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Substance Use in Older Adults:
Brief Intervention Advanced
Skill Building
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Learning Objectives
Review of at-risk drinking, problem drinking, and alcohol dependence in older adults
Review signs and symptoms of alcohol problems and medication misuse in older adults
Review Brief Interventions with older adultsPractice all steps of the F.L.O. Brief
InterventionApply F.L.O. Brief Intervention to Case StudyDiscuss and trouble-shoot implementation
issues
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Review: Is it really a problem?
Prevalence of problematic alcohol and other substance use
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Moderate or Low Risk Drinking*
Under age 65Men: up to 2 drinks per day on averageWomen: 1 drink per day on average
65 and over: Men and Women: no more than 1 drink
per day on average.Never more than 2 drinks on any
drinking day (binge drinking)
(Source: USDHHS)
4*Average rates for general population without additional risk factors
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Potential Comorbidities withAlcohol Use
Interference with metabolizing medications
Increased side effects from medicationSleep disordersPsychiatric conditions
(e.g. depression, anxiety)Increased risk of suicideDementia
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Past Month Use of Any Illicit Drug or Alcohol by Age Group: 2000
15
.9
56
.8
37
.8
12
.8
7.8
58
.3
30
.3
7.6
4.9
53
.0
21
.1
5.3
1.0
37
.5
9.4
2.3
0
10
20
30
40
50
60
70
Any IllicitDrug Use
Any AlcoholUse
"Binge"Alcohol use
HeavyAlcohol Use
18 to 25
26 to 34
35 to 54
55 or Older
Per
cen
t R
epo
rtin
g U
se i
n P
ast
Mo
nth
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Review: Issues Unique to Older Adults
Loss (people, vocation, status)
Social Isolation and loneliness
Major financial problems
Changes in housing Family concerns Burden of time
management
Complex medical problems
Multiple medications Sensory deficits Reduced mobility Cognitive impairment
or loss Impaired self-care
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Age-Related Factors that Increase Risks from Alcohol & Psychoactive Drugs in Older Persons
Physiological factors ratio body fat to lean muscle mass
blood alcohol levels clearance rate benzodiazepines
susceptibility to psychomotor effects (e.g. sedation, confusion, falls)
Other concomitants of aging morbidity medication use
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Barriers to Diagnosis
Criteria used for dx abuse (DSM-IV) less pertinent in older adultsFailure to fulfill major obligations at work, school or homeSubstance-related legal problems
Ageism Denial Access—financial, cultural, functioning
Time constraints Medication use causing or confusing
symptoms
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The Spectrum of Interventions for Older Adults
Prevention/Education
Formal Specialized Treatments
Pre-Treatment Intervention
Brief Advice
Brief Interventions
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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
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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
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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
Age-Specific Treatment Elements (continued)
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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.
(Sources: Field & Caetano, 2010; Miranda et al., 2005; Munoz & Mendelson, 2005) 14
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Alcohol Metabolism – Race as a Factor
The most common pathways of metabolism involve 2 enzymes: Alcohol Dehydrogenase (ADH) Aldehyde Dehydrogenase (ALDH)
Different people carry different variations of the ADH & ALDH enzymes.
Variations in these enzymes affect how much people drink and their risk for alcoholism.
Alcohol Acetaldehyde Acetate
H2O
CO2
ADH ALDH
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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.
(Source: NIH/NIAAA, 2007) 16
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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?
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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”
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.18
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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 IVNumber of Prescriptions Collected Annually:
21 millionNumber of Controlled Substance
Dispensers: 155,000Website: http://ag.ca.gov/bne/cures.php
SOURCE: State of California Department of Justice, Office of the Attorney General.SOURCE: State of California Department of Justice, Office of the Attorney General.
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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
SOURCE: State of California Department of Justice, Office of the Attorney General.SOURCE: State of California Department of Justice, Office of the Attorney General.
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Screening to Identify Consumers at risk for Substance Use Problems
How do we conduct the screening?
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Substance Use Problems Among Mental Health Populations
SBIRT
SBIRT
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Include prescription
misuse
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Interviewing for interconnected problems
Medical
Substa
nce
Use Mental Health
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Review: LAC DMH Assessment
Mental Health Considerations
DepressionAnxiety
AnhedoniaPsychotic Thinking
Trauma/PTSDConfusion
Memory Issues…
Medical Considerations
CirrhosisGastroenteritis
AbscessDiabetes
High Blood PressureHIV/HCV
Cardiac ProblemsTB…
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Review: LAC DMH Assessment
SUD Mental Health
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Effecting Change through the Use of Motivational Interviewing
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Ambivalence
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
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Stages of ChangeProchaska & DiClemente
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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)
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SUD
Family
Con-fusion Medical
Issues
Pain
SUD
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Conducting the Brief Intervention
FLO
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The 3 Tasks of a BI
Avoid Warnings!
F L O WFeed
back
Listen
& U
nd
erstand
Warn
Op
tion
s Exp
lored
(that’s it)
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How does it all fit together?
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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)
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The 3 Tasks of a BI
F L OFeed
back
Listen
& U
nd
erstand
Op
tion
s Exp
lored
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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…
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To avoid this…
LET GO!!!
The First Task: Feedback
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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….
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Hyp
erte
nsio
nD
iabe
tes
Canc
er
SUD
Family
Pain
Con-fusion Medical
Issue
SUD
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Feedback: Content Areas for Older Adults
Alcohol UseIllicit Drug UsePrescription Medication UseOTC Medication Use
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Always ask this question: “What role, if any, do you think
(substance) played in (problem) ?
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The First Task: Feedback
Let’s practice F: Role Play Giving Feedback Using
Completed Screening Tools
Focus the conversationGet the ball rollingGauge where the consumer is Hear their side of the story
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The 3 Tasks of a BI
F L OFeed
back
Listen
& U
nd
erstand
Op
tion
s Exp
lored
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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.
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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?
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The Second Task: Listen and Understand
Tools for Change Talk
• Pros and Cons
• Importance & Confidence Scales
• Readiness Ruler
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The Second Task: Listen and Understand
Strategies for weighing the pros and cons…•“What do you like about drinking?”•“What do you see as the downside of drinking?”•“What Else?”
Summarize both pros and cons…
“On the one hand you said..,and on the other you said….
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The Second Task: Listen and Understand
Importance/Confidence/Readiness
On a scale of 1–10… • How important is it for you to change your
drinking?• How confident are you that you can change your
drinking?• How ready are you to change your drinking?
For each ask…• Why didn’t you give it a lower number?• What would it take to raise that number?
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The Second Task: Listen & Understand
Let’s practice L: Role Play Listen & Understand
Using Completed Screening Tools Pros and Cons Importance/Confidence/Readiness ScalesDevelop DiscrepancyDig for ChangeCreate movement in Consumer’s Stage of
Readiness for Change50
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The 3 Tasks of a BI
F L OFeed
back
Listen
& U
nd
erstand
Op
tion
s Exp
lored
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What now?
What do you think you will do?
What changes are you thinking about making?
What do you see as your options?
Where do we go from here?
What happens next?
The Third Task: Options for Change
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Offer a Menu of Options
• Manage drinking/use (cut down to low-risk limits)
• Eliminate your drinking/drug use (quit)
• Never drink and drive (reduce harm)
• Utterly nothing (no change)
• Seek help (refer to treatment)
• Set up appointment with prescribing physician
The Third Task: Options for Change
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During MENUS You can also explore previous strengths, resources and successes
•“Have you stopped drinking/using drugs before?”
•“What personal strengths allowed you to do it?”
•“Who helped you and what did you do?”
•“Have you made other kinds of changes successfully in the past?”
•“How did you accomplish these things?”
The Third Task: Options for Change
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The Third Task: Options for Change
Giving Advice Without Telling Someone What to Do
Ask for Permission explicitlyThere’s something that concerns me.Would it be ok if I shared my concerns with
you?Preface advice with permission to disagree
This may or may not be helpful to you
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The Third Task: Options for Change
Giving Advice Without Telling Someone What to Do
Provide Clear Information or FeedbackWhat happens to some people is that…My recommendation would be that…
Elicit their reactionWhat do you think?What are your thoughts?
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The Third Task: Options for Change
Closing the Conversation
S E W
Summarize consumers’ views (especially the pro)
Encourage them to share their viewsWhat agreement was reached (repeat it)
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Putting it all together
Feedback
Range
Pros and ConsImportance/Confidence/Readiness Scales
Summary
Options Explored
Listen and Understand
Menu of Options58
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Case Study 1: Mr. Jackson
Anthony Jackson is a 67-year old man living alone in an apartment in a mixed-age housing project. For the past month he has been seen by a visiting nurse from your agency. The nurse was assigned upon his discharge from the hospital where he spent 4 days. He had a fall in the middle of the night prior to the hospitalization , was a bit confused on admission, and was also diagnosed of anemia in the hospital. The nurse noted the smell of alcohol during two of his visits, but Mr. Jackson did not ever appear intoxicated.
When the nurse asked him about his drinking, he said, “Oh, I don’t drink very much, really. I just seem so tired all the time and a little drink now and then makes me feel better”. He has complained about difficulty sleeping at night and was prescribed medication for sleep 6 months ago.
A homemaker is assigned to his case and visits two times/week. In addition, he has one friend who visits almost every day. Not counting his stay in the hospital, he has been confined to his apartment for the last two months.
The nurse asked you to see Mr. Jackson to assess his alcohol problems and determine what additional services are needed. 59
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Role Play for Mr. Jackson
Provide FeedbackWhat would he identify as THE problem
Listen and UnderstandExplore readiness for change
Explore OptionWhat is he willing and able to do right now?
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Case Study 2: Mrs. Alvarez
Maria Alvarez is a 70 year old who is depressed and uses a sedative (lorazepam 1mg) most nights
Sometimes she takes two pills Osteoarthitis of knees and uses acetaminophen
and codeine Has fallen twice in last month Widowed for 3 months Wants to get more lorazepam to help her sleep
better
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Role Play for Mrs. Alvarez
Provide FeedbackWhat would he identify as THE problem
Listen and UnderstandExplore readiness for change
Explore OptionWhat is he willing and able to do right now?
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Important Internet Sites
[email protected]://sbirt.samhsa.gov/about.htmhttp://sbirt.samhsa.gov/trauma.htmhttp://www.saem.org/SAEMDNN/Portals/
0/IGroups/PublicHealth/sbirt2008/SBIRTResourceManual051608.doc
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