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

1. Substance Abuse/Misuse and Older Adults Cori Robin, LCSWHealth and AgingRush University Medical CenterIllinois Elder Rights ConferenceJuly 12, 2012 Session T14

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

3. Objectives • 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

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

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

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

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)

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

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

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

11. Prescription Medication Use (Cont) • 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

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

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

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

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

16. Unique Aspects with Older Adults 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

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

18. Barriers to Identification • 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

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

20. Standard Drink

21. SBIRT Intervention 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.

22. Prescreen Questions 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?

23. Screening • 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

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

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

26. When Intervening with Older Adults… • 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

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