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Managing Suicidality

Substance Abuse Among Older Adults
Treatment Improvement Protocol (TIP) Series 26
Substance Abuse and Mental Health Services Administration (SAMHSA)

http://ncadi.samhsa.gov/govpubs/BKD250/

Alcohol and prescription drug misuse affects as many as 17% of older adults. This 136-page expert panel report presents best practice guidelines for the treatment of substance abuse among those aged 60 and over.  The work was sponsored by SAMHSA’s Center for Substance Abuse Treatment (CSAT).

Health care providers tend to overlook substance abuse and misuse among older people, mistaking the symptoms for those of dementia, depression, or other problems common to older adults.  Older adults are more likely to hide their substance abuse and less likely to seek professional help.  Many relatives of older individuals with substance abuse disorders, particularly their adult children, are ashamed of the problem and choose not to address it.  The result is thousands of older adults who need treatment and do not receive it.

The TIP brings together the literature on substance abuse and gerontology to recommend best practices for identifying. Screening, assessing and treating alcohol and prescription drug abuse among people age 60 and older.  The Consensus Panel, whose members include researchers, clinicians, treatment providers, and program directors, supplements this research base with its considerable experience treating and studying substance abuse among older adults.

The TIP aims to advance the understanding of the relationships between aging and substance abuse and to provide practical recommendations for incorporating that understanding into practice.  TIP recommendations are presented in italic type.  Those based on research evidence are marked (1) and those based on Panel members’ clinical experience are marked (2).  Evidence based citations can be found in the body of the text and there is an extensive bibliography, as well as extensive endnotes, screening tools and criteria.


Guideline Category:

  • Assessment of therapeutic effectiveness
  • Diagnosis
  • Screening
  • Treatment

Target Audience:

  • Substance abuse treatment providers
  • Primary care clinicians, including advanced practice nurses, nurses, physicians
  • Social workers
  • Senior center staff
  • Anyone else who has regular contact with older adults

Interventions and Practices Considered:

  • Screening
    • Using CAGE questionnaire
    • Using Michigan Alcohol Screening Test-Geriatric Version (MAST_H)
    • Using Alcohol use Disorders Identification Test (AUDIT)
    • Interjecting screening questions into normal conversations with older homebound adults (friends, Meals on Wheels volunteers, caretakers)
    • As part of a regular physical examination by prefacing questions about alcohol with a link to a medical condition.
  • Diagnosis/Assessment
    • Structured clinical interviews for DSM-III-R (SCID), substance abuse section
    • Diagnostic Interview Schedule (DIS) for DSM-IV, substance abuse section
    • Index of Activities of Daily Living
    • Instrumental Activities of Daily Living Scale
    • Geriatric Depression Scale (GDS) Short Form
    • Center for Epidemiologic Studies – Depression Scale
    • Health Screening Survey
    • Orientation/Memory/Concentration Test
    • Folstein Mini-Mental Status Exam (MMSE)
    • Neurobehavioral Cognitive Status Examination
    • Confusion Assessment Method (CAM)
    • Medical assessment including screening for visual and auditory problems, and the “brown bag approach” to assess current medication use
    • Sleep history
  • Treatment
    • Brief intervention
    • Intervention
    • Motivational interviewing
    • Detoxification
  • Assessment of therapeutic efficacy
    • Medical Outcomes Study 36-item Short Form Health Survey (SF-36)
    • Symptom Checklist-90-Revised (SCL-90-R)
    • Brief Symptom Inventory (BSI)
    • Quality of Life Interview (QLI)
  • Major outcomes considered
    • Quality of life and well-being
    • Physical and emotional health functioning
    • Changes in consumption of substance
    • Changes in patterns of substance use
    • Incidence of substance-related problems

Brief Interventions and Brief Therapies for Substance Abuse
Treatment Improvement Protocol (TIP) Series 34

Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment
http://ncadi.samhsa.gov/govpubs/BKD341/

SUMMARY

This is a report of an expert panel which used both evidence based and clinical experience in arriving at conclusions.  The brief interventions and therapies described in this TIP are intended to introduce a range of techniques to clinicians, who sill find different portions more useful than others depending on their theoretical orientation.  Brief interventions will be useful for a wide variety of service providers and are intended for properly qualified, educated, and licensed professionals. Among the major conclusions/ recommendations of the consensus panel:

  • Brief interventions can be an effective addition to substance abuse treatment.
  • Programs should use quality assurance improvement projects to determine whether the use of a brief intervention or therapy in specific treatment situations is enhancing treatment.
  • Agencies should allocate counselor training time and resources to these modalities.  The panel anticipates that brief interventions will help agencies meet the increasing demands of the managed care industry and fill the gaps that have been left in client care.
  • Substance abuse treatment personnel should collaborate with other providers in developing plans that include both brief interventions and more intensive care to help keep clients focused on treatment and recovery,

Brief interventions

  • Are those practices that aim to investigate a potential problem and motivate and individual to begin to do something about his substance abuse, either by natural, client directed means or by seeking additional substance abuse treatment.
  • Can be used to engage clients who need specialized treatment in specific aspects of treatment programs such as attending group therapy or AA meetings
  • Can be an effective addition to substance abuse treatment programs, especially in treatment settings when they are used to address specific targeted client behaviors and issues in the treatment process that can be difficult to change using standard treatment approaches.
  • Variations have been found to be effective both for motivating alcohol-dependent individuals to enter long-term alcohol treatment and for treating some alcohol-dependent persons.

Goals of brief interventions

  • The basic goal of any brief intervention is to reduce the risk of harm that could result from continued use of substances. 
  • The specific goal for each individual client is determined by his consumption pattern, the consequences of his use, and the setting in which the brief intervention is delivered.
    • Focusing on intermediate goals allows for more immediate success in the interventions and treatment process, whatever the long-term goals may be.
      • Intermediate goals might include quitting one substance, decreasing frequency of use, or attending a meeting.
      • Immediate successes are important to keep the client motivated
    • When conducting a brief intervention, the clinician should set aside the final treatment goal to focus on a single behavioral objective.  Once this objective is established, a brief intervention can be used to help reach it.

The six components of brief interventions (Acronym: FRAMES)

  • Feedback is given to the individual about personal risk or impairment
  • Responsibility for change is placed on the participant
  • Advice to change is given by the clinician
  • Menu of alternative self-help or treatment options is offered to the participant
  • Empathic style is used by the counselor
  • Self-efficacy or optimistic empowerment is engendered in the participant

A brief intervention consists of five basic steps that incorporate FRAMES and remain consistent regardless of the number of sessions or the length of the intervention:

  • Introducing the issues in the context of the client’s health
  • Screening, evaluating and assessing
  • Providing feedback
  • Talking about change and setting goals
  • Summarizing and reaching closure

Providers may not have to use all five of these components in any given session with a client.  However, before eliminating steps in the brief intervention process there should be a well-defined reason for doing so.

The TIP covers:

  • When to use brief therapy
  • Components of effective brief therapy
  • Screening and assessment
  • The first session
  • Maintenance strategies, termination of therapy and follow-up
  • Therapist characteristics
  • Cognitive-behavioral therapy
  • Strategic/interactional therapies
  • Humanistic and existential therapies
  • Psychodynamic therapies
  • Family therapy and its appropriateness
  • Group therapy

Enhancing Motivation for Change in Substance Abuse Treatment
Treatment improvement Protocol (TIP) Series 35
Consensus Panel SAMHSA/CSAT

http://www.health.org/govpubs/bkd342/

SUMMARY

This document provides recommendations of an expert panel in the form of a treatment improvement protocol based on both research and clinical experience.  Those supported by scientific evidence are followed by (1); clinically based recommendations are marked (2).  Topics covered include:

  • Conceptualizing motivation
    • Assumptions about the nature of motivation
    • Strategies for the clinician
  • Transtheoretical model of change
    • Five stages of change –pre-contemplation, contemplation, preparation, action and maintenance
    • Stages can be conceptualized as a cycle through which clients move back and forth and are not viewed as linear
    • Framing the client’s treatment within the stages of change can help the clinician better understand the client’s treatment progress.
    • Takes recurrence into account
    • Endorsed by consensus panel with the qualification that it’s use has been primarily conceptual and that no current technology is available to definitively determine an individual’s stage of readiness for change.
  • Motivational interventions
    • The FRAMES approach (1)
  • Feedback is given to the individual about personal risk or impairment
  • Responsibility for change is placed on the participant
  • Advice to change is given by the clinician
  • Menu of alternative self-help or treatment options is offered to the participant
  • Empathic style is used by the counselor
  • Self-efficacy or optimistic empowerment is engendered in the participant
    • Decisional balance exercises (1)
    • Developing discrepancy (1)
    • Flexible pacing (2)
    • Personal contact with clients who are not actively in treatment (1)
  • Motivational interviewing
  • Intervening through significant others
  • Motivational interventions and coerced clients
  • From contemplation to preparation
  • From preparation to action
  • From action to maintenance
  • Measuring client motivation
  • Integrating motivational approaches into treatment programs

Health Care Guideline: Preventive Counseling and Education, Eighth Edition

Institute for Clinical Systems Improvement
http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=188

SUMMARY

This comprehensive guideline covers multiple topics for all age groups.  Evidence is graded and each individual report is assigned a letter indicating the class of report based on design type.

Recommendations for seniors are listed below for covered topics in mental health and substance abuse:

  • Substance Use/Abuse
    • Tobacco
      • Counseling and education messages
        • Ask about use at every opportunity
        • Advise to quit
        • Assess tobacco user’s willingness to make a quit attempt
        • Assist in quitting arrange follow-up
        • Advise regarding the use of nicotine patches, Nupropion or gum as adjunct to cessation
        • Passive exposure is harmful and should be avoided
      • A prevention and cessation guideline is available at the organization’s website
    • Problem drinking
      • Counseling and Education Messages
        • Assess current use of alcohol by history and/or use of standardized screening questionnaire
        • Reinforce not drinking and driving and the dangers of operating a motor vehicle under the influence – abstinence if driving
        • Discuss acceptable use of alcohol in home
        • Discuss characteristics of dependency
        • Don’t ride with someone who is under the influence of alcohol
        • Prevent others from driving in this condition
    • Alcohol and other drugs
      • Counseling and education messages
        • Assess current use of alcohol/drugs
        • Reinforce not drinking and driving
        • Discuss characteristics of dependency
    • Drinking and Driving Motor Vehicles (see problem drinking)

  • Mental Health
    • Depression/Anxiety Awareness
      • Counseling and education messages-depression
        • Reinforce the fact that anyone is at risk for developing a serious depression
        • Teach the patient that depression can lead to physical symptoms (headaches, chronic pain, digestive symptoms, etc.) poor quality of life and even suicide.
        • Discuss the fact that often it is difficult for depressed people to recognize this problem in themselves.
        • Discuss the fact that all individuals should be aware of the basic signs of depression so that they can identify the problem in themselves or others.
        • Reinforce the fact that effective treatments for depression are available.
      • Counseling and education messages for anxiety
        • Anyone is at risk for developing serious anxiety
        • Anxiety can lead to many symptoms including headaches, poor sleep, chest pain, palpitations, abdominal pain, etc.
        • It is often difficult for anxious people to recognize this problem in themselves.
        • All individuals should be aware of the basic signs of anxiety so that they can identify the problem in themselves or others.
  • A guideline for major depression, panic disorder and generalized anxiety disorder is available at ICSI’s website.
    • Coping skills/stress reduction
      • Counseling and education messages
        • Stress is a normal part of our lives
        • Stress can be positive or negative
        • Everyone has control over their own body’s reaction to stress
        • A negative response to stress may include many symptoms
  • Symptoms of a negative response to stress and coping and stress management skills are presented in an appendix.

Screening for Problem Drinking

United States Preventive Services Task Force
http://www.ahrq.gov/clinic/uspstf/uspsdrin.htm#related

Recommendations

Screening to prevent problem drinking is recommended for all adult and adolescent patients.  Screening should involve a careful history of alcohol use and/or the use of standardized screening questionnaires.

Routine measurement of biochemical markers is not recommended in asymptomatic persons.

Pregnant women should be advised to limit or cease drinking during pregnancy.  Although there is insufficient evidence to prove or disprove harms from light drinking in pregnancy, recommendations that women abstain from alcohol during pregnancy may be made on other grounds.

All persons who use alcohol should be counseled about the dangers of operating a motor vehicle or performing other potentially dangerous activities after drinking alcohol.

Screening for Drug Abuse

US Preventive Services Task Force
http://www.ahrq.gov/clinic/uspstf/uspsdrug.htm

Recommendations

There is insufficient evidence to recommend for or against routine screening for drug abuse with standardized questionnaires or biologic assays.  Including questions about drug use and drug related problems when taking a history from all adolescent and adult patients may be recommended on other grounds.

All pregnant women should be advised of the potential adverse effects of drug use on the development of the fetus.

Clinicians should be alert to the signs and symptoms of drug abuse in patients and refer drug abusing patients to specialized treatment facilities where available.

Pharmacotherapy for Alcohol Dependence

Agency for Health Care Policy and Research, Evidence Report/Technology Assessment.
http://www.ahrq.gov/clinic/epcsums/alcosumm.htm

SUMMARY

Alcoholism is a prevalent disease that will affect approximately 10% of the adult population of the US.  An estimated 100,000 Americans die each year from alcohol related disease or injury.  The serious financial and nonfinancial impact of this disease extends to family members and society in general, and its annual dollar cost to the country has been estimated (as of 1995) to exceed $166 billion.

The treatment of alcohol dependence requires a two-step approach that includes withdrawal and detoxification followed by further interventions to maintain abstinence.  There is considerable uncertainty about the best treatment strategies for patients in the post-detoxification stage.  Some advocate a drug free 12-step approach (Alcoholics Anonymous), while others assert that the 12-step approach or other psychosocial approaches combined with appropriate nonaddictive pharmacotherapies may improve treatment outcomes.

This report reviews the evidence on the efficacy of the following pharmacotherapy agents in treating alcohol dependence:

  • disulfiram
  • naltrexone
  • acamprosate
  • serotonergic agents
  • lithium 

Methodology employed a review of peer reviewed articles and other documents including government documents and monographs, industry reports and publications, unpublished studies and works in progress, review of tables of contents from symposia proceedings, FDA Medical Officer Reviews of efficacy data.  Efficacy data were graded on a 4-point scale (good, fair, poor and incomplete), and harms data were reported as low or high.

Key findings are presented for the five major drugs or drug classes reviewed, and future research needs are listed.

Guidelines for Recognizing, Assessing and Treating Alcohol and Cannabis Abuse in Primary Care

The Health Committee
http://www.nzgg.org.nz/guidelines/0040/full_guideline.pdf

SUMMARY

These guidelines primarily aim to support primary care practitioners in recognizing, assessing and treating patients with problem use of alcohol and marijuana.  They provide detailed information on brief interventions that are effective in reducing consumption and drug-related harm and indicate where referral to specialist services is appropriate. 

  • Recommendations are evidence-based and rely heavily on international research.

They seek to increase access to early intervention in primary care by:

  • Reducing the harm to and promoting the health of those with substance abuse problems.
  • Encouraging primary health care professionals to screen at risk population groups.
  • Identifying treatment options for the individual with substance use problems and
  • Promoting cost-effective brief intervention in primary care.

This well-referenced document, which is not specific to the aging, contains useful statistics and a brief discussion of cultural differences in consumption among the major populations of New Zealand.  The importance of early identification is emphasized and screening is stressed.  The authors believe this can best be achieved by embedding questions about alcohol and cannibis use into the general health and systems’ review.  The guideline offers workable tools for effecting change in a primary care environment and includes the AUDIT (alcohol use disorders identification test), questions to ask about cannabis usage, and a readiness to change questionnaire.  Scoring instructions are included with these instruments.