Substance Use Screening and Brief Intervention (SBI) with Older Adults

Transcription

1 Substance Use Screening and Brief Intervention (SBI) with Older Adults Deborah S. Finnell, DNS, PHMHP-BC, CARN-AP, FAAN Associate Professor, Director of the Master's Program Johns Hopkins School of Nursing 525 N. Wolfe Street, Academic Affairs, Room 129 Baltimore, MD Office:

2 Objectives At the end of this program learners will be able to: Discuss the current and projected prevalence of substance use among older adults Describe the relationship between substance use and health status Develop skills in screening and brief intervention among older adults

3 Global Aging By 2020 globally the number of people aged 65 or older will outnumber children under age 5. In % of the population was 65 or older; by 2050 this will double (16%). Administration on Aging (2013) 3

4 Substance Use and the Older Adult More than 50% of adults aged 50+ use alcohol and/or illicit drugs. Alcohol use has remained relatively stable over years. Rate of illicit drug use has more than doubled from 3.4% in 2002 to 7.2% in (SAMHSA, 2013)

5 NIAAA (n.d.) At-Risk Alcohol Use In the healthy adult this is usually defined as drinking over the recommended limits. In the older adult, changing metabolism and body composition reduces the ability to metabolize alcohol and other drugs thus increasing risk and need to lower the recommended limits. Adults with comorbid conditions may be at greater risk.

6 Levels of Risk for Alcohol Use: Quantity How much is used (based on standard drink)? 6

7 Levels of Risk for Alcohol Use: Frequency How often is the substance used? Usually combined with quantity to reflect average number of drinks/packs/hits, etc. per a specific time period Per day Per week Per past 30 days Per past 12 months 7

8 Levels of Risk for Alcohol Use: Pattern What is the pattern of use? (e.g., daily use, episodic use) Binge drinking is a risk factor for many health problems; 80,000 average annual deaths associated with binge drinking Binge drinking is a pattern of drinking that brings the BAC to 0.08 grams percent or above. The age group > 65 years is the group that binge drinks most often For older adults binge drinking = 4 or more drinks within a short period of time Centers for Disease Control and Prevention (2012) 8

9 Recommended Alcohol Limits based on Quantity and Pattern OLDER ADULTS

10 Level of Risk for Alcohol Use: Duration The longer the use especially over the recommended limits, the greater the risk for adverse consequences Duration is usually measured over a lifetime for both: Persons who are currently using Persons with past use Information to consider Number of years Age at first use

11 Levels of Harm Gradations of risk Healthy/Low risk (at or below the recommended limits) At-risk use (above the recommended limits) Heavy/harmful use: A pattern of substance use that is causing damage to health Substance use disorder (SUD): Meet criteria NIAAA (2007); WHO (2014) SUD Heavy Use At-Risk Healthy/Low risk

12 Early and Late Onset Early Onset: Those who have used alcohol and/or drugs at levels above the recommended limits for many years Hardy survivors Late onset: Those who begin using above the recommended limits later in life. Often following an event such as widowhood.

13 Objectives At the end of this program learners will be able to: Discuss the current and projected prevalence of substance use among older adults Describe the relationship between substance use and health status Develop skills in screening and brief intervention among older adults

14 Health and Social Effects Immediate Risks Injury Overdose Increased risk for communicable diseases Psychotic episodes Long term harm Long-Term Risks Alcohol is linked to 65 adverse health consequences Other drug use is linked to adverse outcomes such as cardiovascular disease, kidney damage, mental disorders Development of a substance use disorder

15 Substance Use and Physical Health Early & Late Onset May affect morbidity associated with comorbid conditions. At increased risk for Adverse interactions with prescription medications Depression Gastritis Falls Driving impairment Suicide

16 Physical Health and Early Onset Liver failure and cirrhosis Hypertension Cognitive impairment/dementia Malnutrition and vitamin deficiencies leading to Wernicke-Korsakoff syndrome Dysrhythmia Cardiomyopathy Withdrawal Overdose

17 Breslow, Dong, & White (2015) Alcohol-Interactive Medications 41.5% of U.S. adults who currently drink used alcohol-interactive medications. The prevalence was higher among older adults who were currently drinking %. Regardless of age, the alcoholinteractive medications most commonly used by persons currently drinkwere cardiovascular agents and CNS agents.

18 Driving Under the Influence Increase in proportion of older adult drivers involved in fatal crashes with BAC > 0.8g/dL age group: 11% (2003) to 14% (2013) 65+ age group: 8% (2003) to 9% (2013) Risk Factors age group at significantly higher risk than 65+ group Male Racial/ethnic minority More disadvantaged with respect to marital status, education, income, and self-rated health Comorbid factors for older adults who drink and use illicit drugs at high risk for DUI Anxiety (10%) Suicidal thoughts (8%) Alcohol disorder (20%) Drug disorder (14%) Choi, DiNitto, & Marti (2015)

19 Objectives At the end of this program learners will be able to: Discuss the current and projected prevalence of substance use among older adults Describe the relationship between substance use and health status Develop skills in screening and brief intervention among older adults

20 SCREENING

21 Detecting Risk Factors Early Researchers have shown that approximately 90% of substance use disorders go untreated (NSDUH, 2007). The nurse is often the first point of contact. Early identification and intervention lead to better outcomes. Patients are often seen by a nurse because of a related physical problem. UN Office on Drugs and Crime, Treat net. (2008). Screening, assessment and treatment planning. Retrieved from

22 Hi, I'm, nice to meet you. If it's okay with you, I'd like to ask you a few questions that will help me give you better medical care. The questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the substances we'll talk about are prescribed by a healthcare provider (like pain medications). But I will only record those if you have taken them for reasons or in doses other than prescribed. I'll also ask you about illicit or illegal drug use but only to better diagnose and treat you.

23 Initial Screening Strategy Alcohol How many times in the past year have you had five (men) or four (women or persons over age 65) drinks or more in a day?) + AUDIT C Drug Use How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons? + DAST Smith, Schmidt, Allensworth-Davies & Saitz, (2009, 2010)

24 Initial Screening Drinking Limits To determine the average drinks per day and average drinks per week ask: On average, how many days a week do you have an alcoholic drink? On a typical drinking day, how many drinks do you have? (Daily average) Weekly average = days X drinks NIAAA Recommended Limits Anyone 65+ = No more than 3 drinks in a day AND no more than 7 drinks in a week. > Recommended limits = at-risk drinker

25 A Positive Alcohol Screen = At-Risk Use Heavy drinking days (in a day 4 for anyone 65+) or patient exceeds regular limits? 65+ = No more than 3 drinks in a day AND no more than 7 drinks in a week > Recommended limits = at-risk drinker NO Patient is at low risk. YES Patient is at risk. Screen for maladaptive pattern of use and clinically significant alcohol impairment using AUDIT.

26 BRIEF INTERVENTION

27 The Brief Negotiated Interview 4. Negotiate a plan 3. Enhance motivation 2. Provide feedback 1. Raise the subject D'Onofrio et al. (1998)

28 BNI Step 1. Raise the Subject Simple but important step Begin with a general conversation & build rapport Ask permission to talk about alcohol or drug use Use specific information from screening as conversation starters

29 Clinician Barriers Experiences Family Friends Own alcohol or drug use Perceptions Attitudes Stigma Fear of damaging the relationship

30 The Brain-Base

31 This was neither your fault nor intention Alcohol and other drugs activate the brain The neurochemical reactions that result translate into feelings, thoughts, memories, and behaviors Substance use can progress to substance use disorder Approach conversations like those about diabetes or hypertension or hyperlipidemia. Explain the brain-base. Finnell & Nowzari (2013)

32 Acceptance of the Conversation It would be okay with me if my nurse Asked me about my use of alcohol (95% agreed) Discussed my use of alcohol with me (95% agreed) Broyles et al. (2012) How acceptable would it be for nurses to ask you about your alcohol use and discuss it with you? Veterans 96% male 90% > 51 years of age

33 If I were a person concerned about my own use of alcohol, it would be ok with me if my nurse Strongly Agree/Agree Provided me with brief counseling about alcohol during my hospital stay 87% Gave me a booklet with ideas on how to change my use of alcohol 88% Gave me information about alcohol self-help groups available in my area 86% Offered to refer me to an alcohol program 78% As part of my care, my nurse should feel free to ask me how much alcohol I drink 92% If my drinking is affecting my health (such as my blood pressure) my nurse should advise me to cut down If my drinking is affecting my health (such as my blood pressure) my nurse should advise me to quit drinking If my nurse offered me a blood test that could tell if I am drinking too much for my health, I would want to be tested 94% 84% 84% Broyles et al. (2012)

34 How You Ask Matters Older adults respond to a more supportive non-confrontational approach than more assertive styles Older adults provide information if the person is genuinely interested in their overall health and well-being Gentle respect Normalize the behavior without endorsing Kuerbis, Sacco, Blazer, & Moore (2014)

35 Orient the Patient Identify yourself and explain your role Get permission Explain the purpose of the discussion 1. Give information about health risks that may be related to substance use 2. Get their opinions about their substance use 3. Discuss what, if anything they want to change about their substance use

36 BNI Step 2. Provide Feedback Discuss screening results including level of risk Help patient link substance use to any known consequences State low risk limits Give recommendation

37 How to put an older adult at ease 20% of Veterans expressed personal discomfort in talking with a nurse about their alcohol use so approaching them with sensitivity is important If I feel able to determine my risk If I am able to decrease my alcoholrelated health risks If I have some concern about my alcohol use Broyles et al. (2012)

38 Feedback Range: The screening scores can range from (meaning) to (meaning) And we know that we can compare your score with thousands of others who have been screened Normal scores are to which represent lowrisk. Give patients their score. Your score of means that you are (at risk or high risk), putting you in danger of health problems. Elicit the patient s reaction. What do you make of that?

39 BNI Step 3. Enhance Motivation Motivational Interviewing Person-centered Directive method Helps enhance intrinsic motivation to change By exploring and resolving ambivalence Miller & Rollnick (2012)

40 Navigating the Waters Open-ended questions Affirmations Reflections Summaries

41 BNI Step 3. Enhance Motivation

42 Importance and Readiness Rulers Not At All Important Extremely Important Not At All Confident Extremely Confident

43 Pros and Cons What do you like about your drinking or drug use? What do you like less about your drinking or drug use? On the one hand. On the other hand Listen for the patient s concerns, problem recognition, and downsides of drinking or drug use.

44 Enhance Motivation Ask On a scale of 0 to 10, with 0 being not at all ready and 10 being completely ready how ready are you to decrease your substance use? Ask, Why did you choose and not a lower number? For people who are not so ready, explore the good and not-so-good things about making a change. Listen for reasons the person identifies and reflect them back to him or her.

45 Listen for Change Talk Is the patient interested in change? If the patient is interested in changing, What would it take to raise that number? How confident are you that you can change your behavior? Reflect and summarize throughout.

46 BNI Step 4. Negotiate a Plan Where does this leave you? Do you want to quit, cut down, or make no change? Options Manage your drinking or drug use, Eliminate alcohol or drugs from your life, Continue Never drink or use drugs and drive, Usual drinking or drug use pattern, or Seek help.

47 BNI Step 4. Negotiate a Plan If you were to make a change, what would be your first step? Encourage a specific plan/goal to reduce use, abstain and/or seek referral Support the person s autonomy Make an affirming statement Schedule follow-up

48 Close on Good Terms Summarize the patient s statement in favor of change. Emphasize the patient s strengths. What agreement was reached? Always thank the patient for speaking with you

49 FOLLOW-UP AND REFERRAL TO TREATMENT

50 Interview Treatment Programs What do you provide? What is the length or duration of treatment? What are the costs? Who are the health care providers? Are they licensed? Are the certified (what specialty)? What evidence-based therapies do you provide? Are approved medications offered? What are the outcomes of your program?

51 Considerations Explore your geographic region to identify substance abuse treatment programs for older adults. Contact Alcoholics Anonymous, Narcotics Anonymous or Secular to inquire about special meetings for older adults. Anticipate possible barriers that you or an older adult may face when attempting to access treatment or engage in mutual support program.

52 Resources National Institute on Alcohol Abuse and Alcoholism - National Institute on Drug Abuse - National Institute of Mental Health - Videos are accessible at and most of them can be accessed on YouTube: search SECSAT APRN

53 REFERENCES

54 Breslow, R. A., Dong, C., & White, A. (2015). Prevalence of alcohol interactive prescription medication use among current drinkers: United States, 1999 to Alcoholism: Clinical and Experimental Research, 39(2), Broyles, L. M., Rosenberger, E., Hanusa, B. H., Kraemer, K. L., & Gordon, A. J. (2012). Hospitalized patients acceptability of nurse delivered screening, brief intervention, and referral to treatment. Alcoholism: Clinical and Experimental Research, 36(4), Centers for Disease Control and Prevention. (2014). Alcohol screening and counseling. CDC Vital Signs. Atlanta, GA: Centers for Disease Control and Prevention. Available at Centers for Disease Control and Prevention. (2012). Binge drinking: Nationwide problem, local solutions. Choi, N.G., DiNitto, D.M., & Marti, C.N. (2015). Older adults who are at risk of driving under the influence: A latent class analysis. Psychology of Addictive Behaviors. Advance online publication. Retrieved from

55 D'Onofrio, G., Bernstein, E., Bernstein, J., Woolard, R. H., Brewer, P. A., Craig, S. A., & Zink, B. J. (1998). Patients with alcohol problems in the emergency department, part 2: Intervention and referral. Academic Emergency Medicine, 5(12), Finnell, D.S., & Nowzari, S. (2013). Providing information about the neurobiology of alcohol use disorders to close the referral to treatment gap. The Nursing Clinics of North America, 48(3), Han, B., Gfroerer, J. C., Colliver, J. D., & Penne, M. A. (2009). Substance use disorder among older adults in the United States in Addiction, 104(1), Hooyman, N. & Asuman, H. (2011). Social Gerontology: A Multidisciplinary Perspective, 9th ed. Pearson Education. Johnson, J. A., Lee, A., Vinson, D., & Seale, J. P. (2013). Use of AUDIT Based Measures to Identify Unhealthy Alcohol Use and Alcohol Dependence in Primary Care: A Validation Study. Alcoholism: Clinical and Experimental Research, 37(s1), E253-E259.

56 Kaner, E. F., Beyer, F., Dickinson, H. O., Pienaar, E., Campbell, F., Schlesinger, C.,... & Burnand, B. (2009). Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews, Issue 2. DOI: CD pub3. Kuerbis, A., Sacco, P., Blazer, D. G., & Moore, A. A. (2014). Substance abuse among older adults. Clinics in Geriatric Medicine, 30, McGinnis, K. A., Justice, A. C., Kraemer, K. L., Saitz, R., Bryant, K. J., & Fiellin, D. A. (2013). Comparing alcohol screening measures Among HIV infected and uninfected men. Alcoholism: Clinical and Experimental Research, 37(3), Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change. Guilford Press. NIAAA (n.d.)

57 National Institute on Alcohol Abuse and Alcoholism. (2007). Helping patients who drink too much: A clinician s guide. NIH Publication No Rubinsky, A. D., Kivlahan, D. R., Volk, R. J., Maynard, C., & Bradley, K. A. (2010). Estimating risk of alcohol dependence using alcohol screening scores. Drug and Alcohol Dependence, 108(1), Skinner, H.A. (1982). The drug abuse screening test. Addictive Behaviors, 7(4), Smith, P.C., Schmidt, S.M., Allensworth-Davies, D., & Saitz, R. (2009). Primary care validation of a single-question alcohol screening test. Journal of General Internal Medicine, 24(7), Smith, P.C., Schmidt, S.M., Allensworth-Davies, D., & Saitz, R. (2010). A single-question screening test for drug use in primary care. Journal of General Internal Medicine,170(13), Substance Abuse and Mental Health Services Administration, (2014). Results from the 2013 National Survey on Drug Use and Health: Mental health findings, NSDUH Series H-49, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration.

58 Substance Abuse and Mental Health Services Administration, (2013). Results from the 2012 National Survey on Drug Use and Health: Summary of national findings, NSDUH Series H-46, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration. US Department of Health and Human Services. (1998). Substance abuse among older adults: Treatment improvement protocol (TIP) Series, 26. DHHS Publication No.(SMA), Available at Adults/SMA World Health Organization (WHO). (2014). Global Status Report on Alcohol and Health Geneva, Switzerland: WHO. Available at Yudko, E., Lozhkina, O., & Fouts, A. (2007). A comprehensive review of the psychometric properties of the Drug Abuse Screening Test. Journal of Substance Abuse Treatment, 32(2),