How Do the Health Crises of COVID-19 and Drug Overdoses Intersect with Aging?

Prior to the COVID-19 pandemic, drug use by older adults was increasing nationally due to higher rates of substance use by the baby boomer generation (now ages 57 to 75) compared to any preceding generation. During the COVID-19 pandemic, the number of drug overdoses in its first six months was 27 percent higher than the number of predicted deaths just 12 months prior. Monthly deaths between February to May 2020 grew by 50 percent, to more than 9,000 overdose deaths.

Due to the physiological changes of aging and a higher prevalence of chronic medical diseases, older adults are particularly vulnerable to drug-related overdose deaths and hospitalizations. The number of drug overdose deaths among adults ages 65 and older in the United States increased from 528 in 1999 to 3,281 in 2019—a 521 percent relative increase.

While adults ages 65 and older have one of the lowest overdose death rates nationally, adults ages 55 to 64 in particular have seen one of the sharpest increases in overdose deaths over the past five years. Therefore, unhealthy substance and drug overdoses will continue to be a significant issue that the aging sector must address.

During the early months of the pandemic, many treatment centers, along with other services such as drop-in centers and syringe service programs, were temporarily shut down, and access to the overdose reversal medication naloxone was reduced. This combination of decreased services, coupled with increasing isolation, placed many at risk of unsafe drug use.

Although at Lower Risk, Middle-Age and Older Adults Also Overdosing at High Rates

While the risk of hospitalization and death from COVID-19 for older adults is well-documented, often overlooked is that the drug overdose crisis also affected middle-age and older adults during the pandemic. In San Francisco, for instance, there was a 46 percent increase in drug overdose deaths among adults ages 45 and older between the eight and a half months before and after the city’s COVID-19 shelter-in-place health order.

There are many reasons older adults are at particular risk for drug-related overdose, especially during the pandemic. Unhealthy substance use by older adults can be complex because of the presence of chronic diseases. Additionally, due to the physiological changes with aging that affect the clearance and distribution of drugs in the body and concurrent medication use, older adults are more sensitive to the adverse effects of a range of substances.

Also, older adults often are not screened for unhealthy substance use behaviors. Even when older adults are screened, there are challenges in accurately diagnosing substance use disorders due to specific biological and social factors unique to older adults. Also, older adults are prescribed opioids and benzodiazepines (psychoactive sedatives) at high rates due to the high prevalence of chronic pain, anxiety and insomnia. Finally, social isolation, a strong risk factor associated with unhealthy substance use among older adults, was exacerbated by COVID-19.

Public Health Approach to Opioid Crisis Will Expand Funding, Resources

Looking forward, the Biden administration proposed a plan to address the opioid crisis using a public health approach that will expand funding and resources, work to reform the criminal justice system, increase insurance coverage and widen access to medications for substance use disorder and mental health care.

Further policy changes that can address the opioid epidemic include expanding Medicaid, which has positively impacted coverage expansion, medications for substance use disorder access and improvements in outcomes for those with a substance use disorder.

The recent modification in Medicare coverage for opioid use disorder treatment through opioid treatment programs was a welcome change to help improve access for older adults to receive evidence-based treatment.

In addition, focusing on the distribution of naloxone, which can reverse opioid overdoses, is also a priority, especially during the COVID-19 pandemic, when access may have been limited. All older adults on high-dose prescription opioids or chronic opioids also should be prescribed naloxone, with these patients, their families and caregivers instructed on its use.

The American Hospital Association has developed an Opioid Stewardship Measurement Implementation Guide, along with a toolkit for addressing the opioid epidemic. The toolkit is a widely used resource that offers guidance and information to hospitals and health systems on partnering with patients, clinicians and communities to address the opioid epidemic.

It outlines the following actions for addressing the epidemic, which should be implemented in all locations where older adults receive care:  

  1. Clinician education on prescribing practices;
  2. Non-opioid pain management;
  3. Addressing stigma;
  4. Treatment options for opioid use disorders;
  5. Patient, family and caregiver education;
  6. Transitions of care;
  7. Safeguarding against diversion; and
  8. Collaborating with communities.

The drug overdose crisis is a problem that affects the entire community and every overdose death is preventable. It is essential to recognize that older adults are at high risk for harm from substance use and that substance use disorders can be fatal.

Destigmatizing substance use disorders can help people feel more comfortable discussing issues around drug use, especially older adults who have lived through the stigmatizing and punitive language of the “War on Drugs.” Finally, all older adults must have access to evidence-based treatment for substance use disorders and receive patient-centered education about the risks for drug overdose.

Makaya Funk-White, MSW, previously was a dementia care consultant with Alzheimer’s San Diego and is a doctoral student at UC San Diego and San Diego State University. Benjamin H. Han, MD, is a geriatrician, addiction medicine physician and clinician-researcher in the Division of Geriatrics, Gerontology and Palliative Care in the Department of Medicine at UC San Diego and a primary care physician at the San Diego VA Medical Center.