November/December 2023

Substance Use Disorders: Drug Overdoses in Older Adults
By J.E. Whilldin
Today’s Geriatric Medicine
Vol. 16 No. 6 P. 28

Statistics from the National Institutes of Health indicate that drug overdose deaths in the United States have more than doubled since 2015. Since 2000, they’ve increased fivefold. There’s a perception that drug overdoses primarily affect younger adults. However, the epidemic of drug overdose deaths has also affected older adults. In US adults aged 65 years and older, deaths have quadrupled in the last two decades, according to recently published research.1

Two California researchers who study drug overdoses and health policy analyzed death certificate data from the CDC. “We were interested in this topic because of the rises we’ve seen in other population segments that previously had low rates of overdose death, says Chelsea L. Shover, PhD, an assistant professor in the department of general internal medicine and health services research at the David Geffen School of Medicine at the University of California, Los Angeles. Her colleague, Keith Humphreys, PhD, a professor in the department of psychiatry and behavioral sciences at Stanford University School of Medicine in Palo Alto, California, and a member of the department of health and human services interdepartmental substance use disorders coordinating committee, adds, “We noticed that elders’ experience with drug use and overdose was receiving little attention, and wanted to test whether that was based on true or false assumptions about the extent of the problem.”

Using the CDC data, Humphreys and Shover calculated annual overdose death rates from 2002 to 2021 for all US adults aged 65 years and older, and analyzed intentional vs unintentional deaths, demographics, and involved drugs to determine trends in drug-related deaths. In addition to the quadrupling of overdose deaths, some key findings from their analysis included the following1:

• All-cause mortality related to drug overdose increased more than 350% from 2002 to 2021, with one in 370 deaths caused by an overdose in older adults aged 65 years and older in 2021.

• Deaths from alcohol poisoning also increased over the same period.

• Most unintentional overdoses (74%) involved illicit drugs, including synthetic opioids, heroin, methamphetamine, and cocaine.

• Approximately one in five unintentional overdoses involved both prescription and illicit drugs.

• 57% of intentional overdoses occurred in female older adults.

• The highest overdose-related deaths occurred among non-Hispanic African American older adults, but only 2% were intentional.

• 38% of intentional deaths occurred in non-Hispanic Asian or Pacific Islander older adults and 18% of non-Hispanic white older adults.

• Most intentional overdoses (68%) involved prescription opioids, benzodiazepines, antidepressants, antiepileptic drugs, and sedative-hypnotic drugs.

Their data analysis also found that about 64% of all overdose deaths among older adults typically involved illicit drugs, and 37% involved prescription drugs; 17% of overdose deaths involved both, Shover says. The high rate of illicit drug use and a subsequent increase in substance use disorders in older adults has been on the public health research radar for more than a decade.2 In its annual report, the International Narcotics Control Board suggests that increased illicit drug use by adults aged 65 years and older is linked to the aging of the baby boomer generation, which grew up when medication misuse and illegal drug use were common in society.3 “We have to remember that baby boomers are increasingly Medicare enrollees, and that generation uses more drugs than did their parents and grandparents,” Humphreys notes.

Humphreys and Shover say that exposure to fentanyl in illicit drugs is likely a primary contributor to increased overdose deaths. “Older adults who are buying illicit drugs on the street are being exposed to fentanyl, which is stronger than their bodies can handle,” Humphreys explains. Shover adds that older adults may be expecting to buy oxycodone or heroin. “But it’s actually fentanyl, which is much stronger. And, because fentanyl is so potent, even a small difference in dosage amount or purity can make the difference between a usual high vs fatal overdose,” she explains further.

Other dangers associated with illicit drug use in older adults relate to those individuals’ existing medical conditions. Chronic stimulant use can cause or exacerbate heart disease, Shover says. And using stimulants like cocaine or methamphetamine is more likely to result in fatal overdose for people with certain underlying conditions, like heart disease, which is more prevalent among older adults, she adds. “So if more older adults are using stimulants now compared to 20 years ago, whether they just started or have been doing so for years, [it] would also contribute to increased deaths,” Shover notes.

Research suggests that substance use disorders among older adults have also risen.2-4 However, Shover says, it’s not possible to determine if substance use disorders are more common based solely on their analysis using death certificate data. Illicit drug use likely plays a big role in overdose deaths, which could point to rising substance use disorders as well as increased toxicity of the illicit drug supply,” Shover says. “For example, fentanyl and methamphetamine are available as prescription medications, but the fentanyl and methamphetamine implicated in overdose deaths are overwhelmingly illicitly manufactured. And oxycodone is a prescription medication, but plenty of people buy it illicitly,” she adds.

The other primary factor contributing to older adult overdose deaths is increased polypharmacy. The International Narcotics Control Board report notes that adults aged 65 years and older comprise approximately 10% of the total US population, but they consume 30% of prescribed medications. And older adults have a higher prevalence of the use of benzodiazepines, pain relievers, tranquilizers, and sedatives than that of the total population.3

“Part of the problem comes from polypharmacy, namely that many older people are on three, four, five, or more medications, in addition to an opioid, and it’s easy to have a fatal interaction between medicines or take a dangerous dose by mistake,” Humphreys says.

Shover adds that prescription of multiple medications that cause respiratory depression, like opioids and benzodiazepines, are especially dangerous. “Prescribing drugs that have potentially fatal interactions, whether alone or with alcohol or illicit drugs, is an important contributor too, and likely a more salient issue for older adults compared to younger people who are on average prescribed fewer medications,” Shover observes.

Guidance for Geriatric Care Providers
Increasing awareness of fatal drug interactions and opioid overuse/addiction among geriatric care providers is essential to reduce drug overdose deaths in older adults. But few physicians have adequate training in how to recognize and manage addiction, and new rules requiring this to receive a prescribing license should help, Humphreys says. Decreasing the prescription of dangerous drug combinations, in particular, opioids with benzodiazepines like Ativan and Xanax, is another critical element, Humphreys and Shover say. Minimizing prescription of drug combinations that can lead to accidental overdose alone or in combination with alcohol and other substances, Shover adds, is also important.

Shover also offers the following additional guidance for geriatric care providers:

• Educate patients about the risks of their medications together vis a vis overdose.

• Provide naloxone and educate families how to use it for overdose.

• Connect older adults with substance use disorders to evidence-based treatments.

• Ask about nonprescribed drug use in a nonstigmatizing way to promote open disclosure of illicit and other drug use.

Medicare policy issues must also be evaluated and revised, according to Humphreys and Shover. “Medicare does not have parity for substance use disorders, meaning that it’s not required to provide the same level of coverage as it does for all other medical conditions. There are excellent evidence-based treatments for substance use disorders that also reduce the risk of overdose (eg, buprenorphine, methadone, or naltrexone for opioid use disorder or contingency management for stimulant use disorder). However, without parity laws, Medicare beneficiaries are less able to access these. Requiring Medicare to have parity, the way Medicaid and private insurance plans are required to do, would be an important step,” Shover says.

— J.E. Whilldin is a medical research analyst and writer from the Reading, Pennsylvania, area.