Substance Abuse in Older Adults Paper

Public Policy Substance Abuse in Older Adults Policy Issues Susan Gage, BSN, RN-BC; and Karen Devereaux Melillo, PhD, GNP, ANP-C, FAANP, FGSA ABSTRACT By 2020, it is projected that the num- tal health outreach teams in community abuse needs of this population. Edu- ber of older adults needing treatment settings where older adults reside or cating primary care providers, includ- for drug and alcohol addictions will receive social services. Increasing fund- ing gerontological nurses, to recognize increase dramatically. Although Medi- ing to states to emphasize primary care signs of substance abuse in this popu- care covers treatment for mental health provider education on the detection, lation and providing age-appropriate issues, copayments can be prohibitive evaluation, and treatment of substance treatment options is critically important for those with lower incomes. The Posi- abuse problems of older adults has the but will require funding beyond what is tive Aging Act, an amendment to the potential to better meet the substance currently available. Public Health Service Act, is a policy alternative that could address substance abuse in the older adult population by (a) demonstrating ways of integrating mental health services for older adults into primary care settings, and (b) supporting the establishment and maintenance of interdisciplinary geriatric menABOUT THE AUTHORS 8 © 2011 iStockphoto.com/Gamer Ms. Gage is an adult-gerontological nurse practitioner MS student, and Dr. Melillo is Professor and Chair, Department of Nursing, University of Massachusetts Lowell, School of Health and Environment, Lowell, Massachusetts. The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. Address correspondence to Susan Gage, BSN, RN-BC, adult-gerontological nurse practitioner MS student, University of Massachusetts Lowell, School of Health and Environment, 3 Solomont Way, Suite 2, Lowell, MA 01854-5126; e-mail: Susan_Gage@ student.uml.edu. Posted: November 16, 2011 doi:10.3928/00989134-20111104-01 Copyright © SLACK Incorporated S ubstance abuse in the older adult population is a poorly recognized but growing problem in the United States. Very few family members or health care providers are aware of the warning signs (Brennan, Schutte, & Moos, 2005; Moos, Brennan, Schutte, & Moos, 2004; Simoni-Wastila & Yang, 2006). Drug use in older adults is insidious and, if not detected, can cause serious physical, emotional, and financial outcomes. In the current unstable economic climate, funding for mental health issues such as substance abuse may be an enormous challenge. In comparing the original Public Health Service Act of 1944 and most recent amendment, the Affordable Care Act (The White House, 2010), with another proposed amendment, the Positive Aging Act, the intended level of funding for older adult mental health services would allow for strengthening and increasing services currently provided to older adults with substance abuse issues. Funding for grants from the Positive Aging Act that are focused on education of nurses, nurse practitioners, and nurse scientists in the field of geriatrics could increase the number of specially trained providers available to care for those with substance abuse issues (Grady, 2011). POPULATION DEMOGRAPHICS It is widely known that the older adult population is the fastest growing demographic group in the United States, and many human service agencies are scrambling to provide services for this population. Substance Abuse in Older Adults Paper

It is estimated that by 2030, as many as 70 to 75 million people will be older than 65 (U.S. Department of Health and Human Services, 2011). With the first of the Baby Boomers now turning 65, there is expected to be a greater need for mental health services. According to Gossop and Moos (2008): The realities of demographic change and the increasing service needs of ageing substance misusers are placing a financial strain on existing resources. The healthcare costs of older adults’ substance use problems are high and are expected to grow. The increasing number of older adults with substance abuse problems will place new and greater demands on treatment services. (pp. 347-348) By 2020, it is projected that the number of older adults needing treatment for drug and alcohol addictions will almost triple to 4 to 4.5 million, compared with 1.7 million in 2000 (Blank, 2009). Alcohol is one of the most commonly known substances of abuse for older adults, followed by prescription drug misuse and abuse, including medications for pain, sleep, and anxiety. Other drugs of abuse in this age group are marijuana, cocaine and other stimulants, sedative agents, hypnotic drugs, and opioids, such as oxycontin and heroin (Boeri, Sterk, & Elifson, 2008; Henderson, 2008). According to the Substance Abuse and Mental Health Services Administration (SAMHSA), Office of Applied Studies (2010), “Between 1992 and 2008, the proportion of older admissions that reported primary alcohol abuse decreased from 84.6 to 59.9 percent, while the proportion that reported primary heroin abuse more than doubled (from 7.2 to 16.0 percent)” (“In Brief” section). Ruth Grabel, coordinator of the Massachusetts Partnership on Substance Use in Older Adults at the Massachusetts Department of Journal of Gerontological Nursing • Vol. 37, No. 12, 2011 Public Health, shared that in Massachusetts, as well as in the rest of the country, the lack of specialized programs for older adults in some treatment centers is a problem. Although some older adults will do well in a treatment center for adults of all ages, others require a more specialized approach. As adults age, they develop various comorbidities. These are better managed by treatment centers that focus on special needs of older adults. In addition, increasing education for society as a whole, and especially for all providers, on appropriate prevention, diagnosis, and treatment of older adults with substance abuse issues is a priority (R. Grabel, personal communication, June 30, 2011). Treatment access is affected by financial barriers as well. Although Medicare covers treatment for mental health issues, copayments can be prohibitive for those with lower incomes. Many older adults have limited incomes and are unable to self-pay for these services. Copayments for outpatient mental health treatments can be up to 45%, while inpatient treatment requires a deductible amount for each benefit period (Centers for Medicaid & Medicare Services, 2009; Gross, 2008; Hinrichsen, 2010). CURRENT POLICY Public Health Service Act The Public Health Service Act (PHSA) is a federal law signed by President Roosevelt on July 3, 1944. This Act was called “a milestone in the 146 year history of the United States Public Health Service” (“Public Health Service Act, 1944,” p. 468). This Act would be used “to coordinate the many new programs that be- 9 came part of the Public Health Service as a result of the New Deal and World War II” (Snyder, 1994, p. 721). One section of this Act was titled Chapter 35–Programs for Older Americans. The purpose of this Act was to provide comprehensive programs for older adults that included health, education, and supportive services, with priority given to older adults with the greatest economic and social need (U.S. Food & Drug Administration, 2009). In a tight economy where money is scarce for public health issues, it can become a matter of “the squeaky wheel” when allocating funds (Morgan, White, & Wallace, 2011). As well intentioned as the original groups and agencies that provide services for older adults (American Geriatrics Society, 2011; Hindman, 2009; Shnitzler, 2011). It was reintroduced on March 9, 2011, by Sen. Susan Collins (R) of Maine. Cosponsored by Sen. Barbara Mikulski (D) of Maryland, the bill summary reads: Positive Aging Act of 2011– Amends the Public Health Service Act to require the Secretary of Health and Human Services (HHS) to make grants to public and private nonprofit entities to: (1) demonstrate ways of integrating mental health services for older adults into primary care settings, and (2) support the establishment and maintenance of interdisciplinary geriatric mental health outreach teams By 2020, it is projected that the number of older adults needing treatment for drug and alcohol addictions will almost triple to 4 to 4.5 million. © 2011 iStockphoto.com/Orsillo Public Health Service Act was toward the plight of older adults, it is clear that it is time for a change. We need more funding specifically directed at services for older adults. Education of health care professionals in the care of older adults, as well as treatment programs for this population, are both in need of increased funding. Substance Abuse in Older Adults Paper

AN ALTERNATIVE POLICY: AMENDMENT TO THE PHSA Positive Aging Act of 2011 This bipartisan bill, first introduced as the Positive Aging Act of 2002, has been introduced in the House and Senate a dozen times since 2002 with minimal variations in text over the years. This bill has been long supported by the American Psychological Association and other 10 in community settings where older adults reside or receive social services. • Requires the Director of the Center for Mental Health Services to designate a Deputy Director for Older Adult Mental Health Services to develop and implement initiatives to address the mental health needs of older adults. • Includes representatives of older adults or their families and geriatric mental health professionals on the Advisory Council for the center. • Directs the Secretary to give special consideration to providing treatment for older adults with substance abuse disorders when developing program priorities for addressing priority substance abuse treatment needs of regional and national significance. • Requires state plans for community mental health services grants to describe: (1) the state’s outreach to, and services for, older individuals, individuals who are homeless, and individuals living in rural areas; and, (2) how community-based services will be provided to these individuals. (“Bill Summary & Status, 112th Congress (2011 – 2012), S.525: CRS Summary,” 2011) According to Sen. Collins: Older adults are more likely to receive appropriate mental health care if there is a mental health professional on the primary care team, rather than simply referring them to a mental health specialist outside the primary setting. Multiple appointments with multiple providers in multiple settings simply don’t work for older patients who must also cope with concurrent chronic illnesses, mobility problems, and limited transportation problems. The research also shows that there is less stigma associated with psychiatric services when they are integrated into general medical care. (Collins, 2011) The Public Health Service Act was amended in 2010 by the Affordable Care Act that seeks to make health insurance more affordable to all. Access to health insurance improves access to health care services (The White House, 2010). The Positive Aging Act differs in that it aims to divert funding specifically for the benefit of older adults and their caregivers. The goal is to increase funding to provide better mental health care in the primary care setting. COSTS TO THE SYSTEM Financial costs to the system are high for both policies. Trillions of dollars are spent on health care (Holahan, 2010). The Positive Aging Act would seek to lower costs by promoting early intervention, but the outcome remains to be seen. Costs could be higher without the services put into place by these policies because people without health insurance or access to health care are often much sicker when they actually do seek care. Copyright © SLACK Incorporated Quality of care is only somewhat dependent on spending and is institution/individual caregiver dependent. Quality of care specifically aimed at older adults with substance abuse issues would likely increase with the Positive Aging Act. A primary care setting that could promote prevention as well as diagnose and treat patients on site for addiction problems is preferred. This could decrease transportation and scheduling issues for families. Patients and families would develop better relationships with consistent, local primary care providers (PCPs). IMPLICATIONS AND CONCLUSION Both the Positive Aging Act and Affordable Care Act have important implications for gerontological nurses and nurse practitioners. PCPs have not always been skilled at caring for older adults with substance abuse and other mental health issues. Detection of the problem has often been a lengthy, difficult process due to lack of awareness and education. Screening tools have been limited and mostly aimed at detection of alcohol use (Morgan et al., 2011). It has often been difficult to find appropriate, affordable treatment options to refer an older patient. It is important for health care providers to know that older adults who receive substance abuse treatment tend to have better outcomes than for other age groups (SAMHSA, 2005). This is especially true if caught early, putting PCPs in a position to evoke positive change by identifying atrisk individuals and early referral for treatment (Morgan et al., 2011). The Affordable Care Act and the Positive Aging Act of 2011 both emphasize treatment in primary care settings. Substance Abuse in Older Adults Paper

Increased funding could provide specialized education for PCPs, pay for research and development of new screening tools, and allow individual practices to hire onsite mental health professionals to prescribe and recommend treatment options. By changing policy to better meet the needs of the older adult population, steps can be taken toward prevention that could greatly decrease the cost of future substance abuse and other mental health treatment programs. REFERENCES American Geriatrics Society. (2011, March 10). AGS lauds Positive Aging Act of 2011. Retrieved from http://www.americangeriatrics. org/advocacy_public_policy/policy_latest_ news/id:1696 Bill Summary & Status, 112th Congress (20112012), S.525: CRS Summary. (2011). Retrieved from the Library of Congress website: http://thomas.loc.gov/cgi-bin/bdquery/ z?d112:SN00525:@@@D&summ2=m&# Blank, K. (2009). Older adults and substance abuse: New data highlight concerns. SAMHSA News, 17(1). Retrieved from http:// www.samhsa.gov/samhsanewletter/ Volume_17_Number_1/OlderAdults.aspx Boeri, M.W., Sterk, C.E., & Elifson, K.W. (2008). Reconceptualizing early and late onset: A life course analysis of older heroin users. The Gerontologist, 48, 637-645. doi:10.1093/ geront/48.5.637 Brennan, P.L., Schutte, K.K., & Moos, R.H. (2005). Pain and use of alcohol to manage pain: Prevalence and 3-year outcomes among older problem and non-problem drinkers. Addiction, 100, 777-786. Centers for Medicare & Medicaid Services. (2009). Medicare and your mental health benefits. Retrieved from http://www.medicare.gov/publications/pubs/pdf/10184.pdf Collins, S.M. (2011, April 20). Statement of Senator Susan M. Collins: Introduction of Positive Aging Act of 2011 [E-mail]. Sent by Legislative Aide Cyrus E. Cheslak. Gossop, M., & Moos, B. (2008). Substance misuse among older adults: A neglected but treatable problem. Addiction, 103, 347-348. doi:10.1111/j.1360-0443.2007.02096.x Grady, P.A. (2011). Advancing the health of our aging population: A lead role for nursing science. Nursing Outlook, 59, 207-209. doi:10.1016/j.outlook.2011.05.017 Gross, J. (2008, March 6). New generation gap as older addicts seek help. New York Times. Retrieved from http://www. nytimes.com/2008/03/06/us/06abuse.html Henderson, L.A. (2008). Age differences in multiple drug use: National admissions to publicly funded substance abuse treatment. In Substance Abuse and Mental Health Services Administration, Office of Applied Studies, Substance use by older adults: Estimates of future impact on the treatment system (DHHS Publication No. [SMA] 03-3763, Chapter 4). Retrieved from http:// www.oas.samhsa.gov/aging/chap4.htm Hindman, S. (2009). Positive Aging Act returns to Congress. Retrieved from the Silver Planet® website: http://www.silverplanet.com/ Journal of Gerontological Nursing • Vol. 37, No. 12, 2011 health/emotional-mental-health/positiveaging-act-returns-congress/55434 Hinrichsen, G.A. (2010). Public policy and the provision of psychological services to older adults. Professional Psychology: Research and Practice, 41, 97-103. doi:10.1037/ a0018643 Holahan, J. (2010, August). Will health care reform hurt the economy and increase unemployment? Timely Analysis of Immediate Health Policy Issues. Retrieved from the Robert Wood Johnson Foundation website: http://www.rwjf.org/files/research/68888. pdf Moos, R.H, Brennan, P.L., Schutte, K.K., & Moos, B.S. (2004). High-risk alcohol consumption and late-life alcohol use problems. American Journal of Public Health, 94, 1985-1991. Morgan, B.D., White, D.M., & Wallace, A.X. (2011). Substance abuse in older adults. In K.D. Melillo & S.C. Houde (Eds.), Geropsychiatric and mental health nursing (2nd ed., pp. 227-252). Sudbury, MA: Jones & Bartlett. Positive Aging Act of 2011, S. 525, 112d Cong. (2011-2012). Substance Abuse in Older Adults Paper

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