First Responders:First Responders:

Drug Abuse and Drug Drug Abuse and Drug Misuse Among Older Misuse Among Older

AdultsAdults

Rhode Island Elder Mental Health and Addiction Coalition and

Rhode Island Elderly and Addiction Recovery Taskforce

October 26, 2011

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Officer Sandra Marinucci Officer Sandra Marinucci West Warwick Police West Warwick Police

DepartmentDepartmentElderly Affairs AdvocateElderly Affairs Advocate

Janet Spinelli, RN, PCNSJanet Spinelli, RN, PCNSRI Division of Behavioral RI Division of Behavioral

HealthCareHealthCare

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Why is the Problem Getting Why is the Problem Getting

Worse?Worse?

• 20% of the population is expected to be 65 or older by 2030.

• 66% of men and 65% of women use alcohol (Blazer & Wu, 2009).

• Seventy six % of adults 60 and over use two or more prescription drugs and 37% use five or more (Gu, et al., 2010).

• One in four older adults may use prescription medication with abusive potential (Blow, 2011).1

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Why is the problem getting Why is the problem getting

worse? (cont.)worse? (cont.)• By 2020, non-medical use of prescription drugs

among adults 50 and over will increase dramatically (Simoni-Wastila & Yang, 2006).

• One in five older adults may be affected with difficulties from alcohol and medication misuse (Blow, 2011).1

• Non-medical use of prescription drugs was as common as marijuana use among adults aged 60 or over (NSDUH, 2007-2009).2

• Aging Baby Boomers are predicted to triple marijuana use among persons aged 50 or over between 1999/2001 and 20201(NSDUH, 2007-2009).2

Source: 1Blow, F., 2011. Substance Use Disorders Among Older Adults. Available at: http://www.nattc.org

2Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (September 1, 2011). The National Survey on Drug Use and Health Report. Illicit Drug Use among Older Adults. Rockville, MD.

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Why is the Problem So Serious? Why is the Problem So Serious? • 2006-Overall deaths caused by overdose of

pharmaceuticals has exceeded deaths from traffic accidents. (T. Prough, DEA from CDC June 18, 2010).

• Overdose deaths in RI-9th in US: Average 2-3 per week (T. Green, 2011).

• Older adults present unique challenges; requiring different strategies for problem recognition (NSDUH 2007-2009).

• Education is needed to can change perception of the problem.

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Early Intervention & TreatmentEarly Intervention & Treatment• Early intervention works!

• Early intervention can prevent unintentional drug poisoning.

• Early intervention may improve medical care for the many health conditions associated with drug abuse (NSDUH 2007-2009).

• Treatment can reduce ER visits, hospitalization, institutionalization, overdose, and death associated with illicit drug and pharmaceutical use.

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Police and Fire Police and Fire First ResponderFirst Responder

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How were you dispatched?How were you dispatched?

• Who is the caller?• 911• Lifeline• Concerned family member, friend or

neighbor• What is the nature of the call?

• Medical• Well being check• Self initiated• Wandering

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Common SituationsCommon Situations

• Wandering • Unusual or Risky behaviors• Not making sense• Mood changes• Environmental risk• Falls/Injuries• Requesting help with personal care• Intoxication• Complaints with neighbors

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Potential ImpairmentsPotential Impairments

• Hearing deficit• Visual deficit• Speech deficits• Language issues• Specialized communication needs• Cognitive impairment• Intellectual special needs• Medical issues/Medication reaction issues• Drug and Alcohol intoxication issues

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Initial ContactInitial Contact

• Try to establish rapport and trust.• Respect personal space.• Follow their lead, try not to rush the

situation.• Use slow, even, and low speech.• Avoid talking down to the individual.• Use a “sit and chat” scenarios when

possible.• Do not argue, use listening.

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Recognizing Substance Abuse Recognizing Substance Abuse • Communication

o What difficulties are you having?o What concerns do you have?o How can we help you?

• Can they hold a conversation?o Use short sentences.o Use non-verbal communication.

• Can they talk about current events?

• Look for common signs of drug abuse.

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Responding: Elder’s HomeResponding: Elder’s Home• Look around the home.

o Are there fire hazards? • Are windows or doorways blocked?

o Are there building violations?• Are wires exposed? • Smoke detectors?• Deplorable conditions?

oDog, cat, human feces on the flooroBugs

• Is there food?• When was the last time they ate?• Check the refrigerator

• Is this person able to care for themselves?o If the answer is No, they need to go to the

hospital• Document everything.• Police and Fire: Take photos. 13

Fire &Police First ResponderFire &Police First Responder

and Hospital Collaborationand Hospital Collaboration• If time prevails, respond to the hospital.• Talking to triage:

o Locate the charge nurse, social services and/or the doctor. Give them the history and data on living conditions.

o Report anything of importance.o Be descriptive and give details.o Recognize and report repetitive incidences.o Address discharge planning, if appropriate.

• Consider recidivism and related history.

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Coordination with Social Coordination with Social

ServicesServices• Mandatory Reporting: DEA – fax a copy to them

ASAP 401-462-0545• The Point 211/www.DEA.RI.GOV• ER card• Case management agencies

o West Bay Community Action– West Warwick, Coventry, Warwick, East Greenwich, West Greenwich (401-732-4660)

o Child & Family Services of Newport (401-845-2270)

o East Bay Community Action (401-437-1000)o Tri-Town Community Action

• Southern RI (401-789-3016 x7)• Providence & Northern RI (401-349-5760 x3)

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First Response:First Response:Integration with Integration with

TreatmentTreatment

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How can we Partner to Address How can we Partner to Address

Substance Misuse?Substance Misuse?

•Screen: Scan the Environment•Recognize Signs of Health and Safety Risk•Develop Opportunities to use Motivation, Education, and Other Brief Interventions•Balance Privacy vs. Health Concerns•Refer to Treatment

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Recognizing Common Recognizing Common

ScenariosScenarios

• Elders with Substance Use Issues• Self Neglect• Environmental & Community Safety

Issues• Abusive Caregiver

• Elder Victims of Abuse or Neglect from Substance Abusing Caregivers

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Possible Signs of Drug UsePossible Signs of Drug UsePhysical or Emotional Indicators:• Smell of alcohol or marijuana on clothes• Burned fingers, lips, or needle track marks• Slurs speech, stutters, or incoherent• Dilated or constricted pupils• Tremors of hands or eyelids• Hyperactive or overly energetic• Lethargic or falls asleep easily• Impaired coordination, staggering, off balance• Speaks rapidly or slowly• Mood swings, fearful or anxious• Impatient, agitated, irritable, angry or defiantBehavioral Indicators:• Impulsive or inappropriate• Denies, lies or covers up; breaks or bends rules

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Recognizing Possible Signs Recognizing Possible Signs

(Cont.)(Cont.)Cognitive Indicators:•Difficulty concentrating, focusing, attending to task•Appears distracted or disoriented•Makes inappropriate or unreasonable choices•Difficulty making decisions•Memory loss, or black outs•Makes frequent errors, or needs repeated directions•Difficulty recalling known details•Needs repeated assistance completing ordinary paperworkAdapted from: SAMHSA Tips for First Responders: Possible Alcohol and Substance Abuse Indicators. Publication # NMH05-0212 . Available at www.samhsa.gov

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Signs of Neglect in the Home Signs of Neglect in the Home • Absence of necessities including food, water,

heat • Inadequate living environment evidenced by

lack of utilities, sufficient space, and ventilation

• Animal or insect infestations • Signs of medication mismanagement, including

empty or unmarked bottles or outdated prescriptions

• Housing is unsafe as a result of disrepair, faulty wiring, inadequate sanitation, substandard cleanliness, or architectural barriers

Source: National Committee for the Prevention of Elder Abuse (NCPEA) March 2003.21

Signs of Neglect in the Home Signs of Neglect in the Home

(Cont.)(Cont.)Physical indicators •Poor personal hygiene including soiled clothing, dirty nails and skin, matted or lice infested hair, odors, and the presence of feces or urine •Unclothed, or improperly clothed for weather •Decubiti (bedsores) or skin rashes •Dehydration, evidenced by low urinary output, dry fragile skin, dry sore mouth, apathy, lack of energy, and mental confusion •Worsening dementia

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Signs of Neglect in the Home Signs of Neglect in the Home

(Cont.)(Cont.)Physical Indicators (cont.)•Untreated medical or mental conditions including infections, soiled bandages, and unattended fractures •Absence of needed dentures, eyeglasses, hearing aids, walkers, wheelchairs, braces, or commodes •Exacerbation of chronic diseases despite a care plan

Source: National Committee for the Prevention of Elder Abuse (NCPEA) March 2003.

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Signs of Caregiver Abuse in the Signs of Caregiver Abuse in the

Home Home Indicators for caregiver abuser •Expresses anger, frustration, or exhaustion •Isolates the elder from the outside world, friends, or relatives •Obviously lacks care giving skills •Is unreasonably critical and/or dissatisfied with social and health care providers and changes providers frequently •Refuses to apply for economic aid or services for the elder and resists outside help

Source: National Committee for the Prevention of Elder Abuse (NCPEA) March 2003.

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Signs of AbuseSigns of AbuseIndicators observed in Abuse Victim •Exhibits emotional distress such as crying, depression, or despair •Has nightmares or difficulty sleeping •Has had a sudden loss of appetite that is unrelated to a medical condition •Is confused and disoriented (this may be the result of malnutrition) •Is emotionally numb, withdrawn, or detached •Exhibits regressive behavior •Exhibits self-destructive behavior •Exhibits fear toward the caregiver •Expresses unrealistic expectations about their care

Source: National Committee for the Prevention of Elder Abuse (NCPEA) March 2003.

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Specialized Specialized Interventions Interventions

with with Older AdultsOlder Adults

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Use Specialized TechniquesUse Specialized Techniques• LINK Concerns with Interview Questions.

• Ask DIRECT questions about identified concerns.

• PREFACE questions with link to medical, health or safety concerns.

• Use non-judgmental approach; avoid stigmatizing terms.

Adapted from: F. Blow. (2011) Substance Use Disorders Among Older Adults. Available at: http://www.nattc.org

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Screening leads to TreatmentScreening leads to Treatment

• Ask about what drugs are used?o alcohol, misuse/use of prescription

drugs, marijuana, cocaine, inhalants, hallucinogens, or heroin

• How much? When? o Identify recent intake, binge use,

quantity and frequency• What are the health conditions, functional

issues and risks?o Identify comorbid risks.

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Brief Intervention:Brief Intervention:

Motivation using the 4 “R’s”Motivation using the 4 “R’s”

• Relevance to the Older Adult

• Risks of Continued Use

• Rewards of Quitting

• Repetition at Each Encounter

Source Blow, F. (2011) Substance Use Disorders Among Older Adults. Available at: http://www.nattc.org

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Health Education WorksHealth Education Works• A non judgmental and empathic educational

approach can highlight personal responsibility and capacity for behavior change.

Alcohol Issues:• Alcohol interacts with prescription drugs; and

affects balance, appetite, sleep, nutrition, blood glucose levels, memory, and cognition.

• Health risks: Identify needs vs. adequate supports for medical, behavioral health and/or environmental issues.

• Education on Social Drinking : Choosing drinks with lower alcohol content and mixing with non alcoholic beverages may reduce the risk of dangerous consumption.

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Health Education Works Health Education Works

Prevention of Medication Misuse• Use Only One Pharmacy.• Ask your Health Care Provider or

Pharmacist about potential side effects or drug interactions.

• Have a health care advocate.• Report changes in health status to Health

Care Providers.

Other Specialized StrategiesOther Specialized Strategies• Establish Strength Based Approach for

Consumer Directed Goal Setting.

• Engage in Brief Interventions for Problem Solving, Coping with Losses and Changes in Health Status.

• Support Self Care Management and Skill Development.

• Establish Social Connection; Rebuild Social Supports.

• Promote Meaningful Day Activities.

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ResourcesResources• Rhode Island Council on Alcoholism and Other

Drug Dependence http://www.ricaodd.org/• RI Department of Behavioral Healthcare,

Developmental Disabilities and Hospitals http://www.bhddh.ri.gov/

• Substance Abuse and Mental Health Service Administration (SAMHSA) http://www.samhsa.gov/

• Addiction Technology Transfer Center (ATTC) Network http://www.nattc.org

• Alcohol Screening: The Short Michigan Alcoholism Screening Test- Geriatric Version (SMAST-G); AUDIT-C, CAGE, MAST-Geriatric Version.

• The Drug Abuse Screening Test: DAST 33