Some years ago, we met with a group of mental health commissioners in upstate New York to raise awareness of the growing need to address problems of behavioral health among older adults as the baby boom becomes the elder boom. When we got to the topic of substance abuse, one of the commissioners said that she had asked her county’s police chief about substance abuse among older people and that he had said that he did not know of any. Of course, he was talking about arrests for possession or sale of illegal drugs as well as for public intoxication, drunken domestic violence, or driving while intoxicated. We pointed out that problems of substance abuse and misuse among older adults mostly don’t look like substance abuse problems among young adults. They are not likely to be noticeable in public. They are not likely to lead to arrests. And, they are far more likely to involve excessive or misuse use of alcohol and inappropriate use of prescription drugs than alcoholism or addiction to illegal substances.
Though not obviously as severe and dangerous as substance abuse among younger people, substance abuse and misuse by older adults can have a terrible impact on the lives of both those who have a problem and on their friends and families. Substance abuse and misuse contribute to impaired social relationships and inability to participate in the kinds of activities that help older adults age well. Substance abuse and misuse contribute to poor physical and mental health. It also leads to greater caregiver and social burden including increased costs for health care.
In this article we will provide an overview of substance use problems among older adults, stressing challenges related to: excessive alcohol consumption; misuse and abuse of prescription and over-the-counter medications, especially painkillers and sleep aids; the growing use of illegal substances; co-morbidity of substance use and other mental and physical disorders including dementia/Alzheimer’s disease; and issues related to aging heroin addicts and patients in methadone maintenance treatment.
Prevalence
Estimates of problematic substance use by older adults vary widely, in part because in different studies the definition of “older adult” varies from 50 to 55, 60, or 65 and above—and in part because the definitions of “substance abuse” and “misuse” vary. The usual estimate is that approximately 20-25% of older adults have substance abuse problems. The bulk of this population is older adults who consume alcohol in excess of standards established by the National Institutes of Health (NIH); this is potentially dangerous but not to be confused with being alcoholic. A much smaller proportion of older adults—perhaps 3-5 % have a diagnosable substance use disorder including addiction to alcohol and other drugs. This is similar to the prevalence of serious mental illness.
Although the numbers are a bit elusive, we know that:
- A significant proportion of older adults have substance use problems, though most do not.
- As the elder boom unfolds the number of older adults with substance use problems will at least double by 2030.
- If, as expected, rates of misuse—especially of prescription and illegal drugs—rise, the number of older adults with substance use problems will outpace the growth of the older population.
- Most problematic substance use is excessive use of alcohol as defined by NIH.
- Most older adults who drink alcohol do not drink to excess. Some alcohol consumption may even have health benefits.
- There is a significant and growing problem of misuse of prescription and over the counter drugs, especially painkillers and sleep aids. There is also rising inappropriate use of psychoactive medications, including anti-depressants and anti-psychotics, which are almost certainly over-prescribed for older adults.
- Some older adults become addicted to prescription medications—especially opiate painkillers, which are linked to many deaths from overdoses.
- Dosages of medications often need to be lower for older adults, leading to misuse of some prescription medications, which may have been prescribed in excessive dosages or which may have been taken for years in larger doses than are appropriate for older adults.
- A very small—but growing—proportion of older adults use, misuse, or abuse illegal substances—primarily marijuana. (Now that marijuana is increasingly a legal substance—whether for medical or recreational use—there will need to be an adjustment regarding how use of illegal substances is defined.)
- Co-morbidity of substance use problems and mental disorders as well as substance use problems and physical disorders is increasingly common as people age.
- Co-occurring inappropriate substance use and dementia can exacerbate the effects of dementia on cognitive and other capacities. For example, in some nursing homes and other facilities for older adults with disabilities, anti-psychotic medications and anti-depressants are over-prescribed and probably hasten death.
- Recreational use of alcohol and other drugs becomes more dangerous with age because of slowed metabolism and medical conditions that may be exacerbated by alcohol and other drug use.
- Alcohol and drugs, even in relatively small amounts, also increase the likelihood of falls, a major cause of disability and premature mortality in older adults.
- People addicted to alcohol, cocaine, and heroin or other opiates have lower than average life expectancy, but some survive into old age. This includes patients in methadone maintenance treatment programs who are aging.
Identification: Substance abuse and misuse by older adults often goes unnoticed not only by friends and relatives by also by primary care practitioners and other service providers. In part this reflects the stereotypical belief that old people don’t drink alcohol and use drugs. In part it reflects ignorance about the signs of substance use problems among old people. It also reflects the failure of primary care practitioners and other health professionals to routinely ask about and screen for substance use problems.
Signs of substance use problems are often difficult to distinguish from changes that may take place as people age such as increasing fatigue, diminished cognitive capacities, balance problems, and so forth. It is critical, therefore, to ask about drinking habits, use of illegal substances, and, perhaps most importantly, prescription and over-the-counter drugs.
In addition, there are a variety of screening tools that can be used by medical, mental health, and social services practitioners. These include: the CAGE questionnaire, the Alcohol Use Disorders Identification Test (AUDIT), and the Michigan Alcoholism Screening Test—Geriatric Version (MAST-G).
In the last decade, a model for substance abuse screening and initial intervention, SBIRT – Screening, Brief Intervention, and Referral to Treatment – has been increasingly disseminated in an ever-growing list of programs. The strong research support shows efficacy in reducing alcohol and illicit drug use among older adults as well as other populations.
Identification of excessive substance use in residential facilities for older adults with cognitive and/or medical problems may be especially difficult because it may result in subdued behavior of the kind preferred in these facilities.
Interventions
According to Nora Volkow, MD, the Director of the National Institute of Drug Abuse, “Older adults respond at least as well as younger [adults] to substance abuse therapies.” * These interventions include:
- Motivational interviewing
- Cognitive behavioral therapy
- Medication therapy (with special care about the impact of medications such as naltrexone and disulfiram on the physical condition of older adults)
- Inpatient and outpatient detoxification (with particularly careful evaluation of the impact of withdrawal symptoms on older patients
- Community-based and residential rehabilitation programs
- Self-help/mutual aid, such as Alcoholics Anonymous and other 12 step programs.
- Footnote: Olivera Bogunovic, MD, a psychiatrist contests this claim, stating, “There is a general lack of evidence-based treatment approaches for substance abuse in the elderly. As a result, much of what is recommended is based on interventions that have been validated in younger populations.”
There appears to be some consensus that programs should be tailored for older adults, but some disagreement about whether programs should be segregated by age. Older adults may be more comfortable with people their own age, but they may also benefit from becoming wise mentors to younger people.
Because people with substance use problems so often have co-occurring physical and mental disorders, integrated treatment models are regarded as the ideal way to serve older (as well as younger) people with substance use problems. This includes integration of treatment for substance use and mental disorders as well as integration of behavioral and physical health conditions. It is also important to integrate medical, behavioral, and aging services.
There are some special issues regarding older adults who were heroin or cocaine addicts when they were younger and regarding those who are patients in methadone maintenance treatment (MMT). For survivors of long periods of addiction, reconstituting a life, reconnecting with family, making amends, and achieving a sense of forgiveness of themselves are critical tasks. For people in methadone maintenance treatment (MMT), a variety of issues related to developmental changes as well as shifts in life circumstances and physical conditions often are not addressed in MMT programs as they currently exist.
As noted above, there are also special issues regarding older adults with dementia, especially those in residential facilities.
Needed Actions
Public Awareness: In general, behavioral health issues among older adults are relatively neglected in comparison to these issues among working aging adults and even youth—who are also relatively neglected. Much needs to be done to draw attention to how important behavioral health issues can be for older adults and their families and to how much substance use problems interfere with health, mental health, successful aging, and quality of life.
Enhanced Identification: Most substance use problems among older adults go unidentified by family and friends and medical, mental health, and aging services professionals. Public education may help build recognition of the presence and importance of substance use problems. Greater awareness and better screening by service providers is exceedingly important.
Enhanced Access to Effective Interventions: In general, there is a shortage of behavioral health service providers who are competent to serve older adults. This includes psychiatrists, psychologists, social workers, nurses, and others. In addition, there is a shortage of behavioral health programs specifically for older adults. Those providers and programs that do exist are often hard to access because they are overloaded, they are not available in some geographic areas, they may not be prepared to serve people who do not speak English, or they are not affordable. (Many geriatric psychiatrists, for example, do not accept Medicare).
Also, many older adults who need these services need them at home or, because they will not voluntarily go to mental health or substance abuse programs, need to be able to get services in community-based settings where they do spend time, such as primary care offices, senior centers, senior housing, and naturally occurring retirement communities.
Possible promising programs include hospital discharge programs, prescription guidelines for providers, and medication review procedures in settings such as home care and nursing homes. Brief informational and intervention sessions represent viable and nonthreatening opportunities to provide support and relief.
In general, uneven quality of care makes it necessary to build clinical as well as generational competence via enhanced training and greater dissemination of effective practices.
Integrated Treatment Structures: Because of the frequency of co-occurring disorders and because primary care presents an opportunity to identify substance use and mental health problems, it is likely that treatment will increasingly be provided in primary care practices and other medical and social service settings. It is, therefore, critical to enhance the delivery of integrated services. Various structures emerging in the health care such as medical homes, health homes, accountable care organizations, etc. should help in this regard. But there also needs to be closer working relationships among substance abuse, mental health, and aging services providers.
Research: As noted above, there are very few evidence-based practices related to interventions for older adults with substance abuse issues. Clinical research is needed to fill this void.
In addition, there is a need for far better epidemiological research using consistent definitions and providing more information about subpopulations of older adults such as those who are very old and those living in institutions as well as those in the community.
Control of Access to Drugs: Growing awareness of the extent and dangers of misuse of prescription medications—especially painkillers—has led to a major public health effort to control access to these substances. This appears to have led to some decline in the number of prescriptions being written, but not an enormous decline. It is reminiscent of the effort to stop the use of illegal drugs via criminalization—the impact of which is questionable. It is noteworthy that better pain management, which would vastly reduce the excessive use and/or addiction to prescription painkillers, does not appear to be on the agenda while efforts to control access to such medications make headlines.
Conclusion
It is of utmost importance to mobilize resources and prepare for the significant impact that the growth of the aging population will have on our mental health and substance abuse delivery systems. To adequately address the need, our supporting systems need to join forces now to advocate for appropriate planning and funding. With our unified voice we can make a difference in the lives of elders with behavioral problems.
To speak with a qualified professional about a patient’s or family member’s substance abuse problem, call the New York State HOPEline 1-877-8-HOPENY.
Michael B. Friedman, LMSW, is the Co-founder and Honorary Chairman of the Geriatric Mental Health Alliance. He teaches at Columbia University School of Social Work. Kimberly A. Williams, LMSW, is Vice-President of Integrated Policy and Program Solutions of The Mental Health Association of NYC. She is also the Co-Founder and Director of the Geriatric Mental Health Alliance and Chairs the National Coalition on Mental Health and Aging.
Selected References
SAMHSA. “Results of the 2013 Survey on Drug Use and Health: Summary of National Findings and Detailed Tables”. 2014. http://www.samhsa.gov/data/NSDUH.aspx
Blank, K. “Older Adults and Substance Use: New Data Highlight Concerns” in SAMHSA News, Jan/Feb 2009. http://www.samhsa.gov/samhsanewsletter/Volume_17_Number_1/OlderAdults.aspx
Volkow, N. “Substance Abuse Among Older Adults” in NIDA Notes, December 19, 2011. http://www.drugabuse.gov/news-events/nida-notes/2011/12/substance-abuse-among-older-adults
Bogunovic, O. “Substance Abuse in Aging and Elderly Adults” in Psychiatric Times, July 27, 2012. http://www.psychiatrictimes.com/geriatric-psychiatry/substance-abuse-aging-and-elderly-adults
Blow, F. “Substance Abuse Among Older Adults: Treatment Improvement Protocol 26” SAMHSA, 1998 http://adaiclearinghouse.org/downloads/TIP-26-Substance-Abuse-Among-Older-Adults-67.pdf
Administration on Aging/SAMHSA. “Issue Brief 5: Prescription Medication Misuse and Abuse Among Older Adults” in Older Americans Behavioral Health.
Schonfeld, L. et al. “Screening and Brief Intervention for Substance Misuse Among Older Adults: The Florida BRITE Project” in American Journal of Public Health, January 2010. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791238/
Rosen, D. et al. “Older Adults and Substance-Related Disorders: Trends and Associated Costs” in ISRN Addiction 2013. http://www.hindawi.com/journals/isrn/2013/905368/
Rosen, D. et al. “Characteristics and Consequences of Heroin Use Among Older Adults in the United States” in Addictive Behaviors, April 2011. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3127414/
Doukas, N. “Older Adults in Methadone Maintenance Treatment: A Literature Review” in Journal of Social Work Practice in the Addictions, 2011. http://www.tandfonline.com/doi/abs/10.1080/1533256X.2011.596456#preview
