Treating substance misuse in older adults

Substance use among older adults has been on the rise for years. Between 2001 and 2013, alcohol misuse increased 107%, then continued to rise during the Covid-19 pandemic. By 2022, 1 in 11 adults over 60 had a substance use disorder. As the population ages, psychologists expect that upward trend to continue (Grant, B. F., et al. JAMA Psychiatry, Vol. 74, No. 9, 2017opens in new window; Nordeck, C. D., et al. Addiction, Vol. 117, No. 2, 2021opens in new window; Behavioral Health Among Older Adults: Results From the 2021 and 2022 National Surveys on Drug Use and Health , Substance Abuse and Mental Health Services Administration [SAMHSA], 2024 [PDF, 552KB] opens in new window).

Alcohol use is the biggest threat, with growing rates of binge drinking and heavy drinking, especially among older women (Han, B. H., et al. Journal of the American Geriatrics Society, Vol. 67, No. 10, 2019opens in new window). Cannabis use is also on the rise, partly because of changing laws and norms, despite little research on how it affects the aging brain.

“The baby boomers experienced much higher rates of substance use in their youth than previous generations,” said Wilson Compton, MD, deputy director of the National Institute on Drug Abuse (NIDA) of the National Institutes of Health. “In some cases, they’re bringing those habits with them, either continuing their use or starting up again in their later adult years.”

But older adults struggling with substance use are often overlooked and undertreated, despite the serious mental and physical health risks those habits pose. Physiological changes, including decreases in muscle mass and liver function, alter the way the body processes alcohol and drugs as we age. That can, in turn, increase the risk of medication interactions, falls, and vehicle accidents, and may even exacerbate cognitive decline ( Treating Substance Use Disorder in Older Adultsopens in new window , SAMHSA, 2020 [PDF, 10MB]opens in new window).

“Smaller amounts of substances have bigger effects in older individuals because of changes in absorption and metabolism. Even low levels of use—one or two drinks, for example—can have a big impact on everyday functioning,” said psychologist Frederic C. Blow, PhD, a professor of psychiatry and director of the U-M Addiction Center at the University of Michigan who has overseen the development of national consensus statements for treating substance misuse in older adults.

Fortunately, research shows that this group can be well served by substance use treatment programs, especially when interventions are adapted for their stage of life. By routinely screening for problematic substance use and learning to recognize risk factors, such as retirement or the death of a spouse, mental health professionals can prevent a problem from starting or intervene before it causes harm.

“A lot of the change in later life is thematic of loss, and we know that loss can contribute to all kinds of mental health challenges, including substance use,” said Kimberly Burton, a peer recovery educator and the retired director of older adult programs for the Mental Health Association of Marylandopens in new window who herself has been sober for more than 30 years. “So how can we be proactive about keeping people connected to the things they really care about?”

Substance use is highest in young adults, ages 18 to 25, but older adults today are using more substances than did people of the same age group from past generations. Most experts attribute the shift to changing attitudes toward heavy drinking, cannabis, and other substances over the past few decades.

Nearly 13% of older adults from SAMSHA’s latest National Survey on Drug Use and Health (NSDUH) reported binge drinking in the past month. About 10% used cannabis and 2.3% misused opioids. Of those who needed treatment, fewer than 1 in 3 received it ( Behavioral Health Among Older Adults: Results From the 2021 and 2022 NSDUH , SAMHSA, 2024 [PDF, 552KB] opens in new window).

“The media has attended to other substances, but alcohol is by far the most common among older adults,” said clinical psychologist Erin Woodhead, PhD, an associate professor of psychology at San José State University who studies substance use treatment for older adults.

Alcohol and other substances can be seen as a way to cope with later in life challenges, including the death of a spouse or the onset of a chronic health problem. They may also be used as a pastime or a way to enhance social outings. For example, happy hours and other alcohol-centered events are regular programming in many senior living communities.

Problematic substance use in this group can fit a few different profiles. Some people may start using substances for the first time to deal with a change or loss; others have a decades-long history of use and tend to be harder to treat. Still others used substances at a low level throughout their life, with that use rising to a problematic level as they age.

“No matter how well we’re doing with aging, we’re all going to have physiological shifts that will make it harder for our body to process alcohol and other substances,” Woodhead said.

Experts say mental health professionals need training to recognize the different risk factors and complications related to substance use in older adulthood, compared with the circumstances younger adults face.

“Older people are not just aged young people. They have different issues and different concerns,” Blow said.

Physical health is one factor to consider, though significant variability among this group means there is no one-size-fits-all solution. For people diagnosed with a chronic medical condition, taking multiple medications, or experiencing cognitive impairment, any amount of alcohol poses risks, said clinical psychologist Derek Satre, PhD, a professor of psychiatry at the University of California, San Francisco Weill Institute for Neurosciences who works to improve mental health services for underserved older adults.

“Partner drinking is also an issue for this age group, and sometimes a person can develop or sustain an alcohol problem if their partner is also drinking,” Satre said.

Other risk factors for substance misuse include financial stress, social isolation, bereavement, forced retirement, a change in living situation, and a past substance use disorder ( Treating Substance Use Disorder in Older Adults , SAMHSA, 2020 [PDF, 10MB] opens in new window).

In older adults, substance use conditions are often missed. These individuals may lack the common checkpoints that younger adults have, such as an employer who pressures them to seek care, Blow said. Symptoms of substance misuse can also be mistaken for medical problems, medication interactions, or age-related shifts, such as balance issues, fatigue, or cognitive changes, said Lisa Lind, PhD, a geropsychologist and chief clinical officer at Deer Oaks, a behavioral health care provider for people who live in long-term care facilities.

“Misuse may often go undetected if mental health professionals aren’t routinely screening for substance use problems using screening instruments designed to detect misuse in older adults,” Lind said.

Behind these missed cases are often assumptions about older adults that may not hold true.

“Among clinicians, there can be a naïve assumption that if a person is 70 years old, they couldn’t possibly be using heroin, opioids, or even cannabis,” Compton said.

In fact, the prevalence of cannabis use in adults 65 and older rose 75% (from 2.4% to 4.2%) between 2015 and 2018 and continues to increase, according to analyses of NSDUH data led by Benjamin H. Han, MD, of the University of California, San Diego ( JAMA Internal Medicine , Vol. 180, No. 4, 2020 opens in new window; Kapner, W. E., et al. Alcohol, Vol. 107, 2023opens in new window).

In a separate study, Han and his colleagues also surveyed 568 adults ages 65 and older on their cannabis use habits, finding physical and mental health concerns to be the primary reason for use, including to reduce pain, arthritis symptoms, sleep disturbances, anxiety, and depression ( Journal of the American Geriatrics Society , Vol. 69, No. 1, 2021 opens in new window). Clinical psychologist Claudia Padula, PhD, an assistant professor of psychiatry and behavioral sciences at Stanford University, found a similar pattern when she and her colleagues studied motivations to use cannabis by age group ( Addictive Behaviors , Vol. 72, 2017 opens in new window).

“We found that older adults were most motivated to use cannabis for chronic medical conditions, including to address pain concerns or stimulate appetite,” compared with younger adults who were more likely to report using cannabis for social reasons, Padula said.

[Related: The changing marijuana landscape: What you need to know] 

Cannabis may be more widely accepted today, but the substance is not without its dangers. Han and his colleagues analyzed cannabis-related California emergency room visits, including cannabis poisoning or symptoms linked to overuse that required urgent medical attention, in adults 65 and older. They found an overall 1,804% relative increase in visits, with the highest jumps in older men and older Black adults (Journal of the American Geriatrics Society, Vol. 71, No. 4, 2023opens in new window).

That increase is likely linked to the higher levels of the psychoactive compound tetrahydrocannabinol (THC) in today’s cannabis strains—typically 20% or more compared with 2% or less before 1990 (Stuyt, E., Missouri Medicine, Vol. 115, No. 6, 2018opens in new window).

In other words, people whose most recent cannabis use was decades ago may accidentally overdose on today’s stronger versions. “The THC content across these different modes has increased dramatically,” Blow said. “This is not the Woodstock generation’s cannabis.”

Education is an important first step. Cannabis can have medical utility for managing chronic pain and other health concerns in older adults (Abuhasira, R., et al. Journal of Clinical Medicine, Vol. 8, No. 11, 2019opens in new window). However, it is not always a safe or advisable remedy for daily problems such as anxiety or sleep, Burton said.

“Older adults need accurate information about vulnerabilities, and we just don’t know yet what cannabis does in aging bodies,” she said.

Compared with cannabis and alcohol use, opioid use is uncommon among adults over 65. But some groups face a higher risk, including people with a history of opioid use disorder who receive a prescription for painkillers following a medical procedure. Asking about medical history and offering alternatives for pain control can minimize the risk of relapse in such patients, Compton said.

Compared with other racial groups, older Black men are also particularly vulnerable to opioid overdose, a pattern that requires urgent attention and research (Volkow, N., NIDA, Aug. 30, 2024opens in new window).

“We should really be concerned about those disparities,” Blow said.

First and foremost, both primary-care and mental health care providers should routinely ask patients of all ages about their substance use. Burton suggests taking a nonconfrontational approach, for example: “You’re talking about your health issues, which makes me wonder about medications. A lot of people are unaware that their medications make them more vulnerable to the effects of alcohol.”

That could lead to an educational conversation about alcohol metabolism—or it could alert the provider to a mental health emergency. Suicide rates are highest among adults ages 75 and older, and alcohol use is a key risk factor.

“If we see someone with increased drinking who also has a constellation of losses, we need to do what we know reduces suicide risk,” including connecting people to services and prioritizing firearm safety, Blow said.

For most older patients dealing with substance use challenges, the prospects are good. Large-scale reviews of treatment for substance use disorders, including alcohol use disorder and opioid use disorder, have found that older adults achieve equivalent or better treatment outcomes compared with their younger counterparts (Sahker, E., et al. Journal of the American Geriatrics Society, Vol. 63, No. 11, 2015opens in new window; Carew, A. M., & Comiskey, C., Drug and Alcohol Dependence, Vol. 182, 2018opens in new window).

“Particularly for those who start using these substances later in life, when they do enter a formal treatment program, the success rate is overwhelmingly positive,” Padula said.

SAMHSA’s Treatment Improvement Protocol (TIP) 26, Treating Substance Use Disorder in Older Adultsopens in new window, provides detailed guidance on evidence-based ways to address substance misuse in older adults, including brief interventions, inpatient programs, sleep and pain support, medications, cognitive behavioral therapy, skills-based approaches, and motivational interviewing (MI).

Adapting programs so they are relevant for this age group may include respecting certain social conventions, such as conversing more formally than practitioners may act with younger patients. Providers should also adopt a supportive, nonjudgmental approach that recognizes a person’s wisdom gained from lived experience, builds their sense of worth and value, and helps them set and meet treatment goals.

“The MI model in particular seems to fit really well with older adults because it supports autonomy in decision-making, something that is often ignored among older adults seeking health care,” Woodhead said, adding that the intervention can be effective in just a few sessions in a primary or integrated care setting.

Working with families can be a key part of the solution because well-meaning adult children often make decisions that rob older adults of their dignity and autonomy, Burton said. Keeping people engaged in their communities—for example, empowering dad to take a woodworking class, even if there’s some risk involved—is a healthy way to offer meaning and entertainment that can take the place of substances.

That individualized approach requires persistence and creativity on the part of families and providers, but experts say it is worth the effort. When Burton’s grandmother, a lifelong painter, lost her vision, she became addicted to alcohol and pain medication.

“Had I known then what I do now, I would have said, ‘I get that this macular degeneration really sucks, but we need to find a way to keep you connected with art,’” for instance, by volunteering to teach children about the joy and mechanics of painting, Burton said.

Adapting proven interventions for substance misuse can help older adults, but emerging research also points to additional ways to support this group. Using alcohol and other drugs can increase the risk of cognitive problems, including spurring the transition from mild cognitive impairment to Alzheimer’s disease (Xue, H., et al. Comprehensive Psychiatry, Vol. 78, 2017opens in new window). Padula, who studies the neurocircuitry of substance use, is applying for funding to explore the brain circuits that underlie the link between alcohol use and dementia.

“Most older adults are concerned about their attention, memory, and cognitive function,” Padula said. “If we can demonstrate that removing alcohol and substances might actually protect your brain, that would be a really impactful intervention.”

More research is also needed to explore the neurological effects of cannabis in older adults and to determine what interventions can help reduce problematic cannabis use, Satre said. Clinical researchers can also help identify substance use interventions that work best with various subgroups, such as women versus men.

“We really want to encourage researchers to bring us their best ideas on how to fine-tune treatment,” Compton said, emphasizing that preventing and treating substance use in older adults is an important topic for research.

Ultimately, treatment that respects the autonomy of older individuals while supporting them in making healthy choices based on scientific evidence is what is likely to succeed.

“We should be paying attention to any substance use as people get older, especially drinking, where the risks clearly outweigh the benefits,” Blow said. “That’s a message, supported by literally thousands of studies, that clinicians and the public need to understand.”