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196 Substance Use in Older Adults
opioids, but that he does smoke when he is able to find free cigarettes. He
denies use of alcohol, cannabis, or other illicit substance use. His psychiatric evaluation is otherwise normal, with no evidence that he meets
DSM-5-TR criteria for any non–substance use disor
You diagnose Mr. Panamera with OUD, severe. You recommend
MAT and ask the patie
nt to consider starting buprenorphine/naloxone.
ders.
SCREENING AND ASSESSMENT
The Substance Abuse and Mental Health Services Administration
(SAMHSA) Treatment Improvement Protocol (TIP) consensus panel
recommends that all older adults be screened for alcohol, tobacco, prescription drug, and illicit drug use at least annually (SAMHSA 2020).
Establishing a thorough history of substance use can help providers
identify possible substance misuse or concerns and provide an opportunity for education and prevention for older adults with low or absent
bstance use. Screening can lead to earlier treatment and improved
su
health (Office of the Surgeon General 2016).
No screening tools for OUD have been validated specifically in the
older adult population. However, certain signs may suggest inappropriate or problematic opioid use and should prompt further screening.
These signs include overr
dose increases, reporting lost prescriptions, concurrent use of other illicit drugs, and change in mental status (Dufort and Samaan 2021).
Screening
mental manner, eliciting information about the quantity, frequency, and
duration of opioid use. Presc
reports should be checked by the clinician. The diagnosis of OUD is
made according to DSM-5-TR criteria (reviewed earlier in “Problematic
Opioid Use and Use Disorder”). As discussed in that section, DSM-5-TR
criteria have limitations in their applicability to older adults, and clinicians must take unique social factors into consideration.
Ageist beliefs among patients, family members, and providers pose
additional barri
mize their substance use when speaking with health care providers.
Famil
need treatment and consequently overlook substance use among older
adults. Finally, health care providers may refrain from asking about
substance use out of fear of offending older adults or may focus more
on their reports of physical complaints (Santoro and Santoro 2018).
If a patient’s screening results are positive, a clinician should conduct a brief assessment including the following:
should be conducted in an open, empathetic, and nonjudg-
ers to diagnosis and treatment. Older adults may mini-
y members may believe that SUDs in late life do not exist or do not
eporting of pain symptoms, unauthorized
ription drug monitoring program (PDMP)
Opioid Use and Use Disorder Among Older Adults 197
• Medical and psychiatric history, substance use history, family history, and psychosocial supports
• Frequency of opioid use and route of administration (e.g., oral, intravenous, intranasal) to help gauge likelihood of severe withdrawal or
possible infections and guide further testing and interventions
• Prescription drug use history verified by the state’s PDMP to detect
unreported use of other controlled medications, such as benzodiazepines or other opioid medications, that may interact adversely with
the treatment medications
• Previous attempts to stop using opioids, type of treatment used, and
sponse to treatment (SAMHSA 2017)
re
A health history and physical exam should be conducted to identify
common co-occurring
chronic pain that may be suggestive of substance misuse. Physical signs
indicative of opioid use include track marks (scars along veins), which
suggest previous injection drug use. Symptoms consistent with opioid
intoxication include pinpoint pupils, drowsiness, and slurred speech.
The history and physical exam can be supplemented by basic metabolic
tests, liver function and electrolyte tests, and testing for infectious diseases such as HIV and hepatitis B/C. Urine toxicology screens can be
us
ed to quantify recent or underreported substance use as well as comorbid substance use. A physical health assessment and laboratory
workup can identify medical problems related to substance use that
may need treatment, as well as identify comorbidities and potential
drug–drug interactions that can determine choice of treatment.
Individuals should also be assessed for overdose risk. Risk factors
for overdose include a history of over
oid dosages (>50 morphine milligram equivalents per day), and concurrent benzodiazepine use. A prescription of naloxone should be
proactively offered when one or more of these risk factors are present,
and the patient and their family should be educated about the symptoms of opioid overdose and how to administer naloxone (SAMHSA
2020).
conditions such as sleep disturbances and
dose, a history of SUDs, high opi-
MANAGEMENT
Psychoeducation of Patients and Families
Most older adults at risk for substance misuse do not need specialized
SUD treatment. However, most can benefit from screening, brief inter-
198 Substance Use in Older Adults
vention, and referral to treatment (SBIRT) to prevent substance misuse
before it occurs. SBIRT approaches include screening for possible opioid misuse and level of risk, offering a brief outpatient intervention to
help patients u
referrals to SUD treatment programs for patients who need more specialized assessment or intervention. Health care providers can easily
incorporat
brief interventions can reduce substance misuse among older adults
(Schonfeld et al. 2015). Additionally, they may have a range of opinions
and attitudes toward substance use; thus, an age-appropriate and culturally sensitive and individualized approach can improve treatment
outcomes (SAMHSA 2014).
nderstand the need to change their opioid misuse, and
e SBIRT into standard practices. Current research shows that
Detoxification
The first step of OUD treatment is management of acute opioid withdrawal. Symptoms of opioid withdrawal include nausea, vomiting, diarrhea, lacrimation, rhinorrhea, diaphoresis, piloerection, autonomic
arousal
irritability, insomnia, and anxiety (SAMHSA 2020). The course of withdrawal symptoms varies with the half-life of the opioids used.
comfortable, are not life-threatening. For older adults with preexisting
cardiac issues, however, autonomic instability and hypernatremia from
dehydration can lead to fatal cardiac consequences. If the patient requires detoxification, the optimal setting for safe withdrawal will need
to be considered (i.e., outpatient or inpatient). If the patient does not
have access to addiction-specific treatment and does not require medically supervised withdrawal, they may be a candidate for outpatient
detoxification in the general health care setting (SAMHSA 2020). However, outpatient detoxification is less commonly used in older adults,
given the fre
tient detoxification is recommended if the patient requires medically
supervis
and withdrawal symptoms and administration of medications. Of note,
older adults are at higher risk of developing delirium, having protracted withdrawal, and having worsening medical conditions compared with their younger counterparts (Dufort and Samaan 2021).
withdrawal followed by a step-down level of care to an intensive outpatient program (IOP), residential recovery-oriented rehabilitation program, or outpatient clinic (SAMHSA 2020). Medications for OUD
(hypertension, mydriasis, and tachycardia), yawning, myalgia,
In the general population, opioid withdrawal symptoms, while un-
quency of medical comorbidities in this population. Inpa-
ed withdrawal, which includes routine monitoring of vitals
Acute inpatient treatment may be limited to medically supervised
Opioid Use and Use Disorder Among Older Adults 199
(MOUD), including buprenorphine and methadone, can be used at this
stage. Additionally, non-opioid options can be used for symptomatic
treatment. α
tidiarrheal medications such as loperamide, and antinausea medications such as ondansetron are commonly used. Analgesics such as
acetaminophen and nonster
are used to manage pain, and medications such as trazodone, mirtazapine, doxepin, and quetiapine are offered for sleep. In clinical practice,
patients have reported improvement of anxiety with mirtazapine and
quetiapine, which also seem to be beneficial for sleep. Clonidine and diazepam are helpful for acute anxiety but should be used cautiously because of the risk of excessive sedation and dependence.
As noted above in “Comorbidities,” psychiatric illness can often be
seen in conjunction
occurring psychiatric illness are present, treatment of the underlying psychiatric illness should also be addressed; successful addiction treatment is
more likely if the illness is stabilized (SAMHSA 2020). Most older adults
with OUD can be managed safely in the outpatient setting. Consultation
with geriatric or addiction psychiatry specialists may be helpful for older
adults with comorbid OUD and psychiatric illness. Telementoring programs such as Project ECHO (Extension for Community Healthcare Outcomes) provide collaborative medical education and care management to
help prim
Under this model, Project ECHO increases access to specialty treatment in
rural and underserved areas for a variety of conditions.
-Adrenergic agonists such as clonidine and lofexidine, an-
2
oidal anti-inflammatory drugs (NSAIDs)
with OUD. When active, untreated symptoms of a co-
ary care clinicians provide expert-level care to their patients.
Pharmacological Interventions
Once medical stabilization is complete, including outpatient or inpatient detoxification, we recommend that patients receive ongoing opioid agonist maintenance, which is associated with a reduced risk of
re
lapse and overdose compared with those who do not receive ongoing
treatment (Dufort and Samaan 2021). MAT—the use of FDA-approved
medications, in combination with counseling and behavioral therapies,
to provide a “whole-patient” approach to the treatment of SUDs—is an
effective strategy for addiction treatment (SAMHSA 2020).
Three medications are approved by the FDA for OUD: methadone,
buprenorphine, and naltrexone. Despite the availability of an array of
formulations (tabs, films, liquid, etc.) and delivery methods (oral, sublingual, intramuscular, implant), a number of fundamental challenges
remain in optimizing MAT for OUD. The efficacy of MAT is well established for the general population, but we lack evidence-based guide-
200 Substance Use in Older Adults
lines for MAT in older adults (Jeste et al. 2018). MAT appears to be
underused for SUD treatment, with one study observing only 7.9%–
9.8% of total admissions in older adults reporting MAT as part of their
treatment plan (Chhatre et al. 2017).
Methadone
Methadone is a full agonist at the μ opioid receptor and the oldest available agonist treatment for OUD. Methadone prevents opioid withdrawal symptoms and reduces cravings. SAMHSA guidelines for OUD
in older adults
age >60 (SAMHSA 2020). In the United States, methadone may be dispensed only at federally designated centers.
Methadone management in older adults is particularly challenging
because of the population’s
and polypharmacy, which have implications for monitoring and managing OUD. Age-related physical and cognitive impairments pose challenges to adults enrolled in methadone maintenance treatment
programs
quirements of MMTPs, such as mandated counseling sessions, toxicology screens, and same-day screening requests, may be prohibitive for
individuals as they age. Although these requirements ensure safety and
prevent diversion, they are particularly difficult for older adults experiencing cognitive decline, physical impairments, and restricted mobility
(Cotton et al. 2018).
Moreover, methadone management in older adults can cause complex pharmacokinetic dilemmas. It must be used cautiously in individuals with renal and hepatic impairment, as renal impairment and drugs
that impact the cytochr
done levels (Chhabra and Bull 2008). Methadone is associated with prolonged cardiac QT interval, especially in individuals with structural
heart disease and treatment with other QT-prolonging drugs (Chhabra
and Bull 2008). Methadone programs should generally be reserved for
the most acute patients, who have failed to induce on naltrexone or buprenorphine, suffer multiple relapses or overdoses on naltrexone or bupropion, or would benefit from a highly structured program.
recommend starting methadone at lower doses in adults
physical limitations, medical comorbidities,
(MMTPs). Federal regulations and treatment adherence re-
ome P450 3A4 system can impact serum metha-
Buprenorphine
Buprenorphine is a partial μ opioid receptor agonist and κ and δ opioid
receptor antagonist. It is available in a variety of formulations (Table 7–1).
Buprenorphine can treat opioid withdrawal and provide long-term
maintenance for OUD.
Opioid Use and Use Disorder Among Older Adults 201
Table 7–1. Buprenorphine formulations
Product name Formulation Active ingredients
Bunavail Buccal film Buprenorphine/naloxone
Suboxone Sublingual tablet and
buccal film
Subutex Sublingual tablet Buprenorphine
Zubsolv Sublingual tablet Buprenorphine/naloxone
Buprenorphine HCl Sublingual tablet Buprenorphine
Probuphine Implant Buprenorphine
Sublocade Long-acting injection Buprenorphine
Source. SAMHSA 2017.
Buprenorphine/n
aloxone
There is limited evidence on buprenorphine for treating OUD in the
geriatric population, indicating a significant gap in the literature and
the need for further research. Buprenorphine is a well-established treatment approach for OUD in younger adults. A review of 31 trials reported substantial evidence that at all doses, buprenorphine was
superior to placebo medication in re
tention of participants in opioid use
treatment (Mattick et al. 2014). Furthermore, buprenorphine has been
found to be safer in overdose compared with methadone, has fewer
withdrawal symptoms than methadone, and has not been shown to
considerably prolong QT interval (Loreck et al. 2016).
Older adults on opioids are at increased risk of falls because of increased sedation and balance disturbances, and the partial agonistic
qualities of buprenorphine ar
e associated with reduced risks of both
compared with methadone (Payne et al. 2018). Buprenorphine is less
likely to cause erectile dysfunction in men than methadone, and it may
be safer than methadone for individuals with severe cardiac or respiratory illness (Payne et al. 2018).
Additionally, it may be challenging for older adults to routinely access a methadone clinic, whereas buprenorphine can be managed in an
outpatient off
ice-based setting. Thus the use of buprenorphine, unlike
methadone, allows physicians to treat OUD with a medical approach
similar to that used with any chronic medical disorder. Also, buprenorphine’s partial-agonist opioid activity decreases the likelihood for overdose and causes minimal toxicity even at high doses, making it a safer
drug for the older patient (Ling 2012
).
Buprenorphine treatment is the preferred first-line treatment for pa-
tients with more complicated OUDs, particularly those requiring some
202 Substance Use in Older Adults
treatment for pain or with significant co-occurring anxiety, as it has
some effectiveness for both conditions. It is also likely the best treatment for patients whose OUD revolves around fentanyl use, as it is far
more
reinforcing than naltrexone. Buprenorphine is available both as a
monoproduct tablet and as a tablet or film in combination with naloxone (Suboxone, Zubsolv). The addition of naloxone requires the medication to be taken orally as directed, where the naloxone will have little
to no pharmacological activity and
Although the monoproduct tablets are the least expensive formulation,
they can be more difficult to obtain, and prescribing the combination
buprenorphine/naloxone product is strongly recommended, as it has
no street value and is therefore less subject to misuse and diversion.
Although some patients may report side effects from buprenorphine
with naloxone, such as headaches,
monoproduct should be investigated for any concerns of potential diversion. Buprenorphine dosing is more complicated, with patients reporting good control of cravings with doses from as little as 2 mg/day
to as hi
of 8–16 mg/day total, and then assessed for control of symptoms. Many
patients are managed at doses of 16 mg/day, as this seems to provide
almost full coverage of μ opioid receptors and provide good control
over cravings. Doses of 32 mg/da
with severe symptoms but sometimes declined by insurance. Buprenorphine IM (Sublocade) is easy to dose, with the recommendation that patients are first stabilized on 16 mg/day, and then administered 300 mg
in
symptoms may be continued on doses of 300 mg monthly, but most p a tients can be reduced to a 100-mg monthly maintenance dose after the
first 2 months. Sublocade is subject to a REMS (risk evaluation and mitigation strategy) program, and as such is typically offered only by specialist providers. Random urine drug screens should be collected for
patients on buprenorphine to ensure compliance with treatment and
abstinence from illicit opioid use. Because buprenorphine is a partial
agonist of the μ opioid receptor and therefore blocks the receptor, a
urine drug screen positive for illicit opioids should not be considered a
contraindication for further treatment but may imply too low a buprenorphine dose or the need for additional support.
gh as 32 mg/day. Patients should generally be initiated on doses
tramuscularly every 4 weeks for 2 months. Patients with severe
prevents insufflation or injection.
repeated requests for buprenorphine
y are often well tolerated by patients
Naltrexone
Naltrexone is an opioid receptor antagonist that can be administered either orally or intramuscularly (Bart 2012). When initiated after medi-
Opioid Use and Use Disorder Among Older Adults 203
cally supervised opioid withdrawal, it can prevent relapse. As
naltrexone does not have inherent opioid activity, it confers minimal
risk for abuse or diversion (Bart 2012). Naltrexone also does not cause
respiratory depression or reduce respiratory drive. Retention in treatment for extended-release naltrexone is comparable with 1-year retentions in methadone maintenance (Bart 2012). A 24-week randomized
controlled trial comparing extended-release naltrexone and buprenorphine found that while extended-release naltrexone was more difficult
to induce, relapse rates were similar for extended-release naltrexone
and buprenorphine once successfully induced (Lee et al. 2018). The difficulty in induction arises from the need for prolonged abstinence before the initiation of naltrexone, compared with a much shorter period
for buprenorphine. It is
for both buprenorphine and extended-release naltrexone for prescription opioid use or heroin use. However, for fentanyl use disorder, relapse rates seem to be higher for patients on intramuscular naltrexone
rol), and especially higher on oral naltrexone.
(vivit
The extended-release formulation of naltrexone may lead to better
tr
eatment outcomes by its once-monthly intramuscular administration.
This is of particular interest in the older population, as non-adherence
and confusion regarding multiple daily medication regimens are common obstacles. Although the efficacy and safety data on buprenorphine
and naltr
tend to older adults, making them viable treatment options for this population. However, as an opioid antagonist, naltrexone is a poor choice for
individuals on concurrent pain medication, as it has no analgesic effect.
rently abstinent from opioid use, have co-occurring issues with alcohol
use, endorse a preference to be treated for OUD with a non-opioid medication, or might struggle to comply with requirements related to treatment with a controlled substance such as buprenorphine. Generally
speaking, naltrexone prescribing necessitates less frequent visits, urine
drug screens, and in-person evaluations compared with treatment with
a controlled substance such as buprenorphine. Another benefit of naltrexone is that patients will not experience withdrawal if they fail to
take the oral medication. Patients taking oral naltrexone should be encouraged to consider intramuscular naltrexone (Vivitrol), which is
shown to be more effective at addressing cravings and preventing relapse. Naltrexone is an easy medication to prescribe and manage; the
oral dose is 50 mg/day
Some pharmacies offer injectable naltrexone and will administer it directly to a patient if ordered. There is little evidence to support a higher
exone are from studies in younger adults, the trends likely ex-
Naltrexone is a good first-line medication for patients who are cur-
generally accepted that relapse rates are similar
, and the injectable dose is 380 mg every 4 weeks.
204 Substance Use in Older Adults
or lower oral dose, but patients complaining of nausea upon initiation
of naltrexone will often find that these symptoms pass if they continue
on quarter- or half-tablet doses before escalating to the full 50-mg dose.
Psychotherapeutic and Psychosocial
Interventions
Nonpharmacologic interventions for OUD are important to consider
and are an integral part of MAT. These may include continuing care interventions such as brief telephone counseling or telephone recovery
checku
With the patient’s permission, keeping in contact with caregivers can be
an invaluable resource, as caregivers are often first to notice “red flags”
indicating return to use and can offer important details about the patient’s recovery (SAMHSA 2020).
treatment p
help people address mixed feelings about substance use, explore their
thoughts about changing their behaviors, and create an action plan for
behavioral change. It has demonstrated success when used with older
adults (Purath et al. 2014). Other psychotherapeutic modalities that
have been shown to improve outcomes for older adults with SUDs include cognitive-behavioral therapy (CBT), supportive therapy, and
group therapy (Kuerbis and Sacco 2013).
are pr
based contingency management typically involves the provision of
voucher-based rewards for patients who attend appointments and provide appropriate urine drug screens demonstrating the absence of illicit
substance u
be given a raffle ticket for a gift card or a coupon for a meal.
treatment of OUDs (Bolívar et al. 2021), it is likely beyond the ability of
nonspecialty providers and will remain in the realm of IOPs and partial
hospitalization programs (PHPs), where such protocols may be supported financially. Prescribers without the benefit of their own contingency management program may consider a prescribable mobile
device application or another appr
therapeutics.
OUD. Older adults have better long-term outcomes when their social
supports promote recovery (Nicholson 2012; Satre et al. 2012). Sources
ps done by either the prescribing clinician or other clinic staff.
Motivational interviewing (MI) is a client-centered approach to
lanning that is effective in SUDs (SAMHSA 2019). MI can
Contingency management is a behavioral therapy in which incentives
ovided to motivate patients along their path to recovery. Incentive-
se; for instance, a patient with a clear urine drug screen might
Although contingency management has been proven effective in the
oach that uses prescription digital
Connecting patients to social support is also key to recovery from
Opioid Use and Use Disorder Among Older Adults 205
of social support include family and friends, religious or spiritual
groups, and mutual-help groups. Mutual-help programs can include
more structured programs such as Narcotics Anonymous (NA), which
helps connect patients to a network of peers to whom they can relate
(SAMHSA 2020). For patients seeking an alternative to NA, SelfManagement and Recovery Training (SMART) differs from NA in that
it is run by trained volunteers and is based on principles of CBT and MI.
Some of the CBT and MI skills include building and keeping up motivation; coping with urges; managing thoughts, feelings, and behaviors;
and living a bala
demic, mutual-help groups were more likely found through virtual
plat
forms such as video or smartphone, which can be an advantage if a
patient needs physical distance or transportation is a barrier. However,
some older adults may lack the necessary technology.
nced life (SAMHSA 2020). During the COVID-19 pan-
Complementary and Alternative Medicine
There is increasing interest and investigation into integrative medicine
for OUD. Treatments include acupuncture, herbs, and Chinese herbal
medicine such as passionflower, weinicom, fu-yuan pellet, jinniu capsules, tai-kang-ning, and molecules such as dynorphin and
dropalmatine. While these items are generally reported to be well
tolerated and alleviate symptoms, there is wide heterogeneity in their
dosing and administration. Kruszecki et al. (2021) conducted a systematic review of 382 publications for integrative medicine approaches for
opioid withdrawal
found evidence that multiple integrative medicine approaches were
helpful for opioid withdrawal symptoms, but the strength of the conclusions was limited due to the small sample size.
symptoms, of which five met their criteria. They
L-tetrahy-
PUBLIC HEALTH INTERVENTIONS
There are no public health interventions specifically targeted toward
older adults with OUD. However, the majority of public health interventions aimed at younger adults are relevant to older adults with OUD and
hopefully can be tailor
ture. A variety of interventions have been implemented at the local, federal, regulatory, and epidemiological level, as summarized in Table 7–2.
There have been significant efforts for safer prescribing from the
CDC (Cente
including
rs for Disease Control and Prevention 2016) and DEA,
ed specifically to older adults with OUD in the fu-
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