Background/Significance

Although overall rates of substance use disorders tend to decrease with age, with younger adults more likely to meet criteria for a substance use disorder than older adults (Barry & Blow, 2016), there is concern that rates of alcohol and substance use are increasing among older adults. Additionally, the COVID-19 pandemic had a disproportionate impact on older adults, particularly around social isolation, increasing concerns about substance use among older adults (Satre et al., 2020). The current article focuses on both alcohol and other substance use among older adults, as well as best practices for assessment and intervention.

Prevalence

            In a representative sample of older adults in the U.S., 32.7% reported drinking in the past month (any alcohol use) and 10.6% reported engaging in current (past-month) binge drinking, defined as five or more drinks on the same occasion for men and four or more for women (Han et al., 2019). Binge drinking was more likely among men, those with fewer chronic diseases, those who used cannabis or tobacco, and those who had recently visited the emergency department. Younger and middle-aged adults were more likely than older adults to report an overall increase in alcohol use during the COVID-19 pandemic; among older adults, alcohol use increased substantially among those with co-morbid mental health problems, specifically depression and anxiety (Capasso et al., 2021). In terms of cannabis use among older adults, Han and Palamar (2020) noted a 75% relative increase in past-year cannabis use between surveys conducted in 2006/2007 and 2015/2016, and the increase was particularly pronounced among women and older adults with diabetes.

The recent opioid epidemic in the U.S. has also affected older adults. Although the prevalence of opioid use disorder among older adults is relatively low (0.13%), the number of adults aged 50 and over with opioid use disorder tripled between 2013 and 2018 (Dufort & Samaan, 2021). More adults aged 55 and older are presenting for treatment for opioid use disorder than in previous years, with the 55+ age group accounting for 14.1% of heroin-related admissions (Chhatre et al., 2017). Misuse of prescription opioids is not uncommon in this age group, with 35% of adults aged 50 and older misusing their prescription for chronic pain (Chang, 2018). Overall, problematic opioid use and opioid use disorder among older adults should be on the radar for clinicians as the opioid epidemic continues.

Conceptualization

            There are several ways to conceptualize older adult substance use that can be helpful in the context of providing clinical care. First, clinicians should consider that age-related changes impact the metabolism of alcohol and other substances. For example, the decrease in muscle mass and increase in fat that occurs with age leads to a decrease in total body water of about 15% (Malczyk et al., 2016). Alcohol and other substances are absorbed more quickly into muscle than fat, leading to a slower absorption time among older adults compared to other age groups due to the changing ratio of muscle to fat and the resulting lower total body water. This means that alcohol and other substances stay in the bloodstream for a longer amount of time, increasing the overall effects of the substance. The decrease in total body water leads to concerns about lower tolerance and greater sensitivity to intoxication. A second age-related change that older adults experience is the longer time that is takes to digest alcohol and other substances. In the case of alcohol, the enzyme that metabolizes alcohol (gastric alcohol dehydrogenase) decreases, contributing to a higher blood alcohol content. In the case of opioids, the decline in renal function with age reduces the clearance of opioids and can lead to a buildup of metabolites. The clinical relevance of these changes is that older adults are more sensitive to the effects of alcohol and other substances compared to other age groups and begin to experience effects at low levels of the substance. This is particularly relevant for opioid prescribing because it means that there is a narrow therapeutic index for older adults compared to other age groups, increasing the likelihood of adverse effects at low doses.

Second, clinicians should consider whether substance use represents a new behavior or continuation of a pattern established in younger adulthood. Substance use that has its first onset in older adulthood is termed late onset substance use, and typically occurs in response to a stressor. Older women tend to be overrepresented in late onset substance use (Breslow et al., 2017). Treatment is generally brief and more focused for late onset substance use because the substance use typically occurs in response to a specific situation. Substance use that started at an earlier age is termed early onset substance use and can show different patterns across the adult lifespan. For example, the older adult may have chronically used alcohol and other substances throughout adulthood, or they may have used in an intermittent pattern, such as in response to stressful life events. Another possible pattern is that an older adult is returning to use after a period of sobriety. Among older adults, older men are disproportionally represented in the early onset group (Breslow et al., 2017). Treatment for early onset substance use tends to be more challenging because of the far-reaching impacts that long-term substance use can have on health, cognitive functioning, and social relationships. Placing the current substance use in the context of the older adult’s life often provides details about the extent of the problem and helps in the treatment phase when identifying antecedents or triggers of use.

Identifying recent life transitions is an important step in conceptualizing substance use among older adults. One common pattern is that older adults reduce or eliminate substance use entirely as they get older due to increasing health concerns. At the same time, some older adults may increase their substance use in response to life transitions such as adult children leaving the home, taking on a caregiving role, loss of a partner or other friends or family members, change in functioning because of medical conditions or other situations, or a change in social roles due to a transition like retirement (Satre et al., 2012). Research suggests that, although relatively uncommon, the transition from low risk use to unhealthy use among older adults is related to unemployment, relationship problems, and chronic health problems (Towers et al., 2018).

Assessment

Underdiagnosis and undertreatment of substance use among older adults is a significant problem (Kuerbis, 2020). Underdiagnosis can occur because certain red flags for substance use are misattributed to other conditions or typical aging. Symptoms that should trigger a substance use screening in older adults include memory problems, difficulties in judgment and decision-making, fluctuations in weight or changes in appetite, isolation from family and friends or a change in social groups, lethargy/low energy, falls/bruises, trouble adhering to prescription medications, changes in sleep patterns, or difficulties in roles across settings common for older adults, which may not include work.

Assessment of substance use among older adults involves choosing an appropriate measure while also understanding how chronic health conditions may be exacerbated by substance use and vice versa. In addition, obtaining a list of current prescription and over-the-counter medications is helpful in order to determine if substance use, particularly alcohol use, interacts negatively with any medications. Other areas to assess in a comprehensive evaluation include comorbid medical and mental health conditions, relationship status, social support, and current living situation.

The most common assessments for alcohol use among older adults include the Alcohol Use Disorders Identification Test (AUDIT; Saunders et al., 1993), including its short form the AUDIT-C, and the Michigan Alcoholism Screening Test – Geriatric Version (MAST-G), including its short form the SMAST-G (Blow et al., 1992). Due to older adults’ higher sensitivity to alcohol and other substances, some researchers have found that a lower cut-off score is needed when screening older adults in order to capture older adults who are not drinking heavily but are still experiencing alcohol-related consequences. For example, the sensitivity of the full 10-item AUDIT is increased when a cut-off score of five or greater is used, as opposed to the typical cut-off score of eight or greater (Aalto et al., 2011). The short form of the AUDIT, the AUDIT-C, focuses on frequency and quantity of alcohol use, including an item assessing for binge drinking. Because older adults do not need to drink the same quantity of alcohol as other age groups to experience alcohol-related consequences, the AUDIT-C may result in lower scores that are below the cut-off. Due to this reason, the current recommendation is to use the full AUDIT with older adults with a lower cut-off score or the MAST-G/SMAST-G, which was designed specifically for older adults.

The full 24-item MAST-G, designed to account for social and employment differences between younger and older adults, includes 24 yes or no items. A score of five or more is used as a typical cut-off score. In comparison to other measures of alcohol use, include those based on the AUDIT, the MAST-G was significantly more sensitive than other measures (Knightly et al., 2016), indicating that use of an alcohol assessment that was developed on younger adults may lead clinicians to miss older adults who are having alcohol-related consequences. The briefer SMAST-G includes 10 yes or no items. A score of two or more is indicative of likely unhealthy alcohol use.

Although there are measures available to assess for other types of substances, including cannabis and opioids, these have not been validated among older adults. Currently there are no validated screening instruments for opioid use disorder among older adults. The Cannabis Use Disorders Identification Test – Revised (CUDIT-R; Adamson et al., 2010) has been used with older samples but has not been studied extensively among older adults.

Treatment

For older adults who screen positive for substance use problems, the current recommendation is to begin with a less intensive approach such as a brief intervention that integrates motivational interviewing with cognitive-behavioral skills. This is consistent with the most recent SAMHSA Treatment Improvement Protocol (TIP) for substance use problems in older adults (2020). Offering a variety of treatment options is helpful to support client autonomy. For clients with low to moderate severity substance use problems who are not experiencing major consequences of substance use, brief interventions are an appropriate starting point. Generally, brief interventions for substance use include three to four sessions focused on a combination of strategies based on motivational interviewing (MI) and cognitive behavioral therapy (CBT). The strategies that are common in brief interventions for substance use are:

• Provide normative feedback to older adult clients about their alcohol and other substance use. Chan et al. (2007) found that the majority of older adults have zero or one drink per week and a minority of older adults drink above the NIAAA guidelines of no more than three drinks per day and seven drinks per week for women and no more than four drinks per day and 14 per week for men. In support of this, Han et al. (2019) found that 67.3% of older adults reported no alcohol use in the past year.
• Asking the client to self-monitor their substance use by writing it down each week, including specific amounts and time of day, in order to identify patterns of use.
• Collaboratively determine common antecedents or triggers for substance use based on the daily logs. This is often called a functional analysis. Short- and long-term consequences of substance use can also be discussed here. A helpful MI strategy is to ask clients about both the positive and negative consequences of use. This acknowledges that the client may be feeling ambivalent about change and that substance use often serves a purpose for individuals, such as reducing negative emotions. A functional analysis also helps to determine high-risk situations that are likely to lead to substance use. This is often presented as “people, places, things” that increase the likelihood of substance use.
• Identify behaviors that can replace substance use during high-risk situations. This could involve increasing pleasant events in the older adult’s life that do not involve alcohol or other substances, such as spending time with family or friends, doing exercise, watching movies, doing hobbies, or any other activity that clients find enjoyable.

For many older adults, these strategies may be enough to curtail unhealthy alcohol or substance use. However, there are some barriers to treatment for older adults that may limit their engagement. For example, Choi et al. (2014) found that older adults reported less perceived need for substance use treatment compared to younger adults and tended to report low readiness to stop using. In light of this, clinicians may find that older adults are less motivated to cut down on substance use and may view it as “one last pleasure.” For older adults who need more intensive treatment, additional CBT-oriented sessions can focus on examination of thoughts that occur before or after substance use, mood management skills, dealings with urges or cravings, practicing refusal skills, and increasing use of healthy coping mechanisms.

Conclusions

            Substance use disorders among older adults are underdiagnosed and undertreated. Prevalence data suggest that more clinicians may find themselves working with older adults who either have a primary substance use disorder or are reporting concerning levels of substance use that are a secondary problem. For more details about assessing and treating alcohol use among older adults, please see Unhealthy Alcohol Use in Older Adults (Woodhead, 2023).

Written by Erin L. Woodhead, Ph.D., San Jose State University

REFERENCES

GENERAL

ASSESSMENT OF SUBSTANCE ABUSE IN LATER LIFE

Look at the extensive assessment database of geriatric measures from the University of Alabama’s Alabama Research Institute on Aging! Register for access to the database HERE.

TREATMENT FOR SUBSTANCE ABUSE IN LATER LIFE

MEASURES OF SUBSTANCE ABUSE IN LATER LIFE

Coming soon from the University of Alabama!