Combined motivational interviewing and cognitive-behavioral therapy with older adult drug and alcohol abusers.
Article Type: Report
Subject: Cognitive therapy (Research)
Drug addicts (Demographic aspects)
Aged patients (Drug use)
Aged patients (Alcohol use)
Substance abuse (Care and treatment)
Substance abuse (Research)
Author: Cooper, Lyle
Pub Date: 08/01/2012
Publication: Name: Health and Social Work Publisher: Oxford University Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health; Sociology and social work Copyright: COPYRIGHT 2012 Oxford University Press ISSN: 0360-7283
Issue: Date: August, 2012 Source Volume: 37 Source Issue: 3
Topic: Event Code: 310 Science & research Canadian Subject Form: Cognitive-behavioural therapy
Product: Product Code: E199610 Drug Addicts; 8000143 Alcohol & Drug Abuse Programs NAICS Code: 62142 Outpatient Mental Health and Substance Abuse Centers SIC Code: 8093 Specialty outpatient clinics, not elsewhere classified
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 309792874
Full Text: More than 2.5 million older Americans struggle with alcohol abuse and its associated medical and social consequences. This number is expected to double to 5 million by 2020 (Gfoerer, Penne, Pemberton, & Folsom, 2003). Marijuana is the most commonly used illicit drug among older people followed by the nonmedical use of prescription drugs (Bartles, Blow, Brockmann, & Van Citters, 2005). The number of marijuana users age 50 and over is expected to grow from the current 719,000 to 3.3 million by 2020. It is estimated that one in four older adults use psychotropic drugs with abuse potential and that nonmedical use of such drugs will increase from the current 911,000 to 2.7 million by 2020 (Colliver, Compton, Gfroerer, & Condon, 2006; Simoni-Wastila & Yang, 2006).

Comorbidity of drug and alcohol use is also a problem among older drug and alcohol users. Older people with alcohol disorders are at high risk for prescription drug abuse (Culberson & Ziska, 2008). Overall, physical and mental difficulties related to combined misuse of alcohol and medications affect up to 19 percent of the older population (Bartles et al., 2005; Cummings & Cooper, 2011). The combination of drugs, such as marijuana, with alcohol and prescription medications can lead to decreased cognition, impairment of memory and attention, and increased falls (Benshoff, Harrawood, & Koch, 2003). Comorbid psychiatric illness, including depression and anxiety, are also common among elderly drug and alcohol abusers. Additionally, older adults who use alcohol and marijuana have a higher risk of suicide (Rigler, 2000). Substance abuse and the related physical and mental comorbidities are expected to rise among the population of older adults in the coming decades.

This increase in substance abuse among the older adult population coupled with the high comorbidity of substance misuse with mental and physical health disorders presents many challenges to the current treatment system. The Older Adult Healthy Living Program (HELP) was developed to address these challenges. This article describes both the barriers to older adult treatment effectiveness and the means by which HeLP overcomes these barriers.

BARRIERS TO EFFECTIVE OLDER ADULT TREATMENT

Older people see medical professionals frequently, which makes medical offices an efficacious place to screen for alcohol and drug use among this population. However, studies indicate that medical professionals overlook substance abuse and misuse among older people (O'Connell, Chin, Cunningham, & Lawlor, 2003), Additionally, medical professionals are often unaware of the special physiological vulnerabilities to substances that the elderly experience and of the altered substance use guidelines established for older adults (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2005; Simoni-Wastila & Yang, 2006), For these reasons, medical professionals underdiagnose older patients with alcohol and drug abuse disorders and rarely refer their older clients to substance abuse treatment (Weintraub et al., 2002). Poor communication among prescribing physicians (Benshoff et al., 2003), lack of physician inquiry concerning older patients' medication concerns (Alemagno, Niles, & Treiber, 2004), and medical professionals' failure to determine whether an older patient uses alcohol or other substances along with prescription medication (Simoni-Wastila & Yang, 2006) contribute to the lack of recognition of alcohol and drug abuse by older adults as well.

Older people often do not recognize the signs of addiction and, therefore, do not present for treatment. They often perceive the negative effects of substance use as a natural consequence of aging (Benshoff et al., 2003). They sometimes engage in dangerous behavior such as borrowing medications from a friend, taking medications for other than approved purposes, and taking higher than prescribed doses, without realizing the potentially dangerous effects of such behaviors (Simoni-Wastila & Yang, 2006).

Older adults who are restricted to their homes due to health problems and functional impairments are at particular risk for substance use problems due to isolation and difficulties accessing transportation. Social isolation due to the loss of family members and friends makes the geriatric population uniquely vulnerable to substance abuse problems that are caused by lonliness, grief, and depression. Yet functionally impaired and homebound individuals are less likely to have such problems detected or treated (NIAAA, 2005). In spite of physiological changes that make older adults more susceptible to substance use problems, their heightened risk of comorbid problems, and the functional disability and social isolation faced by the elderly, most assessment and treatment strategies are not sensitive to these unique physical and social challenges (Battles et al., 2005).

Thus far, the barriers discussed have pertained to seeking substance abuse treatment. Older adults face additional obstacles once they have entered treatment. As noted previously, older adults have rates of physical illness and disability disproportionate to the general treatment-seeking population and, as a result, access to treatment is more difficult for them. Oftentimes, providers will suggest residential modes of treatment to mediate the effect of a physical illness. However, residential modes of therapy are typically recommended only for clients with more severe problems. Older adults may face a "mismatch" of the modality and their peer cohort due to a less severe substance abuse diagnosis.

A second obstacle older adults face to effective substance abuse treatment is a lack of individualized treatment. Several authors have been critical of a one-size-fits-all approach to substance abuse treatment (Benshoff et al., 2003; Koch & Rubin, 1997). The psychoeducation needs of older adults are different, because their bodies respond differently to drugs and alcohol. The family constellation of older adults is different, and thus family counseling should be different. Even the cognitions supporting drug and alcohol use are somewhat different for older adults (Levin & Kruger, 2000; Norton, 1998). Because of all of these differences, the one- size-fits-all approach is especially ineffective for older adults in substance abuse treatment.

Finally, referral to Alcoholics Anonymous (AA) and other self-help groups is ubiquitous for substance misusing clients (Koch & Benshoff, 2002). Although self-help has been found to be an important adjunct to treatment in several studies, it may not meet the needs of the geriatric population. Being transported to meetings can be difficult for the elderly population due to their problems with mobility. Once in the meetings, older adults often do not find similarly aged peers and thus do not derive the same benefit from these meetings, which utilize mutual experiences as the chief means to bonding. AA and other self-help groups may be helpful for older adults in recovery, but the treatment providers making referrals have to take into account their limited mobility and age.

OLDER ADULT HEALTHY LIVING PROGRAM

HeLP was developed to meet the needs of older substance abusers by utilizing evidence-based substance abuse treatment approaches and specifically targeting the barriers faced by older adults when they seek treatment (see Table 1). HeLP combines motivational interviewing (MI) and cognitive-behavioral therapy (CBT) to treat older adults. Previous studies have supported the efficacy of both MI (Cummings, Cooper, & Cassie, 2009) and CBT (Center for Substance Abuse Treatment [CSAT], 2005) in this population. The HeLP program expands on the implementation of these interventions with this population by tailoring it to fit the unique needs of the geriatric substance- misusing population. In addition to modifying the clinical intervention, HeLP is delivered on-site to ensure clients can access treatment. The clinician is cross-trained to address frequent mental health comorbidities, and strong relationships with community service providers have been developed to enable seamless referral to physical health providers and other needed services.

The HeLP intervention is being implemented in two public housing facilities for older residents (50 years and over). Prior to developing the intervention, a thorough needs assessment was conducted of the residents in these two facilities. Findings from this assessment evidenced elevated levels of substance misuse and mental health disorders coupled with very limited service utilization among older residents and, thus, pointed to the need for substance abuse treatment in the public housing facilities. The residents' background characteristics, drug and alcohol use, mental and physical health status, and current receipt of treatment are described in Table 2.

Residents are referred to HeLP in two ways: (1) by public housing staff who recognize that the residents have a problem and (2) by self-referral. Residents are screened using the Healthy Living Survey, a multidimensional questionnaire used to assess medical, social, functional, mental health, and substance use issues (see Table 3). If residents screen positive for substance misuse or mental illness, they are given the opportunity to receive HeLP services. During the first session, the HeLP clinician completes the assessment. If no substance abuse or mental health problem is present, the HeLP clinician answers any questions the clients may have and refers them to a case manager or social service coordinator, as needed. If substance abuse or a mental health disorder is present, a second session is schedule to provide the clients with feedback from the assessment using an MI counseling style. Feedback and discussion continue in the third session. In the fourth MI session, a change plan is developed that includes action steps for abstinence or use reduction as well as contingencies in case the plan does not work. For substance-abusing residents, these steps may include in-home CBT to address substance use problems or referral to detoxification. For persons with mental illness, these steps may include referral to additional counseling, psychopharmacological care, or both. Clients may also be referred to medical services. To ensure seamless referrals, the public housing agency that operates the buildings in which HeLP is provided has developed partnerships with community mental health and medical providers. At the end of treatment, the HeLP clinician re-administers the mental health, substance abuse, or treatment measure related to the issue for which the clients are being treated. One month post treatment, all clients receive a follow-up visit during which the entire assessment tool is re-administered.

Healthy Living Survey

A Healthy Living Survey serves as an initial assessment to determine whether the older adults need HeLP services and is the mechanism by which data are gathered to provide individual feedback to potential HeLP clients. Additionally, the HeLP assessment uses empirically validated instruments to measure illicit drug and alcohol abuse, prescription drug misuse, mental and physical health status, social support, ability to engage in activities of daily living, and service receipt in each of these areas. Each of the instruments is listed in Table 3. Clients who are identified as experiencing substance abuse or mental health problems receive immediate feedback from the HeLP social worker based upon information gathered during the assessment. This feedback is delivered using an MI approach.

MI

MI is a client-centered directive style of counseling designed to resolve ambivalence to enable client behavior change. Ambivalence, in this context, is an internal conflict regarding the pros and cons of behavior change. This internal conflict must be resolved in order for a client to make a decision to change his or her behavior. Cummings and colleagues (2009) found that MI with older adults is effective at achieving a range of health behavior changes in a relatively short time.

The HeLP social worker utilizes MI in the feedback session to enable the client to recognize substance abuse-specific symptoms and to connect current social, medical, mental health, or other problems identified in the Healthy Living Survey to substance use. One modification of MI is that the social worker points out the aging-specific consequences of the use of alcohol and other drugs. As described previously, older adults often do not recognize the effects of substance use. Although education is not typically a part of MI, it is needed in this population to ensure that older persons make the connection between the difficulties they may be facing and substance use. Additionally, because older adults often have physical health consequences that are either caused or exacerbated by drug and alcohol use, the HeLP worker does background research between sessions one and two on the link between drug use and any health problem the older adults may be struggling with and makes this connection a significant part of the interview.

The two subsequent sessions are used to strengthen the clients' motivation for behavior change and elicit treatment goals prior to the start of an active phase of treatment utilizing CBT. During the feedback session, the worker provides information on the effects of alcohol and drug use that are specific to the clients' use patterns. In the next two sessions, the HeLP worker uses MI to enable the clients to explore and resolve ambivalence related to drug and alcohol use. At the end of the last session of MI, a change plan is developed, which becomes the document by which progress is measured.

It should be noted that some clients may not wish to achieve abstinence, but rather may want to reduce or change their use. In such cases, the HeLP worker is forthright about any concerns he or she has regarding the clients' choice of treatment goals but is ultimately supportive of the clients' decision. Many of the residents may not have a diagnosable alcohol or drug abuse or dependence disorder, but rather are misusing a prescription or have begun to feel the effects of alcohol differently due to age-related altered pharmacokinetics. Many clients in this category will end treatment after the MI sessions as brief motivational interventions are often sufficient to overcome their less severe alcohol and drug problems (Cummings et al., 2009; Project MATCH Research Group, 1998). In these cases, the worker will provide follow-up to ensure that the clients have met treatment goals and will resume treatment as necessary. For many residents with more severe substance misuse histories, brief MI intervention will not be sufficient and additional treatment will be needed. These clients will also receive CBT for substance abuse.

CBT

After completion of the Healthy Living Survey and the MI sessions, some clients enter into individual older adult-focused CBT for drug and alcohol abuse. The clients who begin CBT have expressed a need to receive additional treatment and do not have a drug problem so severe that it warrants detoxification. This intervention takes place over five sessions. Following a previous large-scale study on CBT for drug abuse among the older population (CSAT, 2005), the intervention addresses specific topics germane to older adult substance abuse, including identifying and challenging thought patterns regarding drug and alcohol use specific to older adults, assessing and enhancing social support networks, identifying and increasing activities that provide feelings of joy and accomplishment, and developing a relapse prevention plan.

Challenging Drug-related Thought Patterns. In the first two sessions of CBT, the HeLP social worker teaches the older adults about the "behavioral chain" that leads to substance use (CSAT, 2005). As with other CBT interventions, the clients are taught that behaviors begin with thought and that thought leads to emotions and behaviors. Through administration of this intervention, common thoughts that spur older adult drug users to misuse alcohol and other drugs are systematically identified and challenged. These include thoughts that, as older people, they have no control over their lives, they are no longer needed, and intimate relationships are no longer possible. The older adults are taught how to continue challenging these thoughts using a detailed thought record. Thought records are reviewed at the beginning of each subsequent session.

Social Support Networks. The social support networks of many older adults have changed over time. Often, older adults have family but do not want to be a burden to them. These networks may have dwindled over time. During the third session, the older adults analyze current social support, project possible changes in this network, and practice skills for developing the needed support.

Increasing Feelings of Joy and Accomplishment. The fourth session of CBT involves encouraging the older adults to discover (or in many cases rediscover) activities that give them a sense of joy and accomplishment. Drug and alcohol use is often a coping mechanism for negative feelings the older adults have about their current fife situation. Increasing the number of activities that elicit joy and positive feelings makes it less likely that the older adults will turn to alcohol and drag for these feelings.

Relapse Prevention and Follow-up. The final session of CBT focuses on possible barriers to continued reduction or abstinence. During this session, the clients identify high-risk situations, both external (in the social environment) and internal (thoughts and feelings states). The clients develop specific strategies for addressing these barriers in collaboration with the HeLP social worker. The worker schedules a one-month follow-up appointment with the clients to collect data and address any problems that have arisen between the last session and the follow-up interview. After the follow-up interview, the counseling relationship is terminated, and the worker explains that the older adults can reengage in treatment at any time.

CONCLUSION

Considering the projected growth of the population of older adults engaged in substance abuse, increased awareness and specific interventions for this population are a necessity. HeLP is designed specifically to address barriers that inhibit detection and treatment of substance abuse among older adults. Older adults face unique challenges regarding substance abuse detection and referral to treatment. Screening and assessment of this population is crucial to improving identification of substance abuse and providing age-specific services. HeLP builds on previous interventions for substance abuse among the elderly by employing evidence-based interventions. As discussed, previous research supports the elements of the HeLP intervention, and formative data from the project support its efficacy with the elderly population. To ensure that HeLP is an effective intervention for this population, baseline and follow-up data are being collected and will be reported in subsequent articles.

Social workers in all settings will likely see more older adults in their practices, and the number of older adults with substance abuse problems will increase. Social workers often focus on the low-income and marginalized populations, therefore it is important to have interventions, like HELP, that have been designed to address the needs of and treatment barriers faced by these populations.

doi: 10.1093/hsw/hls023

REFERENCES

Alemagno, S. A., Niles, S. A., & Treiber, E. A. (2004). Using computers to reduce medication misuse of community-based seniors: Results of a pilot intervention program. Geriatric Nursing, 25, 281-285.

Bartels, S.J., Blow, F. C., Brockmann, L. M., & Van Citters, A. D. (2005). Substance abuse and mental health among older Americans: The state of knowledge and future directions. Rockville, MD: Older American Substance Abuse and Mental Health Technical Assistance Center

Benshoff, J. J., Harrawood, L.K., & Koch, D. S. (2003). Substance abuse and the elderly: Unique issues and concerns. Journal of Rehabilitation, 69, 43-48.

Butler, S. F., Budman, S. H., Fernandez, K. C., Houle, B., Benoit, C., Katz, N., & Jamison, R. N. (2007). Development and validation of the Current Opioid Misuse Measure. Pain, 130, 144-156.

Cacciola, J. S., Alterman, A. I., Lynch, K. G., Martin, J. M., Beauchamp, M. L., & McLellan, A. T. (2008). Initial reliability and validity studies of the revised Treatment Services Review (TSR-6). Drug and Alcohol Dependence, 92, 37-47.

Colliver, J. D., Compton, W. M., Gfroerer, J. C., & Condon, T. (2006). Projecting drug use among aging baby boomers in 2020. Annals of Epidemiology, 16, 257-265.

Center for Substance Abuse Treatment. (2005). Substance abuse relapse prevention for older Adults: A group treatment approach (DHHS Publication No. [SMA] 05-4053). Rockville, MD: Substance Abuse and Mental Health Services Administration.

Cuevas, C., Sanz, E.J., De La Fuente, J. A., Padilla, J., & Beruenger, J. C. (2000). The Severity of Dependence Scale (SDS) as screening test for benzodiazepine dependence: SDS validation study. Addiction, 95, 245-250.

Culberson, J. W., & Ziska, M. (2008). Prescription drug misuse/abuse in the elderly. Geriatrics, 63(9), 22-31.

Cummings, S., & Cooper, R. L. (2011). The addicted geriatric patient. In E. O. Bryon, & E.A.M. Frost (Eds.), Perioperative addiction: Clinical management of the addicted patient (pp. 239-252). New York, NY: Springer.

Cummings, S. M., Cooper, R. L., & Cassie, K. M. (2009). Motivational interviewing to affect behavioral change in older adults with chronic and acute illnesses. Research on Social Work Practice, 19, 195-204.

Derogatis, L. R. (2001). BSI-18: Administration, scoring and procedures manual. Minneapolis, MN: NC Pearson.

Gfroerer, 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, 127-135.

Goldberg, P., Gueguen, A., Schmaus, A., Nakache, J. P., & Goldberg, M. (2001). Longitudinal study of associations between perceived health status and self-reported diseases in the French Gazel cohort. Journal of Epidemiology & Community Health, 55, 233-238.

Katz, S., Down, T. D., Cash, H. R., & Grotz, R. C. (1970). Progress in the development of the index of ADL. Gerontologist, 10, 20-28.

Koch, D. S., & Benshoff, J. J. (2002). Rehabilitation professionals' familiarity with and utilization of Alcoholics Anonymous. Journal of Applied Rehabilitation Counseling, 33(3), 35-40.

Koch, D. S., & Rubin, S. E. (1997). Challenges faced by rehabilitation counselors working with alcohol and other drug abuse in a "one size fits all" treatment tradition. Journal of Applied Rehabilitation Counseling, 28(1), 31-35

Levin, S. M., & Kruger, J. (Eds.). (2000). Substance abuse among older adults: A guide for social service providers. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Lubben, J., Blozik, E., Gillman, G., Iliffe, S., Kruse, W. V., Beck, J. C., & Stuck, A. E. (2006). Performance of an abbreviated version of the Lubben Social Network Scale among three European community-dwelling older adult populations. Gerontologist, 46, 503-513.

McLellan, A. T., Cacciola, J., Kushner, H., Peters, R., Smith, I., & Pettinati, H. (1992). The fifth edition of the Addiction Severity Index: Cautions, additions and normative data. Journal of Substance Abuse Treatment, 9, 461-480.

National Institute on Alcohol Abuse and Alcoholism. (2005). Social work education for the prevention and treatment of alcohol use disorders. Retrieved from http://pubs: niaaa.nih.gov/publications/Social/Module10COlder Adults

Norton, E. D. (1998). Counseling substance abusing older adults. Educational Gerontology, 24, 373-390.

O'Connell, H., Chin, A. V., Cunningham, C., & Lawlor, B. (2003). Alcohol use disorders in elderly people: Redefining an age old problem in old age. British Medical Journal, 327, 664-667.

Project MATCH Research Group. (1998). Matching patients with alcohol disorders to treatments: Clinical implications from Project MATCH. Journal of Mental Health, 7, 589-602.

Rigler, S. K. (2000). Alcoholism in the elderly. American Family Physician, 261, 1710-1716.

Simoni-Wastila, L., & Yang, H. K. (2006). Psychoactive drug use in older adults. American Journal of Geriatric Pkarmacotherapy, 4, 380-394.

Weintraub, E., Weintraub, D., Dixon, L., Delahanty, J., Gandhi, D., Cohen, A., & Hirsch, M. (2002). Geriatric patients in a substance abuse consultation service. American Journal of Geriatric Psychiatry, 10, 337-342.

Lyle Cooper, PhD, LCSW, is assistant professor, College of Social Work, University of Tennessee, Nashville, TN 37210; e-mail: reoope10@utk.edu.

Original manuscript received December 12, 2011

Final revision received February 10, 2012

Accepted February 15, 2012

Advance Access Publication October 16, 2012
Table 1: Connecting Treatment Elements
to Treatment Barriers

                                    Elements of HeLP
Treatment Barrier                     Intervention

Lack of detection by        * In-home screening and
  medical professionals       assessment
                            * Assessment of illicit and
                              prescription drug use as well as
                              alcohol
Older adults' lack of       * Personalized age-appropriate
  symptom recognition         feedback on alcohol and drug
                              use
                            * Focus on the interactions of
                              prescription drug use with
                              alcohol and other drug use in
                              assessment and treatment
Comorbidity                 * Flexible CBT intervention
                              encompassing alcohol and drug
                              misuse as well as mental health
                              symptoms
                            * Referral to mental health and
                              physical health care providers
Functional disability and   * In-home screening and
  social isolation            assessment and treatment
                            * Enhancement of social support
                              through CB'F intervention

Note: HeLP = Healthy Living Program; CBT = cognitive-behavioral
therapy.

Table 2: Client Characteristics

Variable                                     %      n

Gender
  Male                                      54.0   102
Race (a)
  African American                          74.9   140
  Caucasian                                 23.0    43
Income
  $900 and under                            79.0   147
  More than $900                            21.0    39
Employment
  Unemployed                                14.4    27
  Retired                                   49.2    92
  Working                                    4.8     9
  Disability                                31.0    58
Self-rated Health
  Very bad/poor                             13.1    25
  Fair                                      36.9    69
  Good/very good                            49.8    93
Alcohol
  Drank at all in the last 30 days          44.4    83
  At risk (>2 per day)                       4.3     8
  Hazardous (>3 per day)                    13.9    26
  Binge (>4 in a sitting in last 30 days)   20.9    39
Illicit drug use                             6.4    12
Screen positive for pain medication
  misuse on the COMM                         5.3    10
Screen positive for benzodiazepine
  dependence on SDS                          0.5     1
BSI scores
  Depression                                18.2    34
  Anxiety                                   10.2    19
Currently services received
  Medical treatment                         41.2    77
  Psychiatric treatment                      4.3     8
  Substance abuse treatment                    0     0

Notes: Clients' mean age was 66.2 years (SD = 7.5). COMM = Current
Opioid Misuse
Measure; SDS = Severity of Dependence Scale; BSI = Brief Symptom
Inventory.

(a) Less than 2 percent Hispanic or other.

Table 3: Measurement Instruments in the
Healthy Living Survey

Client Problem
Area                                   Measure

Alcohol and illicit   Addiction Severity Index: McLellan et al.
  drug use            (1992)
Prescription misuse   Current Opioid Misuse Measure: Butler
  and abuse           et al. (2007)
                      Severity of Dependence Scale: Cuevas,
                      Sanz, De La Fuente, Padilla, and
                      Beruenger (2000)
Physical health       Self-Rated Health: Goldberg, Gueguen,
                      Schmaus, Nakache, and Goldberg
                      (2001)
                      Medical Conditions Checklist
Mental health         Brief Symptom Inventory 18: Derogatis
                      (2001)
ADLs                  Katz Index of Independence in Activities
                      of Daily Living: Katz, Down, Cash, and
                      Grotz (1970)
Social support        Lubben Social Network Scale: Lubben
                      et al. (2006)
Receiving treatment   Treatment Service Review: Cacciola
                      et al. (2008)

Note: ADLs = activities of daily living.
Gale Copyright: Copyright 2012 Gale, Cengage Learning. All rights reserved.