Substance Abuse Among Older Adults
Treatment Improvement Protocol (TIP) Series 26

This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.

This publication was written under contract number ADM 270-95-0013. Sandra Clunies, M.S., I.C.A.D.C., served as the CSAT Government project officer. Writers were Paddy Cook, Carolyn Davis, Deborah L. Howard, Phyllis Kimbrough, Anne Nelson, Michelle Paul, Deborah Shuman, Margaret K. Brooks, Esq., Mary Lou Dogoloff, Virginia Vitzthum, and Elizabeth Hayes. Special thanks go to Roland M. Atkinson, M.D.; David Oslin, M.D.; Edith Gomberg, Ph.D.; Kristen Lawton Barry, Ph.D.; Richard E. Finlayson, M.D.; Mary Smolenski, Ed.D., C.R.N.P.; MaryLou Leonard; Annie Thornton; Jack Rhode; Cecil Gross; Niyati Pandya; Mark A. Meschter; and Wendy Carter for their considerable contributions to this document.

The opinions expressed herein are the views of the Consensus Panel members and do not reflect the official position of CSAT, SAMHSA, or the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT, SAMHSA, or DHHS for these opinions or for particular instruments or software that may be described in this document is intended or should be inferred. The guidelines in this document should not be considered substitutes for individualized patient care and treatment decisions.

DHHS Publication No. (SMA) 98-3179
Printed 1998

What Is a TIP?

Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance abuse, provided as a service of the Substance Abuse and Mental Health Service Administration's Center for Substance Abuse Treatment (CSAT). CSAT's Office of Evaluation, Scientific Analysis, and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private substance abuse treatment facilities as alcohol and other drug disorders are increasingly recognized as a major problem.

The TIPs Editorial Editorial Advisory Board, a distinguished group of substance abuse experts and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Other Drug Abuse Directors to generate topics for the TIPs based on the field's current needs for information and guidance.

After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content of the TIP. Then recommendations are communicated to a Consensus Panel composed of non-Federal experts on the topic who have been nominated by their peers. This Panel participates in a series of discussions; the information and recommendations on which they reach consensus form the foundation of the TIP. The members of each Consensus Panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group's collaboration.

A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet on the National Library of Medicine's home page at the URL: http://text.nlm.nih.gov. The move to electronic media also means that the TIPs can be updated more easily so they continue to provide the field with state-of-the-art information.

Although each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front-line" information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there is research to support a particular approach, citations are provided.

This TIP, Substance Abuse Among Older Adults, presents treatment providers with much-needed information about a population that is underdiagnosed and underserved. Substance abuse, particularly of alcohol and prescription drugs, often goes undetected among adults over 60 in part due to societal reasons - older adults tend to be ashamed about drinking or drug problems and see them as a moral failing. Providers, for their part, may confuse symptoms of substance use disorders with age-related changes. Because so much of older adults' substance abuse is never even identified, this TIP is aimed at not only substance abuse treatment providers but also primary care clinicians, social workers, senior center staff, and anyone else who has regular contact with older adults.

The TIP discusses the relationship between aging and substance abuse and offers guidance on identifying, screening, and assessing not only substance abuse but also disorders such as dementia and delirium that can mask or mimic an alcohol or prescription drug problem. Practical accommodations to treatment for older adults and a discussion of how to assess outcomes and treat within a managed care context round out the document.

Other TIPs may be ordered by contacting the National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.Editorial Advisory Board

Editorial Advisory Board

Karen Allen, Ph.D., R.N., C.A.R.N.
President of the National Nurses Society on Addictions
Associate Professor
Department of Psychiatry, Community Health, and Adult Primary Care
University of Maryland
School of Nursing
Baltimore, Maryland

Richard L. Brown, M.D., M.P.H.
Associate Professor
Department of Family Medicine
University of Wisconsin School of Medicine
Madison, Wisconsin

Dorynne Czechowicz, M.D.
Associate Director
Medical/Professional Affairs
Treatment Research Branch
Division of Clinical and Services Research
National Institute on Drug Abuse
Rockville, Maryland

Linda S. Foley, M.A.
Former Director
Project for Addiction Counselor Training
National Association of State Alcohol and Drug Directors
Washington, D.C.

Wayde A. Glover, M.I.S., N.C.A.C. II
Director
Commonwealth Addictions Consultants and Trainers
Richmond, Virginia

Pedro J. Greer, M.D.
Assistant Dean for Homeless Education
University of Miami School of Medicine
Miami, Florida

Thomas W. Hester, M.D.
Former State Director
Substance Abuse Services
Division of Mental Health, Mental Retardation and Substance Abuse
Georgia Department of Human Resources
Atlanta, Georgia

Gil Hill
Director
Office of Substance Abuse
American Psychological Association
Washington, D.C.

Douglas B. Kamerow, M.D., M.P.H.
Director
Office of the Forum for Quality and Effectiveness in Health Care
Agency for Health Care Policy and Research
Rockville, Maryland

Stephen W. Long
Director
Office of Policy Analysis
National Institute on Alcohol Abuse and Alcoholism
Rockville, Maryland

Richard A. Rawson, Ph.D.
Executive Director
Matrix Center
Los Angeles, California

Ellen A. Renz, Ph.D.
Former Vice President of Clinical Systems
MEDCO Behavioral Care Corporation
Kamuela, Hawaii

Richard K. Ries, M.D.
Director and Associate Professor
Outpatient Mental Health Services and Dual Disorder Programs
Harborview Medical Center
Seattle, Washington

Sidney H. Schnoll, M.D., Ph.D.
Chairman
Division of Substance Abuse Medicine
Medical College of Virginia
Richmond, Virginia

Consensus Panel

Chair
Frederic C. Blow, Ph.D.
Assistant Professor and Assistant Research Scientist
Department of Psychiatry
Alcohol Research Center
University of Michigan
Ann Arbor, Michigan

Workgroup Leaders

Roland M. Atkinson, M.D.
Professor
Head of Division of Geriatric Psychiatry
Department of Psychiatry
School of Medicine
Oregon Health Sciences University
Portland, Oregon

James Campbell, M.D., M.S.
Associate Professor
Acting Chairman
Department of Family Medicine
Case Western Reserve University
Medical Director
Senior Health Recovery Resources
Metrohealth Medical Center
Cleveland, Ohio

Anne M. Gurnack, Ph.D.
Professor and Director of Assessment
Department of Political Science
University of Wisconsin at Parkside
Kenosha, Wisconsin

Jeanie L. Holt, R.N.C.
Clinical Staff Nurse
Heritage Home Health and Hospice
Meredith, New Hampshire

David Oslin, M.D.
Assistant Professor
Addiction and Geriatric Psychiatry
Department of Psychiatry
University of Pennsylvania
Philadelphia, Pennsylvania

Gerald D. Shulman, M.A.,
F.A.C.A.T.A.
Consultant
Winter Haven, Florida

Panelists

Charles Bearcomesout
Traditional Coordinator
Traditional Component
Northern Cheyenne Recovery Center
Lame Deer, Montana

Larry W. Dupree, Ph.D.
Professor
Department of Aging and Mental Health
Florida Mental Health Institute
University of South Florida Tampa, Florida

Richard E. Finlayson, M.D.
Consultant in Adult Psychiatry
Former Medical Director of Addiction Services
Department of Psychiatry and Psychology
Mayo Clinic
Associate Professor of Psychiatry
Mayo Medical School
Rochester, Minnesota

Lissy F. Jarvik, M.D., Ph.D.
Distinguished Physician (11L)
Psychiatry Department
West Los Angeles VA Medical Center
Professor Emerita
Department of Psychiatry and Biobehavioral Sciences
University of California-Los Angeles
Los Angeles, California

Hila Richardson, Dr.P.H.
Deputy Director
Medical Research and Practice Policy
National Center on Addiction and Substance Abuse
Columbia University
New York, New York

Marguerite T. Saunders, M.S.
Saunders Consulting Services
Albany, New York

Sharon L. Sheahan, Ph.D., C.F.N.P.
Associate Professor of Nursing
College of Nursing
University of Kentucky
Lexington, Kentucky

Erma Polly Williams, M.R.E. Program Support Specialist
Robert Wood Johnson Medical School
University of Medicine and Dentistry of New Jersey
New Brunswick, New Jersey