Special Considerations for Addiction Prevention and Treatment Butler Center for Research Update | March 1, 2015 Misuse of illicit and prescription drugs among people aged 50 and older is a serious health issue accompanied by a number of adverse consequences (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). Studies predict that as the baby-boom generation ages, rates of alcohol and drug abuse will continue to increase through the year 2020 (Simoni-Wastila & Yang, 2006). This Research Update summarizes the current state of knowledge regarding hazardous drug use among older adults and discusses the implications of both hazardous use and dependence. Prevalence of Drug Abuse Among Older Adults Each year, the Substance Abuse and Mental Health Services Administration (SAMHSA) administers a nationwide survey called the National Survey on Drug Use and Health (NSDUH). The primary purpose of the survey is to collect detailed information regarding alcohol and drug use in the United States and track trends in use over time. The following graph was adapted directly from the 2013 NSDUH report (SAMHSA, 2014) and shows the percentage of older adult respondents who reported using an illicit drug (e.g., cocaine, marijuana, heroin, hallucinogens, inhalants, and prescribed therapeutic drugs used non-medically) at least once during the month prior to the survey: Patients aged 50–54 had the highest rates of recent illicit drug use and the percentage of participants using illicit drugs has generally increased over time for all three age groups. In another study, Simoni-Wastila and Yang (2006) reviewed over 60 studies of drug abuse among adults aged 50 and older published between 1990 and 2006. This review revealed inappropriate use of prescription drugs such as benzodiazepines and opioid analgesics. Further, this inappropriate use ranged from sharing medications, using higher doses for longer periods than prescribed, and using the medications for recreational use (e.g., for their mood-altering effects). Benzodiazepines are often prescribed to treat anxiety and sleep disturbances; opioid analgesics are often prescribed to manage chronic pain and pain related to health problems prevalent among older adults (e.g., arthritis, back problems, and neuropathy; Williams et al., 2008; Solomon et al., 2006). A number of factors place older adults at risk for problematic substance use, including a loss of social and economic support and the presence of other life stressors such as retirement and the loss or death of a spouse (SAMHSA, 1998). Being female, being socially isolated (i.e., not having a social support system and spending a great deal of time alone), having a history of substance abuse, and having a history of mental illness are also risk factors for developing alcohol and/or drug abuse (Culberson & Ziska, 2008). Another complicating factor involves the detection of substance abuse among older adults, which may be challenging for a number of reasons, including a general lack of awareness of the prevalence of substance use and misuse among older adults and the difficulty in separating symptoms of substance abuse from other co-occurring physical or mental health conditions (SAMHSA, 1998). In addition, assessment tools and other screening surveys for substance use may use criteria that are not applicable to older adults (for example, the impact of use on work or school performance) and may be limited in their effectiveness (SAMHSA, 2011). Impact of Drug Use Among Older Adults Though illicit drug use among adults aged 50 and over is much lower than younger age groups, substance use poses a serious threat to the well-being of older adults for a number of reasons, particularly when use is frequent and heavy. Because the aging process involves physiological changes and the advent of a number of physical health problems, older adults may not be able to process and metabolize drugs as quickly as younger people, placing them at increased risk for toxicity and overdose (SAMHSA, 1998). The consumption of alcohol, benzodiazepines, or prescription opioids can cause significant impairments in motor coordination, vision, and attentional processing, which can result in falls and accidents (Simoni-Wastila, 2006; Trevisan, 2014). Cognitive impairment that often accompanies aging can also compromise an individual's ability to effectively self-monitor alcohol and drug intake and understand feedback about substance use from a doctor or health care provider (Trevisan, 2014). Abuse of Prescription Drugs Among the Elderly Older adults are more likely than younger adults to have conditions such as chronic pain, sleep disturbances, and mental health symptoms, including anxiety and depression. Because of this, prescription drugs, particularly narcotics (opioid analgesics) and benzodiazepines (antianxiety agents), are being prescribed for older patients in alarmingly high numbers. A U.K. study of older adults who were long-term benzodiazepine users revealed that 60% had taken the drugs continuously for more than 10 years, and 27% had taken them for more than 20 years (Curran et al., 2003). A large-scale study of the U.S. population sponsored by the National Institutes of Health found that nearly 9% of participants aged 65–80 had received a recent benzodiazepine prescription, and 31% of these individuals had received prescriptions for long- term use (Olfson, King, & Schoenbaum, 2014). Regarding prescription opioids, a study of adults aged 65 and older who participated in a Canadian drug benefit program found that 18% received at least one prescription for an opioid during the past year (Williams et al., 2008). Won et al. (2004) examined over 21,000 residents of nursing homes throughout the United States aged 65 and older and found that 30% were being prescribed a prescription opioid. Because medical exposure to prescription narcotics with abuse potential is a risk factor for drug abuse, receiving prescriptions for these medications may place older adults at risk of developing problems and potentially an addiction to these drugs (SAMHSA, 1998). Benzodiazepines such as Valium and Xanax also have addictive potential and present similar risks, including excessive sedation, falls and cognitive impairment (SAMHSA, 2011). Substance Dependence Among Older Adults Studies estimate that by 2020, as many as 5.7 million adults aged 50 and older will have a substance use disorder (Han, Gfroerer, Colliver, & Penne, 2009). There is considerable concern that this will place increased demands on the substance abuse treatment system over the next couple of decades. Further complicating the treatment picture for older adults is the fact that they may be less likely than younger adults to recognize the need for treatment (Han et al., 2009). Abuse of prescription drugs, particularly prescription opioids, is on the rise among older adults and is projected to become worse over the next several years (SAMHSA, 1998, 2014). The Butler Center for Research at the Hazelden Betty Ford Foundation conducted statistical analyses of administrative data from 10,907 patients who attended adult residential treatment at the foundation during the period spanning January 1, 2010, through March 31, 2014. Regarding opioid use, 16% of patients aged 50–64 had a current ICD-9 diagnosis of opioid dependence at the time of treatment admission, compared to 11% of patients aged 65 and over. Younger patients were more likely to be opioid dependent than either of these two older groups. However, the number of use days during the 90 days prior to treatment admission for opioid drugs other than heroin was much higher for older patients. On average, patients aged 65 and older used opioids for 56.90 days and patients aged 50–64 used opioids for 52.52 days. Both of these averages are significantly higher than the average pretreatment opioid use days of younger patients (all ps < .05). It is important to note that the opioid use question asks patients to indicate the total number of days they used any opioid drug besides heroin (including morphine, methadone, and prescription painkillers), so it was not possible to determine to what extent patients were using prescription opioids specifically before treatment admission. Lastly, the percentage of older adults with a co-occurring ICD-9 mental health disorder (in addition to substance dependence) was 48% for 50- to 64-year-olds and 61% for those aged 65 and over. Taken as a whole, these data suggest that older patients arrive at treatment with a high degree of clinical severity, particularly regarding frequency of pre-treatment substance use. This severity, combined with the fact that the need for intervention among older adults will increase in the future, underscores the importance of efforts aimed at both the prevention and treatment of substance abuse among these individuals. This may be particularly true for adults over 65 years old, who are likely to face a number of physical, mental, and social issues that may put them at elevated risk for developing substance-related problems. Download the Research Update Drug Use, Misuse and Dependence Among Older Adults.