Screening and Brief Interven0on for Substance Use in Older Adults Gerontology Grand Rounds May 6, 2016 Kate Krajci, MA, LCSW Rush University Medical Center Health and Aging Coordinator, Mental Health Services Ms. Krajci has disclosed that there is no actual or poten0al conflict of interest in regards to this presenta0on The planners, editors, faculty and reviewers of this ac0vity have no relevant financial rela0onships to disclose. This presenta0on was created without any commercial support.
Transcript
Screening and Brief Interven0on for Substance Use in Older Adults
Gerontology Grand Rounds May 6, 2016
Kate Krajci, MA, LCSW Rush University Medical Center Health and Aging
Coordinator, Mental Health Services
Ms. Krajci has disclosed that there is no actual or poten0al conflict of interest in regards to this presenta0on
The planners, editors, faculty and reviewers of this ac0vity have no relevant financial rela0onships
to disclose. This presenta0on was created without any commercial support.
Learning Objec0ves
At the conclusion of this course par0cipants will be able to • Recognize the biopsychosocial aspects of older adulthood that impact substance use
• Assess an older pa0ent's level of risk for nega0ve consequences as a result of their substance use
• U0lize the Screening Brief Interven0on and Referral to Treatment (SBIRT) model during pa0ent care
To obtain credit you must
– Be present for the en,re session – Complete an evalua,on form – Return the evalua,on form to staff
Cer0ficate will be sent to you by e-‐mail upon request. This course is eligible for 1 (one) AMA PRA Category 1 Credit™ Accredita0on and Designa0on Statement: Rush University Medical Center is accredited by the
Accredita0on Council for Con0nuing Medical Educa0on to provide con0nuing medical educa0on for physicians.
Rush University Medical Center designates this live ac0vity for a maximum of 1 AMA PRA Category 1
Credit(s)TM Physicians should claim only credit commensurate with the extent of their par0cipa0on in the ac0vity.
Rush University is accredited as a provider of con0nuing nursing educa0on by the American Nurses
Creden0aling Center's Commission on Accredita0on. Rush University is an approved provider for physical therapy (216.000272), occupa0onal therapy,
respiratory therapy, social work (159.001203), nutri0on, speech-‐audiology, and psychology by the Illinois Department of Professional Regula0on. Rush University designates this live ac0vity for (1) Con0nuing Educa0on credit(s).
Why Do Older Adults Use?
ENHANCEMENT SOCIALIZATION COPING
(Gilson et al., 2013; Sacco et al., 2015; Burruss, Sacco, & Smith, 2015; Aira, Har0kainen, & Sulkava, 2008)
HEALTH/ MEDICINE? CONTINUITY?
Medical and Psychosocial Issues as We Age
• Loss (roles, driving, social or economic status, loved ones) • Financial problems • Mental health • Transi0ons in housing • Social isola0on • Caregiving • Complex medical problems • Mul0ple medica0ons • Reduced mobility • Cogni0ve impairment or loss • Sensory deficits
The Importance of Cohort
• Impacts what is norma0ve • Informs client values
• Views on substance use and mental health in general
• Percep0ons about coping strategies and treatment – Par0cularly impacts engagement
• Tendency of older cohorts to have difficulty iden0fying feelings; soma0ze
Age Related Physical Changes
Normal aging changes the way alcohol and medica,ons are absorbed, metabolized, distributed and removed from the body.
• Decrease in body water – May result in quicker intoxica0on from alcohol – Certain medica0ons are more concentrated and potent
• Decrease in liver func0on – Slower metabolism of alcohol makes it easier to become intoxicated – Some medica0ons accumulate in the body because they are
metabolized too slowly • Decrease in kidney func0on
– Alcohol and medica0ons stay in the body longer, so its effects are prolonged
• Increase in body fat – Medica0ons are less immediate and more prolonged effect
Typical Substances Used by Older Adults
• Alcohol
• Psychoac0ve medica0ons
• Illicit drugs
Alcohol Use By Age, 2013
(SAMHSA, 2014)
Alcohol Use
• Depends on defini0on 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 prescrip0on, herbal, and over-‐the-‐counter medica0ons
Psychoac0ve Medica0ons
• Psychoac0ve medica0on misuse affects a small, but significant, minority of the older adult popula0on – Up to 25% of older adults use prescrip0on psychoac0ve medica0ons with abuse poten0al
• 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 uninten0onal (at present)
Opioid Pain Medica0ons
Medica,ons for Pain: Generic Name Brand Name(s)
buprenorphine Butrans Skin Patch, Stadol Nasal Spray codeine and acetaminophen Tylenol #2, Tylenol #3, Tylenol #4, Capital with
codeine codeine and aspirin Empirin with codeine codeine, butalbital, aspirin, caffeine Fiorinal with codeine fentanyl lozenge Ac0q Lozenge /Lollipop fentanyl skin patch Duragesic Skin Patches hydrocodone and acetaminophen Vicodin, Vicodin ES, Lorcet, Lorcet Plus, Lortab,
Anexsia, Maxidone, Norco, Zamicet, Zydone
hydrocodone and aspirin Panasal 5/500, Lortab ASA hydromorphone Dilaudid, Dilaudid HP, Exalgo meperidine Demerol methodone Dolophine morphine MS Con0n, Kadian, Atramorph, Avinza, MS IR, Roxanol oxycodone immediate release OxyIR, Endocodone oxycodone controlled release OxyCon0n oxycodone and acetaminophen Percocet, Tylox, Roxicet, Endocet, oxycodone and aspirin Percodan, Roxipirin, Endodan pentazocine Talwin tramadol Rybix, Ryzolt, Ultram
Benzodiazepines
Medica,ons for Anxiety/Sleep
Generic Name Brand Name(s)
Alprazolam Xanax
Clorazepate Tranxene
Diazepam Valium
Estazolam ProSom
Flurazepam Dalmane
Lorazepam A0van
Oxazepam Serax
Quazepam Doral
Temazepam Restoril
Triazolam Halcion
Illicit Drug Use: 2002-‐2013
(SAMHSA, 2014)
Who is at Risk?
• Alcohol – Young-‐Old – Male – ETOH History – Never married/Divorced – Substance related coping
– Financial Resources – Friends who drink
• Prescrip0on Drugs – Health problems – Female – ETOH Use
• Illicit Drugs – Younger old – Significant disability – Male
Per Na0onal Ins0tute on Alcohol Abuse and Alcoholism
• Adults over age 65 who are healthy and do not take medica0ons – No more than 7 standard drinks per week – On any drinking day, no more than 3 standard drinks
• Abs0nence recommended for individuals with medical condi0ons or those with mul0ple medica0ons
Guidelines for Other Substances
• Prescrip0on medica0ons – No more than as prescribed
• Medica0ons with abuse poten0al and/or significant alcohol interac0ons – Benzodiazepines – Other seda0ves – Opioid analgesics – Some an0convulsants – Some psychotropics – Some an0depressants – Some barbiturates
• Illicit drugs
– Abstain – Medical marijuana?
DAST-‐10 Ques0onnaire
DAST-‐10 Interpreta0on
General Risk Guidelines
• Low – No use – Use within “safe” guidelines – No combina0on of alcohol and psychoac0ve meds
• Moderate – Exceeds daily or weekly limits – Any combina0on of alcohol and psychoac0ve med use
• Higher – Exceeds daily and weekly limits – Any combina0on of alcohol and psychoac0ve med use – Drank more than meant to – Thought of cuwng down – Intoxicated when could have harmed self/others
Screening Brief Interven0on and Referral to Treatment (SBIRT)
A Model for Screening and Psychoeduca;on
SBIRT Goal
• Iden0fy and effec0vely intervene with those who are at moderate or high risk for psychosocial or health care problems related to their substance use
SBIRT Model
• Screening: Universal screening for quickly assessing use and severity of substance use, misuse, and abuse
• Brief Interven0on: Brief mo0va0onal and awareness-‐raising interven0on given to pa0ents at risk for substance use issues
• Referral to Treatment: Referrals to specialty care for pa0ents with substance use disorders – Treatment may consist of brief treatment or specialty AOD (alcohol and other drugs) treatment
1. www.integra,on.samhsa.gov/clinical-‐prac,ce/SBIRT 2. Medicare Learning Network ICN904084 October 2015
SBIRT for Older Adults
Barry, Blow and Schonfeld (2004) • Alcohol • Psychoac0ve medica0ons
• It is brief • It is a screening and educa0on interven0on
– Not formal treatment • It can be performed by anyone, regardless of educa0onal background/licensure
• It views alcohol and drug use on a con0nuum – as opposed to the tradi0onal dichotomous view
• It can be used to mo0vate a person to consider changing their substance use behaviors – Pa0ent-‐centered approach as opposed to direc0ve/advice giving
Collabora,on
Evoca,on
Spirit of MI
Miller & Rollnick, 2013
Compassion
Mo0va0onal Interviewing
Acceptance
Screening
• Screen everyone • Use a validated tool (AUDIT, DAST-‐10) • Demonstrate nonjudgmental, empathic verbal and nonverbal behaviors
• Screen both alcohol and drug use including prescrip0on drugs and tobacco
• Explore each substance; many pa0ents use more than one
Older Adult Screening
• During the past 3 months, have you used any of these prescrip0on medica0ons for pain for problems like back pain, muscle pain, headaches, arthri0s, fibromyalgia, etc.? – Use targeted medica0on list to determine posi0ve response
• During the past 3 months, have you used any prescrip0on medica0ons to help you fall asleep or for anxiety or for your nerves or feeling agitated? – Use targeted medica0on list to determine posi0ve response
• 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 to any of these ques,ons means further screening is needed
Pa0ent asked to complete AUDIT and/or DAST
Brief Interven0on
• Prac00oner reviews results of screening tool and delivers brief interven0on.
Older Adult Brief Interven0on
Ten page workbook 1. Iden0fy future goals (related to physical/mental health, social life/
rela0onships, finances, etc.) 2. Summary of health habits 3. Psycho-‐educa0on on standard drinks, level of consump0on and
physical changes with aging and substances 4. Types of older drinkers in U.S. 5. Psycho-‐educa0on on interac0on of alcohol and medica0ons 6. Consequences of at-‐risk drinking or medica0on misuse (discuss
posi0ve and nega0ve effects) 7. Reasons to quit or cut down 8. Agreed-‐upon plan 9. Handling risky situa0ons or triggers 10. Visit summary
Brief Interven0on Step #1
• Raise the Subject: – “Would it be ok with you if we discussed the results of the screening you filled out today?”
Asking permission makes it a collabora;ve process
Brief Interven0on Step #2
• Provide feedback and process response: – “In reviewing your screening results, I no0ced that you are drinking (or using drugs) at a level that may be harmful to your health.”
– “How do you feel about your alcohol (or drug) use?”
Providing the informa;on and then elici;ng the person’s own views allows you to collaborate and to
gauge person’s mo;va;on level
Brief Interven0on Step #3
• Explore and enhance mo0va0on to change: – “Would it be alright if I asked you a few more ques0ons about your alcohol (or drug) use?”
– “On a scale from 0 to 10, how mo0vated are you to cut down or abstain from alcohol (or drug) use?”
Brief Interven0on Step #3 cont.
• If pa0ent responds with a number other than “0” – “Why that number (their answer) and not a ___
(lower number)?” – The pa;ent’s reply usually contains reasons for change
• If the pa0ent responds with “0” – “Thanks for being open to talk about this. May I ask one more ques0on before we con0nue with your visit?”
– “If you were to reduce or abstain from substance use, in what ways would your life poten0ally change (and/or improve)?”
Brief Interven0on Step #4
• Nego0ate a change plan • Pa0ent is ready to talk further about change
– “What changes would you like to make?” – “How could you go about making those changes in order to be successful?”
• Pa0ent is not ready to talk about change – “What are some warning signs that you could look out for that would indicate your alcohol (or drug use) has become problema0c?”
Referral to Treatment
• SBIRT is not formal substance use treatment
• Refer to treatment when substance use disorder is present or client desired
• Referral can be to one’s own services or external partners – Ac0ve referral – Resources for self-‐directed or future use
Referral to Treatment
• The pa0ent is ready to seek treatment – “Treatment services are available in your area. Would it be ok if I provided you with a referral (and/or helped you schedule an ini0al consult)?”
• The pa0ent is not ready to seek treatment: – “Would it be ok if I gave you some resources you could use if you decide to make a change in the future?”
SBIRT at Rush Health and Aging (RHA)
• 2-‐year grant from The Re0rement Research Founda0on (2011-‐2013)
• Goals: – Understand best prac0ces and how to integrate SBIRT into services – Iden0fy individuals age 60 and older at risk for alcohol and/or psychoac0ve
medica0on misuse and provide appropriate interven0on • Universally screen clients in the following sewngs:
– Rush Genera0ons events – RHA Social Work Services – RHA Transi0onal Care Services – Rush University Senior Care – City of Chicago Department of Family and Support Services Senior Centers – RUMC Emergency Department
Results
4,352 Total Prescreened
2,593 (60%) Prescreened posi0vely
1,415 denied further follow-‐
up
1,178 agreed to further follow-‐up
170 (14%) Screened posi0vely
66 (38%) Received Brief Interven0on
671 (57%) Screened nega0vely
91 (8%) Refused screening
246 (21%) Unable to screen
1,759 (40%) Prescreened nega0vely
Referral to Treatment = 1
SBIRT at Rush
Rush University Life Course SBIRT Training • SAMHSA grant • Aims to train medical residents and nursing students to
provide SBIRT services – Focus on training throughout the College of Nursing and for Residents in Pediatrics, Internal Medicine, and Psychiatry
– SBIRT training to replace the current substance abuse curriculum in each department
– Life-‐course perspec0ve on training aims to make SBIRT services available to pa0ents of all ages.
• Training began in mid-‐January 2015 – Didac0c lectures – Interac0ve internet-‐based program
The SBIRT for Older Adults implementa;on at Rush Health and Aging was made possible by
the generous support of The Re;rement Research Founda;on
References
• Administra0on on Aging, U.S. Department of Health and Human Services (2011). A Profile of Older Americans: 2011. htp://www.aoa.gov/aoaroot/aging_sta0s0cs/Profile/2011/docs/2011profile.pdf
• Aira, M., Har0kainen, S., & Sulkava, R. (2008). Drinking alcohol for medicinal purposes by people aged over 75: a community-‐based interview study. Family prac;ce, 25(6), 445-‐449.
• Babor TF, de la Fuente JR, Saunders J, Grant M. AUDIT The Alcohol Use Disorders Iden0fica0on Test: Guidelines for Use in Primary Health Care. WHO/MNH/DAT 89.4. Geneva: World Health Organiza0on;1989.
• Barry, K.L., Blow, F.C., Schonfeld, L. (2004). Health promo0on workbook for older adults (adapted to include medica0on misuse).
• Barry, K.L., Oslin, D.W, & Blow, F.C. (2001). Alcohol Problems in Older Adults: Preven0on and Management. New York, NY: Springer Publishing Company, Inc.
• Blazer, D. G., & Wu, L. T. (2009). The epidemiology of substance use and disorders among middle aged and elderly community adults: Na0onal Survey on Drug Use and Health (NSDUH). American Journal of Geriatric Psychiatry, 17(3), 237-‐245. doi: 10.1097/JGP.0b013e318190b8ef
References
• Blazer, D. G., & Wu, L. (2009). The epidemiology of at risk and binge drinking among middle-‐aged and elderly community adults: Na0onal Survey on Drug Use and Health. American Journal of Psychiatry, 166, 1162-‐1169.
• Blazer, D. G., & Wu, L.T. (2009). Nonprescrip0on Use of Pain Relievers by Middle-‐Aged and Elderly Community-‐Living Adults: Na0onal Survey on Drug Use and Health. Journal of the American Geriatrics Society, 57(7), 1252-‐1257.
• Blow, F.C., Barry, K.L. (2011). Substance use disorders among older adults. Presented at SAMHSA/Substance Abuse Preven0on Older Americans Technical Assistance Center Training, Chicago, IL.
• Blow, F.C., Barry, K.L (2012). Alcohol and Substance Misuse in Older Adults. Curr Psychiatry Rep. 12, 310-‐19.
• Burruss, K., Sacco, P., & Smith, C. A. (2015). Understanding older adults' awtudes and beliefs about drinking: perspec0ves of residents in congregate living. Ageing & Society, 35(9), 1889-‐1904. doi: 10.1017/S0144686x14000671
References
• Gilson, K.-‐M., Bryant, C., Bei, B., Komi0, A., Jackson, H., & Judd, F. (2013). Valida0on of the Drinking Mo0ves Ques0onnaire (DMQ) in older adults. Addic;ve Behaviors, 38(5), 2196-‐2202. doi: htp://dx.doi.org/10.1016/j.addbeh.2013.01.021
• Merrick, E. L., Horgan, C. M., Hodgkin, D., Garnick, D. W., Houghton, S. F., Panas, L., Blow, F. C. (2008). Unhealthy drinking paterns in older adults: prevalence and associated characteris0cs. Journal of the American Geriatrics Society, 56(2), 214-‐223.
• Miller, W. R., & Rollnick, S. (2013). Mo0va0onal interviewing–Helping People Change, 3rd edn. New York, NY: The Guilford Press.
• Na0onal Ins0tute on Alcohol Abuse and Alcoholism. (1995). The physicians' guide to helping pa0ents with alcohol problems. Rockville, MD: U. S. Department of Health and Social Services, Public Health Service, Na0onal Ins0tutes of Health, NIAAA.
• Sacco, P., Bucholz, K. K., & Spitznagel, E. L. (2009). Alcohol use among older adults in the Na0onal Epidemiologic Survey on Alcohol and Related Condi0ons: A latent class analysis. Journal of Studies on Alcohol and Drugs, 70(6), 829-‐838.
References
• Sacco, P., Burruss, K., Smith, C. A., Kuerbis, A., Harrington, D., Moore, A. A., & Resnick, B. (2015). Drinking behavior among older adults at a con0nuing care re0rement community: affec0ve and mo0va0onal influences. Aging Mental Health, 19(3), 279-‐289. doi: 10.1080/13607863.2014.933307
• Schonfeld, L, King-‐Kallimanis, BL, Duchene, DM, Etheridge, RL, Herrera, JR, Barry, KL, Lynn. N. (2010). Screening and brief interven0on for substance misuse among older adults: the Florida BRITE project. Am J Public Health. 100(1):108-‐14.
• Substance Abuse and Mental Health Services Administra0on. (1998). Center for Substance Abuse Treatment: Substance Abuse Among Older Adults: Treatment Improvement Protocol (TIP) Series, No. 26. HHS Publica0on No. (SMA)12-‐3918. Rockville, MD. htp://store.samhsa.gov/product/TIP-‐26-‐Substance-‐Abuse-‐Among-‐Older-‐Adults/SMA12-‐3918
References
• Substance Abuse and Mental Health Administra0on. (2011). White Paper on Screening, Brief Interven0on and Referral to Treatment (SBIRT) in Behavioral Healthcare. htp://www.samhsa.gov/preven0on/SBIRT/SBIRTwhitepaper.pdf
• Substance Abuse and Mental Health Services Administra0on. (2014). Results from the 2013 Na0onal Survey on Drug Use and Health: Summary of Na0onal Findings, NSDUH Series H-‐48, HHS Publica0on No. (SMA) 14-‐4863. Rockville, MD. htp://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf
• Wray, L. A., Alwin, D. F., & McCammon, R. J. (2005). Social status and risky health behaviors: results from the health and re0rement study. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 60 (Special Issue 2), S85-‐S92.
• Wu, L.-‐T., & Blazer, D. G. (2011). Illicit and Nonmedical Drug Use Among Older Adults: A Review. Journal of Aging and Health, 23(3), 481-‐504. doi: 10.1177/0898264310386224
