Changes and life experiences that occur throughout the aging process can be overwhelming, leading many older adults to turn to substances to cope. However, providers frequently dismiss older adults as an at-risk group for substance use disorder (SUD), leaving many with co-occurring health concerns that go untreated. Recognizing the prevalence of substance use in older adults and offering an integrated approach to treatment can vastly improve physical and mental health among this age group.
The 5th Annual Older Adult Mental Health Awareness Day Symposium featured several presentations and breakout sessions to raise awareness of older adult mental health. The event, co-sponsored by the U.S. Administration for Community Living (ACL), the Health Resources and Services Administration (HRSA), and the Substance Abuse and Mental Health Services Administration (SAMHSA), covered topics such as trauma-informed care, suicide prevention, substance use in older adults, and more.
Alcohol, Cannabis, and Opioid Use and Misuse in Older Adults, presented by Namkee Choi, PhD, MSW, Gwendolyn Gilbert, MS, and Henry Tyler, identified the prevalence of substance use among older adults and provided suggestions for developing integrated approaches. Dr. Choi, a professor at the University of Texas at Austin, presented research on SUD among older adults. Gilbert, chief behavioral health officer at Agape Health Services, offered an overview of Agape’s successful model for an integrated care approach. Tyler, a Wellness Recovery Action Plan (WRAP) instructor and veteran, shared his personal experience with depression and substance use.
“I suspected that I suffered from depression from an early age,” Tyler said, recalling his childhood and being raised by his mother and grandmother. “At the time, no one really talked about it.” As a teen, he discovered alcohol eased his social anxiety, allowing him to feel more comfortable in his own skin.
At age 18, he joined the U.S. Army. During his 14 years of service, he battled trauma and mental health struggles in his personal life as well as his career. In addition to challenges with personal relationships back home, he also narrowly avoided a tragic accident that killed several of his fellow soldiers. The survivor’s guilt and post-traumatic stress disorder (PTSD) he developed exacerbated his existing depression and substance use.
Though Tyler made several recovery attempts throughout the years following, they were not successful. He believed if he treated the substance use, the rest would follow, but the PTSD and depression did not automatically disappear. It wasn’t until he took an integrated approach to wellness that addressed all of his co-occurring issues that he saw successful and sustainable results. Now, at age 63, he continues to actively recover and serves as a support group leader, helping others normalize their own challenges and develop healthy coping skills.
Coping with Late Life Changes
Tyler’s experience mirrors that of many older adults – substances are used to cope with unaddressed mental health challenges or trauma, which then compound existing and future health issues. Unfortunately, this age group is frequently dismissed in terms of substance use, despite the high likelihood of life events in later life that may cause someone to turn to substances to cope.
“Substance use disorders are often overlooked and under-treated, partially because there is kind of a false belief among providers that older adults do not develop or need treatment for substance use disorder,” Gilbert said. However, nearly one million adults age 65 and older live with a substance use disorder. Potential causes for addiction include:
- Retirement or loss of purpose.
- Death of a family member, spouse, friend, or pet.
- Loss of income or financial strain.
- Relocation or placement in a nursing home.
- Trouble sleeping.
- Chronic pain or illness.
- Physical, mental, and/or cognitive health decline.
Many of these experiences and changes are traumatic, though they often aren’t recognized as such. Traumatic events can include a broad range of experiences, whether it is a service-related tragedy such as Tyler’s loss or something as seemingly normal as the aging process. Though it is natural, the aging process brings with it several changes that affect one’s independence, sense of self, and coping skills. Identifying and acknowledging trauma in older adults can aid the process of treating co-occurring issues, including substance use and health concerns.
Older adults are especially vulnerable to SUD due to exposure to medication. Chronic health conditions commonly develop as part of aging, causing older adults to be prescribed more medicines than other age groups. This also leads to a higher rate of exposure to potentially addictive medications, which can eventually lead to illicit use (misuse) or other adverse outcomes. Most older adults take at least one medication, and many take more, increasing the chances of drug-drug reactions as well as drug-substance reactions and making SUD hard to identify.
Alcohol Use in Older Adults
Alcohol use exacerbates existing physical and mental health problems and can lead to problems such as poor sleep, liver disease, depression, anxiety, and increased risk of injury and suicide. In a study of 5.3 million emergency room (ER) visits by individuals ages 65 and older, conducted by Dr. Choi and partners, AUD increased the odds of falls by three times and the odds of suicide by 6.5. Supporting research found drinking within the past year was associated with a 70% increase in the risk of death from a fall or motor vehicle crash and 60% increased risk of suicide in individuals ages 55 and older.
According to Dr. Choi, reasons for alcohol use among older adults are similar to those for younger adults, including coping with difficult emotions, easing social anxiety, celebrating, or enhancing one’s mood. However, the stark difference among older adults is the use of alcohol to manage pain and other symptoms.
“The problem with alcohol use in late life is that large proportions of older adults have chronic conditions,” Dr. Choi said. According to research she presented, nearly 88% of people ages 65 and older have at least one chronic condition; 64% have two or more. Concurrent use of alcohol with prescribed drugs, especially pain relievers, opioids, and benzodiazepines, can lead to fatal and nonfatal overdose, traumatic injury, and increased ER visits.
One of the greatest concerns surrounding substance use in older adults is the rapidly growing opioid crisis. Between 2015 – 2020, although reported cases of prescribed opioid use went down, the number of illicit opioid use cases increased by 300%. In this study, Dr. Choi found that 18.6% of prescription opioid cases and 79.9% of illicit opioid cases were intentionally misused; 35.5% of prescription opioid cases and 11.5% of illicit opioid cases were involved in suspected suicide.
Opioids are a potentially addictive drug, with nearly half of all outcomes resulting in serious effects and sometimes death. Older patients prescribed opioids and other medications need to be made aware of the consequences of possible drug-drug and drug-substance reactions to avoid adverse and fatal outcomes. As the opioid crisis continues to worsen, easy access to naloxone to reverse overdoses is also a necessity.
Is Cannabis the Solution?
As cannabis grows in popularity and becomes legalized in more states, it seems as though the drug offers a possible solution to SUD in older adults. According to a report by the National Academies of Sciences, Engineering, and Medicine, cannabis is somewhat effective in treating different types of pain, chemotherapy-induced nausea and vomiting, multiple sclerosis spasticity symptoms, and sleep disturbances associated with some chronic conditions.
Supporting research finds that state medical cannabis laws are associated with significant reductions in opioid prescriptions in the Medicare Part D population, as well as lower pain, better self-assessed health, and increased labor supply among those ages 51 and older. A majority of older cannabis users, especially medical cannabis users, report beneficial physical and/or mental health effects.
However, a systematic review and analysis of 83 studies and clinical trials found little evidence of cannabis significantly improving mental health, if at all. In some studies, cannabis is associated with adverse physical, psychiatric, and cognitive effects as well as physical injury. These effects are exacerbated in cases involving interactions between cannabis and medications, alcohol, or other illicit substances.
Cannabis use within the last year, both medical and nonmedical, has been linked to co-use with alcohol, illicit substances, and tobacco. According to Dr. Choi, cannabis users with mental illness also have a higher likelihood of using prescription tranquilizers, sedatives, stimulants, and pain relievers, including prescribed and illicit opioids. Individuals with co-occurring SUDs were also found to have low rates of outpatient treatment completion.
To truly determine whether cannabis can assist SUD, more research is needed – especially among older adults. Areas of research to further explore include the benefits and harms of cannabis in late life, the health effects of cannabidiol (CBD) products, the lifespan effects of cannabis use on physical, mental, and cognitive health, and evidence-based treatment for reduction and abstinence among individuals with cannabis use disorder (CUD).
An Integrated Approach to SUD in Older Adults
Effectively treating co-occurring issues such as chronic illness and pain, physical and mental illness, SUD, life stressors, and trauma requires an integrated approach that connects the dots. Agape Health Services recognized a need to treat SUD in older adult patients and has since developed a process proven to be successful. Now, they implore other providers to follow suit.
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a comprehensive and integrated approach to the delivery of services for people with SUD and those at risk of these disorders. According to Gilbert, Agape screens 100% of patients using a variety of tools to identify needs, including identifying any social determinants of health (SDoH) that may affect an individual’s well-being.
The screening quickly assesses the severity of substance use and identifies an appropriate level of treatment. At this time, patients are introduced to a clinician to discuss screening results and provide a brief intervention. The intervention serves to provide insight and increase awareness regarding substance use and its impact on co-occurring issues, including mental health, as well as motivates patients to make behavioral changes.
A behavioral health clinician is then invited into the session to present available resources and services. Patients are encouraged to participate in therapy and other treatment but are not required to. A case manager and/or peer support specialist follows up with the patient and assists with scheduling an appointment when the patient is ready to be treated.
At Agape, this process has proven to be successful in increasing treatment of patients over 55, keeping patients engaged in outpatient services for at least one year, referring patients 55 and older to services, and providing medication-assisted treatment (MAT) to patients 55 and older. Because trauma and SUD may go unrecognized in older adults, early diagnosis and intervention is crucial. Screening every patient for both health and social care needs helps immediately identify possible comorbidities and reduce adverse outcomes.