July/August 2023

Substance Use Disorder in Older Adults
By Mark Coggins, PharmD, BCGP, FASCP
Today’s Geriatric Medicine
Vol. 16 No. 4 P. 18

Substance use disorder (SUD) is a treatable, chronic disease characterized by a problematic pattern of use of a substance or substances leading to serious and harmful consequences to a person’s physical and mental health, relationships, work, and social functioning. SUDs affect millions of Americans and do so without regard to age, gender, race, or socioeconomic status. And while SUD is more common in adolescents and younger adults, research shows that substance use and misuse is a growing health concern among older adults. As the population of older adults continues to increase rapidly, more attention and action from health care professionals will be necessary to help prevent SUD by educating older adults about its risks and harms and supporting them to overcome existing substance use problems and improve their quality of life.

Statistics
According to the 2020 National Survey on Drug Use and Health, 40.3 million Americans aged 12 or older had an SUD in the past year.1 And while illicit drug use typically declines after young adulthood, nearly one million adults aged 65 and older live with an SUD, as reported in 2018 data.2 Furthermore, while the total number of admissions to treatment facilities for SUDs between 2000 and 2012 differed slightly, the proportion of admissions of older adults increased from 3.4% to 7% during this time.2

Diagnosing SUD
SUD is a complex condition in which there is uncontrolled use of a substance despite harmful consequences. People with SUDs have an intense focus on using a certain substance(s) even when they know it’s causing or will cause problems. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, or DSM-5, recognizes 10 unique classes of substance-related disorders, including those involving cannabis, alcohol, caffeine, hallucinogens, opioids, sedatives, inhalants, stimulants, hypnotics, and tobacco. Also, the DSM-5 provides criteria that help treatment professionals identify and treat people affected by substance abuse issues. The features of SUDs, as described by the DSM-5, include symptoms of drug abuse as well as the adverse effects it has on individuals’ daily lives. To be diagnosed with SUD, an individual must exhibit at least two of the following 11 symptoms within a 12-month period:3

• losing of control over drug/alcohol use—wanting to stop or reduce use but being unable to;
• investing large amounts of time obtaining the substance;
• feeling cravings and desire to use the substance;
• continuing to use despite relationship conflicts;
• taking risks, such as use while driving;
• continuing to use despite the substance contributing to health problems;
• increasing tolerance levels—needing more of the substance to achieve the desired effect;
• losing interest in activities (social, recreational, occupational) once enjoyed;
• experiencing withdrawal episodes when not using the substance;
• failing in attempts to stop using the substance; and
• failing to meet obligations (work, home, school).

The number of criteria that a person meets helps define the severity of that person’s drug addiction. For example, if an individual demonstrates two to three symptoms, their condition is described as mild. On the other hand, identifying with four to five symptoms indicates a moderate SUD, and six or more is classified as severe.3

Challenges for Older Adults
SUD among older adults is especially complex and may go unrecognized due to several factors. One potential challenge is that there may be a lack of awareness by health care professionals and others, including older adults themselves, about the prevalence and impact of SUD on this population. There also may be false assumptions that older adults don’t use or misuse substances or that their substance use is harmless or normal. Another issue is that signs of substance abuse are often attributed to health-related aging complications (eg, physical or mental health issues). Social isolation may also play a role as older adults are often retired, are less ambulatory, may live far from family members, and have fewer social interactions as friends and family members pass away. As a result of reduced contact with others, there are fewer people to notice troubling concerns of substance abuse and intervene. Older adults may also use substances for different reasons than younger adults do, such as coping with chronic pain, loneliness, depression, anxiety, grief, or stress. They also may have different patterns of use, such as binge drinking, prescription drug misuse, or polypharmacy (using multiple medications or supplements). All of these may result in missed opportunities for screening and intervention.

Factors Contributing to SUD in Older Adults
There are a number of factors that increase the vulnerability of older adults to misusing drugs.

Physiological Factors
Aging affects how medications are metabolized and eliminated from the body, resulting in higher blood drug levels and increased drug effects. Additionally, increased blood-brain barrier permeability and neuronal receptor sensitivity make older adults more sensitive to the effects of alcohol and other drugs.

Medical Factors
Older adults are more likely to experience chronic health problems such as pain, insomnia, depression, anxiety, or cognitive impairment, which may lead to substance misuse or self-medication.4 The treatment of comorbid conditions frequently requires multiple medications, which can result in additive effects or increase the potential for interactions with alcohol or other drugs.

Societal Factors
Social and emotional challenges may arise from retirement, disability, loss of loved ones, isolation, loneliness, or depression. The loss of social support or meaningful activities can be mentally overwhelming and lead to mental health issues such as depression and place older adults at greater risk of abusing substances, especially alcohol abuse.

Recognizing Signs of SUD
It’s important to be aware of the signs and symptoms of SUD in older adults, which may be physical, cognitive, social, and psychiatric.

Physical symptoms may include falls or other injuries (eg, bruises, burns), poor hygiene or impaired ability to perform self-care, dizziness, headaches, incontinence, unexplained weight loss or gain, poor nutrition, idiopathic seizures, blackout, and chronic pain.

Cognitive symptoms may include cognitive impairment, disorientation, memory loss or confusion, and recent difficulties in decision making.

Social symptoms may include neglecting responsibilities or hobbies, social withdrawal or isolation, family problems, legal problems, financial problems, frequent doctor visits or hospitalizations, running out of medications early or requesting refills often, hiding or lying about substance use, and borrowing or stealing medications from others.

Psychiatric symptoms may include excessive mood swings, sleep problems, anxiety, and depression.

Health Care Provider Screening
In addition to educating and increasing awareness about SUD in older adults, health care providers also should take steps to improve identification of older adults who may need further assessment or intervention for their substance use problems. A number of screening tools to identify SUD are available and include the Alcohol Use Disorders Identification Test, the Drug Abuse Screening Test, and the Prescription Drug Use Questionnaire.

Commonly Abused Substances
Following are some of the most common substances abused by older adults.

Alcohol
Alcohol is the most used drug by older adults, accounting for most admissions to substance use treatment centers in those aged 55 and older.5 Also, about 65% of people 65 and older report high-risk drinking, defined as exceeding daily guidelines at least weekly in the past year. Furthermore, more than 10% of adults aged 65 and older report that they are currently binge drinking, which is defined as drinking five or more drinks on the same occasion for men and four or more drinks on the same occasion for women.

Potential signs may include frequent injuries; increased tolerance for other medications; an overabundance of empty beer, wine, or liquor bottles; increased signs of cognitive impairment (eg, forgetfulness, unsteadiness, confusion, and memory loss); slurred speech; symptoms of depression or anxiety; and unpredictable mood swings.

Cannabis
Research suggests medical cannabis may relieve symptoms related to chronic pain, sleep hygiene, malnutrition, and depression and help with side effects of cancer treatment.6 Nine percent of adults aged 50 to 64 reported past-year cannabis use from 2015 to 2016, compared with 7.1% from 2012 to 2013.7 The use of cannabis in the past year by adults 65 years and older increased sharply from 0.4% in 2006 and 2007 to 2.9% in 2015 and 2016.8 While cannabis may have some health benefits, it also can interact with a number of prescription drugs and complicate already existing health issues and common physiological changes in older adults.

Another concern is that today’s available strains of cannabis have much higher levels of tetrahydrocannabinol, or THC, than did those of past strains. The higher THC levels mean users receive higher doses, making the potential for dependency more likely. Potential signs of cannabis dependency may include consistently bloodshot eyes, challenges with coordination, lethargy and lack of motivation, memory loss, and frequent daily use or use multiple times a day.

Benzodiazepines
Benzodiazepines such as diazepam, lorazepam, and alprazolam are a class of medications that act as relaxers and are commonly prescribed for anxiety, insomnia, muscle relaxation, and seizures. Despite their widespread use, benzodiazepines are not considered first line medications for any indication in older adults and carry considerable risk of dependence and side effects, including drowsiness, dizziness, memory loss, withdrawal symptoms, and increased risk of falls and fractures. When their use is indicated, it should be for the short term. Potential signs of abuse may include decreased attention span, drowsiness, memory loss, profuse sweating, difficulty with spatial reasoning (running into objects or walls), and slurred speech.

Opioids
The prevalence of chronic pain increases with age, resulting in increased prescriptions for opioids that can be highly addictive and have serious side effects.9 Some common opioids prescribed for severe or chronic pain include oxycodone (Percocet and OxyContin), hydrocodone (Vicodin), codeine, morphine, and fentanyl. It’s important for health care providers, family, and caregivers to be aware of potential warning signs of opioid abuse, which may include taking more opioids than prescribed or for longer than needed, running out of opioid prescriptions quickly, mixing opioids with alcohol or other drugs, withdrawal symptoms (eg, nausea and vomiting), using multiple pharmacies, frequent falls or injuries, unexplained weight loss or weight gain, and changes in mood, memory, cognition, or behavior.

Cocaine
Cocaine use in generations of older adults prior to the baby boomers isn’t nearly as common. However, cultural changes seen in the 1960s and changing views and acceptance of drug use by many have also resulted in a greater likelihood of cocaine abuse in many older adults than was previously seen.10 Cocaine is a party drug that became popular due to its ability to induce an initial sense of euphoria, increased self-confidence, and increased desire to be social. Unfortunately, the effects are short-term, and the crash is hard. Cocaine may be snorted in the powder form or smoked in the freebase form known as “crack.” Signs of cocaine use may include dilated pupils, excess energy and overexcitement, paranoia, reduced appetite, runny or red nose, sniffling often, and not sleeping.

Heroin
Heroin is a natural opioid made from the opium poppy plant. It’s turned into a fine powder or black sticky substance. People addicted to prescription opioids are often at risk of turning to heroin, especially if it gets too difficult for them to acquire opioid prescriptions. Signs of heroin use may include constricted pupils, sleep difficulties, slowed thoughts or movements, visible injection marks on the skin, and withdrawal symptoms (eg, pain, chills, vomiting, itchiness, and nervousness).

Increased Suicide Risk
Older adults who abuse drugs are at a significantly increased risk of suicide and should be screened for suicidality. Both past-year prescription opioid and benzodiazepine misuse are associated with past-year suicidal ideation in older adults in the United States.11 Compared with the general population, individuals with alcohol dependence and persons who use drugs have a 10 to 14 times greater risk of death by suicide.12 Factors contributing to increased suicide risk among older adults include chronic physical illness, pain, disability, cognitive decline, social isolation, bereavement, and depression. However, SUD is also a significant risk factor for suicide among this population, as it can exacerbate depression and other mental health problems, impair judgment and impulse control, increase hopelessness and despair, and reduce the effectiveness of treatment.13

Alcohol is the most common substance involved in suicide among older adults, accounting for about 22% of all suicide deaths in this group.12 Alcohol can impair brain function and mood regulation, increase aggression and impulsivity, lower inhibitions and self-esteem, and interfere with medication adherence and effectiveness. Alcohol can also interact with other drugs that older adults may take for medical reasons, such as opioids, benzodiazepines, antidepressants, and anticoagulants, increasing the risk of overdose and death.

Treatment
Older adults with substance abuse disorders may be referred for treatment that includes the following:

• Detoxification: The process of safely removing the substance from the body under medical supervision.

• Medication: The use of drugs that can help reduce cravings or withdrawal symptoms or block the effects of the substance.

• Behavioral therapy: The use of psychological techniques that can help change the thoughts and behaviors that contribute to SUD.

• Support groups: The participation in peer-led groups that can provide emotional support and mutual aid for people with SUD.

• Recovery programs: The involvement in structured programs that can offer comprehensive services and resources for people with SUD.

Treatment for depression should also be integrated with the treatment for SUD, as both conditions can influence each other and their treatment outcomes.

Collaboration Is Key
SUDs in older adults are complex and multifaceted issues that require collaboration between health care providers, family members, and older patients. By raising awareness and increasing support for older adults, health care professionals can help them better address SUDs and improve their quality of life.

— Mark Coggins, PharmD, BCGP, FASCP, is vice president of pharmacy services and medication management for skilled nursing centers operated by Diversicare in nine states and is a past director on the board of the American Society of Consultant Pharmacists. He was nationally recognized by the Commission for Certification in Geriatric Pharmacy with the 2010 Excellence in Geriatric Pharmacy Practice Award.

References
1. Substance Abuse and Mental Health Services Administration. Highlights for the 2020 National Survey on Drug Use and Health. https://www.samhsa.gov/data/sites/default/files/2021-10/2020_NSDUH_Highlights.pdf

2. Substance Abuse and Mental Health Services Administration. Results from the 2018 National Survey on Drug Use and Health: detailed tables. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHDetailedTabs2018R2/NSDUHDetailedTabs2018.pdf. Published 2019.

3. McNeely J, Adam A. Table 3: DSM-5 diagnostic criteria for diagnosing and classifying substance use disorders. In: Substance Use Screening and Risk Assessment in Adults [Internet]. Baltimore, MD: Johns Hopkins University; October 2020. https://www.ncbi.nlm.nih.gov/books/NBK565474/table/nycgsubuse.tab9/

4. Addiction Rehab for Seniors & Elderly Adults. American Addiction Centers website. https://americanaddictioncenters.org/rehab-guide/elderly. Updated September 14, 2022.

5. Chhatre S, Cook R, Mallik E, Jayadevappa R. Trends in substance use admissions among older adults. BMC Health Serv Res. 2017;17(1):584.

6. Volkow N, Baler R, Compton W, Weiss S. Adverse health effects of marijuana use. N Engl J Med. 2014;370(23):2219-2227.

7. Han BH, Palamar JJ. Marijuana use by middle-aged and older adults in the United States, 2015-2016. Drug Alcohol Depend. 2018;191:374-381.

8. Han BH, Sherman S, Mauro PM, Martins SS, Rotenberg J, Palamar JJ. Demographic trends among older cannabis users in the United States, 2006-2013. Addiction. 2017;112(3):516-525.

9. Zelaya CE, Dahlhamer JM, Lucas JW, Connor EM. Chronic pain and high-impact chronic pain among US adults, 2019. NCHS Data Brief. 2020;(390):1-8.

10. Na PJ, Rosenheck R, Rhee TG. Increased admissions of older adults to substance use treatment facilities and associated changes in admission characteristics, 2000–2017. J Clin Psychiatry. 2022;83(3):21m13938.

11. Schepis TS, Simoni-Wastila L, McCabe SE. Prescription opioid and benzodiazepine misuse is associated with suicidal ideation in older adults. Int J Geriatr Psychiatry. 2019;34(1):122-129.

12. Wilcox HC, Conner KR, Caine ED. Association of alcohol and drug use disorders and completed suicide: an empirical review of cohort studies. Drug Alcohol Depend. 2004;76 Suppl:S11-S19.

13. Esang M, Ahmed S. A closer look at substance use and suicide. Am J Psychiatry Resid J. 2018;13(6):6-8.