An official website of the United States government
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Treating Substance Use Disorder in Older Adults: Updated 2020 [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2020. (Treatment Improvement Protocol (TIP) Series, No. 26.)
Estimated rates of substance misuse in older adults vary widely. Substance misuse by this population is underrecognized and undertreated.
Substance misuse can be very dangerous for older adults. They are affected by substances differently than younger adults, and smaller amounts of substances can have more of an impact. Substance misuse by older adults can worsen any chronic medical conditions they may have. Older adults also often take more than one medication, which increases their odds of being exposed to harmful drug interactions.
It is never too late to stop misusing substances, no matter one's age. Treatment for older adults is available. Providers need to learn about effective interventions for older adults so that they can offer treatment or referrals for treatment quickly and appropriately.
Chapter 1 of this Treatment Improvement Protocol (TIP) benefits all audiences (providers, supervisors, administrators, older adults, caregivers, and family members). It summarizes the extent of substance use and substance misuse, including substance use disorders (SUDs), among older adults. Chapter 1 will help you understand the current situation and trends to gain an overall, broad understanding of this critical issue. This TIP is for all audiences who provide care and support to older adults, including older adults themselves as well as individuals who are connected to an older adult, such as family members, friends, formal and informal caregivers, behavioral health service and healthcare providers, and aging services providers.
Chapter 1 contains information of value to all audiences: it is an overview of substance misuse and addiction treatment among older adults. Chapter 1 also defines terms and summarizes issues to help clients and providers communicate more clearly with each other.
Exhibit 1.1 defines important terms this TIP uses.
EXHIBIT 1.1 Key Terms.
The demand for services to address substance misuse in older adults is increasing. All healthcare, behavioral health, and aging service/long-term care providers need training in working on substance misuse-related problems with older adults, their families and friends, and formal and informal caregivers.16,17 Such providers include primary and specialty healthcare providers, case workers, social workers, psychologists, drug and alcohol counselors, peer recovery support specialists, clergy, providers of aging-related services, and direct care workers.
Caregivers and families need resources to help navigate initial identification, screening, assessment, and treatment options for older people who misuse substances or have SUDs. Key societal changes have made this a critical time to address substance misuse in the aging population:
Substance use and SUDs among older adults are rising:
Illicit drug use is more common among current older adults than among previous generations of older adults. Current 65-and-older individuals and aging baby boomers (those born between 1946 and 1964) are more likely than members of previous generations to use illicit drugs.
SUDs among older adults are expected to continue increasing. Rapidly growing numbers of older adults will need substance misuse prevention and counseling, and sometimes SUD treatment services, particularly to address nonmedical use of prescription medication.
Substance use and chronic health conditions have compound effects on older individuals. Chronic health conditions in older adults can complicate the effects of their substance use, increasing their need for comprehensive, integrated services.19 Likewise, substance use can complicate the management of chronic conditions.20
Older adults are increasingly willing to seek services. Baby boomers tend to view addiction treatment as more acceptable than previous generations have.21,22 As baby boomers continue to enter old age, the number of older people needing treatment will continue to increase— and so therefore will the overall percentage willing to seek treatment. However, feelings of shame and stigma linked to SUD treatment settings cause many older adults to seek addiction care from providers who do not specialize in addiction treatment, including primary care and emergency department providers.23
Older adults are affected by co-occurring mental disorders and SUDs. In the 2019 National Survey on Drug Use and Health (NSDUH):24
1.5 percent of Americans ages 50 and older (1.7 million) had any past-year mental illness and SUD; an estimated 0.5 percent (607,000) reported both a past-year serious mental illness (SMI) and a past-year SUD.
37 percent with a past-year SUD also had any mental illness; 13 percent, an SMI.
11 percent of older adults with any mental illness in the past year also had an SUD.
18 percent of older adults with an SMI in the past year also had an SUD.
Few providers specialize in dealing with geriatric substance use.
Much research has been done with older adult populations, but guidance has lagged on implementing research findings in ways that will improve services. This TIP fills gaps in the field by focusing on ways to implement and improve the delivery of SUD treatment based on evidence and promising practices specifically for older adults. Current gaps include:
A science-to-service gap in resources for providers. Few service improvement resources focus on tailoring treatment services for older clients with SUDs who may also have co-occurring physical disabilities or mental disorders.
A gap in addiction treatment resources for clients, their families and friends, and caregivers. Free, user-friendly publications that inform older clients and those close to them about substance use and addiction services are difficult to find.
When reading this TIP, remember that some misuse is accidental or inadvertent. For example, individuals who are unaware of a medication's potential to cause dependence or other harms may consume more than prescribed. Other individuals may have difficulty in monitoring when they have taken their medication and take more than the recommended dose. Some individuals may become substance dependent even though they take their medication as prescribed. The pathway to misuse helps guide the selection of interventions and, if necessary, treatment. Accidental misuse stills requires a response.
The older adult population is becoming more diverse. In the coming decades, the percentage of non-Hispanic White older adults in the U.S. population is projected to drop, whereas the percentages of Hispanics and races other than White are expected to increase. Gender ratios are also changing. The gap between the number of women and men is beginning to narrow because of the increased life expectancy of men, especially among men ages 85 years and older.25
Healthcare and behavioral health service providers and caregivers must understand this diversity to provide culturally responsive services, including interventions and treatments for alcohol and other substance misuse.26 Providers should also recognize differences between generations of older adults that may make some older adults more willing than others to discuss addiction and mental illness with their healthcare providers.
The number of older adults with SUDs is increasing. The U.S. population of older adults increasingly consists of baby boomers. Baby boomers came of age at a time when substance use tended to be more culturally acceptable, making them more open to and less judgmental about substance use than prior generations. (Not all subgroups of baby boomers experienced this openness and freedom from judgment about substance use, such as racially and ethnically diverse populations.) Because of baby boomers' exposure to drugs and alcohol at a younger age, their generation has higher rates of past or current SUDs compared with previous generations.27,28
These changes in older adult demographics will have major consequences for SUD prevention and treatment programs. Shifts in the older population will strain retirement systems, healthcare facilities, and other services. A rapidly increasing number of older adults will need comprehensive, integrated, age-specific SUD screening, assessment, and treatment services.29
Substance misuse in older adults is dangerous and potentially deadly. They have increased vulnerability to alcohol and to adverse drug reactions (whether the drugs are prescription or illicit)30 because of physiological and mental changes associated with aging. Such changes include slower metabolism and lower body fat. This increased vulnerability makes identifying SUDs in older adults especially critical.
SUDs do occur in older adults, although less often than in younger people. Of adults ages 65 and older in the 2012–2013 Wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC III):
2.3 percent had a 12-month AUD, and 13.4 percent had a lifetime AUD.31
0.8 percent had a past-year drug use disorder, and 2 percent had any lifetime drug use disorder.32
Substance misuse rates in older adults vary by gender, race/ethnicity, and education level:
In NESARC III, past-year cannabis use was reported by about 4 percent of non-Hispanic Whites, 6 percent of non-Hispanic Blacks, 3 percent of Hispanics, 0.7 percent of Asians, and 11 percent of American Indians/Alaska Natives ages 50 and older.33
In the 2004–2005 Wave of NESARC, past-year prevalence of any SUD in adults 55 and older was:34
3.9 percent for non-Hispanic Whites, 3.6 percent for African Americans, 3.3 percent for Hispanics, 3.0 percent for American Indians/Alaska Natives, and 1.7 percent for Asian/Native Hawaiian/other Pacific Islanders.
2.9 percent for individuals with less than a high school education, 3.1 percent for individuals with a high school education, and 4.5 percent for those with at least some college.
Older adults are often willing to seek help for substance misuse or SUDs, as they are tending to take more accepting views about addiction treatment.35 Yet negative attitudes (sometimes termed “ageism”) about older adults' ability to recover from addiction persist, despite evidence that treatment is effective in reducing or stopping substance misuse and improving older adults' health and quality of life.36,37,38,39,40,41
Substance misuse, including SUDs, among older adults often goes unrecognized and untreated. Societal norms, values, and biases play a large role in this phenomenon. Some people hold the ageist false belief that SUDs do not exist or need no treatment in this age group. Others—even some healthcare providers—mistake SUD symptoms for normal age-related changes. Some healthcare providers may focus more on older adults' reports of physical/medical complaints. Similarly, some older adults may deny or hide their substance use-related problems from their healthcare providers.42
Current cultural biases tend to minimize the scope of substance misuse among older adults, but this public health concern is more urgent than ever.
Alcohol is the substance that older adults use and misuse most frequently. The 2019 NSDUH43 found that, in individuals ages 65 and older, an estimated 5.6 million (10.7 percent) engaged in past-month binge alcohol use and an estimated 1.5 million (2.8 percent) engaged in past-month heavy alcohol use.
The survey also showed that 903,000 adults ages 60 to 64 and 1.04 million adults ages 65 and older met Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for alcohol dependence or abuse in the past year. These numbers were similar among slightly younger groups of older adults, with 939,000 adults ages 50 to 54 and 1.02 million adults ages 55 to 59 meeting DSM-IV criteria for alcohol dependence or abuse in the past year.
Exhibit 1.2 shows what constitutes a standard drink by type of alcohol.
EXHIBIT 1.2 What Is a Standard Drink?
In healthcare settings, up to 15 percent of older patients may meet criteria for at-risk drinking.45,46,47 For example, one study48 of 24,863 adults ages 65 and older in military and civilian healthcare clinics found that 9.2 percent of men and 2.1 percent of women regularly drank in excess of federal guidelines. The study found that 21.5 percent of patients drank moderately, 4.1 percent engaged in at-risk drinking, and 4.5 percent drank heavily or engaged in binge drinking. Among those who drank moderately, 10.2 percent had engaged in heavy episodic drinking one to three times in the past 3 months.
The Dietary Guidelines define moderate drinking as consuming up to one drink a day for women and up to two drinks a day for men. Exceeding these numbers can lead to high-risk drinking. Older adults who drink at all in the following situations are also engaging in high-risk drinking:49
While taking certain prescription medications (such as opioids or sedatives)
Despite having a medical condition that drinking could worsen (like diabetes or heart disease)
When planning to drive a car or engage in other activities that require alertness
While recovering from AUD
Older clients who engage in heavy drinking are at risk for worsening of existing health problems (e.g., diabetes, high blood pressure, mood disorders, cancer).50,51,52 In addition, certain life stressors53,54 are linked to increased risk of alcohol misuse in older adults and could cause existing health problems to worsen. Such life stressors include:
Financial strain.
Job loss/retirement.
Housing changes.
Bereavement.
Being a victim of theft.
As adults age, they metabolize alcohol differently and become more sensitive to its effects even when they drink less.55 This increases risk of confusion, falls, and injury, and worsens existing health issues.
Establishing clients' history of use can help providers recognize possible substance use concerns in the future. Taking a history is also an opportunity to offer prevention messages and encouragement to individuals maintaining abstinence or very low use.
Older adults are more likely to take medications that interact badly with alcohol. Exhibit 1.3 lists some of these “alcohol-interactive” (AI) medications. In a review of 20 studies on reported use of alcohol and AI medication, more than half of individuals who used AI medication reported drinking alcohol.56 Another study found that 77.8 percent of older adults who drank alcohol also took AI medications.57
EXHIBIT 1.3 Potential AI Medications.
Older adults who drink and regularly take AI medications may experience severe negative reactions (e.g., falls, gastrointestinal bleeding, low blood pressure, drowsiness, heart problems, liver damage).59 Drinking can also make these medications less effective in treating health conditions. Healthcare and behavioral health service providers should discuss the risks of combining alcohol and AI prescription medications with older clients, especially those with a history of alcohol use.
Most older adults take at least one prescription medication. Many take more than one. According to national estimates released in 2019,60 87.5 percent of older adults in the United States have at least one prescribed medication, and 39.8 percent take five or more prescription medications at the same time. From 2015 to 2016, the percentage of adults taking a prescription medication was greater for the 65 and older age group (87.5 percent) than for any other adult age group.
High prescription medication use puts older adults at greater risk than the general population for harmful side effects and drug-drug interactions, especially when they use over-the-counter (OTC) medications in addition to their prescriptions.61 Many prescription medications may interact badly with alcohol (Exhibit 1.3) and other substances, compounding this risk. Additionally, older individuals are more likely to experience negative side effects from prescription medications because of aging-related changes that alter how the body processes such substances.62
In addition, older adults may make medication errors (e.g., take too much, forget to take medications) because they have difficult or complex medication regimens. According to the Agency for Healthcare Research and Quality,64 50 percent of emergency department visits for adverse drug events in Medicare recipients are caused by four medication types: medications for diabetes (e.g., insulin), oral blood thinners (e.g., warfarin), anti-blood-clotting medications (e.g., aspirin, clopidogrel), and opioid pain relievers. Many older adults take numerous medications, thus increasing their chances of making errors.
Adults 65 and older are particularly vulnerable to misusing prescription medications. Prescription medication misuse involves taking a medication other than as prescribed, whether accidently or on purpose.
In 2019, the most commonly misused medications were pain relievers, with an estimated 1.7 percent (900,000) of adults ages 65 and older misusing them in the past year.65 In 2019, pain reliever misuse was the fourth most common type of substance misuse among adults ages 65 and older in the United States.66 Some older adults do use prescription medications to “get high,” but many develop SUDs from misusing prescription medications to address sleep problems, chronic pain, or anxiety.67,68,69
The medications of most concern are psychoactive medications such as opioids and central nervous system (CNS) depressants. Opioids are medications that relieve pain. CNS depressants include antianxiety medications, tranquilizers, sedatives, and hypnotics. These medications affect brain function, which can result in changes in consciousness, behavior, mood, pain, perception, and thinking.
Nonmedical use of prescription medications by older adults will likely increase in the future. Most misused medications (e.g., pain relievers, stimulants, tranquillizers, sedatives) are obtained by prescription.70
Older adults are at risk for nonmedical use of opioids, given the high prevalence of chronic pain in this population.71 Chronic pain is among the most common reasons for taking opioid medications, but for some individuals, prescription opioids do not relieve pain.72
Older adults are also at risk for alcohol-opioid interactions. When taken with opioids, alcohol increases the risk of negative outcomes in older adults, including death.73,74,75
Rates of death and suicide caused by prescription opioid misuse are increasing.76 In 2016, the Food and Drug Administration (FDA) issued a warning about serious risks, including death, from combining opioids with benzodiazepines or other CNS depressants, and required boxed warnings for prescription opioids and benzodiazepines. FDA's action was not meant to suggest that providers withhold buprenorphine or methadone, which treat opioid use disorder (OUD), from patients also prescribed benzodiazepines, although FDA recommends careful medication management of these patients.77 Exhibit 1.4 lists common opioids.
EXHIBIT 1.4 Common Forms of Opioids.
Older adults may receive prescriptions for opioids to help manage their pain. For some, this creates a desire to get more pain medication than prescribed, because of tolerance. Having staff trained in the administration of naloxone is important in case clients experience an overdose of opioid medication. Providers should also learn about and offer older adults nonopioid pain medications (e.g., acetaminophen, antidepressants) and nonpharmacological pain management options (e.g., cognitive-behavioral therapy, relaxation training, exercise).
Opioids can be appropriate in the short term and for specific uses, such as postsurgical discomfort or cancer-related pain. But for many older adults with chronic (e.g., greater than 3 to 6 months) noncancer pain, nonopioid options are appropriate, effective, and well tolerated.
Benzodiazepines are frequently prescribed to older adults to treat anxiety and insomnia, despite having a high dependence potential. Benzodiazepines interact with alcohol, increasing the risk of negative outcomes. Recent research shows that, frequently, benzodiazepines are prescribed long term for older adults without a clear need for ongoing treatment.78
Benzodiazepines are linked with a number of risks in older adults, including falls,79 problems with thinking,80 motor vehicle accidents,81 and overdose death.82 Exhibit 1.5 lists common benzodiazepines.
EXHIBIT 1.5 Common Benzodiazepines.
Cannabis is illegal at the federal level, although an increasing number of states have legalized the recreational and medical use of cannabis. In 2019, about 2.7 million adults ages 65 and older (5.1 percent) engaged in past-year cannabis use.83 The number of older adults using prescribed cannabis is unknown. From 2013 to 2014, 12-month prevalence of medical cannabis use among U.S. adults ages 50 and older was only 0.6 percent.84
Older adults using medical cannabis are at risk for misuse and diversion (including forced or coerced diversion by others).85 Other adverse effects can include psychomotor slowing (e.g., gait instability leading to fall risk), cognitive problems (e.g., short-term memory impairment), and increased risk of heart attack, stroke, psychotic episodes, and suicide.86 Studies have shown limited benefits of cannabis for medical purposes, with, for example, some evidence suggesting possible improvements in neuropathic pain and spasticity from multiple sclerosis in older adults;87 also, certain components of cannabis have demonstrated some medical value when treating seizure disorders (Dravet's syndrome, Lennox-Gastaut syndrome), wasting illnesses, and lack of appetite.88 Other medications can treat these conditions, but they do not always work for older adults and may have unpleasant side effects.
Little is known about interactions of cannabis with specific medications.89 Cannabis affects the CNS. The substance is associated with memory and thinking problems, difficulties with motor skills, depression, and anxiety, among other negative effects.90,91,92,93 Moreover, the increasing potency of cannabis in recent decades may make cannabis use riskier.94
Older adults are much less likely to use illicit drugs than younger adults. However, the pattern of drug use in older adults is changing. According to national survey data, use of illicit drugs among adults ages 50 to 64 rose from 2.7 to 10.4 percent from 2002 to 2019.95,96 Baby boomers are more likely than earlier generations to report use of heroin and psychoactive drugs like cocaine or methamphetamine.97
According to a 2016 analysis of national survey data,98 about 38 percent of older adults take at least one OTC medication; more than 63 percent take a dietary supplement (e.g., herbal products, vitamins). Among those who take prescription medications, 71.7 percent also take OTC medication or dietary supplements.
OTC medications, including OTC pain medications like acetaminophen and ibuprofen, and dietary supplements can interact harmfully with prescription medications, illicit substances, and alcohol. Older adults may lack awareness of side effects and possible negative interactions, because information that comes with OTC medications often does not include warnings specifically for older adults.
Providers should routinely discuss OTC medication use with older clients and advise them of possibly harmful interactions with prescribed medications, alcohol, and other substances.99
Older adults (and their families and caregivers) should inform their healthcare providers of any OTC medications and dietary supplements, including herbal products, they take. Asking for guidance on safety is crucial when taking multiple OTC medications or using them in combination with alcohol or a prescribed medication.
The unique physical, emotional, and cognitive challenges older adults face tend to mask SUD symptoms, making it harder for providers to identify and address SUDs.
The aging process often includes major life changes and transitions. Some older adults turn to drugs or alcohol to cope.100 Older adults also face many aging-related physical and mental health issues that may increase their risk of substance misuse and make detection and treatment difficult.
The aging process can cause changes in and problems with thinking. Symptoms of cognitive decline and symptoms of substance misuse may be similar. This makes it harder for family members, caregivers, and healthcare and behavioral health service providers to recognize when older adults misuse substances.
Many older adults who misuse substances have a history of co-occurring mental disorders, which suggests that mental illness is a risk factor for this population. Older adults with co-occurring mental and substance use disorders are at risk for negative outcomes like greater need for behavioral health services and higher rates of homelessness and suicidal thoughts.101,102,103
Exhibit 1.6 lists risk factors for substance misuse in older adults.
EXHIBIT 1.6 Substance Misuse Risk Factors in Older Adults,.
Protective factors help prevent or reduce substance misuse in older adults.106,107,108 Exhibit 1.7 lists protective factors against substance misuse in older adults.
EXHIBIT 1.7 Substance Misuse Protective Factors in Older Adults.
Exhibit 1.8 lists some of the barriers that prevent older adults from getting the SUD treatment they need. Understanding these barriers is a key step in reducing substance misuse in the older adult population. Such misuse limits one's ability to function and to achieve the best possible quality of life, regardless of age.
EXHIBIT 1.8 Barriers to Seeking Treatment.
The following two sections will be of greater interest to healthcare providers. These sections give overviews of basic information on screening, diagnosis, and treatment as they apply to older clients from the provider's point of view.
Screening, brief intervention, and referral to treatment (SBIRT) is the overall model for and approach to screening and intervening with individuals who misuse, or are at risk for misusing, substances. Older adults with SUDs may receive screening, diagnosis, and treatment for SUDs in many different settings and from a variety of professionals. Few older adults seek help in specialized addiction treatment settings.
All healthcare, behavioral health, and aging service providers must know the signs/symptoms of SUDs and substance misuse in older adults and have protocols for screening, treatment, or referral.117,118
See Chapters 3, 4, and 5 of this TIP for more information about screening, assessment, and SBIRT.
Universal screening is key in SBIRT. Providers should screen all older clients for substance use (type of substance, frequency, quantity), misuse (including of prescriptions), consequences, and drug-drug interactions.
UNIVERSAL SCREENING.
Settings in which older adults may receive screening for substance-related problems include:
Healthcare clinics.
Hospitals.
SUD treatment programs.
Home health care.
Nursing homes.
Social service agencies.
Senior centers.
Assisted living facilities.
Faith-based organizations.
The TIP consensus panel recommends yearly screening for all adults ages 60 and older and when major life changes occur (e.g., retirement, loss of partner/spouse, changes in health). For more accurate histories, ask questions about substance use in the recent past while asking about other health behaviors (e.g., exercise, smoking, diet). Asking straightforward questions in a nonjudgmental manner is the best approach. Providers should also ask about medical marijuana prescriptions or use.
Screening helps fully determine which substances (including alcohol) and medications a client takes and what, if any, interactions these substances, prescription medications, OTC medications, and dietary supplements may have with each other. Many providers fail to ask about OTC medications. However, some OTC medications (particularly anticholinergic agents, like diphenhydramine [Benadryl], doxylamine [Unisom], and acetaminophen/diphenhydramine [e.g., Tylenol PM]) can be problematic in combination with alcohol or prescription medications as well as illicit drugs.
Screening for older adults can be verbal (e.g., by interview), with paper-and-pencil forms, or with computerized forms. All three methods are reliable and valid.120 Any positive responses should lead to further questions constituting full assessment (or referral for full assessment by a qualified provider).
Chapter 3 of this TIP offers further information about substance misuse screening measures and how to follow up with clients who screen positive as well as those who screen negative.
Some DSM-5 SUD criteria may not apply to older adults with substance use problems, even though DSM-5 criteria generally determine SUD diagnoses. For example, in retired older individuals with fewer familial and work obligations, substance use may not cause failure to fulfill major obligations at work, school, or home. Even so, it may negatively affect health, daily activities, or functioning.121
Older adults have unique risk factors that increase their vulnerability to substance misuse, but signs and symptoms of SUDs often resemble those of other health issues, making detection difficult. Bodily changes (e.g., slower metabolism, reduced muscle mass, altered body fat percentages and organ functions) make older adults more sensitive to the effects of alcohol and drugs. Because of such changes, smaller amounts of substances may cause more harmful effects. These changes can occur gradually, which may make them harder to notice.
Older individuals who misuse substances may require treatment even if they do not meet DSM-5 criteria for an SUD. Quantity-frequency measures may be less effective than assessment of impact on overall well-being and quality of life in identifying substance misuse for this population. Healthcare and behavioral health service providers must determine these effects before focusing on interventions and treatments.
Addiction treatment programs have begun to see an increase in admissions among older adults because of the population increase and the higher prevalence of lifetime substance use among baby boomers.122,123 Although alcohol use remains the primary reason for admission, the years 2000 to 2012 saw a decrease in alcohol-related admissions and steep increases in admissions for prescription opioids as well as illicit drugs such as cocaine, crack, and heroin.124
SUD diagnosis and treatment planning depend, in part, on when substance use began in older adults. “Early onset” substance use is present in those with a history of at-risk or harmful substance use that began before age 50.125 “Late-onset” substance use is present in those who began to misuse substances only later in life. Exhibit 1.9 shows early-versus late-onset aspects of alcohol misuse as an example.
EXHIBIT 1.9 Characteristics of Early-Onset Versus Late-Onset Alcohol Misuse.
People with late-onset misuse may seem “too healthy” to raise concern. Providers should ask older clients about lifetime substance use patterns. Problems can arise with stressors in older adulthood.128,129
Acamprosate, disulfiram, and naltrexone are approved to treat AUD. They can improve outcomes130 but are not usually used for long-term treatment of older adults with AUD.
Acamprosate is approved by FDA to treat AUD.131 Clinical evidence suggests that acamprosate can help people with alcohol dependence maintain abstinence by reducing cravings and the pleasurable effects associated with alcohol.132,133 It may also lessen symptoms of prolonged abstinence such as anxiety and insomnia.134 To date, research on acamprosate use in older adults is not readily available. Because acamprosate is removed from the body through the kidneys and older adults are at elevated risk of diminished kidney function, this population should have baseline and frequent renal function tests as part of acamprosate treatment.135
Disulfiram is approved by FDA to treat AUD.136 Disulfiram triggers an acute physical reaction to alcohol, including flushing, fast heartbeat, nausea, chest pain, dizziness, and changes in blood pressure.137,138 These reactions are supposed to motivate a person to avoid drinking alcohol.
Because the effects of taking this medication in combination with alcohol can be harmful to older people, it is generally not recommended for use in this population and, if used, is done so only with great caution.139,140
Also, for disulfiram to be useful, clients must stick to strict medication protocols.141 Doing so may be hard for older adults who have cognitive impairment or live alone and have no one to support them in taking medication as prescribed. A meta-analysis suggests that when compliance with disulfiram is not monitored, its efficacy is no different from that of control conditions.142 Monitoring for adherence is essential for disulfiram to be effective. People taking disulfiram may also need to be observed, as some may stop taking it on a day during which they want to drink.
Naltrexone is approved by FDA to treat AUD.143 It reduces craving for alcohol and decreases the rate of relapse to heavy drinking. Some research suggests that naltrexone is tolerable in adults ages 50 and older, but widespread data on its tolerability in older individuals are lacking.144
Naltrexone is an opioid blocker and cannot be used in clients who require prescription opioids for pain relief. Giving naltrexone to a client who takes opioid medication for pain may cause significant opioid withdrawal symptoms.
Medication treatment for OUD can reduce risk of relapse.145,146 Three medications can treat older adults with OUD: naltrexone, buprenorphine, and methadone. The opioid overdose medication naloxone is also safe and effective in older adults. Learn more about medication for OUD in the Substance Abuse and Mental Health Services Administration's (SAMHSA) TIP 63, Medications for Opioid Use Disorder (https://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Full-Document/PEP20-02-01-006).
Naltrexone can prevent relapse after medically supervised opioid withdrawal.147 It is not a pain medication. It is a medication that reduces cravings for and effects of opioids and alcohol. Research on its use in older adults with OUD is not readily available, but some studies have shown it to be safe and acceptable in older adults with AUD.148,149
Buprenorphine can treat opioid withdrawal or provide long-term medication maintenance for OUD. It is so effective that the World Health Organization (WHO) lists it as “an essential medication.”150,151 Compared with methadone, less is known about use of buprenorphine in older adults with OUD. It may be preferable to methadone, because it is less likely to cause withdrawal symptoms, erectile dysfunction, and prolonged QT interval (see “Methadone” section). It may be safer than methadone for older adults with cardiovascular/respiratory disorders.152 A study of short-term use of low-dose buprenorphine for older adults with depression found the medication to be safe and well tolerated.153 However, more studies are needed to fully understand the benefits and side effects of buprenorphine in older adults with OUD.
Certain buprenorphine formulations are FDA approved to treat chronic pain. One such formulation is the buprenorphine transdermal system,154 which appears safe for pain treatment among older adults.155
Methadone is used to prevent opioid withdrawal symptoms and reduce cravings for people with OUD.156 As with buprenorphine, it is considered so effective that WHO lists it as “an essential medication.”157,158 Methadone is available through federally certified and accredited opioid treatment programs. It can be effective on its own, but research shows that it is often more effective in treating OUD when used with behavioral, social, and other medical services.159 Methadone can also be prescribed to treat chronic pain in older adults.160,161
Older adults taking methadone may experience certain side effects, some of which can be serious.162 Methadone is associated with higher risk of prolonged QT interval, which can cause a potentially deadly cardiac arrhythmia.163 This risk is even greater when methadone is taken at higher doses, with other QT-prolonging medication, or by someone with congestive heart failure. Many medications negatively interact with methadone.164 This is an important consideration in older adults, who are likely to take multiple medications. As with other opioids, methadone can increase the risk of falls in older adults.165
RESOURCE ALERT: METHADONE SAFETY.
Naloxone does not treat OUD or pain by itself, but it can reverse potentially fatal opioid overdoses. It is so effective that WHO lists it as “an essential medication.”166 Older adults are at increased risk of opioid overdose. Bodily changes that occur normally in aging cause older adults to experience a higher concentration of opioid metabolites than younger adults when the same dose is consumed.167 Low-dose naloxone is safe and effective in older adults in case of opioid overdose.
People can change their substance use at any age. Once substance misuse becomes apparent, hope for recovery should always follow. A wide range of professionals and providers across a variety of settings share the responsibility to help older clients achieve recovery.
Some studies suggest that older adults who enter specialized SUD treatment have better outcomes than younger adults.168,169,170,171 However, many traditional SUD treatment programs do not serve many older adults (compared with the number of younger people they serve). In 2019, only about 23 percent of SUD treatment facilities had older adult-specific programming.172 Thus, few studies with significant older populations have examined effectiveness of residential programming in this age group.
Older adults do best in SUD treatment programs that offer age-appropriate care with providers who are knowledgeable about aging issues.173 In the community-based Geriatric Addictions Program, for older adults with SUDs and co-occurring mental disorders, a multidimensional approach connected more older adults to outpatient and inpatient treatment than did traditional assessment and referral. The multidimensional approach included geriatric care management assessment, motivational counseling, in-home counseling, and referral to aging services and addiction treatment.174
Many pathways lead to recovery, and many treatment options work for older adults (Exhibit 1.10).
EXHIBIT 1.10 Range of Intervention and Treatment Strategies for Older Adults.
Few older adults who screen positive for substance misuse need specialized addiction treatment. Many can change their misuse through less intensive approaches,175,176 such as:
Professional and personal advice and discussions.
Education about alcohol misuse, drug use, and prescription medication misuse.
Brief structured interventions and treatments (both individual and group).
Each older adult has an individual history and unique needs. Each older client's intervention or treatment path will also be unique. The path to improving outcomes is determined, in part, by the severity of the problem, the individual's willingness to get help with reducing or stopping substance misuse, the types of programs available, and the cost of care.
Evidence-based screening techniques, brief interventions or treatments, and specialized care options give older adults the best chances of improving their physical and emotional health. Identification and treatment of SUDs can be challenging, but is possible with the right knowledge and tools.
This TIP will guide SUD treatment providers, supervisors, and administrators; mental health service providers; state and community behavioral health service agencies; healthcare providers; caregivers; families; and older adults in understanding and accessing evidence-based screening, intervention, and treatment options to address substance misuse in a number of settings.
Older adults face barriers at many levels in accessing SUD treatment and mental health services. Barriers can be personal, interpersonal, structural, or a combination. Recognizing, understanding, and working to remove barriers will help all older clients receive the best possible care for substance misuse.
The following table shows the many types of barriers older adults potentially face in addressing substance misuse. The table includes citations of supporting research; access these references to learn more about each barrier and how it affects older adults.
Barriers Older Adults Face in Addressing Substance Misuse.
This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
Your browsing activity is empty.
Activity recording is turned off.
See more...
