Table Of Content

Substance Abuse Among Older Adults Treatment Improvement Protocol (TIP) Series 26 Frederic C. Blow, Ph.D. Consensus Panel Chair U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Rockwall II, 5600 Fishers Lane Rockville, MD 20857 Table of Contents • [Front Matter] • Executive Summary and Recommendations • Chapter 1 -- Substance Abuse Among Older Adults: An Invisible Epidemic • Chapter 2 -- Alcohol • Chapter 3 -- Use and Abuse of Psychoactive Prescription Drugs and Over-the-Counter Medications • Chapter 4 -- Identification, Screening, and Assessment • Chapter 5 -- Referral and Treatment Approaches • Chapter 6 -- Outcomes and Cost Issues in Alcohol Treatment for Older Adults • Appendix A -- Legal and Ethical Issues • Appendix B -- Tools • Appendix C -- Bibliography • Appendix D -- Resource Panel • Appendix E -- Field Reviewer • [Figures] Substance Abuse Among Older Adults Treatment Improvement Protocol (TIP) Series 26 Frederic C. Blow, Ph.D. Consensus Panel Chair U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Rockwall II, 5600 Fishers Lane Rockville, MD 20857 [Disclaimer] This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated. This publication was written under contract number ADM 270-95-0013. Sandra Clunies, M.S., I.C.A.D.C., served as the CSAT Government project officer. Writers were Paddy Cook, Carolyn Davis, Deborah L. Howard, Phyllis Kimbrough, Anne Nelson, Michelle Paul, Deborah Shuman, Margaret K. Brooks, Esq., Mary Lou Dogoloff, Virginia Vitzthum, and Elizabeth Hayes. Special thanks go to Roland M. Atkinson, M.D.; David Oslin, M.D.; Edith Gomberg, Ph.D.; Kristen Lawton Barry, Ph.D.; Richard E. Finlayson, M.D.; Mary Smolenski, Ed.D., C.R.N.P.; MaryLou Leonard; Annie Thornton; Jack Rhode; Cecil Gross; Niyati Pandya; Mark A. Meschter; and Wendy Carter for their considerable contributions to this document. The opinions expressed herein are the views of the Consensus Panel members and do not reflect the official position of CSAT, SAMHSA, or the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT, SAMHSA, or DHHS for these opinions or for particular instruments or software that may be described in this document is intended or should be inferred. The guidelines in this document should not be considered substitutes for individualized patient care and treatment decisions. DHHS Publication No. (SMA) 98-3179 Printed 1998 Return to top. What Is a TIP? Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance abuse, provided as a service of the Substance Abuse and Mental Health Service Administration's Center for Substance Abuse Treatment (CSAT). CSAT's Office of Evaluation, Scientific Analysis, and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private substance abuse treatment facilities as alcohol and other drug disorders are increasingly recognized as a major problem. The TIPs Editorial Editorial Advisory Board, a distinguished group of substance abuse experts and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Other Drug Abuse Directors to generate topics for the TIPs based on the field's current needs for information and guidance. After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content of the TIP. Then recommendations are communicated to a Consensus Panel composed of non-Federal experts on the topic who have been nominated by their peers. This Panel participates in a series of discussions; the information and recommendations on which they reach consensus form the foundation of the TIP. The members of each Consensus Panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group's collaboration. Return to top. A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet on the National Library of Medicine's home page at the URL: http://text.nlm.nih.gov. The move to electronic media also means that the TIPs can be updated more easily so they continue to provide the field with state-of-the-art information. Although each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front-line" information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there is research to support a particular approach, citations are provided. This TIP, Substance Abuse Among Older Adults, presents treatment providers with much-needed information about a population that is underdiagnosed and underserved. Substance abuse, particularly of alcohol and prescription drugs, often goes undetected among adults over 60 in part due to societal reasons - older adults tend to be ashamed about drinking or drug problems and see them as a moral failing. Providers, for their part, may confuse symptoms of substance use disorders with age-related changes. Because so much of older adults' substance abuse is never even identified, this TIP is aimed at not only substance abuse treatment providers but also primary care clinicians, social workers, senior center staff, and anyone else who has regular contact with older adults. The TIP discusses the relationship between aging and substance abuse and offers guidance on identifying, screening, and assessing not only substance abuse but also disorders such as dementia and delirium that can mask or mimic an alcohol or prescription drug problem. Practical accommodations to treatment for older adults and a discussion of how to assess outcomes and treat within a managed care context round out the document. Other TIPs may be ordered by contacting the National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.Editorial Advisory Board Return to top. Editorial Advisory Board Karen Allen, Ph.D., R.N., C.A.R.N. President of the National Nurses Society on Addictions Associate Professor Department of Psychiatry, Community Health, and Adult Primary Care University of Maryland School of Nursing Baltimore, Maryland Richard L. Brown, M.D., M.P.H. Associate Professor Department of Family Medicine University of Wisconsin School of Medicine Madison, Wisconsin Dorynne Czechowicz, M.D. Associate Director Medical/Professional Affairs Treatment Research Branch Division of Clinical and Services Research National Institute on Drug Abuse Rockville, Maryland Linda S. Foley, M.A. Former Director Project for Addiction Counselor Training National Association of State Alcohol and Drug Directors Washington, D.C. Wayde A. Glover, M.I.S., N.C.A.C. II Director Commonwealth Addictions Consultants and Trainers Richmond, Virginia Pedro J. Greer, M.D. Assistant Dean for Homeless Education University of Miami School of Medicine Miami, Florida Thomas W. Hester, M.D. Former State Director Substance Abuse Services Division of Mental Health, Mental Retardation and Substance Abuse Georgia Department of Human Resources Atlanta, Georgia Gil Hill Director Office of Substance Abuse American Psychological Association Washington, D.C. Douglas B. Kamerow, M.D., M.P.H. Director Office of the Forum for Quality and Effectiveness in Health Care Agency for Health Care Policy and Research Rockville, Maryland Stephen W. Long Director Office of Policy Analysis National Institute on Alcohol Abuse and Alcoholism Rockville, Maryland Richard A. Rawson, Ph.D. Executive Director Matrix Center Los Angeles, California Ellen A. Renz, Ph.D. Former Vice President of Clinical Systems MEDCO Behavioral Care Corporation Kamuela, Hawaii Richard K. Ries, M.D. Director and Associate Professor Outpatient Mental Health Services and Dual Disorder Programs Harborview Medical Center Seattle, Washington Sidney H. Schnoll, M.D., Ph.D. Chairman Division of Substance Abuse Medicine Medical College of Virginia Richmond, Virginia Return to top. Consensus Panel Chair Frederic C. Blow, Ph.D. Assistant Professor and Assistant Research Scientist Department of Psychiatry Alcohol Research Center University of Michigan Ann Arbor, Michigan Return to top. Workgroup Leaders Roland M. Atkinson, M.D. Professor Head of Division of Geriatric Psychiatry Department of Psychiatry School of Medicine Oregon Health Sciences University Portland, Oregon James Campbell, M.D., M.S. Associate Professor Acting Chairman Department of Family Medicine Case Western Reserve University Medical Director Senior Health Recovery Resources Metrohealth Medical Center Cleveland, Ohio Anne M. Gurnack, Ph.D. Professor and Director of Assessment Department of Political Science University of Wisconsin at Parkside Kenosha, Wisconsin Jeanie L. Holt, R.N.C. Clinical Staff Nurse Heritage Home Health and Hospice Meredith, New Hampshire David Oslin, M.D. Assistant Professor Addiction and Geriatric Psychiatry Department of Psychiatry University of Pennsylvania Philadelphia, Pennsylvania Gerald D. Shulman, M.A., F.A.C.A.T.A. Consultant Winter Haven, Florida Return to top. Panelists Charles Bearcomesout Traditional Coordinator Traditional Component Northern Cheyenne Recovery Center Lame Deer, Montana Larry W. Dupree, Ph.D. Professor Department of Aging and Mental Health Florida Mental Health Institute University of South Florida Tampa, Florida Richard E. Finlayson, M.D. Consultant in Adult Psychiatry Former Medical Director of Addiction Services Department of Psychiatry and Psychology Mayo Clinic Associate Professor of Psychiatry Mayo Medical School Rochester, Minnesota Lissy F. Jarvik, M.D., Ph.D. Distinguished Physician (11L) Psychiatry Department West Los Angeles VA Medical Center Professor Emerita Department of Psychiatry and Biobehavioral Sciences University of California-Los Angeles Los Angeles, California Hila Richardson, Dr.P.H. Deputy Director Medical Research and Practice Policy National Center on Addiction and Substance Abuse Columbia University New York, New York Marguerite T. Saunders, M.S. Saunders Consulting Services Albany, New York Sharon L. Sheahan, Ph.D., C.F.N.P. Associate Professor of Nursing College of Nursing University of Kentucky Lexington, Kentucky Erma Polly Williams, M.R.E. Program Support Specialist Robert Wood Johnson Medical School University of Medicine and Dentistry of New Jersey New Brunswick, New Jersey Foreword The Treatment Improvement Protocol (TIP) series fulfills SAMHSA/CSAT's mission to improve treatment of substance use disorders by providing best practices guidance to clinicians, program administrators, and payers. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best practices. This panel's work is then reviewed and critiqued by field reviewers. The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. We are grateful to all who have joined with us to contribute to advances in the substance abuse treatment field. Nelba Chavez, Ph.D. Administrator Substance Abuse and Mental Health Services Administration David J. Mactas Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration Return to top. Substance Abuse Among Older Adults Treatment Improvement Protocol (TIP) Series 26 Executive Summary and Recommendations Researchers are only beginning to realize the pervasiveness of substance abuse among people age 60 and older. Until relatively recently, alcohol and prescription drug misuse, which affects as many as 17 percent of older adults, was not discussed in either the substance abuse or the gerontological literature. The reasons for this silence are varied: Health care providers tend to overlook substance abuse and misuse among older people, mistaking the symptoms for those of dementia, depression, or other problems common to older adults. In addition, older adults are more likely to hide their substance abuse and less likely to seek professional help. Many relatives of older individuals with substance use disorders, particularly their adult children, are ashamed of the problem and choose not to address it. The result is thousands of older adults who need treatment and do not receive it. This TIP brings together the literature on substance abuse and gerontology to recommend best practices for identifying, screening, assessing, and treating alcohol and prescription drug abuse among people age 60 and older. The Consensus Panel, whose members include researchers, clinicians, treatment providers, and program directors, supplements this research base with its considerable experience treating and studying substance abuse among older adults. Because so much of older people's substance abuse is never identified, this TIP is aimed not only at substance abuse treatment providers but also at primary care clinicians, social workers, senior center staff, and anyone else who has regular contact with older adults. The TIP aims to advance the understanding of the relationships between aging and substance abuse and to provide practical recommendations for incorporating that understanding into practice. The TIP's recommendations appear below in italic type. Those based on research evidence are marked (1), whereas those based on Panel members' clinical experience are marked (2). Citations for the former can be found in the body of the text. Alcohol Abuse Return to top. Physiological changes, as well as changes in the kinds of responsibilities and activities pursued by older adults, make established criteria for classifying alcohol problems often inadequate for this population. One widely used model for understanding alcohol problems is the medical diagnostic model as defined in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental