Topics
Kathleen J. Farkas, PhD Case Western Reserve University, Mandel School of Applied Social Sciences
Laurie Drabble, PhD San Jose State University, School of Social Work
Access to AODA services is a broad topic and includes issues of availability, accessibility, use, and costs of services. Medicare is a primary source of insurance funding for older adults for both medical and psychological care. Bartels, Blow, Brockmann, and Van Citters (2005) outline funding barriers to both mental health and substance abuse services for older adults. Their review of funding barriers includes the following: inequitable co-payment of psychologically-based services versus medical services; the gap between costs and Medicare payments; the preference for outpatient, clinic-based services, and cost containment policies that do not match clinical guidelines. For older people in need of alcohol and other drug assessment and treatment, the combination of high co-pays and forced use of clinics rather than neighborhood-based services may deter them from seeking help. Medicare programs typically cover 12 days of inpatient alcohol treatment, but for those with medical complications and complex medical needs, longer stays and additional services may be warranted. Approximately 75% of Medicare spending on substance abuse treatment is dedicated to inpatient, detoxification treatment (Alcoholism and Drug Abuse Weekly, 2006). Only a small percentage of those who receive detoxification are enrolled in follow-up care, which is associated with better long-term outcomes. Younger people share many, if not all of these barriers to alcohol and drug treatment services. The federal Medicaid program policy changed in January 2007 and now provides reimbursement for screening and brief intervention for alcohol and other drug addictions. Under the Medicaid program, 38 states cover some treatment for nicotine dependence (Centers for Disease Control and Prevention, 2006). However, disability insurance under Social Security (SSI) has not considered alcohol or drug abuse/dependence as a disability since 1996. The SSI criteria define a disability as a limiting medical condition that continues after a person stops using alcohol or drugs.
Alcohol and other drug problems among older adults are not the most common concerns for gerontological social workers or for social workers in AODA practice; both the aging services system and the AODA treatment system often fail to address the needs of older adults with AODA. Since indicators of alcohol and other drug problems are often more subtle among older people than among younger people, service providers may easily overlook assessment and referral for AODA. Few treatment programs focus on older people’s needs. However, data from the PRISM-E studies show that older at risk drinkers are likely to engage in treatment and to benefit from either an integrated care model or an enhanced specialty referral model (Oslin et al., 2006).
Service delivery strategies and policies to improve mental health services to older adults may serve as examples to develop an effective AODA system for older adults over the coming years (Blasinsky, Goldman, & Unutzer, 2006; Karlin & Duffy, 2004). The service delivery system challenges for social workers in AODA practice will be to develop referral mechanisms and linkages with aging services programs, to develop clear guidelines for age appropriate screening and assessment, and to implement evidence-based practices for treatment and recovery services effective with older adults.
In addition to prevention strategies designed to reach individuals, policy changes are critical to addressing alcohol, tobacco, and other drug problems. Environmental strategies for prevention of health problems are often effective in reducing these problems and changing social norms. These strategies include policy changes in the behavioral environment (e.g., clean air laws and reducing youth access to tobacco), the financial environment (e.g., increased tobacco or alcohol taxes and reduced costs for smoking cessation), and the communication environment (e.g., advertising restrictions) (Brownson, Koffman, Novotny, Hughes, & Erikson, 1995; Mosher, 1996). Environmental prevention strategies are designed to reduce problems and improve health across population groups and have relevance for older adults. Specifically, some older adults may be impacted disproportionately by marketing of tobacco and alcohol, which is often targeted to specific communities based on geography, age, culture, gender, and lifestyle (Cummings, 1999; Hill & Casswell, 2001).
Tobacco and alcohol products are often heavily promoted in communities already disproportionately impacted by tobacco or alcohol problems including African-American communities, immigrant communities, and LGBT communities (Alaniz, 1998; Lee, Cutler, & Burns, 2004; Stevens, Carlson, & Hinman, 2004; Sutton & Robinson, 2004). One specific example of an environmental strategy for addressing the impact of marketing is the use of counter-ads. Counter-ads are a valuable tool for contextualizing health problems, focusing attention on the misinformation promoted by specific corporations such as the alcohol or tobacco industry, and generating support for change in policy (Dorfman & Wallack, 1993). For example, in relation to tobacco industry marketing, research suggests that counter-advertising strategies and messages focusing on industry manipulation and secondhand smoke appear to be the most useful for reducing tobacco consumption and challenging cultural norms that enable smoking (Goldman & Glantz, 1998). Communities have also been successful in organizing to reduce point-of-purchase advertising, such as store window and sidewalk tobacco promotions designed to target specific populations and increase tobacco purchases (Rogers, Feighery, Tencati, Butler, & Weiner, 1995).
Another related facet of the larger social and policy environment that impacts older adults is that of the pharmaceutical industry and DTC advertising of prescription drugs. DTC advertising has remained controversial since it began approximately 20 years ago. Proponents argue that DTC educates patients about illnesses and related treatment, whereas opponents argue that the information provided in DTC is geared toward marketing rather than consumer education, which may serve to promote overuse or inappropriate use of prescription drugs (Royne & Myers, 2008). Despite criticism, between 1996 and 2005, pharmaceutical industry promotions to physicians have expanded, and spending on DTC advertising has increased by 330% (Donohue, Cevasco, & Rosenthal, 2007). Despite an increase in prescription drugs obtaining approval through the Food and Drug Administration (FDA), there appears to be important gaps in the FDA’s regulation guidance of pharmaceutical industry DTC advertising (Government Accounting Office, 2006). For example, Royne and Myers note that although the FDA “requires a ‘fair balance’ of the risks and benefits of a drug, the FDA guidelines offer little assistance in defining that balance” (p. 72). As a case in point, a recent study examining the content of ads found that DTC television ads were not providing sufficient information in relation to FDA fair balance requirements, particularly in describing risks (Macias, Pashupati, & Lewis, 2007).
These advertising practices may be particularly salient to older adults. A study of prescription and over-the-counter advertising found that DTC ads occupied a significant percentage of television advertising (approximately 8%), and, based on placement and air times, appeared to target older adults and women (Brown, Bernhardt, Phan, Williams, & Parker, 2004). Although older adults do not perceive themselves as influenced by DTC when asked directly, they report behaviors that are congruent with DTC ads (DeLorme, Huh, & Reid, 2007). DTC advertising influences patient-doctor communications and the likelihood for both requesting and receiving prescription drugs (Datti & Carter, 2006; Government Accounting Office, 2006).
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