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Preventing and reducing alcohol- and other drug-related harm among older people: A practical guide for health and welfare professionals


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This guide was developed to assist specialist and generalist clinicians to assess and respond to the needs of older people experiencing, or at risk of experiencing, alcohol- and other drug-(AOD) related harm. Longer life expectancy, more people living longer, and different expectations of current and future generations of older people will increase service delivery demands.This resource is a practical guide for: • Health workers • Service providers • Policy makers. Alcohol and other drug use patterns and problems among older Australians have been under-researched and are not well understood. It is an emerging area of concern that requires: • Greater resources • Improved understanding • Changes in health service provision and delivery. The term ‘older people’ can be defined in various ways. Here, we generally refer to people aged 55 years and above. For Aboriginal and Torres Strait Islanders, services may also need to target people younger than 55 years. The term ‘older people’ should not be interpreted to mean a single undifferentiated group. Sensitive responses are required to address the needs of the diverse population groups that fall under the broad umbrella heading of ‘older people’. The unique requirements of different age groups need to be addressed. Those aged 55-65, 66-80 and 80+ may have had diverse life experiences and be at very different places in their life’s journey. Similarly, those from different cultural backgrounds may have specific needs, as will Aboriginal and Torres Strait Islanders. The substances addressed in this guide fall into four broad categories: 1. Alcohol 2. Illicit drugs (including cannabis, heroin, amphetamines) 3. Medicines used in opioid substitution therapy (OST) 4. Prescription and over the counter (OTC) drugs. Each drug group is addressed separately, followed by generic principles applicable across all AOD issues. Finally, this resource contains details of the Older Wiser Lifestyles (OWL) Program as an example of an intervention and response approach.
Content may be subject to copyright.
Roger Nicholas
Ann Roche
Nicole Lee
Stephen Bright
Katherine Walsh
A practical guide for
health and welfare professionals
Ageing is not lost youth
but a new stage of
opportunity and strength
Bey Friedan
A practical guide for
health and welfare professionals
Roger Nicholas
Ann Roche
Nicole Lee
Stephen Bright
Katherine Walsh
Nicholas, R., Roche, A., Lee, N., Bright, S., & Walsh, K. (2015). Prevenng and reducing alcohol- and other drug-
related harm among older people: A praccal guide for health and welfare professionals. Naonal Centre for
Educaon and Training on Addicon (NCETA), Flinders University: Adelaide, South Australia.
ISBN: 978-1-876897-60-4
A resource like this cannot be produced without the extensive knowledge and hard work of many individuals. We
would like to gratefully acknowledge Mr Simon Ruth, for his vision and creave persistence in the establishment of
the Older Wiser Lifestyles (OWL) Program at Peninsula Health following his Travelling Fellowship which idened a
signicant service gap in Australia. We would also like to acknowledge the valuable contribuons of the Building
Up Dual Diagnosis Holisc Aged Services (BUDDHAS) working alliance, in parcular Dr Kathleen Ryan and Dr
Kar-Seong Loki. Dellie McKenzie RN and Adam Searby PhD(c) RN dedicated a wealth of experse in their reviews
of this project. A special menon is well deserved for the OWL Program clinicians, past and present, for their
dedicaon and commitment to both the program development and the consumers.
Last but not least, we greatly appreciate and acknowledge the following funding sources that have made the OWL
Program and this resource possible:
Peninsula Health
Victorian Department of Health and Human Services
Australian Government Department of Health
St. John of God Health Care.
The Older Wiser Lifestyles (OWL) Program, Peninsula Health, Victoria
Older Wiser Lifestyles (OWL) is Australia’s rst older adult age-specic alcohol and other drug (AOD) service. It
was established by Peninsula Health in 2009 following the idencaon of a service gap. OWL aims to elevate the
issues in regard to AOD use among older adults and provide leadership in the development and delivery of
evidence-based models of care.
Peninsula Health commissioned the Naonal Centre for Educaon and Training on Addicon (NCETA) to develop
this resource.
The Naonal Centre for Educaon and Training on Addicon (NCETA) is an internaonally recognised research
centre that works as a catalyst for change in the alcohol and other drugs eld. Our mission is to advance the
capacity of organisaons and workers to respond to alcohol- and drug-related problems. Our core business is the
promoon of workforce development (WFD) principles, research and evaluaon of eecve pracces;
invesgang the prevalence and eects of alcohol and other drug use in society; and the development and
evaluaon of prevenon and intervenon programs, policy and resources for workplaces and organisaons.
NCETA is based at Flinders University and is a collaboraon between the University and the Australian
Government Department of Health.
This project formed part of NCETAs program of work funded by the Australian Government Department of Health.
Tania Steenson, from NCETA, is thanked for the desktopping and preparaon of this report.
For further informaon about NCETAs work on alcohol and other drugs and older people visit our website
Part 1: Introducon 1
1.1 Epidemiology 2
1.2 Reasons for alcohol and other drug use 7
1.3 AOD-related preventave measures 8
1.4 Reasons why older people experience alcohol and other drug harm 9
1.5 Physiological changes 9
1.6 ‘Safe’ limits for use of alcohol 10
1.7Harms 11
1.8 The spectrum of use and harms 13
1.9 Early versus late onset problems 15
1.10 Mulple morbidies 15
1.11 Interacons with other medicines 20
1.12 Falls and other injuries 22
1.13 The experience of sgma 23
1.14 Vulnerability to exploitaon 23
1.15 Groups at parcular risk 24
Part 2: Prevenon and treatment 27
2.1 The importance of harm reducon and primary, secondary and terary prevenon eorts 28
2.2 Does treatment work? 32
2.3 Features of successful intervenons 32
2.4 Challenges to accessing help / treatment and responses 36
2.5 Enhancing communicaon with older clients 39
2.6 Primary health care and community services 40
2.7 Assessing readiness to change 44
2.8 Movaonal interviewing 48
2.9 Relapse prevenon and management 50
2.10 The role of AOD specialist services 50
Part 3: The Older Wiser Lifestyles (OWL) Program
Australia’s rst older person-specic AOD program 53
3.1 What is the OWL program? 54
3.2 OWL Early Intervenon (OWL-EI) 56
3.3 OWL Treatment (OWL-TR) 58
3.4 Promoonal and networking acvies and resources 61
3.5 OWL resources 61
3.6 Community awareness 62
3.7 Service sector awareness 62
3.8 Referral pathways 63
References 65
This guide was developed to assist specialist and generalist clinicians to assess and respond to the needs of older
people experiencing, or at risk of experiencing, alcohol- and other drug-(AOD) related harm. Longer life expectancy,
more people living longer, and dierent expectaons of current and future generaons of older people will
increase service delivery demands.
This resource is a praccal guide for:
• Health workers
• Service providers
• Policy makers.
Alcohol and other drug use paerns and problems among older Australians have been under-researched and are
not well understood. It is an emerging area of concern that requires:
• Greater resources
• Improved understanding
• Changes in health service provision and delivery.
The term ‘older people’ can be dened in various ways. Here, we generally refer to people aged 55 years and
above. For Aboriginal and Torres Strait Islanders, services may also need to target people younger than 55 years.
The term ‘older people’ should not be interpreted to mean a single undierenated group. Sensive responses are
required to address the needs of the diverse populaon groups that fall under the broad umbrella heading of ‘older
The unique requirements of dierent age groups need to be addressed. Those aged 55-65, 66-80 and 80+ may
have had diverse life experiences and be at very dierent places in their life’s journey. Similarly, those from
dierent cultural backgrounds may have specic needs, as will Aboriginal and Torres Strait Islanders.
The substances addressed in this guide fall into four broad categories:
1. Alcohol
2. Illicit drugs (including cannabis, heroin, amphetamines)
3. Medicines used in opioid substuon therapy (OST)
4. Prescripon and over the counter (OTC) drugs.
Each drug group is addressed separately, followed by generic principles applicable across all AOD issues. Finally,
this resource contains details of the Older Wiser Lifestyles (OWL) Program as an example of an intervenon and
response approach.
Alcohol- and other drug-(AOD) related harms among older Australians are
Australia’s populaon is ageing and the current cohort of ‘younger older’
Australians (i.e., the ‘baby boomers’ born between 1946 and 1964) use alcohol and
other drugs at higher rates than their predecessors. Consequently, a larger number
of older people will require treatment for substance use problems in the future.
Problemac use of alcohol and illicit drugs is increasing among older Australians, as
is the use of prescribed psychoacve drugs. In addion, opioid substuon clients
are ageing.
Older harmful substance users can be categorised as:
• Maintainers (those whose previously unproblemac use has become
• Reactors (late onset users)
• Survivors (early onset users).
Older Australians are highly heterogeneous and require a range of prevenon and
treatment programs that reect this diversity.
Older people use alcohol and other drugs for similar reasons to the rest of the
populaon, but have physiological, psychological and social characteriscs that
make them more vulnerable to problemac use.
Many older people with substance use problems have physical and mental health
comorbidies and are vulnerable to interacons between prescribed and non-
prescribed substances.
Older Australians parcularly at risk of AOD-related harm include:
• Aboriginal and Torres Strait Islanders
• Culturally and linguiscally diverse people
• Lesbian, gay, bisexual, transgender, queer, and intersex people
• Women
• Injecng drug users.
1.1 Epidemiology
1.1.1 Demographics
Australia’s populaon is ageing, primarily as a result of sustained low ferlity and increasing life
expectancy. The proporon of the populaon aged ≥65 years is projected to increase from 14% in
2014 to 18-20% in 2032 (see Figure 1).
Current projecons suggest that there will be 40,000 people aged over 100 years by 2054-55. This is:
• Almost nine mes the number in 2014-15
• Well over 300 mes the number in 1974-75 (The Treasury, 2015).
In the next 40 years, there will also be substanal reducons in the number of people aged 15 to 64
relave to the number of people aged 65 and over (see Figure 2). By 2054-55, more than 22% of the
Australian populaon will be aged ≥65 years, compared to 15% today (The Treasury, 2015).
Current demographic trends have major implicaons for the future provision of services to older
people with alcohol and other drug problems.
Baby boomers use alcohol and drugs at higher rates than previous generaons, and greater numbers
of older people will experience harm as a result (Han, Gfroerer, & Colliver, 2009; Hunter, Lubman,
& Barra, 2011). Even if the proporon of older adults with AOD problems remained constant, the
increased size of this populaon will produce a dramac growth in the absolute number of older
people with AOD problems (Dowling, Weiss, & Condon, 2008).
65+ 85+
Millions Projection
Figure 1: Historical and projected Australian populaon, 1922–2032
Source: Australian Instute of Health and Welfare, 2013.
In the future
greater proporons of
Australia’s populaon will be
aged over 65 years.
There will also
be fewer younger people
available to care for
older adults.
Figure 2: Number of people aged 15 to 64 relave to the number of
people aged 65 and over
Source: The Treasury, 2015.
1.1.2 Patterns of use Alcohol
Alcohol is the most commonly used drug and causes most AOD-related problems and harms among
older people. Between 2001 and 2013, among 60-69 year olds:
• Short-term risky drinkers1 increased by 31% (12.4% vs 16.3%)
• Lifeme risky drinkers2 increased by 20% (15.5% vs 18.6%) (see Figure 3).
Short-Term Risky Drinkers Lifetime Risky Drinkers
2001 2013
Figure 3: Percentage of Australians aged 60-69 who were short-term and lifeme risky drinkers 2001 and
2013 – Naonal Drug Strategy Household Survey data
Source: Australian Instute of Health and Welfare, 2014a.
1 Short-term risky drinking is dened by NHMRC as the consumpon of more than 4 standard drinks on a single occasion at
least once per month.
2 Lifeme risky drinking is dened by NHMRC as the consumpon of more than 2 standard drinks per day on average.
The data in Figure 3 may be conservave due to under-reporng. Older people also pour alcohol-
ic drinks that are 16-32% larger than a standard drink (10 grams of alcohol). Older men have been
shown to over-pour spirits by 58% (Wilkinson, Allsop, & Chikritzhs, 2011).
Older people also comprise the largest proporon of the populaon who drink on a daily basis (see
Figure 4).
16% 16% 20%
37% 30% 26%
35% 27%
13% 10%
9% 14% 15%
14-24 25-39 40-59 60-69 70+
Age Group
Abstainers 1-3 days p/mth 1-4 days p/wk 5-6 days p/wk Everyday
Figure 4: Frequency of Australian alcohol consumpon by age group 2013
Source: Naonal Centre for Educaon and Training on Addicon (2015a). Secondary analysis of Naonal Drug
Strategy Household Survey data (Australian Instute of Health and Welfare, 2014a).
In sucient quanes, daily drinking can:
• Impair funconality and hand-eye coordinaon
• Cause sleeping dicules
• Elevate cancer risk (especially bowel and breast cancer)
• Contribute to economic hardship and weight gain.
Older Australians (especially women) living in rerement villages appear to drink more frequently
than those living in private homes, but do not necessarily consume larger quanes of alcohol. This
may stem from:
• Greater levels of social engagement in rerement villages, facilitang opportunies to
drink alcohol
• No need to drive home aer social acvies
• Posive normave drinking pracces within rerement village communies (Wilkinson,
Dare, Waters, Allsop, & McHale, 2012).
The type of alcohol people drink also changes over the life span. Older people consume
proporonally more cask, boled and fored wine, and low strength beer (Naonal Centre for
Educaon and Training on Addicon, 2015a).
5 Other drugs (illicits)
In previous generaons, it was rare for an older person to use illicit drugs. Today, a substanal
proporon of older people have previously used some form of illicit drug and some have connued
to do so as they have aged (Beynon, 2009; Han et al., 2009; Wu & Blazer, 2011). Recent illicit drug
use (i.e., last 12 months) among older Australians has also increased over the past decade, in
contrast to other age groups where drug use has declined (see Figure 5).
1419 20-29 30-39 4049 5059 60+
Per cent
Age Group (Years)
2001 2004 2007 2010 2013
Figure 5: Recent illicit use of any drug, people aged 14 or older, by age, 2001 to 2013
Source: Naonal Centre for Educaon and Training on Addicon (2015a). Secondary analysis of Naonal Drug
Strategy Household Survey data (Australian Instute of Health and Welfare, 2014a).
Cannabis is the illicit drug most frequently used by older Australians, with 7.3% of 50-59 year olds
and 1.2% of 60+ year olds having used it in the last 12 months (Australian Instute of Health and
Welfare, 2014a). Opioid substitution therapy (OST)
Australians receiving OST are ageing. From 2006 to 2013 the proporon of OST clients aged <30
years more than halved (from 28% to 11%), while those aged ≥50 more than doubled (from 8% to
19%) (see Figure 6). Contributory factors include:
• Some clients remaining in treatment for several decades
• Pharmacotherapy treatment reducing the risk of premature death
• More clients seeking treatment for the rst me at an older age
(Australian Instute of Health and Welfare, 2014b).
10.6% 11.1%
13.3% 14.1%
2006 2007 2008 2009 2010 2011 2012 2013
Figure 6: Proporon of clients aged ≥50 years receiving opioid pharmacotherapy in Australia on a snapshot
day 2006-2013
Source: Australian Pharmacotherapy Data (Australian Instute of Health and Welfare, 2014b). Prescription and over the counter (OTC) drugs
The use of sleeping and sedave medicaon is highest among Australians aged ≥65 years, and peaks
among those aged 85–89. Those aged 85–89 use these medicaons at a rate ve mes that of
people aged 45–49. Use among women is 1.5 mes greater than among men. Use of
benzodiazepines, especially temazepam, nitrazepam and oxazepam is parcularly high among older
people (Hollingworth & Siskind, 2010).
Use of prescripon opioids also peaks among older Australians. Between 2002-03 and 2007-08
oxycodone prescribing increased substanally, parcularly among those aged 80+ years (see Figure
7). Between 2002 and 2012, fentanyl prescripons also increased dramacally among this age group
(Roxburgh et al., 2013).
Use of strong opioids may increase endocrine and sexual dysfuncon, osteoporosis and hyperalgesia
(Baldini, Von Kor, & Lin, 2012). Long-term, high-level use of OTC opioid-containing medicines can
lead to gastro-intesnal perforaon, clong disorders and liver and kidney problems (related to the
paracetamol and ibuprofen they contain) and codeine dependence (Dobbin, 2008).
A recent study (Veal, Bereznicki, Thompson, & Peterson, 2015) raised concerns regarding the use of
opioids by vulnerable older Australians. The study involved a sample of 20,000 older people who
were either living in the community and deemed at risk for adverse medicaon outcomes or living
full me in an aged care facility.
Issues highlighted in the study included:
• The high prevalence of opioid use (32%), with 22% receiving regular dosages
• Nearly 12% of regular opioid users exceeded maximum recommended dosages
• Over-reliance on opioid analgesics at the expense of non-opioid analgesics
• Concurrent use of sedaves and opioids was commonplace
• Sedave use was most common among those receiving high dose opioids, increasing the
risk of falls and fractures
• Insucient use of laxaves to prevent opioid-related conspaon.
The study concluded that there is a signicant evidence-to-pracce gap regarding the use of opioids
among older Australians (Veal, Bereznicki, Thompson, & Peterson, 2015).
Figure 7: Prescripons for oxycodone dispensed on the Australian Pharmaceucal Benets Scheme from 2002
to 2008, per thousand populaon, by 10-year age groups
Source: Roxburgh, Bruno, Larance, & Burns (2011).
1.2 Reasons for alcohol and other drug use
Older people use alcohol and other drugs for much the same reasons as the rest of the populaon,
• For pleasurable eects and social funcon
• To block out physical pain
• To block out emoonal pain.
Changes in alcohol and drug use as people age can occur for a number of reasons, including:
• Increased free me
• Boredom
• Loss of identy
• Loss and grief
• Loneliness.
Increases in disposable income and buying power of many older people may also facilitate greater
alcohol and drug consumpon and associated problems (Anderson, Scafato, & Galluzzo, 2012).
Evidence regarding the role of rerement on alcohol problems among older adults is variable. There
are many studies which suggest that rerement:
• Increases drinking
• Decreases drinking
• Has no impact on drinking
(Bamberger, 2014).
It is not rerement itself which exclusively impacts paerns of drinking. Rather, drinking is
inuenced by a range of individual, social, and environmental characteriscs that include:
• Whether rerement was voluntary or involuntary
• The person’s gender and health status (e.g., pain or sleep problems)
• A history of problem drinking
• Extent of stressors in rerement (e.g., nancial, marital)
• Whether harmful drinking was part of the former workplace culture or post-work social
• Whether rerement is perceived by the reree as a ‘loss’ or a ‘relief’
• The extent of non-work-related support networks
(Bamberger, 2014; Kuerbis & Sacco, 2012).
There are also more medicaons available now to treat more condions than ever before. Increased
awareness of these medicaons may drive increased use of psychoacve substances as the use of
these substances becomes more normalised. Further, some members of the baby boomer
generaon may hold expectaons of a ‘quick-x’ which may contribute to greater use of medicaons
(Dowling et al., 2008).
Larger numbers of older people are using alcohol and other drugs in conjuncon with prescribed
and OTC medicaons. Some combinaons are contra-indicated and can result in adverse outcomes
(see Table 3, p21). Many such medicaons may not provide informaon about their potenal for
adverse interacons with alcohol.
1.3 AOD-related preventative measures
Australians are living longer and more healthily. A range of measures (such as health screening,
u shots, diabetes control measures, and prevenve medicaons) have averted many premature
deaths. AOD-related preventave measures include:
• Widespread introducon of opioid substuon programs
• Needle and syringe programs
• Enhanced treatments for blood borne and other AOD-related diseases.
However, improved health status and advances in health care can reduce incenves to modify
problemac AOD use (Dowling et al., 2008).
1.4 Reasons why older people experience alcohol and other drug
AOD-related dicules among older Australians may result from:
• Social factors, including:
Rerement (and associated boredom and loss of idenfy)
Increased aordability of AOD
Bereavement (and associated grief, loss and loneliness)
Social isolaon
• Psychological factors, including:
• Physical factors, including:
Chronic painful illness resulng in long-term use of analgesics, alcohol and illicits
Physiological changes leading to dierences in drug eects
Comorbid medical / psychological condions
(DrugScope, 2014).
1.5 Physiological changes
As people age, their ability to metabolise drugs decreases. There is also an ageing-related decrease
in the body’s water to fat rao. A reducon in body water can:
• Increase drug concentraons
• Reduce liver blood ow
• Decrease liver enzyme eciency.
The eects of alcohol or other drugs can therefore be more pronounced and longer-lasng at lower
thresholds. This can increase suscepbility to AOD problems among older people.
Alcohol, for example, may produce a more rapid depressant eect and increased impairment of
motor coordinaon and memory funcon in older people (Royal College of Psychiatrists, 2011). For
a given quanty of alcohol, older people will generally have a higher blood alcohol concentraon
compared to younger people.
Individual dierences in metabolism can be dicult to predict (Kinirons & O'Mahony, 2004) for:
• Alcohol
• Illicit drugs
• OST
• Prescribed and OTC medicines.
Underlying and / or compounding problems may include:
• Anxiety
• Depression
• Post-traumac stress disorder
• Drug-induced psychosis
• Schizophrenia
• Delirium3
• Demena (Royal College of Psychiatrists, 2011).
As people age, the toxic eects of alcohol or drug use and associated diseases (e.g., blood borne
viruses) can compromise the body’s ability to recover from related illnesses.
Older drinkers are more vulnerable to alcohol-related harm than their younger counterparts, even
when drinking at relavely low levels. Older heavy drinkers with health problems are parcularly
vulnerable (Royal College of Psychiatrists, 2011). Older problem drinkers also have more physical
health problems related to their drinking than younger people, even if they drink less and are less
alcohol dependent (Gossop et al., 2007).
Excessive drinking among older people is complicated by a reduced capacity to break down alcohol
and can cause or aggravate medical problems associated with ageing. Because older heavy drinkers
with health problems are at elevated risk, they should be targeted for intervenon (Gossop, 2008).
1.6 ‘Safe’ limits for use of alcohol
There has been lile research on safe, or low risk, limits for older people’s use of alcohol. General
populaon consumpon guidelines may not be suitable, as they were developed from research
conducted with younger populaons. Their applicability to older populaons has not been
Current guidelines (Naonal Health and Medical Health Research Council, 2009) do not indicate a
low risk consumpon level for older people, but state that the lifeme risk of harm from alcohol-
related disease or injury is minimised for healthy men and women when they drink:
no more than two standard drinks
on any one day.
3 Delirium, for example, may be associated with withdrawal from alcohol or benzodiazepines, but can also be the result of
demena, head injury or serious infecon (Royal College of Psychiatrists, 2011).
4 A standard drink in Australia contains 10 grams of alcohol.
The guidelines highlight that drinking alcohol increases the risk of falls and injuries and some chronic
condions, and suggest that older people should drink less than the general recommended
guidelines and that they should consult their health professionals about an appropriate level of
Clinicians should be conservave when advising older paents about low risk use of alcohol, illicit
drug use, opioid substuon therapy medicines, and prescribed and OTC drugs (see Secon 1.11
It is important that advice is tailored to each individual’s
circumstances and risk factors such as:
Concurrent medicaon use
Physical health
Psycho-social context.
1.7 Harms
Changing paerns of alcohol and drug use among older people, as highlighted above, have resulted
in increased harms.
Victorian ambulance data have found an increase in aendances for intoxicaon related to alcohol,
benzodiazepines and pain medicaons for people aged over 65. Alcohol intoxicaon-related
aendances nearly trebled from 3.3 individuals per 10,000 in 2004 to 8.2 per 10,000 in 2008 (Hunter
et al., 2011).
The number and proporon of older people who received publicly funded treatment for alcohol
and other drug problems in Australia also increased over the past decade. Among those aged 60-69
there was a 79% increase in treatment episodes. In 2012/13, there were 4,343 treatment episodes
for 60-69 year olds (2.7% of all episodes) up from 2,419 episodes (1.8% of all episodes) in 2003/04
(see Figure 8).
Figure 8: Total number of publicly funded alcohol and other drug treatment episodes for older Australians
2003/04 to 2012/13
Source: Naonal Centre for Educaon and Training on Addicon (2015b). Secondary analysis of Alcohol and
Other Drug Treatment Services Naonal Minimum Data Set (Australian Instute of Health and Welfare, 2014).
Publicly funded AOD treatment episodes for those aged ≥50 years rose from 9.6% in 2003/04 to
12.1% in 2012/13, an increase of 26% (Naonal Centre for Educaon and Training on Addicon,
0-29 30-39 40-49 50-59 60-69 70+
Age Group
Figure 9: Alcohol-caused hospitalisaons by age group, Australia 2009-2010
Source: Naonal Centre for Educaon and Training on Addicon (2013b). Secondary analysis of Naonal
Hospital Morbidity Database 2009/10 (Australian Instute of Health and Welfare, 2011).
Hospitalisaons caused by alcohol also increase with age and peak among those aged 40-49
(Naonal Centre for Educaon and Training on Addicon, 2013c) (see Figure 9). Falls,
supraventricular cardiac dysrhythmias and alcohol dependence were the major causes of alcohol-
related hospitalisaon among Australians aged 65-74 between 1994-2003 (Chikritzhs & Pascal, 2005)
(see Table 1).
Deaths due to alcohol-aributable diseases peak among 50-69 year olds (see Figure 10). Older
Australians aged 65-74 years living in non-metropolitan areas are more likely to die from alcohol-
aributable condions than city dwellers. Alcoholic liver cirrhosis and haemorrhagic stroke are the
major causes of death among this age group (Chikritzhs & Pascal, 2005) (see Table 1).
Table 1: Causes of alcohol-related deaths and hospitalisaons
Most common causes of alcohol-related death and hospitalisaon
among Australians aged 65-74 between 1994-2003 (Chikritzhs & Pascal, 2005)
Causes of death Causes of hospitalisaons
Alcoholic liver cirrhosis
Haemorrhagic stroke
Supraventricular cardiac
Alcohol dependence
14-39 40-49 50-59 60-69 70+
Age Group
Figure 10: Australian deaths due to alcohol-caused diseases, 2010
Source: Naonal Centre for Educaon and Training on Addicon (2013b). Secondary analysis of 2010 Australian
mortality data (Australian Bureau of Stascs, 2010).
1.8 The spectrum of use and harms
Alcohol and other drug use among older people occurs along a spectrum. At one end of the
spectrum are individuals who do not use any alcohol or drugs. Among those who do use alcohol or
drugs, some people experience unproblemac use while others may develop a range of problems.
Individuals can move backwards and forwards along the spectrum of use (see Figure 11).
Figure 11: The spectrum of alcohol and other drug use and problems
Dierent approaches are needed to prevent and reduce harm at various points on the spectrum.
Educave measures may be appropriate for non-users or non-problemac users to help maintain the
status quo or idenfy emergent problems. Problems related to intoxicaon or regular hazardous use
(see Figure 12) may respond to brief intervenon. Clients who are dependent may require
counselling and withdrawal services.
Issues related to problemac AOD use fall into three groups:
• Intoxicaon
• Regular hazardous use
• Dependence (see Figure 12).
These paerns of problems:
• May be disnct or overlap in the same individual
• Can stem from dierent contributory factors
• Require dierent responses and intervenons.
Intoxication problems
Accidents, Falls,
Medication interactions,
Poisoning, Hangovers,
Risky behaviour
Regular hazardous
use problems
Health harms,
Financial problems
Impaired control,
Figure 12: Dierent types of alcohol and drug problems
1.9 Early versus late onset problems
Older harmful substance users can be categorised as:
• Maintainers
• Reactors (late onset users) (Schonfeld & Dupree, 1991)
• Survivors (early onset users) (Schonfeld & Dupree, 1991).
The maintainer / survivor/ reactor typology parcularly applies to alcohol and prescripon drugs.
The extent to which it also applies to illicit drugs is unclear, as studies to-date have largely
overlooked illicit drug use among older populaons (Wu & Blazer, 2011).
Three factors could potenally facilitate the uptake of illicit drug use among older people:
• The medicalisaon of cannabis for the treatment of pain and other condions (Leung,
2011) may enhance uptake among older people for non-medical purposes
• As a greater proporon of baby boomers used illicit drugs when they were younger
compared with previous cohorts (Han et al., 2009; Wu & Blazer, 2011) they may be more
likely to recommence illicit drug use later in life
• The high level of prescripon opioid (and OTC) use among older people may act as a
pathway to heroin use as has been seen overseas (Dertadian & Maher, 2014; Kolodny
et al., 2015; Lankenau et al., 2012; Mars, Bourgois, Karandinos, Montero, & Ciccarone,
1.10 Multiple morbidities5
Mulple morbidies are common among older people experiencing AOD problems. Health care
advances have averted many substance-related deaths, and more people are surviving into older age
with comorbidies as a result. Ageing is associated with a range of social, psychological and health
problems which can be risk factors for, and / or exacerbated by, substance use. These may also lead
to the development or connuaon of substance use problems to cope with physical or psychologi-
cal pain / distress (Gossop, 2008).
Mulple morbidies can interfere with physical funconing and emoonal, cognive and social
behaviour and result in poorer outcomes. Comorbidies also make assessment and treatment more
dicult (Royal College of Psychiatrists, 2011).
1.10.1 Mental health comorbidities
Mental health / alcohol and other drug comorbidies are common across the Australian community
(see Figure 13). These comorbidies are also common among older people but widely under-
diagnosed (Royal College of Psychiatrists, 2011; Searby, Maude, & McGrath, 2015).
5 At the me of wring, work was currently underway on the development of a manual for clinicians whose clients are aged
55 years and older and have a mental illness and / or use substances. The resource is being developed by Building Up Dual
Diagnosis Holisc Aged Services (BUDDHAS) under the auspices of the Victorian Dual Diagnosis Iniave.
Table 2: A typology of older users
Group Characteriscs Case Illustraon
This group has connued previously
unproblemac use into old age.
Ageing-related changes and comorbidies
aect the body’s ability to absorb,
distribute and excrete alcohol and other
Levels of use that may be relavely
unproblemac in younger years can
become harmful in older age.
Age-related changes in metabolism may
result in AOD harms later in life.
Mrs H is a 66-year-old woman living alone
in a rerement village aer the death of her
husband 6 years ago. On most evenings over
the past forty years she has enjoyed 2 large
glasses of white wine. She exceeded this
amount only on special occasions. Recently
she has had a series of falls aer returning
home from social funcons at the rerement
village at which alcohol was served. Her GP
informs her that her liver enzyme results and
blood pressure are both elevated. It appears
that Mrs H is not able to metabolise alcohol
as well as in the past.
Usually begin problemac drinking in their
50s or 60s.
Can have problems related to intoxicaon,
regular hazardous use or dependence.
Tend to have a stronger associaon with
stressful / adverse life events such as
bereavement, rerement, marital
breakdown and social isolaon.
Tend to have a beer prognosis than
Are less likely to know where to seek help
and be too embarrassed to speak with
their GP
(Royal College of Psychiatrists, 2011).
Mr W, a 73-year-old rered pharmacist, lives
alone in his own house since his wife’s death
3 years ago. He has been experiencing
progressive memory loss over the last 2
years along with deteriorang self-care,
weight loss and several falls. His daughter
is concerned that he is becoming muddled,
parcularly when driving. His daughter said
that Mr W’s drinking has gradually increased
since his wife’s death and he was now
drinking at least half a bole of scotch per
Have a long history of substance use which
persists into older age.
Oen have mulple morbidies.
Make up two thirds of older problem
drinkers in the US (Rigler, 2000).
Are more likely to experience loneliness
and depression as a result of their AOD-
related problems, having alienated
signicant others over a long period of
me (Schonfeld & Dupree, 1994).
May have less self-ecacy than reactors as
a result of mulple aempts at treatment
(Wadd, Lapworth, Sullivan, Forrester, &
Galvani, 2011).
Oen have beer knowledge of the AOD
services that are available.
Mr B is a 74-year-old man living in rented
accommodaon with his wife. He has
mulple chronic alcohol-related physical
problems, which have resulted in many
hospital admissions. He has been drinking
at least two boles of wine per day for
almost 40 years. He lost his job in his late
50s because of his drinking. His wife can no
longer cope with him as a result of his poor
hygiene, threatening behaviour, drink
driving and poor medicaon adherence.
3% 3%
15% 13%
Anxiety disorder
disorder only
Other drug use
disorder only
Anxiety and
Anxiety or
disorder plus
other drug use
No other mental
Type of Disorder
Figure 13: Mental health comorbidies amongst Australians with an alcohol disorder
Source: Naonal Centre for Educaon and Training on Addicon (2013). Secondary analysis of 2007 Naonal
Survey of Mental Health and Wellbeing (Australian Bureau of Stascs, 2009).
Many older people with major alcohol-related problems have a history of depression (Caputo et al.,
2012). Alcohol problems can be 3 to 4 mes more common among depressed compared to non-
depressed older people (Devanand, 2002). The relaonship between alcohol and late life depression
is complex, but depressed older people who stop drinking improve more than those who connue
to drink (Caputo et al., 2012).
One Australian study of males in Geelong reported a U-shaped relaonship between alcohol
consumpon and depression among older people. Depression was most prevalent among non-
drinkers and those drinking ≥3 drinks per day, and lowest among moderate drinkers (Coulson et al.,
Substance use problems can:
• Worsen or precipitate mental health problems, including demena
• Trigger the onset of mental health problems in suscepble individuals
• Be an aempt to self-treat or relieve mental health symptoms
• Lead to general life dicules which can precipitate or worsen mental health problems
(Substance Abuse and Mental Health Services Administraon, 1998).
Comorbid AOD and mental health problems among older people are oen associated with:
• Frequent relapse
• Poor treatment engagement
• Unsasfactory treatment outcomes overall
(Searby et al., 2015).
Other mental health comorbidies among older people with AOD problems include:
• Anxiety
• Confusional states
• Sleep problems
• Post-traumac stress disorder
• Drug-induced psychosis
• Schizophrenia
• Self-harm
• Delirium
(Royal College of Psychiatrists, 2011).
Heavy, prolonged alcohol use may also increase risk of vascular demena and Alzheimer’s disease. In
addion, it can have indirect eects on brain funcon through decreased absorpon of thiamine,
resulng in problems such as Wernicke–Korsako syndrome. Alcohol may also have a direct
neurotoxic eect, producing ‘alcoholic demena’. The management of alcohol misuse in paents
with cognive impairment / demena presents a signicant clinical challenge (Royal College of
Psychiatrists, 2011).
Case study 1: Mental health comorbidies
Eric is a 64-year old ler who had been treated for depression by his GP for six years. His GP
prescribed an andepressant, which he had been taking in increasing doses, but his
depression was worsening. An assessment by a locum GP revealed he was drinking a carton
of full strength beer per day (360 grams or 36 standard drinks) and was alcohol dependent.
Following admission to a detoxicaon facility Eric stopped drinking for ve months and his
mood improved. However he relapsed and began drinking at former levels. He was again
admied to a detoxicaon facility and then engaged with a counsellor as an outpaent.
One year later Eric was sll not drinking, was no longer depressed and was reducing his
andepressant use.
1.10.2 Physical comorbidities
Mulple physical morbidies are largely the norm among older people experiencing severe AOD
problems. The physical complicaons of alcohol use are numerous and manifest in almost all organs
of the body (Crome & Bloor, 2005). Problem alcohol and other drug use can cause and exacerbate
some medical problems.
Interacons between these morbidies can not only interfere with physical funconing and
emoonal, cognive and social behaviour, but can result in poorer treatment adherence and short-
and longer-term outcomes (Royal College of Psychiatrists, 2011).
Common physical comorbidies include:
• Injuries related to falls and trauma
• Cardiovascular problems (e.g., hypertension, heart enlargement, heart rhythm and blood
clong abnormalies, hyperlipidaemia, stroke)
• Liver diseases (e.g., fay liver, brosis, infecve and non-infecve hepas and cirrhosis)
• Blood borne diseases
• Irritable bowel syndrome and inconnence
• Dietary deciencies, diabetes, malnutrion and pancreas
• Overweight and obesity
• Seizures and neuropathy
• Sexual dysfuncon
• Cancers (parcularly mouth, oesophagus, throat, liver and breast)
• Immune system impairments
(Devanand, 2002; Hunter & Lubman, 2010; Royal College of Psychiatrists, 2011; Substance
Abuse and Mental Health Services Administraon, 1998).
Case study 2: Physical and mental health comorbidies
Frank is a 72 year old single man who had been a long-term heavy drinker (>200 grams of
alcohol / day, >20 standard drinks per day) living in unstable accommodaon at a boarding
house. On presentaon to an orthopaedic ward following a fall which badly fractured his arm,
he was found to have very high blood pressure and liver cirrhosis. He was very distrusng of
hospital sta. A subsequent psychiatric review found that he had a severe generalised anxiety
disorder with evidence of signicant cognive decline. A case management meeng was
iniated involving orthopaedic, psychiatric, alcohol and other drug, and social work team
members as well as his GP.
Frank made a full recovery from his fracture and he found accommodaon in an aged care
facility. His ongoing care was coordinated by his GP with assistance from psychiatric and
alcohol and other drug outreach service sta.
1.11 Interactions with other medicines
Many older Australians are regular users of prescripon and OTC medicines. As a result, there is a
risk of adverse interacons with other AOD use.
1.11.1 Interactions with alcohol
Alcohol can interact in harmful and unpredictable ways with many prescribed and OTC medicaons
and some herbal preparaons (see Table 3, p21). Such interacons may:
• Change the eect of the alcohol and / or the medicaon
• Occur at low levels of drinking (as low as one standard drink)
• Vary depending on the medicaons and individual dierences.
Alcohol dampens acvity in the brain (by depressing the central nervous system). When used with
medicaons or other drugs that have similar eects, these aects can be amplied and increase po-
tenal for harm especially if operang machinery or when engaged in other risky acvies.
Older people taking medicaons or other health preparaons:
• Should carefully read the labels and pamphlets with their medicaons (including herbal
preparaons), to check for harmful interacons with alcohol
• Seek advice from a health professional about potenal interacons as some products do
not state this on the label or in the informaon pamphlet. Health care professions should
be encouraged to check MIMS or consult with a pharmacist to ensure full and accurate
advice is provided
• May need to reduce or cease alcohol consumpon
• Need to be very cauous if drinking alcohol while using:
methadone (or other forms of opiate substuon)
analgesic patches
other central nervous system depressants
• Are at greater risk of harmful interacons if taking a number of medicaons
(Australian Government Department of Veterans’ Aairs, n.d.).
Health care providers should:
• Be aware of the possibility of medicaon interacons with alcohol
• Advise the client of possible interacons and eects
• Be parcularly mindful of potenal interacons when prescribing medicaons for mental
health problems, pain and blood pressure.
1.11.2 Interactions with illicit drugs
Illicit drugs can interact with medicines in a range of ways (see Table 4, p22.)
Table 3: Potenal eects of medicines used in combinaon with alcohol (Source: Drug Educaon Network, 2014)
Type of substance Potenal eects in combinaon with alcohol
Andepressants and anpsychocs
Impaired mental skills
Worsening of psychiatric symptoms
Sedaon and impaired breathing
Drop in blood pressure
Liver damage
Anhistamines Drowsiness, sedaon, dizziness
Sedave hypnocs
Decreased motor skills and breathing
Fatal overdose
Nausea, voming, headache
Liver damage
Medicaon to control diabetes
Reduced diabetes control
Medicines that contain alcohol Increased alcohol intake
Increased intoxicaon eects
Heart and circulatory system medicaon
Reduced medicaon eecveness
Ancoagulants Increased risk of bleeding
Decreased medicaon eecveness
Arthris medicaons
Stomach upset including gastrointesnal bleeding
Stomach inammaon
Increased risk of liver damage
Opioid-based pain medicaons
Increased sedaon
Decreased motor skills
An-seizure medicaon Decreased medicaon eecveness
Increased medicine side eects
Table 4: Potenal interacons between illicit drugs and medicines (Dean, 2006; Lindsey, Stewart, & Childress, 2012)
Illicit drug Medicine Potenal resultant interacon
Andepressants Mania, fast heartbeat, delirium
Erecle dysfuncon drugs Heart aack
An-alcohol misuse medicine Hypomania
Anpsychocs Reduced treatment eecveness
Sedave hypnocs, pain medicines Sedaon, central nervous system depression
Anviral drugs Reduced anviral eecveness
Andepressants Severely elevated blood pressure
An-seizure medicaon Increased likelihood of seizures
Blood pressure medicines Reduced treatment eecveness
Anpsychocs Reduced treatment eecveness
Urinary alkalinisers Increased eect and duraon of ATS
Heroin Sedave hypnocs, pain medicines Sedaon, reduced breathing, low blood
pressure, fatal overdose
1.12 Falls and other injuries
Alcohol and other drug use is a major risk factor for falls and injuries. Risk is further exacerbated
when medicines are used concurrently with alcohol or other drugs and in the presence of comorbid
condions, parcularly demena (Mallet, Spinewine, & Huang, 2007; Royal College of Psychiatrists,
It is especially important to consider alcohol and other substance use-related problems among
clients who present with unexplained falls (Royal College of Psychiatrists, 2011).
Alcohol misuse is an important risk factor for falls and fractures as it can cause:
• Confusion
• Low blood pressure on standing up
• Nerve damage
• Reduced coordinaon
• Reduced bone mineral density, parcularly in combinaon with smoking
(Caputo et al., 2012).
1.13 The experience of stigma
The sgma associated with having an alcohol or other drug problem remains one of the strongest
barriers to seeking treatment (Conner & Rosen, 2008). Many older people with alcohol and other
drug problems experience the dual sgmas associated with these problems as well as ageing
(Doukas, 2011; Royal College of Psychiatrists, 2011; Wadd et al., 2011).
Sgma is parcularly felt by older women (Wadd et al., 2011) and people with illicit drug problems,
especially those on pharmacotherapy programs (Doukas, 2011; Kelsall, Parkes, Watson, Madden,
& Byrne, 2011). Older people may also feel sgmased by having to aend tradional alcohol and
other drug services developed for younger people (Wadd et al., 2011).
Reducing the sgma experienced by older people with alcohol and other drug problems will require
improved community and praconer atudes towards this group and greater eorts to reduce the
sense of therapeuc hopelessness and social exclusion they oen experience (Royal College of
Psychiatrists, 2011).
In addion, it will be important to enhance program privacy and accessibility by introducing a
broader range of service opons including home vising (Wadd et al., 2011).
1.14 Vulnerability to exploitation
Older people with alcohol and other drug problems can be at risk of exploitaon as a result of:
• Substance-related disabilies resulng in reliance on others for assistance or care
• The need to rely on strangers for care (somemes as a result of poor family relaonships
or estrangement stemming from long-term substance use problems)
• Substance-related cognive loss reducing their ability to resist or detect coercion and
• Being encouraged or forced to take drugs, or drink excessively, to facilitate exploitaon by
• Being substance dependent and unable to purchase the substances themselves
• Being regularly intoxicated
(Wadd et al., 2011; World Health Organizaon, 2006).
It is important for services providing support for older people with AOD problems to be aware of the
potenal for exploitaon and to promote mul-agency partnerships to prevent this (World Health
Organizaon, 2006).
1.15 Groups at particular risk
Groups of older people who are at parcular risk of experiencing alcohol and other drug harm
1. Aboriginal and Torres Strait Islander peoples
2. People from culturally and linguiscally diverse backgrounds
3. Lesbian, gay, bisexual, transgender queer and intersex people
4. Women
5. Injecng drug users.
1.15.1 Aboriginal and Torres Strait Islanders
Substance use among Aboriginal and Torres Strait Islander peoples can:
• Contribute to physical and psychosocial health problems and disadvantage
• Widen the gap between Indigenous and non-Indigenous Australians’ life expectancy
(Australian Instute of Health and Welfare, 2011b)
• Be understood in the context of a history of dispossession, denial of culture and conict
(Gleadle et al., 2010).
Compared with non-Indigenous Australians, Aboriginal and Torres Strait Islander Australians:
• Have higher rates of tobacco and other drug use
• Are less likely to drink alcohol but are more likely to consume at risky or high risk levels
(Australian Instute of Health and Welfare, 2011a, 2011b).
1.15.2 Culturally and linguistically diverse groups
The needs of older people from culturally and linguiscally diverse (CALD) backgrounds are not well
understood. Prevalence of AOD use in CALD communies is generally lower than the broader
populaon but they are under-represented in treatment services. Reasons for this include:
• Lack of awareness of services
• Language barriers
• Lack of understanding and trust
• Treatment retenon problems stemming from:
unrealisc expectaons of treatment
inappropriate referrals to mulcultural or ethno-specic welfare services that lack
necessary AOD knowledge
(Drug and Alcohol Mulcultural Educaon Centre, 2010).
1.15.3 Lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) people
The prevalence of alcohol and other drug problems among older LGBTQI people has not been well
researched. However, most research concerning lesbian, gay, bisexual and transgender people has
found higher rates of alcohol use disorders, illicit drug use and illicit drug use disorders among these
populaons compared to heterosexual populaons. Factors that may account for higher rates of
alcohol and other drug problems include: sgma; abuse and vicmisaon; strained relaonships
with family and friends; and stresses associated with ‘coming out’. Many of these factors are likely
to be inter-related; for example the process of ‘coming out’ may have implicaons for relaonships
with family and friends (Rier, Mahew-Simmons, & Carragher, 2012). This trend may connue in
older age.
1.15.4 Women
Older women have some unique AOD risk factors. Older women are more likely to:
• Live longer than men
• Live alone
• Lack nancial independence / security
• Have physical risk factors that make them suscepble to the negave eects of AOD (such
as having proporonately more body fat) (Blow & Lawton Barry, 2003)
• Experience anxiety and sleep disorders and be prescribed anxiolyc and hypnoc
medicines (Hollingworth & Siskind, 2010)
• Experience chronic pain (Pain Australia, 2011)
• Not have their AOD problems detected, resulng in lost intervenon opportunies and
accumulaon of harm over me (Blow & Lawton Barry, 2003).
1.15.5 People who inject drugs
People who inject drugs in Australia are ageing. Many did not ancipate or prepare for old age and
rerement (Kelsall et al., 2011). People who inject drugs disproporonately report lower socio-
economic status, limited formal educaon and inadequate housing. These factors contribute to poor
physical and mental health (Kelsall et al., 2011).
Dicules experienced by this group include:
• Health problems
injecon-related vascular problems
blood borne diseases
masking of serious health problems as a result of opioid use
• Sgma and discriminaon (older people who inject drugs are oen vilied and considered
beyond help due to their advanced years and may be judged even more harshly than their
younger counterparts)
• Pharmacotherapy problems
transport dicules
lack of exibility
longer term pharmacotherapy eects
• Involvement in criminality to purchase illicit drugs
• Employment issues (parcularly when juggling pharmacotherapy commitments)
• Social isolaon and family problems (Kelsall et al., 2011).
Ageing and injecng drug use can combine to create a set of unique issues (Kelsall et al., 2011). The
needs of this group will require parcular focus by specialist AOD and generalist services alike.
Older people in treatment for alcohol or other drug problems do not achieve worse
outcomes than younger people and may do slightly beer.
Treatment programs for older people are broadly similar to services provided to
other sectors of the populaon, but may need subtle adaptaons and must take
account of older people’s heterogeneity.
The nature and level of intensity of intervenons needs to be tailored to the
characteriscs of the problems being experienced.
The high prevalence of comorbidies among older people with alcohol or drug
problems requires a range of specic approaches.
As a result of the high prevalence of comorbidies among older people with
alcohol or drug problems, it is important to have sound referral protocols in place.
Challenges to older people accessing help / treatment may stem from:
• The knowledge, skills and atudes of health professionals
• Client characteriscs or beliefs
• Praccal problems of accessibility.
There is a range of strategies which can be implemented to enhance
communicaon with older adults.
Reliable screening tools are available to detect alcohol problems among older
people (AUDIT-C and A-ARPS). No similar tools are available for drugs other than
Screening programs for older people have not been widely implemented in primary
health care and community sengs.
Brief intervenons have great potenal to prevent and reduce alcohol- and other
drug-related harm among older people, but their uptake, parcularly in primary
care sengs, has been poor.
Intervenons need to be based on the person’s readiness to change.
Movaonal interviewing can play an important role in enhancing movaon to
change risky substance-related behaviours.
Alcohol and drug specialist services play important policy, funding, workforce
development and service provision roles in relaon to older people and substance
2.1 The importance of harm reduction and primary, secondary and
tertiary prevention efforts
2.1.1 Harm reduction strategies6
Harm reducon involves strategies that can help an older person avoid harms associated with their
alcohol or other drug use, without necessarily resulng in a reducon in use. The goal is to work
towards less problemac AOD use and involves non-confrontaonal and non-judgmental
approaches which help the person make beer decisions and choices.
Helping clients with the problems that are most salient to them (e.g., insecure housing, poor health)
can be helpful, even if the client feels unable to stop or reduce their AOD use. This approach can
also create opportunies for service providers to establish and maintain relaonships with the older
Harm reducon strategies can be used with a range of problems. There are 6 key steps involved in
harm reducon intervenons.
1. Providing feedback to clients, including:
• A summary of the harms being experienced as a result of their AOD use
• Idenfying the connecon between the presenng problem and AOD use
• Idenfying the manner in which the client’s behaviour is contribung to the harms
they are experiencing
2. Adopt a collaborave approach to idenfy harm reducon strategies by:
• Idenfying previously successful strategies
• Exploring barriers to harm reducon intervenons
• Using movaonal techniques
• Focussing on the behaviours the client wants to change
• Brainstorming together
3. Helping the client to idenfy their harm reducon goals. Goals should be SMART.
• Specic
• Measurable
• Aainable
• Realisc
• Time-limited (short-term)
4. Monitoring the client to see how they are faring in relaon to their harm reducon goals
and reinforcing progress made
5. Reviewing the goals to see if they connue to be appropriate
6. Re-establishing goals if necessary.
6 Secon 2.1.1 draws on Seeking Soluons (2004).
29 Health problems
Compared to younger people, older adults are at greater risk of having their health and
independence jeopardised by their AOD use, and may feel that they are facing an inevitable decline.
Older adults may have also lost contact with former health care providers. Relevant harm reducon
strategies include:
• Helping the older adult connect with health praconers and keep appointments
• Ensuring that the client’s care is coordinated among all the agencies involved
• Assisng with transportaon
• Helping the older adult recognise and understand the connecon between paerns of
AOD use and health problems being experienced
• Ensuring pain management needs are addressed. Safety concerns
Intoxicaon-related safety concerns include falls and re risk (e.g., leaving the stove on, falling
asleep while smoking), drink / drugged driving or blood borne diseases. Harm reducon strategies
• Making arrangements through family, friends, volunteers, or neighbours to check on the
older adult or assist with transport
• Providing a telephone reassurance service for frail older adults through community or
police services
• Ensuring that older people who inject drugs have access to sterile injecon consumables. Medication harms
Harm reducon strategies for medicaon harms centre on educang the older adult about potenal
interacons between alcohol and other drugs and their specic medicaons (including OTC drugs,
and herbal medicines). Other useful strategies include:
• With the permission of the client, ensuring that the prescriber has an accurate picture of
the client’s level of alcohol and other drug use
• Working with the prescriber to ensure that the least harmful medicaons are prescribed. Nutritional problems
Older adults misusing alcohol and other drugs are at a greater risk of malnutrion and consequent
illness. Older adults who eat well, compared to those who do not, experience fewer adverse eects
from their AOD use, even at moderately high levels of AOD consumpon.
Heavy alcohol use can aect an older adult’s appete and nutrient absorpon. Money spent on
alcohol or drugs may also result in having insucient money le for food. Strategies to deal with
harms associated with poor nutrion may include:
• Encouraging the client to eat when drinking
• Arranging for the client to buy groceries before purchasing alcohol
• Providing help with accessing meal programs (e.g., Meals on Wheels)
• Helping with praccal maers that can aect access to proper food (e.g., a broken
• Encouraging aendance at cooking classes for people who live and eat alone to enhance
socialisaon and learning opportunies
• Encouraging vitamin and mineral supplementaon (parcularly Vitamin B1 - thiamine). Isolation
Older adults with alcohol and other drug problems may have very few connecons to their
community, health services, or other social services. Eecve harm reducon strategies for reducing
older adults’ isolaon may include:
• Providing outreach services (i.e., going to the person’s home)
• Facilitang access to support groups and social support networks. Vulnerability to exploitation
Older people with alcohol and drug use problems can be vulnerable to assault, abuse, and
exploitaon by family or others. Strategies to reduce this include:
• Helping the client plan how to avoid risky situaons (e.g., withdrawing less money when
drinking, taking precauons so that others do not see the money)
• Pung safeguards in place (e.g., direct deposit, automac rent payment)
• Informing the client’s bank of the potenal for exploitaon
• Informing relevant authories of instances of exploitaon. Risky sex
For some older adults, alcohol and other drug use can leave them at risk of sexually transmied
diseases, including HIV / AIDS which are increasing among older Australians (Carman, Grierson, Hur-
ley, Pis, & Power, 2009). Harm reducon strategies can include:
• Acknowledging that older adults connue to have sexual feelings and can be sexually
• Providing age-appropriate and non-judgmental informaon specically geared to older
adults about risky sexual behaviour and methods of sexual protecon
• Making condoms easily available in washrooms of health centres, seniors’ centres, and
bars or other places that older adults may visit. Family problems
In some instances, an older adult may be unable or unwilling to change their substance use
behaviour despite the eect it may be having on them or others. In the laer case, the harm
reducon goal may be to reduce harms to family members. Relevant harm reducon strategies can
• Educang family members about alcohol and ageing, especially its eects on memory and
• Helping family members establish appropriate personal boundaries to ensure their safety
• Helping family members develop posive coping strategies and avoid developing AOD
problems in their own lives.
2.1.2 Primary, secondary, and tertiary prevention
Reducing alcohol and other drug harm among older people requires aenon to the three levels of
prevenon. Primary prevention
The goal of primary prevenon is to protect older people from experiencing AOD-related harm. This
• Educaon about low risk levels of consumpon and the risk of adverse interacons with
• Regular screening for risk factors for AOD problems
• Regular screening for the emergence of symptoms of AOD problems
• Informaon to help recognise and respond to the emergence of AOD problems. Secondary prevention
The goal of secondary prevenon is to respond to emerging AOD problems, or risk factors, to pre-
vent the situaon from worsening. Appropriate strategies include:
• Brief intervenons
• Harm reducon measures
• Enhancing access to social and other acvies that do not involve alcohol consumpon. Tertiary prevention
The goal of terary prevenon is to treat and reduce the harm experienced by people with
established alcohol and other drug problems. This includes:
• Detoxicaon programs
• Pharmacotherapy (such as OST and benzodiazepine stabilisaon and reducon programs)
• Long-term counselling.
2.2 Does treatment work?
Older people in treatment for AOD problems do not achieve worse outcomes than younger people
and may do slightly beer (Moy, Crome, Crome, & Fisher, 2011). Reactors tend to do beer than
survivors in treatment (see Table 2, p16). Factors associated with older age which may enhance a
posive prognosis, especially for alcohol problems, include:
• Staying in treatment longer, which older people tend to do
• Having a supporve family / friends
• Being less likely to have family and friends who condone AOD use
(Satre, Mertens, Arean, & Weisner, 2004).
Treatment outcomes for older clients could be improved by:
• More specically designated services for older people
• Intervenons tailored to older individuals’ needs
• Meeng transport and healthcare costs
• Minimising discriminaon and sgma
(Crome, Sidhu, & Crome, 2009).
2.3 Features of successful interventions
2.3.1 Alcohol and other drug problems
Evidence-based AOD prevenon and treatment services for older people:
• Are broadly similar to services provided to other sectors of the populaon
• May need subtle adaptaons of widely used approaches
• Need to take account of older people’s heterogeneity.
Successful intervenons for older clients with AOD problems rely on:
• A client-centred, empathec, non-judgmental and trusng relaonship between client
and praconer
• The client seeing the intervenon as a mutual exercise where the client makes acve
• Clients being supported to develop a sense of responsibility for their AOD use and the
self-condence to believe they can change
• Thorough assessment with a view to:
building rapport
gathering informaon to guide treatment planning
providing clients with feedback to help develop alternave responses
personalising the health eects of their AOD use
monitoring progress
• Tailoring intervenon intensity and duraon to the client’s degree of dependence or AOD
harm (see Table 5 and Figure 14).
Table 5: Tailoring the intervenon to paerns of AOD harm experienced by older people
(Babor & Higgins-Biddle, 2001; Heather, 2003).
Type of behaviour / problem Intervenon / response
No use / unproblemac use Prevenon acvies, informaon about parcular AOD-related
risks and strategies to adopt if use becomes problemac
Risky or hazardous use Brief intervenons, discussion of harm reducon measures,
medical assessment
Harmful use / dependence Intensive treatment, counselling, detoxicaon, maintenance
therapy, relapse prevenon
As alcohol and other drug problems become more severe, more intensive intervenons are
required. These range from low intensity prevenon intervenons for those who are not using AOD
problemacally, through to high intensity intervenons for harmful users or those who are
dependent (see Figure 14).
Intensity of Intervention
No Use Unproblematic
Risky Use Harmful Use
Figure 14: The intensity and level of intervenon necessary for dierent paerns of use
2.3.2 Responses to comorbidity
Outcomes for older adults with comorbid substance use and physical / mental health problems are
improved when their problems are approached in a holisc and coordinated way.
In relaon to mental health comorbidies, there are a number of factors that may act as barriers to
alcohol and other drug and mental health agencies rounely screening, assessing and treang these
co-occurring disorders. Potenal barriers to roune screening, assessment, and treatment of
comorbid condions, and possible strategies to address them are idened in Table 6 (Croton,
Table 6: Barriers and strategies to address roune screening, assessment, and treatment of comorbid condions
(Source: Croton, 2007)
Barriers Strategies
Lack of awareness of:
• prevalence and harms associated with
co-occurring disorders
• likely interacons between disorders
• treatment implicaons.
Provide this informaon in mulple formats, for example:
• training sessions
• sta orientaon procedures and manuals
• client and carer educaon packages.
Enhance the capacity of agencies to record the results of
their clients’ dual diagnoses screening.
Percepon of added work, especially when
clinicians may feel overwhelmed by mulple
demands, stresses and paperwork, or are
change-weary and change-wary.
Promote the view that the goal is more eecve, rather than
added, work – that recognising and addressing co-occurring
disorders is likely to lead to more successful treatment of
target disorders.
When introducing a new screening or assessment form, take
the opportunity to review and simplify exisng assessment
forms and processes and remove some of the exisng
paperwork burden.
Lack of familiarity with using screening tools
and diculty integrang their use into
roune pracce. Clinician concerns that
client engagement may be compromised by
formal screening for a disorder that the client
hasn’t presented for help with.
Provide informaon about the raonale for screening and
Provide training, modelling and clinical supervision around
seamlessly integrang screening into roune pracce.
Include careful explanaon to clients of the raonale for and
condenality of screening.
Clinicians may lack skills, knowledge and
condence in their ability to provide
appropriate treatment for a co-occurring
disorder and be reluctant to ask quesons of
the client that would lead to the
idencaon of that disorder.
Provide educaon, training and realisc evidence for
opmism about eecveness of treatment.
Address clinician ‘self-ecacy’ about providing eecve
Lack of clarity about scope of pracce
(e.g., some AOD workers may have anxiety
about whether it is within their scope of
pracce to conduct a detailed risk
Clarify explicit scope of pracce guidelines and treatment
Promote tools which contain an integrated risk assessment
(e.g., PsyCheck).
Table 6 cont. on next page
Barriers Strategies
Implicaon of current ‘wrong pracce’.
Reframe the development of integrated screening,
assessment and treatment as an evoluonary step towards
more eecve treatment approaches.
Need for changes to pracce, language,
beliefs, values, and client exclusion criteria.
Use policy to reinforce that addressing co-occurring
disorders is core business for both mental health and AOD
treatment agencies.
Sgma of client group – two relapsing, highly
sgmased disorders in the one individual.
The clinician’s own cognive dissonance
(e.g., to address my client’s substance use or
mental health issue, it is necessary (at some
level) to examine my own substance use or
mental health issues).
History of own substance-related or mental
health-related trauma.
Encourage treatment providers to idenfy their own
atudes and feelings evoked by dealing with the disorder.
Provide integrated treatment-oriented clinical supervision.
Lack of knowledge of the ‘opposite’
treatment system, its strengths, dierences
and constraints on service.
Provide opportunies to understand and maximise formal
and informal contacts through:
• Rotaons and placements with collaborave services
• Joint training
• Roune provision of service from other agencies
• Worker-developed protocols
• Co-locaon
• Scheduled, regular interagency managerial and
clinician meengs.
Other comorbidity response opons include:
• Adopng a ‘no wrong door approach’ in which older people can get help for a range of
problems regardless of the service inially contacted
• Ensuring the health and welfare workforce has essenal knowledge and skills about AOD
problems, ageing and mulple morbidies
• Enhancing inter-professional pracce
• Improving primary care, ageing and specialist drug service coordinaon
• Using specialist drug workers in consultaon, liaison and educaon roles with other
• Ensuring funding arrangements support services for older people with mulple and
complex needs
• Developing maps of local service referral pathways
• Encouraging consistent approaches to screening, assessment, clinical notes, referral, care
coordinaon, case management, client informaon, data sharing and training between
(Nicholas & Roche, 2014).
Table 6 cont.
Table 7 cont. on next page
Table 7: Challenges and strategies for accessing help / treatment and responses
Challenges Aects
Service Responses
Awareness and Atudes
Aribute problems to ageing, or
concurrent illnesses, rather than
AOD-related causes
 
Recognise older people with substance misuse
problems are not a homogenous group
Provide services and treatment which are relevant
and responsive to individual needs
Educaon for healthcare professionals
Lack awareness that AOD
problems aect older people  
Develop policies and pracces which raise awareness
of AOD problems in older populaons and challenge
tradional percepons / atudes towards old
people and AOD use
Believe it is too late to change  
Believe it is wrong to ‘deprive’
older people of their ‘last
pleasure in life’
 
Be reluctant to ask quesons due
to embarrassment Ensure there are sta members who are interested,
experienced and competent in working with older
Universal screening
Lack condence to intervene
2.4 Challenges to accessing help / treatment and responses
There is an ongoing need for workforce development approaches to ensure that praconers fully
understand the parcular needs of older people with AOD problems, and are supported to meet
them (DrugScope, 2014). Some of these challenges and potenal are outlined in Table 7.
Table 7 cont.
Challenges Aects
Service Responses
Awareness and Atudes
Be reluctant to ask for help or
disclose problems because they
• they shouldn’t need
• embarrassed about
having these problems at
an older age
• reluctant to re-engage
with services if they think
that they have ‘failed’
Develop a culture of respect for older clients
Oer opons of one-to-one counselling and group
Maintain privacy and condenality
Diagnosc Tools
Lack the ability to idenfy signs
and symptoms of AOD problems
in older people
Take a broad, holisc approach that emphasises
age-specic psychological, social and health
Rely on self-diagnosis and / or
inadequate diagnosc tools  
Ensure that services have age-specic diagnosc
tools that are appropriate for clients who may have
cognive impairment
Have cognive problems, such as
substance-induced amnesia or
underlying demena
Access, Equity, and Quality
Transport or mobility problems
(parcularly in communies
lacking public transport)
Ensure equity of access (i.e., services for older
people are given the same priority as other groups
and are physically accessible to older people)
Create outreach services
Involve interpreters and other communicaon aids
where possible
Explain issues in understandable terms
Hearing or language dicules
Table 7 cont. on next page
Challenges Aects
Service Responses
Access, Equity, and Quality
Limited me availability
(e.g., having to care for a spouse,
relave, friend or grandchild; key
performance indicators,
 
Plan and develop exible and adaptable services in
consultaon with consumers
Priorise the treatment of alcohol and other drug
problems as part of a broad, holisc treatment
Mixed aged services (some older
people may nd younger clients
hecc, chaoc or inmidang)
Oer age-specic, supporve, non-confrontaonal
programs that:
• aim to build or rebuild the client’s self-esteem
• focus on coping with depression, loneliness
and loss (e.g., death of a spouse, rerement)
and rebuilding the client’s social support
Not knowing where to refer / turn
for help  
Create linkages with medical services, aged services
and other sengs for referral into and out of treat-
ment, case management, and community support
Colluding family members  
Reversal of the parent-child
dynamic7 
Want to connue using
Sources: DrugScope (2014); Fry (2007); Schonfeld & Dupree (1995); Substance Abuse and Mental Health Services
Administraon (1998); Dowling et al. (2008); Wadd et al. (2011); Royal College of Psychiatrists (2011).
Table 7 cont.
7 This occurs when the adult child sacrices his or her own needs in order to accommodate and care for the logiscal or
emoonal needs of the aged parent when taking on caring roles. They may forego a range of experiences and may develop
a range of emoonal problems.
2.5 Enhancing communication with older clients
Enhancing communicaon with older clients with alcohol and other drug problems draws on skills
which clinicians regularly apply when interacng with older people. These include:
1. Recognising risks of stereotyping older clients which can lead to inappropriate and
demeaning interacons
2. Avoiding overly simple or patronising language (e.g., terms such as “honey” or
3. Asking the client how he or she would like to be addressed and introduced to others
4. Using surnames and formal terms of address unl given permission to do otherwise
5. Maintaining eye contact, rather than focusing on other things (e.g., client notes or a
computer screen)
6. Avoiding looking or sounding impaent
7. Ensuring the environment is quiet and uncluered
8. Facing older adults when speaking with them, with your face at the same level as theirs
9. Paying close aenon to sentence structure when conveying crical informaon
10. Pung individual pieces of informaon into separate sentences and using direct,
concrete, aconable language
11. Using visual aids to clarify and reinforce key points
12. Asking open-ended quesons (e.g., “Tell me about how….”)
13. When others are present, including the older client in the conversaon and avoiding
referring to the client in the third person
14. Sharing decision making and providing complete and imparal informaon about the
pros and cons of each intervenon opon
15. Outlining the issues that need to be discussed with the client and presenng them one
at a me
16. Checking that the client understands what is being said
17. Cauously using humour and direct communicaon styles with older clients from
culturally and linguiscally diverse backgrounds, as this may be seen as condescending
and disrespecul
18. Respecng the client’s privacy and personal space and ensuring the security of the
client’s possessions
19. Using shorter, informal sessions rather than longer sessions
20. Respecng the client’s spiritual concerns and desire to discuss meaning and purpose in
Sources: Substance Abuse and Mental Health Services Administraon (1998); The Gerontological
Society of America (2012).
2.6 Primary health care and community services
Many primary health care and welfare agencies are well placed to provide support and intervenon
for older people, including screening, prevenon, harm minimisaon and early intervenon
(Naonal Centre for Educaon and Training on Addicon Consorum, 2004). The general pracce
seng is parcularly important in this regard.
2.6.1 Screening
Screening programs for older people have not been widely implemented in primary health care and
welfare sengs. This is largely a result of a lack of tools to cater for the unique and oen complex
needs of older people (Bright, Fink, Beck, Gabriel, & Singh, 2013).
Aer the age of 60 every adult should be screened for AOD problems as part of their regular physical
examinaon. Screening, or rescreening, should also occur if the symptoms listed in Table 8 are
present or if the older person is undergoing major life changes or transions.
Table 8: Triggers for screening older people for alcohol and drug problems
Source: Substance Abuse and Mental Health Services Administraon (1998).
Triggers to Screen for AOD Problems
Sleep complaints; observable changes in sleeping paerns; unusual fague, malaise, or dayme drowsiness
Apparent sedaon
Cognive impairment, memory or concentraon disturbances, disorientaon or confusion
Seizures, malnutrion, muscle wasng
Liver funcon abnormalies
Persistent irritability (without obvious cause) and altered mood, depression, or anxiety
Unexplained complaints about chronic pain or other somac complaints
Inconnence, diculty urinang
Poor hygiene and self-neglect
Unusual restlessness and agitaon
Complaints of blurred vision or dry mouth
Unexplained nausea and voming or gastrointesnal distress
Changes in eang habits
Slurred speech
Tremor, motor incoordinaon, shuing gait
Frequent falls and unexplained bruising
AUDIT-C is a 3 item alcohol screening tool that can help idenfy persons who are hazardous drinkers
or have acve alcohol problems. It is a modied version of the 10 queson AUDIT instrument and
can accurately detect alcohol problems among older people if cut o points are tailored to this age
group (Aalto, Alho, Halme, & Seppä, 2011).
While AUDIT-C is an accurate tool to detect alcohol problems it does not detect:
• Other drug problems
• Use of other medicines
• Other comorbidies.
The Australian Alcohol-Related Problems Survey (A-ARPS) is an age-specic 10 minute pencil and
paper or online screening and educaon tool that reliably idenes hazardous and harmful paerns
of alcohol use among older people (Bright, 2011). It takes into account the client’s:
• Quanty and frequency of alcohol consumpon
• Age and gender
• Medical history
• Medicaon use
• Symptoms
• Funconal status
• Binge drinking and drink-driving risks
• Risk of mixing alcohol with medicaon (Bright et al., 2013).
A-ARPS helps clinicians idenfy if a client’s medicaons or health condions could be aected by the
amount of alcohol they drink (Bright et al., 2013). A-ARPS is discussed more fully in Part 3.
Laboratory tesng can also be helpful in detecng alcohol problems among older people. In
parcular, mean corpuscular volume (MCV) and liver funcon tests such as gamma-glutamyl-
transpepdase (GGT) are sensive markers to detect alcohol misuse among older populaons
(Caputo et al., 2012).
To-date no equivalent screening process has been developed for older people’s use of drugs other
than alcohol. Screening tools such as the Alcohol, Smoking and Substance Involvement Screening
Test (ASSIST) may be of assistance but have not been validated in older populaons. There are a
number of characteriscs of the ASSIST tool which may render it insuciently sensive to detect
alcohol and other drug problems among older people.
For example, in assessing the impact of AOD use on fullling usual roles, the scoring of ASSIST may
not take into consideraon role changes that are associated with ageing. Equally, assessing the
extent to which others have expressed concern about the older person’s AOD use may not take into
consideraon social isolaon which may limit the ability of others to express this concern.
Nevertheless, research is underway to determine if ASSIST can be adapted to be more sensive to
detecng AOD problems among older people.
2.6.2 Brief interventions
Brief intervenons involve screening, assessment and feedback to prevent and reduce risky AOD
consumpon (Haber, Lintzeris, Proude, & Lopatko, 2009). They range from ve minutes of advice
in the primary care seng (‘minimal intervenon’) to 5-6 sessions of counselling, more suitable for
AOD specialist sengs (‘brief therapy’).
Brief intervenons in primary care:
• Are cost-eecve
• Can be delivered in a me-limited way
• Involve one or more sessions of between 5 and 30 minutes
• Usually involve movaonal interviewing counselling techniques (see below)
• Can be oered to people who have not sought treatment or assistance but have been
idened through roune screening as risky users
• Inform people that they may be at risk of harm and encourage strategies to reduce risk
(Anderson, Chisholm, & Fuhr, 2009; Haber et al., 2009; O'Donnell et al., 2014).
Six common elements of brief intervenons delivered in primary care sengs have been idened
with the acronym FRAMES (Miller & Sanchez, 1994).
Provide feedback about the risks associated with AOD use
Emphasise the client’s personal responsibility and choice to
reduce AOD use
Provide explicit verbal or wrien advice to the client about
changing hazardous AOD behaviour
Provide the client with a Menu of alternave strategies and
self-help opons to help nd an approach that is appropriate
for them
An empathic, warm and reecve approach adopted by the
Reinforce and enhance the client’s belief in their ability to
complete tasks and reach goals
Despite its potenal, the uptake of AOD brief intervenons in primary care sengs has been poor
(Roche & Freeman, 2004; Swan, Sciacchitano, & Berends, 2008).
2.6.3 Referral
While successful intervenons can occur in primary health and welfare sengs, somemes referral
is necessary. A low threshold for referral for comprehensive medical assessment for older people
experiencing AOD harm is needed, due to:
• Ageing-related physiological changes which make them vulnerable to medical condions
• Increased likelihood of health problems as a result of longer exposure to AOD
• The risk of withdrawal syndromes if use is ceased or abruptly reduced (parcularly
alcohol, prescripon drugs such as benzodiazepines or opioids).
Clients may need referral to specialist agencies if they require:
• Management of intoxicaon, detoxicaon or withdrawal
• Pain management
• Pharmacotherapy treatments
• In-depth counselling
• Treatment of complex psychiatric or other comorbidies
• Follow up or review
(Naonal Centre for Educaon and Training on Addicon Consorum, 2004).
Once medical / specialist assessment has occurred, the client’s AOD issues may be able to be
addressed in non-medical sengs. On-going inter-agency case management may be needed.
In many parts of Australia there are few opons available to refer clients to services such as
detoxicaon and rehabilitaon which are established specically to cater for the needs of older
people. Consequently, older clients may be required to use services which include younger people,
whom older people may regard as ‘hecc’, or ‘chaoc’, or inmidang (Wadd et al., 2011). The
idencaon of referral services should be undertaken in consultaon with the client and formalised
in a referral leer (Carmichael, 2001).
Referral leers should contain:
• Client detail: name, age and date of birth, address and contact details, and signed consent
• Current issues: reasons for presenng at the service being referred from
• Service requested from agency
• Requests for any feedback or follow-up and how this should be arranged
• Details of ongoing services that will be provided by referring worker or their agency.
Referral guidelines can be extremely useful if developed collaboravely among agencies involved in
client referrals. Guidelines should:
• Be developed by those who have to implement them
• Cover all types of appropriate referral, the process of informaon exchange and feedback
• Serve as the basis for client-centred shared care and cover the roles and responsibilies of
(Carmichael, 2001).
2.7 Assessing readiness to change
Many contemporary approaches to helping older clients with AOD problems are underpinned by the
Trans-Theorecal Model (TTM) of behaviour change (Prochaska, 1991; Prochaska, DiClemente, &
Norcross, 1992). This approach suggests that people using AOD in risky or harmful ways are in one of
ve stages of change (SOC). Intervenons are geared to their SOC.
A descripon of the ve stages of change (adapted from Jarvis, Tebbu, & Mack, 1998) appears
Stage 1: Pre-contemplaon
Those in the pre-contemplaon SOC lack recognion of the risky or harmful nature of their AOD use
and have no intenon of changing their behaviour.
Case study 3: Pre-contemplaon
Daryl is a 67-year-old truck driver who presented to his GP aer his wife Sarah “told him to
go and get his dope problem sorted out”. Daryl’s heavy, almost daily, use of cannabis dates
back to his early 20s. He has recently tested posive for cannabis on two occasions at
random drug tesng staons (RDTS) while driving a car and is at risk of losing his truck licence
and livelihood. He is also spending $150 per week on cannabis, which is pung a strain
on household nances. He believes that he was just unlucky to get caught at the RDTS and
doesn’t want to reduce his cannabis use. He said:
“Everyone does it, it’s never done me any harm, I enjoy it. Sarah needs to lighten
His GP explored some of the posive and not so posive eects of his cannabis use (see
movaonal interviewing below). She also advised him to avoid breath-holding or deep
inhalaon to reduce the harm from smoking and gave him some resources to use if he
wanted to stop or reduce his cannabis use in the future.
Stage 2: Contemplaon
In the contemplaon stage individuals begin to recognise the negave consequences of their AOD
use, but do not change it. People in this stage are ambivalent about change and may feel trapped
but don’t act.
Case study 4: Contemplaon
Carol, a 58-year-old rered physiotherapist, began drinking heavily two years ago aer the
sudden death of her husband. She aended a hospital emergency department with
abdominal pain which was diagnosed as alcoholic gastris. She was drinking a bole and a
half of red wine per day. She said:
“I know it’s not good for me and I should stop, but I enjoy it. I like a wine in front
of the telly in the evening”.
Carol was referred to the hospital drug and alcohol worker. He explored Carol’s ambivalent
feelings and beliefs about her drinking. He also informed her that tests showed that her liver
was being damaged and that her blood test results were more elevated than 95% of the
Stage 3: Preparaon
Clients in the third SOC, the preparaon stage, are commied to changing their behaviour and may
have already made a previous aempt to do so. At this point clients believe that the negave conse-
quences of AOD use outweigh the benets.
Case study 4 (cont.): Preparaon
The diagnosis of alcoholic gastris had come as a shock to Carol and had pped the balance
about how she saw the pros and cons of her drinking. When she got home from the hospital
she made an appointment with her GP for 10 days later to discuss the issue. Four days aer
returning home she started drinking again, although not quite at the same level as before.
She had felt much beer when she was not drinking and was concerned that her gastris
would return. She said:
“I’d like some help with cung back on the booze”.
Her GP helped Carol to work out what her goals were. They used the SMART acronym to help
with the development of her goals. The goals were:
ÂTime-limited (short-term).
Carol decided that she wanted to have no more than 2 small glasses of wine per day with one
alcohol-free day per week for the next 3 months.
Stage 4: Acon
During the Acon stage the client implements measures to reduce or stop AOD use.
Case study 4 (cont.): Acon
Carol’s GP gave her some wrien materials with hints about keeping track of, and reducing, her alcohol
intake. Her GP gave her a chart to monitor her drinking in standard drinks. She decided to do a number
of things:
ÂKeep track of how much she was drinking at night
ÂAlternate alcoholic drinks with non-alcoholic ones
ÂCatch up with her friends in the evening, rather than staying home alone
ÂDilute her wine with sparkling mineral water
ÂOer to be the designated driver whenever she went out with her friends
ÂDevelop strategies to get herself back on track if she started drinking heavily again
ÂTake 100mg of Vitamin B1 (thiamine).
Stage 5: Maintenance
At this stage the client has changed their AOD use and is sustaining that change. During this stage a
large number of clients will relapse and return to an earlier stage of change.
Case study 4 (cont.): Maintenance
Carol connued to see her GP fortnightly. Aer three months, Carol and her GP did a ‘stocktake’ of
how things were going. Overall, Carol had kept to her plan for most weeks. Christmas and New Year
occurred during this period and she didn’t sck strictly to her plan over that me. On the other hand,
on some weeks Carol had two or three alcohol free days per week. She felt like she had more energy,
her sleep had improved and she had no symptoms of gastris. Her GP informed her that her blood
tests had almost returned to normal.
Carol and her GP developed some more strategies to prevent and manage relapse. These included:
ÂMonthly follow-up visits with the GP
ÂAvoiding being at home alone each night of the week
ÂSpending the money she had previously spent on alcohol on treats for herself.
Clients may progress sequenally through these stages, however this is the excepon rather than
the rule. They may relapse and return to an earlier stage several mes before they achieve their
goals. Nevertheless each me this happens, they gain new knowledge about their behaviour and will
be able to apply that in the next aempt (Jarvis et al., 1998).
The stages of change cycle is demonstrated diagrammacally in Figure 15.
Figure 15: The stages of change cycle
The contemplaon ladder (or ladder of change) can be a useful tool to idenfy which stage of
change an older person is currently in (Biener & Abrams, 1991; Rusn & Tate, 1993). The client
places a mark at the posion of the ladder that best describes their current intenons. This makes
it easier to work out where the client is at and to record their changes in the stages of change (see
Figure 16).
I have reduced the amount that I drink over 6 months ago
I have recently reduced the amount that I drink (in the last 6
I am planning on reducing the amount that I drink in the next
30 days
I am thinking about reducing the amount that I drink
I am not planning on reducing the amount that I drink any
time soon
The Ladder of Change
Please mark a cross on the rung of the ladder that best describes you.
Figure 16: The Ladder of change
2.8 Motivational interviewing
Movaon interviewing (MI) involves enhancing a client’s movaon to change risky AOD
behaviours. Movaon can be inuenced and it uctuates in response to clinician style.
Authoritave or paternalisc approaches increase clients’ resistance to change.
Collaborave relaonships which respect client autonomy and use the client’s own abilies to
change are most likely to be successful (Hall, Gibbie, & Lubman, 2012). Movaonal interviewing
can be linked to the Stages of Change model discussed above.
There are four key principles for the use of MI (Miller, Rollnick & Butler, 2008 as cited in Hall et al.,
2012). These are represented by the acronym RULE (see p49).
Resisting the righting
The righng reex oen inadvertently reinforces movaon to
maintain the status quo. Most people resist persuasion when they
are ambivalent about change and will respond by strengthening
their resolve not to change.
Understanding client
It is the client’s own reasons for change, rather than the clinician’s,
that will ulmately lead to behaviour change. Openly exploring the
client’s movaons for change helps the clinician beer
understand their movators and barriers.
Listening with empathy
Eecve listening skills are essenal to understand what will
movate the client as well as the pros and cons of their situaon.
Empowering the client
Client outcomes improve when they draw on their knowledge
about what has succeeded in the past. A truly collaborave
therapeuc relaonship is a powerful movator. Client benets are
maximised when the clinician is condent that change is possible.
If a clinician has more me, the following four addional principles can be applied within a longer
therapeuc intervenon (Hall et al., 2012).
Express empathy
Empathic communicaon involves reecve listening skills and
seeking to understand the client’s perspecves, thoughts and
feelings without judging, cricising or blaming. Without condoning
the problemac behaviour, the clinician creates an open and
respecul exchange with the client.
Develop discrepancy
Assisng clients to idenfy discrepancies between their current
behaviour and future goals or values about themselves as a person,
partner, parent, or worker is a powerful movator that helps ‘p the
balance’ toward change. Exploring the pros and cons of change can
help a client develop discrepancy.
Roll with resistance
When clinicians aempt to move a client towards change too quickly,
parcularly if using a coercive or authoritave approach, they oen
encounter resistance. Rolling with this resistance involves reecng
the resistance back to the client, emphasising their choice to change
or not (‘it’s up to you’).
Support self-efficacy
Many older people with AOD problems have made their own
aempts to change and been unsuccessful.
Highlighng the client’s strengths and reecng on mes in their
life when they have successfully changed can be very valuable. The
praconer’s belief in a client’s ability to change is a powerful way to
promote self-ecacy, and in doing so can help the individual develop
the condence that they are capable of change.
8 The righng reex describes the tendency of clinicians to advise paents about the right path for good health.
2.9 Relapse prevention and management
Lapses and relapses occur frequently among older people who are trying to change problemac
AOD behaviour. A lapse occurs when a person inially achieves their AOD-related goals and has a
lapse before geng back on track. If a person has a lapse, but instead of geng back on track with
their goals returns to a pre-intervenon level of use, this is a relapse. Principles that guide relapse
prevenon include encouraging the client to :
• Undertake more posive acvies
• Develop coping skills to manage high risk situaons
• Make lifestyle changes to decrease AOD use
• Be ready to interrupt lapses so that they do not lead to relapses and potenal harms are
minimised (Alcohol and Other Drug Educaon and Training Unit, 2013).
Relapse / lapse management strategies can include:
• Contracng with the client to limit the extent of use
• Contacng the therapist as soon as possible aer the lapse
• Evaluang the situaon and idenfying the triggers that preceded the lapse
• Reframing a relapse as a hiccup, a learning opportunity, or a temporary setback
• Using previously learnt problem solving strategies
• Using posive self-talk to prevent a lapse becoming a relapse
• Ulising a previously negoated support network (e.g. friends, family, doctor, or 24-Hour
Alcohol and Drug Informaon Service)
• Providing simple wrien instrucons (for example a lapse coping card) to refer to in the
event of a lapse (Alcohol and Other Drug Educaon and Training Unit, 2013).
2.10 The role of AOD specialist services
There are important roles for AOD specialist services to play in relaon to older people and alcohol
and drug problems. Some of these roles are complementary to the roles and support that can be
provided by more generic health care services and primary care. Others are specic to the specialist
AOD sector.
For specialist AOD services to beer cater to the needs of older people, a range of responses and
acons are required. These include the following:
1. Policy
It is important that all AOD specialist services have in place appropriate policies that recognise the
growing and dierent needs of older members of the community. Each service should have clear and
explicit policies that address the ways in which their service and their operaons are sensive to the
needs of older people. This includes the physical layout and structure of services, appropriate and
sensive assessment protocols, the recording of appropriate details regarding older people’s needs,
close collaboraon with other sectors, and the delivery and oversight of services designed and
tailored to the needs of older people.
2. Funding
Funding arrangements should reect the growing impost on AOD specialist services of older people
with AOD problems, with funds specically allocated for the needs of this segment of the
populaon. This entails recognion that older adults may require longer episodes of care, and
services will need to be funded accordingly. Reports and deliverables should also incorporate details
of older clients and the extent to which current services cater for the needs of this group.
3. Workforce development (WFD)
AOD services should ensure that appropriate WFD responses are provided to upskill workers. This
includes incorporang relevant clinical supervision components and other forms of support for
workers who will be increasingly dealing with clients from older age groups.
4. Service provision
Many services will need to undergo a degree of service redesign to ensure that older client popula-
ons are appropriately supported and cared for. This will be essenal to ensure high quality,
appropriate and sensive services are provided to this group.
The next secon of this guide provides examples of ways in which services may be beer tailored to
meet the needs of older clients.
Some of these examples may be readily adopted and modied in a range of dierent services. In
other instances, a service may need to address their local and specic needs in a manner that best
reects their parcular circumstances. In either instance, it is crucially important that all agencies
provide close and careful consideraon to the ways in which services can be improved to cater for
the growing needs of this important segment of the community.
The Older Wiser Lifestyles (OWL) Program was developed by Peninsula Health,
Victoria as an age-specic best pracce service model to address alcohol- and
other drug-related harm among older adults.
The program has two disnct arms: early intervenon (OWL-EI) and treatment
(OWL-TR) which are underpinned by ve core elements:
• Comprehensive screening and / or assessment
• Engagement
• Harm reducon strategies
• Oce-based and outreach support
• Evidence-driven best pracce.
The main referral sources for the OWL program are:
• Self-referrals
• Health organisaons
• Allied health programs.
Based on the Florida BRITE project, OWL-EI idenes older adults at risk of
experiencing AOD-related harm and provides age-specic early intervenons. It
oers a stepped care intervenon tailored to the client’s readiness to change and
can be used with older adults within a range of specialist and non-specialist
community health sengs.
OWL-TR idenes older individuals who are currently drinking or using drugs at
harmful levels or experiencing related problems. It involves a holisc assessment
and intensive client-centred counselling, and can be used in a range of specialist
alcohol and other drug sengs.
Promoonal acvies among service providers and the broader community are
crical to the success of OWL as they raise awareness and encourage access to the
The OWL program has developed a number of resources including:
• An informaon pamphlet for disseminaon throughout the community
• The A-ARPS screening tool
• An OWL DVD.
3.1 What is the OWL program?
3.1.1 How was OWL developed?
The Older Wiser Lifestyles (OWL) Program was developed by Peninsula Health as a unique age-
specic best pracce service model to address alcohol- and other drug-related harm among older
In 2007, Peninsula Health idened a gap in services for older adult-specic AOD treatment. Older
people are under-represented in AOD treatment. Physiological changes and increased isolaon put
older people at increased risk of developing substance use issues. They are parcularly vulnerable to
the deleterious eects of substance use. Academic literature recommends developing older
person-specic treatment opons.
In 2008, Peninsula Health appointed the rst older adult age-specic AOD clinician to develop an
older person program. In 2009, funding was received from the Victorian Department of Health to
appoint a specialised older adults psychologist, and develop OWL-Early Intervenon (OWL-EI) with
the aim of reducing risky drinking.
In 2010, Peninsula Health received a grant from St John of God to fund a nursing posion to add to
the team.
Currently the OWL program is comprised of a muldisciplinary team that has overcome barriers
and built strong linkages with key stakeholders such as Aged Persons Mental Health and Aged Care
services and local GPs.
3.1.2 Principles
The OWL program is underpinned by health promoon and harm minimisaon principles and is
designed to respond to the needs of a diverse client group. The program has two disnct arms: early
intervenon and treatment.
Both arms are underpinned by ve core elements:
• Comprehensive screening and / or assessment
• Engagement
• Harm reducon strategies
• Oce-based and outreach support
• Evidence-driven best pracce.
3.1.3 Consumer consultation
Consistent with Peninsula Health’s strong commitment to community parcipaon, during the
development of the OWL program consultaon was undertaken with both the Older Persons’
Community Advisory Group and the Alcohol and Drug Community Advisory Group. Both groups have
been supporve of the OWL program and its direcon.
3.1.4 Community consultation
Establishing and maintaining eecve and meaningful partnerships with services and organisaons
in the broader community is a key priority for the OWL program. In the developmental stage of the
OWL program a partnership was established with the Peninsula General Pracce Network in order to
disseminate informaon relang to the program and AOD issues faced by older adults.
Posters and brochures were designed using markeng images appropriate to older adults and
disseminated by targeng locaons that older adults are likely to aend. More recently the OWL
program has partnered with the Frankston and Mornington Peninsula Medicare Local to distribute
the Older and Wiser DVD.
3.1.5 Effective leadership
Prior to the establishment of OWL, few eorts had been made to increase older Australians’
awareness of the risk of alcohol- and other drug-related harm. Through advocacy, research,
evaluaon, educaon and eecve leadership, OWL has increased awareness and understanding of
these harms to older adults, including the provision of asserve engagement and educaon to
idened ‘at-risk communies’.
In developing and disseminang Australia’s rst older adult-specic early intervenon for alcohol-
and drug-related harm, OWL has led and achieved much at a local, regional, statewide, federal and
internaonal level, including:
• Establishment of a peer-led screening program within Frankston Hospital
• Using iPads to access the screening
• Raising alcohol use among older adults as a priority area for response
• Facilitang training for health care workers, including GPs and HACC workers
• Improving referral and healthcare pathways based upon evidence gleaned from OWL.
In 2012, the OWL program was recognised naonally as a nalist in the Australian Alcohol and other
Drug Awards. The Program has been a leading voice regarding AOD and older adults with a number
of peer-reviewed and professional papers published both naonally and internaonally (e.g., Bright,
2011; Bright et al., 2013). It has received naonal and internaonal media coverage. At one point,
more than 150 Australians accessed the OWL screening tool in a 24 hour period. OWL sta present
at naonal and internaonal conferences and collaborate with internaonal experts, including the
University of Southern Florida and the University of California, Los Angeles.
In November 2012, OWL developed and facilitated a naonal training program for GPs and other
healthcare providers and connues to provide training programs as well as secondary consultaons.
3.1.6 How effective is the program?
An independent evaluaon of OWL was undertaken in 2013 and showed it to be a well-received and
eecve program:
• On the whole there was support for the eecveness of the service model
• The program provided a broad range of intervenons in response to the various needs of
older adults
• Clients beneted from their experience with OWL and reported high sasfacon with the
• Posive changes in drinking behaviour were observed among parcipants
• There were noceable improvements in parcipants’ physical and mental health
• Clients aributed changes in their drinking behaviour and health status to the informaon
and educaon they received from the program
• The outreach mode of service delivery and aercare were idened as key strengths of
the program.
3.2 OWL Early Intervention (OWL-EI)
3.2.1 What is OWL-EI?
OWL Early Intervenon (OWL-EI) is designed to idenfy older adults who are at risk of experiencing
AOD-related harm and to provide an age-specic early intervenon. OWL-EI draws from, and
extends, the Florida BRITE project, adapted for the Australian context.
The Florida Brief Intervenon Treatment for Elders (BRITE) Project oered brief intervenon of one
to ve sessions to address substance use among older adults. A signicant reducon in parcipants’
SMAST-G scores was observed from baseline to discharge, and maintained at a 30 day follow up
(Schonfeld et al., 2010).
OWL-EI oers a stepped care intervenon tailored to the client’s readiness to change. It is framed as
a modulated program with intervenons ranging from informaon, educaon and brief movaonal
intervenon. Clients are inially expected to aend one to two sessions, however further contacts
are scheduled as needed.
Readiness to change is measured using the Transtheorecal Model (TTM) of behaviour change
(Prochaska, 1991; Prochaska, DiClemente, & Norcross, 1992; Prochaska & Velicer, 1997). The
transtheorecal model outlines ve stages of readiness to change (see Fig. 15, p47). Movement
through each stage of change is not necessarily linear and typically progresses as follows:
1. Pre-contemplaon: not thinking about change
2. Contemplaon: beginning to recognise possibility of change but ambivalent about change
3. Preparaon: commied to change, but not yet taking acon
4. Acon: making concrete changes
5. Maintenance: successfully changed her or his behaviour for a substanal period of me.
The content of the OWL-EI program is matched to the client’s readiness to change based on the
transtheorecal model.
3.2.2 Why brief intervention?
To eecvely reduce alcohol- and other drug-related harm, it is essenal to develop intervenons
that target the large populaon of individuals drinking at high levels, and not only those individuals
who are dependent or problemac drinkers. There is extensive evidence that brief intervenons are
eecve in reducing risky alcohol and other drug consumpon and related harms (Kaner et al., 2007;
Miller & Hester, 2003). Eecve brief intervenons range from ve minutes of advice suitable for the
primary care seng (‘minimal intervenon’) to six sessions of counselling that can be
delivered within alcohol and other drug sengs (‘brief therapy’).
3.2.3 Who is OWL-EI for?
OWL-EI is designed to be used with older adults within a range of specialist and non-specialist
community health sengs that respond to people who use alcohol or other drugs, inclusive of
misuse of prescripon medicaons and OTC medicaons.
OWL-EI Case Study
Bob is a 74 year old rered, married male with a 12 year diagnosis of depression which he
started to experience aer he rered. He was referred to OWL by his GP who expressed
concerns to him about a fay liver. His wife also wanted him to enjoy more acvies. Bob
met with the OWL nurse and undertook the A-ARPS (Australian Alcohol-Related Problem Sur-
vey). Bob’s AOD use was assessed as “harmful” due to the combinaon of his andepressant
medicaon and alcohol use, which he reported had increased from “a couple of stubbies” to
about 4 stubbies of full strength beer daily.
Bob was movated to change as he wanted to enjoy his rerement, be healthy and improve
his relaonship with his wife. He engaged in 6 sessions with the OWL nurse. Sessions
covered psycho-educaon regarding the impacts of alcohol on depression, medicaon
interacons and standard drinks, as well as counselling to manage his moods. Bob was
supported to signicantly reduce his alcohol use, develop meaningful acvies and set
achievable goals to improve the quality of his life.
3.3 OWL Treatment (OWL-TR)
3.3.1 What is OWL-TR?
OWL Treatment is aimed at idenfying individuals aged 60 years and over in the community who are
currently drinking or using drugs at harmful levels or experiencing problems with their alcohol or
other drug use. The treatment arm of OWL oers holisc assessment and intensive client-centred
3.3.2 Why OWL-TR?
As discussed in Part 2, the terms ‘early onset’ (survivors), ‘late onset’ (reactors) and ‘maintainers’ are
oen used to describe the drinking behaviour of older adults. These terms reect the age at which a
person starts to experience alcohol-related problems. Typically, early onset drinkers have had a long
history of harmful drinking, spanning early to late adulthood, whereas late onset drinkers started
experiencing alcohol-related problems later in life.
In general, late onset drinkers appear ‘psychologically and physically healthier’, and tend to be more
amenable to treatment compared with early onset drinkers (Atkinson & Misra, 2002). It is esmated
that one-third of older adults experiencing alcohol problems may be late onset drinkers (Liberto,
Oslin, & Ruskin, 1992; Sorocco & Ferrell, 2006).
A number of risk factors have been idened for AOD problems among older people, which have
implicaons for treatment, including:
• Gender: older men are much more likely than older women to have alcohol-related
problems (Myers et al., 1984)
• Loss of spouse: Hazardous drinking is more common among divorced or separated
older adults and widowed men (Bucholz et al., 1995 cited in Substance Abuse and Mental
Health Services Administraon, 1998)
• Other losses: As people age, major life transions are associated with signicant loss for
many older adults, including diminished income, self-esteem, purpose, social support
networks, mobility and sense of independence, capacity to use or access public transport,
and physical health (Substance Abuse and Mental Health Services Administraon, 1998)
• Comorbid psychiatric disorders: Mood disorders may be either precipitang or
maintenance factors associated with late onset drinking. Depression, for example,
appears to precipitate drinking, parcularly among women (Dupree, Broskowski, & Schon-
feld, 1984)
• Family history of alcohol problems: There may be a greater genec aeology of problem
drinking in early onset than in late onset male alcohol abusers (Atkinson, Tolson, & Turner,
• Concomitant substance use: Older adults who misuse alcohol tend to also use nicone
and misuse prescripon drugs more than those who do not misuse alcohol (Goldberg,
Burchel, Reed, Wergowske, & Chiu, 1994).
Given the range of risk factors, signicant life transions, and oen minimal contact with services by
older adults, it is crical to develop services that are responsive to the needs of older people.
3.3.3 Who is OWL-TR for?
OWL-TR is designed to be used with older adults in a range of specialist alcohol and other drug
sengs. Older adults are at increased risk of alcohol- and other drug-related harm because of the
biological changes that occur as part of the ageing process, the interacon of AOD with medicaons,
and the role these substances can play in the aeology, exacerbaon, and perpetuaon of medical
OWL-TR Case Study
Mary presented as a 63 year old female, referred by Complex Care, with a 40-year history of
alcohol and cannabis problems and mental illness due to childhood trauma and abuse. She
currently lives alone with her dog and reports to be consuming 2-3 litres of white wine and
smoking 1-2 grams of cannabis daily. Mary immigrated to Australia from Switzerland 13 years
ago. She states she was sober for 12 years prior to her immigraon but resumed drinking and
using upon arrival due to loneliness and separaon from family. Mary also advised she suers
from agoraphobia, major depressive disorder, anxiety and borderline personality disorder.
She also has several health concerns aer experiencing a bad fall previously this year. Mary
reports she is prescribed several medicaons for pain and sleep and is compliant.
The OWL clinician conducted sessions in Mary’s home where she was assessed and entered
into the OWL program. A treatment plan was developed to include: alcohol and cannabis
use reducon with a goal of absnence; educaon regarding medicaon and AOD; individual
counselling; coping skills development; exposure therapy; and support. The Mental Illness
Fellowship, her general praconer and a physiotherapist provided Mary with addional
Mary had insight into underlying issues yet she struggled with lack of movaon to reduce
her alcohol and cannabis use. Aer four months of weekly counselling sessions she agreed to
enter residenal rehabilitaon. Mary was supported by the OWL clinician through her
admission and remained in the clinic for 40 days. Upon discharge from rehabilitaon, Mary
was slowly geng out of the house, walking her dog, aending the neighborhood
community centre and starng to build a network of friends. She is remaining absnent and
reports she is feeling beer emoonally and physically. Mary has remained engaged with
OWL for relapse prevenon strategies.
3.3.4 Treatment Tips from the OWL Clinicians
Understand that the person with whom you are speaking has lived many
years and their life experience, strengths and personal history are valuable.
Acknowledging this will assist parcularly if the individual is losing or has lost
Anecdotal evidence demonstrates that the old adage “you can’t teach an old
dog new tricks” is a myth. Older adults can indeed change their habits, but
may take longer in doing so. Some older adults may repeat themselves or
have poor short-term memory, and session content may have to be
reiterated a few mes before it is absorbed.
It is important to build rapport to foster and enhance trust. Find an age-
relevant topic to discuss (e.g., interests, hobbies, grandchildren, gardening,
book clubs, etc.). You do not need to be older to work with older adults; you
just need empathy and an ability to relate.
Choose your words carefully when approaching the subjects of alcohol and
other drug use. You will get a more honest and accurate answer if you are
non-judgemental and casual. For example, ask: “Do you enjoy a drink?” as
opposed to “Are you concerned about your drinking?” or “Do you think you
have a problem?”
Older adults are not all the same and will require a wide variety of
intervenons depending on their individual presentaons and goals. Be
willing to adjust goals as they may tend to change depending on the client’s
current movaon and abilies.
Somemes you are the only contact in a person’s life. Depending on your
client’s situaon they may be experiencing loneliness and isolaon. This
could potenally create signicant dependency on you, so it is always best to
be clear about what your role is and the client’s expectaons of your
Be as thorough as possible when assessing an older adult, ensuring you
gather informaon regarding their mental and physical health as well as so-
cial and familial inuences.
Have a good understanding of the variety of issues that are unique to this
stage of life. This may include: rerement, identy and role changes,
bereavement, loneliness, isolaon and sgma just to name a few. Also be
aware of your own beliefs and values regarding the ageing process and
reect on how these beliefs could impact on your percepon of the client
and your subsequent interacons.
3.4 Promotional and networking activities and resources
Promoonal acvies are crical to the success of OWL. Older risky drinkers and drug users can be
a hidden populaon and proacve strategies are essenal for engagement. Promoonal acvies
serve three key purposes:
• Raising awareness of the program among older adults and the broader community
• Educang older adults about AOD-related health risks
• Facilitang access to the program.
Promoonal acvies include:
• Community-based talks (e.g., in nursing homes, rerement villages, ProBUS clubs, Rotary
clubs, community groups)
• Media releases, arcles and events
• Stands at public events (e.g., Annual Ageing Well Expos)
• In-service training and site visits (e.g., GP clinics, sta training sessions within Peninsula
3.5 OWL resources
As part of the development of the OWL program the following resources have been developed:
OWL informaon pamphlet: for disseminaon throughout the community.
A-ARPS screening tool: A partnership was established with the developers of the Alcohol-
Related Problems Survey (ARPS) at The University of California, Los Angeles. The ARPS is a
computerised screening tool that assesses clients’ risk of experiencing alcohol-related harm
using 176 algorithms. These algorithms consider medical history, prescripon and OTC
medicaon use and acvies of daily living. As there is a 40% dierence in what constutes a
standard drink in Australia compared with the USA, the ARPS was rst recalibrated to ensure
that it would be valid to use in Australia. There is no other equivalent tool in Australia. The
Australian ARPS (A-ARPS) is now freely available for use and is valid across all Australian
jurisdicons (see
OWL DVD: Through a partnership with Casuarina Media and a steering commiee of older
consumers, the OWL team developed an educaonal DVD resource targeng older adults and
health professionals. It aims to raise awareness of the risks associated with alcohol use and
provide skill development opportunies for health professionals. The Older and Wiser DVD is a
20 minute lm told through three entwining stories and interspersed with professional
commentary. The DVD includes: Older and Wiser, Older and Wiser with professional
commentary, 10 minute commentary for health praconers, 10 minute meditaon exercise
and a 20 minute Radio Naonal interview on the Older Wiser Lifestyles program.
3.6 Community awareness
 Awareness generates concern and curiosity and that leads to self-referrals
Many older adults are unaware of the impact that ageing can have on their risk of experiencing
alcohol-related harm. Prior to the establishment of the OWL team there had been lile eort within
Australia to increase older adults’ awareness of these issues. The OWL team has enhanced
awareness in the local community through the delivery of community educaon in a variety of
contexts, including: aged care facilies, ageing well expos, demena awareness days, Probus clubs,
rehabilitaon programs, rerement villages and seniors’ clubs.
Community presentaons and media acvies are an eecve way of raising awareness of AOD-
related health issues and generang referrals. During the evaluaon of the OWL Program, one key
referrer associated a peak in referrals with ‘workers being out and about in the community
spreading the word’.
Acvies such as presentaons can provide ‘teachable moments’ for older adults who may not
otherwise receive informaon about alcohol-related health issues such as the interacon between
alcohol and medicaons.
Promoonal material focusing on older adult specic heath concerns, such as demena, tend to
yield more interest than messages about alcohol-related health issues. This illustrates the
importance of tailoring health messages to the target audience and being aware of the sgma oen
associated with alcohol and other drug use.
 It was easy to discuss things with [the OWL worker] and she listened to
what I had to say. It was good to speak to someone who knew about
medications and dierent health problems.
 I was embarrassed to admit I had a drinking problem but [the OWL worker]
was very knowledgeable and non-judgmental.
3.7 Service sector awareness
The broader health service sector may be a more dicult audience to engage than the older people
themselves. Delivering presentaons to sta and conducng in-service training sessions within
health services can raise awareness of the program. Age-specic services, such as aged care and
rerement homes, are recepve services for OWL. Relaonships and referral networks need to be
maintained through regular and ongoing communicaon with the service sector, including GPs and
other primary and community health providers.
Key referrers to the OWL program have described OWL community presentaons and media
acvies as eecve in raising awareness of alcohol-related health issues and generang referrals.
OWL Promoonal acvies study
Alice is a 67 year old rered female who aended a Cardiac Rehab group. She listened to an
informave session that educated her regarding the physiological changes that happen as
we age, interacons between alcohol and medicaons, and gave a demonstraon of what a
standard drink is.
Alice stated that she was never aware of this and will now measure and limit her drinks as she
does enjoy a glass of wine most evenings. She will also discuss what is considered safe for her
with her GP.
3.8 Referral pathways
3.8.1 What are the main referral pathways?
The main referral sources for the OWL program are likely to be:
Self-referrals (e.g., older people registering interest in the program directly)
Health organisaons’ centralised intake services
Allied health programs (e.g., occupaonal therapist, physiotherapist, diecian).
The inial informaon point oen diers for EI and treatment clients. For example, EI clients
typically self-refer in response to aending a health awareness raising presentaon delivered by
OWL sta, whereas treatment clients may learn about OWL via speaking with a health praconer
(e.g., nurse) about their AOD use.
3.8.2 How are referrals facilitated?
Risky or dependent AOD use by older adults is typically idened via standard screens or through
conversaons with paents about other health or lifestyle issues such as poor sleep paerns,
medicaons or grief. This suggests that potenal referrers need to be provided with training and
ongoing informaon about the program in order to facilitate referrals.
Factors facilitang the referral process are:
A clear understanding of the program by referrers through in-service training and ongoing
contact with OWL
Access to informaon about OWL (i.e., pamphlets)
Timely response to referrals
Direct contact with OWL sta either via the telephone or in person.
Aalto, M., Alho, H., Halme, J., & Seppä, K. (2011). The alcohol use disorders idencaon test (AUDIT)
and its derivaves in screening for heavy drinking among the elderly. Internaonal Journal of Geriatric
Psychiatry, 26(9), 881-885. DOI: 10.1002/gps.2498.
Alcohol and Other Drug Educaon and Training Unit (2013). Inducon Module 6: Relapse Prevenon and
Management. Brisbane: Alcohol and Other Drug Educaon and Training Unit, Metro North Mental
Health - Alcohol and Drug Service.
Anderson, P., Chisholm, D., & Fuhr, D. (2009). Eecveness and cost-eecveness of policies and pro-
grammes to reduce the harm caused by alcohol. The Lancet, 373(9682), 2234-2246. DOI: hp://dx.doi.
Anderson, P., Scafato, E., & Galluzzo, L. (2012). Alcohol and older people from a public health
perspecve. Annali dell'Istuto Superiore di Sanità, 48(3), 232-247.
Atkinson, R., & Misra, S. (2002). Mental disorders and symptoms in older alcoholics. In A. Gurnack, R.
Atkinsons & N. Osgood (Eds.), Treang Alcohol and Drug Abuse in the Elderly. New York: Springer.
Atkinson, R., Tolson, R., & Turner, J. (1990). Late versus early onset problem drinking in older men.
Alcoholism: Clinical and Experimental Research, 14(4), 574-579.
Australian Government Department of Veterans’ Aairs. (n.d.). Alcohol and Medicaons. Canberra:
Australian Government Department of Veteran Aairs.
Australian Instute of Health and Welfare. (2011a). 2010 Naonal Drug Strategy Household Survey
Report. Canberra: Australian Instute of Health and Welfare.
Australian Instute of Health and Welfare. (2011b). Substance Use among Aboriginal and Torres Strait
Islander People. Canberra: Australian Instute of Health and Welfare.
Australian Instute of Health and Welfare. (2013). Australia’s Welfare 2013. Australia’s Welfare Series
no.11. Cat. no. AUS 174. Canberra: Australian Instute of Health and Welfare.
Australian Instute of Health and Welfare. (2014a). 2013 Naonal Drug Strategy Household Survey
Detailed Report. Canberra: Australian Instute of Health and Welfare.
Australian Instute of Health and Welfare. (2014b). Naonal Opioid Pharmacotherapy Stascs. 2013
Drug Treatment Series. Canberra: Australian Instute of Health and Welfare.
Babor, T., & Higgins-Biddle, J. (2001). Brief intervenon for hazardous and harmful drinking: A manual for
use in primary care. World Health Organizaon. Downloaded from hp://
Baldini, A., Von Kor, M., & Lin, E. (2012). A review of potenal adverse eects of long-term opioid
therapy: A praconer’s guide. The Primary Care Companion to CNS Disorders, 14(3).
Bamberger, P. (2014). Winding down and boozing up: The complex link between rerement and alcohol
misuse. Work, Aging and Rerement. DOI: hp://
Beynon, C. (2009). Drug use and ageing: Older people do take drugs! Age and Ageing, 38(1), 8-10.
Biener, L., & Abrams, D. (1991). The contemplaon ladder: Validaon of a measure of readiness to
consider smoking cessaon. Health Psychology, 10(5), 360.
Blow, F., & Lawton Barry, K. (2003). Use and Misuse of Alcohol Among Older Women. Bethesda, MD:
Naonal Instute on Alcohol Abuse and Alcoholism.
Bright, S. (2011). Screening Older Adults for Risky Alcohol Consumpon. Melbourne: Australian Drug
Bright, S., Fink, A., Beck, J., Gabriel, J., & Singh, D. (2013). Development of an Australian version of the
Alcohol-Related Problems Survey: A comprehensive computerised screening tool for older adults.
Australasian Journal on Ageing, 34(1):33-7. DOI: 10.1111/ajag.12098.
Caputo, F., Vignoli, T., Leggio, L., Addolorato, G., Zoli, G., & Bernardi, M. (2012). Alcohol use disorders in
the elderly: A brief overview from epidemiology to treatment opons. Experimental Gerontology, 47(6),
411-416. DOI: hp://
Carman, M., Grierson, J., Hurley, M., Pis, M., & Power, J. (2009). HIV Populaons in Australia:
Implicaons for Access to Services and Delivery. Australian Research Centre in Sex, Health and
Society, La Trobe University.
Carmichael, C. (2001). The DISE Manual: A Resource Manual for Direcons in Illicit Substance Educaon.
Herston: Queensland Alcohol and Drug Research and Educaon Centre.
Chikritzhs, T., & Pascal, R. (2005). Trends in Alcohol Consumpon and Related Harms for Australians Aged
65 to 74 Years (The ‘Young-Old’), 1990–2003. Perth: Naonal Drug Research Instute, Curn University,
Conner, K., & Rosen, D. (2008). “You're nothing but a junkie”: Mulple experiences of sgma in an aging
methadone maintenance populaon. Journal of Social Work Pracce in the Addicons, 8(2), 244-264.
Coulson, C., Williams, L., Berk, M., Lubman, D., Quirk, S., & Pasco, J. (2014). Associaon between alcohol
consumpon and self-reported depression among elderly Australian men. Geriatric Mental Health Care,
2(1–2), 3-8. DOI: hp://
Crome, I., & Bloor, R. (2005). Older substance misusers sll deserve beer diagnosis - An update (Part 2).
Reviews in Clinical Gerontology, 15(3-4), 255-262.
Crome, I., Sidhu, H., & Crome, P. (2009). No longer only a young man’s disease: Illicit drugs and older
people. The Journal of Nutrion, Health & Aging, 13(2), 141-143.
Croton, G. (2007). Screening For and Assessment Of Co-Occurring Substance Use and Mental Health
Disorders by Alcohol & Other Drug and Mental Health Services. Melbourne: Victorian Dual Diagnosis
Iniave Advisory Group.
Dean, A. (2006). Illicit drugs and drug interacons. Australian Pharmacist, 25(9), 684.
Dertadian, G., & Maher, L. (2014). From oxycodone to heroin: Two cases of transioning opioid use in
young Australians. Drug and Alcohol Review, 33(1), 102-104.
Devanand, D. (2002). Comorbid psychiatric disorders in late life depression. Biological Psychiatry, 52(3),
Dobbin, M. (2008). Non-Prescripon (Over-The-Counter) Codeine-Containing Analgesic Misuse and Harm.
Melbourne: Mental Health and Drugs Division, Department of Human Services.
Doukas, N. (2011). Older adults in methadone maintenance treatment: A literature review. Journal of
Social Work Pracce in the Addicons, 11(3), 230-244.
Dowling, G., Weiss, S., & Condon, T. (2008). Drugs of abuse and the aging brain.
Neuropsychopharmacology, 33(2), 209-218.
Drug and Alcohol Mulcultural Educaon Centre. (2010). Making Treatment Services and Prevenon
Programs Accessible for Culturally and Linguiscally Diverse Clients. Melbourne: Australian Drug
Drug Educaon Network. (2014). Wiser and Older: Safer Drinking throughout Life. Hobart, Tasmania:
Drug Educaon Network.
DrugScope. (2014). It's About Time: Tackling Substance Misuse in Older People. London: DrugScope.
Dupree, L., Broskowski, H., & Schonfeld, L. (1984). The Gerontology Alcohol Project: A behavioral
treatment program for elderly alcohol abusers. The Gerontologist, 24(5), 510-516.
Fry, C. (2007). Making Values and Ethics Explicit: A New Code of Ethics for the Australian Alcohol and
Other Drugs Field. Canberra: Alcohol and other Drugs Council of Australia.
Gleadle, F., Freeman, T., Duraisingam, V., Roche, A., Baams, S., Marshall, B., Tovell, A., Trifono, A., &
Weetra, D. (2010). Indigenous Alcohol and Drug Workforce Challenges: A Literature Review of Issues Re-
lated to Indigenous AOD Workers’ Wellbeing, Stress and Burnout. Adelaide: Naonal Centre for
Educaon and Training on Addicon (NCETA), Flinders University.
Goldberg, R., Burchel, C., Reed, D., Wergowske, G., & Chiu, D. (1994). A prospecve study of the health
eects of alcohol consumpon in middle-aged and elderly men. The Honolulu Heart Program.
Circulaon, 89(2), 651-659.
Gossop, M. (2008). Substance Use among Older Adults: A Neglected Problem. Lisbon, Portugal: European
Monitoring Centre for Drugs and Drug Addicon.
Gossop, M., Neto, D., Radovanovic, M., Batra, A., Toteva, S., Musalek, M., Skutle, A., & Goos, C. (2007).
Physical health problems among paents seeking treatment for alcohol use disorders: A study in six
European cies. Addicon Biology, 12(2), 190-196.
Haber, P., Lintzeris, N., Proude, E., & Lopatko, O. (2009). Guidelines for the Treatment of Alcohol
Problems. Canberra: Australian Government Department of Health and Ageing.
Hall, K., Gibbie, T., & Lubman, D. (2012). Movaonal interviewing techniques. Facilitang behaviour
change in the general pracce seng. Australian Family Physician, 41, 660-667.
Han, B., Gfroerer, J., & Colliver, J. (2009). An Examinaon of Trends in Illicit Drug Use among Adults Aged
50 to 59 in the United States: Oce of Applied Studies, Substance Abuse and Mental Health Service
Heather, N. (2003). Brief intervenon strategies. In R. Hester & W. Miller (Eds.), Handbook of Alcoholism
Treatment Approaches: Eecve Alternaves (3rd ed). Needham Heights, MA: Allyn & Bacon.
Hollingworth, S. A., & Siskind, D. J. (2010). Anxiolyc, hypnoc and sedave medicaon use in Australia.
Pharmacoepidemiology and Drug Safety, 19(3), 280-288.
Hunter, B., & Lubman, D. (2010). Substance misuse: Management in the older populaon. Australian
Family Physician, 39(10).
Hunter, B., Lubman, D., & Barra, M. (2011). Alcohol and drug misuse in the elderly. Australian and New
Zealand Journal of Psychiatry, 45(4), 343.
Jarvis, T., Tebbu, J., & Mack, R. (1998). Treatment Approaches for Alcohol and Drug Dependence: An
Introductory Guide. Chichester, England: John Wiley and Sons.
Kaner, E., Beyer, F., Dickinson, H., Pienaar, E., Campbell, F., Schlesinger, C., . . . Burnand, B. (2007).
Eecveness of brief alcohol intervenons in primary care populaons. Cochrane Database Syst Rev, 2.
Kelsall, J., Parkes, P., Watson, M., Madden, A., & Byrne, J. (2011). Double Jeopardy: Older Injecng Opioid
Users in Australia. Canberra: Australian Injecng and Illicit Drug Users League.
Kinirons, M. T., & O'Mahony, M. S. (2004). Drug metabolism and ageing. Brish Journal of Clinical
Pharmacology, 57(5), 540-544. DOI: 10.1111/j.1365-2125.2004.02096.x
Kolodny, A., Courtwright, D., Hwang, C., Kreiner, P., Eadie, J., Clark, T., & Alexander, G. (2015). The
Prescripon Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addicon. Annual
Review of Public Health, 36, 559-74. DOI: 10.1146/annurev-publhealth-031914-122957.
Kuerbis, A., & Sacco, P. (2012). The impact of rerement on the drinking paerns of older adults: A
review. Addicve Behaviors, 37(5), 587-595.
Lankenau, S., Te, M., Silva, K., Bloom, J., Harocopos, A., & Treese, M. (2012). Iniaon into prescripon
opioid misuse amongst young injecon drug users. Internaonal Journal of Drug Policy, 23(1), 37-44.
Leung, L. (2011). Cannabis and its derivaves: Review of medical use. The Journal of the American Board
of Family Medicine, 24(4), 452-462.
Liberto, J., Oslin, D., & Ruskin, P. (1992). Alcoholism in older persons: A review of the literature.
Psychiatric Services, 43(10), 975-984.
Lindsey, W., Stewart, D., & Childress, D. (2012). Drug interacons between common illicit drugs and
prescripon therapies. The American Journal of Drug and Alcohol Abuse, 38(4), 334-343.
Mallet, L., Spinewine, A., & Huang, A. (2007). The challenge of managing drug interacons in elderly
people. The Lancet, 370(9582), 185-191.
Mars, S., Bourgois, P., Karandinos, G., Montero, F., & Ciccarone, D. (2014). “Every ‘never’I ever said came
true”: Transions from opioid pills to heroin injecng. Internaonal Journal of Drug Policy, 25(2), 257-
Miller, W., & Hester, R. (2003). Treatment for alcohol problems: Towards an informed ecleccism. In R. K.
Hesters & W. R. Miller (Eds.), Handbook of Alcoholism Treatment Approaches: Eecve Alternaves (3rd
ed). Needham Heights, MA: Allyn & Bacon.
Miller, W., & Sanchez, V. (1994). Movang Young Adults for Treatment and Lifestyle Change. Indiana:
University of Notre Dame Press.
Moy, I., Crome, P., Crome, I., & Fisher, M. (2011). Systemac and narrave review of treatment for older
people with substance problems. European Geriatric Medicine, 2(4), 212-236. DOI: hp://dx.doi.
Myers, J., Weissman, M., Tischler, G., Holzer, C., Leaf, P., Orvaschel, H., Anthony, J., Boyd, J., Burke, J.,
Kramer, M., & Stoltzman, R. (1984). Six-month prevalence of psychiatric disorders in three communies:
1980 to 1982. Archives of General Psychiatry, 41(10), 959-967.
Naonal Centre for Educaon and Training on Addicon. (2013). Secondary analysis of 2007 Naonal
Survey of Mental Health and Wellbeing (Australian Bureau of Stascs, 2009). Adelaide: Naonal Centre
for Educaon and Training on Addicon, Flinders University.
Naonal Centre for Educaon and Training on Addicon. (2013a). Secondary analysis of 2010 Australian
Mortality data (Australian Bureau of Stascs, 2010). Adelaide: Naonal Centre for Educaon and
Training on Addicon, Flinders University.
Naonal Centre for Educaon and Training on Addicon. (2013b). Secondary analysis of Naonal
Hospital Morbidity Database 2009/10 (Australian Instute of Health and Welfare, 2011). Adelaide:
Naonal Centre for Educaon and Training on Addicon, Flinders University.
Naonal Centre for Educaon and Training on Addicon. (2015a). Secondary analysis of 2013 Naonal
Drug Strategy Household Survey data (Australian Instute of Health and Welfare, 2014a). Adelaide:
Naonal Centre for Educaon and Training on Addicon, Flinders University.
Naonal Centre for Educaon and Training on Addicon. (2015b). Secondary analysis of Alcohol and
Other Drug Treatment Services Naonal Minimum Data Set (Australian Instute of Health and Welfare,
2014). Adelaide: Naonal Centre for Educaon and Training on Addicon, Flinders University.
Naonal Centre for Educaon and Training on Addicon Consorum. (2004). Alcohol and Other Drugs:
A Handbook for Health Professionals. Adelaide: Australian Government Department of Health and
Naonal Health and Medical Health Research Council. (2009). Australian Guidelines to Reduce Health
Risks from Drinking Alcohol. Canberra: Naonal Health and Medical Health Research Council.
Nicholas, R., & Roche, A. (2014). Common substance use co-morbidies. Grey Maers Informaon Sheet
Series. Adelaide: Naonal Centre for Educaon and Training on Addicon, Flinders University.
O'Donnell, A., Anderson, P., Newbury-Birch, D., Schulte, B., Schmidt, C., Reimer, J., & Kaner, E. (2014). The
impact of brief alcohol intervenons in primary healthcare: A systemac review of reviews. Alcohol and
Alcoholism, 49(1), 66-78.
Pain Australia. (2011). Naonal Pain Strategy. Tamarama, NSW: Pain Australia.
Prochaska, J. (1991). Assessing how people change. Cancer, 67(S3), 805-807.
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applicaons
to addicve behaviors. American Psychologist, 47, 1102-1114.
Prochaska, J. O., & Velicer, W. F. (1997). The transtheorecal model of health behavior change. American
Journal of Health Promoon, 12, 38-48.
Rigler, S. (2000). Alcoholism in the elderly. American Family Physician, 61(6), 1710-1716.
Rier, A., Mahew-Simmons, F., & Carragher, N. (2012). Monograph No. 23: Prevalence of and
intervenons for mental health and alcohol and other drug problems amongst the gay, lesbian,
bisexual and transgender community: A review of the literature. Drug Policy Modelling Program
Monograph Series. Sydney: Naonal Drug and Alcohol Research Centre.
Roche, A., & Freeman, T. (2004). Brief intervenons: Good in theory but weak in pracce. Drug and
Alcohol Review, 23(1), 11-18.
Roxburgh, A., Bruno, R., Larance, B., & Burns, L. (2011). Prescripon of opioid analgesics and related
harms in Australia. Medical Journal of Australia, 195(5), 280.
Roxburgh, A., Burns, L., Drummer, O., Pilgrim, J., Farrell, M., & Degenhardt, L. (2013). Trends in fentanyl
prescripons and fentanyl-related mortality in Australia. Drug and Alcohol Review, 32(3), 269-275.
Royal College of Psychiatrists. (2011). Our Invisible Addicts: First Report of the Older Persons' Substance
Misuse Working Group of the Royal College of Psychiatrists. London: Royal College of Psychatrists.
Rusn, T., & Tate, J. (1993). Measuring the stages of change in cigaree smokers. Journal of Substance
Abuse Treatment, 10(2), 209-220.
Satre, D., Mertens, J., Arean, P., & Weisner, C. (2004). Five-year alcohol and drug treatment outcomes of
older adults versus middle-aged and younger adults in a managed care program. Addicon, 99(10), 1286-
Schonfeld, L., & Dupree, L. (1991). Antecedents of drinking for early-and late-onset elderly alcohol
abusers. Journal of Studies on Alcohol and Drugs, 52(6), 587.
Schonfeld, L., King-Kallimanis, B., Duchene, D. M., Etheridge, R., Herrera, J., Barry, K., & Lynn, N. (2010).
Screening and brief intervenon for substance misuse among older adults: The Florida BRITE project.
American Journal of Public Health, 100(1), 108-114.
Searby, A., Maude, P., & McGrath, I. (2015). Dual diagnosis in older adults: A review. Issues in Mental
Health Nursing, 36, 104-111.
Seeking Soluons. (2004). Best Pracces using Harm Reducon. Oawa: Health Canada.
Sorocco, K., & Ferrell, S. (2006). Alcohol use among older adults. The Journal of General Psychology,
133(4), 453-467.
Substance Abuse and Mental Health Services Administraon. (1998). Substance Abuse among Older
Adults: Treatment Improvement Protocol (TIP) Series, No. 26. Rockville, MD: Substance Abuse and
Mental Health Services Administraon.
Swan, A., Sciacchitano, L., & Berends, L. (2008). Alcohol and Other Drug Brief Intervenon in Primary
Care. Fitzroy, Victoria Turning Point Alcohol and Drug Centre.
The Gerontological Society of America. (2012). Communicang with Older Adults: An Evidence-Based
Review of What Really Works. Washington: The Gerontological Society of America.
The Treasury. (2015). 2015 Intergeneraonal Report Australia in 2055. Canberra: The Treasury,
Commonwealth of Australia.
Veal, F., Bereznicki, L., Thompson, A., & Peterson, G. (2015). Use of Opioid Analgesics in Older
Australians. Pain Medicine. DOI: 10.1111/pme.12720.
Wadd, S., Lapworth, K., Sullivan, M., Forrester, D., & Galvani, S. (2011). Working with Older Drinkers.
Bedford: Tilda Goldberg Centre, University of Bedfordshire.
Wilkinson, C., Allsop, S., & Chikritzhs, T. (2011). Alcohol pouring pracces among 65- to 74-year-olds in
Western Australia. Drug and Alcohol Review, 30(2), 200-206. doi: 10.1111/j.1465-3362.2010.00218.x
Wilkinson, C., Dare, J., Waters, S., Allsop, S., & McHale, S. (2012). An Exploraon of How Social Context
and Type of Living Arrangement are Linked to Alcohol Consumpon amongst Older Australians.
Canberra: Foundaon for Alcohol Research and Educaon.
World Health Organizaon. (2006). Elder abuse and alcohol. Geneva: WHO.
Wu, L., & Blazer, D. (2011). Illicit and nonmedical drug use among older adults: a review. Journal of Aging
and Health, 23(3), 481-504.
ResearchGate has not been able to resolve any citations for this publication.
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The first edition of this book was based upon the recommendations of the Quality Assurance in the Treatment of Drug Dependence Project, and provided a step-by-step-guide for therapists working with clients with alcohol or other drug dependency or misuse. Since publication in 1995 it has become well known for its easy-to-read style and wealth of practical resource materials. However, the evidence in the field has moved forward in the last eight years, creating a need for an updated edition. Retaining the trademark easy-to-use, up-to-date style, the Second Edition offers new chapters on pharmacotherapies, case management, young people, and dual diagnosis. Other chapters have been updated to reflect the latest research findings and current practice, and the practice sheets and client handouts are made available online for downloading and customization by therapists.
To identify potential medication management issues associated with opioid use in older Australians. Retrospective cross-sectional review of the utilization of analgesics in 19,581 people who underwent a medication review in Australia between 2010 and 2012. Australian residents living in the community deemed at risk for adverse medication outcomes or any resident living fulltime in an aged care facility. Patient characteristics in those taking regularly dosed opioids and not and those taking opioid doses >120 mg and ≤120 mg MEQ/day were compared. Multivariable binary logistic regression was used to analyze the association between regular opioid and high dose opioid usage and key variables. Additionally, medication management issues associated with opioids were identified. Opioids were taken by 31.8% of patients, with 22.1% taking them regularly. Several major medication management issues were identified. There was suboptimal use of multimodal analgesia, particularly a low use of non-opioid analgesics, in patients taking regular opioids. There was extensive use (45%) of concurrent anxiolytics/hypnotics among those taking regular opioid analgesics. Laxative use in those prescribed opioids regularly was low (60%). Additionally, almost 12% of patients were taking doses of opioid that exceeded Australian recommendations. A significant evidence to practice gap exists regarding the use of opioids amongst older Australians. These findings highlight the need for a quick reference guide to support prescribers in making appropriate decisions regarding pain management in older patients with persistent pain. This should also be combined with patient and caregiver education about the importance of regular acetaminophen to manage persistent pain. Wiley Periodicals, Inc.
Substance misuse in the elderly population has been referred to as a silent epidemic. One of the factors that contributes to the appropriateness of this description is the difficulty of diagnosis in this age group. There is abundant evidence that substance misuse is under-diagnosed in elderly people and that this applies to both alcohol and drug misuse, although the general principles of a diagnostic approach are not age-related. The increased incidence of anxiety, depression, dementing illness, and physical illness in this population, independent of substance misuse, means that diagnoses can often be missed. The impact of co-morbidity (Figure 1) in older age groups is such that it remains the most important confounding factor in diagnosis. In this second section of the review we explore the range of psychiatric and physical illnesses that can coexist with, or be caused by, substance misuse in the elderly population. The issue of assessment as part of a treatment framework is considered in the third section of the review. The risk of missed diagnosis in this age group was illustrated in a study of diagnosis of substance misuse problems in patients aged 65 and over who had been admitted to hospital. Only three out of a total of 88 patients using benzodiazepines, 29 out of 76 smokers, and 33 out of 99 problem drinkers were correctly identified. Of those who were identified only a small proportion were referred on for specialist treatment.
Purpose: Substance misuse among older people is a growing concern. Treatment outcomes are perceived to be poor. The aim of the study was to examine the evidence for effective treatment for older substance misusers. Methods: PubMed, The Cochrane Library, Medline, Project CORK, and EMBASE were searched up to January 2007. Trials were included if participants were over the age of 50, sample size was sufficient, follow-up was undertaken, baseline and outcome measures were reported, the design was randomised controlled (RCT), controlled without randomisation or non-experimental descriptive, and pharmacological or psychological treatments for alcohol, nicotine, prescription medications or illicit drugs were investigated. Sixteen papers met inclusion criteria. Results: Most studies were carried out in the USA. Sample sizes ranged from 24 to 3622 (mean = 704) with follow-up from 1 month to 5 years (mean = 18 months). Eight randomised controlled trials and eight descriptive studies, covering alcohol with or without drug misuse (n = 11); methadone maintenance (n = 1), prescription drugs (n = 1), smoking (n = 3) were examined systematically. All had baseline and outcome measures, which varied across studies. Outcome depended on self-report in 11 out of 16 studies: most did not utilise biological measures or other corroboration. A range of psychological treatment interventions was tested. Older people do respond to treatment, do not achieve worse outcomes than younger counterparts, and sometimes do even better. Conclusions: This is the first systematic review on this topic. These preliminary results show an optimistic picture, which provides a foundation for further research to determine the most appropriate treatments for this group. © 2011 Elsevier Masson SAS and European Union Geriatric Medicine Society.
Background Links between alcohol consumption and depression have been reported; however, associations amongst the elderly remain unclear. We aimed to investigate the relationship between alcohol consumption and self-reported depression in a population-based sample of 514 men aged 65+ (median 76.4yr, IQR 71.2–82.4). Methods Alcohol intake over the previous 12 months was estimated from a food frequency questionnaire. Participants were classified as non-drinkers or habitual consumers of ≤2 or ≥3 standard drinks per day. Symptoms of past and 12-month depression were ascertained by self-report based on DSM-IV criteria. Using logistic regression, we estimated the association between alcohol intake and depression, adjusting for age and lifestyle factors. Results There were 91 non-drinkers (17.7%), 249 (48.4%) consuming ≤2 drinks/day, and 174 (33.9%) consuming ≥3 drinks/day. Forty eight (9.3%) were identified as having lifetime depression and 31 (6.0%) with 12-month depression. With those consuming ≤2 drinks/day as the reference, the odds of lifetime depression were greater for non-drinkers (OR=2.50, 95%CI 1.15–5.44) and tended to be greater for those consuming ≥3 (OR=1.45 95%CI 0.70–3.00). After excluding those with past depression, the likelihood of 12-month depression tended to be greater for non-drinkers (OR=2.38 95% CI 0.89–6.38) and those consuming ≥3 drinks/day (OR=1.68 95%CI 0.70–4.07). These associations were not explained by age, mobility, smoking, BMI, SES or number of medications. Conclusions These results suggest a U-shaped relationship between alcohol consumption and depression in this sample of elderly men.