Addiction is a growing issue for folks over 65; prescription meds pose additional risks

On this blog, we’ve explored many groups and the issues particular to their use of substances. We’ve talked about HIV in rural Indiana, substance use in deaf communities, and treatment barriers for Asian Americans and Pacific Islanders.

Today, let’s talk about a group who makes up 15% of the American population. We know that combining substances can be dangerous, and this demographic is twice as likely to be prescribed more than four drugs at once than anyone else. Maybe you’ve already guessed who I’m talking about. Maybe you are one! We’re talking about older adults.

According to the CDC, 39% of Americans ages 65 and over are using five or more prescription drugs per month. That’s compared to just 16% of 45- to 64-year-olds. And SAMHSA calculates that over one million adults 65 or older have a substance use disorder (SUD), a figure incorporating the 978,000 with an alcohol use disorder and 161,000 with an illicit drug use disorder.

Who Are We Talking About?

When you read about older adults and safe prescription use, the cutoff for who is “older” and who is just “adult” can seem pretty arbitrary. Some resources address issues for people who can no longer manage their own care, others include active adults in their mid-50s. For the purposes of this article, “older adults” are 65 and up.

Naturally, the concerns of a 66-year-old with employment and hobbies are different from an 89-year-old with limited mobility and a caretaker. But when we look at people as cohorts, 65 is a good place to start since it’s around when people begin to retire, and it’s also when alcohol consumption guidelines shift.

Prescription Medications Can Be Overwhelming

Managing a complicated prescription drug regimen can be overwhelming to anyone facing serious or chronic health issues, especially older adults who are more likely to face memory issues. Even in the general population, 30-60% of patients are non-adherent to their prescribed regimen. Throw memory issues into the mix, and older adults may choose behaviors that to their providers read as “non-compliance” when the intent is mostly about trying to follow a manageable routine.

Here’s an illustration: if you’re supposed to take one pill upon waking, another with breakfast, a third at least four hours away from both the first pill and any sustenance with calcium, and then the second one again with dinner, it’s tempting to just take them all at once–and some people do just that, figuring it’s close enough and better than repeatedly missing and having to make up doses.

Alcohol and Illegal Drugs

As people age, physical changes including decreases in water and muscle mass change how the body metabolizes alcohol. A low-risk alcohol consumption pattern for a younger person, unchanged as time passes, can become problematic. For the 55% of older adults who do choose to drink, even a single glass can mix poorly with many common medications, and someone who habitually has a one beer every evening may be unaware of the risks.

For example, older adults who take antidepressants are already at a 68% greater chance of falling than their peers. As we know, alcohol takes a toll on balance and coordination, and is also associated with a heightened fall risk. Combining the two exacerbates the potential for injury, but few people know it.

Older adults are less likely than their younger peers to use illicit drugs. That said, many of today’s seniors came of age during the 60s and 70s and experimented with marijuana and psychedelics at higher rates than their predecessors. As a result, today’s older adult uses illicit drugs more than previous generations did.

Working With Older Adults to Address Substance Use

As with so many other groups, using the SBIRT model is a vital way to learn about and address older adults’ substance use. The World Health Organization suggests using the ASSIST screening tool, which covers alcohol, tobacco, and other drugs. The geriatric depression scale SGDS is suggested as complementary.

One strong example of SBIRT directed toward seniors is the Florida BRITE project. After receiving funding for a three-year pilot program, it went on to screen over 85,000 older adults in a variety of settings across the state.

Learn More About the Florida BRITE Program
Visit our Webinar Library for an on-demand presentation about an SBIRT program for older adults that screened over 85,000 patients ages 55 and older in a variety of settings.

Will Talking About Substance Use Make Older Adults Feel Weird?

Some providers worry about offending their patients while screening, but discomfort can be overcome. For a start, a substance use screen may be welcome if conducted when a patient would otherwise be bored and alone. According to Bob Hazlett, PhD, who developed significant portions of the BRITE program, “They really like having someone in the exam room to talk to. Because sometimes it takes 15-20 minutes for the physician to get into that exam room.”

However, older adults who recognize that their substance use is problematic may feel reluctant to share that sensitive information, having been ingrained with stigmatized attitudes about addiction or drug use. SAMHSA’s TIP 26 notes that older adult may feel “shame about use and misuse of substances, along with a reluctance to seek professional help for what many in this age group consider a private matter.”

Fortunately, SBIRT in medical settings may create an interaction that feels more comfortable. In a 2013 webinar, Hazlett reported that “there’s a sense of shame about having negative personal information shared with others. But you know what? It’s different when they go to the doctor. They want the doctor to talk to them. They share more with the physicians than they would with their kids, than they would share with a social worker.”

Hazlett also recommended that providers take care to frame their screening as a health consideration, like the routine screening of blood pressure. In a doctor’s office, he offered, a considerate way to introduce your screen might be to say, “This is going to affect the treatment the doctors prescribe for you. Your health is the main concern. Do you mind us asking you a few of these questions?”

Additional Ways To Assess Medication Use

One clever strategy that’s particularly useful for assessing substance use among older adults is the “Brown bag” technique. Before their appointment, ask a patient to fill a brown paper bag with everything they regularly take. That includes prescription pills, ointments, over-the-counter medications such as Tylenol, and supplements like vitamins. Bringing this into an appointment helps a health professional check for risky combinations–and can be a conversation starter, nudging the patient to ask questions.

Prescription drug monitoring programs, where available, can help providers navigate the confusing world of multiple prescriptions. Patients have reported being inadvertently issued the same prescription twice, and taking them both on faith. A patient seeing multiple doctors for various health concerns is less likely to end up with dangerous combinations when the doctors utilize PDMPs.

What If An Older Adult Needs Addiction Treatment?

It is not uncommon for an older adult to seek addiction treatment. According to SAMHSA, there were 14,230 admissions aged 65 or older to SUD treatment programs in 2012. Older adults are more likely than the general population to self-refer to treatment, or to be referred by another person in their lives, as opposed to being mandated to treatment by the criminal justice system.

17 older adults fell into the admissions category of "Self or other individuals" compared to 10 as "Criminal justice system"

Providers should be aware that seeking a suitable program is important. For one-on-one counseling, connecting the patient with a professional who specializes in or at least has previous experience aiding similar clients helps. If an older person joins group treatment, they may have issues connecting if everyone else is much younger. For older adults who are seeking recovery, like other groups, peer support can be valuable.

In a Nutshell

Like other populations, older adults do use substances, which can influence physical and mental health. Knowing how to speak with this group about alcohol, prescriptions, and other drugs is an important skill that should not be overlooked.


Recommended Resources

A Day in the Life of Older Adults: Substance Use Facts

TIP 26: Substance Abuse Among Older Adults

ATTC online course on Older Adult screening, assessment, and interventions