Substance abuse counseling

Definition

Substance abuse counseling refers to a type of intervention (action intended to alter the course of a disease process) to help individuals recover from abuse of alcohol (or other drug) by abstaining completely from the substance or cutting down on its use. With regard to alcohol abuse—which is the most common form of substance abuse in seniors—the most widely used form of counseling is called brief alcohol intervention or BAI.

Physicians and other substance abuse counselors distinguish between substance abuse and substance dependence. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) defines substance dependence as “a maladaptive pattern of substance use, leading to clinically significant impairment or distress” over a 12-month period. Substance abuse is defined as “a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances.” These consequences may be social or occupational (repeated absences from work), legal (being arrested for driving while drunk), or social (marital separation or divorce). These definitions, however, often complicate the diagnosis of substance-related problems in seniors because they may have retired from work, may have given up driving, and may be living alone. In addition, seniors are less likely to go to bars or participate in other group activities (e.g., office parties, tailgate parties at sports events) that include or encourage drinking.

With alcohol in particular, it is important to define what counts as a “drink”: this is usually defined as 0.5 oz of pure alcohol, which is the amount contained in 1.5 oz of whiskey or other distilled liquors; 12 oz of beer; and 5 oz of wine. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) considers one drink per day to be the maximum safe amount for seniors over 65.

Purpose

The purpose of substance abuse counseling in seniors is the same as its purpose in the general population—namely, to improve or maintain health by changing behaviors that are causing present or potential harm to the substance user and others. Alcohol and substance abuse can trigger a number of health-related problems in seniors and worsen those that already exist. A major reason for these negative effects on health is that the human body metabolizes (digests and uses) alcohol much less efficiently as it ages; thus, seniors may get drunk on the same amount of alcohol that they could drink without noticeable effects when they were younger. Studies have shown that a 65-year-old who consumes the same amount of alcohol as a 20-year-old will have a blood alcohol level 20 percent higher, and a 90-year-old will have a blood alcohol 50 percent higher. Some of the specific health risks of substance abuse in the elderly are:

• High blood pressure and increased risk of stroke.
• Increased risk of cancer of the head, neck, or esophagus.
• Increased risk of cirrhosis of the liver.
• Increased risk of falls and fall-related injuries, particularly in women. Studies indicate that heavy drinking in older women increases the risk of osteoporosis.
• Decline in cognitive function. Some researchers think that alcohol abuse increases a senior's risk of Alzheimer's disease, although further research is needed.
• Increased risk of malnutrition.
• High risk of interactions with prescription drugs that the senior may be taking.

Scope of the problem

Alcohol and substance abuse are a greater problem among seniors than many people recognize. The NIAAA estimates that between 2 and 10 percent of seniors living in the community meet the DSM-IV criteria for substance dependence or abuse. Another study reported that 6 percent of seniors are heavy drinkers, which is defined as having two or more drinks per day. A public health study in upstate New York found in the late 1990s that 62 percent of seniors between the ages of 60 and 94 who were living in the community drank alcohol at least occasionally, and heavy drinking was reported in 13 percent of men and 2 percent of women in this group.

Abuse of other substances is less common in seniors as of the early 2000s, affecting only a small percentage of seniors. Abuse of narcotics and other illicit drugs is rare in persons over 65 as of 2008, although this finding is expected to change as the so-called baby boomers retire. Most seniors who abuse other substances are alcoholics who misuse prescription drugs—most commonly benzodiazepines (tranquilizers) and opiates (painkillers). Like alcohol, these drugs are metabolized less quickly by the aging body and tend to remain in the bloodstream longer. Thus, seniors who drink heavily after taking a prescribed tranquilizer may become intoxicated from the combination of substances.

As of 2008, most seniors diagnosed with substance abuse problems are men; the gender ratio is expected to change in the coming years, however, as women tend to outlive men and a higher proportion of women who are middle-aged in the late 2000s are heavy drinkers compared to women in previous generations. In addition, a woman's body at any age metabolizes alcohol less efficiently than a man's; women can become intoxicated on smaller amounts of alcohol than a man of the same height and weight. Last, women progress more rapidly than men from moderate use of alcohol to dependence and abuse of the substance.

Diagnosis

Diagnosis of alcohol or substance abuse in the elderly is complicated by several factors. One is that the signs of alcohol or substance dependence are easy to confuse with age-related changes in muscle coordination, cognition, mood, social functioning, and the like. As noted above, older alcoholics are less likely to be noticed if they no longer drive or work outside the home. In addition, about a third of seniors who abuse alcohol are so-called late-onset drinkers; they are people who did not abuse alcohol previously but have turned to it out of loneliness or bereavement. These late-onset seniors typically have higher levels of education and income than the two-thirds of older substance abusers with previous histories of alcohol or drug dependence.

Primary care physicians are the healthcare professionals most likely to notice signs of alcohol or substance abuse in seniors. These “red flags” include:

• Decline in personal hygiene and self-care.
• Frequent falls or accidents.
• Uncontrolled high blood pressure.
• Unexpected delirium during hospitalization.
• Frequent visits to the hospital emergency department.
• Frequent arguments with or estrangement from family members.
• Gastrointestinal disorders.
• Failure to keep appointments with the doctor or comply with treatment.

Precautions

Medical Substance abuse counseling should not be offered if individuals are currently having a health crisis, have another psychiatric disorder, or are already in treatment for substance abuse. In addition, rapid cessation of alcohol intake may produce withdrawal symptoms; thus, the doctor needs to be alert for such signs of alcohol withdrawal as trembling, delirium , and hallucinations, and take care not to confuse them with symptoms of other medical conditions.

In many cases a primary care physician who suspects a senior may be having problems with alcohol or other substances may need to consult friends or family members. Consultation is particularly important if the senior is already in the early stages of cognitive decline or may be otherwise unable to answer the doctor's questions about alcohol and drug use. In some cases the primary care doctor may consult a psychiatrist to evaluate the patient's behavior or physical symptoms.

Psychological

Beginning substance abuse counseling with a senior requires a good relationship between physician and patient, particularly if the senior has already begun to miss appointments because of substance use. In addition, older alcoholics are more likely than younger ones to feel embarrassed or ashamed by a diagnosis of substance dependence or abuse, and the doctor may need to be tactful and proceed slowly.

Steps of recovery

Substance abuse counseling often has to be conducted during as well as before treatment for problem drinking or drug use. The following sections outline the most common pattern of counseling:

Primary care evaluation and BAI

The first stage of substance abuse counseling for most seniors takes place in their primary care doctor's office. It often takes the form of a brief alcohol intervention or BAI, a five-or ten-minute discussion that has been shown to be successful in spite of its brevity in getting seniors with substance abuse problems to get help. A BAI consists of three steps: an evaluation of the senior's actual consumption of alcohol (more than 1 drink per day for a senior of either sex over 65 is considered risky); an assessment of whether the patient has problems related to alcohol (e.g., days missed from work; arguments with family members); and the intervention itself.

The intervention has six specific steps:

• The doctor expresses concern about the senior's drinking.
• The doctor reviews a list of medical and social reasons for quitting.
• The doctor advises the patient to at least cut down on the amount of drinking (or substance use).
• The doctor and the senior together set a goal of acceptable daily intake, preferably within the safe limit.
• If the senior refuses to make a change, the doctor avoids getting confrontational, recognizing that admitting one has a problem and getting ready to change often takes time.
• The doctor recommends keeping a diary of the senior's drinking or substance use.

Detoxification

If the senior is severely dependent on alcohol, an inpatient detoxification program is often recommended. The senior will be given medications (usually benzodiazepines) in the hospital to manage withdrawal symptoms and be evaluated for nutritional deficiencies and other possible physical disorders. The senior should be referred to an outpatient support group or a community-based group such as Alcoholics Anonymous as soon as he or she completes the detoxification program. Elder-specific therapy groups are reported to be more successful than mixed-age groups.

Treatment options

Treatment options for seniors who do not require detoxification include ongoing counseling with the primary care physician, support groups, and support from family members. The doctor may need to educate the senior's friends and family about the harmful effects of heavy drinking and substance use because they may have been reluctant to interfere on the grounds that the senior had been comforted by the alcohol or drugs.

Naltrexone and acamprosate, two drugs that reduce the desire to drink, appear to reduce the rate of relapse in seniors by 50 percent when the medications are combined with counseling and social support. Disulfiram (Antabuse), the oldest drug given to control the desire to drink, should not be used in seniors because it may cause too-low blood pressure as a side effect.

Seniors with dementia who cannot stop drinking or abusing substances may have to be placed in a nursing home for long-term care.

Challenges

The primary challenge that a senior receiving substance abuse counseling confronts is the risk of relapse. Returning to heavy drinking (or drug use) means further risks to physical and mental health. Even limiting one's drinking to smaller amounts is preferable to uncontrolled use.

Risks

There are no physical risks involved with receiving substance abuse counseling by itself, although seniors may have some emotional reactions related to admitting that they have a problem with substance dependence or abuse.

Results

The results of substance abuse counseling for seniors depend on a variety of factors ranging from the person's overall level of physical health and the point at life in which he or she began abusing substances to income level and the amount of available family support. Such statistics as are available indicate that older adults have the same rate of abstinence after counseling as younger substance abusers; about 50 percent remain abstinent 1 year after treatment. As a rule, late-onset alcohol abusers do better than seniors with previous histories of substance abuse; one study found that they are twice as likely to avoid relapse as those who had abused alcohol or substances in the past.

KEY TERMS

Abstinence —Complete nonuse of alcohol (or other substance). Abstinence is the goal of substance abuse counseling in the elderly.

Detoxification —A program of medical care in which alcoholic or substance abusers are withdrawn from alcohol or other drugs and treated with medications while their body is cleared of the abused substance.

Intervention —A general medical term for any action taken to interrupt a disease process. In the field of substance abuse, it is used in a narrower sense to refer to an attempt on the part of a physician or family members to persuade an alcoholic or substance abuser to get help.

Moderation —Limiting one's drinking to what is considered a safe amount for one's age and sex.

Relapse —Returning to a previous behavior pattern of heavy drinking or substance abuse after treatment.

Withdrawal —A group of physical and psychological symptoms that occur when a person abruptly stops drinking or taking a drug of abuse. Seniors who are abruptly withdrawn from alcohol may become confused, have seizures or hallucinations, vomit, or suffer from insomnia.

Resources

PERIODICALS

Bertholet, Nicolas, Jean-Bernard Daeppen, Vincent Wietlisbach, et al. “Reduction of Alcohol Consumption by Brief Intervention in Primary Care.” Archives of Internal Medicine 165 (May 9, 2005): 986–995.

Epstein, E. E., K. Fischer-Elber, and Z. Al-Otaiba. “Women, Aging, and Alcohol Use Disorders.” Journal of Women and Aging 19 (January/February 2007):31–48.

Simoni-Wastila, L., and H. K. Yang. “Psychoactive Drug Abuse in Older Adults.” American Journal of Geriatric Pharmacotherapy 4 (December 2006): 380–394.

Zanjani, F., et al. “Predictors of Adherence within an Intervention Research Study of the At-risk Older Drinker: PRISM-E.” Journal of Geriatric Psychiatry and Neurology 19 (December 2006): 231–238.

OTHER

“Alcohol Use and Abuse.” National Institute on Aging (NIA) Age Page. Bethesda, MD: NIA. 2005 [cited March 21, 2008].. http://www.nia.nih.gov/NR/rdonlyres/89CF17D6-ADF4-498A-AD58-F4C85D606E66/7410/Alcohol_Use_And_Abuse.pdf.

Larson, Michael. “Alcohol-Related Psychosis.” eMedicine. March 30, 2006 [cited March 21, 2008].. http://www.emedicine.com/med/topic3113.htm.

Thompson, Warren. “Alcoholism.” eMedicine. June 6, 2007 [cited March 21, 2008]. http://www.emedicine.com/med/topic98.htm.

ORGANIZATIONS

American Psychiatric Association, 1000 Wilson Blvd., Suite 1825, Arlington, VA, 22209, (703) 907-7300, [email protected], http://www.psych.org/.

National Institute on Alcohol Abuse and Alcoholism (NIAAA), 5635 Fishers Lane, MSC 9304, Bethesda, MD, 20892, (301) 443-3860, http://www.niaaa.nih.gov/.

Rebecca J. Frey Ph.D.