Substance Use Resource Review

Kathleen J. Farkas, PhD Case Western Reserve University, Mandel School of Applied Social Sciences

Laurie Drabble, PhD San Jose State University, School of Social Work.

Introduction and Overview

The Substance Use and Older Adults Resource Review for Teaching is intended to assist faculty teaching courses in Alcohol and other Drug Abuse (AODA) in schools of Social Work. The review focuses on older adults and substance abuse topics of prevalence, screening and assessment, treatment and intervention, and prevention. The content level assumes instructors have specific knowledge and are familiar with the general literature on alcohol and other drug abuse. Since the majority of research and teaching in AODA is with younger populations, instructors may not be familiar with the relevant information pertaining to substance use, abuse, and dependence among older adults. With the expected increase in the older populations in the coming decades, there is a need for teaching tools that address the knowledge gaps and prevailing assumptions about use of alcohol and other drugs among older populations. Students entering AODA social work practice need information and skills to address the AODA needs of older adults, but most social work students do not receive this preparation. This review provides useful information on AODA social work practice with older adults for classroom and field setting instruction.

Organization of Research and Curricula Review

This review provides a synopsis of recent research literature and key curriculum resources in six areas:

1. Chapter 2: Prevalence of alcohol, tobacco, and other drug use and substance related problems among older adults.
2. Chapter 3: Strengths and vulnerabilities associated with older age and substance use.
3. Chapter 4: Detection of substance use, misuse, abuse and dependence among older adults.
4. Chapter 5: Treatment and intervention.
5. Chapter 6: Policy issues.
6. Chapter 7: Research questions and future research directions.

In this Review, we assess and describe recent empirical literature, curricula, and teaching resources such as DVDs and web sites. Our goal in this resource review is to provide social work faculty with current and empirically based information on substance use, misuse, abuse, and dependence among older adults. The primary focus is to develop content about older adults that can be added AODA classes within schools of social work. The research and curricula assessments are constructed so that instructors may use each Chapter independently or in combination to increase the content on older adults available to their students. To facilitate the use of separate Chapters of the review, we used planned repetition of information. Each Chapter includes 1) an overview of recent, empirically-based literature, 2) a list of references associated with the section, and 3) a brief list of key readings, web sites, and user-friendly instructional materials that may be adopted or adapted by instructors for their own courses. This review builds on the advances in knowledge over the past 10 years as well as curricula developed in the separate areas of alcohol abuse and medication management among older adults. The resource review is not another curriculum in alcohol and other drug use/abuse and older people. Instead, it critically reviews available curricula in substance use and abuse among older people in order to provide a guide for faculty who are interested in adding content on older adults to their AODA courses.

One advantage of this resource review is that it covers a range of substances: alcohol, tobacco, prescription drugs, and illicit drugs. The review is divided into Chapters that fit closely with direct practice social work knowledge and tasks. These core tasks apply across practice settings, reflecting that fact that social workers practice in a variety of service delivery systems and organizational contexts. The review includes information useful for those working within an array of social work roles—clinician, educator, advocate—requiring knowledge and skills related to alcohol and other drug abuse.

The goal of the resource review is to provide information and knowledge that can be used to increase social work practice skills in working with the full and diverse range of older adults who use or abuse alcohol, tobacco, prescription medications, or illicit drugs. Consistent with social work values, the review includes information on the following diversity issues: race/ethnicity, gender, social class and sexual orientation, as available. The review also includes a chapter on policy to assist faculty in developing students’ appreciation of advocacy and its role in social work practice.

The first two chapters provide an important overview of the prevalence, trends, and consequences associated with substance use and abuse in older adults. Content in these chapters focuses particularly on establishing the reasons professional social workers need to understand and be prepared to address substance use, abuse, and dependence among older adults. The material in these chapters can be covered in depth, extracted for use in course content about prevalence of problems in diverse populations, or condensed into a brief introductory overview as a prelude to covering content on direct practice or policy. The remaining chapters address screening and assessment (Chapter 3); detection and assessment (Chapter 4) treatment and intervention (Chapter 5); policy issues (Chapter 6); and research questions and future research (Chapter 7). The research and curriculum resources described in the chapters on screening and assessment, treatment and intervention, and prevention may be particularly salient to course content related to direct practice. In addition to using Chapter 6, instructors seeking useful materials for policy content may elect to draw from the treatment and intervention chapter (5), which includes content on strategies for the prevention of alcohol and other drug problems. Chapter 7 explores future directions and poses questions for research and knowledge development to advance policy and practice may be particularly useful in research courses. A separate PowerPoint file with slides that correspond to the literature review sections is also available for instructors to use as they present the information in their classes.

This Resource Review concludes with an appendix listing key curriculum resources for use in MSW advanced courses. We selected curricula resources based on their accessibility (e.g., free or low cost, easy to obtain), ease of use, and utility for advanced MSW courses. The descriptions provide detailed information that allow instructors to select and obtain materials best suited to their courses. Our intention in structuring this Resource Review for Teaching is to facilitate the instructor’s inclusion of content on older adults in AODA practice and policy courses and to strengthen the curriculum- and skill-building goals in preparing social work practitioners for AODA practice.

Methodology for the Research Review

Even though older adults are a minority in alcohol and other drug treatment facilities, practitioners and researchers have been writing about AODA and older people, especially in relation to alcohol use and abuse, for several decades (Nace, 1984; National Institute on Alcohol Abuse and Alcoholism, 1988; Liberto, Oslin, & Ruskin, 1992; Dufour & Fuller, 1995). A number of books and descriptive articles provide information on the nature of alcohol and drug problems among older people and recommendations for treatment and recovery. Social work texts in chemical dependency have included chapters on older adults (McNeece & DiNitto, 2005; Straussner, 2004). However, even new editions of standard textbooks on chemical dependency counseling have scant information on older adults (Perkinson, 2008). This research review focuses on the empirical literature in the social sciences published within the past 10 years. In some cases the review includes a study published prior to 1997, but only if that study provided a particularly important perspective or empirical finding related to the topic.

Evidence Criteria: In social work, educators, researchers, and practitioners are engaged in a continuing debate about how to define and operationalize evidence to support practice interventions. To choose the resources included in this review, we sorted information according to the strength of the evidence base using guidelines from Siwek and colleagues (2002) and the Center for Substance Abuse Services (2007). We excluded pilot studies, case studies, clinical impressions, and descriptive studies without empirical data. We have included studies that used quasi-experimental or randomized controlled designs as well as retrospective and prospective epidemiological investigations. We also have included meta-analyses and literature reviews focused on empirical studies. In addition, we did not exclude studies based on sample size because much of the treatment literature includes programmatic evaluations of specific interventions with older adults. However, we do discuss briefly the type of evidence provided in the studies reviewed so the reader may make an informed decision about the strength of the information. This is not a classic evidence-based review, but it does take into account the level of evidence.

The Search Process: Selecting search terms was the first step in the process. In consultation with a reference librarian at the Lillian and Milford Harris Library, Mandel School of Applied Social Sciences, Case Western Reserve University, we chose a broad strategy to identify studies of older adults. Because different search engines identify the population of older adults differently, using a variety of search terms is important. To capture studies of older adults we selected the following search terms: aging, aged, elder, elderly, frail elderly, old, older adult, and older people. We used a similarly broad selection of terms to identify literature on alcohol and other drug abuses including the following: alcohol, alcoholism, drug abuse, drug misuse, chemical dependence, prescription drug abuse, medication misuse, polypharmacy, problem drinker, substance abuse, substance use, and substance dependence. We used the following electronic databases: Abstracts in Social Gerontology, Academic Search Complete, Ageline Silver Platter, Annual Reviews of Social Sciences (including anthropology, medicine, psychology and sociology), CINAHL plus with full text, Cochrane Database of Systematic Reviews, Medline, Medline with full text, PubMed, Psychology & Behavioral Sciences Collection, SocINDEX, SocINDEX with full text. Searches were also restricted to the inclusion parameter “from 1997 through 2007”. Selected abstracts and full text pdfs, when available, were entered in to RefWorks bibliographic software.

References

Center for Substance Abuse Treatment. (2007). Understanding evidence-based practices for co-occurring disorders. COCE overview paper 5. (DHHS Publication No. (SMA) 07-4278). Rockville, MD: Author.

Dufour, M., & Fuller, R. (1995). Alcohol in the elderly. Annual Review of Medicine, 46, 123-132.

Liberto, J., Oslin, D., & Ruskin, P. (1992). Alcoholism in older persons: A review of the literature. Hospital & Community Psychiatry. 43(10), 975-984.

McNeece, A., & DiNitto, D. (2005). Chemical dependency: A systems approach. Third Edition. Boston, MA: Pearson/Allyn & Bacon.

Nace, E. (1984). Epidemiology of alcoholism and prospects for treatment. Annual Review of Medicine, 35, 293-309.

National Institute on Alcohol Abuse and Alcoholism. (1988). Alcohol & Aging. Rockville, MD: U.S. Department of Health and Human Services.
Retrieved from http://pubs.niaaa.nih.gov/publications/aa02.htm.

Perkinson, R. (2008). Chemical dependency counseling: A practical guide. Third Edition. Thousand Oaks, CA: Sage Publications.

Straussner, S. L. A. (2004). Clinical work with substance-abusing clients. Second Edition. New York: The Guilford Press.

Siwek, J., Gourlay, M., Slawson, D., & Shaughnessy, A. (2002). How to write an evidence-based clinical review article. American Family Physician, 65(2), 251-258.

Document Date: September 11, 2009 

Kathleen J. Farkas PhD Case Western Reserve University, Mandel School of Applied Social Sciences
Laurie Drabble PhD, San Jose State University, School of Social Work.

Prevalence of Alcohol, Tobacco, and Other Drug Use Problems Among Older Adults

The Demographic Imperative and Social Work Practice in the Addictions

• The proportion of older people in the population is increasing rapidly.
• Tomorrow’s older adults will have different experiences, attitudes, and substance use patterns than did previous cohorts of older adults.

Cohort issues will loom large in the area of social work practice in the addictions over the next several decades. The presence of an increasing number of older adults in the AODA treatment arena will create a moving target for social work educators and professionals. The characteristics of the current cohorts of older adults may or may not resemble those of future cohorts. For example, it is not clear if patterns of alcohol and drug use will drop in future cohorts as they traditionally they have in older cohorts. Advances in health care and preventative medicine may change the incidence in the health problems that traditionally motivated older people to decrease their use of alcohol and other drugs. Today’s middle-aged cohorts are accustomed to using pharmaceuticals, both prescription and over the counter, to treat a variety of illness and discomforts. Alcohol and illicit drugs have also been part of life for the “baby boom” generation, and alcohol and drugs are expected to be part of later life for this group. One indication of this trend is the increasing proportion of older patients in methadone treatment programs (Rosen, Smith, & Reynolds, 2008).

• Future cohorts of older adults will comprise increased numbers of persons from ethnic/racial identity groups.

The number of older adults who belong to minority ethnic/racial identity groups is on the rise. By 2050 the Census Bureau predicts that 21% of people older than 65 will be a member of a minority group and that African Americans will constitute a large proportion of that population (Ford & Hatchett, 2001). Older populations of Asians and Latinos are also expected to increase as are the number of people who openly self-identify as gay or lesbian.

Social work professionals in the addictions must refine their skills to address issues of culture and ethnicity in their work with older adults. Instead of using a narrow range of cultural variables, professionals will need to adopt a greater range of diversity options in the categories of economics, sexual orientation, education, religion, and ethnic origin (Yali & Revenson, 2004).

Substance Use, Abuse, and Dependence Continuum and Definitions

• Definitions of substance use and abuse are especially important to understanding the impact of substances on older adults’ health and wellbeing.

Substance use, misuse, abuse, and dependence can be placed along a continuum ranging from total abstinence to psychological and physiological dependence (Doweiko, 2002; McNeese & DiNitto, 2005). Definitional issues often blur the lines among and between continuum categories. The Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000) terminology presents problems for detection and diagnosis of substance use problems among older adults. However, DSM-IV-TR does offer standardization of definition and terminology from which to begin a discussion of substance use/abuse/dependence among older adults.

• Substance use among older adults is both a current problem and a future concern.

In comparison to younger age groups, relatively little attention has been paid to the issues of substance use and abuse among older adults. Over several decades theorists have discussed drug and alcohol use as a self-limiting disease so that addicts “mature out” before later life (Menninger, 2002). However, evidence indicates that current cohorts of older adults experience substance-related problems and disorders. In fact, substance abuse among older adults has been labeled “an invisible epidemic” (U.S. Department of Health and Human Services, 1998). The number of older adults with substance-related problems is expected to increase rapidly and dramatically over the coming decades. This demographic trend signifies an important area for researchers and practitioners, since it strongly suggests an increased need for substance abuse treatment services over the next 15 or so years (Korper & Council, 2002; Bartels, Blow, Brockman, & Van Critters, 2005; Bartels, 2006).

Prevalence of Substance Use, Abuse, and Dependence among Older Adults

• Substance use and abuse among older adults involve a range of substances both legal (alcohol, tobacco, and prescription medications) and illegal (street drugs).
• Currently, substance use of any kind is less common among older than younger cohorts, but the aging of the baby boomer cohorts is expected to increase the prevalence rates of substance use and abuse among older adults.

Both demographic trends and epidemiological studies indicate an increase in the numbers of older adults with possible accompanying changes in the use patterns of both legal and illegal substances. Korper and Rasken (2003) forecast an escalation from the approximately 1.7 million current dependent and abusing adults over age 50 to 4.4 million by 2020. Bartels (2006) describes this age cohort change as a “demographic tsunami” that will require additional attention to issues of substance use and commonly occurring mental disorders such as depression. Studies of clinical populations, especially those in health clinics and nursing homes, have yielded higher estimates of substance abuse than representative samples of community dwelling older adults (Callahan & Tierney, 1995). Setting, definitions of use categories, and age categorizations are all important for understanding epidemiology of substance use, misuse, abuse, and dependence.

• Prospective cohort studies are necessary to understand how patterns of substance use may change with age and how culture and living conditions will influence substance use, misuse, abuse, and dependence.
• Prospective cohort studies are needed to understand and better prepare social workers to address gender and racial/ethnic differences in incidence and prevalence of substance-related disorders.

Future prospective epidemiological research will need to include adequate samples of older adults (50+) as well as standard definitions for substance use (Johnson, 2000). Prevalence rates for substance use and abuse range widely depending on setting and population (Bartels, Blow, Van Citters, & Brockmann, 2006), and differences between community-based and institutionally-based prevalence studies need to be carefully interpreted. Few epidemiological studies have examined gender or racial/ethnic differences in substance use (Cummings, Bride, & Rawlins-Shaw, 2006). However, the National Survey on Drug Use and Health (NSDUH) is an important source of information on the emerging trends of substance use, misuse, abuse, and dependence among older adults.

Alcohol Use Prevalence

• In the 2006 NSDUH, among older age groups, the prevalence of alcohol use decreased with increasing age, from 63.5% among 26 to 29 year olds to 48.0% among 60 to 64 year olds, to 38.4% among people aged 65 or older (Substance Abuse and Mental Health Services, 2006).
• In the 2002 and 2003 NSDUH, 45.1% of persons 50 or older reporting drinking alcohol.

Alcohol is the most commonly used and abused substance among all age groups in the United States. Alcohol use and abuse is less common among older adults than younger age groups, and approximately 60% of current cohorts of older adults are abstinent. However, larger percentages of people moving into later life have used alcohol through their lives and are expected to continue to drink alcohol as they age. Even though alcohol-related problems are not as common among older adult populations, a significant number of older adults experience substance-related problems, and problems can occur at low levels as well as higher levels of alcohol use.

Problem Use of Alcohol among Older Adults

• In the 2006 NSDUH, persons aged 65 or older had lower rates of binge drinking (7.6%) than did adults in other age groups. The rate of heavy drinking among persons aged 65 or older was 1.6%. Binge drinking is defined as five or more drinks on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past 30 days (includes heavy use) (Substance Abuse and Mental Health Services (2006).
• Unhealthy drinking patterns (monthly use exceeding 30 drinks per typical month and “heavy episodic drinking” of four or more drinks in any single day during a typical month in the previous year) were found in 9% of older Medicare beneficiaries. More men (16%) than women (4%) reported unhealthy drinking patterns (Merrick et al., 2008).
• Estimates of problem-related drinking among community dwelling older adults ranges widely from 1% to over 15% (Project Mainstream, 2005).
• In one study, 24% of frail elderly under the care of a county Health and Social Services Department actively used alcohol, and, of those who used alcohol, 17% fell into the category of problem drinkers (Project Mainstream, 2005).

The National Epidemiological Survey on Alcohol and Related Conditions (NESARC) is based on a representative sample of the U.S. population and provides estimates on alcohol and drug use, abuse, and dependence, and associated disabilities. NESARC’s design is a longitudinal study of 43,093 non-institutionalized Americans. Older adults are represented in this study and provide a base for studies focused on late life use and abuse of alcohol and drugs and on associated problems. Although most publications based on NESARC data are not focused on older adults, they provide important questions for future research on alcohol and drug use among this group. Of particular note are studies of life course trajectories (Sher, Gothan, & Watson, 2004), studies of alcohol dependence subtypes (Moss, Chen, & Yi, 2007), alcohol treatment utilization (Cohen, Feinn, Arias, & Kranzler, 2007), the relationship of transitional life events on recovery (Dawson, Grant, Stinson, & Chou, 2006); and the relationships between drinking patterns and co-occurring disabilities (Dawson, Li, & Grant, 2007; Saha, Chou, & Grant, 2006).

Alcohol Use among Minority Groups

• Research reviews indicate that determining risk factors for alcohol problems based on gender and racial/ethnic identity is an imperfect science. In some studies, African American women are at the lowest risk of alcohol problems and White men are at the highest risk, but in others there are no differences between racial groups (Cummings, Bride, & Rawlins-Shaw, 2006).
• Whereas general population studies that do not differentiate by sexual orientation have shown declining rates of drinking in older adults, studies among sexual minority populations have found that rates do not appear to decline with age (Hughes & Eliason, 2002). Population-based studies suggest that alcohol dependence and alcohol-related problems are significantly higher among lesbian and bisexual women than among heterosexual women, and that rates are elevated, but not always significantly greater, between homosexual/bisexual men and heterosexual men (Cochran, Keenan, Schober, & Mays, 2000; Cochran & Mays, 2000; Drabble, Trocki, & Midanik, 2005).
• Data from the 1991-1993 national Survey on Drug Abuse indicated that older Native Americans, South Americans, and non-Hispanic Whites had higher prevalence rates for alcohol abuse than did other racial/ethnic groups (Gurnack & Johnson-Wendell, 2002).

For substance abuse treatment professionals, today’s older adults do not constitute a large percentage of their client population and this is particularly true for minority older adults. However prevalence studies indicate that a proportion of older adults use alcohol and experience problems related to drinking. Given the demographic changes in the U.S. age structure in the next 10-15 years and the cohort changes in alcohol use, social workers must be prepared to screen and treat alcohol-related problems among older adults with a special emphasis on members of racial ethnic, and sexual orientation identity groups. Acculturation and acculturative stress and the use of substances among older adults are also important areas of interest.

Alcohol Use Guidelines and Older Adults

• A U.S. Department of Health and Human Services 1998 report indicates that many older adults who experience alcohol-related problems do not meet standard criteria for abuse or dependence.
• Alcohol use and medication interaction is a common problem among older adults (U.S. Department of Health and Human Services, 1998).
• Epidemiological research should further explore the relationship between drinking limits and physical and psychosocial health in samples of community-dwelling older people.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the Center on Substance Abuse Treatment (NIAAA, 1995; U.S. Department of Health and Human Services, 1998) have issued age-specific drinking guidelines to decrease alcohol-related vulnerabilities and to recognize the evidence on beneficial health effects of drinking, especially for males (Chermack, Blow, Hill, & Mudd, 1996). These guidelines recommend that men age 60 and older consume no more than one standard drink per day or seven standard drinks per week and no more than two standard drinks on any drinking day. For women the limit is less than one standard drink per day. However, when Blow and colleagues (2000) conducted a large cross-sectional study of 37 primary care clinics to determine the relationship between alcohol consumption and health function among older adults, they found that the relationship between health function and alcohol consumption was complex. Low-risk drinkers fared better than abstainers on measures of physical and psychosocial health. At-risk drinkers did not necessarily have poor physical health function, but at-risk drinkers showed poorer mental health functioning than low-risk drinkers. In a sample of 8,883 older people enrolled in a community insurance plan, Pringle and colleagues determined that ill health most often preceded reductions in alcohol use (Pringle, Heller, Ahern, Gold, & Brown, 2006). Evidence on health conditions and alcohol consumption from a large population-based cohort study has raised the need for additional studies on the relationships between alcohol consumption and disability risk for older men and women (Lang, Guralnik, Wallace, & Melzer, 2007).

Tobacco Use Prevalence

• In the 2006 NSDUH, 26.7% of the population aged 50 to 54 had smoked cigarettes in the past month compared to 22.7% of 55- to 59-year-olds, 18.6% of 60- to 64-year-olds, and 9.5% of people aged 65 and older.
• Combined 2002 and 2003 NSDUH data indicated that an estimated 17.1% of persons aged 50 or older (13.7 million persons) had smoked cigarettes in the past month.
• Among older adults, the leading cause of premature death is cigarette smoking, and mortality linked to tobacco smoking is expected to increase worldwide (World Bank, 1999).

The American Lung association has targeted today’s older adults for special attention because of the cohort’s smoking rates and the severity of morbidity and mortality related to tobacco use (2007). Older adults are more likely than younger adults to be chronic smokers with longer histories of tobacco use.

Tobacco Use among Minority Groups

• In a small study of African Americans aged 50 to 91, who attended senior activity centers (n=102), current smokers were, on average, younger than nonsmokers, and males were more likely than females to be current smokers (Williams, Lewis-Jack, Johnson, & Adams-Campbell, 2001).
• Population-based studies indicate that smoking is higher among both lesbians and gay men than among heterosexual women and men (Burgard, Cochran, & Mays, 2005; Dilley et al., 2005; Greenwood et al., 2005; Gruskin, Greenwood, Matevia, Pollack, & Bye, 2007; Tang et al., 2004).

As with alcohol use prevalence studies, there are many unknowns about tobacco use among older adults and how changes in demographics will affect prevalence rates in future cohorts of older adults. For example, it will be important to understand the differences and similarities between tobacco use patterns of men and women in older populations and how those patterns change with age in each cohort. The success of smoking cessation efforts in general points toward hope for declines in tobacco use among older adults.

Illicit Drug Use Prevalence

• Among adults aged 50 to 59, the rate of current illicit drug use increased between 2002 and 2005, then remained unchanged in 2006. For those aged 50 to 54, the rate increased from 3.4% in 2002 to 6.0% in 2006. Among those aged 55 to 59, current illicit drug use showed a mixed trend with no significant difference between the rates in 2002 and 2006. (NSDUH, 2006).
• According to the combined 2002 and 2003 NSDUH data, estimated 1.8% of older adults (1.4 million persons) had used an illicit drug in the month prior to completing the survey. Marijuana was the most commonly used illicit drug (1.1%), followed by prescription–type drugs used non-medically (0.7%), and cocaine (0.2%).

Illicit drug use includes the use and abuse of marijuana/hashish, cocaine, inhalants, hallucinogens, heroin, or any prescription-type psychotherapeutic drug used non-medically. The literature on the epidemiology of illicit drug use among older adult populations is limited. The lack of standard definitions, the under-sampling of older population groups, and variations across settings all contribute to the lack of information about illicit drug use among older people. Professionals and the general public both are often misinformed about older adults’ use of illicit drugs, and a disproportionate number of people who abuse illicit drugs die prematurely (Neumark, Van Etten, & Anthony, 2000). Illicit drug use among older adults has long been thought of as a relatively rare phenomenon; however, illicit drug abuse is expected to increase with future cohorts (Addiction Treatment Forum, 2003; Simoni-Wastila & Yang, 2006).

• These patterns and trends may partially reflect the aging of the baby boom cohort, whose lifetime rates of illicit drug us—especially marijuana use—are higher than those of previous cohorts (Substance Abuse and Mental Health Services Administration, 2006).
•  Emerging research on middle-aged cohorts indicates that patterns of illicit drug use continue throughout life (Anderson & Levy, 2003).
• Future prospective epidemiological research needs to include older adults and to monitor changes in illicit drug use among these older cohorts.

The extent to which future cohorts of older adults continue to use marijuana is an area of special interest for substance abuse treatment professionals. Medical use or self medication uses of marijuana by older adults with chronic health problems is another area for further research in the coming cohorts.

Illicit Drug Use among Minority Groups

• In younger age groups, marijuana use is higher among sexual minority women and men, and other illicit drug use and abuse appears to be particularly pronounced among sexual minority men (Cochran Ackerman, Mays, & Ross, 2004; Stall et al., 2001; Woody et al., 2001).
• Analysis of the 1991-1993 National Survey on Drug Abuse found that older Native Americans, Puerto Ricans, Mexicans, and non-Hispanic Blacks had higher prevalence rates for misuse of illicit drugs than other racial/ethnic groups did (Gurnack & Johnson-Wendell, 2002).
• Data from the Treatment Episode Data Set (TEDS) indicate increased prevalence of cocaine use among older African Americans in treatment for substance abuse (Gurnack & Johnson-Wendell, 2002).

Minority group status is confounded with social variables including economic, education, and social opportunities. Studies of minority group status and drug use must be seen in the context of these other social variables and used to develop more effective prevention and treatment options for older minority adults (McNeece & DiNitto, 2005).

Prescription Medications and Medication Misuse Prevalence

• Poly-pharmacy is a broadly based term used to describe medication use that is not clinically warranted (Zarowitz, 2006) and prescription stimulants, sedatives, tranquilizers, and analgesics are all subject to misuse.
• Lack of a standard definition for prescription drug abuse has caused limitations in epidemiological research (Isaacson, Hopper, Alford, & Parran, 2005).
•  Estimates are that the nonmedical use of psychoactive prescription drugs by adults age 50 and older will increase from 911,000 in 2001 to nearly 2.7 million in 2020 (Colliver, Compton, Gfrorer, & Condon, 2006).

The risk for medication non-compliance, defined as the extent to which the patient’s use of medications is in line with the prescriber’s directions, is great among older adults for a number of reasons, including number of medications prescribed, cognitive and communication deficits, inadequate education about the medication’s effects, and increased chance of side effects (Russell, Conn, & Jantarakupt, 2006).

• In the 2003 NSDUH, older adults (65 years and older) comprised 13% of the population but used approximately 33% of all prescribed medications in the U.S. (National Institute on Drug Abuse, 2007).
• Risks associated with medication error include adverse physical reactions, cognitive impairments, falls, and bone fractures (National Institute on Drug Abuse Research Report Series, undated).
• Intentional medication overuse among older adults may be associated with efforts to deal with chronic, untreated, or undertreated pain.
• Further research is needed on the exposure to abusable prescription medications and the prevalence of prescription drug abuse and dependency among older populations. The settings for research should include individuals in long-term care facilities and emergency rooms, as well as those in the community (Simoni-Wastila & Yang, 2006).

Older adults are more likely than any other age group to use both prescription and over-the-counter medications. Many prescription drugs are counter-indicated with alcohol use. Medication misuse among older adults may be intentional or unintentional. The area of medication mismanagement, especially if it is unintentional, is not one that has been addressed by substance abuse treatment professionals. In treating older adults, professionals will need to be knowledgeable about medications, medication interactions, and possible medication mismanagement problems—both intentional and unintentional.

Herbal Remedies

• Herbal remedies have become an important aspect in self-care among older adults.
• Approximately 25% of Asians and Hispanics in a large population study reported using herbal remedies. Close to 10% of African American and White older adults reported use of herbal remedies (Arcury et al., 2007).

Herbal and other home remedies have not been included in many studies of drug use among older people. Further research is necessary to understand the role these remedies play in development of medication misuse and substance-related disorders among older people. In addition to prescription medications misuse, herbal remedies are increasing in popularity, especially among specific ethnic groups, and may also be misused. Cultural beliefs and traditional healing and health customs often involve use of substances indigenous to an older adult’s homeland. Many herbal substances may have toxic side-effects, harmful additives, or interact adversely with prescription medications. Some older members of specific cultural groups may depend heavily on herbal remedies even though they may have lived in the U.S. for many years. Traditionally, substance abuse professionals have not addressed medication management and herbal remedy use. However, this is likely to increase as an area of substance abuse treatment among older (and younger) adults in the population.

References

American Lung Association. (2007). Smoking among Older Adults Fact Sheet. Retrieved February 1, 2008, from http://www.lungusa.org/site/pp.Asp?c=dvLUK90oE&b=39862.

American Psychiatric Association. (2004). Diagnostic and statistical manual of mental disorders. Fourth Edition. Text Revised. Washington, DC: American Psychiatric Association.

Arcury, T., Grzywacz, J., Bell, R., Neiberg, R., Lang, W., & Quandt, S. (2007). Herbal remedy use as health self-management among older adults. Journal of Gerontology: Social Sciences, 62B(2), S142-S149.

Addiction Treatment Forum. (2003). The further “graying of methadone.” Addiction Treatment Forum. Winter, 12, 4-5.

Anderson, T., & Levy, J. (2003). Marginality among older injectors in today’s illicit drug culture: Assessing the impact of ageing.Addiction, 98, 761-770.

Bartels, S. (2006). The aging tsunami and geriatric mental health and substance use disorders. Journal of Dual Diagnosis, 2(3), 5-7.

Bartels, S., Blow, F., Brockmann, L., & Van Citters, A. (2005). Substance abuse and mental health among older Americans: The state of the knowledge and future directions. Older Americans Substance Abuse and Mental Health Technical Assistance Center: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Prevention.
Retrieved November 15, 2007, from http://www.samhsa.gov/OlderAdultsTAC.

Bartels, S., Blow, F., Van Citters, A., & Brockmann, L. (2006) Dual diagnosis among older adults: Co-occurring substance abuse and psychiatric illness. Journal of Dual Diagnosis, 2(3), 9-30.

Blow, F., Walton, M., Barry, K. Coyne, J., Mudd, S., & Copeland, L. A. (2000). The relationship between alcohol problems and health functioning of older adults in primary care settings. Journal of the American Geriatrics Society, 48(7), 769-774.

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Document Date: September 11, 2009

Kathleen J. Farkas, PhD Case Western Reserve University, Mandel School of Applied Social Sciences
Laurie Drabble, PhD  San Jose State University, School of Social Work.

Strengths and Vulnerabilities Associated With Older Age and Substance Use
 
While there are many unknowns about the prevalence and incidence of alcohol and drug use in future older cohorts, some concomitants of the aging process are important to note in the assessment and treatment of older adults.

Age-related Physiological Changes

• In general, increases in chronological age bring decreases in lean body mass, increases in the percentage of body fat, and decreases in absorption, distribution and disposition of alcohol, drugs and medications (Steiner, 1996).
• Age-related physical changes serve to increase the effects of alcohol and other drugs on older people (U.S. Department of Health and Human Services, 1998).
• The various physiological changes associated with aging have a significant impact on an older adult who uses or misuses alcohol or drugs, since these substances can have potentially harmful effects in older adults, even at low levels of consumption (U.S. Department of Health and Human Services, 1998).
• Age-related pharmacokinetic and pharmacodynamic changes result in an increased sensitivity to alcohol, prescription drugs, over-the-counter drugs, and other substances in older adults.
• Pharmacokinetics (the process by which drugs are absorbed, distributed, metabolized and eliminated by the body) changes with age and has a significant impact upon the efficacy of prescription drug use in the older person (Dowling, Weiss, & Condon, 2008). Prescription drugs may cause potentially adverse reactions in the individual if the physiological changes of aging are not considered.

The physical changes that accompany aging are important to understand because they often have a direct impact on the effects of alcohol and other drug use in older adults. Because of these metabolic and body composition changes, appropriate quantities and frequencies of alcohol and various drug use must be evaluated and standardized for older age groups. Alcohol use has a profound physiological effect on older adults because of the decrease in lean body mass versus total body mass, which results in a decrease in total body volume, as well as decreased efficiency of liver enzymes that metabolize alcohol.

Risk of alcohol or drug-related problems may be associated with much lower consumption levels in older adults than in younger populations. However, chronological age is not the only risk factor for the many diseases and problems related to age. Care needs to be taken in designing studies, recruiting appropriate samples, and interpreting data to understand the relationships between age and other factors and risks for particular problems in later life (Kaplan, Haan, & Wallace, 1999).

The Aging Brain

• Age-related changes in the brain itself, effects of past substance use on the aging brain, and the impact of current substance use on the aging brain are all important for understanding the etiology of substance-related problems in older people (Dowling, Weiss, & Condon, 2008).
• The literature contains minimal information on how illicit drugs may affect the aging physiological processes; however, there is some understanding of how the brain changes throughout the lifespan. This understanding of the brain implies a need for special consideration of the effects and consequences of alcohol and other drug use in older populations (Dowling, Weiss, &Condon, 2008).

The 1990s were declared the decade of the brain. The National Institutes of Health initiatives widely focused on addiction as a brain disease, and researchers and clinicians showed increased interest in neurobiological aspects of the etiology and treatment of substance use disorders (Spence, DiNitto, & Straussner, 2001). These topics will most likely be popular areas of research as the prevalence of substance-related problems among older adults increases and as brain imaging technology improves and becomes more accessible to the research community.

Substance Use and Health among Older Adults

• As a result of age-related physiological changes, substance use, particularly alcohol use, can trigger or exacerbate medical problems (U.S. Department of Health and Human Services, 1998).
• There are gender differences in health risks related to alcohol consumption. For example, growing evidence suggests a relationship between alcohol consumption and risk of breast cancer in women (Aronson, 2003).
• In a study of 211 primary care medical patients, older women were more likely than older men to stop drinking in response to health problems (Satre & Areán, 2005).
• In a small, unpublished study of people diagnosed with possible or probable Alzheimer’s disease, heavy smoking and heavy drinking in middle age were associated with earlier onset of symptoms of dementia (Edelson, 2008).
• Studies show that long-term illicit drug use, particularly amphetamine and cocaine abuse, may predispose an individual to premature atherosclerosis, ventricular hypertrophy, and cardio-myopathy; these conditions may have severe consequences in an older individual who is already prone to aging-related cardiovascular disease (Dowling, Weiss, &Condon, 2008).
• With increases in substance use and abuse in older cohorts comes increased risk for HIV/AIDS (Topolski, Gotham, Klinkenberg, O’Neill, & Brooks-Ashley, 2002).

As a result of the age-related physiological changes, substance use, particularly alcohol use, can trigger or exacerbate medical conditions including an increased risk for hypertension, heart problems, and stroke; impaired immune system and capacity to combat infection and cancer; liver disease; decreased bone density; gastrointestinal bleeding; and malnutrition (U.S. Department of Health and Human Services, 1998). The association between substance use, health, and medical problems among older adults presents issues in assessment, treatment, and prevention for substance abuse professionals. Understanding the complex relationships between substance use, health, and specific medical problems among older adults provides important avenues for intervention and health promotion activities.

Among the emerging health issues for addictions professionals working with older adults is HIV infections and AIDS (Emlet & Farkas, 2001). While there is relatively little empirical work on this issue, the need to develop specific educational and treatment strategies to decrease HIV/AIDS risk is well documented (Topolski, Gotham, Klinkenberg, O’Neill, & Brooks-Ashley, 2002).

• Evidence from a prospective cohort study provides support for the hypothesis that alcohol consumption may be associated with lower risk for coronary disease in older adults (Mukamal et al., 2006).

Another important area for future study includes the relationship between alcohol consumption and cardiovascular health among older adults. Age- and gender-specific quantity and frequency tables developed from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) can be used to provide normative feedback to individuals and groups (Chan, Neighbors, Gilson, Larimer, & Marlett, 2007). However, the NIAAA guidelines still suggest one drink per day for all adults over 60.

Drug Interactions

• Negative interactions between psychoactive medications and alcohol can be harmful for an older person. Benzodiazepines, barbiturates, and antidepressants are particularly hazardous when combined with alcohol because of risk for harmful interactions (U.S. Department of Health and Human Services, 1998).
• Many psychoactive medications impair alertness and cognitive functioning and may lead to an increase in blood alcohol levels (Moos, Schutte, Brennen, & Moos, 2004). Smoking also compromises the performance of some prescription drugs resulting in a need for a potentially higher dose of psychoactive medication to achieve the same result (U.S. Department of Health and Human Services, 1998).

The interactions between prescribed or over the counter drugs and alcohol or other substances are of particular concern for older adults because of their increased sensitivity and because of their increased use of all types of medications. Inclusion of over-the-counter and prescription drug use is an important aspect of alcohol and other drug screening for older adults.

Social Context of Later Life and Substance Use

• Sociological changes and context in older adulthood play a critical role in the prevalence of substance use, abuse, and dependence in older adults.
• Moos, Schutte, Brennan, and Moos (2004) note that life context (such as role changes, loss, or death of loved ones) and coping factors are strongly associated with late-life drinking, though it is not clear whether these sociological effects increase an already present drinking habit or predict a future one.
• Being divorced or separated, without health insurance, and in relatively poor health are associated with increased rates of nonmedical use of psychotherapeutic drugs (analgesics, stimulants, and sedatives/tranquilizers), according to the National Household Survey on Drug Abuse, 1994-2002 (Zarba, Storr, & Wagner, 2005).

Various sociological changes across the life-span may increase the risk for substance use or abuse. An increase in these changes in older adulthood may play a significant role in assessing an older individual for substance use, misuse, abuse, and/or dependence. Zarba et al. (2005) found that older persons who used alcohol or tobacco were approximately twice as likely as non-users to also have used psychotherapeutic drugs non-medically in the previous year.

A consistent predictor of substance use in later life, particularly alcohol use and abuse, is family and friends’ approval of the individual’s drinking. Families and friends who promote heavy drinking do so at all stages of the life span. Moos et al. (2004) noted that comparable to recommendations for young adult alcohol users, older individuals “should embed themselves in a social network composed of low- or non-drinking peers” (p. 836).

Sociological changes in later life may also serve as a protective factor, particularly for older women. According to Moos et al. (2004), the frequency of alcohol consumption among older women drinkers declined throughout the 10-year study, and this may be attributed to social circumstances that differ from those of older men; i.e., women are less likely to be married and possibly less likely to participate in social functions where alcohol is available. Cultural issues, including gender, racial/ethnic identification, sexual orientation, and socioeconomic status, all influence the social context of aging and substance use. Sensitivity to these differences and perspectives is important for understanding the social context of aging and working with older adults in the substance abuse treatment arena.

• Sociological factors include significant cohort effects.

Few studies have assessed the impact of cohort effect on older adults and substance abuse, although many authors and researchers speculate that it plays a significant role in current and future generations of older persons. For example, Moos et al. (2004) found an overall 10-year decline in the alcohol consumption habits of their participants and attributed some influence on these findings to the history (less social acceptance of alcohol use due to prohibition) of the cohort they studied. The challenge will be to separate cohort effects in consumption habits and attitudes from the physiological effects of aging in future studies.

• Data from a retrospective analysis of the 1996 Medical Expenditure Survey (MEPS) show that a relatively high education level is a common predisposing factor for sedative/hypnotic drug usage among community-dwelling older adults; those with high school degrees including those who went on to obtain undergraduate degrees were more likely to use sedatives and/or hypnotic drugs than were those with no degrees (Aparasu, Mort, & Brandt, 2003).

Later life is a time of many physiological and social changes. These changes may impact decisions to use or to stop using alcohol and other drugs. The balance of social forces in the lives of older adults can be important in understanding the use of substances, the motivation for treatment, and the support to foster recovery.

Changes in sensory ability and the presence of sensory impairments can also limit social resources in later life. Hearing or vision loss can be mistaken for dementia or depression and need to evaluated. Hearing or vision loss can affect assessment as well as treatment participation among older adults.

References

Aparasu, R., Mort, J., & Brandt, H. (2003). Psychotropic medication expenditures for community-dwelling elderly persons. Psychiatric Services, 54(5), 739-742.

Aronson K. (2003). Alcohol: A recently identified risk factor for breast cancer. Canadian Medical Association Journal, 168, 1147-1148.

Chan, K., Neighbors, C., Gilson, M., Larimer, M., & Marlett, G. (2007). Epidemiological trends in drinking by age and gender: Providing normative feedback to adults. Addictive Behaviors, 32, 967-976.

Dowling, G., Weiss, S., & Condon, T. (2008). Drugs of abuse and the aging brain. Neuropsychopharmacology, 33, 209-218.

Edelson, E. (2008, April 16). Smoking, drinking, cholesterol may be Alzheimer’s risk factors. HealthDay:News for Healthier Living. Retrieved on April 19, 2008, from http://jointogether.org/news/research/summaries/2008/middle-aged-drinking-smoking.html.

Emlet, C. & Farkas, K. (2001). A descriptive analysis of older adults with HIV/AIDS in California. Health & Social Work, 26(4), 226-234.

Kaplan, G., Haan, M., & Wallace, R. (1999). Understanding changing risk factor associations with increasing age in adults. Annual Review of Public Health, 20, 89-108.

Moos, R., Schutte, K., Brennen, P., & Moos, B. (2004). Ten-year patterns of alcohol consumption and drinking problems among old women. Addiction, 99, 829-838.

Mukamal, K., Chung, H., Jenny, N., Kuller, L., Longstreth, W., Mittleman, M., et al. (2006). Alcohol Consumption and risk of coronary heart disease in older adults: The cardiovascular health study. Journal of the American Geriatrics Society, 54(1), 30-37.

Satre, D., & Areán, P. (2005). Effects of gender, ethnicity and medical illness on drinking cessation in older primary care patients. Journal of Aging and Health, 17(1), 70-84.

Seiner, J. (1996). Pharmacotherapy problems in the elderly. Journal of the American Pharmacy Association, 36, 431-437.

Spence, R., DiNitto, D., & Straussner, S. (Eds.) (2001). Neurobiology of additions: Implications for clinical practice. New York: The Haworth
Social Work Practice Press.

Topolski, J., Gotham, H., Klinkenberg, D., O’Neill, D., & Brooks-Ashley, R. (2002). Older adults, substance use and HIV/AIDS: Preparing for a future crisis. Journal of Mental Health and Aging, 8(4), 349-363.

U.S. Department of Health and Human Services (1998) Substance Abuse among Older Adults: Treatment Improvement Protocol (TIP) Series 26. (DHHS Publication No. (SMA) 98-3179) Rockville, MD: Public Health Service. Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.

Zarba, A., Storr, C., & Wagner, F. (2005). Carrying habits into old age: Prescription drug use without medical advice by older American adults. Letter to the Editor. Journal of the American Geriatrics Society, 53(1), 170-171.

Document Date: September 11, 2009 

Kathleen J. Farkas, PhD  Case Western Reserve University, Mandel School of Applied Social Sciences
Laurie Drabble, PhD  San Jose State University, School of Social Work

Detection of Substance Use, Abuse, and Dependence Among Older Adults

• Both health care and substance abuse professionals frequently underestimate or misunderstand problems related to substance use among older adults.
• There are a number of barriers that explain why professionals underestimate or misunderstand problems related to substance use among older adults

A number of factors contribute to the under-detection of substance use and substance-related problems among older adults. Beullens and Gertgeerts (2004) catalogue earlier studies that have linked a variety of factors to under-detection of alcohol use and abuse among older adults: the similarity of age-related health problems and substance abuse symptoms (Thibault & Maly, 1993); the relationship between decreased consumption and desired mood state (Thibault & Maly, 1993); stereotypic understanding of alcohol problems among professionals (Curtis, Geller, Stokes, Levine, & Moore, 1989); and use of unreliable self reports and age-insensitive screening instruments (Graham, 1986).

Similar factors affect assessment for substances other than alcohol (King, van Hasselt, Segal, & Hersen, 1994; Lynskey, Day, & Hall, 2003). Menninger (2002) details the barriers to identification of alcohol problems in older people including the following: 1) stereotypic thinking about alcohol and people who have alcohol-related problems; 2) pessimism about treatment and lack of knowledge about treatment; 3) feelings of stigma or shame that lead to underreporting or denial; 4) placing too much emphasis on alcohol-related consequences associated with work, legal problems, or family conflicts; 5) overlap of medical conditions and alcohol-related health problems; and 6) unintentional use of alcohol or other substances contained in over-the-counter medications.

Families may create barriers to screening and assessment by trying to protect or minimize an older adult’s substance use and related problems. Stigma associated with alcohol and other drug use has been discussed as a barrier among older adult cohorts. A number of publications address barriers to screening and assessment among older cohorts; however, these barriers and other issues of age-related stigmas and social taboos related to substance use and abuse have not been explored systematically.

• Detection of substance use, abuse, and dependence among older adults relies most often on self-report.
• Research on barriers to screening and assessment should examine differences in stigma among and between different cohorts of older adults and their families.

As in younger adults, detection and assessment of substance use, abuse, and dependence in older adults relies heavily on self-report. Because of this reliance on self-report, interviewers must be able to ask questions about alcohol and other drug use in a non-judgmental and supportive manner and know how to use screening tools that have demonstrated reliability and validity with older adults.

Frequency and Patterns of Use Questions

• Patterns and changes in patterns of alcohol use and expectancies of alcohol use can be helpful in detection and assessment efforts with older adults.
• Questions about frequency of use are as important as quantity in assessing older people.
• Questions about reasons for use and patterns of use (frequency of use and amount consumed) should be repeated annually as part of annual health screenings for all older adults (Blow, 2000).
• Satre and Knight (2001), in a study of patterns of alcohol use in a small convenience sample, found older people consumed less alcohol per occasion than younger people, but that older people reported more drinking occasions per month than younger people.

Satre and Knight (2001) concluded that “quantity and frequency appeared to compensate for one another in the total quantity of alcohol consumed” (p. 77). In a small convenience sample, the majority of those who drank alcohol said they drank for social reasons and enjoyment (Kahn, Wilkinson, & Keeling , 2006). A beginning assessment of alcohol use might well focus on social opportunities for drinking alcohol.

• Studies show a relationship between an older person’s beliefs about alcohol’s effects and his or her alcohol consumption (Satre & Knight, 2001).

In the Satre and Knight study (2001), older people showed lower levels of positive attitudes towards alcohol use than younger people. Both positive and negative beliefs about alcohol were related to alcohol use among older men. Among older women, negative attitudes were related to less alcohol use.

• Currently, research on the cohort effects of alcohol expectancies is limited.

There is a need for longitudinal analysis of attitudes regarding alcohol and how attitudinal changes are related to decisions about alcohol use. Future research should focus on the ages at which changes in attitudes toward alcohol use occur and under what circumstances.

Kahn, Wilkinson, and Keeling (2006) found that older people reduce their use of alcohol due to health concerns or encouragement from family and friends. There is a continuing debate on the nature of the relationship among alcohol use, traumatic loss, and depression among older adults (Colleran, 2002; D’Agostino, 2003; Shafer, 2004), indicating a need to develop systematic empirical investigations of these relationships in assessing alcohol and other drug use among older adults.

Early and Late Onset among Older Persons

• Early- and late-onset groupings have been used to characterize need and prognosis of older people with alcohol-related problems (Rosin & Glatt, 1971; Liberto, Oslin, & Ruskin, 1992).

Early onset drinkers have been described as people whose problematic alcohol use begins early and continues through life. Increased rates of psychiatric comorbidity have been associated with early onset groups (Schonfeld & Dupree, 1991; Atkinson, 1990). However, there is disagreement about what age should be used as the cut-off, and studies use different definitions of what should be considered “early” (U. S. Department of Health and Human Services, 1998). Late-onset drinkers have been described as those who develop alcohol-related problems later in life, but age cut-offs for this group have also varied.

• Stresses and losses of later life have been posited as triggers for late-onset alcoholism, but research has not generally supported these relationships (Gomberg, 2003).

Wetterling, John, Veltrup, and Driessen (2003) examined the data from 286 admissions to an alcohol detoxification program and compared early onset alcoholism (age <25) with late onset alcoholism (age > 45) and reported that late-onset individuals were more likely to have a familial history of alcoholism, had fewer detoxifications, suffered less psychiatric co-morbidity, and had a higher abstinence rate at 12 months post-treatment. In a recent literature review, Wood (2006) presented a theoretical discussion of older drinkers’ decisions to drink that is relevant to the discussion of onset classifications. Onset remains an important question in the study and treatment of alcohol and other drug abuse among older adults and is an area in need of continued research.

Alcohol Screening and Assessment among Older Adults

• Most screening and assessment tools are tied to DSM criteria, which are less appropriate for older than younger populations.
• Few alcohol abuse screening tools have been developed specifically for use with older people. Research on sensitivity and specificity of standardized screening tools in older populations is growing, but the information is not definitive.
• Effective screening depends on assessment setting, client characteristics, prevalence of alcohol use in the population, and cultural context.
• Screening and assessment should focus on both current and lifetime use of alcohol and other drugs.
• Some screening tools developed for use with younger populations do not adequately identify problems related to alcohol use among older adults.

Screening and assessment tools in AODA have focused on younger people and often miss problems in older populations. Practitioners must understand the need to tailor interviewing approaches and styles to facilitate a trusting and supportive relationship with the older person and his or her family, as appropriate. Questions should be stated clearly and with a non-judgmental attitude regardless of which approaches or tools are used.

• The most commonly used alcohol abuse screening tools for adults include the CAGE (Mayfield, McLeod, & Hall, 1974); MAST (Selzer, 1971); AUDIT (Saunders, 1993); AUDIT-C (U.S. Department of Health and Human Services, 2001) and ARPS and short ARPS (shARPS) (Fink, 2002); however, none of these tools were developed specifically for older adults.
• Screening tools specifically developed or adapted for use with older adults provide higher levels of sensitivity to and specificity of alcohol-related problems, though there are few such tools. The MAST-G, developed specifically for use with older adults (Blow et al., 1992), has been shown to be a high quality screening tool for use with older people in both clinical and community settings.
• Future research should focus on appropriate cut-off scores for screening tools to balance specificity and sensitivity.
• Future research is needed on screening tools that can accurately detect alcohol-related problems with cognitively impaired older persons and those with psychiatric illnesses.

The DSM criteria for alcohol or drug abuse and alcohol or drug dependence provide the base for most of the questions in the available tools. Since older adults are less likely to suffer the consequences addressed in these tools, such as legal or work-related problems from their use, screening tools based strictly on DSM criteria have diminished utility for identifying alcohol-related problems (Beullens & Aertgeerts, 2004; O’Connell et al., 2004). The MAST-G (Blow et al., 1992) was specifically designed to capture alcohol-related consequences among older people (Conigliaro, Kraemer, & McNeil, 2000).

Systematic reviews have compared commonly used self-report screening tools (O’Conell et al., 2004; Beullens & Aertgeerts, 2004). The MAST-G, used with a score of five or more as a cut-off, was found to be a sensitive screening instrument for use with older adults in a clinical setting, but specificity results indicate false positives are possible with this tool.

The CAGE, used with a cut-off score of two, was found to have low sensitivity (13%), but very high specificity (98%) in clinical settings; it is seen as a useful first-screening tool, especially in settings where clients have a high prevalence of alcohol-related problems. The CAGE was less useful in community settings, and its sensitivity was low in psychiatric populations.

In a study of 166 drinkers aged 60 and older who were patients at outpatient primary care clinics, Moore and colleagues compared the results from ARPS and the shARPS (Moore, Beck, Babor, Hays, & Reuben, 2002). Both were sensitive for identifying older drinkers, especially those classified as harmful or hazardous drinkers.

Co-Occurring Conditions Screening and Assessment among Older Adults

• Alcohol use and depression can present a difficult diagnostic problem among older people. Alcohol use among depressed older adults does not always meet criteria of abuse or dependence, but it can nevertheless be problematic (Blow, Serras, & Barry, 2007). Alcohol can exacerbate depression, and depression can exacerbate alcohol use—making the assessment process complex.

Alcohol and other drug abuse problems among older adults are often associated with depression and cognitive status and other issues of dual diagnoses (Bartels, Blow, Van Citters, & Brockmann, 2006). Depression and smoking tobacco have been linked in a sample of older HMO members (Green, Polen, & Brody, 2003). Risk for suicide should be a part of a thorough depression assessment with older adults. A frequently used scale to screen for depression is the Hamilton Rating Scale for Depression (Hamilton, 1960), which consists of 21 items, each rated in terms of severity. The reliability in samples of older adults is .73 (Riskind, Beck, Brown, & Steer, 1987).

• Cognitive problems should be ruled out or identified during the screening and assessment process with older adults.

The Mini Mental State Exam (MSSE) is a 30-item scale with brief measures of attention and concentration, orientation, language, and executive control (Folstein, Folstein, & McHugh, 1975). Scores must be adjusted to reflect differences in education levels.

In a study of substance abuse treatment initiation, older male veterans (aged 55+) with better cognitive status were more likely to initiate substance abuse treatment (Satre, Knight, Dickson-Fuhrmann, & Jarvik, 2004). Data from the Second Longitudinal Study of Aging indicated that an average of one drink or less each day was protective for women to maintain cognitive functioning, but not for men (McGuire, Ajani, & Ford, 2007). However, caution was suggested in using this finding as a guide because of other risks of alcohol consumption.

Tobacco Screening and Assessment among Older Adults

• Research findings are clear that smoking cessation can improve health outcomes for older adults across a range of conditions and demographic groups (Fiore, Bailey, & Cohen, 2000).
• Smoking cessation can be especially challenging for older adults because most are chronic smokers who experience a variety of barriers to change (Appel & Aldrich, 2003).

Fisher and colleagues (2008) found that older cohorts of smokers were more likely than younger cohorts to deny smoking. Some have argued that older adults can benefit the most from smoking cessation efforts because they have been smoking the longest, have high levels of nicotine dependence, lifelong psychological dependence on tobacco, and are more vulnerable to smoking-related health problems (American Lung Association, 2007).

• Screening for tobacco use should involve clear questions about tobacco use and a non-judgmental attitude. The five As (Ask, Advise, Assess, Assist, and Arrange for follow-up) provide a framework for assessment and intervention for older adults who use tobacco (Rigotti, 2002; Andrews, Heath, & Graham-Garcia, 2004).
• The role of social taboo should be considered in the development of screening and assessment techniques, since denial of smoking has been found to increase with age in one national study (Fisher, Taylor, Shelton, & Debanne, 2008); 25% of smokers, as determined by biomarker testing, in the 75+ age group denied use. Research on tobacco screening and assessment has not focused on older adults and there is a need to understand differences and similarities among various age cohorts.
• Frail elderly participants in a community health service who continued to smoke cigarettes sought health services at an earlier age than non-smokers did, drank alcohol regularly, and obtained cigarettes without assistance (Haas, Eng, Dowling, Schmitt, & Hall, 2005).
• The Fagerstrom test is a six-item screening tool for detecting severity of nicotine dependence. Though not developed for specific use with older adults, it is a commonly used clinical and research tool (Heatherton, Kozlowski, Frecker, & Fagerstrom, 1991; Andrews, Heath, & Graham-Garcia, 2004).

Scoring for the Fagerstrom test is standardized: 0 to 4, low; 5, medium; 6 or 7, high; and 8 to 10, very high nicotine dependence. A score of 7 or more may indicate more severe withdrawal symptoms. This scoring system has not been validated with older adults.

• Policy research has indicted a relationship between state tobacco control program expenditures and reductions in smoking among adults, but information specific to older adults was not included (Farrelly, Penchacek, Thomas, & Nelson, 2008).

There is clearly a need for additional research in the area of age appropriate tools for screening and detection of tobacco use among older adults.

Medication Misuse Screening and Assessment among Older Adults

• Medication misuse is a broad topic that involves several types of medication problems (U.S. Department of Health and Human Services, 2006).
• Poly-pharmacy is another broadly based term used to describe medication use that is not clinically warranted (Zarowitz, 2006).
• Medications, both prescription and over-the-counter, can interact with each other and with alcohol and/or street drugs, causing difficulties in diagnosis and assessment (Meadows, 2006).

Older adults may take the wrong medications because of prescribing errors on the part of the physician. Older adults may also incorrectly use medications because they have cognitive deficits, they do not understand the instructions for proper use, or they do not have the resources to obtain adequate supplies of a medication. Medication misuse may arise because older adults attempt to self-treat pain and/or other conditions. Misuse of prescription medications, especially opiate drugs, can lead to substance abuse and substance dependence in all age groups. Substance abuse treatment professionals are typically most interested in the use and abuse of prescription drugs with addiction potential.

Gerontological social workers or hospital or health care social workers are often responsible for assessing medication misuse among older adults. However, the increase in the numbers of older adults seeking treatment for substance abuse problems provides a rationale for teaching substance abuse professionals how to screen for medication misuse as part a routine assessment for substance-related problems.

 

• Assessment for medication misuse begins with “The Brown Bag Review” (Colt & Shapiro, 1989).

The Brown Bag Review method requires the older adult to bring all of his or her medications in their original containers and to discuss their use with the health care provider. This method of assessment requires that the provider understand different types of medications, their utility in older adult populations, and possible interactions and side effects. Included in the “The Brown Bag Review” should be all prescription medications, over-the-counter medications, herbs, vitamins, dietary supplements, and topical treatments such as ointments and creams (Meadows, 2006).

Situations that may increase the risk of medication misuse (Bergman-Evans, Adams, & Titler, 2006) include 1) self management/treatment of physical and mental health problems, 2) absence of coordinated health care, 3) an older adult’s impaired cognitive status, and 4) an older adult’s complicated medication regimen.

• Chronic pain is often a reason for misuse of prescription medications or drug-seeking behaviors (Trafton, Oliva, Horst, Minkel, & Humphreys, 2004).

Misuse of prescription drugs with addiction potential includes sharing medications, using high doses for a longer time than prescribed, and recreational rather than medical use. The two major classes of prescription drugs abused by older adults are benzodiazepine sedative-hypnotics and opioid analgesics (Simoni-Wastila & Yang, 2006). Younger people with a history of alcohol or drug abuse problems are known to be at risk when exposed to controlled substances (Isaacson, Hopper, Alford, & Parran, 2005), but this risk has not been well studied among older adults (Menninger, 2002).

The risk factors for medication mis-management are the same regardless of age. These factors include being female, social isolation, poor health status, chronic physical illness, previous and/or current substance use disorder, and previous/current psychiatric illness (Simoni-Wastila &Yang, 2006).

• Research on medication effects and misuse specific to older adults is needed.

Research on medication effects—both prescription and over-the-counter—must include adequate samples of older adults from various settings and cultural groups. Commonly used research measures of inappropriate drug use are of limited use with older adults. Future research on psychoactive drug use should incorporate clinical assessment, target symptom measures, measures of functional status, and consensus-based criteria for appropriate drug and dosage (Talerico, 2002).

Illicit Drug Screening and Assessment among Older Adults

• Research on illicit drug screening and assessment specific to older adults is limited.

The empirical literature on illicit drug use among older adults is limited, and no tools have been developed to assess illicit drug use specifically among older adults. Questions about previous drug use and drug-related problems are useful because of the high correlation of current use with lifetime patterns of use (Rivers et al., 2004; Simoni-Wastila &Yang, 2006).

Over the next decade, clinicians and researchers should collaborate to develop screening and assessment tools for illicit drug use and drug-related problems among older adult cohorts with special emphasis on marijuana and non-medical use of prescription drugs.

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Document Date: September 11, 2009

Kathleen J. Farkas, PhD  Case Western Reserve University, Mandel School of Applied Social Sciences
Laurie Drabble, PhD  San Jose State University, School of Social Work

Treatment and Intervention

Impact of Demographic Changes on Substance Abuse Treatment Systems

• Expected changes in the age structure of the U. S. population over the next 15 to 20 years will have an impact on the substance abuse treatment system.
• Social workers and other substance abuse treatment professionals must develop appropriate treatment skills and effective treatment approaches to address older adults who experience alcohol and other drug misuse, abuse, and dependence.

A number of older adults in need of treatment today are not receiving care because of the failure of professionals to recognize the problem, the reluctance of older individuals and families to access substance abuse treatment, and/or the lack of insurance or funds to pay for treatment (U.S. Department of Health and Human Services, 1998). Models developed from the National Household Survey on Drug Abuse indicate that the number of adults aged 50+ in need of treatment will increase from 1.7 million in 2000-2001 to 4.4 million in 2020 (Gfoerer, Penne, Pemberton, & Folsom, 2003; Office of Applied Studies, 2005). The cohorts of aging “baby boomers” (those born between 1946 and 1964) who have used and or abused alcohol and other drugs throughout life are expected to create a “demographic tsunami” for substance abuse and mental health treatment systems (Bartels, 2006).

Satre, Mertens, Areán, and Weisner (2003) reported that the older adults in treatment programs (aged 55+) had higher rates of alcohol dependence, lower rates of drug dependence, and lower psychiatric symptoms compared to the younger adults (40-54 and 18-39) in treatment. Differences in baseline characteristics may also influence treatment retention and outcomes. In a study of male veterans, the older men had similar alcohol consumption and dependence symptoms, but had fewer alcohol-related problems and fewer symptoms of psychiatric distress compared to younger men (Lemke & Moos, 2003).

Substance Abuse Treatment Use Among Older Adults

• Substance abuse treatment facilities have always provided care to older adults, but the majority of people admitted for treatment have been younger than 50.

In 2001, 143,900 persons admitted for treatment were aged 50 and older (8%); by 2005 184,400 were aged 50 or older and represented 10% of all those admitted (Substance Abuse and Mental Health Services Administration, 2007).

The Treatment Episode Data Set (TEDS) provides a description of persons older than 50 across the U.S. among three types of service treatment settings. TEDS data can be analyzed by specific age groups: 50 to 54, 55 to 59, 60 to 64, 65 to 69, and 70 and older. Among older adults, those admitted for treatment were more likely to be younger than older: 58% were between 50 and 54, 25% were between 55 and 59, and 17% were aged 60 and older.

• Proportion of White persons admitted increased by age; the proportion of Blacks decreased by age.
• Alcohol was the most frequently reported drug of choice, and opiates were the second most frequently reported drug of choice among those older than 50.
• Alcohol was the primary substance for those aged 65-69 and 70+.
• Opiates were most frequently the drug of choice for persons aged 50-54 and 55-59. These groups also had the highest proportion of admissions for cocaine, marijuana, and stimulants.
• Younger persons admitted tended to report more extensive histories of substance abuse treatment than older ones did; 15 to 20% of the groups aged 50 to 64 had five or more prior treatments; 9 to 7% of the groups aged 65+ had had five or more prior treatments.
• Most older persons admitted were treated in ambulatory settings: 55% of the younger groups (aged 50 to 54, 55 to 59, and 60 to 64) were in ambulatory settings, and 61% to 63% of the older groups (aged 65+) were in ambulatory care. Older persons also sought treatment in detoxification and/or rehabilitation settings.
• Of those admitted for treatment, the oldest group (aged 70+) was more likely than the youngest group (aged 50-54) (13%) to include veterans (31%).

Older adults in need of substance abuse treatment are not a homogenous group. The TEDS provides a snapshot of the similarities and differences among age cohorts older than 50 in treatment for substance abuse and offers a glimpse of what changes may be in store (Substance Abuse and Mental Health Services Administration, 2007).

Motivational Strategies for Assessment and Treatment

• Hanson and Gutheil (2004) applied several types of motivational strategies to social work practice with older adults using alcohol. Their recommendations, while not empirically tested, provide useful information for the substance abuse practitioner interested in improving assessment skills with older adults.
• Supportive, non-confrontational approaches have been used in age-specific treatment programs for older adults and have been associated with positive outcomes (Blow, Walton, Chermack, Mudd, & Brower, 2000; Kashner, Rodell, Ogden, Guggenheim, & Karson, 1992).

Few empirical studies have addressed the use of motivational interviewing techniques with older adults. However, motivational interviewing has provided a strategy for behavior and attitudinal change in substance abuse treatment (Miller & Rollnick, 2002). Motivational strategies offer professionals a range of stages of change and specific steps to engage clients at each of these stages. In a small study designed to study referral approaches, D’Agostino, Barry, Blow, and Podgorski (2006) found that a multi-dimensional approach involving motivational counseling as one component had greater referral rates to alcohol treatment services. Incorporation of motivational strategies into randomized studies of treatment access and assessment will improve the knowledge base.

Substance Abuse Treatment Outcomes for Older Adults

• Age-specific treatment programs as well as age-specific components embedded in mixed-aged treatment programs became popular in the early to late 1980s (Dupree, Broskowski, & Schonfeld, 1984) and have continued in use with older populations (U.S. Department of Health and Human Services, 1998).
• There is a limited, but growing, number of empirical investigations on the outcomes of treatment with older adults (Oslin, Pettinati, & Volpicelli, 2002; Lemke & Moos, 2003a, 2003b; Satre, Mertens, Areán, & Weisner, 2004; Satre, Mertens, & Weisner, 2004; Cummins, Bride, & Rawlins-Shaw, 2006).

The literature provides a number of descriptive studies of programs developed for older adults with alcohol and other drug problems. Outcome studies are important, but often difficult to compare because of differences in age cut-offs, outcome variables, and treatment components. In many studies, the sample sizes are small and the sites vary between inpatient and outpatient settings, and Veterans Affairs (VA) and community-based treatment.

Lemke and Moos (2002) compared older men (aged 55+) with matched samples of younger (aged 21-39) and middle aged (aged 40-54) men treated in substance abuse programs in the VA system and concluded that older men do as well as younger ones in a mixed-age setting. Initial differences in alcohol consumption, negative consequences of drinking, and psychological symptoms were associated with treatment outcomes. Older men reported drinking less, having fewer social consequences related to alcohol, and having fewer psychological symptoms compared to the younger men.

• Treatment adherence has been shown to be associated with age; older adults attend more treatment sessions and comply better with medication regimens for alcohol dependence as compared to younger adults (Oslin, Pettinati, & Volpicelli, 2002).

In a randomized, double-blind placebo-controlled efficacy trial of naltrexone for treatment of alcohol dependence, Oslin, Pettinati, and Volpicelli (2002) found that older adults (aged 55 and older) were more likely than younger ones to attend treatment sessions and to take medication as directed. These two variables were associated with less relapse.

Satre, Mertens, Areán, and Weisner (2004) compared 5-year outcomes from a managed care substance abuse treatment program and found age differences in drug dependence at base-line, 30-day abstinence rates, social supports, and treatment retention. The older age group (aged 55-74) was less likely to be drug dependent at baseline and had longer treatment retention than did younger groups (aged 40-54 and 18-39). The older group at the 5-year follow-up was more likely to report that family and friends did not encourage alcohol or drug use, and a larger percentage of the older group reported total abstinence in the past 30 days. In this study, older women were more likely than older or younger men to report 30-day abstinence. In a related study (Satre, Mertens, & Weisner, 2004), a higher percentage of women than of men in the older group (aged 55-77) reported abstinence from alcohol and drugs at the 6-month follow-up from treatment (79% of women vs. 54% of men).

Elder-specific programming is associated with better compliance and outcomes, and most often includes other programmatic components such as individualized treatment planning and motivational strategies. It is unclear if the age requirement is the only active component in these studies or if these other components also contribute (Blow et al., 2000; Oslin, Pettinati, & Volpicelli, 2002).

• Future research should focus on the interactions between age group and treatment strategy.

Few studies have analyzed any interaction between age group and treatment strategy. In a one study, Rice, Longabaugh, Beattie, and Noel (1993) used random assignment to explore differences between three treatments: 1)extended cognitive behavioral treatment; 2) relationship enhancement; and 3) vocational enhancement. For adults aged 50 and older, extended cognitive behavioral treatment showed the best outcomes in increased percentage of days abstinent and decreased percentage of heavy drinking days. The least favorable treatment outcomes for older adults were associated with vocational enhancement. In another study, Kashner et al. (1992) randomly assigned male veterans in alcohol treatment to mixed-age treatment or age-specific treatment. The age-specific treatment was built around principles of respectful and supportive interactions. Reported abstinence rates were twice as likely in the age-specific group, and the 60+ age group reported the most favorable responses.

• Outcome studies of treatment for drugs other than alcohol among older adults are limited, but this area of research is increasing.

Studies indicate that older adults can benefit from age-integrated alcohol treatment programs at least as much as younger adults do (Lemke & Moos, 2002; Lemke & Moos, 2003a, 2003b; Lofwall, Brooner, Bigelow, Kindbom, & Strain, 2005). For example, Lofwall and colleagues (2005) compared a group of older (aged 50-60) and younger (aged 25-34) men and women enrolled in an ambulatory opioid maintenance program. In comparison with findings from general population studies, both older and younger people had increased rates of psychiatric and substance abuse or dependence problems and had worse general health. Health status and functioning, however, were worse in the older group than in the younger group. The treatment program did not include age-specific or age-appropriate program components, but the older people showed a strong positive response to the program, as measured by low percentages of opiate-positive urine tests.

• Future outcome-based research should differentiate between age segregation and age appropriate strategies in determining treatment adherence and program outcomes.
• Outcome studies should examine interactions between age group and treatment intervention type.
• Studies of older adults need to include more women and members of racial/ethnic and sexual minority groups to determine the most effective treatments for these groups.

Older adults benefit from alcohol treatment programs (Dupree, Broskowski, & Schoenfeld, 1984; Carstensen, Rychtarik, & Prue, 1985; Kofoed, Tolson, Atkinson, Toth, & Turner, 1987; Kashner, et al., 1992; Rice et al., 1993; Schonfeld et al., 2000; Lemke & Moos, 2003; Blow et al., 2000; Satre et al., 2004) and opiate maintenance programs (Lofwall et al., 2005). Older women may have more favorable drinking outcomes than older men post treatment (Blow, 2000; Satre, Mertens, & Weisner, 2004). For at-risk older drinkers, an integrated system of care model may improve treatment engagement (Zanjani, Zubritsky, Mullahy, & Oslin, 2006). Case management may be a useful tool to increase treatment engagement among older adults (Atkinson, Misra, Ryan, & Turner 2003; Oslin, Pettinati, & Volpicelli, 2002). Factors including social supports, type of substance dependence, treatment retention, and gender interact with age and may provide insight into the relationship between age and treatment outcome (Satre et al., 2004). Stages of change, treatment readiness and motivational interviewing, concepts that have been adapted in AODA treatment for younger people, have been used in studies of health promotion with older people (Popa, 2005) and are beginning to be used in alcohol treatment studies with older people (Zanjani et al., 2006).

Another important area of research is the study of older adults with alcohol and other drug problems who are not in treatment. Walton, Mudd, Blow, Chermack, and Gomberg (2000) interviewed 78 older adult volunteers who met criteria for alcohol abuse or dependence and re-interviewed 48 of them 3 years later. Results showed that health problems (68%) and doctor recommendations (41%) were most common reasons people changed their drinking habits. Only 11% of the sample resolved their alcohol problems when alcohol consumption and alcohol-related consequences were considered. Consideration of alcohol use and alcohol-related problems as a health issue may provide a fruitful avenue for intervention for older adults. Brief treatment advice, usually provided by a physician or other health care professional has been shown to be an effective intervention to reduce alcohol consumption in older and younger adults (Moyer, Finney, Swearingen, & Vergun, 2002). In a randomized community-based study, Fleming, Manwell, Barry, Adams, and Stauffacher (1999) found that two 10- to 15-minute physician delivered education and counseling sessions decreased alcohol use, binge drinking, and excessive drinking over 12 months. The Screening, Brief Intervention, and Referral to Treatment (SBIRT) initiative of the Substance Abuse and Mental Health Services Administration (SAMHSA) may be an especially useful approach for intervention with older adults, especially if it is integrated within established community care and/or primary health organizations (SAMHSA, 2008).

Prevention Efforts

• With the expected increases in the population over age 60, there is a renewed interest in prevention efforts in alcohol and other drug use and abuse.

Prevention efforts with older adults are important for several reasons: older adults can be negatively affected by consumption of smaller quantities of alcohol or other drugs; negative consequences of use may not be recognized as associated with use; adverse medication interactions may occur with any amount of alcohol use; medication mismanagement among older adults is common. Health promotion and health education efforts with older adults should include these issues related to older adults’ changing vulnerabilities. However, Blow, Bartels, Brockmann, and Van Citters (2005) reviewed evidence-based practice prevention practices and found no substantive evidence that universal prevention programs for prevention or reduction of alcohol misuse are successful for older adults. Theses authors echo the support for brief interventions, especially those set in health care settings, as effective tools to reduce alcohol misuse and hazardous drinking. Effective prevention avenues to decrease medication mismanagement include computer-based tools to increase the older person’s knowledge about potential drug interactions (Blow et al., 2005). Team efforts including health care professionals both in health care institutions and in the community may prove to be effective. The process of implementing evidence-based practice to prevent substance abuse and mental health problems among older adults requires organizational change and involvement of provider and service delivery systems (Blow, Bartels, Brockmann, & Van Citters, forthcoming).

References

Atkinson, R. M., Misra, S., Ryan, S. C., & Turner, J. A. (2003). Referral paths, patient profiles and treatment adherence of older alcoholic men. Journal of Substance Abuse Treatment, 25, 29-35.

Bartels, S. (2006). The aging tsunami and geriatric mental health and substance use disorders. Journal of Dual Diagnosis, 2(3), 5-7.

Blow, F. (2000). Treatment of older women with alcohol problems; meeting the challenge for a special population. Alcohol Clinical and Experimental Research, 24(8), 1257-1266.

Blow, F., Bartels, S., Brockmann, L., & Van Citters, A. (forthcoming). Evidence-based practices for preventing substance abuse and mental health problems in older adults. Older Americans Substance Abuse and Mental Health Technical Assistance Center: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Prevention. Retrieved on March 8, 2008, from http://www.samhsa.gov/OlderAdultsTAC.

Blow, F., Bartels, S., Brockmann, L., & Van Citters, A. (2005). Evidence-based practices for preventing substance abuse and mental health problems in older adults. Older Americans Substance Abuse and Mental Health Technical Assistance Center: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Prevention. Retrieved on February 25, 2008, from http://www.samhsa.gov/OlderAdultsTAC.

Blow, F., Walton, M., Chermack, S., Mudd, D., & Brower, K. (2000). Older adult treatment outcome following elder-specific inpatient alcoholism treatment. Journal of Substance Abuse Treatment, 19, 67-75.

Carstensen, L, Rychtarik, R., & Prue, D. (1985). Behavioral treatment of the geriatric alcohol abuser: A long term follow-up study.Addictive Behaviors, 10, 307-311.

Center for Substance Abuse Treatment (CSAT). (1998). Substance abuse among older adults. Treatment Improvement Protocol (TIP) Series 26. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.

Conigliaro, J., Kraemer, K., & McNeil, M. (2000). Screening and identification of older adults with alcohol problems in primary care.Journal of Geriatric Psychiatry and Neurology, 13, 106-114.

Cummings, S., Bride, B., & Rawlins-Shaw, A. (2006). Alcohol abuse treatment for older adults: A review of recent empirical research.Journal of Evidence-based Social Work, 3(1), 77-99.

D’Agostino, C., Barry, K., Blow, F., & Podgorski, C. (2006). Community interventions for older adults with comorbid substance abuse: The geriatric addictions program. Journal of Dual Diagnosis, 2(3), 31-45.

Dupree, L., Broskowski, H., & Schonfeld, L. (1984). The gerontology alcohol project: A behavioral treatment program for elderly alcohol abusers. The Gerontologist, 24(5), 510-516.

Fleming, M., Manwell, L., Barry, K., Adams, W., & Stauffacher, E. (1999). Brief physician advice for alcohol problems in older adults: a randomized community-based trial. Journal of Family Practice, 48(5), 378-384.

Gfoerer, J., Penne, M., Pemberton, M., & Folsom, R. (2003). Substance abuse treatment need among older adults in 2020: The impact of the aging baby-boom cohort. Drug and Alcohol Dependence, 69(2), 127-135.

Green, C., Polen, M., & Brody, K. (2003). Depression, functional status, treatment for psychiatric problems and health-related practices of elderly HMO members. American Journal of Health Promotion, 17(4), 270-275.

Kofoed, L., Tolson, R., Atkinson, R., Toth, R., & Turner, J. (1987). Treatment compliance of older alcoholic: An elder-specific approach is superior to “mainstreaming.” Journal of Studies on Alcohol, 48, 47-51.

Kashner, M., Rodell, D. Ogden, S., Guggenheim, F., & Karson, C. (1992). Outcomes and costs of two VA impatient treatment programs for older alcoholic patients. Hospital and Community Psychiatry, 43, 985-989.

Lemke, S., & Moos, R. (2002). Prognosis of older patients in mixed-age alcoholism treatment programs. Journal of Substance Abuse Treatment, 22, 33-43.

Lemke S., & Moos, R. (2003a). Outcomes at 1 and 5 years for older patients with alcohol use disorders. Journal of Substance Abuse Treatment. 24(1), 43-51.

Lemke, S., & Moos, R. (2003b). Treatment outcomes of older patients with alcohol use disorders in community residential programs.Journal
of Studies on Alcohol, 64(2), 219-226.

Lofwall, M., Brooner, R., Bigelow, G., Kindbom, K., & Strain, E. (2005). Characteristics of older opioid maintenance patients. Journal of Substance Abuse Treatment, 28, 265-272.

Moyer, A., Finney, J., Swearingen, C., & Vergun, P. (2002). Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction, 97(3), 279-292.

O’Connell, H., Chin, A., Hamilton, F., Cunningham, C. Walsh, J., Coakley, D. et al. (2004). A systematic review of the utility of self-report alcohol screening instruments in the elderly. International Journal of Geriatric Psychiatry, 19, 1074-1086.

Office of Applied Studies. (2005 ). The NSDUH Report: Substance Use among Older Adults: 2002 &2003 Update. Retrieved on March 15, 2008, from http://www.oas.samhsa.gov.

Oslin, D., Pettinati, H., & Volpicelli, J. (2002). Alcoholism Treatment Adherence: Older age predicts better adherence and drinking outcomes. American Journal of Geriatric Psychiatry, 10(6), 740-747.

Popa, M. (2005). Stages of Change for osteoporosis prevention behaviors. Journal of Aging & Health, 17(3), 336-350.

Rice, C., Longabaugh, R., Beattie, M., & Noel, N. (1993). Age group differences in response to treatment for problematic alcohol use.Addiction. 88, 1369-1375.

Satre, D., Mertens, J., Areán, P., & Weisner, C. (2003). Contrasting outcomes of older versus middle-aged and younger adult chemical dependency patients in a managed care program. Journal of Studies on Alcohol, 64(4), 520-531.

Satre, D., Mertens, J., Areán, P., & Weisner, C. (2004). Five-year alcohol and drug treatment outcomes of older adults versus middle-aged and younger adults in a managed care program. Addiction, 99, 1286-1297.

Satre, D., Mertens, J., & Weisner, C. (2004). Gender differences in treatment outcomes for alcohol dependence among older adults.Journal of Studies on Alcohol, 65(4), 638-642.

Schonfeld, L., Dupree, L., Dickson-Fuhrman, E., Royer, C, McDermott, C., Rosansky, J., et al. (2000). Cognitive-behavioral treatment of older veterans with substance abuse problems. Journal of Geriatric Psychiatry & Neurology, 13, 124-128.

Substance Abuse and Mental Health Services Administration. (2008). Screening, Brief Intervention, and Referral to Treatment. Retrieved March 10, 2008, from http://sbirt.samhsa.gov/about.htm.

Substance Abuse and Mental Health Services Administration. (2007). Results from the 2006 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-32, DHHS Publication No. SMA 07-4293). Rockville, MD. http://oas.samhsa.gov/nsduh/2k6nsduh/2k6Results.cfm#3.3.

Substance Abuse and Mental Health Services Administration, Office of Applied Studies (November 8, 2007). The DASIS Report: Older Adults in Substance Abuse Treatment: 2005. (DHHS Publication No. SMA 03-3763, OAS Analytic Series #A-21). Rockville, MD.

Substance Abuse and Mental Health Services Administration. (2005). Substance Use among Older Adults: 2002 and 200: The NSDUH Report. (Office of Applied Studies, NSDUH) RTI International. Research Triangle Park, N. Carolina.

Substance Abuse and Mental Health Services Administration Office of Applied Studies. (2002). Substance use by older adults: Estimates of future impact on the treatment system. (DHHS Publication No. SMA 03-3763, OAS Analytic Series #A-21). Rockville, MD.

Substance Abuse and Mental Health Services Administration Office of Applied Studies. (2002). Substance use by older adults: Estimates of future impact on the treatment system. (DHHS Publication No. SMA 03-3763, OAS Analytic Series #A-21). Rockville, MD.

U.S. Department of Health and Human Services. (1998). Substance Abuse among Older Adults: Treatment Improvement Protocol (TIP) Series 26. Public Health Service. Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. DHHS Publication No. (SMA) 98-3179.

Walton, M., Mudd, S., Blow, F., Chermack, S., & Gomberg, E. (2000). Stability in the drinking habits of older problem-drinkers from non-treatment settings. Journal of Substance Abuse Treatment, 18, 169-177.

Zanjani, F.; Zubritsky, C., Mullahy, M., & Oslin, D. (2006). Predictors of Adherence within an intervention research study of the at-risk older drinker: PRISM-E. Journal of Geriatric Psychiatry and Neurology, 19(4), 231-238.
 
Document Date: September 11, 2009

Kathleen J. Farkas, PhD  Case Western Reserve University, Mandel School of Applied Social Sciences
Laurie Drabble, PhD  San Jose State University, School of Social Work

Access to Alcohol and Other Drug Abuse Services for Older Adults

• Funding for alcohol and other drug abuse (AODA) treatment may not be adequate for older adults’ needs. However, all older adults have Medicare coverage, whereas many younger adults have no insurance.
• Stigma and low rates of problem identification hinder access to AODA services for older adults.
• The service delivery system for alcohol and other drug assessment and treatment is often fragmented and doesn’t meet older people’s needs.

Access to AODA services is a broad topic and includes issues of availability, accessibility, use, and costs of services. Medicare is a primary source of insurance funding for older adults for both medical and psychological care. Bartels, Blow, Brockmann, and Van Citters (2005) outline funding barriers to both mental health and substance abuse services for older adults. Their review of funding barriers includes the following: inequitable co-payment of psychologically-based services versus medical services; the gap between costs and Medicare payments; the preference for outpatient, clinic-based services, and cost containment policies that do not match clinical guidelines. For older people in need of alcohol and other drug assessment and treatment, the combination of high co-pays and forced use of clinics rather than neighborhood-based services may deter them from seeking help. Medicare programs typically cover 12 days of inpatient alcohol treatment, but for those with medical complications and complex medical needs, longer stays and additional services may be warranted. Approximately 75% of Medicare spending on substance abuse treatment is dedicated to inpatient, detoxification treatment (Alcoholism and Drug Abuse Weekly, 2006). Only a small percentage of those who receive detoxification are enrolled in follow-up care, which is associated with better long-term outcomes. Younger people share many, if not all of these barriers to alcohol and drug treatment services. The federal Medicaid program policy changed in January 2007 and now provides reimbursement for screening and brief intervention for alcohol and other drug addictions. Under the Medicaid program, 38 states cover some treatment for nicotine dependence (Centers for Disease Control and Prevention, 2006). However, disability insurance under Social Security (SSI) has not considered alcohol or drug abuse/dependence as a disability since 1996. The SSI criteria define a disability as a limiting medical condition that continues after a person stops using alcohol or drugs.

Alcohol and other drug problems among older adults are not the most common concerns for gerontological social workers or for social workers in AODA practice; both the aging services system and the AODA treatment system often fail to address the needs of older adults with AODA. Since indicators of alcohol and other drug problems are often more subtle among older people than among younger people, service providers may easily overlook assessment and referral for AODA. Few treatment programs focus on older people’s needs. However, data from the PRISM-E studies show that older at risk drinkers are likely to engage in treatment and to benefit from either an integrated care model or an enhanced specialty referral model (Oslin et al., 2006).

Service delivery strategies and policies to improve mental health services to older adults may serve as examples to develop an effective AODA system for older adults over the coming years (Blasinsky, Goldman, & Unutzer, 2006; Karlin & Duffy, 2004). The service delivery system challenges for social workers in AODA practice will be to develop referral mechanisms and linkages with aging services programs, to develop clear guidelines for age appropriate screening and assessment, and to implement evidence-based practices for treatment and recovery services effective with older adults.

Environmental Prevention and Regulation of Alcohol, Tobacco, and Pharmaceutical Industries

• Environmental prevention strategies, such as advertising restrictions, are relevant to marginalized populations, including older adults.

In addition to prevention strategies designed to reach individuals, policy changes are critical to addressing alcohol, tobacco, and other drug problems. Environmental strategies for prevention of health problems are often effective in reducing these problems and changing social norms. These strategies include policy changes in the behavioral environment (e.g., clean air laws and reducing youth access to tobacco), the financial environment (e.g., increased tobacco or alcohol taxes and reduced costs for smoking cessation), and the communication environment (e.g., advertising restrictions) (Brownson, Koffman, Novotny, Hughes, & Erikson, 1995; Mosher, 1996). Environmental prevention strategies are designed to reduce problems and improve health across population groups and have relevance for older adults. Specifically, some older adults may be impacted disproportionately by marketing of tobacco and alcohol, which is often targeted to specific communities based on geography, age, culture, gender, and lifestyle (Cummings, 1999; Hill & Casswell, 2001).

• Challenging target-marketing of tobacco and other drugs is a policy-level intervention designed to prevent and reduce problems.

Tobacco and alcohol products are often heavily promoted in communities already disproportionately impacted by tobacco or alcohol problems including African-American communities, immigrant communities, and LGBT communities (Alaniz, 1998; Lee, Cutler, & Burns, 2004; Stevens, Carlson, & Hinman, 2004; Sutton & Robinson, 2004). One specific example of an environmental strategy for addressing the impact of marketing is the use of counter-ads. Counter-ads are a valuable tool for contextualizing health problems, focusing attention on the misinformation promoted by specific corporations such as the alcohol or tobacco industry, and generating support for change in policy (Dorfman & Wallack, 1993). For example, in relation to tobacco industry marketing, research suggests that counter-advertising strategies and messages focusing on industry manipulation and secondhand smoke appear to be the most useful for reducing tobacco consumption and challenging cultural norms that enable smoking (Goldman & Glantz, 1998). Communities have also been successful in organizing to reduce point-of-purchase advertising, such as store window and sidewalk tobacco promotions designed to target specific populations and increase tobacco purchases (Rogers, Feighery, Tencati, Butler, & Weiner, 1995).

• Direct-to-consumer (DTC) advertising by pharmaceutical industries has increased dramatically in the past 10 years, while FDA regulation of advertising has weakened.
• DTC appears to target older adults and women.
• Marketing practices designed to influence consumers to request drugs may contribute to overuse or misuse of prescription drugs.

Another related facet of the larger social and policy environment that impacts older adults is that of the pharmaceutical industry and DTC advertising of prescription drugs. DTC advertising has remained controversial since it began approximately 20 years ago. Proponents argue that DTC educates patients about illnesses and related treatment, whereas opponents argue that the information provided in DTC is geared toward marketing rather than consumer education, which may serve to promote overuse or inappropriate use of prescription drugs (Royne & Myers, 2008). Despite criticism, between 1996 and 2005, pharmaceutical industry promotions to physicians have expanded, and spending on DTC advertising has increased by 330% (Donohue, Cevasco, & Rosenthal, 2007). Despite an increase in prescription drugs obtaining approval through the Food and Drug Administration (FDA), there appears to be important gaps in the FDA’s regulation guidance of pharmaceutical industry DTC advertising (Government Accounting Office, 2006). For example, Royne and Myers note that although the FDA “requires a ‘fair balance’ of the risks and benefits of a drug, the FDA guidelines offer little assistance in defining that balance” (p. 72). As a case in point, a recent study examining the content of ads found that DTC television ads were not providing sufficient information in relation to FDA fair balance requirements, particularly in describing risks (Macias, Pashupati, & Lewis, 2007).

These advertising practices may be particularly salient to older adults. A study of prescription and over-the-counter advertising found that DTC ads occupied a significant percentage of television advertising (approximately 8%), and, based on placement and air times, appeared to target older adults and women (Brown, Bernhardt, Phan, Williams, & Parker, 2004). Although older adults do not perceive themselves as influenced by DTC when asked directly, they report behaviors that are congruent with DTC ads (DeLorme, Huh, & Reid, 2007). DTC advertising influences patient-doctor communications and the likelihood for both requesting and receiving prescription drugs (Datti & Carter, 2006; Government Accounting Office, 2006).

References

Alaniz, M. L. (1998). Alcohol availability and targeted advertising in racial/ethnic minority communities. Alcohol Health & Research World, 22(4), 286-298.

Alcoholism and Drug Abuse Weekly. (2006). More older adults need treatment, but where, and who will pay? 18(9) 1-2. Retrieved on April 27, 2008, from www.interscience.wiley.com.

Blasinsky, M., Goldman, H., & Unutzer, J. (2006). Project IMPACT: A report on barriers and facilitators to sustainability. Administration & Policy in Mental Health and Mental Health Services Research, 33(6) 718-729.

Bartels, S., Blow, F., Brockmann, L., & Van Citters, A. (2005). Substance abuse and mental health among older Americans: The state of the knowledge and Future Directions. Older Americans Substance Abuse and Mental Health Technical Assistance Center: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Prevention. Retrieved on November 15, 2007, from http://www.samhsa.gov/OlderAdultsTAC.

Brown, E. D., Bernhardt, J. M., Phan, J. L., Williams, M. V., & Parker, R. M. (2004). Direct-to-consumer drug advertisements on network television: An exploration of quantity, frequency, and placement. Journal of Health Communication, 9, 491-497.

Brownson, R. C., Koffman, D. M., Novotny, T. E., Hughes, R. G., & Erikson, M. P. (1995). Environmental and policy interventions to control tobacco use and prevent cardiovascular disease. Health Education Quarterly, 22(4), 478-498.

Centers for Disease Control and Prevention: Morbidity and Mortality Weekly Report. (2006). Journal of the American Medical Association, 296(24), 2917-2919.

Cummings, M. K. (1999). Community-wide interventions for tobacco control. Nicotine & Tobacco Research, 1, S113-S116.

Datti, B., & Carter, M. W. (2006). The effect of direct-to-consumer advertising on prescription drug use by older adults. Drugs Aging, 23(1), 71-81.

DeLorme, D. E., Huh, J., & Reid, L. N. (2007). “Others are influenced by not me”: Older adults’ perceptions of DTC prescription drug advertising effects. Journal of Aging Studies, 21, 135-151.

Donohue, J. M., Cevasco, M., & Rosenthal, M. B. (2007). A decade of direct-to-consumer advertising of prescription drugs. New England Journal of Medicine, 357, 673-681.

Dorfman, L., & Wallack, L. (1993). Advertising health: The case for counter-ads. Public Health Reports, 108(6), 716-726.

Goldman, L. K., & Glantz, S. A. (1998). Evaluation of antismoking advertising campaigns. Journal of the American Medical Association, 279(10), 772-777.

Government Accounting Office. (2006). Prescription drugs: Improvements needed in FDA's oversight of direct-to-consumer advertising (GAO-07-54). Washington DC: GAO.

Hill, L., & Casswell, S. (2001). Alcohol advertising and sponsorship: Commercial freedom or control in the public interest? In N. Heather, T. J. Peters, & T. Stockwell (Eds.), International handbook of alcohol dependence and problems (pp. 823-846). New York: John Wiley & Sons.

Karlin, B., & Duffy, M. (2004). Geriatric mental health policy: Impact on service delivery and directions for effecting change. Professional Psychology: Research & Practice, 36(5), 509-519.

Lee, D., Cutler, B. D., & Burns, J. (2004). The marketing and demarketing of tobacco products to low-income African Americans. Health Marketing Quarterly, 22(2), 51-68.

Macias, W., Pashupati, K., & Lewis, L. S. (2007). A wonderful life or diarrhea and dry mouth? Policy issues of direct-to-consumer drug advertising on television. Health Communication, 22(3), 241-252.

Mosher, J. (1996). A public health approach to alcohol and other drug problems: Theory and practice. In F. D. Scutchfield & C. W. Keck (Eds.), Principles of public health practice (pp. 243-260). Albany, NY: Delmar Publisher.

Oslin, D., Grantham, S., Coakley, E., Maxwell, J., Miles, K., Ware, J., et al. (2006). PRISM-E: Comparison of integrated care and enhanced specialty referral in managing at-risk alcohol use. Psychiatric Services, 57(7) 954-958.

Rogers, T., Feighery, E. C., Tencati, E. M., Butler, J. L., & Weiner, L. (1995). Community mobilization to reduce point-of-purchase advertising of tobacco products. Health Education Quarterly, 22(4), 427-442.

Royne, M. B., & Myers, S. B. (2008). Recognizing consumer issues in DTC pharmaceutical advertising. Journal of Consumer Affairs, 42(1), 60-80.

Stevens, P., Carlson, L. M., & Hinman, J. M. (2004). An analysis of tobacco industry marketing to lesbian, gay, bisexual, and transgender (LGBT) populations: Strategies for mainstream tobacco control and prevention. Health Promotion Practice, 5(3), 129S-134S.

Sutton, C. D., & Robinson, R. G. (2004). The marketing of menthol cigarettes in the United States: Populations, messages, and channels.Nicotine & Tobacco Research, 6(Suppl 1), s83-s91.
 
Document Date: September 11, 2009

Kathleen J. Farkas, PhD  Case Western Reserve University, Mandel School of Applied Social Sciences
Laurie Drabble, PhD  San Jose State University, School of Social Work

Research Questions and and Future Directions

Central to the future of knowledge about substance use, abuse, and dependence among older populations are questions about the relationships between substance use, chronological age, and cohort effects. In past decades, epidemiological studies have consistently shown that older people use alcohol and drugs less often and have fewer substance-related problems than do younger cohorts. Past epidemiological studies have also consistently demonstrated that older adults tend to decrease their use of alcohol with age, usually in response to poor health or changing social circumstances. Epidemiological research has documented that a segment of the older population does experience substance-related problems and disorders. Soon the increased size of this segment of older adults, resulting from the entry of the “baby boomers” into this age bracket, will increase the need for substance abuse assessment and treatment services even if prevalence rates remain constant in future older cohorts. Epidemiological research has also indicated that the “baby boom” cohort has used alcohol and other substances, especially marijuana, at higher rates than previous age cohorts, so there is reason to believe the potential exists for changes in the prevalence and incidence rates of substance use and substance-related disorders among future older cohorts.

Large, community-based data sets that include older age groups, such as Treatment Episode Data Set (TEDS) and the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), provide exciting opportunities to understand longitudinal changes in older adults’ alcohol and other drug use. Analysis of these data should focus on the differences between and similarities among age groups of older adults as well as on comparisons between older and younger adults. The growing literature on the complex relationships between alcohol use and beneficial health effects as well as on the relationships between alcohol use and health problems indicates that this is a rich area for future research. Some of the questions raised by the research include:

• To what extent will age-related changes in physical health determine alcohol and/or tobacco use and misuse among healthy older adults?
• To what extent will age-related changes in physical health determine use of over-the-counter drugs and herbal remedies among healthy older adults?
• To what extent will age-related changes in physical health determine other drug use, especially recreational use of marijuana or use of other illicit drugs, among older adults?
• How will social factors, such as widowhood, economic trends, and retirement practices affect substance use among future cohorts of older adults?
• How will minority group status affect prevalence of substance use in older cohorts?
• What, if any, are the relationships between sexual and racial/ethnic identity group status and use of particular types of substances?
• What are the relationships between drinking limits and physical and psychosocial health in samples of community-dwelling older people?
• What is the relationship between chronic pain and substance use and misuse among older adults both in the community and in health care facilities?
• What is the relationship between direct to consumer advertising of abusable prescription medications and prevalence of prescription drug abuse among older adults?

Screening and assessment of substance use and substance-related problems present many opportunities for continued research. The literature has provided some clear evidence about the types of problems and issues most often associated with substance use. However, there are differences in the sensitivity and specificity of various screening tools across settings and populations. With changes in prevalence of substance use in future cohorts, practitioners will need to understand elements of social desirability and social stigma associated with various types of substance use across the range of older age groups. There is also a need to understand gender differences and differences among racial/ethnic and other cultural groups. Some of the research questions include the following:

• What are the differences and similarities in the barriers affecting detection of substance use and abuse among older cohorts?
• Which screening tools demonstrate acceptable levels of sensitivity and specificity in different populations of older people?
• Are there differences in levels of social desirability and social stigma in alcohol and drug use between older age cohorts? Are there differences in levels of social desirability and social stigma in alcohol and other drug use between older racial/ethnic, gender, and other groups? What is the relationship between social desirability, social stigma, and self report of alcohol and other drug use and abuse?
• How will future older cohorts’ attitudes about alcohol be related to decisions about alcohol use?
• Will the future cohorts of older adults experience the same types of alcohol- or other drug-related problems as current cohorts of older adults?
• What factors will determine older adults’ decisions to increase or decrease alcohol and/or other drug use? How will these factors be associated with age-related physical, social, or psychological changes?
• What types of motivational strategies will be effective with future cohorts of older adults in both assessment and referral to treatment for alcohol and other drug problems?
• How can screening and assessment methods be improved for older adults with cognitive impairments and psychiatric illness?

Research in treatment approaches and outcomes has progressed over the past 10 years but many questions remain concerning treatment engagement strategies, elements of effective programming, and treatment outcomes for older adults. Elder-specific programming has been shown effective in some studies, but it is unclear which components of the treatment account for the positive changes in alcohol consumption.

• What are the interactions between age group and type of treatment?
• What are the interactions between age group, drug of choice, and type of treatment?
• Most treatment efforts with older adults have focused on alcohol exclusively. Will these same treatment approaches yield effective results with older adults who are more likely to use other drugs like marijuana and cocaine or prescription drugs?
• What are the interactions between age group, gender, and minority group status, type of treatment, and treatment outcomes?
• Which treatment engagement and treatment approaches will yield effective results with older women and members of ethnic/racial minorities and other minority groups?
• Which treatment engagement and treatment approaches will yield effective results with older lesbian and gay people?
   

Document Date: September 11, 2009

Download this PDF for a detailed overview and recommendations of curricular resources related to substance use and aging.

Document Date: September 11, 2009

We acknowledge the contributions of the following individuals to the Resource Reviews:

Bethany Mikovitz-Wibby - Case Western Reserve University 
Elizabeth Noble – San Jose State University

We acknowledge the contributions of the following faculty for providing peer reviews and helpful suggestions on various chapters of the Resource Reviews:

Audrey Begun, University of Wisconsin, Milwaukee 
Diana DiNitto, University of Texas, Austin 
Lala Straussner, New York University 
Michie Hesselbrock, University of Connecticut 
Beth Reed, University of Michigan
 
Document Date: September 11, 2009

Suggested Citation for Resource Reviews:
AUTHOR NAMES for specific chapter (2008). CHAPTER TITLE. In S. Diwan (ed.), SOURCE (list the title of the particular Resource Review ).  PUBLISHER. Retrieval Location (list overall URL for the particular Resource Review.)

Examples: 
Farkas, K.J. & Drabble, L. (2008). Research questions and future research directions. In S. Diwan (Ed.), Substance Use and Older Adults Resource Review. Alexandria, VA: CSWE Gero-Ed Center, Master's Advanced Curriculum Project. Retrieved from www.gero-edcenter.org/mac.

Gellis, Z.D., McClive-Reed, K., &  McCracken, S.G. (2008). Depression in older adults with dementia.  In S. Diwan (Ed.), Mental Health and Older Adults Resource Review. CSWE Gero-Ed Center, Master's Advanced Curriculum Project. Retrieved from www.gero-edcenter.org/mac.

Christ, G. & Diwan, S. (2008). Role of social work in managing chronic illness care. In S. Diwan (Ed.), Health Care and Older Adults Resource Review. CSWE Gero-Ed Center, Master's Advanced Curriculum Project. Retrieved from www.gero-edcenter.org/mac.

Document Date: September 11, 2009