Substance Misuse Treatment Framework (SMTF) Improving Access to Substance Misuse Treatment for Older People

Digital ISBN 978 1 4734 1824 0© Crown copyright 2014 WG22497

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Contents1. Purpose 2

2. Background 2 2.1 Context 2 2.2 SubstanceMisuseinOlderPeople 2 2.3 Drugs 3 2.4 Alcohol 3 2.5 Co-morbidityandComplexity 3 2.6 TheExtentofSubstanceMisuseinOlderPeople 4 2.7 ImplicationsforServices 4

3. ManagementofSubstanceMisuseinOlderPeople 5 3.1 Identification 5 3.2 EvidenceBaseforTreatment 6 3.3 BriefInterventions 7 3.4 SpecialistAssessment 7 3.5 Detoxification 8 3.6 PrescribingforOlderAdults 8 3.7 CarePathways 8

4. ImprovingAccesstoTreatment 9 4.1 PrudentHealthcare 9 4.2 Training 9 4.3 RangeofNeeds 10 4.4 Presentation 10 4.5 AwarenessandAttitudes 10 4.6 HomelessnessandHousingProblems 11 4.7 JointWorking 11 4.8 CommunityPharmacists 11 4.9 PrimaryCare 11 4.10AccidentandEmergencyDepartments 12 4.11 SubstanceMisuseServices 12 4.12 Dentists 12 4.13 OlderPeopleServices 12 4.14 ThirdSectorServices 12 4.15 LocalHealthBoards 13 4.16 AreaPlanningBoards 13

5. SummaryofRecommendations 14

References 15

Appendix–ServiceExamples 18

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1.PurposeThisdocumentprovidessomebackgroundinformationonsubstancemisuseinthoseovertheageof50.Itsfocusisonaccesstotreatmentanditoutlinesactionthatcouldbetakentoimprovethisatlocallevel.ItisaimedatLocalHealthBoards,SubstanceMisuseAreaPlanningBoards,substancemisuseandmentalhealthserviceproviders,LocalMentalHealthPartnershipBoards,localauthorityadultservicesandthoseworkinginprimarycare.Itisintendedtoinformthedevelopmentoflocalcarepathwaysandwillbeofrelevancetopractitionersandthoseresponsibleforplanningandmanagingservicesaswellasserviceusersthemselves.Thisdocumentmayalsobeofrelevancetoothersworkingwiththeolderpopulationincludinggeneralpractitioners,socialworkers,thirdsectorserviceprovidersandothersprovidinghealthandsocialcareforthisagegroup.

Preventionofsubstancemisuseisnotspecificallyaddressedwithinthisdocumentbuttherearespecificissuesinrelationtothisagegroupthatwillneedtobeconsidered.ActionsthatarebeingtakentopreventsubstancemisuseinolderpeoplearesetoutinWorking Together to Reduce Harm,theWelshGovernment’stenyearsubstancemisusestrategyandassociateddeliveryplan2013-2015.Furtherconsiderationwillalsoneedtobegiventoraisingawareness,amongstthepublicandprofessionals,ontheissueofsubstancemisuseinolderpeople.

AreaPlanningBoardsshouldreviewtheirexistinglocalcarepathwayswithaviewtoensuringthataccesstosubstancemisusetreatmentforthoseagedover50yearsisimproved.Thisreviewwillneedtotakeintoaccountlocalfactorsandserviceavailability.LocalauthoritieswillneedtoconsidertheneedsofolderadultswithsubstancemisuseproblemswithinSingleIntegratedPlans.

2.Background

2.1ContextSubstancemisuseamongolderpeoplereceivesrelativelylittleattention.Theevidencesuggeststhatitisnotidentifiedandtreatedadequatelyinthisagegroupdespitetheirgreatersusceptiblytoharmatlowerlevelsofusethanyoungerpeople.Thisisparticularlyconcerning,giventhemorepronouncedtrendinWalesforanincreasedageingpopulation.The2008-2018SubstanceMisuseStrategyforWales,Working Together to Reduce Harm,recognisesthischallengeandtheparticularneedsofolderpeople1.Living longer, ageing well2013-2023,theWelshGovernmentstrategyforolderpeopleinWalesaimstoaddressthebarriersfacedbyolderpeople2.Thestrategyrecognisesthatgoodphysicalandmentalhealthcontributesgreatlytooverallwellbeing.Otherinitiatives,suchasthehealthchecksprogrammeforpeopleagedover50arepartoftheoverallpolicyresponseandareaimedatallowingpeopletohavegreatercontrolovertheirhealthandwellbeing.

2.2SubstanceMisuseinOlderPeopleSubstancemisuseproblemsinthoseover50arepredominantlyrelatedtoalcoholuse;howeverbothillicitandprescribeddrugswillalsobeanissue.Ingeneral,oldermenareconsideredtobeatgreatestriskofsubstancemisuse,includingalcoholandillicitdrugsbutolderwomenmaybemoreatriskofproblematicuseofsedative/hypnoticandanxiolyticmedication3.

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2.3DrugsResearchsuggeststhatthoseolderpeoplewhouseillicitdrugslargelystartedforrecreationaluseasadolescentsoryoungpeople.Aproportion,however,dostartusinglaterinlife(intheirforties)asaconsequenceofadverselifeevents,tomanagepainorbecausetheyhadapartnerwhouseddrugs4.

Misuseinolderpeopleisnotrestrictedtoillicitdrugs.Theymayhaveproblemswithdependenceonprescriptiondrugsandoverthecountermedication.Problemswithprescriptiondrugscanbeexacerbatedbythecomplexityofregimes,hoardinganddrugsharingwithotherpeople.Misuseofsedativesandanalgesicsmaybeaparticularissue.Mixingofalcoholandprescriptiondrugsmayalsobeaproblem.

2.4AlcoholEarly-onsetdrinkersmayhavehadproblemsoverseveraldecadesbuthavesurvivedintoolderage.Later-onsetproblemdrinkersoftenbeginintheir50sor60sandtheirdrinkingmaybemoreassociatedwithlifeeventsandtransitionssuchaslossofapartner,retirement(lossofstatus,routine,boredom,theopportunitytospendmoretimedrinking).Lonelinessandisolationmaybefactorsandsomemaydrinkmoreinanefforttocopewithproblemssuchaspainorinsomnia.

Thereisdebateaboutwhatconstitutesharmful/hazardousdrinkinginolderpeople.TheRoyalCollegeofPsychiatristsarguethatcurrentsafelimitsarebasedonresearchonyoungerpeoplearguingthattheuppersafelimitforolderpeopleis1.5unitsadayor11unitsaweek3.Theyalsorecommendthatinolderpeoplebingedrinkingshouldbedefinedas>4.5unitsinasinglesessionformenand>3unitsforwomen.Giventhechangesinphysiologyaspeopleageitisprudenttoconsideralowerlevelinolderagegroups.ThereisageneralacceptanceinWales,thatthelowerlimitsrecommendedbytheRoyalCollegeofPsychiatristsshouldbeadoptedforthoseover65years.

2.5Co-morbidityandComplexitySomefactorsthatapplymoregenerallytoolderadultsmeanthatsubstancemisuseinthisgroupmaybemorecomplexandpresentmanagementproblemsthatdifferfromthoseinyoungerpeople.

Underlyingmedicalconditions,agerelatedchangesinliverandrenalfunctionandinteractionsbetweenmultiplemedicationsincreaserisksofolderpeopledevelopingsubstancerelatedproblemsatlowerlevelsofconsumption3.

Anxiety,depression,posttraumaticstressdisorder,druginducedpsychosis,schizophrenia,deliriumanddementiamayleadto,beaconsequenceoforcoincidewithdrugmisuse3.

Therelationshipbetweenalcoholandcognitiveimpairmentinolderpeopleiscomplex.Prolonged,excessiveusecanincreasetherisksofdementiaandalcoholrelatedcognitiveimpairment.Themanagementofthosewithalcoholmisuseanddementia/cognitiveimpairmentischallenging3.

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Somearguethatacutealcoholwithdrawalsyndromeismoreprotractedandsevereinolderpeoplethaninyoungerpeoplewithdrinkingproblemsofequalseverity5.Thishasledtotherecommendationthatwithdrawalinolderpeopleshouldbemanagedonalargelyinpatientbasis.

Thereissomeevidencethatolderadultsmayusealcoholtomanagepain.Olderproblemdrinkerstendtoreportmorepainthannonproblemdrinkers6.

2.6TheExtentofSubstanceMisuseinOlderPeopleTheUKhasanageingpopulationbutthistrendismostpronouncedinWales7.TheproportionoftheWalespopulationaged50+isprojectedtobe41percent(1,301,000)by2020withactualnumbersincreasingto1,398,000by2035.

The2007ONSAdultPsychiatricMorbiditySurveyfoundthatthreepercentofmenandonepercentofwomenagedbetween65and74and0.5percentofmenagedover75reportedalcoholdependenceinthelast6months8.Thosewhobeginmisusingsubstancesaftertheageof65aremostlikelytomisusealcohol.Prevalenceofdrugdependenceinthepastyearforthoseagedover65waslessthanonepercentforbothmenandwomen8.

Inthe2012WelshHealthsurvey10percentofthoseaged45andoverreportedtheiraveragefrequencyofdrinkingasalmosteveryday9.48percentofthoseaged45to64and26percentofthose65andover,reportedthattheirmaximumdailyalcoholintakeinthepastweekwasaboverecommendedguidelines.

During2012-2013thetotalnumberofpeopleaged50andoverreferredforsubstancemisusetreatmentinWaleswas3783.Ofthese3266werereferredbecauseofproblemswithalcohol;24.4percentofallreferralsforalcoholmisuse10.Overthelastfiveyearstheproportionofallthosereferredwhosemainproblemwaswithalcoholandwhoareagedover50hasincreasedbyaboutfivepercent10.

2.7ImplicationsforServicesGiventheincreasingnumberofpeopleagedover50intheWelshpopulationandtheincreasingproportionofthosepresentingfortreatmentitislikelythatdemandforservicesinthisagegroupwillincrease.Manyspecialistdrugandalcoholservicesarefundedfor,ortargetedat,workingageadults.Considerationneedstobegiventodevelopingspecialistservicesspecificallyforolderpeoplewithsubstancemisuseproblems.Suchserviceswouldalsoneedtotakeintoaccountthedifferingneedsacrosstheover50sagerange.

Whilstserviceuserinvolvementmustplayasubstantialroleintheprovisionofallsubstancemisuseservices,theconceptofco-productionmustalsobeconsideredbyservicecommissioners,providersandusers.

Theneedforthepublicsectortoembed‘co-production’intoserviceprovisionisbecomingapparent.NESTA(NationalEndowmentforScience,TechnologyandtheArts)describeco-productionas‘deliveringpublicservicesinanequalandreciprocalrelationshipbetweenprofessionals,peopleusingservices,theirfamiliesandtheirneighbours’.

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Co-productionalignstothehighestlevelofserviceuserinvolvement.Itallowsthoseserviceuserswhowishtobeinvolvedinco-commission,co-design,co-deliveryandco-evaluationofservices.OvertimeitisultimatelythislevelofserviceuserinvolvementwhichshouldbeaspiredtointheproductionofallsubstancemisuseservicesacrossWales.

InafewareasoftheUKspecialistsubstancemisuseservicesforolderpeoplearebeingdeveloped;thesetendtobeforthosewithco-morbidmentalhealthproblemsandnopublishedevidenceontheireffectivenesshasbeenidentifiedtodate10.SomeexamplesofservicesprovidedinWalesareincludedintheappendix.

3.ManagementofSubstanceMisuseinOlderPeople

3.1IdentificationItcanbedifficulttoidentifysubstancemisuseinolderpeople.Lackofawarenessandknowledgeregardingsubstancemisuseinthisgroupisasignificantbarrier.Clinicalandotherstaffworkingwitholderpeoplemaybereluctanttoraisetheissueofsubstanceusewiththisgroup.SubstancemisuseshouldbeconsideredinolderpeoplewhomakefrequentuseofhealthcareinprimarycareandparticularlyA&Edepartments(includingfractureclinics)andthoseusingmentalhealthservices5.Itshouldalsobeconsideredinthosepresentingwithselfneglect.Alcoholmisusemaybeanissueinsituationswheredomesticabuseisaproblem.Itshouldalsoberecognisedthatolderpeoplewithsubstancemisuseproblemsmaybeatgreaterriskofexploitation.Debtandlossofemploymentorarelationshipmayalsobesignsofanunderlyingsubstancemisuseproblem.

TheRoyalCollegeofPsychiatristsnotethattheInternationalClassificationofDiseases(ICD-10,WHO,1992)andDiagnosticandStatisticalManual(DSM-IV,AmericanPsychiatricAssociation,1994)criteriashouldbeadministeredthoughtfullyandwithclinicaljudgementwhenbeingusedtodiagnosesubstancemisuseinolderpeople3.TheyarguethattheDSM-IVcriteriainparticular,maynotbeadequatetodiagnoseolderpeoplewithsubstancemisuseproblems.

Assessmentshouldinvolveaninformant,forexampleafamilymemberorcarerandhomeassessmentmaybehelpfulastheenvironmentmayprovideevidenceofsubstancemisuse4.Involvementofaninformantmustbewiththeconsentoftheindividualbeingassessed.Assessinglevelsofconsumptioncanbedifficult,particularlywherethereiscognitiveimpairment.Signsandsymptomsofsubstancemisusemaybeattributedto,ormaskedby,otherproblems.Physicalsymptomsthatshouldtriggerscreeningforsubstancemisuseinclude11:

• Sleepcomplaints

• Cognitiveimpairment,memoryorconcentrationdisturbance

• Seizures,malnutrition,musclewasting

• Liverfunctionabnormalities

• Unexplainedmedicationinteractions

• Persistentirritabilitywithoutobviouscause

• Unexplainedchronicpainorothersomaticsymptoms

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• Incontinence,urinaryretention

• Poorhygieneandselfneglect

• Unusualrestlessnessoragitation

• Complaintsofblurredvisionordrymouth

• Unexplainednauseaandvomiting

• Changesineatinghabits

• Slurredspeech

• Tremor,poormotorcoordination,shufflinggait

• Frequentfallsandunexplainedbruising.

3.1.1Screeningtools

NICEguidance(www.nice.org.uk/nicemedia/live/13001/48984/48984.pdf)recommendsuseofAlcoholUseDisordersIdentificationTest(AUDIT)todecideonwhethertousebriefinterventionortorefertospecialistservices12.

TheRoyalCollegeofPsychiatrists(www.rcpsych.ac.uk/files/pdfversion/cr165.pdf)recommendthatGPsaskeverypersonover65yearsofageaboutsubstancemisuseaspartofaroutinehealthcheckusingspecifictoolssuchastheShortMichiganAlcoholismScreeningTest–Geriatricversion(SMAST-G)3.ThisisvalidatedforuseintheolderadultpopulationandtakesintoaccounttheRoyalCollegerecommendationswithregardtosafedrinkinglevelsinthisgroup.Theyfurtherrecommendthatthisscreeningincorporatescognitivetestingusingtools,forexample,theMini-MentalStateExamination(MMSE).Wherescreeningtoolsareusedthisshouldbeinconjunctionwiththoroughclinicalassessment3.

Theover50shealthcheckinWalesusesAUDITC.Opportunisticquestionsshouldbeconsideredasshouldwhenanindividualisundergoingmajorlifechangesortransitions.ScreeningshouldbeincludedasanelementoftheFrameworkonIntegratedAssessmentforOlderPeoplebeingdevelopedinWales.

Arangeofotherbriefandmoreindepthscreeningtoolsareavailable.Choiceoftoolwilldependonthesettingandspecificpurposeforwhichitisused.Thechosentoolshouldbevalidatedforuseinolderpopulations.

3.2EvidenceBaseforTreatment3.2.1Guidelines

Theevidencebaseforsubstancemisusetreatmentspecifictoolderpeopleissparse13buttheprinciplesoftreatmentintheworkingagepopulationapply14.NICEguidanceisavailableonDiagnosis,assessmentandmanagement15(www.nice.org.uk/nicemedia/live/13337/53191/53191.pdf)ofharmfuldrinkingandalcoholdependenceandontreatingthephysicalcomplications16(www.guidance.nice.org.uk/cg100/niceguidance/pdf/english)ofalcoholusedisorders.

TheUKclinicalguidelines(www.nta.nhs.uk/uploads/clinical_guidelines_2007.pdf)ondrugmisuseanddependencedonotspecificallyaddresstheneedsofolderpeople17.

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IntheUSAtheDepartmentofHealthandHumanServiceshaspublishedatreatmentimprovementprotocol(www.ncbi.nim.nih.gov/books/nbk64419/pdf/toc.pdf)onsubstanceabuseamongolderadults18.Thisisbasedonevidenceandprofessionalconsensusandwasrevisedin2012.

TheRoyalCollegeofPsychiatristsreport Our Invisible Addicts(www.rcpsych.ac.uk/files/pdfversion/cr165.pdf)makesrecommendationsontheassessmentandtreatmentofsubstancemisuseinolderpeopleanddiscussesappropriateservicemodels3.Thedocumentalsoprovidesguidanceonpharmacologicaltreatmentofsubstanceproblemsinolderpeople.

3.2.2Psychologicaltreatment

Evidenceshowsthatpsychologicaltreatmentsforolderpeoplewhomisusesubstances(overtheageof50)areeffectiveandinsomecasestheymayrespondbetterthantheiryoungercounterparts19.Thosewithlate-onsetsubstancemisusehaveabetterresponsetotreatmentthanthosewithearly-onset3.Cliniciansmaybereluctanttotreatsubstancemisuseinolderadults;howeverresponsetotreatmentislikelytobegoodandreducemortalityinthisagegroup.NICEhasissuedguidanceonpsychosocialinterventions(www.nice.org.uk/nicemedia/live/11812/35973/35973.pdf)fordrugmisuse20.

3.2.3Dualdiagnosis

Thereissomeevidencethatolderpeoplewithco-existingmentalhealthandsubstancemisuseproblemsrequireanintensivesupportservicethatisprimarilyhomebased,supportedbylinkstootherservicesandusingmotivationalapproachesmaybebeneficial13.

WelshGovernmenthasalreadyissuedaserviceframework(www.wales.gov.uk/topics/housingandcommunity/safety/substancemisuse/publications/cooccuring/;jsessionid=d2374060981f7b85c6ab9aa953738687?lang=en)onmeetingtheneedsofpeoplewithaco-occurringsubstancemisuseandmentalhealthproblems21andwillbere-issuingupdatedguidanceforconsultationlaterin2014.

3.3BriefInterventionsBriefinterventionisacost-effectivefirststepforthosewhosedrinkingmeetsdiagnosticcriteriaforharmfuluse5.Thesecanbedeliveredinprimarycareandothersettings.Admissiontogeneralhospitalmedicalwardsandtraumacentresofferstheopportunityforbriefinterventionwithheavyalcoholusersandthereisgoodevidencethatthisiseffectiveinreducingbothconsumptionanddeathrates22.

3.4SpecialistAssessmentTheWelshIntegratedIndepthSubstanceMisuseAssessmentTool(www.wales.gov.uk/topics/housingandcommunity/safety/substancemisuse/publications/wiismat/;jsessionid=d2374060981f7b85c6ab9aa953738687?lang=en)(WIISMAT)providesassessmentinrelationtosubstancemisuse23.Thoroughphysicalassessmentisneededastreatmentneedstotakeaccountofco-morbidphysicalproblemsincludingneuropsychiatricdisorderandhepaticandrespiratorycomplications.Afullhistoryshouldbetakenincludingcollateralhistoryfromareliableinformant3.

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3.5DetoxificationOut-patientdetoxificationmaynotbeappropriateforolderadultswhoarefrail,wholivealonewithlimitedsupport,orwhohavemultiplemedicalproblems5.ThetreatmentimprovementprotocolfromtheUSAalsorecommendsthatwithdrawalfromalcoholorprescriptiondrugsshouldbeonaninpatientbasisforsomepatients18.Thefollowingareindicatorsoftheneedforinpatientsupervision:-

• Highpotentialfordevelopingseizuresordeliriumbecausethedosageofbenzodiazepineorbarbituratehasbeenparticularlyhighorprolongedandhasbeenabruptlydiscontinuedorbecausethepatienthaspreviouslyexperiencedserioussymptoms.

• Anypatientwheretherehasbeenapasthistoryofcomplicatedalcoholwithdrawals(forexamplewithdrawalseizures,deliriumtremens,acuteconfusionalstates).

• Suicidalideationorthreatsorothermajorpsychopathology.

• Unstableoruncontrolledmedicalco-morbiditiesrequiring24hourcareorparenterallyadministeredmedications(forexamplerenaldisease,diabetes).

• Mixedaddictions,includingalcohol.

• Patientlivesaloneandhascontinuedaccesstoabusedsubstance(s).

TheWelshGovernmentcontinuestoringfence£1mofitssubstanceMisuseActionFundspecificallyforResidentialRehabilitationandInpatientDetoxification.AnAllWalesTier4brochureandapreferredresidentialrehabilitationproviderlistforWalesarecurrentlybeingdeveloped.

3.6PrescribingforOlderAdultsOlderadultspresentingwithaddictiontoopioids(prescribedorillicit)mayrequiresubstituteprescribing.Cautionmayberequiredbecauseofreducedhepaticfunctionassociatedwithageandtheissueofpolypharmacyinolderadults.However,patientsshouldnotbedeniedeffectivetreatmentsimplyonthebasisofage.Referraltospecialistswithexperienceofprescribingforthisgroupmaybenecessary.

Relapsepreventionprescribingmayalsobeappropriateinolderadults.Extremecareneedstobetakenwithdisulfiramandhepaticfunctionneedstobemonitoredwhentreatingwithnaltrexone.

3.7CarePathwaysThisdocumentfocusesonaccesstotreatment.Comprehensivecarepathwayswillneedtobedevelopedtakingaccountofspecificlocalcircumstances,needs,serviceavailabilityandaccess.Aswellastheissueshighlightedinthissection,followupandaftercareprovisionwillneedtobeconsidered.

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4.ImprovingAccesstoTreatment

4.1PrudentHealthcarePublicservicesinWalesarerequiredtomovetowardsacultureof‘prudenthealthcare’–notprovidingtreatmentwhereitisunlikelytobenefitthepatient,orcoulddoharm.Prudenthealthcareinthiscontextrequirestherightserviceinterveningattherighttimeandintherightway.Wheremorethanoneserviceisrequiredtointervenethisshouldbedonecollaborativelymakingbestuseofresources,ensuringaproportionateresponseandavoidingduplicationofeffortandtreatment.

Thisculturalshiftisofrelevancewhencommissioningolderpeople’ssubstancemisuseservicesasweneedtoensurethatservicesareefficient,effectiveandempowering.Toassistthefollowingbroaderprincipleshavebeendeveloped:

• Donoharm.Theprinciplethatinterventionswhichdoharmorprovidenoclinicalbenefitareeliminated.

• Carryouttheminimumappropriateintervention.Theprinciplethattreatmentshouldbeginwiththebasicproventestsandinterventions.Theintensityoftestingandtreatmentisconsistentwiththeseriousnessoftheillnessandthepatient’sgoals.

• Organisetheworkforcearoundthe“onlydo,whatonlyyoucando”principle.TheprinciplethatallpeopleworkingfortheNHSinWalesshouldoperateatthetopoftheirclinicalcompetence.Nobodyshouldbeseenroutinelybyaconsultant,forexample,whentheirneedscouldbeappropriatelydealtwithbyanadvancednursepractitioner.

• Promoteequity.Theprinciplethatitistheindividual’sclinicalneedwhichmatterswhenitcomestodecidingNHStreatment.

• Remodeltherelationshipbetweenuserandprovideronthebasisofco-production.

4.2TrainingAppropriateeducationandtrainingisneededforabroadrangeofprofessionalhealthcarestafftoensurethatsubstancemisuseinolderpeopleisdetectedandmanaged.Thiswillincludeallservicesspecificallyforolderpeople(providingbothphysicalandmentalhealthcare)aswellasmoregenericservicesforexamplesexualhealthservices.Trainingshouldalsobegiventothoseworkinginotherrelevantagenciessuchassocialservices,socialcareandhousingproviders,relevantthirdsectoragencies,thoseworkingwiththehomeless,thepoliceandothercriminaljusticeservices.Educationandtrainingshouldaimtoincreaselevelsofawarenessandunderstanding,addressanyreluctancetoraisethetopicofsubstancemisusewitholderpeople,enableonwardreferral/signpostingand,forrelevantstaff,developskillsinscreening,assessment,basicmanagement,knowledgeofspecialistservicesandreferralpathways.BriefinterventiontrainingisavailableinWalesandshouldalsobeconsidered.

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4.3RangeofNeedsThetermolderpeopleinthecontextofthisdocumentencompassesabroadagerangeandneedswithinthismaydiffer.A50yearoldwithasubstancemisuseproblemislikelytoneedadifferentservicetothatprovidedtoa75yearold.Ageofonset,co-morbidityandavailabilityofsupportnetworkswillneedtobeconsideredinthedevelopmentofindividualcareplans24.

‘Morethanjustwords…/Mwynageiriau…’isthestrategicframeworkdevelopedtoensurethatWelshspeakerscanaccessservicesinHealthandSocialServicesintheWelshLanguage.WeknowthatwhereWelshisafirstlanguage,beingabletouseandreceiveservicesinthislanguageoptimisessuccessfuloutcomesfortheserviceuserandthereforeshouldbeacorecomponentofcareandnotanoptionalextra.EffectivecommunicationisakeyrequirementofcareservicesandtheWelshLanguageinSocialCareframeworkrecognisesthisneedacrossallaspectsofphysicalhealthandmentalhealthcare.

4.4PresentationThepresentationofsubstancemisuseproblemsmaydifferinolderpeople.Forexampletheyarelesslikelytobeinvolvedinantisocialbehaviourandcriminalactivity.Substancemisusepresentationmaybenon-specificandmaypresentasotherdisorders,forexample,weightloss,neglect,falls,depressionorcognitiveimpairment.

Inthosepresentingfrequentlytohealthcare,forexampleinprimarycareorA&E,substancemisuseshouldbeconsidered.Substancemisuseshouldalsobeconsideredinthosepresentingtogeneralmedicine,gastroenterologyandoldagepsychiatry.Evidencesuggeststhatupto30percentofhospitalisedolderpatientsongeneralmedicalwardsmayhavehighlevelsofalcoholuse25.ResearchundertakenintheUKhasshownthatmedicalstaffmayfailtoidentifyuptotwothirdsofproblemdrinkersandmistakebothdementiaanddepressionforsubstancemisuse26.Presentationcouldalsobetootheragenciessuchassocialservicesorthepolice3.

4.5AwarenessandAttitudesHealthcareandotherstaffmaynotconsidersubstancemisuseinolderpeople.Theymaybereluctanttoraisethetopic.Somemaybelieveitisinappropriatetoaskolderpeopletogiveupestablishedhabits3.Thosewithsubstancemisuseproblems,theirrelativesorcarersmaybereluctanttoprovideinformation.Itisrecognisedthatevenwheremisuseisidentifiedinolderpeopletheyarelesslikelythantheiryoungercounterpartstobereferredtospecialistservicesorreceiveadequatetreatment.

RaisingawarenessandunderstandingofissuesassociatedwithsubstancemisuseinolderagehasbeenhighlightedasanissueintheStrategyforOlderPeopleinWales2013-2023.TheAdvisoryPanelonSubstanceMisuse(APoSM)willalsobetakingraisingawarenessintoconsiderationaspartoftheirreviewofthepolicyinterventionsnecessarytotacklesubstancemisuseinanageingpopulation.

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4.6HomelessnessandHousingProblemsOlderpeoplewithsubstancemisuseproblemsmaybeatriskoflosingtheirtenancies.Lossofaccommodation,rentarrearsordeteriorationintheirlivingenvironmentmaybesignsofaproblem26.Housingrelatedsupportprovidersmanagingtenancyrelatedproblemsinolderpeople,particularlywherethesehavenotpreviouslybeenissues,shouldconsiderifsubstancemisuse,particularlyalcohol,maybeafactorandmakeappropriateonwardreferral.Akeyactionofthe‘Working Together to Reduce Harm Substance Misuse Delivery Plan 2013-2015’istoreducehomelessnessandhelppeoplewithsubstancemisuseproblemssustaintheirtenancies.

Older,homelessmen(whomaybeheavydrinkersorhavealcoholrelatedproblems)willneedtobeconsiderediftheyaretobesuccessfullyhoused3.Evidenceshowsthat‘housingfirst’approachesthatofferimmediateaccesstohousingandsupportforhomelesspeoplewithmentalillnessand/orsubstancemisuseproblemstoindependenthousingandsupportiveserviceswithoutanyrequirementforthemtofirstengagewithtreatment,canbeeffective27.

TheSupportingPeopleRegionalCollaborativeCommitteeinplaceacrossWalesprovideforawherehealthpractitionerscanworkwithlandlords,localauthoritySupportingPeopleteamsandtheThirdSectorhousingrelatedsupportproviderstoensurethatthereisanappropriatespectrumofservicestoaddresstheneedsofolderpeoplewithcooccurringhousingandsubstancemisuseneeds.

4.7JointWorkingEffectivemanagementofolderpeoplewithsubstancemisuseproblemswillrequirejointworkingbetweenspecialistalcoholanddrugservicesandotherserviceswitharoleincaringforthem.Thismayincludeolderpeople’steamsfrombothgeneralandmentalhealthservices.SharedcarewithGPsshouldalsobeencouraged.Wherethepatienthasdualdiagnosistherewillneedtobeclarificationofresponsibilitiesandaccountability(includingunambiguousclinicalresponsibility)betweenmentalhealthandsubstancemisusetreatmentservices.Considerationshouldalsobegiventowhereservicesareprovided;venuesneedtobeacceptabletoolderpeopleforexampleattendingahospitaloutpatientdepartmentoraGPsurgerymaybepreferabletoattendingservicesinvenuesspecificallylabelledasdrugandalcoholservices.

4.8CommunityPharmacistsCommunitypharmacistsmaybebestplacedforsurveillanceofrepeatprescriptionsandsupervisionofoverthecountersales.Acomparativelythoroughassessmentofanolderperson’sproblemsandprescribedmedicationmayhelptoreducemisuse3.

4.9PrimaryCareGPsshouldaskeverypersonincludingthoseover65yearsofageaboutsubstancemisuseaspartofanyroutinehealthcheck,suchasanewpatientquestionnaire.Briefinterventiontrainingshouldbeconsideredforprimarycarestaff.Allclinicalstaffworkinginprimarycareshouldhavetrainingtoincreasetheirunderstandingofsubstancemisuseinolderpeople,addressanyreluctancetoraisetheissueandensurethatappropriatereferralstospecialistservicesaremade.

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4.10AccidentandEmergencyDepartmentsStaffinaccidentandemergencydepartmentsshouldhavetrainingtoensurethattheyunderstandtheextentandnatureofsubstancemisuseinolderpeople.Substancemisuseshouldalwaysbeconsideredinfrequentattendersandthosepresentingwithfallsorselfneglect.Briefinterventionstrainingforstaffshouldbeconsideredwherenotalreadyoffered.Whereavailableinaccidentandemergencydepartments,mentalhealthliaisonservicescanprovidealinkforolderpeoplewithsubstancemisuseproblems.

4.11SubstanceMisuseServicesSpecialistsubstancemisuseservicesshouldconsiderthespecificneedsofolderpeople,takingaccountofdifferingneedsacrosstheover50sagerange,includingculturaldifferencesandensuringthosewithadisabilityhaveequalaccesstoservices.Clinicalstaffneedappropriatetrainingtoequipthemtomanagecomorbidityandthecomplexityofsubstancemisuseinthisagegroup.Thereshouldbeeffectivejointworkingwitholderpeoplesphysicalandmentalhealthservicesandclearagreementsonclinicalresponsibility.WhereaddictiontoprescribedpainkillersisanissueGPsandspecialistpainservicesshouldbeinvolved.

4.12DentistsDentistsandtheirteamsmaybeinagoodpositiontodetectalcoholabuseandoralchangesduetosubstancemisuseasalcoholcancontributetothedevelopmentofmouthcancer.Substancemisusersareatriskofarangeoforaldiseaseasaresultofsubstancemisuseitselforpoororalhygieneandfrequentsugarintake.Dentalteamsfrequentlyseepatientsformanyyearsandmaybecomeawareofclinicalandbehaviouralchangeswhichindicateabuseofalcoholordrugs.Theywillneedtohandleissuesofsubstancemisusewithsensitivity–advisingtheirpatientofanyriskstooralhealthanddirectingpatientstoappropriatesupportservices.Dentalteamsworkinginprimarycareshouldhavetrainingtoincreasetheirunderstandingofsubstancemisuseinolderpeople,addressanyreluctancetoraisetheissueandensurethatappropriatereferralstospecialistservicesaremade.

4.13OlderPeoplesServicesLiving Longer, Ageing Well 2013-2023,theWelshGovernmentStrategyforOlderPeopleinWalesaimstoaddressthebarriersfacedbyolderpeopletoaccessinghealthandotherservices2.Staffworkinginolderpeoplesservices,inparticularoldagepsychiatry,generalmedicineandgastroenterology,shouldconsidersubstancemisuseinthosepresentingfrequentlytoservices.Stafftrainingshouldfocusonaddressinganyreluctancetoraisethistopicwitholderpeopleandtoreferthemtospecialistservices.

4.14ThirdSectorServicesThirdsectororganisationsshouldconsiderawarenesstrainingforstaffprovidingservicesforolderpeopletoincreasethelikelihoodthattheywillrecogniseolderpeoplewithsubstancemisuseproblems.Organisationsshouldalsoconsiderwhethertheremightbebenefitintrainingsomeoftheirstafftodeliverbriefinterventions.

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4.15LocalHealthBoardsLocalHealthBoardswillneedtoensurethattheStrategyforOlderPeopleinWalesisimplemented2.Theywillneedtoensurethatsubstancemisuseservicesmeettherangeofneedspresentedbythoseagedover50years.

4.16AreaPlanningBoardsAreaPlanningBoardswillneedtoreviewtheirexistingcarepathwaystoensurethatolderpeoplewithsubstancemisuseproblemsareidentifiedandthattheirneedsareappropriatelymetbyexistingservices.AreaPlanningBoardsarerequiredtoproduceaSubstanceMisuseCommissioningStrategywhichhasbeeninformedbyarobustneedsanalysis.AspartoftheneedsanalysisAPBsshouldreviewtheirexistinglocalcarepathways(takingintoaccountlocalfactorsandserviceavailability)withaviewtoensuringthataccesstosubstancemisusetreatmentforthoseagedover50yearsisimproved.

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5.SummaryofRecommendations• AreaPlanningBoards,LocalHealthBoardsandlocalauthorityadults

servicesshouldworktogethertoreviewexistinglocalcarepathwayswithaviewtoensuringthataccesstosubstancemisusetreatmentforthoseagedover50yearsisimproved.LocalMentalHealthPartnershipBoardsshouldalsobeinvolved.ThisreviewshouldbeundertakenaspartoftheneedsanalysisinformingAPBcommissioningstrategiesandwillneedtotakeintoaccountlocalfactorsandserviceavailability.

• Considerationshouldtobegiventodevelopingspecialistservicesspecificallyforolderpeoplewithsubstancemisuseproblems.Suchservicesshouldalsotakeintoaccountthedifferingneedsacrosstheover50’sagerange.

• Substancemisuseshouldbeconsidered,andwherenecessaryaddressed,inolderpeoplewhomakefrequentuseofhealthcareinprimarycarebutalsoA&Edepartments(includingfractureclinics)andthoseusingmentalhealthservices.Itshouldalsobeaddressedinthosepresentingwithselfneglect.

• PeopleinWalesshouldbeencouragedtoundertakeaselfassessmentthroughthe‘Addtoyourlife’assessmentforover50sincludingdetailedquestionsonalcoholwww.addtoyourlife.co.uk/

• Whereolderpatientspresentwithanysymptomsthatmightsuggestalcoholorothersubstancemisuse,GPsshoulduseappropriatetools,suchastheShortMichiganAlcoholismScreeningTest–Geriatricversion(SMAST-G)toassessolderpeopleinordernottomisswhatisanincreasinglycommonproblem.

• GPsshouldconsideropportunitiestoidentifysubstancemisuseissuesfornewlyregisteredpatientsincludingthoseover65yearsofage.

• Appropriateeducationandtrainingisneededforarangeofprofessionalhealthcarestafftoensurethatsubstancemisuseinolderpeopleisdetectedandmanaged.Trainingonsubstancemisuserelatedissuesshouldalsobegiventothoseworkinginotherrelevantagenciessuchassocialservices,socialcareandhousingproviders,relevantthirdsectoragencies,thoseworkingwiththehomeless,thepoliceandothercriminaljusticestaff.

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References1. WelshAssemblyGovernment.(2008).Working together to reduce harm.

The substance misuse strategy for Wales 2008-2018.Cardiff:WAG.Availableat:www.wales.gov.uk/dsjlg/publications/commmunitysafety/strategy/strategye.pdf;jsessionid=2F329C62AD4CA3C5315EE02F2A4AB3CA?lang=en[Accessed6November2012]

2. WelshAssemblyGovernment.(2013).Living longer, ageing well. The strategy for older people in Wales 2013-2023.Cardiff:WG.Availableat:www.wales.gov.uk/docs/dhss/publications/130521olderpeoplestrategyen.pdf[Accessed4Aug2014]

3. RoyalCollegeofPsychiatrists.(2011).Our invisible addicts. First report of the older persons’ substance misuse working group of the Royal College of Psychiatrists. College Report CR165.London:RCPsych.Availableat:www.rcpsych.ac.uk/files/pdfversion/CR165.pdf[Accessed8Jan2013]

4. RoeBetal.(2010).Experiencesofdruguseandageing:health,qualityoflife,relationshipandserviceimplications. J Adv Nurs66(9):pp.1968-79

5. BadrakalimuthuVR,RumballDandWagleA.(2010).Drugmisuseinolderpeople:oldproblemsandnewchallenges.Adv Psychiatr Treat16(6):pp.421-9

6. BrennanPL,SchutteKKandMoosRH.(2005).Painanduseofalcoholtomanagepain:prevalenceand3yearoutcomesamongproblemandnonproblemdrinkers.Addiction100:pp.777-86

7. WelshAssemblyGovernment.(2008).Mid-year population estimates 2007.Cardiff:WAGStatisticalDirectorate

8. McManusSetal.(2007).Adult psychiatric morbidity in England, 2007. Results of a household survey.Leeds:HSCIC.Availableat:www.hscic.gov.uk/catalogue/PUB02931/adul-psyc-morb-res-hou-sur-eng-2007-rep.pdf[Accessed4Aug2014]

9. WelshGovernment.(2012).Welsh health survey 2011.Cardiff:WG.Availableat:www.wales.gov.uk/docs/statistics/2012/120919healthsurvey2011en.pdf[Accessed4Aug2014]

10. WelshGovernment.(2014).Substance misuse statistics.Cardiff:WG.Availableat:www.wales.gov.uk/statistics-and-research/substance-misuse/?lang=en#/statistics-and-research/substance-misuse/?lang=en[Accessed4Nov2013]

11. LangIetal.(2007).Whatlevelofalcoholconsumptionishazardousforolderpeople?FunctioningandmortalityinUSandEnglishnationalcohorts.J Am Geriatr Soc55:pp.49-57

12. NationalInstituteforHealthandClinicalExcellence.(2010).Alcohol-use disorders: preventing the development of hazardous and harmful drinking. Public Health Guidance 24.London:NICE.www.nice.org.uk/nicemedia/live/13001/48984/48984.pdf[Accessed4Jan2013]

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13. GalvaniSetal.(2011).Social work services and recovery from substance misuse: a review of the evidence.Edinburgh:ScottishGovernment.Availableat:www.scotland.gov.uk/Resource/Doc/346164/0115212.pdf[Accessed4Aug2014]

14. DarK.(2006).Alcoholusedisordersinelderlypeople:factorfiction?Adv Psychiatr Treat12(3):pp.173-81

15. NationalInstituteforHealthandClinicalExcellence.(2011).Alcohol-use disorders; Diagnosis, assessment and management of harmful drinking and alcohol dependence.CG115.London:NICE.Availableat:www.guidance.nice.org.uk/CG115/NICEGuidance/pdf/English[Accessed4Dec2013]

16. NationalInstituteforHealthandClinicalExcellence.(2010).Alcohol-use disorders. Diagnosis and clinical management of alcohol-related physical complications. CG100.London:NICE.Availableat:www.guidance.nice.org.uk/CG100/NICEGuidance/pdf/English[Accessed4Dec2013]

17. DepartmentofHealth(England)andthedevolvedadministrations.(2007).Drug misuse and dependence: UK guidelines on clinical management.London:DepartmentofHealth(England),theScottishGovernment,WelshAssemblyGovernmentandNorthernIrelandExecutive.Availableat:www.nta.nhs.uk/uploads/clinical_guidelines_2007.pdf[Accessed12Dec2012]

18. CenterforSubstanceAbuseTreatment.(2012).Substance abuse among older adults. Treatment improvement protocol 26.Rockville,USA.www.ncbi.nlm.nih.gov/books/NBK64419/pdf/TOC.pdf[Accessed4Jan2013]

19. MoyIetal.(2011).Systematicandnarrativereviewoftreatmentforolderpeoplewithsubstanceproblems.Eur Geriatr Med2(4):pp.212-36

20.NationalInstituteforHealthandClinicalExcellence.(2007.)Drug misuse psychosocial interventions.CG51.London:NICE.Availableat:www.nice.org.uk/nicemedia/live/11812/35973/35973.pdf[Accessed29May2014]

21. WelshAssemblyGovernment.(2007).A service framework to meet the needs of people with a co-occurring substance misuse and mental health problem.Cardiff:WAG.Availableat:www.wales.gov.uk/topics/housingandcommunity/safety/substancemisuse/publications/cooccuring/;jsessionid=D2374060981F7B85C6AB9AA953738687?lang=en[Accessed19Dec2012]

22.McQueenJetal.Briefinterventionforheavyalcoholusersadmittedtogeneralhospital.Cochrane Database Syst Rev2011,Issue8.ArtNo.:CD005191.doi:10.1002/14651858.CD005191.pub3

23. WelshAssemblyGovernment.(2008).Wales Integrated In-Depth Substance Misuse Assessment Tool (WIISMAT) and guidance for use.Cardiff:WAG.Availableat:www.wales.gov.uk/topics/housingandcommunity/safety/publications/wiismat/;jsessionid=D2374060981F7B85C6AB9AA953738687?lang=en[Accessed19Dec2012]

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24.BelfastStrategicPartnership/PublicHealthAgency(2011).Substance misuse among people over 55. Perspectives from the community and voluntary sector in Belfast.Belfast:GEMSNorthernIrelandLtd.Availableat:www.publichealth.hscni.net/sites/default/files/GEMSNI_SubMisInTheOlderPopInBelfast_May2011.pdf[Accessed4Aug2014]

25. AtkinsonJHandSchuckitMA(1983).Geriatricalcoholanddrugmisuseandabuse.Adv Subst Abuse3:pp.195-237

26.McInnesEandPowellJ(1994).Drugandalcoholreferrals;areelderlysubstanceabusediagnosesandreferralsbeingmade.BMJ308:pp.444-6

27. LarimerMEetal.(2009).Healthcareandpublicserviceuseandcostsbeforeandafterprovisionofhousingforchronicallyhomelesspersonswithseverealcoholproblems.JAMA30:pp.1349-57

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Appendix–ServiceExample1

AlcoholServiceforOlderPeoplePilotProjectwithintheCardiffandValeofGlamorganAreaPlanningBoardTheWallichwerecommissionedbyCardiffandValeAreaPlanningBoard(APB)toundertakeafourmonthpilotstudyofthelevelandnatureofalcoholuseandmisuseamongtheover65sacrossCardiffandVale,inordertobuildtheevidencebaserelatingtotheneedforasupportservicespecificallyaimedatolderpeopleinSouthWales.

Thestudyranfrom1December2013until31March2014andprovidedanopportunitytocollectdataandinformationthatwillinformafundingbidforBigLotterymoneytofundthisprojectintothefuture,aswellasthenecessaryevidenceneededtoshapeandredesignlocalservicestomeettheneedsofolderpeople.Thepilotwasdesignedtodemonstratethelevelofneedinrelationtonumbersofolderpeoplewhoarecurrentlydependentonalcohol,ordrinkingatharmfullevels.Therewasaparticularfocusonthoseindividualsovertheageof60whowouldbemostabletoaddresstheiralcoholmisuseandeithersignificantlyreducetheiralcoholintaketowithinsafeguidelinesorstopdrinkingalcoholinfavourofabstinence.

WhattheprojectaimstoachieveThestudyaimedtoresearchthelevelandnatureofalcoholuseamongtheover65sacrossCardiffandVale,andtheextenttowhichtheseindividualsengagewithservices,inordertoenabletheAPBandotherhealthandsocialcareservicecommissionerstoeffectively:

• Buildawarenesswithprofessionalsinnonspecialistservicesaboutharmfuldrinkingamongstolderpeople.

• Increasecapacitywithingenericolderpeople’sservicestoidentifyalcoholmisuse,actupontheproblemand/orreferontospecialistserviceswhereappropriate.

• Increasethoseabletoidentifyandactuponalcoholmisusethroughengagementwithwiderworkforce.

• WorktowardsacommongoalasoutlinedintheAPBAlcoholActionPlan2013-2016.

• Addresskeyaim1oftheWelshGovernment’sSubstanceMisusedeliveryplanfor2013-2015.

• Provideeducation,trainingandconsultancyforprofessionalsworkingwitholderpeople.

• Providescreeningtoolstoidentifyolderpeoplewithharmfuldrinking.

• Gatherdataonneed.

• Gatherdataandinformationonengagementlevels.

• Makeconnectionswithservicesthatcurrentlysupportolderpeoplee.g.residentialcare,extracareschemes,shelteredhousing,AgeUK.

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KeyFindings• Asignificantnumberofolderadults,livinginCardiffandtheVale,

demonstratepotentiallyunsafelevelsofalcoholuseandneedadvicebasedaroundsafelimits.

• Asignificantproportionofthosewhoshouldpotentiallybeengagingwithserviceswerenotdoingso.

• Barrierstoengagementwerebothwithintheindividual(shame,embarrassment,denialand/oralackofawareness)andexternaltotheindividual(servicesnotbeingageappropriate).

• Resultsfromserviceprovidersandpractitionersrevealedhighlevelsofalcoholrelatedphysicalinjuries,detrimentalhealthconsequences,mentalhealthcorrelationsandday-to-dayeffectsincludingselfneglectandpoorhygiene.

• Theageingofthe‘babyboomers’,coupledwithariseinlifeexpectancy,suggeststhatthisisnotjustaproblemthatolderadults,servicesandpractitionersarefacedwithnow,butwillbeanincreasingproblemforthefuture.

RecommendationsTheresearchreportprovidestheevidencethatthefollowingactionsareneededthroughtheAPBworkprogramme:

• Developage-appropriateservicesforolderproblemdrinkers(oratleastaclearlydefinedelementwithincurrentservices).

• Improvethecommunicationandpathwaysbetweencurrentservices.

• Increasethefrequencyofscreening,andthecapacityofage-appropriateinterventionsandspecialistaftercare.

• Ensuretheprovisionoftrainingandprofessionaldevelopmentforallstaffworkingwitholderadults.

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Appendix–ServiceExample2

WelshCentreforActiononDependencyandAddiction(WCADA)

OlderPersonsServiceinNeathPortTalbotWithinNeathPortTalbotthereisadesignatedOlderPersonsServicethathasbeenoperationalsince2001.TheOlderPersonsWorkerprovidesarangeofinterventionstoolderpeople(aged50yearsplus)toreducetheharmcausedbytheirsubstancemisusetothemselves,theirfamiliesandthewidercommunity.Inordertoachievethis,theOlderPersonsworkerundertakeseffectivecasemanagement;assessingsupportneeds,careplanningandliaisonworkwithprimarycare,SocialServices,residential/nursinghomesandmentalhealthservices.Acomprehensivesupportpackageisavailabletoolderpeopleincludingadviceandawarenesssessions,healthpromotion,structuredindividualsupportandaccesstootheralcoholanddrugtreatmentservicesasappropriateandwraparoundservices,suchastheirdiversionaryactivitiesproject.

Asignificantamountoffocusisplacedonreducingisolationandsupportingolderpeopletoenhancetheirsupportnetwork.Thiscanincludeattendanceatself-helpgroupsandengagementwithlocalcommunityprojectsthatfacilitateactivitiesandshortcourses.