Best Practices - Treatment and Rehabilitation for Seniors with Substance Use Problems

3. Interviews With Key Experts (continued)

3.2.8 Model Program Components

a) Model Program Components Addressing Physical Health

The role of the physician was identified as being central for effective service delivery, assessments and ongoing medical care. Key experts acknowledged the importance of having physicians who are sensitized to issues of substance use in seniors. Services need to increase awareness among physicians of how substance use and prescribed medications can interact with physical health and medical conditions. Respondents highlighted that model programs often have a consulting physician available who has experience with both geriatrics and substance use problems.

Several key experts indicated the importance of a multidisciplinary team approach, with case management services. Suggested team members included a nutritionist and an exercise trainer with access to exercise equipment. Other model services that were outlined included home detoxification services or designated beds for seniors in the local hospital detoxification facility.

b) Model Program Components Addressing Psychological Health

Key experts advised that model services must address personal and psychological issues. They emphasized the need for counselling services to target areas beyond substance use, such as depression, loneliness, suicidal ideation, anxiety and abuse. The importance of using multidisciplinary teams with experienced and well-trained personnel was noted. In addition, referrals must be available to such services as:

• psychologists;
• psychiatrists;
• specialists in dual diagnosis (mental health and substance use problems);
• spiritual care; and
• nutritionists.

Opportunities for exercise, social activities and connections to the community were also valued by respondents.

c) Model Program Components Addressing Interpersonal Relationships

Family, caregivers and friends are often involved with seniors as a support network. Key experts recommended that such individuals be involved in the intervention offered to the senior, or that they also be eligible for counselling services. In many instances, family members and/or close friends need acknowledgement and support in their coping efforts and need to understand how they may be inadvertently contributing to the substance use. In some cases, the failing health of the senior and/or the caregiver may require a move, resulting in a need to address the changes in the interpersonal dynamics within a treatment context. Support groups for family and peers were also among some of the program strategies recommended by the key experts.

d) Model Program Components Addressing Social and Cultural Issues

Key experts recommended the use of peer helpers to overcome treatment obstacles related to cultural differences. Through collaboration and networking with peer helpers, service providers can assist them in supporting the senior.

It is important to provide treatment services that respect and appreciate cultural differences. In the case of First Nations peoples, the principle of elder respect must be recognized, thereby ensuring services do not create embarrassment. Certain key experts also suggested buddy systems where seniors of similar backgrounds are a support system for each other. Outreach was also suggested as an effective method to ensure sensitivity to cultural issues.

Many key experts emphasized the importance of education and awareness to better understand cultural issues.

3.2.9 Aftercare

a) Challenges to Maintaining Treatment Gains

The most frequent challenge to maintaining treatment gains is a return to the circumstances, patterns, or situations that contributed to the substance use. Seniors risk:

• having continued access to the substance of their choice;
• returning to the same doctor who was over-prescribing;
• being in a milieu that encourages substance use; and
• being faced with isolation.

If social networks are based on problematic substance use, seniors may face the difficult task of developing new social networks. To overcome such challenges, key experts recommended the establishment of social supports through follow-up programs. Seniors must feel welcome in accessing group supports while transportation needs should be anticipated and met.

Seniors often face the loss of their health, mobility, driver's licence or independence, hearing and sight, and loved ones. Clients may still be experiencing physical pain in instances where the substance use was related to pain killers. New coping mechanisms and relapse prevention strategies must be developed and integrated. Education components should be in place to teach clients and their caregivers that relapse is likely, problems do not end after treatment, recovery is a continuing process, and maintenance is an integral part of treatment.

b) Development and Implementation of Relapse Prevention Programs

Key experts highlight the need for community supports as a key part of maintaining treatment gains. These supports can take various forms, including senior led support groups, Meals on Wheels, church involvement, or outreach visits. Of prime importance is the avoidance of a return to isolation.

Services must take the initiative in contacting clients rather than leaving follow-up to them. Counsellors should be available and easily accessible, so that with one phone call seniors can be reconnected to their supports. Use of a consistent counsellor throughout treatment and follow-up is helpful. Services must strive to identify potential factors that may trigger a relapse to problematic use, and prepare a response to those factors.

Several key experts suggested that the idea of relapse should be revisited. Relapses are often considered a natural part of achieving reductions in use, and some respondents advocated the need to normalize relapse for clients, families, and communities through proper education. The term "relapse" may also suggest an abstinence approach, which for many is inconsistent with the harm reduction philosophy.

c) Necessary Post-treatment Supports

Key experts highlighted the importance of establishing and maintaining social supports to reduce isolation and help secure treatment gains. Most effective strategies ensure that seniors take part in activities that provide a sense of involvement. Social supports may take the form of self-help groups, family members or friends. Social support groups that focus on abstinence from substance use may also be used as a supportive post-treatment intervention.

Counselling services must be accessible, either through help lines or through an open door policy. Back-up plans must be established in the event of any crises. Finally, families should be kept up-to-date regarding what is happening, bearing in mind confidentiality, and have access to needed supports.

Many key experts stressed the importance of medical monitoring, as physicians must be made aware of the senior's substance use risks. In addition, home care and in-home services should be made available.

3.2.10 Measuring Effectiveness

a) Current Evaluation Processes

Key experts reported that treatment programs are most often informally evaluated. This usually involves anecdotal evidence of effectiveness by measuring client satisfaction and evaluating client comments on the various aspects of the program. Some services have gathered outcome measures such as statistics on level of use, recidivism, discharge, and measures of quality of life. Others rely on length of abstinence to evaluate the effectiveness of their service or programs.

b) Consideration of Outcome Variables or Indicators

Some key experts recommended using outcome indicators that measure changes in substance use patterns. Quality of life measures were identified by key experts as some of the most valid indicators of program success. These measures may include the extent to which clients have:

• maintained their treatment goals;
• maintained social relationships and activities;
• achieved independence or maintained self-care; and
• shown improvement in key life areas.

c) Steps to Enhance Evaluation Efforts

Several key experts recommended longitudinal or pre-post comparative studies, while others recommended the use of qualitative measures such as narratives, thus accepting clients' subjective interpretations of service effectiveness. Efforts to evaluate program effectiveness could be significantly improved by re-directing resources toward implementation of proper evaluation processes. Key experts indicated a need for more information and best practice protocols on seniors with substance use problems. Service providers are often concerned with issues related to direct service delivery but are uncomfortable with conducting evaluations of service provision. The lack of standardized tools that are senior specific was also noted by certain key experts as impeding evaluation effectiveness.