Barbara Hunter

Alcohol and drug misuse in the elderly

In the September 2010 issue, Sellman et al . discussed strategies to reduce alcohol-related problems among adolescents [1]. In the same issue, Ryan et al . provided an overview of parenting strategies that effectively infl uence adolescent drinking patterns [2]. While it is critical that strategies to reduce youth substance misuse are acted upon, it is essential that policymakers do not ignore the impact of alcohol and drug problems among older people. Currently, there is limited data available on alcohol and drug trends among the elderly, and little evidence on the most effective treatment approaches for this age group. We recently undertook a project to gain a better understanding of these issues among older people in the Australian state of Victoria. Using data from the 2007 National Household Drug Strategy Survey, we identifi ed that those aged over 65 years were more likely than other Victorians to consume alcohol daily (15% of people aged 65 years compared with 4% of people aged 50), but not at levels that may result in short-term harm. However, analysis of Victorian ambulance attendance data from 2004 to 2008 revealed that there had been an increase in the rate of ambulance attendance for alcohol intoxication for people aged over 65 years (from a median rate of 3.3 individuals per 10 000 in 2004 to 8.2 per 10 000 in 2008). Analysis of Victorian hospital admissions data over the same period also revealed an increase in the number and rate of alcohol-related admissions for people aged over 65 (from 4189 in 2004 to 5193 in 2008; from a median rate of 64.5 individuals per 10 000 in 2004 to 73.9 per 10 000 in 2008). Ambulance attendance data also identifi ed that a sizeable minority of older people are misusing benzodiazepines (22% of 2966 attendances from 2004 to 2008) and pain medication (14% of attendances from 2004 to 2008), although hospital admissions data indicate that only around 1% of admissions are related to drugs other than alcohol or tobacco. However, previous research has found that older people are likely to signifi cantly under report their substance use [3], suggesting that there may be major problems in this age group that we are not identifying or capturing through currently available datasets. Experts suggest that levels of alcohol consumption identifi ed as safe for the average adult may constitute higher risk for older people [4]. This higher level of risk relates to a decreased ability to metabolize alcohol and other drugs [4], as well as higher rates of other morbidities and associated multiple prescriptions. However, studies examining what safe levels of drinking are for older people who are taking prescription and/or over the counter medications are yet to be conducted. There is also a gap in our understanding of the reasons why older people misuse alcohol or other drugs. What are the cultural habits and meanings associated with alcohol and drug use in older people? Are they self-medicating to deal with underlying mental health concerns or social isolation? Do older people change the way they interact with and consume drugs and alcohol as they age? Where are they likely to seek help for problematic use? There are many unanswered questions about alcohol and drug use in this vulnerable, forgotten population. It ’ s time to start talking about it. Thanks to Bridget Roberts, Heidi Strickland, Lynda Berends and Sue Carswell for their contribution to the project, which was funded by the Victorian Government Department of Health.

‘Holy shit, didn’t realise my drinking was high risk’: an analysis of the way risk is enacted through an online alcohol and drug screening intervention

Commentators view online screening and automated feedback interventions as low-cost ways of addressing alcohol and other drug-related harms. These interventions place people into categories of risk based upon scores from standardised screens and provide automated feedback about a person’s level of risk of developing alcohol and other drug ‘problems’. In this article, we examine how one particular alcohol and other drug online screening and feedback intervention enacts risky alcohol and other drug use and users, and explore how these enactments compare to alcohol and other drug users’ own accounts of risk. In order to do this, we undertook a qualitative analysis of intervention content and intervention recipients’ responses (n = 489) to an open-ended question about their experience of the online screening and feedback intervention. Our analysis highlights how the online screening and feedback intervention draws on prevention science to cultivate a sense of expertness and objectivity. Intervention recipients’ accounts of risk were either overshadowed by the ‘expert’ risk account provided by the intervention, ‘validated’ by the intervention or were not accurately reflected by the intervention. In the latter case, intervention recipient comments draw attention to the way in which the intervention enacts alcohol and other drug use as inherently risky without accounting for the context and purpose of use. While the online screening and feedback intervention assumes that people are capable of self-monitoring and managing their alcohol and other drug use and risk, recommendations for help provided enact intervention recipients as fragile and in need of professional help. We suggest that there is a need for the development of interventions that are better equipped to take account of the complexity of alcohol and other drug use and risk experiences and subjectivities.

It Seemed like a Good Idea at the Time: Experiences in centralised intake for alcohol and drug treatment across three jurisdictions

■ AIM Identify whether centralised assessment and intake programs are useful for alcohol and drug systems. ■ DESIGN Review of evaluation findings on centralised programs in Ontario, Canada, the USA and Victoria, Australia. ■ FINDINGS Models implemented in Canada and the US operated at local level and variations were a product of settings and stakeholders. Some advances were made. The assessment and referral centres (A/Rs) in Canada accounted for around one fifth of all case loads. A greater proportion of treatment naïve people attended A/Rs and these agencies had a considerable network of services. However, A/Rs were not the hub of the system; many agencies developed their own intake structures and A/Rs took on treatment functions. In the US, only some locations with centralised intake units (CIUs) reported a greater uptake of referrals and high needs clients were more likely to attend. Centralisation resulted in improved assessments and increased levels of client satisfaction but not treatment matching. Some treatment agencies in Victoria developed centralised models for screening / assessment while referral destinations were generally in-house. In rural settings, there was cross-agency centralisation. ■ CONCLUSIONS Centralised intake requires extensive implementation planning to counter pressures that impede the potential for systems change.

A Model for Predicting Clinician Satisfaction with Clinical Supervision

Clinical supervision can improve staff satisfaction and reduce stress and burnout within the workplace and can be a component of organizational readiness to implement evidence-based practice. This study explores clinical supervision processes in alcohol and drug counselors working in telephone and online services, assessing how their experiences of supervision link to workplace satisfaction and well-being. Standardized surveys (Manchester Clinical Supervision Scale and the TCU Survey of Organizational Functioning) were completed by 43 alcohol and drug telephone counselors. Consistency of supervisors and good communication were the strongest predictors of satisfaction with clinical supervision, and satisfaction with supervision was a good predictor of overall workplace satisfaction.

Factors that enable and hinder the implementation of projects in the alcohol and other drug field

Objective: Few studies systematically explore elements of successful project implementation across a range of alcohol and other drug (AOD) activities. This paper provides an evidence base to inform project implementation in the AOD field.

Development and implementation of a structured intervention for alcohol use disorders for telephone helpline services

A six-session intervention for harmful alcohol use was piloted via a 24-hour alcohol and other drug (AOD) helpline, assessing feasibility of telephone-delivered treatment. The intervention, involving practice elements from Motivational Interviewing, Cognitive-Behavioral Therapy, and node-link mapping, was evaluated using a case file audit (n = 30) and a structured telephone interview one month after the last session (n = 22). Average scores on the Alcohol Use Disorder Identification Test (AUDIT) dropped by more than 50%, and there were significant reductions in psychological distress. Results suggest that, even among dependent drinkers, a telephone intervention offers effective and efficient treatment for those unable or unwilling to access face-to-face treatment.