Substance Abuse Among Older Adults

Substance Abuse in Older Adults

Substance Abuse Among Older Adults: Alcohol, Prescription Drugs, Illicit Drugs, Cannabis, and Tobacco

Substance use disorder (SUD) is a treatable mental disorder that affects a person’s brain and behavior, leading to their inability to control their use of substances like legal or illegal drugs, alcohol, or medications.

Although the rates of SUD and the use of drugs and alcohol are generally lower among older adults than the general population, aging itself presents specific risks for harm when considering even minimal amounts of substance use among older adults.  Risk factors include age, medical co-morbidities (more than one disease or condition, usually long-term or chronic), current medications, and health history.

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The scope of substance abuse in older adults

Aging can lead to social and physical changes that may increase vulnerability to substance misuse. Older adults typically metabolize substances more slowly, and their brains can be more sensitive to drugs.

While illegal drug use usually declines after young adulthood, nearly 1 million adults aged 65 and older live with a substance use disorder (SUD), as reported in 2018 data. While the total number of SUD admissions to treatment facilities between 2000 and 2012 differed slightly, the proportion of admissions of older adults increased from 3.4% to 7.0% during this time.

Baby boomers are distinct compared with past generations as they came of age during the 1960s and 1970s, a period of changing attitudes toward and rates of drug and alcohol use. The prevalence rates of substance use disorder (SUD) have remained high among this group as they age, and both the proportions and actual numbers of older adults needing treatment of SUD are expected to grow substantially. The initial wave of the baby boom generation turned 65 years old in 2011, a generation that comprises 30% of the total US population. This group is now in their mid-70s and the size of this generation, as well as other older adults, are living longer life expectancies.

Historically, older adults have not demonstrated high rates of alcohol or other drug use compared with younger adults or presented in large numbers to substance abuse treatment programs. These facts have helped to perpetuate a misconception that older adults do not use or abuse mood-altering substances. Indeed, substantial evidence suggests that substance use among older adults has been under-identified for decades. The aging of the baby boom generation creates a new urgency to effectively identify and treat substance use among older adults.

Recognizing that SUD rates among people older than 50 years are projected to almost double in early 2020 from 2006. There is, therefore, widespread recognition among both generalists and specialists in gerontology and psychiatry, and health care overall, of the need for more information about assessment and interventions related to problematic substance use among older adults.

Older adults may be more likely to experience mood disorders, lung and heart problems, or memory issues. Drugs can worsen these conditions, exacerbating the negative health consequences of substance use. Additionally, the effects of some drugs—like impaired judgment, coordination, or reaction time—can result in accidents, such as falls and motor vehicle crashes. These sorts of injuries can pose a significant risk to health and cause a longer recovery time.

Older Adult Population Facts

The United States

  • 3 million adults ages 65 and older live in the United States, accounting for about 16.9% of the nation’s population.
  • The last report from the U.S. Census Bureau in June 2020 estimates that the 65-and-older population grew by over a third (34.2% or 13,787,044) during the decade of 2009-2019, and by 3.2% (1,688,924) from 2018 to 2019.
  • The size of baby boomer generation and their longer life expectancies led the US Census Bureau to project that the number of older adults will increase from 40.3 million to 72.1 million between 2010 and 2030, when the last of that generation  ages into older adulthood.

Texas

  • 12.9% of the population, or 3,738,727 are age 65 or older. The 65+ Texas population is projected to be 17.4 percent of the population in 2050.
  • This age group is growing faster than the overall state population, and is expected to more than triple between 2010 and 2050; from 2.6 million to 9.4 million. 
  • Alcohol and prescription drug abuse affects up to 17% of adults over the age of 60 per the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
  • The number of Americans aged 50+ years with a substance use disorder is projected to double from 2.8 million in 2002–2006 to 5.7 million in 2020, when the most recent data was published.
Baby boomers are distinct compared with past generations as they came of age during the 1960s and 1970s, a period of changing attitudes toward and rates of drug and alcohol use. The prevalence rates of substance use disorder (SUD) have remained high among this group as they age, and the actual number of older adults needing treatment for SUD is expected to grow.

Substantial evidence suggests that substance use among older adults has been under-identified for decades. The aging of the baby boom generation creates a new urgency to effectively identify and treat substance use among older adults.

Historically, older adults have not demonstrated high rates of alcohol or other drug use compared with younger adults nor are they present in large numbers in substance abuse treatment programs. These facts have helped to perpetuate a misconception that older adults do not use or abuse mood-altering substances.

Illicit drug use is more prevalent among American older adults than among older adults in almost any other country in the world. Results from the 2012 National Survey on Drug Use and Health revealed that rates of past month use of illicit substances doubled on average (from 1.9%–3.4% to 3.6%–7.2%) among 50 to 65 year olds between 2002 and 2012 – a statistically significant increase driven by the baby boom generation. Generally, individuals aged 50 to 64 years report more psychoactive drug use than older groups. For example, in 2012, 19.3% of adults aged 65 years and older reported having ever used illicit drugs in their lifetime, whereas 47.6% of adults between 60 and 64 years of age reported lifetime drug use. Among those that do use illicit substances, 11.7% meet the criteria for past-year Substance Abuse Disorder or SUD. There are no recommendations for safe levels of illicit drug use among older adults.

There is widespread recognition among both generalists and specialists in gerontology and psychiatry, as well as health care providers overall, of the need for more information about assessment and interventions related to substance abuse among older adults.

Potential risk factors for older adults misusing substances

Potential risk factors for older adults associated with the use of alcohol and, where known, other substances.

Profile

  • Males (for alcohol), females (for prescription drugs)
  • Caucasian ethnicity
  • Chronic pain
  • Physical disabilities or reduced mobility
  • Transitions in care/living situations
  • Poor health status
  • Chronic physical illness/polymorbidity (multiple concurrent illnesses) 
  • Significant drug burden/polypharmacy (multiple medications)

Psychiatric risk factors

  • Coping styles of avoiding or denying problems
  • History of alcohol problems
  • Previous and/or concurrent substance and alcohol abuse disorder
  • Previous and/or concurrent psychiatric illness

Social risk factors

  • Grief and loss of loved one(s) or lifestyle (having to move from family home)
  • Unexpected or forced retirement
  • Social isolation (living alone or with a non-spouse)                                                                 

Demographic profile

  • Being male (females have a higher incidence of prescription drug abuse)
  • More affluent
  • Caucasian
  • Younger old (ages 65 – 74 or those in the early stages of late life) are consistently associated with unhealthy drinking in late life. 
  • Having more financial resources or longer financial horizons.

Alcohol

Despite increasing rates of illicit and prescription drug misuse among adults older than 65 years, alcohol remains the most commonly used substance among older adults.  Most of the research on substance use in late life has been on alcohol use, not SUD. Individual, social, and familial factors that contribute to or are associated with late-life unhealthy drinking may also apply to other substances. 

Among the population at large, older adults reduce their alcohol use as they age. Within healthcare settings, the rates of AUD among older adults can be up to 22%. Although these rates are lower than for younger adults, they are likely impacted by the underreporting of heavy drinking, difficulties with diagnoses of AUDs in older adults, and unidentified other illnesses at the same time, such as depression.

Alcohol has a unique physical impact on the body in late life. As one ages, the percentages of lean body mass and total body water decrease, the ability of the liver to process alcohol is also diminished; and how the brain processes alcohol changes. .Because of these changes, older adults experience higher blood alcohol concentrations and increased impairment compared with younger adults at equivalent consumption levels. Older adults have less awareness of their impairment, making them more vulnerable to the ill effects of alcohol even in moderate amounts.

Compared with moderate drinkers, older-adult heavy drinkers are more likely to experience alcohol-related problems and Impairment in what is known as instrumental activities of daily living (IADLs).  These include paying bills and managing financial assets; driving or organizing other means of transport; shopping and meal preparation, clothing and other items required for daily life, housecleaning, home maintenance, ability to communicate through use of a cell phone, telephone,  mail, and total responsibility for organizing and taking medications.

The more complicated their health and alcohol use, the more complex the risk and vulnerability vulnerabilities for older adults.  Even healthy drinking levels established in young to middle age and then sustained through older age may be a risk factor for health problems among older adults.

Moderate Drinkers

Surprisingly, they may be safer. A large body of research suggests that those older adults who are moderate drinkers (no more than one standard drink per day) experience better health than their heavier drinking and abstinent peers. Moderate-drinking older adults have been discovered to have fewer falls, greater mobility, and improved physical functioning when compared with nondrinkers.

However, it is important to note many of the health benefits of moderate alcohol use for older adults may come with negative trade-offs. Given the average number of medications taken by older adults, alcohol misuse can have serious interactions with medications. For example, moderate drinking may decrease the risk of TIAs (Temporary ischemic attack) strokes but increase the risk of the more commonly known hemorrhagic stroke. The benefits of alcohol for older adults vary across individuals and depend on age, chronic illnesses, sex, and genetics.

Medications & Illicit Drugs

Prescription, Nonprescription, and Over-the-Counter Medication Use 

Older adults take more prescribed and over-the-counter medications than younger adults, increasing the risk of harmful drug interactions, misuse, and abuse. A cross-sectional community-based study of 3005 individuals aged 57 to 85 years found that 37.1% of men and 36.0% of women used at least 5 prescription medications concurrently. The study also found that about one in 25 of the participants were at risk for a major drug interaction, and half of these situations involved nonprescription medications

All medications should be reviewed yearly with the primary care physician. Visit, What is a Medication Review?, to learn more about it.  Almost 90% of older adults regularly take at least one prescription drug, almost 80% regularly take at least two prescription drugs, and 36% regularly take at least five different prescription drugs. Risks associated with medication use in older adults occur because they may see multiple doctors, each of who may prescribe them medications that may interact with each other and/or with alcohol or other substances.

The same changes that increase the effect of alcohol among older adults also increase the effect of medications and illicit drugs, causing an increased vulnerability to drug effects and drug interactions. Although alcohol is the most addictive, other substances are also creating addiction in the older adult population. Alcohol and marijuana increase the sedative effects of drugs such as barbiturates, benzodiazepines, and opiates.52 

Older adults may also unintentionally misuse a medication by borrowing a prescribed medication from another person (eg, taking a dose of another person’s lorazepam or zolpidem for sleep), taking more than intended, or confusing pills. For example, older adults process benzodiazepines and opiates differently than younger adults.  

Benzodiazepines

Benzodiazepine dependence is a serious problem among older people. Benzodiazepines, such as Alprazolam, are fat-soluble drugs.  Alprazolam is often prescribed for older adults to manage anxiety and sleep disturbance. Adults have less lean muscle mass and more body fat as they age so these drugs have a longer effect.   Further research is needed to better characterize the risk factors and potential markers for benzodiazepine abuse among the older population. 

Older people are more likely to have unwanted side effects (eg, severe drowsiness, dizziness, confusion, clumsiness, or unsteadiness) and kidney, liver, or lung problems. Adjustments in the type of medications and dosage may be needed.

Alprazolam (trade name Xanax), is one of the most widely prescribed benzodiazepines for the treatment of generalized anxiety disorder and panic disorder. Its clinical use has been a point of contention as most addiction specialists consider it to be highly addictive, given its unique psychodynamic properties which limit its clinical usefulness. Many primary care physicians continue to prescribe it for more extended periods than recommended. Alprazolam use should be reviewed with your doctor in case other medications would be just as helpful.

Adverse reactions to benzodiazepines are more common among elderly patients and occur more frequently with advancing age. Dosages that may have a therapeutic effect for a 65- to 70-year-old patient can produce significant side effects among patients aged 75 years or older.

Despite contraindications for use with older adults, Benzodiazepines are widely prescribed and are disproportionately prescribed to older adults. Rates of benzodiazepine use among older adults have ranged from 15.2% to 32.0%. It is important to note that the rates of benzodiazepine use may be impacted by over-prescription, misdiagnosis, or polypharmacy (multiple medications) rather than intentional misuse or abuse.

Tobacco 

Tobacco use is prevalent among older adults, with about 14% of those aged 65 years and older reporting tobacco use in the last 12 months, and just more than 6% used tobacco and alcohol together in the last 12 months. Clinical trials examining smoking cessation interventions demonstrate that older-adult smokers tend to be long-term, heavy smokers who are also physiologically dependent on nicotine.

Cannabis

Cannabis use by older adults is considerably more prevalent than other drugs. Among adults aged 50 years and older in 2012, 4.6 million reported past-year marijuana use, and less than one million reported cocaine, inhalants, hallucinogens, methamphetamine, and/or heroin use in the previous year. These rates are consistent with those reported by other studies.

With the passage of medical marijuana legislation and relaxed enforcement of drug possession related to marijuana, the prevalence rate of use among older adults may increase as they use it to cope with illness-related side effects, potentially facilitating an increase in recreational use

The increasing acceptance of marijuana use, both medicinally and recreationally, may also pose unique risks in an aging population. Marijuana is known to cause impairment of short-term memory; increased heart rate, respiratory rate, elevated blood pressure; and a 4-time increase in the risk for heart attack after the first hour of smoking marijuana. These risks may be pronounced in older adults whose cognitive or cardiovascular systems may already be compromised.

Cocaine

One study suggests that people addicted to cocaine in their youth may have an accelerated age-related decline in temporal lobe gray matter and a smaller temporal lobe compared to control groups who do not use cocaine. The temporal lobe is largely responsible for creating and preserving both conscious and long-term memory. It also plays a role in visual and sound processing and is crucial for both object recognition and language recognition. Also, dysfunction in the temporal lobe may cause dysfunction in the mind. This could make them more vulnerable to adverse consequences of cocaine use as they age.

Marijuana

The self-reported use of cannabis by older adults has grown significantly and is the fastest growing demographic reporting marijuana use in the United States is those adults ages 55 and older. 

Nine percent of adults aged 50-64 reported past year marijuana use in 2015-2016, compared to 7.1% in 2012-2013. The use of cannabis in the past year by adults 65 years and older increased sharply from 0.4% in 2006 and 2007 to 2.9% in 2015 and 2016.

The use of cannabis by adults 65 years and older increased sharply from 0.4% in 2006 and 2007 to 2.9% in 2015 and 2016 Between 2016 and 2018, the self-reported use of cannabis among those ages 65 to 69 years old nearly doubled to 8 percent among men and to nearly 4 percent among women.

Pot is fast becoming a pill alternative. Marijuana use is up 53 percent with the 55-and-over crowd. Comparing older nonmedical and medical cannabis users: Health-related characteristics, cannabis use patterns, and cannabis sources.

Among a nationally representative sample of US adults ages 65 and older, the percentage of older adults “who believe that people who smoke cannabis once or twice a week are at great risk of harming themselves physically and in other ways” decreased nearly 20 percent between the years 2015 and 2019.

Decreasing is the perceived risk associated with regular cannabis use among older adults in the United States from 2015 to 2019. Among a nationally representative sample of US adults ages 65 and older, the percentage of older adults “who believe that people who smoke cannabis once or twice a week are at great risk of harming themselves physically and in other ways” decreased nearly 20 percent between the years 2015 and 2019.

Medical Marijuana

One U.S. study suggests that close to a quarter of marijuana users age 65 or older report that a doctor had recommended marijuana in the past year. Research suggests medical marijuana may relieve symptoms related to chronic pain, sleep problems, malnutrition, depression, or to help with side effects from cancer treatment. Of course, the marijuana plant has not been approved by the Food and Drug Administration (FDA) as a medicine. Therefore, the potential benefits of medical marijuana must be weighed against its risks, particularly for individuals who have other health conditions or take prescribed medications.

Risks of Marijuana Use

Regular marijuana use for medical or other reasons at any age has been linked to chronic respiratory conditions, depression, impaired memory, adverse cardiovascular functions, and altered judgement and motor skills. Marijuana can interact with a number of prescription drugs and complicate already existing health issues and common physiological changes in older adults.

Nicotine

The Centers for Disease Control and Prevention (CDC) reports that in 2017, about 8 of every 100 adults aged 65 and older smoked cigarettes, increasing their risk for heart disease and cancer. While this rate is lower than that for younger adults, research suggests that older people who smoke have increased risk of becoming frail, though smokers who have quit do not appear to be at higher risk. Although about 300,000 smoking-related deaths occur each year among people who are age 65 and older, the risk diminishes in older adults who quit smoking. A typical smoker who quits after age 65 could add two to three years to their life expectancy. Within a year of quitting, most former smokers reduce their risk of coronary heart disease by half.

Nicotine Vaping

There has been little research on the effects of vaping nicotine (e-cigarettes) among older adults; however, certain risks exist in all age groups. Some research suggests that e-cigarettes might be less harmful than cigarettes when people who regularly smoke switch to vaping as a complete replacement. However, research on this is mixed, and the FDA has not approved e-cigarettes as a smoking cessation aid. There is also evidence that many people continue to use both delivery systems to inhale nicotine, which is a highly addictive drug.

Opioid Pain Medicines

Persistent pain may be more complicated in older adults experiencing other health conditions. Between 4-9% of adults age 65 or older use prescription opioid medications for pain relief. Up to 80% of patients with advanced cancer report pain, as well as 77% of heart disease patients, and up to 40% of outpatients 65 and older. From 1995 to 2010, opioids prescribed for older adults during regular office visits increased by a factor of nine.

The U.S. population of adults 55 and older increased by about 6% between 2013-2015, yet the proportion of people in that age group seeking treatment for opioid use disorder increased nearly 54%. The proportion of older adults using heroin—an illicit opioid—more than doubled between 2013-2015, in part because some people misusing prescription opioids switch to this cheaper drug.

Risk Factors for Substance Abuse in Older Adults

Physical risk factors for substance use disorders in older adults can include chronic pain, physical disabilities or reduced mobility, transitions in living or care situations, loss of loved ones, forced retirement or change in income, poor health status, chronic illness and taking a lot of medicines and supplements. Psychiatric risk factors include avoidance coping style, history of substance use disorders, previous or current mental illness, and feeling socially isolated.

Alcohol Use Disorder: Most admissions to substance use treatment centers in this age group relate to alcohol. One study documented a 107% increase in alcohol use disorder among adults aged 65 years and older from 2001 to 2013. Alcohol use disorder can put older people at greater risk for a range of health problems, including diabetes, high blood pressure, congestive heart failure, liver and bone problems, memory issues and mood disorders.

How is substance abuse treated in older adults?

Many behavioral therapies and medications have been successful in treating substance use disorders in older adults. Little is known about the best models of care, but research shows that older patients have better results with longer durations of care. Ideal models include diagnosis and management of other chronic conditions, re-building support networks, improving access to medical services, improved case management, and staff training in evidence-based strategies for this age group.

Providers may confuse SUD symptoms with those of other chronic health conditions or with natural, age-related changes. Research is needed to develop targeted SUD screening methods for older adults. Integrated models of care for those with coexisting medical and psychiatric conditions are also needed. It is important to note that once in treatment, people can respond well to care.

Points to Remember

  • While use of illicit drugs in older adults is much lower than among other adults, it is currently increasing.
  • Older adults are often more susceptible to the effects of drugs, because as the body ages, it often cannot absorb and break down drugs and alcohol as easily as it once did.
  • Older adults are more likely to unintentionally misuse medicines by forgetting to take their medicine, taking it too often, or taking the wrong amount.
  • Some older adults may take substances to cope with big life changes such as retirement, grief and loss, declining health, or a change in living situation.
  • Most admissions to substance use treatment centers in this age group are for alcohol.
  • Many behavioral therapies and medications have been successful in treating substance use disorders, although medications are underutilized.
  • It is never too late to quit using substances—quitting can improve quality of life and future health.
  • More science is needed on the effects of substance use on the aging brain, as well as into effective models of care for older adults with substance use disorders.
  • Providers may confuse symptoms of substance use with other symptoms of aging, which could include chronic health conditions or reactions to stressful, life-changing events.

Additional Resources

References

  1. 2020 Profile of Older Americans, The Administration for Community Living, including Administration on Aging, 2021
  2. National Library of Medicine, Substance Abuse Among Older Adults
  3. National Library of Medicine, A Review of Alprazolam Use, Misuse, and Withdrawal
  4. Journal of the American Geriatric Society, 2021, Recent trends in cannabis use in older Americans. Annals of Internal Medicine, 2021
  5. JAMA Internal Medicine, 2020, Trends in cannabis use among older adults in the United States, 2015-2018
  6. National Library of Medicine – Substance Abuse Among Older Adults
  7. The American Journal of Drug and Alcohol Abuse, 2021
  8. Seniors are filling their Prescriptions at a Pot Shop CBS News, May 19, 2016

Please note research slowed during the COVID pandemic and data reported here are primarily pre-pandemic as the nation re-aligns all services from research through alcohol and drug abuse treatment.

Resources for Caregivers

  • Call 2-1-1 throughout Texas for information and access to health and human service information for all ages.
  • Call 800-252-9240 to find local Texas Area Agency on Aging.
  • Call 800-677-1116 – Elder Care Locator service to find help throughout the U.S.

Use resources such as Area Agency on Aging (AAA). Types of assistance provided by AAAs:

  • Information and referral
  • Caregiver education and training
  • Caregiver respite
  • Caregiver support coordination
  • Case management
  • Transportation assistance

Assistance available through AAAs for persons age 60 and older may include:

  • Benefits counseling
  • Ombudsman – advocacy for those who live in nursing homes and assisted living facilities
  • Home-delivered meals
  • Congregate meals
  • Light housekeeping

Be sure to check out our Resource Directory, FAQ, and Educational Events Calendar for more great information! Permission is granted to duplicate any and all parts of this page to use in education programs supporting family members caring for elders. 

Reviewed May 2023
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