starting the conversation with older adults about medication and alcohol use and misuse ·...
TRANSCRIPT
Starting the Conversation with Older Adults
about Medication and Alcohol Use and Misuse
Governor’s Conference on Aging and Disability
Wednesday, December 11, 2013
Michelle Hochwert, MPH, Program Coordinator,
Rush University Medical Center Health and Aging
Kate Krajci, LCSW, Manager, Social Work Services,
Rush University Medical Center Health and Aging
Stan McCracken, Ph.D., LCSW, Senior Lecturer,
University of Chicago,
School of Social Service Administration
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The SBIRT implementation at Rush
Health and Aging was made possible
by the generous support of
The Retirement Research Foundation
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Learning Objectives
1. Gain knowledge of the current prevalence and risks of
alcohol and psychoactive medication use/misuse in
older adults
2. Understand the SBIRT (Screening, Brief Intervention
and Referral to Treatment) model
3. Become familiar with using Motivational Interviewing
techniques in your practice
4. Learn implementation strategies for SBIRT delivery
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Focus on Older Adults
• In 2010, there were 40 million people age 65 and over in the United States
–13% of the population
• The older adult population in 2030 is projected to be twice as large as in 2000
–Growing from 35 million to 72 million
–Representing nearly 20% of the total U.S. population
Administration on Aging, 2011 4
Alcohol Use
Depends on definition of at-
risk or problem drinking:
◦ 1-15% of older adults are at-risk
or problem drinkers
Differs with sampling
approach
Alcohol use problems are the
most common substance
issues for older adults
◦ Confounded by prescription,
herbal, and over-the-counter
medications
at-risk
drinking
15%
general
population
85%
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Alcohol Use By Age
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Psychoactive Medications
Psychoactive medication misuse affects a small, but significant, minority of the older adult population
◦ 25% of older adults use prescription psychoactive medications with abuse potential
Most of these drugs are obtained legally and not typically used to “get high”
Misuse and abuse of these drugs by older adults is usually unintentional
Blow and Barry, 2012 7
Illicit Drug Use
The “Baby Boomer” cohort (born 1946-
1964) is the first generation in history with
a majority having used illicit drugs at some
time in their lifetime.
Not only do the data show that lifetime
rates are higher than previous cohorts but
that patterns of illicit drug use continues
throughout life.
◦ That is, this a cohort effect, not increased use
within a cohort. 8
5.1
6.1
7.2 7 7.2
9.4
3.13.8
5.1 4.9 4.7
5.7
2.2 2.4 2.22.9 2.9
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0
1
2
3
4
5
6
7
8
9
10
2002 2003 2005 2005 2006 2007
%
Any IllicitDrug Use
Marijuana
Non-MedicalRx Drug Use
Past Year Illicit Drug Use among
Persons Aged 50 to 59: 2002-2007
Source: 2002 to 2007 SAMHSA National Surveys on Drug Use and Health (NSDUH)
National surveys of civilian, non-institutionalized adults. N=16,656 of 51,474 total. 9
Characteristics of Boomer Illicit
Drug User ~90% of past year users initiated use prior to
age 30. Initiation >50 quite rare (3%).
1 in 7 lifetime users used in past year.
Characteristics associated with continued use:
◦ Male, unmarried, early age of initiation, living in the West, low education and income, unemployed due to disability, using alcohol and tobacco in past year, episode of major depression in past year, rarely attending religious service. There were no differences related to race/ethnicity.
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Need for an Older Adult Specific
Intervention
• Substance use problems are often unrecognized and generally under-treated among older adults
• Difficult to apply standard diagnostic criteria for abuse/dependence
• Older adults are less likely to endorse key diagnostic criteria (e.g., problems related to work, social interactions)
Blow and Barry, 2012 12
Medical and Psychosocial Issues As We Age
• Loss (loved ones, employment, driving, social or economic status)
• Financial problems
• Mental health
• Transitions in housing
• Social isolation
• Caregiving for loved ones
• Complex medical problems
• Multiple medications
• Reduced mobility
• Cognitive impairment or loss
• Sensory deficits
Blow, 2007 13
Age Related Physical Changes Normal aging changes the way alcohol and medications are
absorbed, metabolized, distributed and removed from the body.
Decrease in body water
◦ May result in quicker intoxication from alcohol
◦ Certain medications are more concentrated and potent
Decrease in liver function
◦ Slower metabolism of alcohol makes it easier to become intoxicated
◦ Some medications accumulate in the body because they are metabolized too slowly
Decrease in kidney function
◦ Alcohol and medications stay in the body longer, so its effects are prolonged
Increase in body fat
◦ Medications are less immediate and more prolonged effect
Barry and Blow, 2004
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Public Health Approach:
Address AOD Use on a Continuum
None
Light Moderate
Heavy
None
Small Moderate
Severe
AOD Problems
AOD Use
Low Risk High Risk Problem Dependent
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Levels of Drinking
• 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)
WHO, 2011 16
Screening, Brief Intervention and Referral to
Treatment
1. It is brief.
2. The screening is universal.
3. One or more specific behaviors are targeted.
4. The services occur in a public health, or other
non-substance abuse treatment setting.
5. It is comprehensive.
6. Strong research and substantial experiential
evidence supports the model.
SAMHSA, 2011 17
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.
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Prescreen Questionnaire –
Targeted Questions
3) 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
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
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Screening
Screening:
◦ Comprehensive questionnaire focused on substance consumption and consequences
◦ Positive Screen
Alcohol Use: 14 or more drinks/week (men)
10 or more drinks/week (women)
2 or more binge occasions in the last 3 months (Binge = 4 or more drinks/occasion for men; 3 or more drinks/occasion for women)
Medication Use: Score based on response to 5 questions related to
consequences of use (ASSIST)
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Brief Intervention 1. Identify future goals (related to physical/mental health,
social life/relationships, finances, etc)
2. Summary of health habits
3. Psycho-education on standard drinks, level of consumption and physical changes with aging and substances
4. Types of older drinkers in U.S.
5. Psycho-education on interaction of alcohol and medications
6. Consequences of at-risk drinking or medication misuse (discuss positive and negative effects)
7. Reasons to quit or cut down
8. Agreed-upon plan
9. Handling risky situations or triggers
10.Visit summary
Barry, Blow and Schonfeld, 2004 21
What is Motivational Interviewing?
Layperson’s definition: Motivational
Interviewing is a collaborative conversation
style for strengthening a person’s own
motivation and commitment to change.
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Collaboration
Acceptance
Evocation
Spirit of MI
Miller & Rollnick, 2013
Compassion
These 4 Processes Can Help Answer the
Question – What is MI?
Settle into a helpful conversation - Engaging
Find a useful direction - Focusing
Elicit their own reasons for change - Evoking
Help plan & implement change - Planning
Miller & Rollnick, 2013 24
Core Skills of MI: OARS
Ask Open questions
Affirm (accentuate the positive)
Reflective Listening
Summarize
Informing and Advising (always with
permission)
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What is Motivational Interviewing?
Practitioner’s definition: MI is a person-
centered counseling style for addressing the
common problem of ambivalence about
change.
26
Referral To Treatment— Substance Use Disorder
Substance use disorders span a wide variety of problems arising from
substance use, and cover 11 different criteria:
Taking the substance in larger amounts or for longer than the you meant to
Wanting to cut down or stop using the substance but not managing to
Spending a lot of time getting, using, or recovering from use of the substance
Cravings and urges to use the substance
Not managing to do what you should at work, home or school, because of
substance use
Continuing to use, even when it causes problems in relationships
Giving up important social, occupational or recreational activities because of
substance use
Using substances again and again, even when it puts the you in danger
Continuing to use, even when the you know you have a physical or
psychological problem that could have been caused or made worse by the
substance
Needing more of the substance to get the effect you want (tolerance)
Development of withdrawal symptoms, which can be relieved by taking more
of the substance.
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Referral To Treatment – Substance Use Disorder
The DSMV allows clinicians to specify how severe the substance use
disorder is, depending on how many symptoms are identified.
Two or three symptoms indicate a mild substance use disorder
Four or five symptoms indicate a moderate substance use
disorder
Six or more symptoms indicate a severe substance use disorder
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Conversations about Change
Why would you want to make this change?
How might you go about it in order to succeed?
What are the best three reasons for you to do it?
How important is it for you to make this change, and
why?
After listening to the responses, give back a short
summary of what your client said, “So what do you
think you will do?”
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Role Playing
Look for the following core concepts:
◦ OARS
◦ Acceptance
◦ Collaboration
◦ Compassion
◦ Evocation
What else did you notice?
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Practice
Break into groups of 2
You will have 40 minutes to practice
Decide who will be the clinician and older
adult (see older adult script)
Take 20 minutes to introduce the Brief
Intervention and conduct it
Switch roles
We will briefly discuss your experience of
both roles after the exercise 31
Implementation Strategies:
Lessons Learned Focus on integration
“Padding” prescreen form to include additional health and
wellness questions
◦ Helps reduce the fear and stigma associated with substance abuse and
misuse
◦ Clients are more willing to discuss alcohol and/or medication use
Engage committed “Champions” to make the program a
success
◦ Acknowledge staff buy-in
◦ Train staff in substance use issues in older adulthood and motivational
interviewing
Make adaptations based on specific sites
◦ Clear and concise protocol steps
◦ Naturally imbed SBIRT questions into existing assessments 32
Questions, Comments, Case
Examples?
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Thank you!
Michelle Hochwert, MPH
Kate Krajci, LCSW
Stan McCracken, PhD, LCSW
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