Substance Misuse In The Elderly And Use Of Screening, Brief Intervention, And Referral To Treatment (SBIRT)

Editor's Note: This text-based course is a transcript of the webinar, Substance Misuse In The Elderly And Use Of Screening, Brief Intervention, And Referral To Treatment (SBIRT), presented by Ingrid Provident, EdD, OTR/L, FAOTA.

Learning Outcomes

• After this course, participants will be able to identify the process of screening, brief interventions, and referral to treatment for elders with substance use disorders.
• After this course, participants will be able to examine evidence-based screening tools appropriate for the care of the elderly.
• After this course, participants will be able to compare common substance use disorders in persons over age 65 to other aged populations.

Introduction

Thanks so much. It's a pleasure to be here. I look forward to this presentation, and I hope each of you takes a little something away from this.

National Statistics

• Over 70,000 fatal drug overdoses nationally
• Alcohol causes an average of 88,000 deaths per year
• Addiction among people 65 and up is often underestimated and underdiagnosed
• Alcohol and prescription drug abuse affects up to 17% of adults over the age of 60
• Stigma is part of the reason for low detection and undertreatment
• Baby boomers are the largest population demographic of the elderly to date

National Institute on Alcohol Abuse and Alcoholism (NIAAA)

Substance abuse among older adults is a growing yet often overlooked issue. According to the National Institute on Alcohol Abuse and Alcoholism, alcohol and prescription drug abuse affects up to 17% of adults over 60. However, addiction in this age group tends to be underestimated and underdiagnosed due to insufficient knowledge, limited research, and rushed doctor visits. These problems can be compounded by medical or behavioral disorders that mimic substance abuse symptoms like depression, diabetes, or dementia. 

The Office of Alcoholism and Substance Abuse Services notes that substance abuse in seniors falls into a couple of categories. There are the "hardy survivors" - those who have misused substances for years and lived to 65. There are also those with late-onset addictions who develop problems later in life. Stigma and ageism contribute to the low detection and treatment rates. With baby boomers being the largest elderly population to date, they have a high potential for substance abuse that must not be overlooked.

Focusing more research and medical resources on this issue to properly identify and treat addiction in seniors is imperative. Their well-being and quality of life depend on it.

Older Adult Statistics

• 10.7% reported binge drinking in the last month
• 2.5% reported heavy alcohol use in the last month
• 1.6% reported having an alcohol abuse disorder
• 1.3% reported misuse of opioids during the past year
• 0.5% reported misuse of tranquilizers during the past year
• 0.2% reported misuse of sedatives during the past year.
• Substance abuse is one of the fastest-growing health problems in the US

Substance abuse in older adults is rapidly increasing, fueled by longer lifespans and better medical care. A 2012 survey, though dated, gives insight into this troubling trend. It found 10.7% of seniors reported binge drinking in the past month. Additionally, 2.5% reported very heavy alcohol use, 1.6% met the criteria for an alcohol use disorder, and 1.3% reported misusing opioids, tranquilizers, or sedatives. 

While these percentages seem small, they likely underestimate the current rates in 2023, given shifting demographics. With more seniors living longer lives, there are greater opportunities for substance misuse to develop. This makes addiction one of the fastest-growing health issues facing older Americans. Proper screening, diagnosis, and treatment are imperative to curb this silent epidemic. Ignoring this growing public health crisis puts millions at risk of declining health and well-being. Urgent action must be taken to address substance abuse in our aging population.

Causes of Addiction in the Elderly

• Retirement
• Death of a family member, spouse, pet, or close friend
• Loss of income or financial strain
• Loss of purpose
• Relocation or placement in a nursing home
• Trouble sleeping
• Family conflict
• Mental or physical health decline (depression, memory loss, major surgeries, etc.)
• Pain/Poor health/Chronic diseases
• Avoidance coping style
• History of substance use disorders

Major life transitions often trigger substance abuse in the elderly. Retirement can lead to feelings of aimlessness and turn to alcohol or drugs to cope. Grief from losing a spouse, family member, friend, or pet can cause loneliness that substances "fill." Financial strains due to lost income may drive addiction. Relocating to a nursing home disrupts one's sense of home and security. 

Physical and mental health issues also contribute. Chronic pain and illness can lead to overusing medications or other substances. Trouble sleeping may prompt more drug use in hopes of rest, though substances also disrupt sleep. Avoidant coping styles result in using alcohol or drugs rather than addressing conflicts. Most importantly, a history of prior addiction puts seniors at high risk for continued substance misuse.  

Screening older adults for these risk factors allows for early intervention when substance use problems emerge. Awareness of what causes addiction in seniors is key to prevention and treatment.

Commonly Abused Substances

• Alcohol and prescription opioids are the most commonly abused substances among seniors
• Over time, the abuse of alcohol causes harmful effects on brain structure and function that can lead to a decline in cognitive function and memory
• There are at least 37.1% of men and 36.0% of women concurrently prescribed at least five different medications in individuals aged 57 to 85 years
• It contributes to or complicates other health problems such as liver and pancreas diseases, immune system disorders, osteoporosis, diabetes, high blood pressure, stroke, and seizures

As expected, alcohol and prescription opioids are the substances most commonly abused by seniors. Many older adults take multiple medications, putting those using prescription painkillers at risk for addiction. Alcohol also becomes increasingly harmful to aging bodies. 

Alcohol decreases circulation, slows cognition, and impairs decision-making in seniors. Studies show alcohol misuse in later adulthood heightens health risks. The body breaks down alcohol more slowly, so seniors feel greater effects from even small amounts. This leads to higher risks of accidents, falls, fractures, and impaired driving. Mixing alcohol with medications, as many seniors do, can cause dangerous interactions. 

Research shows over 20% of older drinkers consume alcohol excessively or in ways likely to interact with medications. As people age, their bodies change, and alcohol impacts them more strongly. Seniors need education on the risks of mixing alcohol with medications or health conditions. Concurrently taking just five prescription drugs, common in older adults, already creates complications before adding alcohol.

Substance misuse exacerbates many health issues in seniors - liver/pancreas diseases, osteoporosis, diabetes, high blood pressure, stroke, and seizures. For seniors in recovery, alcohol can severely slow progress. The impacts of addiction create elevated dangers for this population. Careful screening and treatment is crucial.

Dangers of Substance Abuse in the Elderly

• More susceptible to the deteriorating effects of these substances
• Decreased ability to metabolize drugs or alcohol
• Increased brain sensitivity
• Benzodiazepines used to treat anxiety, pain, or insomnia are some of the most dangerous prescription drugs for seniors- highly addictive
• Side effects of drugs can lead to falls or accidents.

In summary, alcohol, and drug use have become increasingly dangerous for aging adults. Seniors have a decreased ability to metabolize substances, so drugs and alcohol stay in their systems longer. This leads to greater brain sensitivity and slowed reactions. 

Benzodiazepines, used for anxiety, pain, and sleep, are particularly high-risk for older adults given their highly addictive properties. Screening for the use of these drugs is important, especially for those with any history of prior addiction. 

The side effects of combining medications and alcohol produce even greater risks for seniors. It can lead to more falls, fractures, accidents, and cognitive impairment. With aging bodies becoming more susceptible to detrimental effects, awareness and caution around substance use in seniors is critical. Careful screening, education, and treatment approaches are needed to address this growing issue.

Alcohol

• Alcohol is the most used drug among older adults, with about 65% of people 65 and older reporting high-risk drinking
• High-risk drinking- exceeding daily guidelines at least weekly in the past year
• More than 1/10 of adults age 65 and older currently binge drink
• Binge drinking- five or more drinks on the same occasion for men and four or more drinks on the same occasion for women
• Alcohol use disorder greater risk for diabetes, high blood pressure, congestive heart failure, liver and bone problems, memory issues, and mood disorders

Alcohol is a commonly used yet risky substance among seniors. About 65% of adults over 65 report high-risk drinking, defined as exceeding daily recommended limits. This includes binge drinking - having five or more drinks (4 for women) on one occasion. Even if only done weekly, exceeding guidelines endangers health. 

Alcohol use disorder from overconsumption increases risks of diabetes, high blood pressure, heart failure, liver issues, bone problems, memory loss, and mood disorders. Alcohol disrupts emotional regulation and self-control needed for positive social interactions.

Among older adults specifically, alcohol has heightened impacts. Aging bodies metabolize it more slowly, leading to greater intoxication and impairment. Alcohol's effects on circulation, cognition, and motor control also worsen with age. This makes seniors more susceptible to falls, accidents, injuries, and declines in functioning. 

Given alcohol's severe effects on older adults, screening and education are critical. Seniors should understand how drinking guidelines change with age as metabolism slows. Avoiding binge drinking and limiting intake protects health and safety. Careful monitoring of alcohol use enables early intervention when problems emerge.

Alcohol Use Disorder

• Often undiagnosed due to atypical presentation
• Lack of awareness and sensitization about AUD among physicians
• Results in emotional, physical, and social consequences
• Alcohol problems exist in 10% to 15% of older adults.
• Recent studies show that, although the vast majority of those with alcohol use disorder see their doctors regularly for a range of issues, fewer than 1 in 10 ever get treatment for drinking.
• Only 13% of physicians use a formal screening tool for alcohol problems with elderly patients.

Substance abuse in older adults is often underdiagnosed despite being a growing issue. In 2019, Americans over 65 accounted for 16.5% of the population - around 54 million people. This is projected to reach 22% - over 81 million - by 2040. As the senior population rapidly increases, so does the potential for unchecked addiction.

However, only 13% of physicians report using formal screening tools to detect alcohol problems in elderly patients. This highlights the need for more proactive screening and education to identify at-risk seniors. With earlier intervention, we can help modify behaviors and sustain quality of life.

As clinicians who work with older adults, we have an opportunity to better support this population. In less than 20 years, over 81 million seniors could potentially face substance abuse issues without the proper awareness and treatment. Implementing more rigorous screening processes and having open conversations is key to getting our older adults the help they need.

Alcohol Use Disorder Categories

• Racial Ethnic Differences
  • Higher prevalence in white, male, divorced, or widowed
  • Binge drinking in women is lower compared to male counterparts.
• Before Age 60
  • Account for about two-thirds of the elderly
  • Predominately male and have more alcohol-related medical and psychiatric comorbidities.
  • Less well-adjusted and having more antisocial traits
• After Age 60
  • Milder clinical picture and few medical problems
  • Tend to be affluent women
  • Are likely to have begun alcohol misuse after a stressful event

Looking at the demographics of alcohol use disorders in seniors reveals some patterns. There is a higher prevalence among white males, those divorced or widowed, and the more affluent. Binge drinking is more common in men than women. 

Before age 60, alcohol abuse is more prevalent in males and those with antisocial tendencies, likely using it to self-medicate loneliness or other problems. About 2/3 of the elderly population have alcohol use issues prior to 60.

After age 60, those who continue drinking tend to have milder clinical and medical problems, possibly allowing more consumption. At this stage, more affluent women newly misusing alcohol after a stressful life event are most at risk. 

These demographic patterns provide insights into groups most vulnerable to problematic drinking. Men dealing with life adjustments and women going through transitions like retirement or spousal loss need adequate support systems. Otherwise, alcohol can become an unhealthy coping mechanism. Screening patients for major stressors and risk factors enables early interventions when appropriate.

Problems in the Elderly

• Anxiety
• Poor hygiene, urinary or fecal incontinence
• Malnutrition
• Confusion, memory loss, dementia, or delirium
• Falls
• Marital problems
• Sleep problems
• Depression or mood swings
• Financial problems
• Seizures (new-onset, idiopathic)
• Worsening of chronic medical problems (hypertension, diabetes, heart failure)

Alcohol abuse in the elderly can exacerbate several health issues. It increases anxiety, worsens personal hygiene, and leads to malnutrition from poor eating. Confusion, memory problems, dementia, and delirium have been linked to excessive drinking. Seniors who overuse alcohol also have higher fall risks. 

Beyond physical health, alcohol abuse causes marital problems, sleep disruptions, mood swings, and depression. Financial struggles may emerge as funds are spent on substances rather than needs. Seizures may be triggered in those drinking heavily. Most critically, chronic medical conditions tend to worsen with alcohol misuse.

Screening seniors for these red flags can identify emerging addiction issues. Declining hygiene, malnutrition, confusion, and mood changes may reflect unhealthy drinking habits. Fall risks and financial or relationship problems are also common signs. Catching alcohol abuse early on prevents exacerbation of the many health conditions already facing older adults. Awareness and action are key.

Prescription Medicines

• Drugs prescribed for chronic health conditions may be mixed with over-the-counter medications, alcohol, and dietary supplements, putting adults at risk for drug-to-drug interactions.
• A high percentage of persons over 65 are prescribed more than five medications or supplements daily.
• 25% who misuse prescription opioids or benzodiazepines expressed suicidal ideation

Prescription drug use is increasingly common, which helps manage chronic conditions but also risks misuse. With more pharmaceuticals available, many seniors take 5+ medications daily, mixing prescriptions, over-the-counter drugs, and supplements. This creates a high likelihood of dangerous interactions that most do not understand.  

When prescription opioids are misused, risks grow severely. 25% of older adults misusing these painkillers report suicidal ideation. The chemical changes from mixing substances can profoundly impact mental health. Adding depressants like alcohol further endangers wellbeing.

As clinicians, we must increase education about medication use, particularly for seniors on multiple prescriptions. Screening for suicidal thoughts and substance misuse is crucial when red flags emerge. Understanding the factors behind suicidal ideation enables proper treatment. Careful management of medications and supplementation is key to the health of older adults.

Opioid Pain Medicines

• Persistent pain may be more complicated in older adults experiencing other health conditions.
  • 80% of patients with advanced cancer report pain
  • 77% of heart disease patients
  • Close to 40% of outpatients 65 and older
  • Between 4-9% of adults age 65 or older use prescription opioid medications for pain relief
  • Higher % of adults using heroin and marijuana for pain relief

Managing pain is crucial but complicated in older adults with persistent pain and other health issues. 80% of those with advanced cancer use opioids for pain relief, though other strategies may now be considered, given the risks of opioids. 77% with heart disease report ongoing pain as well. 

Up to 10% of seniors over 65 use opioids for pain, a concerning amount with the potential for misuse or addiction. Even more alarmingly, rates of heroin and marijuana use for pain relief are rising rapidly in this population. 

As clinicians, we must find a careful balance in treating pain while preventing substance misuse. Screening for alternative methods like physical therapy, acupuncture, mindfulness, or massage should come before prescription opioids. If opioids are used, vigilant monitoring of usage and effects is essential. Multimodal pain management optimizes quality of life while reducing risks of addiction.

Medical Marijuana

• 25% of marijuana users aged 65 or older report that a doctor recommended marijuana in the past year
• Medical marijuana may relieve symptoms related to chronic pain, sleep hygiene, malnutrition, depression, or side effects from cancer treatment
• Marijuana has not been approved by the Food and Drug Administration (FDA) as a medicine
• Regular marijuana use for medical use has been linked to chronic respiratory conditions, depression, impaired memory, adverse cardiovascular functions, and altered judgment and motor skills
• Marijuana can interact with prescription drugs and complicate already existing health issues and common physiological changes in older adults

Medical marijuana use is growing among seniors, with nearly 1/4 of users over 65 having a doctor's recommendation. However, marijuana is not FDA-approved and still carries risks, especially for older adults.

While it may relieve some chronic pain and sleep problems, marijuana can also worsen issues like depression and malnutrition. Respiratory problems, memory loss, cardiovascular effects, and impaired judgment/coordination have been linked to its use. 

With older adults often on multiple prescription medications, marijuana interactions are concerning. More research is still needed on both its benefits and drawbacks in seniors.  

As clinicians, staying abreast of the evidence helps us educate patients. Seniors considering medical marijuana need full information to weigh the pros and cons. Screening for risk factors, drug interactions, and side effects allows for careful monitoring. Open conversations support wise, informed decisions.

Cigarettes and Vaping

• Approximately 8 of every 100 adults aged 65 and older smoked cigarettes
• Older people who smoke have an increased risk of becoming frail
• 300,000 smoking-related deaths occur each year among people who are age 65 and older
• Little research on the effects of vaping nicotine (e-cigarettes) among older adults

While declining, cigarette smoking still affects around 8% of adults over 65. This poses serious health risks, as older smokers are more prone to frailty, osteoporosis, and other detrimental impacts. Over 300,000 smoking-related deaths occur in this age group per year.

The effects of vaping and e-cigarettes remain under-researched in the senior population. However, nicotine addiction and exposure to toxic chemicals in any form are concerning for older adults with declining physiological resilience.

Challenges of Identifying Addiction

• Alcohol or drug abuse may mimic symptoms of other medical or mental health disorders
• Important to use screening tools that accurately ask questions to elicit useful information in a non-threatening manner

Identifying addiction in the elderly poses challenges, as symptoms often mimic other conditions like cognitive decline or depression. A grieving senior may seem situationally depressed when underlying substance abuse actually drives their mental health changes.

Rather than making assumptions, clinicians should universally screen all older patients for addiction. Using validated screening tools in a non-threatening way, framed as routine questions asked of everyone, can uncover issues that otherwise go undetected. 

Familiarizing ourselves with appropriate screening instruments and integrating them into standard assessment processes is key. This enables early intervention that improves outcomes. Aging adults dealing with loss and life transitions need thorough evaluations to provide proper support, treatment referrals, and improved quality of life. Removing the stigma around screening encourages honesty so problems can be caught before they reach crisis levels.

Solutions to the Problem

• Clinicians are essential to identifying those who need treatment
• SAMHSA recommends that men and women aged 65 and older consume no more than one standard drink per day or seven standard drinks per week
• Formal screening tools
  • Should be asked in a confidential setting and in a non-threatening, nonjudgmental manner

As clinicians, we play an essential role in identifying older adults who need addiction treatment. Substance Abuse and Mental Health Services Administration (SAMHSA) provides excellent resources, including screening tools and educational materials to help address this issue.

Formal screening should be done confidentially and sensitively. Creating a non-threatening, non-judgmental environment encourages honest disclosure. Therapists can apply our skills in building rapport and trust to have open conversations about substance use. 

Using SAMHSA resources to educate ourselves and implement universal screening protocols allows for early intervention. We can catch addiction issues in seniors before they become crises. Our roles on the frontlines of geriatric care give us unique opportunities to improve identification and get older adults needed treatment. Implementing regular screening processes is a vital first step.

Screening Tools

• Cut Annoyed Guilty Eye (CAGE)
• Michigan Alcohol Screening Test–Geriatric Version (MAST-G)
• Short Michigan Alcoholism Screening Test—Geriatric Version (SMAST-G)
• Alcohol Use Disorder Identification Test (AUDIT)

Screening tools are vital for evaluating various aspects of our client's well-being. One of them, intriguingly named the "Curt Annoyed Guilty Eye," is commonly referred to as CAGE. This assessment, while seemingly simple, holds significant importance in our practice, and we'll delve deeper into it shortly.

Another valuable tool in our repertoire is the Michigan Alcohol Screening Test (MAST), which also comes in a geriatric version tailored specifically to the elderly population. I'll be providing a more comprehensive overview of the geriatric MAST shortly.

In addition to MAST, there's the Short Michigan Alcohol Screening Test (SMAST), often referred to as MAST-G or SMAST-G, depending on the version.

Lastly, we have the AUDIT, which stands for Alcohol Use Disorders Identification Test. This tool plays a crucial role in identifying and assessing alcohol use disorders, helping us provide effective support to our clients.

Let's explore each of these screening tools in detail to better understand their applications and significance in our professional practice.

CAGE

The CAGE comprises four questions, each corresponding to a letter in its acronym. The first question, represented by the letter "C" for "cutting down," inquires whether an individual has ever felt the need to reduce their drinking. This query provides insight into the person's subjective perspective on their alcohol consumption, helping us gauge if they perceive it as excessive.

Moving on to the second question, which aligns with the "A" in CAGE, it addresses the issue of annoyance by criticism. The question probes whether people in the individual's life have caused annoyance by criticizing their drinking habits. This helps us understand the interpersonal dynamics surrounding their alcohol consumption.

The third question, associated with the "G" for "guilty feelings," explores whether the person has ever experienced feelings of guilt or remorse regarding their drinking behavior. This touches upon the emotional aspect of their relationship with alcohol.

Lastly, the "E" in CAGE stands for "eye-opener." Here, the assessment becomes quite literal. The question asks if the individual has ever resorted to having a drink first thing in the morning to alleviate nervousness, hangovers, or to kickstart their day. This query offers insights into potential dependency on alcohol as a coping mechanism.

Indeed, CAGE is a straightforward and user-friendly screening tool that allows us to initiate critical conversations with our clients regarding their alcohol consumption. Furthermore, it is worth noting that a similar screening tool exists for assessing drug use, employing analogous questions to those found in CAGE, making it an invaluable resource for comprehensively assessing substance use disorders.

What is Your Patient's Standard Drink?

• It is ok to ask...
  • How much do you drink?
  • How often do drinking days occur?
  • What size is your drink?
  • What do you drink?

Exploring a person's drinking habits is not only acceptable but also a vital part of responsible screening. When done universally and professionally, it provides essential insights into an individual's relationship with alcohol.

We can begin by simply asking if they consume alcohol. If they answer affirmatively, we can delve deeper to gain a comprehensive understanding:

First, we aim to gauge their typical alcohol consumption. How much do they drink on average? This gives us a sense of their drinking habits.

Next, it's crucial to determine the frequency of their drinking. Is it limited to social occasions, a daily ritual like having wine with dinner, or more sporadic, such as a few beers at the bar with friends? This paints a clearer picture of their drinking patterns.

As we gather this information, we're essentially constructing a profile akin to an occupational one to comprehend their relationship with alcohol better.

Once we have these details, we can address the concept of a standard-sized drink. It's an opportunity for education, ensuring they understand the variations in alcohol content among different beverages and serving sizes. 

Furthermore, we can discuss the potential implications of overconsumption. For example, if someone regularly consumes large glasses of wine or multiple such servings each night, it's crucial to highlight that such portions can be substantial compared to the average American serving size. This can serve as an eye-opener for those who may not have considered the consequences of their drinking habits.

Lastly, we inquire about their preferred type of alcoholic beverage. Some individuals may not consider beer as alcohol, viewing it more as a standard beverage. Here, we help them recognize the alcohol content in various drinks and the importance of this distinction.

In essence, our approach is to foster an open and non-judgmental dialogue, aiming to increase awareness, promote responsible drinking choices, and ultimately support individuals in making informed decisions about their well-being.

Full Exam 

• A Full Exam Should Include:
  • Question Falls/Level of Social Activities
  • Sleep Problems
  • Physiologic Dependence or Withdrawl
  • Cognitive Functioning/Readiness and Motivation to Change
  • Drug Interactions – Chart Review
  • Psychosocial Evaluation- Anxiety
  • Presence of Pain
  • Family Dynamics
  • Suicidal Ideation

First and foremost, we consider the issue of falls. How often do these episodes occur? By understanding the frequency of falls, we gain invaluable insights into an individual's mobility and safety, helping us address potential hazards.

Next, we look at social activities. Do they venture out into the community, engaging in social events, or do they predominantly remain within the confines of their home? This exploration provides a glimpse into their social integration and overall sense of belonging.

A good night's rest is integral to well-being, so we investigate the duration and quality of their sleep, uncovering any potential disruptions that may be affecting their daily functioning.

For those grappling with alcohol dependency, the assessment extends to physiological dependence and the possibility of withdrawal symptoms, especially if hospitalization is on the horizon.

Cognitive functioning and the readiness and motivation for change are also crucial, particularly when alcohol-related issues are in play. Tools like motivational interviewing and readiness scales become invaluable allies in this endeavor.

The intricate web of drug interactions is another realm we explore. Delving into pharmaceutical prescriptions and supplement use helps us ensure the safety and efficacy of our interventions.

We examine the presence of anxiety, depression, and thoughts of suicide. These aspects, intricately woven into one's psyche, have a profound influence on their occupational profile and overall well-being.

Pain, a persistent companion for many, merits careful consideration. We employ pain scales to quantify its presence and inquire into the sources of pain. Understanding how pain impacts daily activities and the strategies individuals employ to manage it is essential.

Interpersonal relationships also offer a unique window into the client's psychological outlook and the support system they have in place.

Finally, we broach the sensitive topic of self-harm. While not a comfortable subject, it's a crucial one, allowing us to address any potential issues related to self-harm and offer the necessary support and guidance.

SBIRT

• Screening, Brief Intervention, Referral to Treatment (SBIRT)
• SBIRT is an evidence-based, comprehensive, and integrated public health approach for the delivery of early screening, intervention, and treatment services employing empirically-based and clinically useful practices to circumvent harmful consequences from substance use, including impeding the development of alcohol and other drug use disorders.

Screening, Brief Intervention, and Referral to Treatment (SBIRT) represents a well-established, evidence-based approach within the realm of public health. This approach is pivotal in identifying and addressing potential issues related to substance misuse, particularly alcohol.

The "S" in SBIRT signifies the initial phase: screening. Through the use of carefully selected tools, we aim to unearth whether an individual is grappling with alcohol misuse problems. These screening tools provide us with the insights needed to gauge the extent of the issue.

Following the screening, we transition to the "BI" or Brief Intervention stage. Here, we engage individuals in strategies designed to provide valuable education and support. This might involve explaining concepts like standard drink sizes and elucidating the impact of alcohol, especially on an aging body. While we may not aspire to become alcohol intervention specialists, these brief interventions fall within our skill set as occupational therapists. They can be powerful tools for fostering awareness and motivation for change.

The final phase, "R" for Referral to Treatment, comes into play when an issue goes beyond our expertise. Ensuring that individuals receive the appropriate treatment is crucial for the resumption of their quality of life. This step is about connecting them with the necessary resources and specialists who can offer targeted support.

SBIRT in Practice

• Use and misuse of tobacco, alcohol, and drugs all have a direct impact on patient health
• Harms associated with substance use contribute heavily to the burden of disease for millions
• SBIRT can easily be applied within a variety of healthcare settings
• It enables healthcare professionals to systematically screen and assist patients whose drinking or drug use may threaten or complicate their ability to successfully manage health, work, and social responsibilities

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a versatile and essential approach that extends its reach to address not only alcohol but also tobacco and drug misuse. These behaviors have a direct and profound impact on our patients' health and overall well-being. The aim is to ensure that our therapeutic interventions remain effective and are not undermined by these potentially detrimental habits.

As healthcare providers, it's imperative that we recognize how substance misuse can hinder a patient's progress and gains during therapeutic interventions. Being attuned to this aspect allows us to provide more holistic care, considering the broader context of their health.

Substance misuse carries a multitude of associated harms, contributing to increased hospitalizations, disease burden, and a decline in a person's overall quality of life. SBIRT becomes a valuable tool in our professional toolbox, empowering individuals to regain control over their lives.

The beauty of SBIRT lies in its adaptability to various healthcare settings. Whether you're working with physical disabilities, psychiatric conditions, in-home care, nursing homes, or any other practice area, there's a place for SBIRT. It can be implemented systematically to screen and assist patients who may be struggling with alcohol or drug use, which in turn could complicate their ability to manage their own health effectively.

In outpatient settings, substance misuse may compromise a patient's work performance or social interactions. As occupational therapists, we play a vital role in helping individuals rediscover healthy leisure interests, which not only contribute to their overall well-being but also foster social connectedness.

Goals of SBIRT

• Healthier patients are at lower risk for Substance Use Disorders (SUD)
• Prompt connection of substance use and clinical findings
• Prevention of early substance use prior to more severe or permanent harm
• Identification of substance use dependence with appropriate referral to specialized treatment when patients are medically stable

The overarching objectives of employing SBIRT are rooted in the desire to safeguard the health of our patients by reducing the risk of substance use disorders. This comprehensive approach helps us gain a deeper understanding of how various substances can contribute to the deterioration of the human body. Timely intervention is pivotal, as it can lead to significantly improved outcomes for individuals who may be struggling with substance misuse issues.

Early identification of potential substance use problems is a cornerstone of SBIRT, and it empowers us to take proactive steps. Through education integrated into various settings, we can engage in preventive efforts. This educational component is instrumental in promoting awareness and influencing behaviors related to substance use.

Additionally, identifying substance use disorders or dependence through the SBIRT process facilitates appropriate referrals for specialized treatments. This is particularly valuable when dealing with patients who have experienced traumatic injuries, such as car accidents or falls, as seen in acute care settings. Once these individuals are medically stable, the continuity of care or discharge planning can seamlessly integrate referrals to professionals who specialize in behavior change.

SBIRT Outcomes

• Small to moderate reductions in alcohol consumption that are sustained over 6 to 12-month periods or longer
• Alcohol consumption reduced in non-dependent patients by about 24% for at least one year
• Risky behavior changes in 50% of patients who receive a brief intervention
• Brief intervention at the time of injury reduces injury recidivism by 47%
• Reduced hospital admissions, traumas, and injuries up to 3 years post-intervention

Even small to moderate reductions in alcohol consumption can yield significantly better outcomes, particularly when sustained over a period of six to twelve months or longer. These changes can contribute to a much healthier lifestyle for individuals. Remarkably, research has shown that for those who are not dependent on alcohol, about 24% have been successful in reducing their alcohol consumption and maintaining these changes over a one-year period.

In addition, SBIRT aims to target risky behaviors, and the statistics are encouraging. Brief interventions, which include education and motivational support, have been effective in changing risky behavior in approximately 50% of cases. These interventions help individuals understand the effects of alcohol, set up motivation plans, and establish short-term goals, enabling them to witness their own progress and stay motivated.

The impact of brief interventions extends beyond behavioral change; they can reduce the occurrence of injuries and prevent future injuries, ultimately lowering recidivism rates, which signify the continuation of injuries. If, for example, someone recognizes that a fall was linked to alcohol overuse and we can help them change their behavior, it results in a substantial reduction in injuries.

Continuum of Drug and Alcohol Use

• No use
• Experimentation
• Risky Use
• Dependence
• Addiction

It's crucial to acknowledge that SBIRT may not be effective for everyone, as there exists a vast continuum of drug and alcohol use within the population. At one end of this spectrum, there's a relatively small percentage of individuals who abstain from drugs and alcohol, are not on any prescription medications, and do not use pain medication. These individuals are at minimal risk for the issues we're discussing today, and SBIRT may not be directly relevant to them.

In contrast, a much larger portion of the population falls into the realm of experimentation. They may use alcohol on occasion and have had experiences where they've overindulged, leading to undesirable outcomes. These incidents could involve falls, heated arguments, emotional instability, or other adverse consequences. Importantly, many individuals within this group recognize these issues on their own and are motivated to make positive changes in their behavior.

Therefore, SBIRT is ideally suited to address the needs of this broader segment of the population, offering support and guidance to those who may be at risk due to their patterns of substance use. It's a valuable tool for engaging with individuals at different stages of substance use and helping them make informed decisions about their health and well-being.

Low-Risk Substance Use

• By most measures, a large portion of the population abstains or consumes alcohol or drugs at levels that, in general, present little risk

The SBIRT Target

• A sizable portion of the population faces an increased risk of harm or may, in fact, be experiencing harm from consuming substances above certain limits or under certain circumstances
• It is important to note that consumption can vary over a lifetime, and an individual may fall into different risk levels at different times with different substances

Our primary focus lies on individuals who exhibit risky substance use behaviors. These are the individuals who repeatedly engage in substance use, often taking risks associated with their behavior. They have a level of awareness and can articulate experiences that have yielded unfavorable outcomes in their lives. These are the individuals who benefit significantly from targeted interventions.

Hazardous

• A pattern or quantity of alcohol use which places the person at increased risk for alcohol-related harm
• Men up to age 65
  • 14 drinks per week
  • 4 per day
• Women; Men > 65
  • 7 drinks per week
  • 3 drinks per day
• Lesser use may be hazardous for persons with medical, psychiatric, or social consequences

While individuals who are in the throes of addiction often require specialized professional help, those who fall within the gradient of alcohol dependence are prime candidates for the kind of interventions that SBIRT offers.

By identifying and engaging individuals in this intermediate stage of alcohol dependence, we can provide valuable brief interventions. These interventions may involve discussing the motivation for change, offering education, and collaborating with them to make behavior changes that align with their best interests.

Drinking Limits and Low-Risk Guidelines

• Below are the low-risk drinking limits based on consumption of “standard drinks” containing alcohol. Research demonstrates that drinking above these limits puts an individual at increased risk for harm or the development of a SUD.

Let's talk a little bit about different risk levels, as shown in Figure 1.

Figure 1. Drinking chart and different risk levels from the NIAAA (2013).

When we examine the population's alcohol consumption, we can envision it as a triangular pyramid, highlighting different risk levels. While a substantial portion of the population either abstains from alcohol or consumes it without presenting significant risks, there exists a sizable segment that falls into the categories of risky use or dependence. This is where SBIRT plays a pivotal role, situated at the center of the pyramid.

It's crucial to recognize that an individual's risk level can vary at different points in their life. Life events like retirement or the loss of a spouse can potentially increase a person's risk of problematic alcohol use during specific chapters of their life.

At one end of the spectrum, we have hazardous behavior, where a pattern or quantity of alcohol use places individuals at an increased risk of harm. For men below the age of 65, consuming 14 drinks per week or four drinks per day is considered hazardous. Women, regardless of age, and men over 65 fall into this category if they consume seven drinks per week or three drinks per day. It's important to note that even lower quantities can be considered hazardous for individuals who are taking multiple medications, dealing with medical or psychiatric conditions, or facing social challenges. In such cases, the risk associated with alcohol consumption may be elevated.

Standard Drink Sizes

Not every drink is considered the same. Figure 2 shows this.

Figure 2. Standard drink sizes by the National Institutes of Health.

The information I'm sharing here is derived from a SAMHSA publication and can be a valuable addition to educational materials, especially when working with individuals who may benefit from understanding the varying alcohol content in different types of beverages.

To put this into perspective, consider the following alcohol content in various types of drinks. In a standard 12-ounce regular beer, you'll find roughly 5% alcohol. However, it's worth noting that malt liquor, which is a higher alcohol-laden beer, contains about 7% alcohol. This may come as a surprise to some, highlighting a 2% difference in alcohol content based on the type of beer consumed.

For those who enjoy wine, a typical 5-ounce glass of table wine contains approximately 12% alcohol. If you venture into fortified wines, such as sherries or ports, you'll encounter a higher alcohol content of about 17% in three to four ounces.

Moving into the realm of cordials, liqueurs, or aperitifs, you'll find even higher alcohol concentrations. Approximately 24% of alcohol is present in just two to three ounces of these beverages.

Now, when it comes to brandies or cognac, even a relatively small 1.5-ounce serving delivers a substantial punch, as it contains 40% alcohol. This is on par with an 80-proof shot, which also provides 40% alcohol.

For many individuals, this information can be eye-opening, especially if they were previously unaware of the varying alcohol percentages in different beverages. Understanding these differences can be a critical aspect of discussing alcohol consumption, especially during brief intervention conversations.

Brief Intervention

• A brief dialogue that assists patients in recognizing the negative consequences of substance use and promotes positive behavior change
• Leads to agreement to specific behavior change
• Assessing change
  • Readiness
  • Importance
• F-L-O Model
  • Asking permission
  • Feedback
  • Listening
  • Options
• •A Little <PAUSE> Goes a Long Way

Brief intervention, at its core, is a conversation or dialogue aimed at helping a patient recognize any negative consequences of their substance use. It's important to emphasize that the goal of this conversation is not to shame or judge the individual but to engage in a respectful and constructive dialogue that can lead to positive behavior change.

During this conversation, providing objective information, such as the alcohol content in different beverages, can be a helpful tool. Sometimes, individuals may lack self-awareness about the effects of their substance use. Asking questions about how their drinking or substance use impacts them and what feedback they receive from loved ones can guide the conversation.

Ultimately, the outcome of the conversation should involve reaching an agreement on specific behavior changes that the individual is willing and capable of making. Assessing their readiness for change is a key aspect of this process. It involves gauging how important it is for them to make changes in their substance use behaviors.

The FLO model is a valuable framework for conducting these conversations. It starts with asking for permission to engage in the conversation and respecting the individual's autonomy in deciding whether to participate. Once permission is granted, providing feedback becomes essential. However, active listening is the cornerstone of effective brief interventions. As therapists, it's crucial to truly understand the individual's perspective, their reasons for substance use, and their holistic picture.

After active listening, the next step is to collaboratively develop client-centered options. These options should align with the individual's goals and facilitate the behavior changes they want to make. This shift from being the expert with all the information to becoming a skilled listener and facilitator of change is a significant aspect of conducting successful brief interventions. Building trust and creating a safe space for individuals to open up can greatly enhance the effectiveness of these conversations.

Motivational Interviewing (MI)

• Respects patient autonomy
• Patient/client-centered
• Minimizes resistance
• But requires the healthcare professional to shift gears…

The principles of motivational interviewing can be a powerful tool when conducting brief interventions. Motivational interviewing is a client-centered, collaborative approach specifically designed to facilitate behavior change. Originally rooted in psychology, its primary purpose is to help individuals recognize and address excessive drinking or other addictive behaviors, guiding them through the process of change.

One of the key strengths of motivational interviewing is its ability to minimize resistance. This is achieved by placing the patient in a position of authority and actively involving them in the decision-making process. In essence, it shifts the dynamic, transforming the therapist or professional into a peer who collaborates with the patient. After all, the individual seeking help is the true expert in their own life, and motivational interviewing respects and leverages this expertise.

Core Elements of MI

• An evidence-based treatment used to:
  • Explore Ambivalence
  • Enhance Motivation
  • Develop a Commitment to Change
  • Support Autonomy
• Embodies a Spirit of:
  • Client Centeredness
  • Unconditional Positive Regard
  • Respect for the Client
  • Understanding of Readiness

At the heart of motivational interviewing lies the core element of exploring ambivalence. It seeks to understand why individuals may be hesitant or resistant to change and then works to enhance their commitment to making positive changes in their behavior. This involves helping them identify specific behaviors they want to change and supporting them in their journey.

Motivational interviewing embodies the spirit of being client-centered. It's a positive and respectful conversation that acknowledges the client's autonomy and expertise in their own life. It's not about imposing change but rather guiding individuals to find their own motivations for change.

Understanding the concept of readiness is pivotal in this approach. It's about recognizing that individuals may be at different stages of readiness for change, and motivational interviewing meets them where they are. It's a collaborative effort that aims to empower individuals to make informed decisions about their own behavior and work towards their goals for change.

SBIRT = A Paradigm Shift

Figure 3 shows another way to think about this as a paradigm shift.

Figure 3. Illustration demonstrating the paradigm shift of the patient or client being the "expert."

In the process of conducting motivational interviewing and similar client-centered approaches, there's a significant shift in the dynamics of the interaction. Healthcare professionals transition from being the directors of the intervention to becoming equals, engaging in a collaborative partnership with the client. The client assumes the role of the expert because they are the ones intimately familiar with their own life and the changes they are seeking to make.

MI- Transtheoretical Model of Change

It's based upon the transtheoretical model of change, which goes through five very specific steps, as noted in Figure 4.

Figure 4. Transtheoretical Model of Change.

The stages of change, as understood in motivational interviewing and similar approaches, offer a framework for assessing an individual's readiness for change. The stages include:

In the pre-contemplation stage, individuals aren't actively considering change. At this point, they may not recognize any issues with their current behavior and might resist the idea of change.

Moving on to the contemplation stage, individuals begin to entertain the idea of change, but their commitment is still tentative. They may be thinking about making a change within the next six months, but it's not an immediate priority.

In the preparation for change stage, individuals are actively getting ready to make a change within the next 30 days. They take concrete steps, such as setting a quit date or seeking information and support, to facilitate their desired change.

Motivational interviewing plays a significant role in helping individuals transition from the pre-contemplation stage to the preparation for change stage. Individuals in this stage may be at a higher risk of relapse. Therefore, ongoing support and strategies for maintaining the change are crucial to prevent relapse and sustain positive behavior changes.

Addressing the Issue

• The Comprehensive Addiction and Recovery Act (CARA) 2016 and the Surgeon General's “Turn the Tide” campaign
• Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (HR6) 2018
• Substance Abuse and Mental Health Services Administration (SAMSHA) - grants
• What is going on in your locality?

Ensuring that individuals have the necessary support in place is crucial in the process of change. Additionally, maintenance signifies that a person has successfully made a change and has sustained that change for a minimum of six months. 

Some notable national efforts to address substance use and addiction include the Comprehensive Addiction and Recovery Act (CARA) in 2016, which highlighted the severity of the issue. In the same year, the surgeon general initiated the Turn the Tide campaign, focusing on education and awareness.

In 2018, the Substance Use Disorder Prevention that Promoted Opioid Recovery and Treatment Act, known as the SUPPORT Act, was enacted to provide resources and support to patients and communities dealing with substance use disorders. This legislation was introduced in Congress to address the opioid crisis comprehensively.

For therapists seeking resources and grants to integrate substance use disorder interventions, SAMHSA (Substance Abuse and Mental Health Services Administration) remains a valuable source. SAMHSA offers both small and large grants to facilities working to implement these initiatives, and it's essential to keep abreast of local developments in your own community as well.

Why Don't Therapists Screen?

• Time to conduct a screening
• Lack of training and familiarity with screening tools
• Concern with antagonizing patients/clients
• Competing medical problems
• Time to manage positive results
• Availability of treatment resources

Therapists may sometimes choose not to screen for substance use disorders for various reasons. Some common reasons include concerns about time constraints, a lack of training or familiarity with screening tools, apprehensions about potentially antagonizing patients by asking these questions, competing medical issues demanding their attention, extensive documentation requirements, and a perceived lack of time to manage a positive screening result.

However, it's essential to recognize that screening for substance use disorders is a valuable component of holistic patient care. Fortunately, there are resources available to address these concerns and facilitate the integration of screening into therapeutic practice. Resources such as those provided by SAMHSA (Substance Abuse and Mental Health Services Administration) offer treatment options and screening tools that can support therapists in providing comprehensive care to their patients.

Case Study

• Sam – a 70-year-old male who is recently widowed. He worked as a construction worker for 40 years and retired at age 67.  He routinely went to the bar with his buddies a few days a week after work and drank 4 to 5 beers. He is experiencing difficulty sleeping, feelings of depression, some new onset memory confusion, and overall not feeling himself.
• Assessing change
  • Readiness
  • Importance
• F-L-O Model
  • Asking permission
  • Feedback
  • Listening
  • Options
• A Little <PAUSE> Goes a Long Way
• Referral for Treatment

Sam, a 70-year-old male who recently experienced a significant life event – the loss of his spouse. Sam had spent 40 years working as a construction worker and retired at the age of 67. He used to frequent the local bar with his friends a few days a week, consuming four to five beers during each visit. However, Sam is currently facing some troubling issues, including difficulty sleeping, feelings of depression, new memory problems, confusion, and a general sense of being out of sorts.

In approaching Sam's situation, there are several steps we can take. First and foremost, it's important to have an open conversation with Sam about his current drinking routine. Is he still consuming four to five beers per day? When does he typically consume them, and does he feel a desire to change this pattern? Listening to his story and gaining insights into his motivations and challenges is crucial.

Additionally, educating Sam on how aging can impact the body's response to alcohol can be beneficial. This information can help him better understand the potential consequences of his drinking habits.

Moreover, suggesting alternative social activities that align with Sam's interests can be helpful in promoting healthier social connections. Encouraging him to reconnect with friends who share different interests or engage in non-alcohol-related activities may be a positive step.

Lastly, if the conversation with Sam reveals that he may require additional support, it's essential to know the available addiction referral resources within your work environment. Referring Sam to specialized addiction services can be a crucial step in addressing his needs and providing him with the necessary support during this challenging time.

Summary

• The healthcare system needs to be prepared to treat substance abuse issues.
• Providers need to be able to distinguish substance abuse problems from physical or mental health problems.
• Brief Intervention and Education can be beneficial to the quality of life for all our patients.

In summary, our healthcare system must be adequately prepared to address substance abuse issues, especially in the elderly population, which is expected to grow in the coming years. It's crucial for healthcare professionals to differentiate between substance abuse problems and physical or mental health issues. Implementing brief interventions and providing education can significantly enhance the quality of life for our patients by addressing substance abuse concerns effectively and promoting healthier behaviors. This proactive approach can lead to improved outcomes and a better overall healthcare experience for individuals, particularly in the aging population.

Resources

Here is an additional resource, AUDIT (Alcohol Use Disorders Identification Test).

References

Aldridge, A., Linford, R., & Bray, J. (2017). Substance use outcomes of patients served by a large US implementation of Screening, Brief Intervention and Referral to Treatment (SBIRT): Outcomes of SAMHSA’s SBIRT program. Addiction. https://doi.org/10.1111/add.13651

Chatre, S., Cook, R., & Mallik, E. (2017). Trends in substance use admissions among older adults. BMC Health Services Research. 584(17). doi: https://doi.org/10.1186/s12913-017-2538-z

Fagbemi, M. (2021) How do you effectively evaluate the elderly for alcohol disorder? Cleveland Clinic Journal of Medicine 88(8), 434-439.

Mattila, A., & Provident, I. (2017). Education for occupational therapists to develop the role of healthcare leaders in Screening, Brief Intervention, and Referral to Treatment (SBIRT). Journal of Occupational Therapy Education, 1(1). https://doi.org/10.26681/jote.2017.010304

National Institute on Alcohol Abuse and Alcoholism. (2018). Alcohol and the aging brain.

Substance Abuse and Mental Health Services Administration. (2019). Results from the 2018 National Survey on Drug Use and Health: Detailed Tables.