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

3. Interviews With Key Experts

3.1 Selection of Key Experts

A list of key experts was identified in consultation with members of Health Canada ADTR Working Group. Twenty-nine key experts were selected from across the country with representation from each province and the Yukon Territory. Tables 3 and 4 provide the location and the professional role of the interviewed professionals:

Table 3: Geographical Distribution of Key Experts

Yukon	2
British Columbia	6
Alberta	2
Saskatchewan	1
Manitoba	4
Ontario	5
Quebec	1
New Brunswick	2
Nova Scotia	1
Prince Edward Island	1
Newfoundland and Labrador	4

Table 4: Professional Roles of Key Experts

Roles of Key Experts	Number of Key Experts
Frontline workers involved in outreach, counselling, peer advocacy or home care	14
Direct service provision and administration	8
Government positions	4
Academic/Researcher	3

Table 5 provides data related to the diversity of training held by the key expert respondents.

Table 5: Academic Background of Key Experts

Number of key experts who answered this question: 29 * Some key experts indicated multiple fields of training
Academic Background	*Number of Key Expert Responses
Social work	12
Medicine and nursing	10
Psychology	7
Administration	3

3.2 Key Expert Interview Process

Key experts were contacted from each province and territory who had expertise in the area of treatment services for seniors with substance use problems. The interviews were structured and covered a range of treatment and service delivery considerations including:

• theoretical orientation;
• risk factors for substance use;
• areas to be addressed in treating seniors with substance use problems;
• outreach, contact and engagement;
• assessment components;
• barriers to participation in treatment and rehabilitation programs;
• principles that guide treatment processes;
• model program components;
• aftercare; and
• measuring effectiveness.

The data from the key expert interviews were subsequently compiled and analyzed for themes.

3.2.1 Theoretical Orientation

Respondents were asked to identify the most influential programs, clinicians, researchers and literature that have contributed to the advancement of treatment services for seniors with substance use problems. The Community Outreach Program in Addictions (COPA) program in Toronto was repeatedly cited as one of the most influential and recognized services. Many respondents were also aware of Spencer's work in increasing awareness of programs for seniors, and mobilizing resources.

With the exception of McKim & Mishira's work, many respondents noted that there is very little literature that is specific to the field of problem substance use in seniors. Experts noted that the more generalized approaches in substance use treatment have commonly been adapted into this specialized area. Noted examples included Miller & Rollnick's motivational interviewing and Prochaska & DiClemente's model of stages of change which both emphasize client-centred treatment and the tailoring of treatment strategies to the specific need of the client. Other noted researchers included Bowen & Bolby who have written on family dynamics and Roland Atkinson who underscores the need for senior specific approaches.

Both the Community Outreach Program in Addictions (COPA) program and the harm reduction approach were recognized as incorporating the most influential and helpful philosophies for many clinicians including:

• a respectful approach towards seniors;
• using outreach services;
• proceeding at a slower pace when appropriate or necessary; and
• meeting the specific needs of seniors rather than exclusively focussing on substance use or abstinence issues.

3.2.2 Risk Factors for Substance Use

a) Alcohol

Key experts noted that major risk factors associated with problem use of alcohol included:

• experiencing multiple losses;
• loneliness;
• isolation; and
• history of use.

Seniors' experiences of the loss of family or spouse can act as a significant risk factor towards substance use problems. The roles that were assumed by a deceased spouse or family member may no longer be filled, which can impact the senior's care, health, mobility, social activities, and/or financial stability. If multiple losses occur with little time to recover between losses, isolation can increase, leading to loneliness and boredom, which may then exacerbate substance use patterns.

The key experts noted further risk factors including:

• a history of long-term habitual family or personal substance use patterns;
• the removal of external structures, such as work, thereby increasing the time for alcohol use;
• social drinking that is central to networking activities, without which increased isolation would be experienced;
• seniors' inability to metabolize alcohol as easily as their younger counterparts;
• cognitive impairments or dementia that may affect memory of, or disinhibition for, excessive drinking;
• other mental health problems including anxiety, depression, unresolved physical or sexual child abuse; and
• elder abuse or neglect.

Key experts noted that alcohol is attractive to seniors, given that it is socially accepted and easily obtained. Alcohol may also be used to manage chronic pain. Seniors may use alcohol or combine it with medications to alleviate symptoms of other chronic medical conditions. Some may also believe it will help with sleep problems although the evidence is to the contrary.

Table 6: Key Experts: Risk Factors for Problem Alcohol Use

Number of key experts who answered this question: 28
Risk Factors for Problem Alcohol Use	Number of Key Expert Responses
Loneliness/isolation and boredom	23
Multiple or sequential losses	19
Family or personal history	15
Chronic conditions	15
Psychiatric co-morbidity	12
Physiological changes due to aging	8
Ease of access	5

b) Illicit Drugs

Key experts indicated that there is currently not a lot of illicit drug use among seniors. They do expect problems to become more evident as baby boomers age, as they will have had different experiences with such drugs as cocaine, marijuana, heroin, and illicitly purchased prescription medications.

Key experts noted that when illicit drug use is observed in seniors, the drugs may be used for their analgesic or euphoric effects. Key experts noted that seniors may be at increased risk of problem use if they are isolated, bored or lonely. In addition, they are at greater risk if they have a history of previous use or if exposed to others using illicit substances.

Key experts noted that protective factors against problem use of illicit substances include:

• their lack of availability;
• social stigma; and
• provision of adequate pain management services.
  

Table 7: Key Experts: Risk Factors for Illicit Drug Use

Number of key experts who answered this question: 28
Risk Factors for Illicit Drug Use	Number of Key Expert Responses
Not a problem yet	20
Effects of the drugs	7
Boredom/isolation/loneliness	7
Past history of use	4
Exposure to users	3

c) Prescription Medications

Key experts most often attributed problem use of prescription medications to over-prescribing by physicians, coupled with the lack of questioning on the part of seniors. Some seniors may assume that prescription medications are not harmful if their physician has recommended them. Some seniors may expect that because medication is available, it should be prescribed at the first sign of an ailment.

Key experts recommended that physicians receive further training in adjusting dosages to the slower metabolism of seniors and that greater emphasis be placed on reviewing the medication history of seniors. Other factors that impact excessive prescribing of medication by physicians include:

• dependence on the use of medications rather than counselling or other alternative treatment regimens such as diet or exercise;
• treatment of side effects of medications with additional medications; and
• prescriptions that are renewed for longer than is necessary, with an "auto repeat" in place.

Other factors that can contribute to misuse of medication among seniors include:

• seniors may be unaware or misunderstand the intended use of their medications;
• they may not recognize that a generic or over-the-counter drug may be the same as a prescription drug, inadvertently leading to double dosing;
• they may be unaware of interactions between multiple prescription medications or in combination with alcohol;
• low literacy levels and/or vision problems may interfere with compliance;
• some seniors may see multiple physicians and request the same prescription, thereby purposely increasing their dose;
• some seniors may experience a greater accessibility to prescription medications through increased contact with the health care system, a sharing of prescription medications among peers or using their spouse's medications; and
• they may be at increased risk of problem use if they are experiencing physical and/or mental health problems such as pain, insomnia, psychological trauma, grief, anxiety or depression.

Key experts reported that problem use with prescription medications is often observed with the following drugs:

• morphine or codeine-based products;
• anti-anxiety medications such as benzodiazepines;
• sleeping aids including sedatives and tranquillizers; and
• anti-depressants such as the selective serotonin reuptake inhibitors.

Table 8: Key Experts: Risk Factors for Misuse of Prescription Medication

Number of key experts who answered this question: 28
Risk Factors for Misuse of Prescription Medication	Number of Key Expert Responses
Over prescribing by physicians	20
Lack of awareness among seniors	13
Accessibility	12
Ill health	10
Expectations among seniors	7

Table 9: Key Experts: Prescription Medication Most Frequently Misused

Number of key experts who answered this question: 28
Prescription Medication Most Frequently Misused	Number of Key Expert Responses
Opiate and codeine-based products	25
Benzodiazepines	18
Sleep aids	13
Anti-anxiety medications	9
Anti-depressant medications	5

d) Over-the-counter Medications (OTC)

Risk factors identified by key experts for the misuse and/or abuse of over-the-counter medication included:

• a lack of awareness;
• a lack of cautionary mechanisms in place to protect seniors;
• a lack of awareness among seniors of the interactions of OTCs with other medications or alcohol;
• the small font labelling on the boxes, inserts and labels;
• literacy problems that make information inaccessible;
• perception that OTC drugs are safe due to their ease of accessibility;
• advertising or television promotions of OTC medications without issuing cautions;
• reduced ability of seniors to metabolize these medications;
• physicians not asking about OTC use; and
• OTCs used together with the same drug by prescription.

OTCs are at times combined with prescription drugs, either inadvertently due to lack of awareness of the interactions, or purposely to increase the effect of prescription drugs. Sleeping problems and pain are the most commonly self-medicated conditions. Key experts reported that the most common OTCs used by seniors are analgesics, sleep medications, cough and cold remedies, and laxatives.

Table 10: Key Experts: Risk Factors for Misuse of Over-the-counter Medication

Number of key experts who answered this question: 26
Risk Factors for Misuse of Over-the-counter Medication	Number of Key Expert Responses
Lack of awareness of interactions	14
Lack of cautions or protective mechanisms	7
Poor labelling of information	7
Intent to increase the effect of prescriptions	5
Slower metabolism	5
Difficult to track OTC use or identify a problem	4
Ease of availability	3

e) Alternate or Herbal Medications

Key experts reported that much like OTCs, the use of herbal and alternate medications is difficult to track, limiting the possibility of establishing patterns of problem use. Lack of standards and scientific knowledge concerning the active ingredients, dosages, and interaction patterns with prescription medications, also confuses any attempts to gain a perspective on the impact of misuse of alternative medication. Concern was raised among several respondents that seniors might perceive herbal medicines as natural and assume that "natural" is "safe." These concerns also apply to ethnocultural Aboriginal communities that have recourse to traditional medicines.

Table 11: Key Experts: Risk Factors for Misuse of Alternative Medications

Number of key experts who answered this question: 25
Risk Factors for Misuse of Alternative Medications	Number of Key Expert Responses
Difficult to track use	8
Do not know effects	7
Do not know interactions with other substances	7
Natural may be perceived as safe	5

f) Multiple Substances

Problem use of multiple substances can refer to the use of alcohol with prescription medications, and/or combining multiple prescription medications, OTCs, illicit, or alternative medications. Key experts reported that substances are often combined because the senior and/or their doctor may be unaware of the dangers related to certain drug interactions. Physicians may not review or have access to the senior's medication history. Alternatively, the senior may combine drugs to elicit a particular reaction or effect, or to increase the dose. Seniors who are in ill health often have need of multiple prescriptions that even when appropriately taken, may cause problems.

Table 12: Key Experts: Risk Factors for Misuse of Multiple Substances

Number of key experts who answered this question: 28
Risk Factors for Misuse of Multiple Substances	Number of Key Expert Responses
Unaware of interactions	10
Combine to increase effects	3
Ill health	4
Over-prescribing practices	2