Understanding Substance Use in Older Adults: Critical Prevention and Treatment Factors

By Frederic C. Blow, PhD, Angela Tiberia, MPH, Erin Emery-Tiburcio, PhD, ABPP, E4 Center of Excellence for Behavioral Health Disparities in Aging

Since 2010, population of adults aged 65 and older has experienced a rapid increase, growing by over a third. This surge is primarily due to advances in health benefiting the baby boomer generation, born between 1946 and 1964. By 2034, one in every five Americans is projected to be over 65 years of age.¹ The growing aging population has growing healthcare needs. For older adults with substance use disorders (SUDs), this demographic shift has significant implications for the prevention and treatment of substance use disorders.

How bad is the problem?

From a public health perspective, while the actual rates of substance use disorders (SUDs) in adults aged 65 and older may seem relatively low, the sheer size of this population means millions are affected and remain untreated. For instance, in 2020, nearly 3.5 million older adults had a SUD, yet only 245,000 received any form of treatment.²

Older adults have a variety of unique factors that contribute to their increased SUD risk. The baby boomer population came of age during a time of changing attitudes and beliefs around drugs and alcohol, contributing to higher rates of drug and alcohol use when compared to previous generations. Those who experienced substance use issues earlier in life are at a higher risk of recurrence as they age.^{3; 4} Other factors include changes in the way older adults metabolize drugs and alcohol, making them more susceptible to adverse effects. Chronic pain and other comorbid medical conditions have led to the long-term use of medications such as opioids and benzodiazepines, and substantial increases in misuse and dependence. Older adults are also uniquely susceptible to SUDs due to life transitions (grief due to loss of loved ones), social isolation and loneliness (retirement and loss of purpose, death of a spouse, distance from family), and financial stressors (medical expenses, living on a fixed income), leaving them vulnerable to the unhealthy use of drugs and/or alcohol.⁵

One of the most influential factors permeating the aforementioned areas is ageism, a form of bias that significantly impacts how older adults are treated. Ageist ideas that older adults don’t use substances contributes to the lack of screening and recognition of SUDs in older adults, as well as the scarcity of age-appropriate treatment options. Ageist ideas that older adults “cannot change” or “do not want to change” their substance use, perpetuate a societal “why bother” mindset, leading to the underdiagnosis and misdiagnosis of SUDs in this population. It is crucial to challenge these stereotypes, as research shows that older adults can and do recover from SUDs. Some research suggests higher recovery rates than their younger counterparts, when provided with proper care and social support.^{5; 6}

Providers across multiple disciplines—including psychologists, physicians, nurses, social workers, peer support specialists, and other mental health professionals—play a crucial role in challenging ageist stereotypes that contribute to the under-recognition and undertreatment of SUDs in older adults. Everyone who interacts with older adults shares the responsibility of fostering a holistic approach to care, ensuring that one of society's most vulnerable populations receives the attention and support they need.

Tips on Screening and Treatment of SUDs in Older Adults

Screening for SUDs in older adults should be done at multiple points: when starting a new medication, in response to new problems or health issues (fall, injury, mental health problems), and as part of their routine annual exam. Key points to keep in mind include:^7,8

• Screening, Brief Interventions and Referral to Treatment (SBIRT) is the gold standard for identifying issues and determining next steps for care.
• Questions around substance use can be asked in the context of other health behaviors (diet, exercise, etc.) to help normalize what can often feel like uncomfortable discussions.
• Brief interventions can be very effective for older adults in a variety of settings.
• Treatment should be person-centered, taking into account the individual’s unique needs and preferences. For example, the ASAM Criteria⁸ provides a solid framework for treatment planning in older adults with considerations for the interplay of comorbid conditions and SUD treatment.
• Behavioral interventions such as cognitive-behavioral therapy and motivational interviewing have been shown to be highly successful in older adults.
• It is crucial to involve and educate social support networks such as families and caretakers in the treatment process. This can greatly reduce the stigma toward older adults with SUDs.

Future Directions

For older adults with SUDs, new and more holistic, adaptive models of care are essential. These models should integrate primary care, geriatric medicine, psychiatry, psychology, pharmacy, social work, and addiction medicine. Additionally, more research is needed to ensure that this important population has the resources they need to thrive both physically and emotionally.

The field would also benefit greatly from increased advocacy to improve comprehensive SUD care for older adults. Although it may seem distant for some, the reality is that all of us are aging. Some of us will need SUD treatment. We all deserve not only respect and value but also the necessary support and equitable access to treatment, relapse prevention, and to thrive.

Resources

Please see the E4 Center website for more information! Specifically, these resources are available:

• Clinician resources regarding older adult substance use
• Community resources regarding older adult substance use
• Webinars on older adult substance use
• Speak Up to Reduce Stigma! Videos of Older Adults with Lived Experience with Mental Health and Substance Abuse
• Toolkits on partnership development and business development to promote equitable services for older adults

References

1.         Vespa, J. E., Armstrong, D. M., & Medina, L. (2018). Demographic Turning Points for the United States: Population Projections for 2020 to 2060. US Department of Commerce, Economics and Statistics Administration, US.

2.         Substance Abuse and Mental Health Services Administration. (2021). The 2020 National Survey on Drug Use and Health Detailed Tables.

3.         Barry, K. L., & Blow, F. C. (2016). Drinking over the Lifespan: Focus on Older Adults. Alcohol research: current reviews, 38(1), 115.

4.         Slagsvold, B., & Hansen, T. (2021). The Baby-Boomer Generation: Another Breed of Elderly People? In Generational Tensions and Solidarity within Advanced Welfare States (pp. 153-172). Routledge.

5.         Kuerbis, A., & Sacco, P. (2013). A Review of Existing Treatments for Substance Abuse among the Elderly and Recommendations for Future Directions. Substance abuse: research and treatment, 7, SART. S7865.

6.         Fishman, M., Wenzel, K., Scodes, J., Pavlicova, M., Lee, J. D., Rotrosen, J., & Nunes, E. (2020). Young Adults Have Worse Outcomes Than Older Adults: Secondary Analysis of a Medication Trial for Opioid Use Disorder. Journal of Adolescent Health, 67(6), 778-785.

7.         Substance Abuse and Mental Health Services Administration. (2020). Treating Substance Use Disorder in Older Adults. Treatment Improvement Protocol (TIP) Series No. 26. 

8.         Blow, F. C., Barry, K. L., Galka, A.M.: Treatment of Substance Use Disorders in Older Adults. In Miller, S.C., Rosenthal, R.N., Levy, S., Saxon, A.J., Tetrault, J.M. & Wakeman, S.E. (Eds.): The ASAM Principles of Addiction Medicine, Seventh Edition. 653-665. (Wolters Kluwer, 2024),