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296 Substance Use in Older Adults
skilled nursing facilities, carceral settings, and rehabilitation facilities.
We discuss the ethical considerations in this population with an emphasis on decision-making capacity and respect for autonomy.
COMPREHENSIVE CULTURAL
ASSESSMENT OF THE OLDER ADULT
WITH A SUBSTANCE USE DISORDER
A cultural assessment elicits information about a patient’s cultural identity,
including their self-identification, beliefs, environment, language, and spirituality. In the clinical context, such an assessment can be used to better understand a patient’s values, supports, coping styles, and way of
understanding their disease or symptoms. We consider a comprehensive
cultural assessment to be a key part of caring for any patient. It is of particular importance, however, in a population of older adults with substance
use disor
A thorough, nonjudgmental history elicits a patient’s beliefs and goals,
while establishing the provider as an ally, someone who honors the wisdom and expertise that the patient brings to their care. Understanding the
patient perspective also allows the provider to advocate
plan that integrates the patient’s values and community supports.
tural Formulation Interview (CFI), a semi-structured interview that
seeks to better u
identity influences disease perception, coping mechanisms, and helpseeking behaviors (American Psychiatric Association 2013b; LewisFernández et al. 2014). The CFI for Older Adults (Table 11–1) explores
age-
ample 11–1.
ders, given the impact of shame and stigma around substance use.
for a treatment
DSM-5 (American Psychiatric Association 2013a) includes the Cul-
nderstand the individual’s identity, as well as how that
related identity and cultural perceptions of aging.
We provide a model for using the CFI for Older Adults in Case Ex-
Case Example 11–1: “Living under my
daughter’s roof”
Mrs. Petrosian is a 72-year-old retired executive assistant with cirrhosis
secondary to alcohol use disorder who presents to her primary care doctor to establish care, after moving to the area to live with her daughter.
While still at her former home in Chicago, she was hospitalized last year
for alcohol withdrawal and cirrhosis, then completed a 28-day residential rehabilitation program, followed by an intensive outpatient program. She currently lives with her husband, daughter, and son-in-law.
Cultural, Structural, and Ethical Considerations 297
Table 11–1. Cultural Formulation Interview for
Older Adults
Conceptions of aging and cultural identity
How would you describe a person of your age?
How does your experience of aging compare to that of your friends and
re
latives who are of a similar age?
Is there anything about being your age that helps you cope with your current
life
situation?
Conceptions of aging in relationship to illness attributions
and coping
How does being older influence your [PROBLEM]? Would it have affected
you differently when you were younger?
Are there ways that being older influences how you deal with your
[PROBLEM]? Would you have dealt with it differently when you were
younger?
Influence of comorbid medical problems and treatments on
illness
Have you had health problems due to your age?
How have your health conditions or the treatments for your health conditions
affected your [PROBLEM]?
Are there any ways that your health conditions or treatments influence how
you deal with your [PROBLEM]?
A
re there things that are important to you that you are unable to do because
of your health or
age?
Quality and nature of social supports and caregiving
Who do you rely on for help or support in your daily life in general? Has this
changed now that you are going through [PROBLEM]?
How has [PROBLEM] affected your relationships with family and friends?
Are you receiving the amount and kind of support you expected?
Do the people you rely on share your view of your [PROBLEM]?
Additional age-related transitions
Are there other changes you are going through related to aging that are
important for us to know about in order to help you with your
[PROBLEM]?
298 Substance Use in Older Adults
Table 11–1. Cultural Formulation Interview for
Older Adults (continued)
Positive/negative attitudes toward aging and clinicianpatient relationship
How has your age affected how health care providers treat you?
Have any people, including health care providers, discriminated against you
or treated you poorly because of your age? Can you tell me more about that?
How has this affected your [PROBLEM] or how you deal with it?
Do you think that the difference in our ages will influence our work in any
way? If so, how?*
Note. The goal of the Cultural Formulation Interview (CFI) for Older Adults is to identify the role of cultural conceptions of aging and aging-related transition in the patient’s
enting problem, referred to in the table as [PROBLEM]. A clinician can incorporate
pres
these questions into their psychiatric diagnostic interview.
*This question may be asked if there is a significant age difference between the clinician
d the patient.
an
Source. DSM-5 Supplementary Module (American Psychiatric Association 2013b).
She requests connection with ophthalmology for bilateral cataracts,
hepatology referral, case management for transportation assistance, and
reconnection with mental health resources.
The primary care doctor administers the CFI for Older Adults. She
learns that Mrs. Pe
came an empty nester.” Her children were not aware of her alcohol use
disord
er until about 5 years ago, when she had a fall and was diagnosed
with cirrhosis after being found to have ascites and hepatic encephalopathy. The doctor learns that Mrs. Petrosian has negative views of aging.
esents that her husband, who is 15 years her senior, “has been sick
She r
for so long.” In addition to advanced chronic obstructive pulmonary
disease, her husband has dementia and has required repeated hospitalizations this past year for falls and aspiration pneumonia. She has not
felt she co
uld rely on him emotionally for many years, and her close
friends have either passed away or still live back in Chicago. She notes
a strained relationship with her daughter, who is struggling to care for
both her teenage children and her parents.
Mrs. Petrosian is skeptical of having a doctor who is so much
younger than she is. She is worried that the doctor will put more restrictions on what she can and cannot do, “just like my daughter does.” Mrs.
Pe
trosian and her doctor discuss their age difference and expectations
for the relationship. The doctor explains that while part of her job is to
consider safety concerns, her goal is to support Mrs. Petrosian in living
as satisfying and healthy a life as she can.
Mrs. Petrosian’s doctor asks how she envisions her transition to this
city and to the clinic. She answers that her priority is to find local Alcoholics Anonymous (AA) groups so that she can connect to others in the area
and continue in her recovery. She requests assistance with transportation
trosian started drinking heavily at age 40, “after I be-
Cultural, Structural, and Ethical Considerations 299
resources, so that she doesn’t have to rely solely on her daughter to drive
her places. Mrs. Petrosian has found that naltrexone and disulfiram work
well for her in supporting her abstinence from alcohol, so her doctor continues those prescriptions. They also agree that while her daughter prefers
mpany her to appointments, Mrs. Petrosian prefers to talk about
to acco
her alcohol use without her daughter in the room for now. Over the course
of the next few months, she attends AA groups locally four times a week
and joins a local knitting group. She continues regular primary care appointments and builds trust and connection with her care team.
Cultural Competence, Cultural Humility, and
Structural Competence
Cultural competence is a term used to describe behaviors, attitudes, and
policies that translate knowledge and value of clients’ cultural beliefs
into effective cross-cultural work (Centers for Disease Control and Prevention 2021). This concept emphasizes the skills required to provide
care to people with different beliefs, behaviors, and needs, with the goal
of improving quality of care and ultimately decreasing health disparities (Centers for Disease Control and Prevention 2021).
While the concept of cultural competence represented an important
evolution fro
ity,” we also highlight literature that advocates for cultural humility. Such
work identifies potent
cluding the risk of conceptualizing minoritized patient belief systems as
a deviation fr
default as a White, cisgender, heterosexual, English-speaking male perspective (Lekas et al. 2020). The idea of “competence” also assumes that
culture is static and cultural groups are homogeneous, which can perpetuate stereotypes; furthermore, we know that people’s beliefs and values relate to a number of intersectional identities (e.g., as an older adult)
and that they evolve over time (Lekas et al. 2020).
Cultural humility is an orientation toward caring for patients that
hold
s in high regard patients’ expertise on their cultural context; it also
requires providers to engage in the practice of self-reflexivity, an intro-
spective process of understanding one’s own preconceived notions and
the origins of these ideas, as well as the potential impact of these beliefs
and biases (Lekas et al. 2020; Patallo 2019; Tervalon and Murray-García
1998). Rather than emphasizing a provider’s efficacy or competence,
self-reflexivity prioritizes providers admitting when they do not understand something and prompts them to actively learn from patients as
duals (Agner 2020). See Case Example 11–2 for an example of self-
indivi
flexivity from one of the authors.
re
m previous notions of cultural “awareness” or “sensitiv-
ial harms of the notion of cultural competence, in-
om normative provider belief systems, which often set the
300 Substance Use in Older Adults
Case Example 11–2: Example of
Self-Reflexivity
A 32-year-old heterosexual multiracial female doctor reflects on her
own multidimensional cultural identities. She feels connected to her
Mexican lineage and connects with her Spanish-speaking patients; however, she does not have direct experience immigrating to the United
States, as
of patients with demographics similar to her own, but that similar demographics or even language concordance does not mean that she understands the way they experience or articulate the intersection of their
identities
education level and her position as a doctor. She considers herself an
ally to the LGBTQ community but lacks lived experience navigating
spaces, including health care settings, with an LGBTQ identity. She
grew up in predominantly white settings and considers how this
shaped the way she expresses her own cultural identities. She takes an
implicit bias test, and her data suggest a slight automatic preference for
European Americans over African Americans. She journals about these
results and about how she processes this outcome, especially practicing
in a predominantly Black city.
many of her patients have. She reflects that she has taken care
. Furthermore, she is in a marked position of power given her
The next term we introduce is structural competency. Metzl and Hansen (2014) affirmed the importance of individual provider-patient discussions about identity and cultural values, while advocating that
providers
go beyond so-called cultural competency to both recognize
the impact of and intervene at the levels of institutions and social conditions. They defined such structural competency as
[t]he trained ability to discern how a host of issues defined clinically
as symptoms, attitudes, or diseases (e.g., depression, hypertension,
obesity, smoking, medication “noncompliance,” trauma, psychosis)
also represent the downstream implications of a number of upstream
decisions about such matters as health care and food delivery systems,
zoning laws, urban and rural infrastructures, medicalization, or even
about the very definitions of illness and health. (p. 128)
Metzl and Hansen (2014) discussed the structural effects on individ-
ual agency, and on stigma, which is commonly conceived as an interpersonal phenomenon yet is operationalized through institutions and
even laws.
They advocated for medical education to better orient learners to the broader social and environmental conditions that manifest
themselves
within the clinical space, as this will also prepare clinicians
to address inequities through structural change.
Cultural, Structural, and Ethical Considerations 301
SOCIAL DETERMINANTS OF SUBSTANCE
USE IN OLDER ADULTS
The World Health Organization’s Commission on the Social Determinants
of Health defines social determinants as “conditions in which people are
born, grow, work, live, and age and the wider set of forces and systems
shaping the conditions of daily life” (World Health Organization 2023).
Such conditions include income, education, food insecurity, housing, access to affordable health services, and social inclusion. We illustrate the
concept of social determinants by applying it to the opioid crisis.
Dasgupta et al. (2018) argued that although the popular narrative
has emphasized
as drivers of the opioid crisis, this model “ignores root causes,” and a
social determinants of health framework must be used to understand and
intervene in this public health crisis. Several authors highlight the role
of “social distress” and socioeconomic marginalization as upstream
forces and describe the interplay between unemployment, working
conditions, pain, poverty, social isolation, and substance use (Dasgupta
et al. 2018; McLean 2016; van Draanen et al. 2020, 2023; Zoorob and Salemi 2017). Previous literature has similarly demonstrated that social
capital and workforce participation are strong predictors of drug overdose among non-Hispanic Whites (Heyman et al. 2019); in such works,
social capital describes norms ar
nity objectives, which includes percentage of active voters and membership rates in political and professional organizations (Heyman et al.
2019). Interestingly, income inequality and lack of upward income mobility correlated more strongly with overdoses than absolute measures
of income or poverty
An estimated 50% of older adults who live alone have inadequate financial resources to pay for their basic needs (Mutchler et al. 2019).
Meanwhile, older adults face relationship losses and functional declines, which affect social connectedness (Donovan and Blazer 2020).
An estimated 24%
isolated, which reflects physical isolation, size of social network, and
frequency of contact with family and friends (Anderson and Thayer
2018). Those who experience social isolation are more likely to be unmarried, with lower education and income, than those who are not socially isolated (Cudjoe et al. 2020).
We use this structural lens to examine data on disparities within the
care
distinction between discussion of cultural factors, which allows us to
the role of physicians and pharmaceutical companies
ound cooperation to achieve commu-
rates (Heyman et al. 2019).
of community-dwelling adults age >65 are socially
302 Substance Use in Older Adults
better understand and align ourselves with individual patients, and
broader discussion of the role of race and ethnicity in the treatment of
adults with substance use disorders in the United States. The latter topic
requires examining the structural drivers of substance use prevalence
and outcomes.
RACIAL AND ETHNIC DISPARITIES IN THE
TREATMENT OF SUBSTANCE USE
DISORDERS
Because there is limited literature on older adults who belong to minority groups, this section reviews literature focused on the larger adult
population.
Medication Access
Medications for opioid use disorder (MOUD), including methadone,
buprenorphine, and naltrexone, have been shown to be safe and efficacious across racial/ethnic groups in the treatment of opioid use disorder. However, research has shown disparities in MOUD initiation
among racial/ethnic groups. One study demonstrated that Black and
Latino patients have a nearly 30% lower odds of receiving MOUD than
White patients in short-term treatment settings (Stahler et al. 2021). Another study of individuals with OUD in western Pennsylvania found
that even after co
Black enrollees were 18% less likely to start MOUD compared with
White enrollees (Hollander et al. 2021).
Within MOUD, there are important divides. Methadone is dispensed from federally regulated clinics and involves considerable surveillance and frequent visits, whereas buprenorphine allows for more
flexibility in clinic-based settings. Studies have illustrated a “bifurcated
opioid treatment system” in which higher-income White patients receive naltrexone and buprenorphine, whereas lower-income Black or
Latino patients are more likely to receive methadone (Guerrero et al.
2022; Hansen and Roberts 2012; Substance Abuse and Mental Health
Services Administration 2020).
ntrolling for gender, age, and Medicaid eligibility,
Treatment Programs
There is evidence that Latino individuals do benefit from treatment, yet
compared with White individuals, Latinos are less likely to engage with
Cultural, Structural, and Ethical Considerations 303
or complete treatment (Guerrero et al. 2013b; Stahler and Mennis 2018).
Similarly, although treatment does appear beneficial if accessed, Black
people initiate and complete substance use treatment for OUD at lower
rates than their White counterparts (Jordan et al. 2021; Lappan et al.
2020; Mennis et al. 2019; Stahler and Mennis 2018; Wu et al. 2016).
Explanations for Racial and Ethnic Disparities
Significant previous literature identifies structural racism within housing, health care, and carceral systems and connects structural racism to
tance use outcome disparities through environmental, social, and
subs
psychological pathways (Hollander et al. 2021; Krawczyk et al. 2017;
Mennis and Stahler 2016; Schmidt et al. 2007; van Draanen et al. 2023;
Verissimo and Grella 2017). One manifestation of structural racism is
that clinics that dispense naltrexone and buprenorphine tend to be in
higher-income White neighborhoods, while methadone clinics tend to
be in lower-income Black or Latino neighborhoods (Goedel et al. 2020;
Guerrero et al. 2022; Schuler et al. 2021). Another manifestation is that
Latino patients may struggle to find Spanish-speaking providers and
counselors in addiction treatment settings, and undocumented patients
may fear risk of deportation if they engage with treatment (Guerrero et
al. 2013a; Pagano 2014; Vargas Bustamante et al. 2012).
In addition to structural determinants of health, some work focuses
ttitudes and social norms as barriers to care. For example, qualita-
on a
tive research on barriers to specialty substance use treatment among
La
tino clients identified several unique themes, including perceived
lack of social support from family, non-abstinence treatment goals, and
low perceived treatment efficacy (Pinedo et al. 2018).
Interventions
The following section explores interventions proposed to better serve
minoritized groups. We present this literature while acknowledging
that minoritized groups are often pooled for the purpose of research but
in reality are not homogeneous.
Linguistic capabilities are a first step for supporting treatment engagement of non-English-speaking patients in the United States. The
pres
ence of language translators has indeed been shown to increase
treatment completion among Latino clients (Guerrero et al. 2012). However, availability of Spanish-language services alone does not mean that
the services are culturally appropriate or align with the knowledge, attitudes, and experiences of patients (Pagano 2014; Pinedo et al. 2018).
304 Substance Use in Older Adults
Previous literature has explored the role of cultural concordance between the patient and the clinician, through matching of race/ethnicity,
language, and socioeconomic status; such literatu
of increased patient satisfaction and increased retention (Guerrero et al.
2012; Sue et al. 1991). As for addiction treatment settings specifically, a
2022 qualitative study of Black adults in Kentucky with recent opioid
misuse identified a common preference among patients for providers
with similar racial identities and substance use histories (Hargons et al.
2022).
Studies that incorporate family members into treatment may also increase treatment engagement. Patients in the same Kentucky study
fied relational support as central to their treatment experience,
identi
and the authors suggested that it may be culturally responsive to involve supportive individuals into treatment of Black individuals (Hargons et al. 2022). Similarly, work focused on Latino communities has
posited that this model would also be suited for Latino communities, by
incorporating the cultural value of familismo (Pinedo et al. 2018).
Lastly, given the core structural drivers of inequity, many authors
advocate for focu
form, eliminating barriers to MOUD access, cultivating a more culturally and linguistically diverse health care workforce, and increasing
dable housing (Guerrero et al. 2013c, 2022; Hollander et al. 2021;
affor
van Draanen et al. 2023).
s on structural changes, including carceral system re-
re has found evidence
CAPACITY, AUTONOMY, AND COERCION
This section presents related yet distinct topics regarding patient
agency within substance use treatment. We begin with defining decision-making capacity. We discuss perspectives on substance use and
autonomy
sion and coercion.
Decision-Making Capacity
Decision-making capacity refers to the ability to understand and articu-
late a decision. The standard framework for assessing decision-making capacity includes four components: 1) understanding the decision;
2) expr
tives; and 4) reasoning (Roberts and Dyer 2004). Capacity is distinct from
cognition, functional status, or competence. Any clinician can assess decision-making capacity. Furthermore, it is important to remember that
decision-making capaci
, involuntary treatment, and the distinction between persua-
essing a choice; 3) appreciation of risks, benefits, and alterna-
ty is evaluated for a particular clinical question,
Cultural, Structural, and Ethical Considerations 305
not as an all-encompassing state. It is inappropriate to draw conclusions about decision-making capacity based on age or substance use
history alone.
An older adul
question, such as whether to under
ture, yet lack decision-making capacity with regard to long-term placement. Importantly, having a designated surrogate decision-maker does
not mea
rogate decision-maker’s perspective.
ing substance use and neuropsychiatric pathology (namely, a patient
with alcohol us
thereby potentially losing capacity to make medical decisions)
(Walaszek 2019). Thus, providers should engage the patient in appropriate evaluation when concerns arise. However, a substance use history alone does not mean that a patient is unable to engage in clinical
de
should be evaluated separately, and patients should be given information relevant to the clinical decision at hand. It is also worth noting that
a person who is experiencing acute intoxication or withdrawal may or
may not have decision-making capacity during that short-term period,
but that does not mean that the person generally lacks the ability to engage in care decisions.
n that a patient’s input should be overlooked in favor of the sur-
The care team should remain aware that there is evidence connect-
cision-making. Ultimately, as stated previously, each clinical question
t may have decision-making capacity for a particular
go orthopedic surgery for a hip frac-
e disorder is at higher risk of developing dementia,
Autonomy in Persons With Substance Use
Disorders
There is long-standing debate in mental health and substance use fields
regarding the concept of autonomy in this patient population.
Some argue that substance use disorders impair one’s ability to care
for oneself or
thus that mandated treatment can actually restore patient autonomy.
They consider that loss of control and continued use despite harms are
part of the definition of addiction (Cavaiola and Dolan 2016); therefore,
if a medication can safely decrease cravings and use, and in doing so restore personal autonomy, short-term mandated treatment could be ethically justifiable (Caplan 2008). This may be likened to the practice of
involu
ntary psychiatric hospitalization, when a patient is treated
against their will because their agency has been compromised by mental illness. One example of a civil commitment law is the Marchman Act
in Florida, which allows for ≤ 7 days of commitment to stabilize a patient, in hopes that the patient will regain rational decision-making ca-
behave in alignment with one’s values and desires, and
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