1. Drug and Alcohol Treatment Outcomes in Older Adults Derek D. Satre, Ph.D. Jennifer Mertens, M.A. Sujaya Parthasarathy, Ph.D. Constance Weisner, Dr.PH., M.S.W. University of California, San Francisco and Kaiser Permanente Division of Research

2. Study Support Studies were supported by the National Institute on Drug Abuse (R01 DA08728 and R37 DA10572) and the National Institute on Alcohol Abuse and Alcoholism (R37 AA10359). The first author was supported by a National Institute on Drug Abuse training grant (T32 DA07250) and center grant (P50 DA09253). The Drug and Alcohol Research Team at the Kaiser Division of Research and the staffs of the Kaiser Chemical Dependency Recovery Programs provided essential support for these studies.

3. Key Older Adult Treatment Research Gaps Clinical needs of older adults in treatment Studies of private programs Factors associated with treatment success Gender differences Long term outcomes Cost impacts

4. Research Questions How are older patients different from others at baseline and at 6-month follow-up? How do older patients differ by gender? How are 5-year outcomes of older adults in treatment different from those of other patients? How do health service utilization and cost offset associated with treatment differ by age group?

5. Sample 1204 patients at Kaiser completed CD treatment intakes at outpatient facilities in Sacramento, from 1994 to 1996. (Day Hospital Study) -Weisner et al., 2000 Drug testing was used to validate self-report 80% of patients completed six-month follow-up response rate increased with age: 77% of younger, 83% of middle-aged, and 91% of older adults

6. Treatment Program Randomized to day hospital outpatient or lower-intensity outpatient care Abstinence-based, 12-step informed, group format included education, relapse prevention and family-oriented therapy Individual counseling and physician appointments were available as needed

7. Theoretical Framework for Analyses Treatment outcome is determined by Individual characteristics Treatment Extra-treatment factors How are older adults different from other patients in these domains that influence outcome?

8. Analyses Compared three age groups: 736 patients ages 17-39, mean age = 30.4 (sd = 6.3) 379 patients ages 40-54, mean age = 45.1 (sd = 3.8) 89 patients ages 55-81, mean age = 61.6 (sd = 6.0) Examined gender differences within the older adult group Tested predictors of abstinence using logistic regression

9. Key Baseline Age Differences Older adults (55-81): Married, Caucasian, retired ASI score means (vs. younger adults): Higher alcohol severity Lower drug severity Greater medical problems Fewer social and family problems Less psychiatric distress (ASI and SCL-66) More likely to have abstinence goal -Satre et al., 2003

10. Length of Stay in Treatment Treatment length was measured in days Older and middle-aged stayed longer than younger, p <.001

11. Abstinence Rates at Six Months Significant overall age group differences, p =.03

12. Factors Associated with Greater Age, and with Abstinence at Six Months Being married* Dependence criteria not met* Less hostility on SCL-66* Abstinence goal*** Greater length of stay*** (Age was NS)

13. Implications Older adults bring several strengths to treatment that younger adults lack, such as lower hostility and greater abstinence motivation, and they stay in treatment longer However, these advantages do not translate into substantially higher abstinence rates

14. Why Study Older Women? Fastest growing segment of the population Heavy users of health services Concerns about prescription drug use May be more sensitive to alcohol or drugs than men May have different treatment needs and access issues

15. Gender Differences in Six-Month Outcome N = 92 (29 women and 63 men) Alcohol dependent adults age 55 and over Data drawn from two outcome studies (Day Hospital Study and Integrated Care Study) to increase sample size - Weisner et al., 2000, 2001.

16. Baseline Characteristics of Older Women versus Older Men Lower income (53% vs. 33% earn under 40K)* Not married (38% vs. 62% married)* Later onset of heavy drinking (5+) (age 35 vs. 28)* Comparable baseline alcohol consumption (16 days per month of 5+ drinks) Comparable tranquilizer use (25% vs. 29%) Perhaps more distress (78% vs. 60% anxiety, NS) Comparable abstinence goal (100% vs. 90%) -Satre et al., 2004a

17. Length of Stay by Gender Older women stayed an average of 24 days longer in treatment than older men (NS)

18. Abstinence at Six Months by Gender 79% of older women abstinent at six months, vs. 54% of older men (p <.05)

19. Clinical Implications for Older Women Strengths Abstinence goal Length of stay Good abstinence outcomes Special needs Social support (living alone) Economic support Depression and anxiety treatment

20. Day Hospital Sample at Five Years 77% of the sample completed 5-year follow-up Older adults more likely to maintain Kaiser membership (91% vs. 80%, 59%) Mortality by age group: 1% of younger 5% of middle-aged 11% of older -Satre et al., 2004b

21. Five Year Outcomes Older adults had lower legal and family/social ASI scores than younger adults No difference on other ASI scores Higher 30-day and 1-year abstinence rates than younger adults (all substance diagnoses) No age difference in abstinence among those only dependent on alcohol

22. 30-day Abstinence Rates at Five Years by Age Group Significant overall age group differences, p =.02

23. 30-day Abstinence at Five Years by Age and Gender

24. Age Differences in Social Networks YoungerMiddleOlder Married (%)*** 395459 AA groups in past 12 months 89 (96)93 (99)61 (77) Ever called AA for help (%)*** 474219 Recovery helpers 8 (11)9 (13)5 (8) Encourages use (% saying yes)* 17128 Kaiser coverage** 598091

25. Predictors of Abstinence at Five Years Female gender** Length of stay*** Nobody encouraged drinking or drug use*** Not significant Age group CD diagnosis Treatment intensity Married at year five Kaiser membership at year five

26. Five-Year Study Key Points Older women have the best outcome Greater length of stay in treatment has long- term benefits Older adults show strengths and weakness in social networks

27. Proposed Intervention Based on profile of social networks Lower AA use in older adults Activate or expand informal support Supplement mixed-age program Age-specific interpersonal psychotherapy group (K award study)

28. Medical Conditions Study compared CD patients in treatment to demographically matched control from the Kaiser membership One third of medical conditions examined were more prevalent in CD patients, especially: Hypertension, liver cirrhoses, COPD, asthma, injuries, lower back pain, arthritis, headache, depression, anxiety, psychosis -Mertens et al., 2003

29. Medical Conditions in Patients Age 55 and Over CD patients had higher rates than age- and sex-matched controls: Ischemic heart disease Depression Anxiety

30. Health Care Utilization and Cost Records of CD patients were examined 18 months pre- and post-intake Compared to utilization and cost records in a non-patient control group, using automated health plan records Examined age group differences - Parthasarathy et al., 2001

31. Utilization and Cost Findings Greater age was positively associated with pre-treatment cost in both samples Post-treatment, decline in cost was larger in the treatment sample than in the matched sample for those aged 40 to 49, but not in older age groups

32. Areas for Further Investigation in Older Adults Improving outpatient CD treatment Social network intervention 9 and 11 year Day Hospital study follow-up Remission, alcohol vs. drug use How CD (and treatment) affects health Health conditions and psychiatric disorders Services utilization and cost Primary care study Dual diagnosis study funded by RWJF

33. References Mertens, J. R., Lu, Y. W., Parthasarathy, S., Moore, C., & Weisner, C. (2003). Medical and psychiatric conditions of alcohol and drug treatment patients in an HMO. Archives of Internal Medicine, 163, 2511-2517. Parthasarathy, S., Weisner, C., Hu, T.W., & Moore, C. (2001). Association of outpatient alcohol and drug treatment with health care utilization and cost: Revisiting the offset hypothesis. Journal of Studies on Alcohol, 62, 89-97. Satre, D. D., Mertens, J. R., Areán, P. A., & Weisner, C. (2003). Contrasting outcomes of older versus middle-aged and younger adult chemical dependency patients in a managed care program. Journal of Studies on Alcohol, 64, 520-530. Satre, D. D., Mertens, J. R., & Weisner, C. (2004a). Gender differences in older adult treatment outcomes for alcohol dependence. Journal of Studies on Alcohol, 65, 638-642.

34. References (cont.) Satre, D. D., Mertens, J. R., Areán, P. A, & Weisner, C. (2004b). Five- year alcohol and drug treatment outcomes of older adults versus middle- aged and younger adults in a managed care program. Addiction, 99, 1286-1297. Weisner, C., Mertens, J., Parthasarathy, S., Moore, C., Hunkeler, E. M., Hu, T.-W. & Selby, J. V. (2000) The outcome and cost of alcohol and drug treatment in an HMO: day hospital versus traditional outpatient regimens. Health Services Research, 35, 791-812. Weisner, C., Mertens, J., Parthasarathy, S., Moore, C., & Lu, Y. (2001) Integrating primary medical care with addiction treatment: a randomized controlled trial. Journal of the American Medical Association, 286, 1715- 1723. Contact: Derek Satre, Ph.D., UCSF, 401 Parnassus, Box 0984-OVS, San Francisco, CA 94143. Email: dereks@lppi.ucsf.edu