Substance Use Challenges In Older Adults

Next Generation: SUD Series

February 17, 2025

Tom O’Connor, Co-Author & Publisher

Alexandra Plante, Co-Author & Senior Advisor in the Strategy Office of the National Council for Mental Wellbeing

Topic 

I am honored to have Alexandra Plante join me as co-author for our “Next Generation: SUD Vital Voyage Series” issue. Like me, Alexandra writes and publishes a substance use newsletter called SUDterranean Newsletter/ The Underground Blog on Substance Use Disorder.

I look forward to each newsletter and recommend that every Vital Voyage Community reader subscribe to Alexandra’s newsletter.

Research shows that the care of older adults is becoming a significant issue within a growing population. In the United States, the proportion of older adults has increased due to advancements in healthcare, particularly preventative medicine, which have boosted life expectancy. By 2030, it is anticipated that the number of individuals aged 65 or older in the United States will reach around 72 million. .

Regrettably, substance abuse in older adults is becoming an increasing public health issue. The overdose crisis has spared no one. However, the impact on some groups has received less attention.  One in 11 adults over 60 had a substance use disorder (SUD) in 2022.  SUD is often under-diagnosed by clinicians.  Older adults are less likely to seek treatment, even though they are just as likely to benefit from treatment as any other age group. Substance use disorders (SUDs) in the elderly represent one of the most rapidly expanding public health challenges in the United States.The growing problem of SUDs among geriatrics demands immediate attention and action!

Additional Information For You

Alexandra Plante

Alexandra Plante is a Senior Advisor in the National Council for Mental Wellbeing Strategy Office. She has consulted U.S. federal agencies and state policymakers, international agencies such as the United Nations Office of Drug Control and Crime (UNODC), and private entities such as Google. Alexandra was previously the Director of Massachusetts General Hospital, Harvard Medical School—Recovery Research Institute, and DynamiCare Health.

Alexandra’s writing has been featured in Harvard Health Publications, Scientific American, and STAT.  She is a current Fulbright Specialist in SUD, holds an M.A. in Quantitative Research in Communications and is a Doctor of Medical Science (DMSc).  

According to Alexandra:

What does substance use in older Americans look like?  Two-thirds of older adults who live with substance use disorder have a persistent condition (early onset beginning before age 22), and one-third develop a substance use challenge later in life. 

Risk factors for substance use development in older adults include loneliness or social isolation (single, divorced, widowed, lack of spiritual community, bereavement, chronic pain or illness, co-occurring mental health conditions such as depression, and changes in employment or living situations. Older adults are more vulnerable as they experience loss in various areas. Taking substances may be a way to cope with loss. 

According to the World Health Organization, opioid use disorders and alcohol use disorders are the second and fourth-most stigmatized health conditions in the world, respectively. This stigma compounds with ageism to exacerbate myths around the inability of older people to assume health change behaviors. The data supports a very different reality in which geriatric patients can change and have similar rates of recovery from substance use disorder when offered treatment. 

It's important to remember that older adults can and do recover. Abstinence or reducing substance use can significantly improve their quality of life and future health, offering a hopeful outlook. 

Screening 

The older age population is notoriously overlooked and undertreated. Annual screenings for substance use are recommended throughout one’s life, but often, providers do not screen for substance use in elderly patients. Screening is arguably more critical for the geriatric population because of their high instance of problematic substance use paired with a high risk for medical complications. 

It's crucial to note that older adults are not only less likely to be screened, but when they are, it’s often not with age-appropriate screening tools. This underscores the urgent need for tools that can also detect common co-morbid and physical health conditions, such as depression and pain. 

It can be challenging for providers to identify substance use disorders in the elderly, as symptoms of diagnostic criteria can mirror the symptoms of diagnostic criteria attached to other age-related conditions. Declines in memory, for example, could be attributable to alcohol use or be a natural decline in cognition as one ages. Thus, symptoms of substance use disorder can easily be conflated to reflect other diagnoses, like dementia or mild cognitive impairment (MCI). 

Access to Services 

Many barriers to access exist for older adults. Most notably, few specialized geriatric addiction treatment programs exist. Hazelden Betty Ford’s BoomerPlus program for adults 50 and older is one of the few specialized programs for older adults. It aims to recognize the distinct physiological, emotional, spiritual, and mental health challenges unique to recovery later in life. However, this program requires patients to be ambulatory and live independently. 

Additional barriers include negative provider and caregiver attitudes, a lack of knowledge about diagnosis and treatment by both providers and patients, and denial of a problem. Even when an older adult and their provider have identified problematic substance use, barriers may remain, including transportation and home care, finances, and new technologies, such as smartphone applications. Older adults may need transportation assistance to and from treatment and someone to take care of their living space while they receive services. That includes caring for pets, collecting mail, and performing other necessary chores. 

Many elderly Americans depend on Medicaid and/or Medicare payments and coverage. They need substance use treatment programs that are in-network and accept public forms of insurance. Affordable, local options could increase access and remove some financial barriers. 

Telehealth options across mental health and substance use treatment services increased during the pandemic. While new telehealth technologies have the potential to improve access for large segments of the population, they can also serve as a barrier to older adults seeking substance use treatment. It may take additional resources to fully train older adults to use these new technologies to access and benefit from telehealth services and smartphone applications. 

Treatment 

Older adults are less likely than younger adults to be correctly diagnosed for substance use. It is essential to understand and differentiate symptoms of substance use and typical aging, as individuals may be less likely to receive treatment, service, or referrals when symptoms are mistaken for chronic health conditions or stress. Older adults are not only screened at different rates, but when it comes to treatment, significant discrepancies exist.

Medication-assisted treatment (MAT) is underutilized and understudied in the geriatric population. Providers often cite challenges in identifying the need for treatment because of co-existing or co-occurring disorders that obscure the signs and symptoms of substance use. 

Substance use treatment for older adults needs to operate at the intersection of addiction, mental health, and physical health. There are age-specific physical health issues around medication management, chronic pain, physical movement, nutritional needs, and sexual health, among others. Older Americans also face unique mental health challenges.

Common obstacles observed in this population include a general decline in cognitive functions, emotional turmoil from significant transitions in employment or housing, and prolonged states of bereavement from the increased incidence of loss of friends and loved ones. 

Age-sensitive treatment approaches accommodate physical needs (e.g., challenges with mobility, hearing, or vision), cognitive needs (e.g., memory and attention challenges), and learning needs (e.g., slower pace, repeating information). Older adult addiction programs also need to incorporate the unique sensitivities of each generation. 

Considering the physical changes associated with aging, the body metabolizes substances more slowly. Of particular concern is the interaction of prescription medications used to treat chronic diseases with substances. 

It has been reported that 65% of people 65 and older reported high-risk drinking; in this population, alcohol is the most used drug (NIDA, 2020), followed by an increase in the use of illicit drugs. 

While addiction research into geriatric populations remains limited, early research has revealed several promising and practical options such as brief structured treatment, continuous patient education, relapse prevention techniques, formal in-patient/out-patient treatment programs, and pharmacotherapy (e.g., methadone, buprenorphine, naloxone, naltrexone). 

Your Call to Action

Additional research on actions and steps to minimize SUD challenges in older adults comprises the following:

• Primary care and mental healthcare providers need to improve their skills in diagnosing and treating substance use disorders in the elderly.

• Primary care and mental healthcare providers need to review this document carefully: SAMHSA’s Treatment Improvement Protocol (TIP), Treating Substance Use Disorder in Older Adults.

• Provide detailed guidance on evidence-based ways to address substance use in older adults, including brief interventions, inpatient programs, sleep and pain support, medications, cognitive behavioral therapy, skill-based approaches, and motivational interviewing (MI). 

• We must shift towards developing health systems that are age-friendly, with a strong emphasis on older adults experiencing substance use disorders.

• Every person 65 years or older should be regularly screened by their primary care and mental healthcare providers for substance use disorder and, when necessary, recommended to evidence-based treatment programs with skilled nursing facilities.

• Ensure evidenced-based life-saving medications are readily available and administered to older adults with substance use disorders.

• Ensure every older adult with substance use disorder has access to the proper evidence-based treatment in age-friendly settings that provide excellent clinical care.

• Create best-practice care benchmarks for every treatment program and facility that provides geriatrics with substance use disorder services. Ensure every substance use disorder program is audited outside by a governing party. 

• Formulate necessary regulatory and policy changes. 

• Accelerate new research on substance use with older adults and develop interventions that are tailored to the unique needs and challenges of the older adult populations.

• Further studies are necessary to investigate the neurological impacts of cannabis on older adults. Clinical researchers must determine which substance use interventions are most effective for different subgroups, like older women compared to older men.