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Filling Efficacy Gaps in Older Adult Alcohol Use and Treatment Research

By Sue Coyle, MSW

Discussions of health tend to focus on the physical. Mental health only comes into play when that key word is added, and substance use is often a completely separate topic. In fact, only recently has society begun to seriously consider substance use a health issue.

As a result, services are more likely to be delivered in silos, with individuals seeking and receiving separate care for each concern—even when those concerns are overlapping. There are, of course, exceptions, but exceptions are not the norm.

Additionally, many treatment models and other services may be delivered to the individual but are designed for the general population—a population that is anything but uniform. This creates efficacy gaps for certain groups. Clients are done a disservice; the best possible care may not be offered or provided to all.

Fortunately, professionals throughout all health fields, including social work, are establishing where these gaps exist and what can be done to offer more coordinated inclusive care.

Drinking and Older Adults
A recent research study highlights these all-important needs.          

Orion Mowbray, MSW, PhD, an assistant professor at the University of Georgia School of Social Work, along with Assistant Professor Tiffany Washington, MSW, PhD; doctoral candidate Greg Purser, MSW; and Jay O’Shields, LMSW, alumnus of the University of Georgia and practicing social worker at Northridge Medical Center, recently looked at the prevalence of problem drinking among older adults and how health factors affect rates of problem drinking.

The term “problem drinking” is more broadly defined than alcoholism or a substance use disorder, Mowbray explains, because it comes from a rapid assessment instrument. “In most health care settings, it’s not efficient to do a full diagnostic assessment for a substance use disorder,” he says. “In substance use research, there are multiple valid and reliable brief screening instruments to detect whether people may have a substance use disorder.”

For their study, Mowbray and his colleagues used data from the National Social Life, Health and Aging Project, a nationwide survey of older adults. Those surveyed had completed the CAGE Questionnaire, an alcohol-related screening. “There’s a high reliability that people who score high on the CAGE also have an alcohol use disorder, but it’s not a true measure of a substance use disorder. We can’t say [‘substance use disorder’], so we call it ‘problem drinking,’” Mowbray says.

The CAGE questionnaire examines the consequences of alcohol use with the following questions:

  • Have you ever felt you should cut down on your drinking?
  • Have people annoyed you by criticizing your drinking?
  • Have you ever felt bad or guilty about your drinking?
  • Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)?

Other factors, such as frequency and quantity of consumption, are not examined.

When the researchers looked solely at the relationship between depression and problem drinking in older adults, there was not a strong connection. Mowbray says this is “pretty interesting when compared to younger adult populations.” Those populations tend to show a strong link between the two.

However, “When we look at only adults with chronic health problems, there was a strong link between depression and problem drinking,” Mowbray says. “When we talk about chronic health issues,” he continues, “we are talking about illnesses that can be managed but not necessarily cured. It [the illness] requires management over the life course.” Examples of chronic health conditions include diabetes, hypertension, arthritis, asthma, and COPD.

This link between chronic health issues, problem drinking, and depression is important to note because in the sample, 64% of respondents had two or more chronic health issues.

“Of the problem drinkers, 66% had multiple chronic health conditions and 30% reported depression,” Mowbray adds.

What, then, are the broad implications of these findings and—potentially—findings from other, similar studies?

Coordinated Care
First, no one aspect of health care can stand alone, a concept that Kerianne J. Guth, MSW, administrative director of addiction medicine at Cooper University Health Care in Camden, NJ, knows well.

“Without access to (and coverage of) all levels of substance use disorder treatment and high-quality coordinated medical services, recovery and wellness are much more difficult to achieve,” Guth says. “In my program, patients have both medical and social complexities that flare up and prevent an individual from attending to other needs.

“For example, I worked with a woman who suffered from unstable housing, opioid use disorder, untreated severe mental illness, diabetes, foot ulcers, vision loss, and a growing mass on her thyroid. Until we were able to provide her with really good medication-assisted treatment for her use disorder, she couldn’t even think about managing her mental health,” Guth says. “Once she engaged in stable treatment for both her mental health and addiction, she was able to address her diabetes with a regular insulin regimen and began exercising. Once her health conditions improved, she could spend time engaging with social service providers to help with housing. This successful outcome was due to her access to a variety of treatment options that met her needs and providers who communicated effectively about comanaging her care.”

When it comes to older adults, the need is that much more pronounced. “When you look at populations accessing care for mental and physical health needs, the aging population (who either rely heavily on family caregivers or have no one navigating with them) are most disserviced and vulnerable when care is not well coordinated,” Guth says. “Consider further the stigma of addiction and mental health treatment, let alone in older adults. Imagine if treatment or care coordination for substance use and mental health conditions came from an individual's trusted longtime primary care office.”

However, achieving such coordinated care is difficult, as the ability for providers to interface with each other regularly is limited. Guth says that electronic health records and information exchanges make such communication possible, but the tools are underutilized. “Even if the technology is there for the transfer of information, providers and organizations have to actually use it, and use it appropriately. For organizations, the time spent coordinating care for patients goes unreimbursed most often. It’s not captured in the current coding and billing system that most states and insurers regulate and has required tremendous innovation, grant funding, and creativity to work around the red tape that prevents providers and their multidisciplinary care teams from sustainably providing coordinated care,” she says.

The coordination, however, does sometimes happen, as evidenced by Guth’s example. But for it to occur more widely, all involved professionals, including social workers, need to take part in improving the system and services.

“Social workers are trained to meet patients where they are, often differently than medical professionals who are trained to solve problems within their clinical scope of training, not social complexities that impact medical care,” Guth says.

“Social workers continue to be the glue between the communities and the health care organizations. We are advocates for individuals, families, neighborhoods, and populations who may have small voices in the course of their care planning. We can speak the language of health care providers—demonstrate high levels of licensure and training while exercising our skills as relationship builders to keep individuals engaged in their options and decision making.”

Inclusive Care
The second implication of the findings is that research and treatment need to be more inclusive and diversely informed. As Mowbray says, the finding that depression and problem drinking were not strongly connected alone for older adults was surprising for the researchers. It provided just one example of how this population differs from younger adults, a more widely analyzed group.

“A lot of substance use research is directed toward younger adults,” he says. “That’s where the majority of individuals with substance use problems are.” As a result, the treatment models that evolve from the research may not address the unique health-related needs of older adults.

“I’d like to see more done to compare effective treatment strategies and how they work for older adults vs. younger adults,” Mowbray says. “We talk about motivational interviewing. Does that work the same [for both populations]? What about other forms of treatment? People go into inpatient care; they could go to intensive outpatient or [Alcoholics Anonymous] meetings. But do we know how well they work for older adults?”

On an even more basic level, the term “older adults” could be more firmly defined with more focus on this population. As it stands, the age brackets vary from source to source. “When I think about older adulthood, I think beyond years lived and about the social roles that a person occupies,” Mowbray says. “An older adult is someone who may be providing support to their own families, has achieved their own means of independence, and is transitioning away from employment-based roles.”

However, he says, “In the field of mental health and substance, use there isn’t agreement on what it means to be an older adult. We could mean age 50 or older. In our study it was 57 and older.” But even there, as lifespans grow longer, there are subsets of this population.

And that’s just one example. For truly comprehensive services to be offered all populations and their subgroups must have time, research, and services aimed at them. This may seem a daunting task, but with social workers at the helm—conducting research and providing services—it is achievable.

— Sue Coyle, MSW, is an award-winning freelance writer, a social worker in the Philadelphia suburbs, and a frequent contributor to Social Work Today.