The year 2020 unfolded in a world dramatically changed by the novel SARS-CoV-2 virus. As we now know, aduIts ages 65 and older have accounted for 80 percent of COVID-19 deaths in the United States, while making up only 16 percent of the U.S. population. These circumstances have challenged society and its caregivers at individual, team, and organizational levels.
The magnitude of the pandemic’s mental health toll on families and communities is yet to be realized. In planning this issue of Generations Journal, we could not have anticipated the stress, anxiety, isolation, grief, and many losses around the world, nor could we have imagined COVID-19’s profound implications for the lives of older adults. The year's events underscore the importance of focusing on substance use, a critical health and mental health issue for older adults.
There is limited research on substance use by older adults, compromising awareness of the problem and development of evidence-based interventions and research initiatives. Recent data, however, (see Blanco and Lennon in this issue) note a jump of 11.9 percent from 2012 to 2017 in substance use by adults ages 65 and older. Fifty-five percent of adults ages 65 and older drink alcohol (Grant et al., 2017), and the frequency of alcohol consumption in adults during the pandemic increased by approximately 14 percent (Pollard et al., 2020), along with reports of anxiety and depression.
Prescriptions for many medications, including opioids for chronic pain are highest (26.8 percent) for people ages 65 and older (Scheiber et al., 2018). These rates, combined with the widespread and increased use of cannabinoids in this population, underscore the need for the routine use of evidence-based interventions to screen and intervene for unhealthy substance use in ways similar to practices for other chronic diseases. Uptake of interventions in the healthcare community, however, has lagged.
This Generations issue aims to raise awareness surrounding the complex issue of substance use for those across disciplines who work with older adults. It provides information on approaches easily learned by care providers and designed to move education, detection, and interventions related to unhealthy substance use by older adults into mainstream care settings.
Contributions by Thomas Babor, Alexis Kuerbis and Silke Behrendt, and Arthur Robin Williams suggest the need for a research roadmap to evaluate innovative approaches to screening and substance use monitoring for older adults. Authors Margaret Flinter, Jordan P. Lewis, Aaron P. Greenstein, Haley V. Solomon, and Margo C. Funk emphasize the need to explore service delivery models targeting specific populations.
Older adults diagnosed and treated for substance use disorders are a small but growing proportion of persons in need of treatment. The stigma tied to these diagnoses across cultures, however, often takes precedent over an understanding of the health implications of substance use. In a framework of “Healthy Aging” and enhanced quality of life, substance use has associated health risks across the lifespan, with alcohol contributing to 5.1 percent of the global burden of disease and injury (World Health Organization, 2021). And smoking remains the second leading risk factor for early death and disability (Forouzanfar et al., 2016).
The vulnerability of older adults, 80 percent of whom have at least one chronic illness, and 77 percent of whom have two (National Council On Aging, 2021) results in complex conditions when substance use is added to the mix. Medical illness is further compounded by co-occurring mental health conditions; 32 percent of adults ages 55 and older who were admitted to treatment for SUDs in 2017 had other psychiatric disorders as well (Chhatre et al., 2017).
Vulnerability to these health outcomes can be reduced when, for example, information about the risks of opioid analgesics and “risky” drinking (exceeding National Institute on Alcohol Abuse and Alcoholism Guidelines) is a basic part of patient education and screening in primary care. When health and behavioral health professionals have the information to deliver patient-centered care such as that described by Deborah S. Finnell and Rossana Lau-Ng, Hollis Day, and Daniel P. Alford, they can place substance use in the context of individualized counseling, primary care, and treatment for chronic illness.
Alcohol in 2018 contributed to 5.1 percent of the global burden of disease and injury.
The roll out of policies on such interventions has been slow but has improved efforts to standardize these types of approaches as Sebastian T. Tong, Elisabeth U. Kato, Mary P. Nix, and Arlene S. Bierman write in this issue. Readers of this journal remain the primary advocates for policy and the advancement of care for more than 55 million older Americans. Generations Journal readership also reflects the optimal composition of interdisciplinary teams that are basic to providing comprehensive care to older adults with complex co-morbid conditions.
We are grateful that our contributing author pool reflects that diversity. It is our hope that this issue can increase dialogue and collaboration among members of varied disciplines and those engaged in efforts to bring policy, research, and education for older adults and substance use in line with the magnitude of need.
Madeline A. Naegle, PhD, CNS-PMH, BC, FAAN, is professor emerita, Global Mental Health consultant, and Health and Aging Policy Fellow, 2016–2017, at New York University Meyers College of Nursing, in New York. Benjamin H. Han, MD, MPH, is an assistant professor of medicine at the University of California San Diego, in La Jolla, California.
Chhatre, S., et al. 2017. “Trends in Substance Use Admissions Among Older Adults.” BMC Health Services Research 17(1): 584. doi:10.1186/ s12913-017-2538-z.
Forouzanfar, M. H., et al. 2016. “Global, Regional, and National Comparative Risk Assessment of 79 Behavioural, Environmental and Occupational, and Metabolic Risks or Clusters of Risks, 1990–2015: A Systematic Analysis for the Global Burden of Disease Study.” Lancet 388: 1659–724.
Grant, B. F. 2017. “Prevalence of 12-Month Alcohol Use, High-Risk Drinking, and DSM-IV Alcohol Use Disorder in the United States, 2001–2002 to 2012–2013: Results From the National Epidemiologic Survey on Alcohol and Related Conditions.” JAMA Psychiatry 74(9): 911–23. doi.org/10.1001/jamapsychiatry.2017.2161.
National Council On Aging. 2021. “Chronic Disease.” Facts About Healthy Aging. Retrieved January 20, 2021.
Schieber, L. Z., et al. 2020. “Variation in Adult Outpatient Opioid Prescription Dispensing by Age and Sex–United States, 2008–2018.” Morbidity and Mortality Weekly Report 69(11): 298–302. doi.org/10.15585/mmwr.mm6911a5external icon.
Pollard, M. S., et al. 2020. “Changes in Adult Alcohol Use and Consequences During the COVID-19 Pandemic in the US.” JAMA Network Open. doi.org/10.1001/jamanetworkopen.2020.22942.
World Health Organization. 2020. “Alcohol.” Retrieved January 20, 2021.