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Substance Use Disorders in Older Adults: A Growing Epidemic

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Source: CMSA Today

BY KELVA EDMUNDS-WALLER, DNP, RN, CCM

Substance use disorders (SUD) are an epidemic in the United States; however, limited attention is given to the extent of the epidemic among adults 60 years of age and older. By 2030, more than 72 million adults in the U.S. will be 65 year of age and older. The baby boomer cohort, born between 1946 and 1964, experienced greater exposure to alcohol and illicit drug use than previous generations. Baby boomers’ attitudes toward alcohol and illicit drug use were also more socially accepting than previous generations. Within this age cohort, specific groups either stopped consumption, continued sustained use or returned to alcohol and illicit substance use later in life. As baby boomers continue to age, the challenges and barriers associated with SUD and treatment in older adults will accelerate. The structure of our current healthcare system is not prepared to adequately meet the present needs of individuals and families suffering from SUD. Without transformational change in addiction treatment for older adults, the future is very dim for aging baby boomers with SUDs (Yarnell et al., 2019).

The most sobering data related to the impact of SUDs among adults 65 years of age and older is the increasing trend in overdose to all-cause mortality rates from 2002 to 2021. The share of all-cause mortality attributable to drug overdose increased from 0.06% to 0.27% between 2002 and 2021. In 2021, overdose was the cause of 1 out of every 370 deaths in persons 65 years of age and older. In 2021,

  • Fatal overdoses quadrupled from 3.0 to 12.0 per 100,000 population, 1060 to 6,702 deaths, respectively
  • Death from alcohol poisoning increased to 0.5 per 100,000 population, 10 to 279 deaths, respectively
  • Of the 6,702 overdoses:
    • 57% involved an opioid.
    • 39% involved a stimulant.
    • 18% involved an opioid and a stimulant.
    • Females accounted for more than half (57%) of intentional overdoses, 505 of 882.
    • Males accounted for 71% of unintentional overdoses, 3,947 of 5,541.
    • 74% of unintentional overdoses involved illicitly manufactured drugs including synthetic opioids, heroin, cocaine and methamphetamines.
    • 68% of unintentional overdoses involved prescription drugs including opioids, antidepressants, benzodiazepines, antiepileptics and sedative hypnotics (Humphreys & Shover, 2023).

Epidemiological research on SUDs specific to older adults identifies risk factors that are primarily physical, psychiatric or social in nature.

Physical risk factors include:

  • chronic pain
  • disabilities
  • loss of mobility and function
  • changes in living situation
  • loss of independence
  • reliance on others for assistance
  • loss of loved ones and friends
  • loss of income
  • chronic illness and deteriorating health
  • polypharmacy

Psychiatric risk factors include:

  • poor coping mechanisms
  • earlier or sustained history of SUD
  • co-occurring mental illness

Social risk factors include:

  • bereavement
  • loneliness
  • social isolation
  • lack of a spiritual community
  • change in employment (Kuerbis et al., 2014)

As older cohorts age, it is increasingly critical to screen older adults for SUD. A recent review of admissions to substance abuse treatment programs reveals that patients are more likely self-referred or referred by the criminal justice system versus referral by the healthcare system or primary care providers. This finding implies that there is an opportunity to improve and increase discussions surrounding SUD with older adults. Routine primary care office visits present barriers to thoroughly assess and screen for SUDS. Other barriers to screening and assessment of SUDs in older adults include:

  • patient discomfort from stigmatism
  • provider discomfort
  • provider bias
  • limited time for formal screening
  • lack of screening in clinic workflows
  • lack of training (Lin et al., 2023)

Most screening tools for SUD were not formulated for older adults; however, several validated screening tools are available to assess problematic alcohol (Table 1) and substance use (Table 2) in older adults.

Table 1

ALCOHOL USE SCREENING TOOLS
Tool Description Comments
AUDIT-C 3-item tool, modified from AUDIT tool Identifies at-risk drinkers who may not be alcohol dependent
CAGE 4-item screening tool For excessive drinking and known AUD
CARET Revised version of ARPS (Alcohol Related Problems Survey) Considers comorbidities, high-risk behaviors and concomitant medication use common in adults
MAST-G 24-item tools that may indicate need for further assessment Highlights employment and social situations of retired persons that increase risk of AUD

(Lin et al., 2023)

Table 2

DRUG USE SCREENING TOOLS
Tool Description Comments
ASSIST 8-item screen tool from WHO Screens for tobacco products, alcohol, cannabis, cocaine, amphetamine-type stimulants, opioids, and other drugs. Can identify acute intoxication and regular, dependent, high-risk use and injecting behaviors.
CAGE-AID 4-item screening tool adapted from CAGE Combines screening for alcohol and drug use problems

(Lin et al., 2023)

In addition to the use of validated screening tools, interprofessional healthcare teams should be alert to potential indicators of substance misuse and abuse among older adults categorized by physical, cognitive, psychiatric and social symptoms. Extensive research surrounding SUDs in older adults include symptoms that fall into the following four categories:

Physical Symptoms

  • falls
  • poor personal hygiene
  • poor nutrition
  • incontinence

Cognitive Symptoms

  • disorientation
  • memory loss

Psychiatric Symptoms

  • sleep disturbances
  • excessive mood swings

Social Symptoms

  • Family issues
  • Financial problems
  • Legal problems
  • Social isolation
  • Running out of medications early (Lin et al., 2023)

Use of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 criteria alone to diagnose SUD in older adults is difficult and lacks accuracy. The DSM-5 criteria are not relevant to biologic and social factors seen in aging older adults. Changes in older adults, like symptoms of tolerance or withdrawal, manifest differently due to biological changes in adults. Additional challenges to diagnosing AUD and SUD in older adults are difficult because symptoms of SUD can be easily mistaken for symptoms of chronic disease or natural aging (Lin et al., 2023).

The key to early diagnosis, prevention and treatment of SUD in older adults lies in the use of validated screening tools for this cohort and careful assessment by an interprofessional team. Treatment of SUDs in older adults is as challenging as screening and diagnosis. Once diagnosed with a SUD, older adults face multiple barriers to accessing treatment. In addition to the shame regarding substance abuse, barriers for older adults include geographic and social isolation, functional immobility, reduced financial resources and limited transportation. Current treatment systems for SUD create access barriers to access for evidence-based treatment that is age-friendly due to the influence of structural ageism and racism. Minority populations, the homeless and justice-involved persons experience racial and ethnic disparities reflected in unequal access to buprenorphine for opioid use and fewer investments in addiction treatment programs (Han et al., 2022).

The extent of the SUD crisis among baby boomers will continue to rise. To address the magnitude of the crisis expected to continue well into the next two decades, transformation of the current model of treatment for SUD is critical. Regulatory and policy changes are necessary for age-friendly care that is integrated into broader addiction treatment healthcare settings. Older adults must have access to evidence-based care where they receive care whether it is in primary care settings, rehabilitation centers, skilled nursing facilities or private treatment centers. Not only must healthcare centers be able to treat the SUD, but they must also be able to provide appropriate care for medical and mental conditions that accompany SUDs and normal aging. Finally, providers and interprofessional teams must gain comfort in managing older adults with substance use disorders (Han et al., 2022).

To learn more about SUDs in older adults including screening, treatment, principles of care, please view this handy resource dedicated to SUDS in older adults:

Treating Substance Use Disorder in Older Adults (updated 2020)
https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-02-01-011%20PDF%20508c.pdf

References

Han, B., Moore, A., & Levander, X. (2022). To care for older adults with substance use disorder, create age-friendly health systems. Health Affairs Forefront. https://doi.10.1377/forefront.20220505.917481

Humphries, K. & Shover, C. (2023). Twenty-year trends in drug overdose fatalities among older adults in the U.S. JAMA Psychiatry (80)5, 518-520. http://doi:10.1001/jamapsychiatry.2022.5159

Kuerbis, A., Sacco, P., Blazer, D. G., & Moore, A. A. (2014). Substance Abuse Among Older Adults. Clinics in Geriatric Medicine, 30(3), 629–654. https://doi.org/10.1016/j.cger.2014.04.008

Lin, J., Arnovitz, M., Kotbi, N., & Francois, D. (2023). Substance use disorders in the geriatric population: A review and synthesis of the literature of a growing problem in a growing population. Current Treatment Options Psychiatry, 10(3). https://doi.org/10.1007/s40501-023-00291-9

Saxon, A. (2021). Imperative for attention to opioid use disorder and substance use disorders in older adults. American Journal of Geriatric Psychiatry (5), 429-432. https://doi.org/10.1016/j.jagp.2020.12.030

Yarnell, S., Luming, L., MacGrory, B., Trevisan, L., & Kirwin, P. (2020). Substance use disorders in later life: A review and synthesis of the literature of an emerging public health concern. The American Journal of Geriatric Psychiatry, 28(2), 226-236. https://doi.org/10.1016/j.jagp.2019.06.005

Kelva Edmunds-Waller, DNP, RN, CCM, has over 40 years of nursing experience, including over 20 years in leadership roles. She has clinical experience in acute care, home health, infusion therapy, public health, managed care and long-term acute care. Kelva earned a DNP degree at Loyola University New Orleans and a MSN and BSN at Virginia Commonwealth University. She serves as Immediate Past President of the Central Virginia Chapter of CMSA and is a member of the CMSA Editorial Board.

 

 

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