive impairment interferes with self-monitoring
Desire to cut down or control use Same across life span
Time in obtaining substance or getting over effects Negative effects with relatively low use
Activities given up or reduced May have fewer activities
Use despite knowledge of problems May not know problems are related to use
29
Some attempts at clarity

• Appropriateness measures
• Prescription drug abuse?
• What does a reasonable professional do?
• Screen
• Refer
• Support / Collaborate
• Case Manage

30
Solutions

• Age specific assessment tools
• Age specific training
• Professional Culture Model
• AKS Attitudes, Knowledge, and Skills
• Examples from Coexisting Disabilities
• Clear understanding of the impact of AODA on
  consumers potential medical and disablitiy
  issues

31
More about ask the APE

• Attitudes
• Ageism and stereotypes about substance abusers
• Attitudes about the effectiveness of
  rehabilitation
• Attitudes about the need for treatment
• Attitudes about our role as professionals
• Programs
• What is offered? Who is attending? Where is it
  help?
• Is the content an EBP?
• Is there linkage with the rest of the service
  sectors
• Are we collaborating and building in successful
  aftercare programs?
• Environments
• Is the program accessible?
• Is the environment welcoming for older adults?

32
Solutions

• Bridging the gaps through local heroes
• No wrong point of access
• Addressing ATTITUDES, knowledge and skills

33
2002 NSSATS (SAMHSA)

• Elder Specific Services were
• Typically offered in facilities owned or operated
  by hospitals, psychiatric hospitals
• More often in for profit
• Less often in substance abuse specific facilities
• More often in programs offering specialized
  programs for other groups
• These are the types of programs we have the least
  number of

34
Evidence Based Practices

• Age specific group treatment
• Supportive
• Non confrontational
• Attend to emotional needs and co-occurring
  disorders
• Depression
• Loneliness
• Loss / Grief
• Samhsa misses the boat on coexisting

35
Evidence Based Practices

• Teach skills to rebuild social support network
• Employ staff experienced in working with elders
• Link with aging, medical, and institutional
  settings
• Slower pace and age appropriate content

36
Evidence Based Practices

• Create a culture of respect
• Broad, holistic approach to treatment recognizing
  age specific psychological, social, and health
  aspects
• Adapt treatment to address gender issues

37
Some other very challenging issues

38
Older Adults RX Abuse

• Although persons 65 years of age and above
  comprise only 13 percent of the population, they
  are prescribed approximately one-third of all
  medications in the United States.
• In addition, older patients are likely to be
  prescribed more long-term prescriptions, as well
  as multiple prescriptions, which could
  potentially result in unintentional misuse.
• A large percentage of older adults also use OTC
  medicines and dietary supplements, along with
  prescription medications, which could lead to
  dangerous results.

39
Older Adults An Overview

• The elderly also are at risk for prescription
  drug abuse, in which they intentionally take
  medications that are not medically necessary.
• Because of high rates of comorbid illnesses among
  the elderly, changes in drug metabolism with age,
  and the potential for drug interactions,
  prescription and OTC drug abuse or misuse can
  have more adverse health consequences among this
  age group.

40
DASIS May,07

• Persons over 65 comprised only .6 of the TOTAL
  admissions in the U.S.
• In each year from 1995 to 2005, alcohol was the
  most frequently reported primary substance of
  abuse for admissions aged 65 or older
• Adults aged 65 to 69 made up the largest part of
  the substance abuse treatment population aged 65
  or older, increasing from 56 percent of older
  adults in treatment in 1995 to 59 percent in 2005
• Between 1995 and 2005, primary opiate admissions
  increased from 6.6 to 10.5 percent of admissions
  aged 65 or older

41
DASIS May, 07

• In 2005, this age group comprised approximately
  37 million people in the United States413
  percent of the total populationand there were
  11,300 admissions aged 65 or older to substance
  abuse treatment (Table 1)
• The admission rate for adults aged 65 or older
  was 30.7 per 100,000, which was considerably
  lower than the rate of 707.3 admissions per
  100,000 for the population younger than 65.

42
Table I (DASIS, 5-07)

• 1995 2000 2001 2002 2003 2004 2005
• Alcohol 84.7 80.4 78.7 77.8 78.5 74.4 75
  .9
• Opiates 6.6 8.2 9.2 9.2 9.3 8.8 10.5
• Sedatives 0.5 0.3 0.4 0.4 0.4 0.8 1.3
• Tranquilizers 0.7 0.8 1.2 0.9 0.8 0.6 0.6

43
Carl Erickson and the ethics of pain

• Recognizing the difference between dependence
  and dependence
• How many older adults are dependent without being
  dependent
• How can we do better at identifying misuse,
  abuse, and dependence in this population?

44
Understanding issues of onset to ensure
effectiveness

• Onset before (aging, disability, medical
  condition, loss, etc.)
• Onset during (aging, disability, medical
  condition, loss, etc.)
• Onset after (aging, disability, medical
  condition, loss, etc.)

45
Detoxification

• In Southern Illinois we have a real problem.
• Complex, life threatening, co-morbid conditions
• Lack of options

46
(No Transcript)