Substance Use in Older Adults:
Brief Intervention Advanced
Skill Building
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 adults
 Practice all steps of the F.L.O. Brief
Intervention
 Apply F.L.O. Brief Intervention to Case Study
 Discuss and trouble-shoot implementation
issues
2
Review: Is it really a problem?
Prevalence of problematic alcohol
and other substance use
Moderate or Low Risk Drinking*
(Source: USDHHS)
 Under
age 65
 Men:
up to 2 drinks per day on average
 Women: 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)
*Average rates for general population without additional risk factors
4
Potential Comorbidities with
Alcohol Use
Interference with metabolizing
medications
 Increased side effects from medication
 Sleep disorders
 Psychiatric conditions
(e.g. depression, anxiety)
 Increased risk of suicide
 Dementia

Past Month Use of Any Illicit Drug
or Alcohol by Age Group: 2000
56.8
58.3
53.0
60
18 to 25
26 to 34
35 to 54
30.3
40
7.6
5.3
2.3
12.8
9.4
7.8
4.9
1.0
10
21.1
30
20
55 or Older
37.8
37.5
50
15.9
Percent Reporting Use in Past Month
70
0
Any Illicit
Drug Use
Any Alcohol
Use
"Binge"
Alcohol use
Heavy
Alcohol Use
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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
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
 morbidity
 medication use
of aging
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Barriers to Diagnosis

Criteria used for dx abuse (DSM-IV) less
pertinent in older adults
 Failure
to fulfill major obligations at work, school or home
 Substance-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
A
B
C
Not
Light-Moderate Heavy
Drinking
Drinking
Drinking
D
Alcohol
Problems
E
F
Mild
Chronic/Severe
Dependence Dependence
Prevention/
Education
Brief Advice
Brief
Interventions
Pre-Treatment
Intervention
Formal Specialized
Treatments
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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)

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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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Age-Specific Treatment Elements (continued)

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Less clinical distance/warmer
relationships using appropriate selfdisclosure
Attention to calming fears regarding
confidentiality
Assistance from social services/family in
medication monitoring
More family involvement
Home visitation
13
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)
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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)
ALDH
ADH
Alcohol
H2O
Acetaldehyde
Acetate
CO2

Different people carry different variations of
the ADH & ALDH enzymes.
 Variations in these enzymes affect how much
people drink and their risk for alcoholism.
15
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)
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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
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 IV
 Number of Prescriptions Collected
Annually: 21 million
 Number of Controlled Substance
Dispensers: 155,000
 Website: http://ag.ca.gov/bne/cures.php

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.
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Screening to Identify Consumers at
risk for Substance Use Problems
How do we conduct the screening?
Substance Use Problems Among Mental Health
Populations
Severe
Problem
Users
Hazardous &
Harmful Users
SBIRT
SBIRT
Non-Users or Low Risk Users
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Include prescription
misuse
23
Interviewing for interconnected problems
*
Medical
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Review: LAC DMH Assessment
Medical
Mental
Health
Considerations
Cirrhosis
Depression
Gastroenteritis
Anxiety
Abscess
Anhedonia
Diabetes
Psychotic
Thinking
High
Blood Pressure
Trauma/PTSD
HIV/HCV
Confusion
Cardiac
MemoryProblems
Issues
TB
…
…
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Review: LAC DMH Assessment
SUD
Mental
Health
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Effecting Change through the
Use of Motivational Interviewing
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 Change
Prochaska & DiClemente
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Reflective Listening
Key-Concepts


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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
Pain
Family
Confusion
Medical
Issues
SUD
Conducting the Brief Intervention
FLO
The 3 Tasks of a BI
L
O
W
Feedback
Listen & Understand
Options Explored
Avoid Warnings!
Warn
F
(that’s it)
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How does it all fit together?
Setting the stage
Feedback
Tell screening results
Explore Pros and Cons
Listen & Understand
Explain Importance
Assess readiness to change
Discuss change options
Options Explored
Follow up
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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)
36
The 3 Tasks of a BI
F
L
O
Feedback
Listen & Understand
Options Explored
37
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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The First Task: Feedback
To avoid this…
LET GO!!!
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The First Task: Feedback

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
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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Pain
Hypertension
Diabetes
Cancer
SUD
SUD
Family
Confusion
Medical
Issue
Feedback: Content Areas for Older
Adults
Alcohol Use
 Illicit Drug Use
 Prescription Medication Use
 OTC Medication Use

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 conversation
 Get the ball rolling
 Gauge where the consumer is
 Hear their side of the story
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The 3 Tasks of a BI
F
L
O
Feedback
Listen & Understand
Options Explored
44
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
47
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?
1
2
3
4
5
6
7
8
9
10
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The Second Task:
Listen & Understand
Let’s practice L:

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Role Play Listen & Understand
Using Completed Screening Tools
Pros and Cons
Importance/Confidence/Readiness Scales
Develop Discrepancy
Dig for Change
Create movement in Consumer’s Stage of
Readiness for Change
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The 3 Tasks of a BI
F
L
O
Feedback
Listen & Understand
Options Explored
51
The Third Task: Options for Change
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?
52
The Third Task: Options for Change
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
53
The Third Task: Options for Change
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?”
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The Third Task: Options for Change
Giving Advice Without
Telling Someone What to Do
 Ask for Permission explicitly
 There’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
55
The Third Task: Options for Change
Giving Advice Without
Telling Someone What to Do
 Provide Clear Information or Feedback
 What happens to some people is that…
 My recommendation would be that…

Elicit their reaction
 What 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 views
 What agreement was reached (repeat it)

57
Putting it all together
Feedback
Range
Listen and Understand
Pros and Cons
Importance/Confidence/Readiness Scales
Summary
Options Explored
Menu of Options
58
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
59
and determine what additional services are needed.
Role Play for Mr. Jackson
 Provide

Feedback
What would he identify as THE problem
Listen and Understand

Explore readiness for change
 Explore

Option
What is he willing and able to do right now?
60
Case Study 2: Mrs. Alvarez

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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
61
Role Play for Mrs. Alvarez
 Provide

Feedback
What would he identify as THE problem
Listen and Understand

Explore readiness for change
 Explore

Option
What is he willing and able to do right now?
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Important Internet Sites
Larkins@ucla.edu
 www.uclaisap.org
 www.psattc.org
 http://sbirt.samhsa.gov/about.htm
 http://sbirt.samhsa.gov/trauma.htm
 http://www.saem.org/SAEMDNN/Portals/
0/IGroups/PublicHealth/sbirt2008/SBIRT
ResourceManual051608.doc

63