From Jan. 30–Feb. 2, ASA presents the Generations Forum on Mental Health & Aging. Day three covers Suicide and Substance Use and Abuse Challenges in Older Populations: Framing Inclusive Prevention and Intervention Strategies. This post details some of those current challenges.
American life expectancy has been on the decline, and recently released data is beginning to reveal how deaths among older adults due to drugs and alcohol are contributing to these changes.
After a steady rise in life expectancy to a peak of 79 years in 2019, average life expectancy fell to just over 76 years in 2021—the largest decrease over a two-year period since the 1920s. Accounting for this rise in death rates, according to the 2022 report, are deaths due to COVID-19 and unintentional injuries, which are driven largely by drug overdoses.
While drug and alcohol-related deaths are increasing across the general population and have been widely documented among middle-age and younger adults, higher rates of mortality related to substance use among the older adult population have been noted recently compared to previous cohorts. Additionally, large racial disparities have been identified, especially among men.
A newly published set of reports from the CDC highlight these concerning trends. In 2020, more than 5,000 adults ages 65 and older died of drug overdoses, with rates tripling over the past two decades (8.8 deaths per 100,000 older adults in 2020 vs. 2.4 in 2000). There also were 11,616 deaths from alcohol-induced causes, representing an 18% increase over 2019.
Social Isolation Among Possible Causes of Increased Drug Use Among Elders
According to the CDC reports, older people of color are disproportionately impacted by drug and alcohol deaths, with the highest drug overdose deaths among non-Hispanic Black adults, while alcohol-induced deaths were highest among American Indian/Alaskan Native adults.
Significant gender disparities also were noted for drug and alcohol-related deaths. Among older men, in 2020 drug overdose rates were 2.1 times higher compared to older women. Alcohol-related death rates for men were 3.4 times higher for the ages 65 to 74 age group and 4.1 times higher for adults ages 75 and older. Among women older than age 75, non-Hispanic White women had the highest rates of death due to overdose, suggesting that harms related to drug use have spanned the population.
Substance use disorders often are underrecognized and undertreated in older adults.
There has been a clear adverse impact of substance use on mortality, and the ways in which substances impact medical, psychiatric, social and economic conditions are complex and unique for older adults. Several factors stand out as potential contributors to the observed trends. The unprecedented COVID-19 pandemic lockdowns contributed to profound social isolation, worsening mental health in some older adults. Already disproportionately vulnerable to the effects of loneliness and social isolation, older adults face greater consequences of social distancing and shelter-in-place guidelines, potentially worsening substance use and substance use disorders (SUDs).
The Baby Boomer generation historically was exposed to drugs and alcohol at younger ages and are continuing their substance use into older adulthood. Yet, as our bodies age, we are less able to metabolize or process drugs leading to amplified effects and increasing the risk of overdose.
The drug supply also has changed significantly in recent years, creating greater risks of death for people who may have been using stably long-term. Fentanyl and other synthetic opioids have flooded the drug supply and have led to a marked increase in drug overdose deaths in young and older adults. Between 2019 and 2020 alone, fentanyl-involved deaths in people older than age 65 increased by 53%. The emergence of potent adulterants, such as Xylazine—which may amplify the effect of opioids and inflict additional toxic effects, has further increased the risks of drug use in recent years.
Proven, effective treatments exist for SUDs. Medications for Opioid Use Disorder (MOUD) like buprenorphine (or Suboxone), for example, have been well documented as life-saving for patients with OUD. Just recently, Congress has eliminated the "DATA-Waiver" requirement, meaning all providers registered with the DEA (Drug Enforcement Agency) no longer need to be “waivered” or submit a “Notice of Intent” to prescribe buprenorphine. This is a welcome step and holds promise to improve access to OUD treatment.
Any expansion of substance use disorder treatment also must take into account issues of structural racism and health inequity.
Perhaps related to cultural norms and internalized stigma around alcohol and drug use, SUDs are often underrecognized and undertreated in older adults, with many self-referring to treatment instead of being referred by a healthcare provider. Older adults with SUDs also tend to have more medical problems than their age-matched counterparts. A recent study showed that older adults receiving treatment for OUD in the outpatient setting have a higher burden of geriatric conditions, such as falls, urinary incontinence, chronic pain, insomnia, poor mobility, and hearing and visual impairment. The additive stressors associated with aging can compound the experience of living with a SUD, along with other chronic diseases common with aging.
Health System Improvements Key to Addressing Older Adult Addiction Treatment
As deaths related to substance use continue to climb in older populations, health system improvements must be made to address the unique needs of addiction treatment in older adults. Caring for older adults presents medically and socially complex challenges and will increasingly demand greater and more effective care coordination and increased resource allocation. Healthcare settings where older adults typically seek care are not well equipped to manage SUDs. For example, older adults often use post-acute care services such as skilled nursing facilities, yet patients with SUDs face barriers to entry to these facilities related to stigma and lack of staff training. There is a need for more accessible substance use programs tailored to meet the biopsychosocial needs of the older adult with SUDs. In 2019, only 24.8% of adult-serving substance use service facilities had a specific program for older adults, and only 53 substance use facilities in 26 states served only older adults.
Any expansion of treatment must take into account issues of structural racism and health inequity. Due to the racialized nature of the “War on Drugs” and the advent of punitive and restrictive methadone programs, we are still dealing with segregation in access to medications for OUD. Neighborhood demographics dictate access to treatments, with higher rates of methadone prescribing in Black communities and higher rates of buprenorphine prescribing in White communities. White patients are more than four times as likely to receive buprenorphine prescriptions compared to Black patients. Buprenorphine is touted as having liberalized treatment for OUD, yet clearly, this is only for some.
For patients on methadone, there remain significant barriers and indignities associated with treatment, including needing to come daily to the clinic to obtain medication even when they have significant disability or serious illnesses like cancer. Changing methadone policy to meet the care needs of older adults and people with serious illness is an important and active area of advocacy.
We cannot take a “wait and see” approach when more older adults are dying of drugs and alcohol than ever before and life-saving treatment options are well within reach—because older adults deserve better.
The authors would like to thank Dr. Benjamin Han for his feedback regarding this article.
Lauren Kelly, MD, MPH, is Assistant Professor in the Department of Geriatrics and Palliative Medicine at the Mount Sinai Icahn School of Medicine. Stephen Supoyo, MD, FASAM, is a Geriatrics Fellow at Swedish First Hill Medical Center in Seattle, WA. Rossana Lau-Ng, MD, MBA, CMD, is Assistant Professor of Medicine at Boston University Chobanian & Avedisian School of Medicine.