0985-0067 Study and Research Design

National Adult Protective Services Technical Assistance Resource Center
Contract Number HHSP233201500042I

TASK 4.1 Opioid Impact on APS
Study Design

Prepared for:
Aiesha Gurley
Contracting Officer’s Representative
Stephanie Whittier Eliason
Co- Contracting Officer’s Representative
Administration for Community Living
330 C Street SW
Washington, DC 20201

Prepared by:
WRMA, Inc. with VA Tech
12300 Twinbrook Parkway, Suite 310
Rockville, MD 20852

Submitted: October 30, 2020

Contents
Introduction ............................................................................................................................................... 3
Purpose ...................................................................................................................................................... 4
Research Design ........................................................................................................................................ 5
Study Population .................................................................................................................................... 6
Recruitment of State APS for study participation ................................................................................. 6
Data Collection Development ................................................................................................................ 6
Eligibility and Exclusion Criteria for Cases .......................................................................................... 6
Piloting the Data Collection Tools......................................................................................................... 7
Data Analyses Plan.................................................................................................................................... 7

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Introduction
Some elder advocates and law enforcement officers believe that the opioid epidemic is
contributing to the increase in elder abuse.1 Aging services and APS networks are likely to be
dealing with more complex clients with opioid-related issues, placing enormous pressure on
health care systems, emergency response services, law enforcement and other community
services.2,3,4 The opioid epidemic affect older adults through opioid misuse, grandfamilies, and
elder abuse as discussed further below.
Many older adults experience chronic pain, for example, 29% filled a prescription for opioid pain
relievers in the past two years, less than 50% report that health providers counsel them about
addition, rick of overdose, or how to safely dispose of excess medication, and 68% of those
prescribed opioids reported keeping leftover pills. 5
As the U.S. older adult population is expected to grow with aging baby boomers, opioid misuse
among this group is becoming more urgent: 25% of long-term opioid users are aged 65+, the
population of older adults who misuse opioids is expected to double from 2004-2020, 6 out of
1,000 Medicare beneficiaries (aged and disabled) are diagnosed with opioid use disorder – one of
the highest and fastest growing rates, and women over age 60 are more likely to use opioids than
men.6
Further, an increasing number of opioid-addicted adults, many of whom have children, are
moving in with their older parents, creating “grandfamilies.” Parental substance misuse is the
most common reason that an estimated 2.5 million children are being raised by grandparents and
other relatives. Rural older adults are more likely than urban adults to be raising their
grandchildren (8.9 vs.7.4%)7.
Finally, many experts believe the opioid epidemic is associated with an increase in elder abuse
including: physical abuse including assault and battery, threatening behavior; emotional abuse;
and financial exploitation including theft, fraud, and forgery. The potential also exists for
homelessness due to arrest, eviction, or illegal activity at the home.
This study was originally conceived a year ago, prior to the COVID-19 pandemic. While the
COVID-19 pandemic is still not over, the study team agreed that the time is right to pursue the
study during the pandemic because of 1) the rise in opioid overdose nationwide 8 and 2) ability
Benson, W.F; Aldrich, N. Raising Awareness and Seeking Solutions to the Opioid Epidemic’s Impact on Rural Older Adults
Blog Post (March 4, 2019): https://eldermistreatment.usc.edu/opioids-and-elder-abuse-a-disquieting-connection/
3 Washington Post Article (June 17, 2019): https://www.washingtonpost.com/business/2019/06/17/how-opioid-crisis-is-leading-elderfinancial-abuse/?utm_term=.594b4dd84d9d
4 https://eldermistreatment.usc.edu/missouris-aps-response-to-the-opioid-crisis/
5 National Poll on Aging, University of Michigan, 2018.
6 Tilly, J, Skowronski, S., Ruiz, S. (2017). The Opioid Public Health Emergency and Older Adults
7 2018 Update Raising the Children of the Opioid Epidemic: Solutions and Support for Grandfamilies. Generations United.
8 Haley DF, Saitz R. The Opioid Epidemic During the COVID-19 Pandemic. JAMA. Published online September 18, 2020.
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doi:10.1001/jama.2020.18543

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of APS offices to operate under COVID-19 modifications to policies and procedures. This study
will also focus on the effects of the COVID-19 pandemic on opioid cases.

Purpose
The purpose of this 12-month study is to understand the nature, extent, and impact of opioids on
older adults and their families by examining Adult Protective Services data in states where the
problem is most egregious. Because of the COVID-19 pandemic, attention will also be made to
the effects of pandemic on client circumstances, service gaps and needs, and outcomes.
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Identify the scope and characteristics of APS caseloads involving opioid abuse.
Identify investigative methods used and challenges to using these methods
Identify interventions used and challenges to implementing these interventions
Identify additional services needed
Identify challenges that are particular to the COVID-19 pandemic
Assist ACL and other federal partners in targeting needed resources to have the highest
impact

Below are preliminary research questions that this study aims to answer:
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What are the characteristics of opioid-related elder abuse cases? (e.g., Who is the abuser?
What types of maltreatment? What is the perpetrator relationship? Are there any other
common demographic characteristics of clients or perpetrators? How is abuse in
community settings different from long-term care settings?)
What is the magnitude of opioid-related elder abuse cases? (e.g., What percent of overall
cases involve opioids? What is the impact on caseload? How has COVID-19 impacted
caseload?)
What are challenges in responding to these cases? What types of services are needed to
address the problem? What is the average length of case? How has COVID-19 impacted
the responses to these cases?
What investigative methods are being used? (What are the challenges in responding to
these cases? What additional resources are required? How has COVID-19 impacted these
investigative methods?)
What interventions are being used? (What are the challenges? What other services are
needed?) How has COVID-19 impacted these interventions?)
How are State APS systems responding to opioid related cases? (Any home-grown
approaches? Are multidisciplinary approaches being used? What steps in the areas of
policy, practice, partnership, performance, and training has the state taken to address the
issues raised by these cases?)

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Research Design
This study will employ a mixed methods design that includes the collection of both quantitative
and qualitative data about opioid cases, employing online data collection and in-depth interviews
with APS state administrators and local field staff.
For the quantitative data, the study team will reach out to all states via the APS-TARC listserv to
invite states who collect opioid data to participate in sharing case data with the study team. We
will ask for opioid cases starting from January 2020 to capture cases that were not affected by
COVID-19 restrictions. Using the National Adult Maltreatment Reporting System (NAMRS)
that collects de-identified case-level data on APS cases, we will compare their opioid case data
with their non-opioid cases. We will examine these cases to compare:
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Maltreatment type and disposition
Demographic information on victim/client and perpetrator
Harm caused to the victim/client
Services provided and referred
Interagency coordination

In particular, we will investigate case comparisons to identify differences in characteristics of
opioid cases and how they are investigated and concluded. We acknowledge limitations to this
methodology. First, we know that only a small handful of states currently collect opioid data, and
quality data may be difficult to collect. This small data collection will function as an initial look
at opioid data in APS and provide support on why and how opioid data can be collected in the
future.
Qualitative data collection will involve two phases of interviews. Phase I interviews will occur at
the beginning of the study with state APS administrators. We will invite states with high opioid
overdose death rates to participate in a 45-minute interview to discuss how the opioid epidemic
has affected their caseload and their work. The purpose of these interviews will be to develop a
general overview of their opioid caseload, and any policies, procedures and practices in handling
opioid cases. For Phase II, the study team will conduct 45-minute small group interviews with
local field staff identified in Phase I, in particular, caseworkers, investigators, and supervisors.
The purpose of these interviews is to get the direct perspective of field workers confronting
opioid cases and its challenges. The interview questions will delve deeper into the complexity of
the cases, challenges and gaps in APS responses and services and any best practices. These
interviews will be conducted via teleconference/telephone and recorded.
In order to collect adequate information, the study team will conduct 10-12 Phase I interviews
and 15-20 Phase II interviews. We will be requesting an OMB extension of a current and similar
study already approved (APS Study on the Impact of COVID-19; OMB Control No. 0985-0067)
to be able to conduct this number of interviews.

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Study Population
The study population will include all U.S. states, territories, and the District of Columbia.
Particular attention will be made to those states with high opioid overdose death rates and those
who participate in the NAMRS data collection.
Recruitment of State APS for study participation
At the beginning of the study, the study team will send out a letter (attached), via email, to all
State APS to introduce the study, build awareness and interest, and inform them of its purpose
and components. We anticipate that this strategy will provide State APS the necessary
background and highlight the importance of participating in the study.
Following this letter, the study team will approach states via the APS-TARC listserv to inquire as
to which states collect opioid data and invite them to share their opioid case data. With the help
of the NAMRS liaisons, the study team will also follow up with the states to answer any
questions and provide additional study information.
For the state administrator interviews, we will prioritize the recruitment of states with high
opioid overdose death rates and geographic location. These state administrators will receive an
invitation letter from the study team and follow-up emails and telephone calls will follow until
they agree or decline. All States who agree to participate will receive a copy of the interview
questions prior to the interview.
For the Phase II local field staff interviews, we will use both the opioid case data collection and
the Phase I interviews to identify APS local offices to invite to participate. We will directly ask
for local contact information via email correspondence during the case data collection and during
the Phase I interview. All interviewees will receive a copy of the interview questions prior to the
interview.
Data Collection Development
Using the research questions above, the study team developed draft questions for the interview
guides. ACL will review and approve the interview guides before piloting the tool with the
states. Once feedback has been received from states, the participating states will finalize the
interview guides.
Eligibility and Exclusion Criteria for Cases
Opioid data cases will be accepted when (1) substantiated cases of ANE where opioids are
involved; (2) substantiated cases that include only older adult victims aged 60+; and (3)
substantiated cases that were investigated in community and facility settings. We are excluding
any cases of younger or disabled adults (different study population), cases that were not
substantiated (causes questions regarding veracity of data), and cases that are being investigated
in facility settings that outside the jurisdiction of APS (different states have differing
investigatory authority).

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Piloting the Data Collection Tools
During the 60 Day Notice period of the OMB extension request, the study team will pilot the
interview guides (see attached) with 4-5 state administrators for review and feedback. We will
ask for feedback on the appropriateness and validity of the questions, whether questions are
consistently understood, and whether respondents have the information needed to answer
questions. Data will not be collected. Feedback will be documented and brought back to the
study team for discussion and consideration for revisions to the data collection instruments.
The following questions will also be given to the State APS to keep in mind during their review
of data collection instruments:
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Are the questions clear and understood?
What terms or scenarios need clarification?
Do you have the information needed to answer the questions?
Do questions flow logically?
Are there any missing questions?

Data Analyses Plan
After the data collection is complete, the study team will convert submitted data into analysisready formats. The study team will summarize quantitative data using a statistical package such
as SPSS and calculate descriptive statistics, such as the frequencies of each type of maltreatment,
each type of perpetrator relationship, and other case characteristics among all of the opioid
related elder abuse cases. The study team will also use cross-tabs and regression analysis as the
data allow. The analysis will be monitored by the Virginia Tech study team, involving all
members, but especially monitored by Dr. Savla, the statistician on the project.
Data on the overall number and proportion of cases that involve opioids may be obtained during
interviews with state-level APS administrators. If possible, these data will be analyzed to create
national estimates; otherwise will be considered only at level of the states provided.
Qualitative interview data will be analyzed by Drs. Teaster and Roberto according to standard
qualitative analytic techniques in order to identify common themes and patterns. Qualitative data
will answer research questions involving the complexity of investigative methods and
interventions, services provided, and challenges encountered in responding to opioid-related
cases.
We expect, at a minimum, to stratify our interview sampling frame to represent cases by
location, type(s) and history of ANE, age of victim, type of perpetrator, cases involving
polyvictimization, and cases where abuse had been ongoing and previously unreported. We can
then compare the responses to the interview questions for respondents from these different
frames. Applicable data may be recoded to quantitative and analyzed with bivariate statistical
tests as warranted.
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