Substance Abuse Prevention, Substance Abuse Prevention, Screening and Identification, and Screening and Identification, and

Assessment for Older Adults Assessment for Older Adults

Frederic C. Blow, Ph.D.Frederic C. Blow, Ph.D. Associate Professor and Research Associate Professor Associate Professor and Research Associate Professor

University of Michigan, Department of PsychiatryUniversity of Michigan, Department of PsychiatryDirector, Serious Mental Illness Director, Serious Mental Illness

Treatment Research & Evaluation CenterTreatment Research & Evaluation Center Department of Veterans Affairs Department of Veterans Affairs

Presentation OverviewPresentation Overview

Prevention IssuesPrevention Issues Diagnostic CriteriaDiagnostic Criteria Barriers to IdentificationBarriers to Identification Signs and SymptomsSigns and Symptoms Psychosocial ManifestationsPsychosocial Manifestations Screening InstrumentsScreening Instruments Special AssessmentsSpecial Assessments Future Research DirectionsFuture Research Directions

Prevention IssuesPrevention Issues

Lifetime Patterns of Substance Use Lifetime Patterns of Substance Use and Abuse: Focus for Prevention and Abuse: Focus for Prevention

StrategiesStrategies

Older

Higher

Prevention of Substance Abuse Among Prevention of Substance Abuse Among Older Adults: Conceptual IssuesOlder Adults: Conceptual Issues

Age group definitions Age group definitions Life course variations in consumption Life course variations in consumption Sensible/appropriate use of alcohol and Sensible/appropriate use of alcohol and

prescription drugs prescription drugs Diagnostic criteria for abuse/dependenceDiagnostic criteria for abuse/dependence Risk profiles for specific subpopulationsRisk profiles for specific subpopulations Prevention goalsPrevention goals

Prevention Strategies Effective with Prevention Strategies Effective with Youth: Relevance to Older AdultsYouth: Relevance to Older Adults

Individual-FocusedIndividual-Focused: education, skills development, : education, skills development, alternate behaviors, health behaviorsalternate behaviors, health behaviors

Families/Social SupportFamilies/Social Support: spousal interventions, : spousal interventions, family supports, caregiversfamily supports, caregivers

Peer NormsPeer Norms: network of friends, perceptions: network of friends, perceptions OrganizationsOrganizations: health care organizations, AARP, : health care organizations, AARP,

other policy changesother policy changes Social EnvironmentSocial Environment: social norms and policies, : social norms and policies,

availability and sanctionsavailability and sanctions

Prevention of Substance Abuse Among Prevention of Substance Abuse Among Older Adults: Additional IssuesOlder Adults: Additional Issues

Access to target populationsAccess to target populations Optimal modality for materialsOptimal modality for materials Appropriateness and acceptability of contentAppropriateness and acceptability of content Delivery systemsDelivery systems Program-driven vs. research-initiated Program-driven vs. research-initiated

interventionsinterventions Policy interventionsPolicy interventions Role of drinking, prescription drugs in late Role of drinking, prescription drugs in late

lifelife

Risk and Protective FactorsRisk and Protective Factors

Prevention of Substance Abuse Among Prevention of Substance Abuse Among Older Adults: Risk FactorsOlder Adults: Risk Factors

Male Male Racial/Ethnic Minority Status Racial/Ethnic Minority Status Psychiatric Comorbidity Psychiatric Comorbidity Higher SESHigher SES Lower Social SupportsLower Social Supports Previous History of ProblemsPrevious History of Problems History of Using Substances as Coping StrategyHistory of Using Substances as Coping Strategy

Prevention of Substance Abuse Among Prevention of Substance Abuse Among Older Adults: Protective FactorsOlder Adults: Protective Factors

Female Female Higher Religiosity Higher Religiosity Fewer Mental/Physical Health Problems Fewer Mental/Physical Health Problems Lower SESLower SES Positive Coping StylesPositive Coping Styles More Social SupportsMore Social Supports

Diagnosis IssuesDiagnosis Issues

Problems with DefinitionsProblems with Definitions

Substance MisuseSubstance Misuse At-risk or Hazardous UseAt-risk or Hazardous Use Problem Use Problem Use Substance Abuse Substance Abuse Substance DependenceSubstance Dependence

Diagnostic Criteria Diagnostic Criteria for Substance Dependence for Substance Dependence

in Older Adultsin Older Adults

The Treatment Improvement Protocol The Treatment Improvement Protocol

(TIP #26) Consensus Panel determined:(TIP #26) Consensus Panel determined:

DSM-IV criteria for substance abuseDSM-IV criteria for substance abuse

and dependence may not be and dependence may not be

adequate to diagnose older adults adequate to diagnose older adults

with substance use problemswith substance use problems

DSM-IV Dependence CriteriaDSM-IV Dependence Criteria Tolerance Withdrawal Use in larger amounts or for longer than intended Desire to cut down or control use Great deal of time spent in obtaining substance

or getting over effects Social, occupational, or recreation activities

given up or reduced Use despite knowledge of physical or

psychological problem

Applying DSM-IV Criteria Applying DSM-IV Criteria to Older Adultsto Older Adults

ToleranceTolerance Even low intake may cause Even low intake may cause problems due to body changesproblems due to body changes

WithdrawalWithdrawal May not develop physiological May not develop physiological dependencedependence

Use in larger amounts or for longer than intended

Cognitive impairment interferes Cognitive impairment interferes with self-monitoringwith self-monitoring

Desire to cut down or control use Same across life spanSame across life span

Time in obtaining substance or getting over effects

Negative effects with relatively Negative effects with relatively low uselow use

Activities given up or reduced May have fewer activitiesMay have fewer activities

Use despite knowledge of problems May not know problems are May not know problems are related to userelated to use

ScreeningScreening

Practitioner Barriers Practitioner Barriers to Identificationto Identification

Ageist assumptionsAgeist assumptionsFailure to recognize symptomsFailure to recognize symptomsLack of knowledge about screeningLack of knowledge about screeningPhysician discomfort with substance abuse Physician discomfort with substance abuse

topictopic- 46.6% of primary care physicians found it - 46.6% of primary care physicians found it difficult to discuss prescription drug abuse with difficult to discuss prescription drug abuse with their patientstheir patients

(CASA, 2000)(CASA, 2000)

Individual Barriers Individual Barriers to Identificationto Identification

Attempts at self-diagnosis Attempts at self-diagnosis Description of symptoms attributed to Description of symptoms attributed to

aging process or diseaseaging process or diseaseMany do not self-refer or seek treatmentMany do not self-refer or seek treatment

- Although most older adults (87 percent) see - Although most older adults (87 percent) see physicians regularly, an estimated 40 percent of physicians regularly, an estimated 40 percent of those who are at risk do not self-identify or seek those who are at risk do not self-identify or seek services for substance abuse services for substance abuse

(Raschko, 1990)(Raschko, 1990)

Signs and Symptoms of Substance Signs and Symptoms of Substance Use Problems in Older AdultsUse Problems in Older Adults

AnxietyAnxiety Blackouts, dizzinessBlackouts, dizziness DepressionDepression DisorientationDisorientation Mood swingsMood swings Falls, bruises, burnsFalls, bruises, burns Family problemsFamily problems Financial problemsFinancial problems HeadachesHeadaches IncontinenceIncontinence

Increased tolerance Increased tolerance Legal difficultiesLegal difficulties Memory lossMemory loss New problems in decision New problems in decision

makingmaking Poor hygienePoor hygiene Seizures, idiopathicSeizures, idiopathic Sleep problemsSleep problems Social isolationSocial isolation Unusual response to Unusual response to

medicationsmedications

Symptom IdentificationSymptom Identification Applying quantity and frequency levels appropriate for Applying quantity and frequency levels appropriate for

younger adults to elders may cause failure to identify younger adults to elders may cause failure to identify substance use problemssubstance use problems

Warning signs can be confused with or masked by Warning signs can be confused with or masked by concurrent illnesses and chronic conditions, or attributed concurrent illnesses and chronic conditions, or attributed to agingto aging– Sleep problems associated with chronic conditions, Sleep problems associated with chronic conditions,

particularly cardiovascular disease and painparticularly cardiovascular disease and pain– Falls attributed to poor lower body strength, poor balance, or Falls attributed to poor lower body strength, poor balance, or

vision limitationsvision limitations– Anxiety attributed to psychosocial concerns Anxiety attributed to psychosocial concerns – Confusion/memory problems associated with Alzheimer’s Confusion/memory problems associated with Alzheimer’s

disease or other dementiasdisease or other dementias

Psychosocial Manifestations of Psychosocial Manifestations of Mild/Moderate Drug DisordersMild/Moderate Drug Disorders

Psychological/BehavioralPsychological/Behavioral– Agitation, irritability, dysphoria, difficulty in coping, Agitation, irritability, dysphoria, difficulty in coping,

mood swings, hostility, violence, psychosomatic mood swings, hostility, violence, psychosomatic symptoms, hyperventilation, generalized anxiety, panic symptoms, hyperventilation, generalized anxiety, panic attacks, depression, psychosisattacks, depression, psychosis

FamilyFamily– Chronic stable family dysfunction, marital problems, Chronic stable family dysfunction, marital problems,

anxiety and depression in family members, divorce, anxiety and depression in family members, divorce, abuse and violenceabuse and violence

(Brown, 1992)(Brown, 1992)

Psychosocial Manifestations of Psychosocial Manifestations of Mild/Moderate Drug DisordersMild/Moderate Drug Disorders

SocialSocial– Alienation and loss of old friends, gravitation toward Alienation and loss of old friends, gravitation toward

others with similar lifestyleothers with similar lifestyle LegalLegal

– Arrests for disturbing the peace or driving while Arrests for disturbing the peace or driving while intoxicated, stealing, drug dealingintoxicated, stealing, drug dealing

FinancialFinancial– Borrowing or owing money, selling personal or family Borrowing or owing money, selling personal or family

possessionspossessions

(Brown, (Brown, 1992)1992)

Screening InstrumentsScreening Instruments

Modified CAGE for drug abuseModified CAGE for drug abuse– Examined for older populations (50 and over)Examined for older populations (50 and over)– Excellent sensitivity, poor specificityExcellent sensitivity, poor specificity

(Hinkin et (Hinkin et al., 2001)al., 2001)

Conjoint two-item screen Conjoint two-item screen – "In the past year, have you ever drunk or used drugs more "In the past year, have you ever drunk or used drugs more

than you meant to?" than you meant to?" – "Have you felt you wanted or needed to cut down on your "Have you felt you wanted or needed to cut down on your

drinking or drug use in the past year?" drinking or drug use in the past year?" » Ages 50-59: Sensitivity 73.9, Specificity 84.8 Ages 50-59: Sensitivity 73.9, Specificity 84.8

(Brown et al., 2001)(Brown et al., 2001)

Drug Abuse Screening Test (DAST-10, 20, 28)Drug Abuse Screening Test (DAST-10, 20, 28)

Drug Abuse Screening Test Drug Abuse Screening Test (DAST-20)(DAST-20)

1.1. Have you used drugs other than those required for medical reasons? Have you used drugs other than those required for medical reasons? 2.2. Have you abused prescription drugs?Have you abused prescription drugs? 3.3. Do you abuse more than one drug at a time?Do you abuse more than one drug at a time?4.4. Can you get through the week without using drugs (other than those Can you get through the week without using drugs (other than those

required for medical reasons)?required for medical reasons)?5.5. Are you always able to stop using drugs when you want to?Are you always able to stop using drugs when you want to? 6.6. Have you had "blackouts" or "flashbacks" as a result of drug use? Have you had "blackouts" or "flashbacks" as a result of drug use? 7.7. Do you ever feel bad or guilty about your drug use?Do you ever feel bad or guilty about your drug use?8.8. Does your spouse (or parents) ever complain about your involvement Does your spouse (or parents) ever complain about your involvement

with drugs?with drugs?9.9. Has drug abuse created problems between you and your spouse or your Has drug abuse created problems between you and your spouse or your

parents?parents?10.10. Have you lost friends because of your use of drugs?Have you lost friends because of your use of drugs?

Drug Abuse Screening Test Drug Abuse Screening Test (DAST-20)(DAST-20)

11.11. Have you neglected your family because of your use of drugs?Have you neglected your family because of your use of drugs?12.12. Have you been in trouble at work because of drug abuse? Have you been in trouble at work because of drug abuse? 13.13. Have you lost a job because of drug abuse?Have you lost a job because of drug abuse? 14.14. Have you gotten into fights when under the influence of drugs? Have you gotten into fights when under the influence of drugs? 15.15. Have you engaged in illegal activities in order to obtain drugs?Have you engaged in illegal activities in order to obtain drugs? 16.16. Have you been arrested for possession of illegal drugs? Have you been arrested for possession of illegal drugs? 17.17. Have you ever experienced withdrawal symptoms (felt sick) when you Have you ever experienced withdrawal symptoms (felt sick) when you

stopped taking drugs?stopped taking drugs?18.18. Have you had medical problems as a result of your drug use (e.g., Have you had medical problems as a result of your drug use (e.g.,

memory loss, hepatitis, convulsions, bleeding, etc.)? memory loss, hepatitis, convulsions, bleeding, etc.)? 19.19. Have you gone to anyone for help for a drug problem? Have you gone to anyone for help for a drug problem? 20.20. Have you been involved in a treatment program specifically related to Have you been involved in a treatment program specifically related to

drug use? drug use?

AssessmentAssessment

Special AssessmentsSpecial Assessments

Functional AbilitiesFunctional Abilities– Activities of Daily Living (ADLs)Activities of Daily Living (ADLs)– Instrumental Activities of Daily Living (IADLs)Instrumental Activities of Daily Living (IADLs)– SF-36SF-36

ComorbiditiesComorbidities– PhysicalPhysical– PsychiatricPsychiatric

» Affective disordersAffective disorders» Suicide riskSuicide risk

Sleep DisordersSleep Disorders

Special AssessmentsSpecial Assessments

Cognitive ImpairmentsCognitive Impairments– DementiaDementia

» Orientation/Memory/Concentration Test Orientation/Memory/Concentration Test

» Folstein Mini-Mental Status Exam (MMSE)Folstein Mini-Mental Status Exam (MMSE)

– DeliriumDelirium» Confusion Assessment Method (CAM)Confusion Assessment Method (CAM)

– Other cognitive impairmentsOther cognitive impairments» Trauma from falls, MVA, accidentsTrauma from falls, MVA, accidents

» Wernicke-Korsakoff syndromeWernicke-Korsakoff syndrome

Screening and Assessment Screening and Assessment Recommendations for Older AdultsRecommendations for Older Adults

Every person over 60 should be screened Every person over 60 should be screened for alcohol and drug abuse as part of regular for alcohol and drug abuse as part of regular physical examinationphysical examination “ “Brown Bag Approach”Brown Bag Approach”

Screen or re-screen if certain physical Screen or re-screen if certain physical symptoms are present or if the older person symptoms are present or if the older person is undergoing major life transitionsis undergoing major life transitions

Screening and Assessment Screening and Assessment Recommendations for Older AdultsRecommendations for Older Adults

Ask direct questions about concernsAsk direct questions about concerns Preface question with link to medical Preface question with link to medical

conditions of health concernsconditions of health concerns Do not use stigmatizing terms (i.e. drug Do not use stigmatizing terms (i.e. drug

addict)addict)

Future DirectionsFuture Directions

Risk and Protective Factors/Prevention/Early Risk and Protective Factors/Prevention/Early IdentificationIdentification

Drug of ChoiceDrug of Choice• Illicit, Prescription, AlcoholIllicit, Prescription, Alcohol

Patterns of usePatterns of use• Drug use trajectoriesDrug use trajectories• Re-emergence of addiction in late lifeRe-emergence of addiction in late life• Late-life onset of substance use disorderLate-life onset of substance use disorder

Screening, Assessment and DiagnosisScreening, Assessment and Diagnosis Identification and treatment of psychiatric Identification and treatment of psychiatric

comorbiditiescomorbidities

Contact InformationContact InformationFrederic C. Blow, Ph.D.Frederic C. Blow, Ph.D.

DirectorDirectorSerious Mental Illness Serious Mental Illness

Treatment Research & Evaluation CenterTreatment Research & Evaluation Center Department of Veterans AffairsDepartment of Veterans Affairs

Associate Professor/Research Associate ProfessorAssociate Professor/Research Associate ProfessorUniversity of Michigan Department of PsychiatryUniversity of Michigan Department of Psychiatry

400 E. Eisenhower Parkway, Suite 2A400 E. Eisenhower Parkway, Suite 2AAnn Arbor, MI 48108Ann Arbor, MI 48108

Phone: 734/761-2210 Fax: 734/761-2617 Phone: 734/761-2210 Fax: 734/761-2617 email: fredblow@umich.eduemail: fredblow@umich.edu