Larry Schonfeld, Ph.D . Interim Executive Director, Florida Mental Health Institute

1. The Florida BRITE Project: Screening and Brief Interventions for Older Adult at Risk of Substance Misuse Larry Schonfeld, Ph.D. Interim Executive Director, Florida Mental Health Institute schonfel@usf.edu http://BRITE.fmhi.usf.edu Presented at the FADAA/FCCMH Conference Aug. 7, 2013

2. Today’s presentation • Overview of substance abuse issues and treatment for older adults • Presentation on the Florida BRITE Project • Pilot project funded by Florida DCF (2004-07) • Expansion through national SBIRT initiative funded by SAMHSA/CSAT $14 million grant • Lessons learned from conducting SBIRT in Florida

3. Alcohol and Illicit Drugs

4. National Household Survey: % Adults Aged 18+ Reporting past month use of alcohol/drugs by age group in 2000 (NHSDA, 2001) 12% of 55+ age group are either binge or heavy alcohol users Percent Reporting Use in Past Month

5. U.S. Substance Abuse Treatment Admissions in 2006Trunzo & Henderson (Gerontological Society of America presentation 2008) NALL ADMISSIONS= 1,798,000 NADMISSIONS OVER 50= 189,000 35-44 yrs27% 45-49 yrs11% 50-54 yrs: 6% 50+ yrs11% 25-34 yrs25% 55-59 yrs: 3% <18 yrs8% 18-24 yrs18% 60-64 yrs: 1% 65+ yrs: <1%

6. Admissions Under 50 and Age 50+by Primary Substance * Excludes methadone

7. Older adults are often “hidden” alcohol abusers • Fewer indicators compared to younger adults: • DUI’s • Work-related problems • Marital Problems • Peer pressure • In contrast, older adults are more likely to be isolated, drinking alone • More likely to identified in healthcare settings as secondary problem to the reason for admissions to ER, primary care.

8. Alcohol Affects the Elderly Differently • Induced impairment increases with age due to: • Higher body fat content, less lean muscle mass, and reduced water volume (alcohol is water soluble) • Decreased absorption rate in gastrointestinal system due to decreased blood flow • Affects alcohol’s distribution within the body • Affects alcohol’s elimination • Results in increased sensitivity and decreased tolerance to alcohol and drugs in older individuals • Drugs and alcohol remain in the body longer and at higher rates of concentration

9. Medication misuse

10. Older Adults: Adverse Drugs Events • People age 65+ make up 12% of U.S. Population, but • account for 34% of all prescription medication use • account for 30% of all over-the-counter medication use • Annually, 1 in 3 adults ages 65+ experience adverse drug events • Susceptible to problems due to altered: • pharmacodynamics (how the drug affects individual) • pharmacokinetics (how the body absorbs, distributes, metabolizes, eliminates a drug)

11. Misuse in older people is often unintentional(Glantz, 1981; Schwartz et al., 1962). • Difficulty of regimen (too many meds to keep track) • Memory issues • Adverse drug reactions • Synergistic effects of multiple drugs • Cost & Access • Multiple prescribing physicians • Lack of understanding of the instructions • They are less likely to ask physician or pharmacist questions or receive written information about prescriptions (Olins, 1985). • Use of/interactions with OTC meds (Coons et al., 1988) • Early discontinuation of medications

12. Medications & Alcohol Use • Use of drugs in combination with alcohol carries greater risk: • hepatoxicity with acetaminophen • increased lithium toxicity • enhanced CNS depression for those prescribed tricyclic antidepressants • death - for those taking benzodiazepines and barbiturates

13. Treatment Recommendations

14. Expert panel recommendations for screening and treating the older adult: SAMHSA/CSAT Treatment Improvement Protocol (TIP) #26

15. TIP#26 Expert Panel Recommendations • Age-specific, group treatment that is supportive, not confrontational • Attend to depression, loneliness; address losses. • Teach skills to rebuild social support network • Employ staff experienced in working with elders • Link with aging, medical, institutional settings • Content should be age-appropriate and offered at a slower pace. • Create a “culture of respect” for older clients • Broad, holistic approach recognizing age-specific psychological, social & health aspects. • Adapt treatment as needed to address gender issues

16. FMHI - developed group treatment Relapse prevention, Cognitive-behavioral/Self-management skills • Gerontology Alcohol Project (1979-1981) –successfully treated late onset, older alcohol abusers and improving social support, mood (Dupree, Broskowski & Schonfeld, 1984) • Substance Abuse Program for Elderly (1986-1994) extended GAP approach to all older adults irrespective of age of onset and type of substance (Schonfeld & Dupree, 1991; Schonfeld , et al., 1995; Schonfeld & Dupree, 1995; 1998) • Replications - programs in other states based on our model • Chelsea Arbor Older Adult Recovery Center in Ann Arbor, Michigan (1990’s) • GET SMART Program (West Los Angeles VA Hospital; 2000-2011) (Schonfeld et al. 2000) • Zablocki VA Medical Center (Milwaukee, 2006) • Older Adult Substance Abuse Treatment Program – Tennessee (2005 - 2008) (Outlaw et al. 2012)

17. The Result: A 16-session curriculum manual for conducting brief treatment (Dupree & Schonfeld, CSAT, 2005) http://kap.samhsa.gov/products/manuals/pdfs/substanceabuserelapse.pdf

18. A Three Stage CBT/Self-Management Treatment Approach(Dupree & Schonfeld, SAMHSA/CSAT manual, 2005) • For each person begin by identifying his/her antecedents and consequences for substance use to create an individualized “substance use behavior chain” using the Substance Abuse Profile for the Elderly • Teach the person how to identify the components of that chain so that he or she can understand the high risk situations for alcohol or drug use. • Teach specific skills to address these high risk situations to prevent relapse.

19. A Three Stage CBT/Self-Management Treatment Approach(Dupree & Schonfeld, SAMHSA/CSAT manual, 2005) • For each person begin by identifying his/her antecedents and consequences for substance use to create an individualized “substance use behavior chain” using the Substance Abuse Profile for the Elderly • Teach the person how to identify the components of that chain so that he or she can understand the high risk situations for alcohol or drug use. • Teach specific skills to address these high risk situations to prevent relapse.

20. However, a change was needed • In Florida, the actions of several task forces and Florida Coalition on Optimal MH and Aging shaped a new agenda: • identified elders as an underserved population • Policy changes identifying them as a target pop. • Despite older adults’ positive outcomes in treatment programs, relatively few actually entered treatment. • In 2000, less than 2% of adults in Florida’s treatment for substance abuse problems, were age 60+ despite the fact that they represent about 24% of the population

21. SBIRT A national initiative for screening, brief intervention, and referral to treatment

22. Substance Abuse Severity and Level of Care Adapted from the SAMHSA TIP #34 (1999) and Institute of Medicine (1990) None Substance Abuse Severity Mild Moderate Severe Specialized Treatment Brief Intervention Primary Prevention

23. Screening and Brief InterventionsEarly Examples • Used within Emergency Departments • Bernstein E, Bernstein J, Levenson S: Project ASSERT: An ED-based intervention to increase access to primary care, preventive services, and the substance abuse treatment system. Ann Emerg Med , 1997; 30:181-189. • Used within primary care practices as “Brief Physician Advice” for older adults • Fleming, MF., Manwell, LB, Barry, KL, Adams, W, & Stauffacher, EA Brief physician advice for alcohol problems in older adults: A randomized community-based trial. J FamPract; 1999 48(5): 378-84

24. http://sbirt.samhsa.gov/about.htm

25. SBIRT Core Components

26. Motivational Interviewing (MI) • People who “screen positive” for substance misuse may be reluctant to seek help and are often ambivalent about making a decision to change behavior • Confrontation & labeling will produce “resistance” or the person will be labeled as being “in denial.” Resistance can also be raised prior to treatment (e.g., spouses, employers, coercion from the legal system). • With MI, resistance is viewed as a reaction to the in-session behavior of the counselor.

27. Key Principles of Motivational Interviewing • Avoiding labeling and confrontation • Enhance Self-efficacy (confidence in one’s coping strategies) • Enhance internal-attribution • Roll with resistance – use it to further explore client’s views • Use cognitive dissonance as a tool – the client is asked to provide more and more evidence that problem(s) exist

28. Videos – examples of Brief Intervention • Boston University: BNI-ART Institute http://www.bu.edu/bniart/sbirt-in-health-care/sbirt-educational-materials/sbirt-videos/ • Provide scenarios for using screening and brief intervention during the delivery of healthcare. • Videos illustrate the use of MI techniques

29. The Pilot: Florida BRITE Project 2004-07 (BRief Intervention and Treatment for Elders) 3,497 people ages 60+ screened and/or served Schonfeld et al (2010) Am. J. of Public Health Four sites in pilot project Broward County Elderly & Veterans Services = 2,116 Gulf Coast Jewish Family Services (Pinellas) = 638 Coastal Behavioral Health Care (Sarasota) = 426 Center for Drug Free Living (Orange) = 317 Most (67%) identified via BRITE outreach & prescreening at health fairs, senior centers, and via referral network. Positive prescreens invited to participate in BI Most received multiple sessions of brief intervention

30. The Florida BRITE ProjectPilot Project (2004-2007) Center for Drug Free Living – added in 2005 Gulf Coast Jewish Family Services Orlando Broward County Elderly & Veterans Services Coastal Behavioral HealthCare

31. The Pilot: Florida BRITE Project 2004-07 (BRief Intervention and Treatment for Elders) Purpose: to identify people ages 60+ who misused or were at risk for misusing: Alcohol Prescription medications Over-the-counter (OTC) medications Illicit drugs Depression and suicide risk also screened by BRITE Depression - most frequent antecedent to substance abuse in elders (Dupree et al., 1984; Schonfeld & Dupree, 1991, Schonfeld et al., 2000) Elders - highest rate of suicides among all age-groups

32. The Pilot: Florida BRITE Project 2004-07 (BRief Intervention and Treatment for Elders) 10% - referred for potential alcohol problems 69% of all 3,497 screened were drinkers 18% of drinkers had 3 or more drinks on a drinking day 26% referred for prescription misuse 32% needed education/assistance on proper med use 17% could not recall purpose of 1 or more meds 11% reported wrong amount for 1 or more meds 8% took medications for wrong reasons/symptom 8% referred for potential OTC misuse 1% referred for illicit drug use

33. The Pilot: Florida BRITE Project 2004-07 (BRief Intervention and Treatment for Elders) • Depression (Short-Geriatric Depression Scale) • 64% of all referrals were for depression • SGDS scores: 25% moderate, 10% serious • Among those referred for reasons other than depression: • SGDS: 18% moderate, 4% serious • Suicide Risk: Only 0.6% referred for suicide risk • But 13% contemplated suicide at some time in the past (most of these within the past year)

34. The Pilot: Outcomes 2004-07Significant improvement at D/C and Follow-ups • Significant decrease in alcohol scores at D/C (n=102) • No further changes at 30 day follow-ups (n =60) • Prescription Medications: a 32% decrease in “flags” at D/C over the number at baseline (n=180) • OTCs: 23 of 24 people flagged at baseline, no flag at D/C • Illicit drugs: 75% of those with flags at baseline (n=12) showed no flag at D/C • Significant decrease1 in depression scores at D/C (n=323) • Further decrease at 30 day follow-up (n = 203)

35. From Pilot Project to Federal Grant

36. State SBIRT Grants Through 2010

37. Florida BRITE Project – the SBIRT Grant:(BRief Intervention and Treatment for Elders) $14 million SAMHSA/CSAT grant to Florida Five years: Oct. 2006-Sept. 2011 Funding mostly went towards direct services Large scale screening in medical, other settings Majority of people are expected to screen negative (receive Screening & Feedback only) Positive screens were typically followed by 1 session of Brief Intervention People could receive 5 BI or 12 BT sessions Referred out for detox, residential care, etc.

38. 30 provider agencies contracted to conduct screening in over 70 sites in 18 counties

39. SBIRT Approach • Universal prescreening (7 items: alcohol, drugs, medications, depressive symptoms) • Full screen (ASSIST) for those with positive prescreens • Level of risk dictates type of service: • Screening & Feedback (SF) for negative screens • Brief Intervention (BI) for moderate risk • Brief Treatment (BT) for moderate to high risk • Referral to Treatment (RT) - high risk/problem use

40. Prescreen – Part 1

41. Prescreen – Part 2

42. Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)World Health Organization (WHO) • An interview style screen administered only if there is a positive prescreen • The ASSIST was developed to help healthcare professionals detect and manage substance use • Scores provide a “level of risk” for alcohol or for other substances and type of service that follows: • Low risk = screening & feedback (SF) about results • Moderate risk = indicates the need for brief intervention (BI) using motivational interviewing • Moderate to High Risk = Brief treatment (BT) • High Risk = Referral to treatment

43. Florida BRITE Project Reasons for Positive Screens at Baseline (n=8,165)

44. BRITE Services Received • For those who screened positive and agreed to receive services: • BI n = 6,338 • BT n = 675 • RT n = 899

48. Sustainability of SBIRT • Nationally, a number of actions and events are fostering SBIRT’s sustainability: • The BIG (Brief Intervention Group) Initiative for EAP programs and Hospitals cross North America • American College of Surgeons’ Committee on Trauma requires SBIRT in Level I & II trauma centers • Billing codes for SBIRT available to providers • Local adoption of BRITE as a model in Florida and nationally (to bill through Older Americans Act $s)

49. Billing codes for SBI were adopted Feb. 2008 • Reimbursement for screening and brief intervention is available through commercial insurance CPT codes, Medicare G codes, and Medicaid HCPCS codes • Florida has not approved Medicaid codes for billing purposes