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

2. Review of the Literature (continued)

2.9 Treatment Approaches

2.9.1 Peer-Led Self Help Groups

Peer-led self help groups do not require a professional to be present at group meetings. Group therapy is based on the idea that recovery is aided by peer identification and by learning from the experiences of others. Groups can foster a sense of optimism and foster social relationships that are not based on substance use.

Many peer-led self help groups are based on the Twelve-step approach such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). The first steps require one to admit to alcoholism and to dismiss any idea that alcoholics could ever again control their drinking. Addiction is attributed to biological factors that are believed to be unalterable. As such, abstinence is the only indicator of continued recovery. The next steps enlist the assistance of a supreme being or a higher power with the phrase "God as we understood Him". Other steps emphasize action, promoting self-evaluation and behavioural changes.

AA is a widespread, free and accessible service for most seniors (Rush & Ogborne, 1992). Some researchers have expressed concern whenever senior clientele are required to admit to being an "alcoholic". AA has a reputation as an effective program (Shipman, 1990), and anecdotal testimonies are common. It is difficult, however, to test the effectiveness of AA given there is no way to follow the anonymous participants, and drop-outs are unrecorded.

Some programs have been developed that maintain an emphasis on group participation, but not on the Twelve-steps. For example, Rational Recovery (RR) emphasizes personal responsibility and control over substance use, rather than lack of control as AA emphasizes. Secular Organizations for Sobriety (SOS) invites individuals to make rational decisions about their substance use (Maisto, Galizio & Connors, 1999).

2.9.2 Brief Interventions

There is a spectrum of severity of substance use problems, and it is believed that those experiencing mild or moderate difficulties comprise the majority of users (Zweben & Fleming, 1999). Full substance abuse treatment, however, may not be warranted, so brief interventions were developed in order to target the at-risk user. In non-dependent clients, brief interventions seek to promote reductions in substance use, while in dependent clients they facilitate referral to full treatment programs. In all cases, the goal is to increase motivation to change behaviour. Specific skills are not taught, nor are attempts made to alter social environments (Zweben & Fleming, 1999). Motivation to change is increased by having the client ask themselves questions about the pros and cons of their substance use, monitor their own behaviour, and self-regulate that behaviour. The premise is that changes will occur when perceived costs outweigh perceived benefits. Brief interventions usually include assessment, goal setting, behaviour modification techniques, and self-help literature. Interventions begin with asking questions about substance use and assessing medical, behavioural, or legal problems that may be related to substance use. Advice is offered in a clear, simple message that expresses concern about the substance use, and feedback is given on how the substance use may be affecting health and life. Goals of reductions in use, or abstention from use, are set. These interventions can be used effectively by a variety of professionals, including substance abuse workers, physicians, nurses, dentists, social workers, psychologists, and counsellors (Zweben & Fleming, 1999).

Interventions can range from one meeting to four or five with a time length anywhere from 10 to 30 minutes. An educational approach is used that helps the senior to understand the reasons for their substance use. They are taught to recognize the triggers of substance use and methods for reducing the behaviour (Blow & Barry, 2000).

Studies on the effectiveness of brief interventions for alcohol use in seniors have yielded positive results (Blow & Barry, 2000; Fitzgerald & Mulford, 1992; Fleming, Manwell, Barry, Adams & Stauffacher, 1999). These methods may be especially effective in late-onset clients, or whenever the substance use is less severe (Schutte et al., 2001).

One barrier to effectiveness of brief interventions is lack of self-efficacy. If the individual doubts their capacity to change, brief interventions will not be sufficient to initiate the change process (Zweben & Fleming, 1999). Another barrier is that seniors can have difficulties identifying their own risky substance use. Similarly, if chronic disease is present, physicians may find it difficult to identify the role the substance use problem plays in the manifestation of the disease (Blow & Barry, 2000).

Technological Innovations

One related option for brief interventions is using a computer to assist in treatment provision. The use of computer generated reminder notes that automatically attach themselves to the front of a patient's chart can be used by service providers. Interactive Voice Recognition technology is a time and cost-effective method that allows service providers to collect data by telephone 24 hours a day, in addition to providing services to seniors whose life circumstances make them unable to attend on-site treatment. Clinic patients phone in and respond verbally or by touch-tone to menu prompts. Menu options include health education, self-help modules and self-monitoring (Blow & Barry, 2000).

Another innovation involves "tailored messaging" (Blow & Barry, 2000). A computer program will generate educational and workbook materials designed to meet the treatment needs of a specific individual, based on the information entered in the person's file. Case history, drinking history, health concerns, co-morbid disorders, social support and other relevant information allows for the creation of a comprehensive guide to treatment. This guide, when used in conjunction with other services, empowers the individual by providing them with the tools to control their own recovery (Blow & Barry, 2000).

2.9.3 Cognitive-Behavioural Approaches

Strict behavioural approaches to alcohol reduction are difficult to implement and reinforce with seniors if they suffer from a cognitive dysfunction that interferes with memory (Segal et al., 1996). Some researchers use a cognitive approach that helps seniors examine the antecedents, behaviours and consequences (A-B-C paradigm) of their substance use. They also provide substance use education, skills training in problem solving and social reinforcement (Dupree, Broskowski & Schonfeld, 1984 as cited in Segal et al., 1996).

Cognitive-behavioural approaches are based on behavioural principles of gradually changing behaviours by shaping and reinforcement, but includes thoughts, beliefs, and emotions among behaviours that can be targeted. Sometimes treatment proceeds by examination of the irrational base of core beliefs. Accordingly, treatment can proceed by addressing the thoughts and beliefs that underlie substance use problems. (Bortz & O'Brien, 1997).

Some irrational beliefs contribute to feelings of hopelessness and uselessness which seniors may self-medicate by abusing substances. Examples of such beliefs include 1) that they have no control over their life now that they are old, 2) that now that they are retired, they are worthless, 3) that if they are dependent on others they are worthless, 4) that they are too old to get married or to have a sex drive, 5) that senility, sickness and disability are inevitable, 6) that isolation and loneliness are a normal part of aging, and 7) that they are too old to change or to respond to therapy (Norton, 1998).

Rice, Longabaugh, Beattiem and Noel (1993) examined the response of older patients (50 and over), and younger patients (18-29 years of age) to three different kinds of treatments, one of which was cognitive-behavioural therapy. While no preferences were found in younger patients, older patients responded better to cognitive-behavioural therapy than they did to therapy targeting relationship enhancement, or relationship and vocational enhancement.

2.9.4 Psychosocial Approaches

Psychosocial treatment begins by focussing on aspects that are important to the senior, and aspects that they feel confident in. Initially, this may not be substance use. By building self-efficacy and social networks, the person will develop the strength to tackle the substance use problem (Baron & Carver, 1997).

Substance use problems can compound psychological problems. After long term reliance on a substance, the senior may exhibit poor coping skills, and feelings of frustration and inadequacy. These can be addressed by providing empathic understanding and training in coping and assertiveness skills. Long term substance use can also mean a history of failures and disapprovals from family, employers and society. If the senior is not returning to work, treatment might focus on the development of skills and interests in leisure time activities (Baron & Carver, 1997).

Difficulties are often observed in being responsible to and for others (Baron & Carver, 1997). Treatment that addresses this lack of interdependency may begin by encouraging dependence on a counsellor or caregiver, then broadening the social support to encourage the client to engage in give and take. Individual counselling may be required initially, but the goal is usually to help the senior person feel comfortable joining a group and sustaining a social network (Baron & Carver, 1997).

The BRENDA is a psychosocial treatment model designed to identify and treat seniors with alcohol problems (Kaempf, O'Donnell & Oslin, 1999).

Components of the program are shown below.

B Biopsychosocial assessment

R Report assessment findings to patient

E use Empathic approach

N patient Needs identified during the assessment

D Direct advice (based on the patient's needs)

A Assessment of the direct advice

The rationale for the model pertains to the fact that primary care givers without specialized substance use knowledge are often the first point of contact for an individual with substance use problems. These primary care givers can use the BRENDA anagram to remember the elements of treatment. An empathic approach is essential throughout the process. They must assess the patient's physical condition and personal history, screen for possible problems (using the CAGE or DSM criteria), identify patient needs, offer advice to alter drinking behaviour and provide follow-up through subsequent contact (phone or office). Kaempf et al. (1999) applied this model in conjunction with a double-blind test of Naltrexone or placebo. The researchers found that older adults (mean age 65) were more likely to attend treatment than younger adults (mean age 41), suggesting that this model is more effective with older adults. In comparisons with older patients receiving the BRENDA model and older patients receiving age-specific group psychotherapy, treatment attendance was higher with the BRENDA model. Kaempf et al. felt the BRENDA model was a valuable addition to alcohol treatment for seniors.

2.9.5 Outreach Services

Outreach services were developed in response to the perception that substance use problems were often hidden problems. Some seniors experience physical limitations that make travelling to treatment sessions difficult, and outreach may mean approaching the client in their own environment rather than expecting them to come to treatment providers (Baron & Carver, 1997; Segal et al., 1996). Also, historical contexts and social stigma may create a reluctance in seniors to admit to substance use problems (Shipman, 1990).

An outreach program in BC uses a systemic approach that reflects the shift to client-centred therapy. Traditional substance use assessment and treatment focusses on the individual, without regard for the external factors that shape behaviour. The systemic approach takes into account a person's social network and the way in which each individual's unique personal relationships influence their actions. Personal "empowerment and partnership among the parts of the individual's social ecology" are emphasized (Todtman & Todtman, 1997, p.406). Treatment is tailored to the needs of the senior and may include education, family consultation and referral to an appropriate program. Evaluation of the program showed that both clients and helpers felt greater self-efficacy, and problem symptoms reduced in severity and frequency (Todtman & Todtman, 1997).

2.9.6 Harm Reduction Approach

A harm reduction approach focusses on the harm that results from substance use problem, as opposed to focussing on the substance use itself (Graham, Brett & Baron, 1994). According to Oslin (2000b), since even low levels of alcohol consumption in seniors can have deleterious effects, any reduction in drinking behaviour will likely be beneficial. Similarly, a reduction in benzodiazepine use will contribute to improved personal health and functioning (Oslin, 2000b). Harm reduction approaches also need to address misuse of prescription medications by finding ways to increase compliance with prescription or over-the-counter medications (Kostyk et al., 1994).

Programs operating under a harm reduction framework may appeal to those who have not been successful with conventional abstinence-oriented treatment (Graham et al., 1994; West & Graham, 1999). In harm reduction approaches, relapses are seen as a normal part of the recovery process, and do not mark the end of treatment. Usually, harm reduction programs will tolerate continued substance use, and may be especially applicable in treating prescription medication problems, for example, if someone with chronic or severe pain needs to remain on a low dose opioid, or those with depression or anxiety require a maintenance dose of benzodiazepine. Decreases in problematic prescription use may be accomplished by "tapering" which involves a slow but steady reduction in the dose and frequency of the drug over time (Kostyk et al., 1994).

Individual counselling under a harm reduction framework offers support irrespective of substance use. The approach is empathic and non-confrontational, and focusses on the overall lifestyle rather than only on the substance use (Graham et al., 1994). When following a harm reduction approach, counsellors and group facilitators demonstrate that they are willing to start from whatever stage the person is at and help them move towards reduced substance use. A non-confrontational, non-judgmental atmosphere is used to encourage learning and self-awareness (Royer, et, 2000) and permits clients to examine the external forces that motivate behaviour.

Many harm reduction programs use group therapy. Group therapy can foster feelings of belonging, help establish goals for recovery, offer support with the practice of new behaviours, provide a venue for discussion of substance use issues, and increase participation in persons who otherwise may be socially isolated (Kostyk, et al., 1994; Segal et al., 1996). A group format allows for general discussion of issues relevant to substance use without targeting a specific individual. It can also provide a social support that facilitates recovery maintenance (Royer et al., 2000).

2.9.7 Pharmacological Interventions

Seniors with alcohol dependence problems have not traditionally received pharmacological agents as part of the treatment process (Oslin & Blow, 2000). Disulfiram is a drug that has been used in the treatment for alcohol problems and has also been used to treat younger patients with a joint cocaine and alcohol dependence (Health Canada, 2000). While it may be a helpful adjunct to therapy for younger individuals, use of disulfiram in seniors has not been recommended because of potentially serious adverse effects (Oslin & Blow, 2000; Rigler, 2000).

Naltrexone is an opioid antagonist. Studies conducted on middle-aged patients with alcohol dependence concluded that naltrexone produced few harmful side effects. It also proved effective in reducing the craving for alcohol and assisted with relapse prevention (Oslin & Blow, 2000). When naltrexone was tested on veterans aged 50 to 70, respondents reported improvements in relapses to heavy drinking, though not improvements in achieving abstinence (Oslin, Liberto, O'Brien, Krois & Norbeck, 1997 as cited in Oslin & Blow, 2000).

Acamprosate is a new agent that is being tested for treatment of alcohol dependence. Results with younger populations have been promising, but studies on its efficacy and safety in senior patients have not been examined (Oslin & Blow, 2000).