Abstract
A Center for Substance Abuse Treatment Knowledge Application Program based on cognitive-behavioral and self-management treatment approaches and targeted to older adults with substance abuse was provided through a community behavioral health center. A sample of 199 adults aged 50 and above participated in the 18-session program. Observations were made at intake and 6 months after intake. Program completers versus noncompleters differed significantly over time, favoring completers with regard to decreased use of nonmedical prescription drugs, improved cognitive functioning, improved mental health, increased vitality, and lack of bodily pain. Significant time effects were noted in participants’ decreased use of alcohol and binge drinking, reduced stress, fewer emotional problems, a decrease in having to reduce important activities, and increased prescription of medication for psychological problems. Participants also reported significant improvement in their social functioning, and their physical health and emotional problems had less impact on what they were able to do.
Although often misdiagnosed or not diagnosed at all, substance abuse by older adults, including alcohol, illegal drugs, prescription drugs, and over-the-counter medications, is a significant public health issue (Substance Abuse and Mental Health Services Administration [SAMHSA], 2002; Widlitz & Martin, 2002). For example, alcohol abuse, although often thought to decrease as people age, has been found to increase in many older adults because of their response to health problems associated with aging, lack of social support, and other life transitions, such as retirement, the death of a spouse, partner, or other family members and friends (Balsa, Homer, Fleming, & French, 2008). Likewise, recent evidence suggests that there will be a significant increase in the number of older adults who need substance abuse treatment by 2020 as illicit drug abuse, traditionally thought to decline with age, has increased significantly in this population (Gfroerer, Penne, Pemberton, & Folsom, 2003; Han, Gfroerer, Colliver, & Penne, 2009; Hess, Kearley, Thomas, & James, 2008). Furthermore, older adults who abuse substances are less likely to seek treatment, their substance abuse problems will not be diagnosed or will be misdiagnosed as a physical health issue, and are often ignored by family, friends, and health care providers because of the associated stigma and shame (Morgan & Brosi, 2007). For these reasons, the extent of the need for effective cultural and linguistically competent specialty programs targeting older adults who abuse substances is imperative. Currently, there are few specialty programs or evidence-based programs designed for this population. It has been reported that drug and alcohol programs created particularly for older adults are limited in the United States, with only about 7% of substance treatment facilities offering specific treatment designed for this population (Han et al., 2009).
Background
Most substance abuse program development and research has primarily focused on adolescents and young adults because they tend to abuse substances at a higher rate than other groups (Hess et al., 2008). However, with the baby-boomer generation aging, the increase in the numbers of older adults who abuse substances and who need treatment will substantially increase by the next decade (Gfroerer et al., 2003). The baby boomers are a generation of aging adults who were influenced by the Vietnam War, the civil rights movement, cultural events such as Woodstock, and a generational commitment to testing social norms. It has been noted by many gerontologists that the abuse of alcohol and drugs by the baby-boomer generation, as they age, will vary notably from other generations because of their lived experiences involving the use of alcohol and other drugs (Center for Substance Abuse Treatment [CSAT], 2001). Finally, although substance abuse is serious at any age, it is very problematic for older adults because the prevalence of the problem has remained underreported and underdiagnosed and, consequently, has not received attention from treatment providers and researchers (Dietz, 2009). It is also less obvious because of social myths and is therefore mistaken for other problems in this population (Barrick & Connors, 2002; CSAT, 2001). However, substance abuse significantly affects the physical and mental health of older adults and, if untreated or not treated effectively, is highly associated with increased risk of suicide as well as physical and mental disorders that affect their quality of life. For example, older adults with a lifetime history of substance abuse are three times more likely to have a co-occurring mental disorder, usually a depressive disorder (CSAT, 2001). Research also suggests that older adults, who have experienced an undiagnosed or untreated depressive illness, are at high risk for developing late-onset drinking (CSAT, 2001).
Alcohol Abuse and Older Adults
Alcohol abuse among older adults has been called the invisible epidemic because of myths that describe it as an infrequent problem, and when it does exist treatment success is limited (Sorocco & Ferrell, 2006). In addition, clinicians because of their beliefs are less likely to consider that older adults, women, and those with a higher socioeconomic status have alcohol and/or substance abuse problems (Morgan & Brosi, 2007; Sorocco & Ferrell, 2006).
Several recent studies have suggested that light-to-moderate alcohol consumption by older adults can be beneficial (Corrao, Bagnaradi, Zambon, & LaVecchia, 2004; Marmot, 2001; Tolstrup et al., 2006). For example, it has been found that older adults who consume moderate amounts of alcohol were at lower risk for such health problems as cardiovascular disease (Abramson, Williams, Krumholz, & Vaccarino, 2001). Although moderate alcohol consumption may have particular protective health benefits for some older adults, there is a lack of clear information about the characteristics and predictors associated with substance misuse among older adults (Dietz, 2009). This lack of clarity about positive versus negative outcomes associated with alcohol use has created some persistent misconceptions about the benefits of drinking for this population.
Research findings, however, are beginning to dispel some of these misconceptions. It has been found that up to 15% of older adults will experience health problems resulting from their alcohol use (Oslin, 2000). A conservative estimate is that 1 in 10 older adult patients admitted to a medical facility has an alcohol problem and, among community-dwelling older adults, 2% to 15% have shown symptoms associated with alcoholism (Sorocco & Ferrell, 2006). There is a plethora of evidence that heavy alcohol consumption by older adults often results in liver damage as well as many older adults have chronic illnesses for which they are prescribed medications that contraindicate even minimal alcohol use (Moore, Whiteman, & Ward, 2007). Adding even one to two drinks to one of the many medications commonly prescribed to older adults may cause an interaction that mimics dementia, contributes to falls, and may have other devastating consequences (McGrath, Crome, & Crome, 2005; Meier & Seitz, 2008; Moore et al., 2007). Because of these contradictory messages and the significance of the problem, it is even more urgent that effective programs that include effective assessment, outreach, and intervention be implemented and further evaluated.
It is also imperative that more systematic study be done of how culture, ethnicity, and gender influence alcohol use among older adults. For example, it has been noted that White people tend to drink more alcohol than African Americans and Hispanics, who tend to drink less but to binge drink when consuming alcohol (Sorocco & Ferrell, 2006). In a new study, at-risk drinking and binge drinking were found to be more prevalent among older adults 50 to 64 years of age (Blazer & Wu, 2009). Several studies have found that although women tend to consume less alcohol than men, women aged 65 and older who drink in moderation experience associated positive health outcomes (Balsa, et al., 2008; Moos, Brennan, Schutte, & Moos, 2004). However, it has been suggested that the prevalence of binge drinking among older women is an increasing public health concern (Blazer & Wu, 2009).
The current study was conducted to determine the effectiveness of the CSAT Knowledge Application Program, Substance Abuse Relapse Prevention for Older Adults: A Group Treatment Approach (CSAT, 2005), targeted to older adults with a co-occurring mental illness and substance abuse diagnosis and implemented in a community-based setting. The evaluation assessed changes in clients’ alcohol and substance use and in mental health and general health functioning from program intake to 6 months after intake. It included a post hoc analysis of program completers and noncompleters to examine the influence of amount of treatment received. This article presents results on the effectiveness of the specialized treatment program and discusses their implications for further program development and research.
Method
Participants
The CSAT Knowledge Application Program curriculum was implemented in a specialized community behavioral health center for older adults in a southeastern city. Inclusion criteria were intentionally broad and included clients (a) aged 50 years and older who were identified at their intake appointment as experiencing problems with the use of alcohol or other substances either currently or anytime within the past year and (b) with substance abuse as the main presenting problem or co-occurring with a mental health diagnosis.
The study sample was comprised of 199 individuals who participated in the substance abuse treatment program sometime between January 2005 and October 2007, provided their informed consent, and completed both a baseline and 6-month follow-up interview. (Excluded from the sample were an additional 24 clients who were enrolled in the evaluation but did not complete the 6-month follow-up interview.) Two primary sources of referrals to the program were clients attending the clinic who were identified with substance abuse and co-occurring mental health problems at intake (70% of 199 study participants), and older adults living in senior high-rise public housing who experienced substance abuse problems or co-occurring disorders and were referred from residential managers (30% of participants).
Program
The program followed a cognitive-behavioral and self-management treatment approach specified by the manualized curriculum, Substance Abuse Relapse Prevention for Older Adults: A Group Treatment Approach (CSAT, 2005). This curriculum is based on the effectiveness of relapse-prevention models that combined behavioral assessment with cognitive-behavioral and self-management approaches to teach older clients how to identify and cope with high-risk substance abuse situations (e.g., the Gerontology Alcohol Project [GAP; Dupree, Broskowski, & Schonfeld, 1984; Schonfeld et al., 2000] and the Florida Brief Intervention and Treatment for Elders project [BRITE; Schonfeld & Lawton-Berry, 2004]). The treatment approach was selected because it is a recommended program in the CSAT Treatment Improvement Protocol 26 (TIP; CSAT, 2001). The curriculum is comprised of nine modules on substance use behavior, management of situations at home and social pressure, management of negative thoughts and emotions associated with substance abuse, recognition and management of feelings such as anxiety and anger, identifying substance use urges and how to cope with them, and relapse prevention strategies (CSAT, 2005). Although the curriculum was developed for use in outpatient group treatment, it can be adapted for use in individual treatment sessions and in a variety of treatment settings. The therapists used the curriculum primarily in treatment with groups but adapted the modules to individual treatment sessions for clients who preferred that approach.
Procedures
Clients were recruited to participate in the program in multiple ways. Current and newly presenting clients who had a sole substance abuse diagnosis or co-occurring substance abuse and mental health diagnosis were informed of the new treatment program and invited to participate. In addition, extensive outreach was conducted in the community to local aging and mental health providers, senior health fairs, senior public housing, home health agencies, and other neighborhood organizations. A focused outreach effort to African Americans was done in less traditional settings such as barber and beauty shops, churches, and a historically Black medical school. To further facilitate participation, transportation was provided to and from the clinic, and the program was alternatively provided on-site in senior public housing.
As part of the standard intake process, clinical staff assessed potential participants for mental health and alcohol or other substance abuse problems. Staff referred clients who met the study age and diagnostic eligibility criteria to a member of the evaluation team who explained the purpose of the study and obtained written informed consent from the clients. Clients were enrolled in the study if they met the age and substance use criteria and were able to provide informed consent (i.e., did not have dementia or another cognitive impairment that limited their ability to understand and respond to the interview protocol). Evaluation staff conducted the baseline interview either at that initial contact or at the client’s subsequent treatment session. Treatment groups met weekly for 18 sessions and were supplemented with individual therapy sessions, case management services, and medication management by a staff psychiatrist and a nurse practitioner. Therapists adapted the curriculum for clients who wished to participate in the program but not in a treatment group. The follow-up interview was conducted typically at the clinic or at the client’s residence within the 6-month window of the baseline interview as defined by CSAT (SAMHSA, 2004). Clients were compensated US$20 for their time for participation in each interview.
Measures
CSAT GPRA client outcome measures. The evaluation used the standardized Government Performance Results Act (GPRA; SAMHSA, 2004) interview protocol that the CSAT requires of all its grants. Selected GPRA sections reported in this article include demographic information; alcohol and drug use within the past 30 days, including binge drinking; mental health problems; impact of substance use on functioning; and program completion status. Substances have been classified into four categories: alcohol, marijuana, nonmedical use of prescription drugs (e.g., opiates other than heroin, benzodiazepines, barbiturates), and all other illegal drugs (e.g., cocaine/crack, heroin, inhalants). As noted in the GPRA protocol, binge drinking items were defined as alcohol to intoxication by consuming five or more drinks in one sitting or by feeling high from four or fewer drinks in one sitting. Four items related to mental health asked how many days within the past 30 days, not due to alcohol or drug use, clients had experienced serious depression; serious anxiety; trouble understanding, concentrating or remembering; and had been prescribed medication for psychological/emotional problems. In addition, three 4-point Likert-type questions asked clients about the impact of alcohol or drug use during the past 30 days on functioning related to experiencing stress in their lives, reducing activities, and causing emotional problems. Response categories were not at all, somewhat, considerably, and extremely.
Short-Form Health Survey Version 2 (SF-12v2). The SF-12v2 (Ware, Kosinski, Turner-Bowker, & Gandeck, 2007) is a 12-item questionnaire used to measure seven domains of health and mental health functioning: general health, physical functioning, lack of bodily pain, mental health (anxiety and depression), vitality, social functioning, and the role of physical health (role physical) and of emotional problems (role emotional) in limiting participation in activities or accomplishing what they want. The general health, bodily pain, mental health, vitality, social functioning, role physical, and role emotional scales 1 had 5-point Likert-type ratings ranging from none of the time to all of the time (or from poor to excellent for general health). The two physical functioning items were rated by limited a lot, limited a little, and not limited at all. The SF-12 has been shown to be both valid and reliable, and norms have been published for different age, gender, and chronic medical condition groups (Ware et al., 2007).
Design and Analysis
The study used a one-group pretest-posttest design to evaluate the effects of the program on participating clients from intake to 6 months after intake. Post hoc statistical comparisons were conducted to explore the impact of program completion versus noncompletion on outcomes. In these analyses, program completion was defined as attending 75% of the program’s 18 sessions.
GPRA substance use and mental health count variables
GPRA items involving counts of events over the past 30 days for the substance use and mental health variables were analyzed using negative binomial mixed regression implemented via the generalized estimating equations (GEE) routine in PASW Advanced Statistics 17.0. GEE is an extension of the generalized linear model that allows for repeated measures. Because preliminary analyses revealed the data were overdispersed, the negative binomial distribution was selected as the error distribution (Elhai, Calhoun, & Ford, 2008), and the link function was the log. Each count variable was modeled as a function of group (completers vs. noncompleters), time (intake vs. follow-up), and the interaction of group and time. Where the interaction effect was not significant, it was dropped from the model and the analysis was repeated.
GPRA impact of substances on functioning items
Separate 2 × 2 mixed model ANOVAs were used to investigate the impact of group (between subjects; completers vs. noncompleters), time (within subjects; intake vs. 6-month follow-up), and the interaction of group and time on participant ratings of how much substance use had caused stress in their lives, reduced activities, and emotional problems. The analyses were implemented using the General Linear Model (GLM) Repeated Measures procedure in PASW Advanced Statistics 17.0.
SF-12 health and mental health status
SF-12 raw scale scores were recoded and transformed to a 0 to 100 scale according to the scoring algorithm in the instrument manual (Ware et al., 2007). Mixed between–within subjects ANOVAs using the GLM Repeated Measures procedure in PASW Advanced Statistics 17.0 were conducted on the seven SF-12 scales comparing completers and noncompleters from intake to follow-up. Because of a change in measuring instrument from Version 1 to Version 2 of the SF-12 during data collection, fewer participants were available for analysis of the Role of Physical Health and Role of Emotional Health Scales.
Results
Demographics and Completion Status
The study sample was predominantly male (67%), was primarily White (54%) or African American (34%), had an average of 11.7 years of education, and was not employed (87%), including 48% who were disabled and 13% who were retired. The age range of participants was from 50 to 89; the mean age was 58.5 years (SD = 7.4) and one third was under 55 years of age. Over four fifths lived independently in their own house, apartment, or room. Many clients lived on low incomes or social security/disability, experienced chronic health conditions, and had long histories of substance abuse and mental health problems.
For the post hoc analyses, we defined completers as clients who participated in at least 75% of the 18 required modules in the curriculum, either through group or individual sessions. According to this definition, of the 199 study participants, 84 (42%) completed the program curriculum and 115 (58%) were terminated without program completion (Table 1). The reasons for noncompletion were involuntary discharge because of nonparticipation (n = 55, 48%), left on own with some progress (n = 35, 30%), left on own without satisfactory progress (n = 11, 10%), transferred to another facility for health reasons (n = 5, 4%), death (n = 5, 4%), referred to another program (n = 3, 3%), and incarceration (n = 1, 1%). The completer group, compared to the noncompleters, had 5% more men, 9% fewer Whites and 4.7% more African Americans, and 4.8% fewer employed. None of these differences was statistically significant.
Demographic Characteristics of Participants
GPRA Client Outcome Measures
Substance use and mental health
Table 2 presents the descriptive statistics by group and time for the substance use and mental health variables. Table 3 presents the main effects of group and time for each count variable and the interaction effect, where significant.
Descriptive Statistics for Substance Use and Mental Health Count Variables
Summary of Negative Binomial Mixed Regression Analysis Predicting Substance Use and Mental Health Count Variables
Significant group-by-time interaction effects were observed for the number of days within the past 30 days of nonmedical prescription drug use and trouble understanding, concentrating, and remembering not due to alcohol and drug use. These significant interactions mean the effect of time differed by group after adjusting for the other terms in the model. Completers reported an 81% average reduction in the number of nonmedical prescription drug use days from intake to follow-up, whereas noncompleters reported only a 21% average reduction. Completers reported a 32% average reduction in the number of days experiencing trouble understanding, concentrating, and remembering not due to alcohol and drug use from intake to follow-up, whereas noncompleters reported only a 4% average reduction.
Significant main effects of time were noted for the number of days within the past 30 days of any alcohol use, drinking five or more drinks in one sitting, experiencing serious depression not due to alcohol or drug use, experiencing serious anxiety not due to alcohol or drug use, and receiving prescribed medication for psychological or emotional problems. These significant main effects of time indicate participants improved on these outcomes over time after adjusting for group. The number of days of any alcohol use reported at follow-up was 0.64 times the number of days of any alcohol use reported at intake. Thus, a 36% average reduction was realized. The number of days where five or more drinks were consumed dropped 41% over the course of the study. Similar reductions of 23% and 25% were observed for the number of days where serious depression was experienced and the number of days where serious anxiety was experienced, respectively. The average number of days within the past 30 days that medication was prescribed for psychological or emotional problems increased 21% from intake to follow-up. Furthermore, the main effect of time for the number of days where four or fewer drinks were consumed in one sitting and the participant felt high approached significance (p = .054) with a reduction of 39%.
There were no statistically significant main effects of group. However, the main effect of group approached significance (p = .06) for the number of days where five or more drinks were consumed in one sitting. Adjusting for time, completers reported 46% fewer such binge drinking days than noncompleters.
Impact of substances on functioning
Using a 4-point Likert-type scale, participants rated how much during the past 30 days their use of alcohol or other drugs caused stress in their lives, a reduction in activities, or emotional problems. (If participants did not report use of substances during the past 30 days, these questions were not applicable; the total possible number of applicable cases for analysis was 122.)
As shown in Table 4, there were statistically significant main effects for time and group but not for the interaction between time and group. The main effect of time was significant for stressfulness, F(1, 121) = 10.33, p = .002; reduced daily activities, F(1, 111) = 4.95, p = .028; and emotional problems, F(1, 117) = 10.54, p = .002, revealing that participants improved over time on average regardless of group status. The main effect of group was also statistically significant for stressfulness, F(1, 121) = 6.94, p = .01; reduced daily activities, F(1, 111) = 4.02, p = .047; and emotional problems, F(1, 117) = 5.08, p = .026, showing that on average completers scored lower than noncompleters.
Descriptive Statistics and Mixed Between-Within Subjects Results for Impact of Substance Use on Functioning
p < .05. **p < .01. ***p < .001.
SF-12 Health and Mental Health Status
Table 5 presents the means, standard deviations, and F values for the SF-12 scales. There were statistically significant interactions between group and time for lack of bodily pain, mental health, and vitality. The effect of time varies significantly by group for lack of bodily pain with the completers showing improvement whereas noncompleters worsened over time, F(1, 101) = 5.84, p = .017. Both groups reported improvement in their mental health, but the completers increased at a greater rate than noncompleters, F(1, 101) = 4.1, p = .045. The effect of time on vitality varies by group with the completers showing significant changes from intake to follow-up, whereas the noncompleters maintained the same rate over time, F(1, 101) = 4.86, p = .03.
Descriptive Statistics and Mixed Between-Within Subjects Results for SF-12 Physical and Mental Health
p < .05. **p < .01. ***p < .001.
There was a statistically significant effect of time on social functioning, F(1, 101) = 3.94, p = .05, where both groups on average showed improvement. In addition, the effect of time was statistically significant for role physical, F(1, 49) = 6.97, p = .01, and role emotional, F(1, 49) = 9.49, p = .003. Participants reported that the role of their physical problems and emotional problems had less of an impact on their activities and what they accomplished by follow-up.
Discussion
This article presents findings from an implementation study of a CSAT Knowledge Application Program, Substance Abuse Relapse Prevention for Older Adults: A Group Treatment Approach (CSAT, 2005), using data from a single, community behavioral health center in a southeastern city. The purpose was to explore the feasibility and effectiveness of the program in a real-world community-based setting. The study explored the main effects of group (completers vs. noncompleters) and time (intake vs. 6-month follow-up) and the group-by-time interaction on a number of valid and reliable measures. This section of the report reviews the significant findings and places them in context of other literature on this topic and discusses some of the study’s limitations and implications for future research. We begin by discussing outcomes with significant interaction effects of time by group, followed by main effects by time and by group.
Program completers who attended 14 or more sessions showed a significantly greater reduction in days of nonmedical prescription drug use and days in which they had trouble understanding, concentrating, and remembering in the past 30 days as measured by the GPRA than those who attended fewer sessions. The significance of these findings is important as nationally and internationally nonmedical use of prescription drugs is growing rapidly (Arkes & Iguchi, 2008). During 2006-2008, 4.3 million older adults, 50 years plus, used an illicit drug, with the most commonly used drugs being marijuana and nonmedical use of prescription-type medications (SAMHSA, 2009). In general, older adults 50 to 59 years old were more likely to use marijuana and those 65 years and older abused prescription drugs. In addition, according to Sorocco and Ferrell (2006), older adults in general take more over-the-counter drugs in concert with their prescription drugs despite the fact that their bodies are more susceptible to adverse physiological and metabolic reactions from these combinations. Several additional reports found older patients who misuse substances reported substantially more medical problems, including difficulty with reasoning and other cognitive skills (Lemke & Moos, 2002; Woodruff et al., 2009).
The two positive outcomes experienced by the completers, taking less nonmedical prescription drugs and improved cognitive functioning, are aligned with the results of a study conducted by Oslin, Slaymaker, Blow, Owen, and Colleran (2005) that found there was value in treating older adults with substance disorders because their quality of life can be improved and their response to treatment can be substantially better than that of younger adults. The fact that the completers, with treatment that lasted 14 sessions or more, experienced improvement in functions such as being able to understand information, concentrate, and remember—all cognitive processes associated with improved quality of life—supports the literature that treatment programs that are age specific are very effective for older adults with substance abuse disorders including helping them to maintain better health (Atkinson, 1994; Han et al., 2009; Lemke & Moos, 2002; Oslin et al., 2005; Sorocco & Ferrell, 2006).
On the SF-12, the effect of time differed significantly between completers and noncompleters on lack of bodily pain, improved mental health, and increased vitality, with completers realizing greater improvements. This finding is in concert with a study that suggested that treatment programs such as the one being reported on, designed specifically for older adults who use nonconfrontational, group-based cognitive behavioral approaches, have demonstrated effectiveness with populations that have a variety of physical, behavioral, and psychosocial health needs (Han et al., 2009).
Furthermore, significant decreases from intake to follow-up were noted in participants’ days of any alcohol use and days of binge drinking (five or more drinks in one sitting) within the past 30 days. Previous studies have shown that older adults improve with treatment, and their treatment response is substantially better than younger adults (Blow et al., 2000; Oslin, 2000). However, Oslin (2000) notes that older adults are less likely to engage in formal aftercare to maintain the treatment improvements. Our program provided services in a traditional behavioral health clinic and in a senior high-rise public housing development. A nurse practitioner connected to the project provided basic primary health care in the high rise as an outreach and recruitment service. Taking substance abuse treatment to where older adults live and socialize, such as their homes, religious institutions, and senior citizens’ centers, may improve their willingness to engage in aftercare. We believe this was an effective approach because it established trust and addressed clients’ primary care needs, many of which had been neglected for a variety of reasons. In addition, it points to the necessity of not separating mental health and substance abuse treatment, viewing them clinically as co-occurring disorders. Han et al. (2009) summarized selected research related to the benefits of integrating substance abuse treatment in primary health care settings, especially for older adults who tend to have comorbid medical conditions that cause them to frequently visit their health care providers. To create an integrated treatment system, Morgan and Brosi (2007) recommended that medical schools, and we would add all schools that educate health care providers such as nurses and social workers, develop curricula that educate them about substance abuse in older adult populations, including innovative approaches like screening, brief intervention (one-five sessions of education), and referral to treatment (SBIRT), to assess, diagnose, and intervene early into substance abuse in older adults. Primary health care providers can play a vital role in integrating primary health and behavioral health treatment models for older adults using approaches such as SBIRT if they are educated to do so. In addition, Dawson Grant, and Ruanthe (2005) found that substance abuse treatment that uses brief interventions need to also focus on tension alleviation and the development of more positive coping strategies to enhance treatment models. Finally, Schonfeld et al. (2010) addressed the underutilization of substance abuse treatment by older adults using an SBIRT model, but instead of delivering it only in health care settings, they provided this innovation where older adults lived and in other aging services sites similar to the outreach method that we used to provide integrated health and substance abuse treatment in this study.
Overall, participants at follow-up reported significantly less stress in their lives, fewer emotional problems such as serious depression and anxiety, a decrease in having to reduce or give up important activities, and increased prescription of medication for psychological and emotional problems. A significant benefit was that those clients who needed psychopharmacological intervention received medication for their untreated anxiety and depression. In addition, participants reported significant improvement in their social functioning, and their physical health and emotional problems had less impact on what they accomplished or activities they were able to do. These results were similar to findings from a study conducted by Lemke and Moos (2002) where older adults (as well as middle-aged and younger patients) experienced significant changes in treatment between intake and discharge, including marked reductions in alcohol intake, an understanding of the benefits of not consuming alcohol, improved confidence and coping skills, and improved psychological symptoms.
Adjusting for time and group-by-time interactions, the two groups were significantly different on the reported impact of their substance use. The completers of the treatment program reported substance abuse had less impact on their perceived stress, reduction of activities, and less emotional problems than noncompleters of the program. It may be the completers were able to complete the program as they had fewer stressors in their life, more mobility, and less emotional problems. In a stress and alcohol study by Dawson, et al. (2005), the researchers found a positive relationship between number of past-year stressors and all measures of heavy drinking. They found that frequency of heavy drinking (five-plus drinks for men, four-plus drinks for women) increased by 24% with each additional stressor reported by men and by 13% with each additional stressor reported by woman. They concluded that stress does not lead individuals to drink more often but to substitute larger quantities of alcohol on the days when they do drink.
Limitations
There are a number of limitations associated with the present study involving the research design, instruments, and construct operationalization. This was a program implementation project with an evaluation component. This study employed a one-group pretest–posttest design. Shadish, Cook, and Campbell (2002) caution that it is difficult to establish causal knowledge with this design as there are numerous possible threats to the internal validity of any observed effect, including maturation, testing, history, and attrition. Stronger designs make use of randomized control groups, matched controls, or incorporate additional design elements for the purpose of eliminating threats to validity. With regard to instrumentation, this study relied exclusively on self-report measures without, for example, corroboration by others such as family or therapists or collection and analysis of biological specimens. This leaves open the possibility of false reporting to minimize substance use and its impact or to present socially desirable behaviors. Another instrumentation issue involved four GPRA items related to mental health, which ask how many days within the past 30 days, not due to alcohol or drug use, clients had experienced serious depression; serious anxiety; trouble understanding, concentrating, or remembering; and had been prescribed medication for psychological/emotional problems. As a SAMHSA grant-funded project, the GPRA is a required measure. However, it is not clear that clients, especially those with co-occurring disorders, have the ability to accurately and reliably distinguish mental health symptoms attributable to substance use and mental health symptoms not attributable to substance use. Last, this study involved construct operationalizations that other researchers might take issue with. This study used the GPRA definition for binge drinking, alcohol to intoxication by consuming five or more drinks in one sitting or by feeling high from four or fewer drinks in one sitting (SAMHSA, 2004), which differs from the National Institute of Alcohol Abuse and Alcoholism’s (NIAAA, 2004) widely used definition of binge drinking of five or more drinks for men or four or more drinks for women in a 2-hr sitting at least once in the past 2 weeks.
To determine whether the amount of treatment affected the outcomes, we selected a criterion for completion of 14 or more sessions (75% of 18 sessions in the curriculum) to differentiate completers from noncompleters. We were surprised to find that the completers did not perform significantly better than the noncompleters on most of the outcomes. The criterion may have been set too high. It is possible that exposure to a lesser amount of treatment was sufficient for the noncompleters to benefit from the curriculum. Furthermore, measuring receipt of treatment was complicated by the fact that the curriculum was delivered flexibly in group or individual sessions and in different settings. In future work to test the efficacy of the specialized curriculum, it would be important to more carefully measure delivery methods, dosage, and treatment fidelity and to use them as covariates in the analyses.
Implications for Future Research
Given the prevalence of older adult substance abuse problems, the growing number of older adults, and current national emphases on prevention and health care cost containment, studies of this type are important for measuring the impacts of programs in real-world settings. Although the results cannot be generalized beyond this local program, there were some important findings that support and inform practice and pose questions for further study. We learned that a specialized curriculum for older adults is an effective treatment modality associated with decreases in alcohol and nonmedical prescription drug use and improvements in their mental health and social functioning.
We support continuing the development of treatment programs for older adults based on what we learned in this study that is in concert with what is in the recent literature. Recommendations from our study support the findings reported by Han et al. (2009) that drug and alcohol programs created particularly for older adults can improve their quality of life if they are designed to be age specific, use curricula that provide supportive, nonconfrontational group treatment based on cognitive behavioral therapy, and are accessible. It has been strongly noted that ethnicity and culture must be considered when designing treatment programs for older adults as minorities and older adults may be more concerned with stigma related to mental health and substance abuse treatment than other groups and thus not seek services for their substance use disorders (Ojeda & McGuire, 2006). Therefore, we suggest that integrated primary and behavioral health care may be more effective, although like other authors we suggest that more research on this subject is needed. In addition, there needs to be more examination of women and substance abuse disorders as, in general, women in community studies have been found to have a later onset of alcohol abuse than men and have been found to experience different physiological effects. Again, we suggest that more study of women and substance abuse is needed. Finally, families and other social supports of older adults with substance abuse problems need to be educated about the issue and should be included in their treatment. To guarantee that this treatment approach is implemented, public policy agendas have to be developed that will ensure that insurance companies are required to pay for family and other social supports to participate in the treatment of older adults with substance use disorders.
Footnotes
Acknowledgements
The authors gratefully acknowledge manuscript assistance from Christina VanRegenmorter and Heather Wilson and the contributions of research assistants Catherine Sewall Martin, Heather Nelms, and Christina Bivens.
The authors declared that they had no conflicts of interest with respect to their authorship or the publication of this article.
The authors disclosed that they received the following support for their research and/or authorship of this article: This research was supported by Grant H79 TI16356 from the Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.