Psychology Annotated bibliography (3)

Make sure you view both attachments for this assignment

An annotated bibliography is a reference list in which each entry is followed by an annotation or description of the source. For this assignment, do the following:

Use the same attached format for Annotated Bibliography Formatting Sample.(see attachment)
Include an APA-formatted title page.
Include four to six peer-reviewed sources.
Include a one-paragraph annotation in your own words for each source.

This will be the basis for your literature review in the Research Proposal assignment.

Please use the references below to complete this assignment and also follow the sample instruction on other attachment .

REFERENCE 1 Time-dependent neuroendocrine alterations and drug craving during the first month of abstinence in heroin addicts

Shi, J., Li, S., Zhang, X., Wang, X., Foll, B. L., Zhang, X., . . . Lu, L. (2009). Time-dependent neuroendocrine alterations and drug craving during the first month of abstinence in heroin addicts. The American Journal of Drug and Alcohol Abuse, 35(5), 267-272. doi:10.1080/00952990902933878

Abstract:

Rationale: Heroin use and withdrawal cause abnormality in the endocrine system. However, the time course of neuroendocrine alterations in heroin addicts during pharmacologically unassisted withdrawal is still unclear. Objectives: To investigate alterations in cortisol, adrenocorticotrophic hormone (ACTH), beta-endorphin (beta-EP), leptin, and neuropeptide Y (NPY) during the first month of abstinence in heroin addicts. Methods: Twelve heroin addicts and eight matched healthy control subjects were recruited for this study. The neuroendocrine alterations and self-reported heroin craving, anxiety, and depression in heroin addicts were assessed at different time points (days 3, 10, and 30) of first month of abstinence from heroin use. Results: Self-reported heroin craving, anxiety, and depression in heroin addicts decreased gradually during the first month of abstinence. The cortisol levels increased from abstinence day 3 to 30, while ACTH and beta-EP levels decreased over this period in heroin addicts. The leptin and NPY levels were significantly decreased on days 3 and 10 but had normalized on day 30 of abstinence. A positive correlation between cortisol level and heroin craving, anxiety, and depression was observed, while a negative correlation was observed between beta-EP level and craving and anxiety and between leptin and depression and NPY and anxiety. Conclusions: Abnormal alterations in the neuroendocrine system, including levels of cortisol, ACTH and beta-EP persist throughout the first month of abstinence. These results suggest that neuroendocrine system dysfunctions in heroin abusers is independent of the acute and protracted withdrawal syndromes, and may thus contribute to relapse to heroin use. [ABSTRACT FROM AUTHOR]

Reference 2 Drug Addiction, Relapse and Recovery

Campa A, Martinez SS, Baum M. Drug Addiction, Relapse and Recovery. J Drug Abuse. 2017, 3:1.

http://drugabuse.imedpub.com/drug-addiction-relapse-and-recovery.php?aid=18390

Received date: February 13, 2017; Accepted date: February 13, 2017; Published date: February 20, 2017

Citation: Campa A, Martinez SS, Baum M. Drug Addiction, Relapse and Recovery. J Drug Abuse. 2017, 3:1.

Visit for more related articles at Journal of Drug Abuse

Abstract

The illegality of drug use has prevented obtaining accurate assessment of the extent of their use and of the adverse effects in individuals and communities. The Centers for Disease Control estimates that approximately 10.2% of the population is involved in illicit drug use, and that among young adults between the ages of 18 and 25 years, illicit drug use is as high as 22% [1]. Recently, the increase in deaths from illicit drug overdose, particularly involving heroin, has become alarming. In 2013 alone, almost 44,000 deaths were related to opioid overdose from both prescribed and illegal sources [2]. From 2010 through 2013, the age-adjusted death rate from heroin overdose nearly tripled [2]. Moreover, the Center on Budget and Policy Priorities estimates that there are 2.8 million people with substance use disorders who currently receive coverage from the current Affordable Care Act (ACA). This coverage allows integrating addiction treatment programs into primary care clinics and health care systems nationwide, making a critical difference in the treatment and recovery from addiction [3]. These programs are needed to address harm reduction and drug prevention to focus as much on relapse reduction as on abstinence.

The use of Methadone as treatment for opioid addiction had already encountered mixed successes, particularly at the advent of the HIV epidemic. The fear of HIV transmission through the use of illicit drugs made medication treatment more politically acceptable and changed the focus of treatment from solely abstinence towards the prevention of relapses.

In Europe, new policies on needle exchange and long-term pharmaceutical treatment became the norm as an accepted strategy for HIV prevention [4]. In the United States, the needle exchange strategy is still controversial in spite of its proven effectiveness. Most of the new strategies entail the “chronic relapsing brain disorder” model [4], accompanied by the development of new pharmaceuticals as the strategy of choice, an approach that has been better accepted.

The stated goal of treatment has evolved from abstinence into “recovery,” which may include longer periods between relapses with the end-goal of potential abstinence. Recovery as a process integrates counseling and other psychological strategies accompanied by the use of pharmaceuticals, entailing a more holistic approach to the problem of addiction.

Prevention, especially targeted to adolescents, the most vulnerable age to become addicted to illicit drugs [5], is probably the most cost-effective and harm-reducing strategy; however, our nation needs to address established addiction in almost a quarter of the national group in the most productive age, and promote recovery as a constant fight against relapses, identifying addiction as a chronic and costly disease.

Therefore, to solve or alleviate the problem of addiction will take fostering political will for long-term investment of resources at a national level. The successful application of the changing paradigm for addiction treatment will depend on the economic and political environment, the evidence on its effectiveness, and the strength of the perception of the threat that illicit drug use poses to health, survival, and social stability.

References

Use of selected substances in the past month among persons aged 12 and over, by age, sex, race, and Hispanic origin: United States, 2002-2014.

(2015) Drug-poisoning Deaths Involving Heroin: United States, 2000-2013. Data from the National Vital Statistics System (Mortality) NCHS Data Brief No. 190.

Seelye KQ, Goodnoughfeb A (2017) Addiction treatment grew under health law. Now what? New York Times.

Berridge V (2012) Perspectives. Lancet.

Georgie JM, Sean H, Deborah MC, Matthew H, Rona C, et al. (2016) Peer-led interventions to prevent tobacco, alcohol and/or drug use among young people aged 11-21 years: A systematic review and meta-analysis. Addiction 111: 391-407.

Reference 3 Adolescent drug abuse - Awareness & prevention

Chakravarthy, Bharath, Shah, Shyam, Lotfipour, & Shahram. (2013). Adolescent drug abuse - Awareness & prevention. (Chakravarthy, Bharath; Shah: Institute for Clinical and Translational Science.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3734705/

The abuse of alcohol and illicit and prescription drugs continues to be a major health problem internationally. The United Nations Office on Drugs and Crime (UNODC) reports that approximately 5 per cent of the world's population used an illicit drug in 2010 and 27 million people, or 0.6 per cent of the worlds adult population, can be classified as problem drug users. It is estimated that alcohol abuse results in 2.5 million deaths per year and that heroin, cocaine and other drugs are responsible for 0.1 to 0.2 million deaths per year. In addition to causing death, substance abuse is also responsible for significant morbidity and the treatment of drug addiction creates a tremendous burden on society. UNODC estimates that worldwide costs related to treating drug abuse total $200-$250 billion, or 0.3-0.4 per cent of global GDP; additionally, it is estimated that only 20 per cent of drug users received treatment for their dependence in 20101.

Existing studies have found a high correlation between adolescent abuse and becoming a problem drug user in adulthood2; therefore, it can be inferred that many problem drug users start abusing drugs at an early age. Additionally, accidental and intentional fatalities that are associated with drug and alcohol use represent one of the leading

preventable causes of death for the 15 to 24-year-old population. Alcohol and other drug use in the adolescent population carries a high risk for school underachievement, delinquency, teenage pregnancy, and depression2.

Preventative science postulates that negative health outcomes, including those resulting from substance abuse, can be prevented by reducing risk factors and enhancing protective factors3. The general framework used in this article is based on research presented by the National Institute of Drug Abuse (NIDA) and emphasizes the strategy of targeting modifiable risk factors and enhancing protective factors through family, school and community prevention programmes.

Identify risk factors

Prevention of substance abuse among adolescents requires awareness of characteristics that place youth at risk and targeting risk factors that are modifiable. Many studies have attempted to identify risk factors associated with adolescent drug and alcohol usage.

In its 2010 report titled “Preventing Drug Use Among Children and Adolescents”, NIDA lists several factors that can enhance or mitigate adolescent risk for initiating or continuing to abuse drugs. These factors include exposure to drugs, socio-economic status, quality of parenting, peer group influence and biological/inherent predisposition towards drug addiction4. A retrospective study by Dube et al5 measured correlations between the number of adverse childhood experiences (ACEs) and future substance abuse behaviour. Adverse childhood events included abuse (physical, emotional or sexual), neglect (physical or emotional); growing up with household substance abuse, criminality of household members, mental illness among household members, and parental discord and illicit drug use. The study specifically compared the number of ACEs resulting in a greater likelihood of drug use initiation under 14 yr of age and also compared the number of ACEs associated with increased risk of developing addiction. The study demonstrated that each additional ACE increased the likelihood for drug use under 14 yr of age by two to fourfold and raised the risk of later addiction by five times. People with five or more ACEs were seven to ten times more likely to report illicit drug use than those with none5.

Hawkins et al3 also reviewed many studies that attempted to identify risk factors for adolescent drug abuse. They discussed specific risk factors occurring at the societal/community level and at the individual level. Of the societal risk factors, the following were identified: laws and norms favorable toward behavior (including lower minimum drinking ages) and availability. Interestingly, socio-economic status did not seem to correlate with increased risk of drug abuse among adolescents; it was only in cases of extreme poverty in conjunction with childhood behavioral problems where increased risk was observed. The personal characteristics that positively correlated with drug and alcohol abuse are numerous and include low harm avoidance, poor impulse control, parents with a history of alcoholism and drug abuse, high levels of family conflict, lack of and/or inconsistent parental discipline, a history of academic failure and a history of antisocial and aggressive behaviour3.

Being aware of these risk factors can assist families, health professionals, schools and other community workers with identifying at risk youth and aid in reducing or eliminating risk factors through prevention and treatment programs.

Prevention programs

Botvin et al6 cited several key factors required in prevention programmes to make them effective. These factors include a need to address multiple risk and protective factors, provide developmentally appropriate information relative to the target age group, include material to help young people recognize and resist pressures to engage in drug use, include comprehensive personal and social skills training to build resistance, deliver information through interactive methods and cultural sensitivity that includes relevant language and audiovisual content familiar to the target audience6. Successful prevention programmes should incorporate all of these characteristics and can then be provided through the family, school, community or healthcare community.

The 2010 NIDA Report4 emphasizes both the role of family and community prevention programmes as vital to deterring child and adolescent substance abuse. Their findings are summarized below:

Family prevention programmes: The NIDA Report emphasizes strengthening protective factors through the family, including increasing family bonding and using appropriate discipline. The following family characteristics place children at a higher risk for substance abuse: parent with a history of alcoholism and drug abuse, high levels of family conflict, lack of and/or inconsistent parental discipline. It follows that eliminating these risk factors can reduce the risk of a child/adolescent abusing drugs and alcohol. Once these risk factors are identified, families may benefit from formal prevention programmes that can focus on enhancing family bonding, parenting skills (including communication, rule-setting, appropriate disciplinary actions) and changing parental behaviours that may place a child at risk for later abuse4.

One example of a family prevention/treatment programme is multi-dimensional family therapy (MDFT). This is a comprehensive family-based outpatient or partial hospitalization (day treatment) programme for substance-abusing adolescents and those at high risk for continued substance abuse and other problem behaviours. MDFT focuses on helping youth develop more effective coping and problem-solving skills for better decision-making and helps the family improve interpersonal functioning as a protective factor against substance abuse and related problems. Liddle et al7 compared multi-dimensional family therapy with individual cognitive behavioural therapy (CBT) and found that although both treatments were promising, MDFT was more efficacious in treating substance use problem severity, in addition to creating more long lasting effects than standard CBT.

Community and school prevention programmes: In addition to family programmes, NIDA emphasizes school and community programmes as being beneficial in substance abuse prevention. The Report also suggests introducing programmes at an early-age (pre-school/first grade) to address risk factors for later substance abuse, such as early aggression, poor social skills and academic difficulty.

One of the many examples of school prevention programmes cited in the NIDA Report4 is Reconnecting Youth (RY); a school-based prevention programme for high school students with poor school achievement and a potential for not completing their education. Participants may also show signs of multiple problem behaviours, such as substance abuse, depression, aggression, or suicidal behaviours. Students are screened for eligibility and then invited to participate in the programme. The programme goals are to increase school performance, reduce drug use, and learn skills to manage mood and emotions. RY blends small group work (10-12 students per class) to foster positive peer bonding, with social skills training in a daily, semester-long class. Early experiments have shown that participation in RY improved school performance (20% improvement in grade point averages), decreased school dropout, reduced hard drug use (by 60%), and decreased drug use control problems, such as progression to heavier drug use8,9.

Role of healthcare providers in prevention: It is believed that less than 30 per cent of primary care providers perform any screening for substance abuse and as many as 69 per cent do not offer any type of counselling10. Hallfors et al11 cited the following barriers affecting the screening and prevention services in primary care: lack of tested screening tools, lack of knowledge, skills and confidence, financial disincentives (third party services for covering prescription abuse vary widely); and lack of follow up services and resource limitations.

Efforts from paediatricians and primary care providers to overcome these barriers can assist in identifying substance abusers and eventually lead to their treatment.

Conclusion

The abuse of alcohol and drugs has resulted in significant morbidity and mortality among adolescents worldwide. Many of these youth will lose their lives to drugs and alcohol and a significant number are likely to grow up to become problem drug users. Although, the substance abuse problem is complex and large in magnitude, there is a substantial amount of evidence-based research available to physicians, community leaders and schools to implement interventions that can decrease adolescent substance abuse rates. Because this issue is not peculiar to any one community or culture, we recognize that individual interventions may not be universally effective. Therefore, we emphasize the NIDA strategy of targeting modifiable risk factors and enhancing protective factors through family, school and community prevention programmes, as a generalized framework for healthcare and community activists to use when researching programmes and strategies best suited for their own community.

Footnotes

This editorial is published on the occasion of International Day Against Drug Abuse and Illicit Trafficking - June 26, 2013.

Article information

Indian J Med Res. 2013 Jun; 137(6): 1021–1023

Reference 4 Drug use and ageing: older people do take drugs!

Caryl M. Beynon; Drug use and ageing: older people do take drugs!. Age Ageing 2009; 38 (1): 8-10. doi: 10.1093/ageing/afn251

https://academic.oup.com/ageing/article/38/1/8/41284/Drug-use-and-ageing-older-people-do-take-drugs

Abstract

While usually perceived as behaviour of the young, use of illicit drugs by people aged 50 and over is increasing in Europe and the USA. This increase largely reflects the ageing of general populations, and people who use drugs continuing to do so as they age. For those people dependent upon drugs [usually users of opiates (heroin) and stimulants (cocaine, crack cocaine and amphetamine)], the last 30 years has seen the advent of effective treatment and harm minimisation initiatives and, coupled with general advances in medicine, has increased the life expectancy of these drug users. Drug use by older people presents unique problems; biological systems and processes alter naturally across the life course and the effect of concurrent drug use on some of these systems is not well understood. The natural progression of certain diseases means that symptoms only manifest in older age and the lives of older drug users are likely to be characterised by considerable levels of morbidity. Further work is needed on the epidemiology of drug use by older people---a group of people who currently represent a hidden and vulnerable population.

Substance abuse, defined here as the abuse of drugs and/or alcohol, is generally perceived as behaviour of the young, but evidence shows that abuse among older adults occurs and is increasing [1–4]. Estimates from Europe suggest that the number of people aged 65 and over with a substance abuse problem or needing treatment for an abuse disorder will more than double between 2001 and 2020 [3], while projections from the United States of America (USA) intimate that the number of adults aged 50 and over in need of substance abuse treatment will increase from 1.7 million in 2000 to 4.4 million in 2020 [4]. The trends described above largely reflect the fact that the general populations of these countries are ageing, and in particular reflect ageing of the baby-boom population—those born between 1946 and 1964. In 1900, the global population was estimated to have only 1% of people aged 65 years and over. By 2000 this figure was 7%, and by 2050, the estimated proportion will be 20% [5]. As the general population ages, those who continue to abuse substances, age also.

While alcohol use among older adults is documented, use of illicit drugs is largely unrecognised but increasing. Using data from Cheshire and Merseyside, the only large geographical area of the United Kingdom (UK) to collect prevalence-based drug treatment data since 1998, and thus the area best able to monitor trends in the age of drug treatment clients, Beynon et al. demonstrated a significant increase in the proportion of drug users aged 50 and over in contact with specialist drug treatment services; the proportion of people aged 50 and over increased between 1998 and 2004/2005 from 1.5 to 3.6% and 1.9 to 3.2% for men and women, respectively [1]. The authors identified a similar trend among those in contact with agencies that provide clean injecting equipment to drug users (syringe exchange schemes) with the median age of injectors in contact with such services increasing by almost 8 years over a 13-year period from 27.0 in 1992 to 34.9 in 2004. The UK's drug treatment services and syringe exchange schemes typically cater for drug-dependent people who are usually users of opiates (mainly heroin) or stimulants (cocaine, crack cocaine and amphetamine) or who inject drugs. The advent of effective treatment and harm minimisation initiatives for these drug-dependent individuals in the past 30 years or so, in addition to general advances in medicine, has increased the average life expectancy of a drug user, and the trends described here demonstrate their survival into older age. Outside the UK, the European Monitoring Centre for Drugs and Drug Addiction has highlighted ageing populations of opiate users in a number of European countries [6].

Accurate figures for the prevalence of illicit drug use in general populations are difficult to identify due to the covert nature of the activity. However, in Great Britain, changes in the age of people taking illicit substances are monitored through the British Crime Survey (BCS). Against a backdrop of significant falls in the rate of last-year prevalence for the use of any illicit drug for the youngest age groups (16–19, 20–24 and 25–29 years) between 1998 and 2006/2007, the BCS shows that illicit drug use among those aged 30–59 years has remained relatively stable and that the proportion of people aged between 55 and 59 years using illicit substances actually increased slightly [7]. No information on illicit drug use among people aged over 60 is available from the BCS because it does not collect this information due to the perceived ‘very low prevalence rates for use of prohibited drugs’ among people aged 60 and over [8], reflecting the prevalent attitude that older people do not use drugs.

Historically, global populations have not witnessed a large number of older illicit drug users and this has resulted in a perception that older people do not use these substances. However, cross-sectional studies fail to account for period and cohort effects and the likelihood that older people in the past did not use drugs because they did not use them when they were younger. Older people of today are using drugs because they did so when younger, and have done little to change their consumption as they have aged [4]. This premise is reflected by a quotation given in an interview with a UK newspaper by the author William Donaldson who was 69 at the time of the interview and an occasional user of crack cocaine: ‘What is a typical 65-year-old—Mick Jagger or Geoffrey Howe? Do you think everyone who took drugs in the 1960s suddenly stopped? People don't change. What you did at 25 you do at 65. At what point do you suddenly change? The heavy users in the 1960s are old men now—they won't have given up’ [9].

Whether there exists a second group of older users of illicit drugs—those who were abstemious when young but who commenced use in later life—remains unknown, because the lack of awareness of drug use among older populations has largely precluded any investigation of this issue.

Irrespective of the age when drug use commenced, population-level evidence from the USA shows that, in 2000/2001, 26% of people aged 50–69 had used some drug in their lifetime (including both illicit drugs and prescribed drugs used non-medically). Modelled projections suggest that for those aged 50–69 in 2020, the lifetime prevalence of drug use will increase to 56% [4]. If even a small proportion of these people have continued to use drugs as they have aged, the USA will experience a large number of older drug users.

Ageing users of illicit drugs present unique problems [10]. The brain changes in a variety of ways across the lifespan, for example, through alterations to the dopaminergic, serotonergic and glutamatergic systems. Illicit drugs act upon these neurotransmission systems, and how these changes alter drug–brain interactions and what implications these changes have for older drug users is not yet clear. In addition, chronic use of some drugs may exacerbate changes normally associated with ageing; people dependent upon on cocaine, for example, exhibit an increased number of age-related white matter (brain) lesions, which in turn are thought to be associated with cognitive abnormalities. Pharmacokinetics—the process by which a substance is absorbed, distributed, metabolised and eliminated from the body—also changes with age. Reductions in lean body mass and total body water content, coupled with reduced drug elimination by the kidneys, may increase elevated drug serum levels, and even moderate use of drugs may have significant effects [10]. Long-term drug use further increases the risk of certain morbidities already prevalent in older age such as myocardial, pulmonary and cerebral infarctions, which are associated with cocaine use. The natural progression of other diseases, for example, cirrhosis and other liver diseases (associated with hepatitis C infection contracted through the sharing of contaminated drug injecting equipment and/or excessive alcohol use), means that symptoms tend to only manifest in drug users of older age [11]. Concurrent ageing and drug use therefore create a discrete set of unique and, as of yet, not fully understood problems for older people [10]. Furthermore, tools that are used to screen for drug use have not been validated for use in older populations. The DSM (Diagnostic and Statistical Manual of Mental Disorders) IV for substance abuse, for example, was developed and validated in young and middle-aged populations and some criteria, such as a reduction in activity, may not be appropriate for older people whose levels of activity often naturally decline as they age [4, 10, 12].

In response, age-appropriate screening and diagnostic tools must be developed and treatment programmes accustomed to dealing with young drug users must adapt to meet the needs of their older counterparts [3]. Further research is needed on the epidemiological and treatment aspects of drug use in older people, and in particular, we need to understand the reasons for use because these may vary greatly from the reasons for drug use among younger people. In order to successfully address drug use by older people, we must primarily acknowledge that such use has no age limits.

Key points

Substance abuse (abuse of drugs and/or alcohol) among older adults is increasing; European estimates suggest the number of people aged 65 and over with substance abuse problems or requiring treatment for substance abuse disorders will more than double between 2001 and 2020. Projections from the USA estimate that the number of people aged over 50 needing treatment will increase to 4.4 million by 2020.
The use of illicit drugs by older adults is largely unacknowledged but will increase as the general population of many developed countries ages, and drug users continue to use drugs.
Concurrent ageing and the use of illicit drugs present unique problems for older people, particularly in terms of the chronic effects of drug use on ageing brains and bodies.
In order to successfully address drug use by older people, we must first acknowledge that such use has no age limits.

Reference Article 5 A Review of Existing Treatments for Substance Abuse Among the Elderly and Recommendations for Future Directions

Kuerbis, A., Moore, A. A., Sacco, P., & Zanjani, F. (2016). Future Directions for Aging and Alcohol. Alcohol and Aging, 261-274. doi:10.1007/978-3-319-47233-1_17

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3583444/

Alexis Kuerbis and Paul Sacco

Additional article information

Abstract (OA) older age (SAT) Substance abuse treatment (SUD) Substance use disorder (AUD) Alcohol Disorder

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.

Prevalence of substance use among OA

This generation of OA is distinct from generations past due to both their magnitude and their level of exposure to and attitudes towards drug and alcohol use.6,7 As a result, unhealthy substance use and substance use disorders (SUD) are estimated to be increasingly prevalent. Despite increasing evidence of substantial cocaine, heroin, and prescription drug use,7,8 alcohol remains the most commonly used mood altering substance among OA.7

The estimated prevalence of OA with alcohol use disorders (AUD) in the general population is approximately 4%, but may be as high as 22% among medical inpatients, those in outpatient geriatric psychiatric care, and those who present to emergency rooms.9–11 At-risk drinking (defined as drinking more than seven drinks per week) and binge drinking (defined as drinking more than 5 drinks on any one occasion) prevalence rates for OA are estimated at around 10%.10,12,13 While these rates of AUD and unhealthy drinking are lower than younger adults, they are likely impacted by underreporting of heavy drinking,14 difficulties with differential diagnoses of AUDs in OA, and unidentified co-morbidity.15

Illicit drug use is more common among American OA than among the elderly in almost any other country in the world.16 In 2007, 9.4% of adults ages 50–59 used an illicit or nonmedical drug in the past year,17 which marks an increase in drug use driven by the Baby Boom generation.18 OA ages 50 to 64 use more psychoactive drugs than individuals 65 and older.19 For example, 3.9% of adults 50 to 64 report past-year marijuana use compared to 0.7% of adults 65 and older. OA using cocaine, inhalants, hallucinogens, methamphetamine, and heroin in the past year are all estimated at less than 1%.17,19 Among those that do use them, 11.7% meet criteria for past-year SUD

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.

Keywords: older adults, alcohol, drugs, substance abuse treatment

Introduction

In 2011, the first of the Baby Boomers turned 65. Boomers make up 30% of the population in the United States.1 The US Census Bureau estimates the number of older adults (OA) will increase from 40.3 million to 72.1 million between 2010 and 2030.2 Lower birth rates3 and longer life expectancies1 contribute to ongoing growth of this population segment.

With population aging, there is widespread recognition that the healthcare system must prepare to serve the unique needs of OA in the decades ahead. Specifically, there is a call for expanded dissemination of knowledge about mental health services and substance abuse treatments (SAT).2,4,5 As such, there is increasing need to identify effective and efficient SAT for OA.

Prevalence of substance use among OA

Misuse of prescription and over-the-counter drug use among OA is also prevalent. Data from the National Surveys on Drug Use and Health20 revealed that 1.4% of adults 50 and older reported past-year non-medical use of prescription opioids, a rate higher than sedatives, tranquilizers, and stimulants. Actual prescription opioid use disorder among this same group was 0.13%, yet dependence was more common than abuse.17

SAT need among OA

Even if the proportion of OA needing treatment remains low, the actual numbers of individuals needing SAT will grow substantially2,4,18,21; however, research on service utilization demonstrates that the proportion of OA seeking SAT for the first time is also growing at a rate faster than that of younger adults.8 It is due to both an estimated 39% increase in the actual number of OA and an estimated 44% increase in the rate of treatment need that prevalence of SUD among people over 50 is expected to increase from an average of 2.8 million from 2002 to 2006 to 5.7 million in 2020.18

Existing knowledge about SAT for OA

Despite widespread acknowledgement of the impending “silver tsunami”2 of OA with SUD treatment needs, there remains a surprising dearth of research on treatment for OA. A variety of potential explanations for this exist, such as the myth that OA do not abuse drugs or alcohol, the myth that OA do not respond to treatments due to long addiction histories, and ageism.22 The perception that OA do not abuse substances arises in part from the tendency of OA to avoid seeking treatment due to shame, stigma, or the perception that their substance use is not severe enough to merit treatment.17,22 OA may also specifically avoid mixed-age treatment, the primary type of treatment available in the US,23 due to feelings of isolation and shame.

Additionally, OA have been systematically excluded from landmark SAT studies, such as Project MATCH.24 While such exclusions are often necessary for research, it has prevented the field from gaining important information about how current evidenced based practices impact OA substance use. Instead, research on OA SAT outcomes has been limited to primarily real world contexts—mainly pilot programs and brief interventions in primary care settings.

Over the last three decades, there have been a number of reviews of treatment research for OA.25–29 Each of these reviews had distinct goals—from a broad review to inform the public about available treatments25,28,30 to reviews of particular techniques used with OA for a number of health behaviors including substance abuse.26 This review adds to this literature by reviewing studies on SAT applied to and specifically designed for OA with an emphasis on the methodologies used and the knowledge gained. This is the first review to include studies published after 2000.

Method

Literature on SAT for OA was reviewed by searching three databases (PsycInfo, PubMed, and Social Science Citation Index) for peer-reviewed journal articles published over the last 30 years, using the keywords “older adult,” “elderly,” “treatment,” “drugs,” “drug use,” “alcohol,” “drinking,” and “substance use.” Studies were included in this review if: (1) at least one group examined in the study had a mean age of 55 or older; (2) the study involved participants undergoing a treatment for substance use; and (3) outcomes of treatment were reported and quantified in terms of substance use (eg, abstinence rates, quantity or frequency of use). All studies reporting treatment

utilization rates only or with outcomes but did not connect the two in a direct way in the analyses31 were excluded. In addition, one study was excluded due to a focus on a sample with comorbid, primary depression.32 Utilizing these selection criteria, a total of 30 articles, representing 25 studies, were identified, retrieved, and are reviewed below

Age-specific treatment

Thirteen studies (Table 2) examined the impact of age-specific treatment on substance using OA. Level of care ranged from BA to inpatient care. Five studies examined the effects of treatment on a veteran population; four took place in primary care settings.

Brief advice

One study examined the impact of BA on OA drinking and drinking problems. Fink and colleagues49 implemented a RCT examining the effect of written personalized feedback on 665 OA with nonhazardous, hazardous, and harmful drinking habits. In this study, three primary care sites were randomized to one of three conditions: patient report (given to patient only), combined report (report given to physician and patient), or usual care (UC, no report given).

Summary

Almost all of treatments demonstrated positive outcomes for OA—even with minimal intervention— both at end of treatment and follow-up. Treatment intensity varied from minimal (BA) to specialized inpatient treatment. Due to emphasis on harm reduction, the outcome of interest among BIs and BA tends to be the proportion of OA drinking at nonhazardous levels. While many BIs demonstrated significant differences between conditions on outcomes, a significant proportion (often over half) within all the BI studies remained at-risk drinkers56,61,63 (drinking beyond recommended guidelines22 for health and safety). In some cases, symptoms of problematic drinking or dependence persisted at the same rate even when quantity and frequency were reduced.60 Among the more intensive treatments, abstinence rate was the common marker of success. Among the general population, the estimated success rate of SAT a year post-discharge is 30%–50%.73 When reported, age-specific

Discussion

Several conclusions can begin to be drawn, with caution, from the findings of the above-described studies. First, OA presenting to SAT (ie, treatment seekers) are heterogeneous, with generally lower severity of alcohol problems than younger cohorts, even at similar rates of alcohol dependence. Among treatment seeking OA,

Studies comparing mixed-age and age-specific treatments

Only two studies directly compared mixed-age and age-specific treatments, and both utilized samples from a veteran population.75,76 The first study was a quasi-experimental study in which 33 participants in an age-specific outpatient treatment program were compared with 24 historical controls who had participated in the same treatment prior to the age-specific adjustments.75 Adjustments included an emphasis on socialization and support, a slower pace of treatment and a less confrontational style than the mixed-aged program. Outpatient treatment was defined as once– a–week groups. Participants were followed during the one year of treatment. Results demonstrated significant differences between the two program types on outcomes, such that participants in the age-specific program were more likely to stay in and complete treatment and have fewer irregular discharges. In addition, while there were equivalent rates of relapse, age-specific participants were more likely to have successfully treated relapses.

A randomized comparison trial explored the differential effectiveness of age-specific versus mixed-age inpatient and outpatient treatments on 166 veterans.76 Participants were randomly assigned to either the Older Alcoholic Rehabilitation (OAR) program or a traditional SAT program that emphasized confrontation. OAR utilized a special inpatient unit and emphasized peer support, promotion of self esteem, and time-limited goal setting.76 The philosophical approach of OAR was to be respectful of patients’ ages, by calling them “sir” and to tolerate being called “girl” if it was not meant to be disrespectful.76, Reminiscence therapy was used to help participants