A Review of Existing Treatments for Substance Abuse Among the Elderly and Recommendations for Future Directions

Background: With population aging, there is widespread recognition that the healthcare system must be prepared to serve the unique needs of substance using older adults (OA) in the decades ahead. As such, there is an increasingly urgent need to identify efficient and effective substance abuse treatments (SAT) for OA. Despite this need, there remains a surprising dearth of research on treatment for OA. Aims of review: This review describes and evaluates studies on SAT applied to and specifically designed for OA over the last 30 years with an emphasis on methodologies used and the knowledge gained. Methods: Using three research databases, 25 studies published in the last 30 years which investigated the impact of SAT on OA and met specific selection criteria were reviewed. Results: A majority of the studies were methodologically limited in that they were pre-to-post or post-test only studies. Of the randomized controlled trials, many were limited by sample sizes of 15 individuals or less per group, making main effects difficult to detect. Thus, with caution, the literature suggests that among treatment seeking OA, treatment, whether age-specific or mixed-age, generally works yielding rates of abstinence comparable to general populations and younger cohorts. It also appears that with greater treatment exposure (higher dosage), regardless of level of care, OA do better. Finally, based on only two studies, age-specific treatment appears to potentiate treatment effects for OA. Like younger adults, OA appear to have a heterogeneous response to treatments, and preliminary evidence suggests a possibility of treatment matching for OA. Conclusions: Expansion of research on SAT for OA is urgently needed for maximum effectiveness and efficiency of the healthcare system serving these individuals. Future research needs to include laboratory and community based randomized controlled trials with high internal validity of previously vetted evidenced-based practices, including Motivational Interviewing, cognitive behavioral therapy, and medications such as naltrexone, to determine the best fit for OA

Preliminary Efficacy of Motivational Interviewing on Problem Drinkers 55 and Older compared to Younger Counterparts

Background: Older adults who drink problematically are the largest group of substance users among those 55 and older. This group often chooses moderation as a goal instead of abstinence, and motivation and self-efficacy are found to have less of an impact on drinking compared to younger adults. No study has examined age effects (specifically 55 and older vs. younger counterparts) on motivational interviewing (MI) compared to brief advice with a sample that includes individuals over 65. Objective: To explore the moderating impact of age on heavy drinkers’ (aged M=50.7 years SD=11.6, range 23-73) response to MI. Methods: Data were from a randomized controlled trial testing stepped care brief interventions for alcohol use disorder. Participants were: 97 aged 22 - 54 years and 66 aged 55-73 years. For this study, generalized estimating equations were used to test drinks per drinking day (DDD) 4 weeks after 2 sessions of MI were implemented compared to brief advice alone. Results: There was no main effect of continuous age on DDD; however, individuals 55 and older demonstrated significantly lower DDD at week 8 than their younger counterparts (on average .20 of standard drink, B=-.17, SE=.07,

An exploratory study of mobile messaging preferences by age: Middle-aged and older adults compared to younger adults

Introduction: Mobile technologies, such as short message service or text messaging, can be an important way to reach individuals with medical and behavioral health problems who are homebound or geographically isolated. Optimally tailoring messages in short message service interventions according to preferences can enhance engagement and positive health outcomes; however, little is known about the messaging preferences of middle-aged and older adults. Methods: Utilizing secondary data, global messaging preferences were examined to inform the development of short message service interventions for adults of all ages. Two hundred and seventy-seven adults were recruited through an online labor market. They completed an online survey by evaluating message dyads in 22 content groupings. Dyads were identical in subject matter but structurally or linguistically varied. Participants selected the message in each dyad they would prefer to receive when attempting to meet a self-selected personal goal. Preferences were tested for two age groups 50 and 51 and older. Results: Findings reveal adults 51 and older have clear messaging preferences that differ significantly from the younger group for only two content groupings; specifically, they prefer no emoticon to a smiley face emoticon and ‘‘you’’ statements rather than ‘‘we’’ statements. Conclusion: Recommendations for optimizing messaging for older adults are reviewed

An overview of causal directed acyclic graphs for substance abuse researchers

Background. Within substance abuse research, quantitative methodologists tend to view randomized controlled trials (RCTs) as the “gold standard” for estimating causal effects, in part due to experimental manipulation and random assignment. Such methods are not always possible due to ethical and other reasons. Causal directed acyclic graphs (causal DAGs) are mathematical tools for (1) precisely stating researchers\u27 causal assumptions and (2) providing guidance regarding the specification of statistical models for causal inference with nonexperimental data (such as epidemiological data). Purpose. This manuscript describes causal DAGs and illustrates their use in regards to a long standing theory within the field of substance use: the gateway hypothesis. Design. Data from the 2013 National Survey of Drug Use and Health are utilized to illustrate the application of causal DAGs in model specification. Then using the model specification constructed via causal DAGs, logistic regression models are used to generate odds ratios of the likelihood of trying heroin, given that one has tried alcohol, marijuana, and/or tobacco. Conclusion. Granting the assumptions encoded in specific causal DAGs, researchers, even in the absence of RCTs, can identify and estimate causal effects of interest

More Than Taking a Chair: The Perceived Group Social Dynamics of Alcoholics Anonymous Related to Changes in Spiritual Practices

Alcoholics Anonymous (AA) meeting attendance and spiritual practices are established predictors of abstinence. This study utilized longitudinal data from two studies of AA to investigate 1) how perceived within meeting social dynamics in AA meetings affect later AA attendance, and thus exposure to the emphasis of spiritual practices and 2) influence the extent that spiritual gains are mobilized, beyond AA attendance. Findings revealed that greater group cohesion was associated with lower AA attrition, and that expressiveness, or openness, of the group predicted reported practice of spiritual behaviors. Findings reveal distinct group dynamics may foster distinct mechanism of change of AA attendees

Characteristics of individuals seeking a text messaging intervention for problem drinking: Adults 51 and older versus middle-aged and younger adults

According to the Institute of Medicine, the vast older adult population is estimated to have mental health and substance use disorders at unprecedented rates and will place high demand on an unprepared healthcare system. Online and mobile health interventions, such as text messaging, could provide an alternative form of frontline intervention that could alleviate some of the burden on the healthcare system; however, it remains unknown what are characteristics of adults over 50 who might be interested in a mobile health behavioral intervention and how they may differ from their younger counterparts. To explore the characteristics of those interested in a text messaging intervention by age, we examined screening data for a randomized controlled trial testing a text messaging intervention to reduce drinking among 1,128 hazardous and problem drinkers, aged 21-30, 31-50, and 51 and older. Participants were recruited online through website advertising on alcoholscreening.org and moderationmanagement.org. Results demonstrated that over a quarter of individuals pursuing online and/or text messaging treatment were 51 and older. These participants reported heavy drinking, with significantly greater number of days drinking and binge drinking than the younger groups, but with fewer consequences. Across age groups, a vast majority of participants were female. Findings demonstrate that a group of adult heavy drinkers 51 and older already pursue online treatment and are interested in using a text messaging intervention to help them reduce drinking, suggesting an avenue to engage this population using an alternative frontline treatment

An exploratory pilot study of mechanisms of action within normative feedback for adult drinkers

Background. Normative feedback (NF), or receiving information about one’s drinking compared to peer drinking norms, is one of the most widely used brief interventions for prevention and intervention for hazardous alcohol use. NF has demonstrated predominantly small but significant effect sizes for intention to change and other drinking related outcomes. Identifying mechanisms of action may improve the effectiveness of NF; however, few studies have examined NF’s mechanisms of action, particularly among adults. Objective. This study is an exploratory analysis of two theorized mechanisms of NF: discrepancy (specifically personal dissonance—the affective response to feedback) and belief in the accuracy of feedback. Method. Using Amazon’s Mechanical Turk, 87 men (n = 56) and women (n = 31) completed an online survey during which they were asked about their perceptions about their drinking and actual drinking behaviors. Then participants were provided tailored NF and evaluated for their reactions. Severity of discrepancy was measured by the difference between one’s estimated percentile ranking of drinking compared to peers and actual percentile ranking. Surprise and worry reported due to the discrepancy were proxies for personal dissonance. Participants were also asked if they believed the feedback and if they had any plans to change their drinking. Mediation analyses were implemented, exploring whether surprise, worry, or belief in the accuracy of feedback mediated severity of discrepancy’s impact on plan for change. Results. Among this sample of adult drinkers, severity of discrepancy did not predict plan for change, and personal dissonance did not mediate severity of discrepancy. Severity of discrepancy was mediated by belief in the accuracy of feedback. In addition, viewing one’s drinking as a problem prior to feedback and post-NF worry both predicted plan for change independently. Conclusions. Results revealed that NF may not work to create personal dissonance through discrepancy, but belief in the accuracy of feedback may be important. It appears the more one believes the feedback, the more one makes a plan for change, suggesting practitioners should be mindful of how information within feedback is presented. Findings also indicate NF may work by validating a preexisting perception that drinking is a problem instead of creating concern related to discrepancy where none existed. Limitations regarding generalizability are discussed

The independent relationship between trouble controlling Facebook use, time spent on the site and distress

Background and Aims There is an emerging literature base on the relationship between maladaptive traits and “addiction” to social networking sites. These studies have operationalized addiction as either spending excessive amounts of time on social networking sites (SNS) or trouble controlling SNS use, but have not assessed the unique contribution of each of these constructs on outcomes in the same models. Moreover, these studies have exclusively been conducted with younger people rather than a heterogeneous sample. This study examined the independent relationship of a brief Facebook addiction scale, time spent on Facebook, and Facebook checking on positive and negative social domains, while controlling for self-esteem and social desirability. Methods Participants were recruited using e-mail, SNS posts and through Amazon’s MTurk system. The sample included 489 respondents ages from 18 to approximately 70, who completed a 10–15 minute survey. Results Results indicate that neither time spent on Facebook nor Facebook checking was significantly associated with either self-esteem, fear of negative social evaluation or social comparison, while SNS addiction symptoms were each independently associated with Facebook usage. Neither time spent on Facebook nor SNS addiction symptoms were associated with positive social relationships. Discussion Overall results suggest that time on SNS and trouble controlling use should be considered independent constructs and that interventions should target underlying loss of control as the primary intervention target above ego syntonic time spent on the site

Characteristics of online treatment seekers interested in a text messaging intervention for problem drinking: adults 51 and older versus middle-aged and younger adults

According to the Institute of Medicine, the vast older adult population is estimated to have mental health and substance use disorders at unprecedented rates and will place high demand on an unprepared healthcare system. Online and mobile health interventions, such as text messaging, could provide an alternative form of frontline intervention that could alleviate some of the burden on the healthcare system; however, it remains unknown what are characteristics of adults over 50 who might be interested in a mobile health behavioral intervention and how they may differ from their younger counterparts. To explore the characteristics of those interested in a text messaging intervention by age, we examined screening data for a randomized controlled trial testing a text messaging intervention to reduce drinking among 1,128 hazardous and problem drinkers, aged 21-30, 31-50, and 51 and older. Participants were recruited online through website advertising on alcoholscreening.org and moderationmanagement.org. Results demonstrated that over a quarter of individuals pursuing online and/or text messaging treatment were 51 and older. These participants reported heavy drinking, with significantly greater number of days drinking and binge drinking than the younger groups, but with fewer consequences. Across age groups, a vast majority of participants were female. Findings demonstrate that a group of adult heavy drinkers 51 and older already pursue online treatment and are interested in using a text messaging intervention to help them reduce drinking, suggesting an avenue to engage this population using an alternative frontline treatment

Exploration of Treatment Matching to Problem Drinker Characteristics With Motivational Interviewing and Non-directive Client-centered Psychotherapy for Problem Drinkers

Motivational Interviewing (MI) is a known effective intervention for alcohol use disorder (AUD). MI\u27s mechanisms of action remain inconsistently substantiated, and research in this area has been reliant on identifying relationships through strength of association rather than experimental manipulation of active ingredients. In two previous studies, a pilot and a larger replication study, we disaggregated MI into its hypothesized active ingredients by creating three conditions: MI, Spirit Only MI (SOMI, in which evocation of change talk was proscribed), and a non-therapy condition (NTC). Results from both studies yielded equivalent findings across all three conditions. In the current analyses, data from both studies were combined to test five participant characteristics as moderators of MI\u27s component parts: 1) severity of baseline drinking, 2) severe AUD (met 6 or more criteria), 3) baseline self-efficacy to moderate drinking, 4) mean daily confidence to resist heavy drinking in the week prior to treatment initiation, and 5) depression. There were no significant findings related to baseline drinking, severe AUD, or baseline self-efficacy. Confidence yielded a significant interaction effect. When participants had high baseline confidence, drinking for those in MI increased compared to those in SOMI. Depression also yielded a significant moderating effect such that in the context of higher depressive symptoms, receipt of either therapy reduced drinking relative to NTC. Results are discussed in light of existing literature on MOBC with MI and the potential role exploring ambivalence may play for participants with particular characteristics