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206 Substance Use in Older Adults
Table 7–2. Public health interventions for opioid use disorder
Public health
intervention
Proposed strategy
Improved data
tion
collec
Build overdose tracking into existing surveillance
systems
Create databases that link information across service
syst
ems
Stigma reduction Avoid stigmatizing language and imagery in media
Campaigns focusing on reducing negative attitudes
and encouraging i
ncreased screening and treatment
Harm reduction Increase access to syringe service programs and
fentanyl test kits
Increase naloxone access by community distribution
rams, coprescription of naloxone, and
prog
equipping first responders
Develop harm-reduction services at local and state levels
Treatment expansion Increase buprenorphine training
Regulations to make opioid agonists easier to access;
recent advances include removing buprenorphine
training requirements and approving naloxone for
OTC use
Help local jurisdictions put effective practices to work
in communities where SUD is common
Increase access to evidence-based SUD treatment
Criminal justice
services
Provide universal MAT in jails and prisons
, including MOUD
reform
Targeted naloxone distribution, overdose education,
and MOUD in jails, prisons, and other correctional
settings
Regulatory change Federal agencies should review applicable regulations
to increase public health input to controlled
substances laws
Note. MAT= medication-assisted treatment; MOUD= medications for opioid use
disorder; OTC= over-the-counter; SUD=substance use disorder.
Source. Adapted from Centers for Disease Control and Prevention 2016 and Saloner et
18.
al. 20
• Increase physician and patient awareness of opioids.
• Increase and maximize use of PDMPs to improve opioid prescribing, inform clinical practice, and protect patients at risk.
Opioid Use and Use Disorder Among Older Adults 207
• Enable health care providers to use best practices through academic
detailing—a process of structured visits by trained professionals
who can provide tailored training and technical assistance.
• Improve prescribing practices to reduce patient risk for overdose
and assess Medicaid, workers’ compensation programs, and staterun health plans.
SUMMARY
The prevalence of OUD is increasing among older adults, which compounds the risk of overdose, falls, cognitive impairments, and drug interactions in this vulnerable population. While the efficacy of MOUD is
well e
stablished, there is a lack of evidence-based guidelines for MOUD
geared toward older adults. Older adults on methadone have a high
prevalence of mood disorders, comorbid substance use, and complex
medical comorbidities, which create unique challenges for health care
services; challenges are likely to increase as the number of older adults
with OUD increases. The lack of evidence on buprenorphine and naltrexone for treating OUD in older adults highlights the need for further
research, given the likelihood that these agents could be useful in this
population. Older patients in MOUD programs can benefit from increased screening for psychiatric and medical comorbidities.
Future efforts should address effective screening strategies, engagement in infectious disease treatment, and optimizing MOUD approaches tailored toward older adults. As the prevalence of substance
use and need for SUD tr
geriatric psychiatrists are increasingly being called on to recognize substance misuse, educate patients and their families, and make treatment
recommendations.
Office-based treatment of OUD with naltrexone or Suboxone is well
with
in the scope of general psychiatrists and primary care physicians
and no longer requires any special training or certification. Ask about
opioid use, and do not hesitate to begin treatment. Many patients will
respond well and will not require referral to a specialist.
eatment among older adults continue to grow,
KEY POINTS
• The prevalence of opioid use disorder (OUD) among older adults
is rising in the United States and is expected to continue rising.
• Prescription pain relievers are the most commonly misused medications among older adults.
208 Substance Use in Older Adults
• Risk factors for problematic opioid use in this population include
pain, comorbid medical illnesses, concurrent alcohol or other substance use disorder, and depression.
• Older adults using opioids are at increased risk for falls, cognitive
d psychomotor impairments, and drug interactions.
an
• Patients with concurrent pain and OUDs make up 37%–61% of
patients seeking OUD treatment.
• The Substance Abuse and Mental Health Services Administration
Tr
eatment Improvement Protocol Consensus Panel recommends
that all older adults be screened for alcohol, tobacco, prescription
drug, and illicit drug use at least annually.
• Most older adults can benefit from screening, brief intervention,
and referral to treatment (SBIR
fore it occurs.
• The first step of OUD treatment is management of acute opioid
withdrawal. This can be done in an inpatient or outpatient setting.
• Medication for opioid use disorder (MOUD) refers to the use of
FDA-appr
behavioral therapies, to provide a “whole-patient” approach to
the treatment of substance use disorders.
• Three medications are approved by the FDA for OUD: methadone,
buprenorphi
prenorphine is safer in overdose, has fewer withdrawal symptoms,
and has fewer drug interactions and cardiac side effects.
• Although there is a lack of evidence for MOUD geared toward
older adults, we recommend routine screening
adults and treatment with naltrexone or buprenorphine as indicated.
oved medications, in combination with counseling and
ne, and naltrexone. Compared with methadone, bu-
T) to prevent substance misuse be-
for OUD in older
RESOURCES FOR PATIENTS, FAMILIES,
AND CAREGIVERS
Substance Abuse and Mental Health Services
Administration
FindTreatment.gov: People seeking treatment for SUDs can use this
federal locator maintained by SAMHSA to find behavioral health
treatment facilities based on location, availability of treatment for
co-occurring mental disorders, availability of telemedicine care,
Opioid Use and Use Disorder Among Older Adults 209
payment option, age, languages spoken, and access to MOUD
(https://findtreatment.gov).
National Helpline: A free, confidential, 24/7, 365-days-a-year treat-
ment referral and information service (in English and Spanish) for
people facing mental disorder
find-help/national-helpline). The toll-free phone number is 1-800662-HELP (4357) or 800-487-4889 (TTY).
Opioid Treatment Program Directory: Search programs by state
(http://dpt2.samhsa.gov/treatment/directory.aspx).
s and SUDs (www.samhsa.gov/
Faces and Voices of Recovery
Guide to Mutual Aid Resources: A listing of mutual-help group con-
tact information (https://facesandvoicesofrecovery.org/engage/
recovery-groups).
RESOURCES FOR CLINICIANS
The Mental Health and Substance Use Workforce for Older Adults: In
Whose Hands? (www.nap.edu/download/13400; can be down-
loaded for free as a guest): The Institute of Medicine provides this
2012 r
eport as an overview of the eldercare workforce and work-
force development barriers and needs.
Opioid Safety Initiative Toolkit: Created by the Veterans Health
Administr
source can aid in clinical decisions about starting, continuing, or
tapering opioid therapy
opioid prescribing (www.va.gov/PAINMANAGEMENT/
Opioid_Safety_Initiative_OSI.asp). Clinical teams caring for older
adult veterans with chronic pain may find this useful.
ation National Pain Management Program, this re-
and other challenges related to safe
REFERENCES
American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2022
Bart G: Maintenance medication for opiate addiction: the foundation of recov-
ery. J Addict Dis 31(3):207–225, 2012 22873183
Bolívar HA, Klemperer EM, Coleman SRM, et al: Contingency management for
patients receiving medication for opioid use disorder: a systematic review
and meta-analysis. JAMA Psychiatry 78(10):1092–1102, 2021 34347030 Erratum in: JAMA Psychiatry 79(3):272, 2022
210 Substance Use in Older Adults
Center for Behavioral Health Statistics and Quality: Results From the 2019 Na-
tional Survey on Drug Use and Health: Detailed Tables. Rockville, MD,
SAMHSA, 2020
Centers for Disease Control and Prevention: Module 5: Assessing and Address-
ing Opioid Use Disorder (OUD). Atlanta, GA, Centers for Disease Control
and Preventio
training/oud/accessible/index.html. Accessed January 14, 2024.
Chang Y-P: Factors associated with prescription opioid misuse in adults aged 50
or older. Nurs Outlook 66(
Chhabra S, Bull J: Methadone. Am J Hosp Palliat Care 25(2):146–150, 2008
18445864
Chhatre S, Cook R, Mallik E, Jayadevappa R: Trends in substance use admis-
sions among older adults. BMC Health Serv Res 17(1):584, 2017 28830504
Cicero TJ, Surratt HL, Kurtz S, et al: Patterns of prescription opioid abuse and
co
morbidity in an aging treatment population. J Subst Abuse Treat
42(1):87–94, 2012 21831562
Cotton BP, Bryson WC, Bruce ML: Methadone maintenance treatment for older
adults: cost and logistical co
2018 29089014
Dufort A, Samaan Z: Problematic opioid use among older adults: epidemiology,
adverse outcom
1053, 2021 34490542
Dürsteler-MacFarland KM, Vogel M, Wiesbeck GA, et al: There is no age limit
methadone: a retrospective cohort study. Subst Abuse Treat Prev Policy
for
6:9, 2011 21592331
Fareed A, Casarella J, Amar R, et al: Benefits of retention in methadone mainte-
nance and chronic medical conditions as risk factors for premature death
among older heroin addicts. J Psychiatr Pract 15(3):227–234, 2009 19461397
Grella CE, Lovinger K: Gender differences in physical and mental health out-
comes among an aging cohort of individuals with a history of heroin dependence. Addict Behav 37(3):306–312, 2012 22154506
Han B, Polydorou S, Ferris R, et al: Demographic trends of adults in New York
City
opioid treatment programs—an aging population. Subst Use Misuse
50(13):1660–1667, 2015 26584180
Huhn AS, Strain EC, Tompkins DA, Dunn KE: A hidden aspect of the U.S. opi-
oid crisis: rise in first-time treatment admissions for older adults with opioid use disorder. Drug Alcohol Depend 193:142–147, 2018 30384321
Humphreys K, Shover CL: Twenty-year trends in drug overdose fatalities
among older adults in the US. JAMA Psychiatry 80(5):518–520, 2023
36988923
Jeste DV, Peschin S, Buckwalter K, et al: Promoting wellness in older adults
with mental illnesses and substance use disorders: call to action to all stakeholders. Am J Geriatr Psychiatry 26(6):617–630, 2018 29880118
Kruszecki C, Cameron CR, Hume AL, Ward KE: A systematic review of integra-
tive medicine for opioid withdrawal. J Subst Abuse Treat 125:108279, 2021
34016305
Kuerbis A, Sacco P: A review of existing treatments for substance abuse among
the elderly and recommendations for future directions. Subst Abuse 7:13–
37, 2013 23471422
n, 2016. Available at: https://www.cdc.gov/drugoverdose/
2):112–120, 2018 29523356
nsiderations. Psychiatr Serv 69(3):338–340,
es and treatment considerations. Drugs Aging 38(12):1043–
Opioid Use and Use Disorder Among Older Adults 211
Kuerbis A, Sacco P, Blazer DG, et al: Substance abuse among older adults. Clin
Geriatr Med 30(3):629–654, 2014 25037298
Lee JD, Nunes EV Jr, Novo P, et al: Comparative effectiveness of extended-
re
lease naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomised controlled trial.
Lancet 391(101
Lehmann SW, Fingerhood M: Substance-use disorders in later life. N Engl J
Med 379(24):2351–2360, 2018 30575463
Levi-Minzi MA, Surratt HL, Kurtz SP, Buttram ME: Under treatment of pain: a
prescription fo
1729, 2013 23841571
Ling W: Buprenorphine implant for opioid addiction. Pain Manag 2(4):345–350,
2012 24654720
Lofwall MR, Brooner RK, Bigelow GE, et al: Characteristics of older opioid
maintena
Loreck D, Brandt NJ, DiPaula B: Managing opioid abuse in older adults: clinical
considerations and challenges. J Ger
Lynch A, Arndt S, Acion L: Late- and typical-onset heroin use among older
adul
ts seeking treatment for opioid use disorder. Am J Geriatr Psychiatry
29(5):417–425, 2021 33353852
Manhapra A, Becker WC: Pain and addiction: an integrative therapeutic ap-
proach. Med Clin North Am 102(4):745–763, 2018 29933827
Maree RD, Marcum ZA, Saghafi E, et al: A systematic review of opioid and ben-
epine misuse in older adults. Am J Geriatr Psychiatry 24(11):949–
zodiaz
963, 2016 27567185
Maruyama A, Macdonald S, Borycki E, Zhao J: Hypertension, chronic obstruc-
tive pulmonary disease, diabetes and depression among older methadone
maintenance patients in British Columbia. Drug Alcohol Rev 32(4):412–
418, 2013 23480234
Mattick RP, Breen C, Kimber J, Davoli M: Buprenorphine maintenance versus
placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2014(2):CD002207, 2014 24500948
Mortazavi SS, Shati M, Malakouti SK, et al: Psychiatric comorbidities among
Iranian elderly patients on methadone maintenance treatment. Arch Iran
Med 18(11):740–746, 2015 26497370
Nicholson NR: A review of social isolation: an important but underassessed
condition in older adults. J Prim Prev 33(2-3):137–152, 2012 22766606
Office of the Surgeon General: Facing addiction in America: the Surgeon Gen-
eral’s report on alcohol, drugs, and health. DHHS, 2016. Washington, DC:
ment of Health and Human Services. Available at: https://
Depart
www.ncbi.nlm.nih.gov/books/NBK424857/. Accessed January 30, 2024.
Payne RA, Hrisko S, Srinivasan S: Treatment approaches for opioid use disor-
ders in late life. Curr Treat Options Psychol 5:242–254, 2018
Purath J, Keck A, Fitzgerald CE: Motivational interviewing for older adults in
primary care: a systematic review. Geriatr Nurs 35(3):219–224, 2014
24656051
Rajaratnam R, Sivesind D, Todman M, et al: The aging methadone maintenance
patient: treatment adjustment, long-term success, and quality of life. J Opioid Manag 5(1):27–37, 2009 19344046
18):309–318, 2018 29150198
r opioid misuse among the elderly? Pain Med 14(11):1719–
nce patients. J Subst Abuse Treat 28(3):265–272, 2005 15857727
ontol Nurs 42(4):10–15, 2016 27027362
212 Substance Use in Older Adults
Rosen D, Smith ML, Reynolds CF 3rd: The prevalence of mental and physical
health disorders among older methadone patients. Am J Geriatr Psychiatry
16(6):488–497, 2008 18515693
Rosenblum A, Joseph H, Fong C, et al: Prevalence and characteristics of chronic
pain among chemically
and residential treatment facilities. JAMA 289(18):2370–2378, 2003
12746360
Saloner B, McGinty EE, Beletsky L, et al: A public health strategy for the opioid
crisis. Public Health Rep 133(1
SAMHSA: Opioid misuse increases among older adults. The CBHSQ Report,
July 25, 2017. Available at: https://www.samhsa.gov/data/sites/default/
files/report_3186/Spotlight-3186.pdf. Accessed June 17, 2021.
SAMHSA: Enhancing Motivation for Change in Substance Use Disorder Treat-
ment (Treatment Improvement Protocol [TIP] Series 35; HHS Publ. No.
PEP19-02-01-003).
SAMHSA: Treating Substance Use Disorder in Older Adults (Treatment Im-
provement Protocol [TIP] Series 26; HHS Publ. No. PEP20-02-01-011).
Rockville, MD,
Santoro TN, Santoro JD: Racial bias in the US opioid epidemic: a review of the
history of
2018 30800543
Satre DD, Chi FW, Mertens JR, Weisner CM: Effects of age and life transitions
on alcohol and drug
Drugs 73(3):459–468, 2012 22456251
Schonfeld L, Hazlett RW, Hedgecock DK, et al: Screening, brief intervention,
ferral to treatment for older adults with substance misuse. Am J Pub-
and re
lic Health 105(1):205–211, 2015 24832147
Shoff C, Yang T-C, Shaw BA: Trends in opioid use disorder among older adults:
analyzing Medicar
33812694
Simoni-Wastila L, Zuckerman IH, Singhal PK, et al: National estimates of expo-
sure to prescription drugs with addiction potential in community-dwelling
elders. Subst
Substance Abuse and Mental Health Services Administration (SAMHSA): Im-
proving Cultural Competence (Treatment Improvement Protocol [TIP] Series 59; HHS Publ No [SMA] 14-4849). Rockville, MD, SAMHSA, 2014
Taylor MH, Grossberg GT: The growing problem of illicit substance abuse in the
elderly: a review. Prim Care Companion CNS Disord 14(4):PCC.11r01320,
2012 23251860
Wu L-T, Blazer DG: Illicit and nonmedical drug use among older adults: a re-
view. J Aging Health 23(3):481–504, 2011 21084724
Yarnell S, Li L, MacGrory B, et al: Substance use disorders in later life: a review
and synthesis of the literature of an emerging public health concern. Am J
Geriatr Psychiatry 28(2):226–236, 2020 31340887
Zahr NM, Pohl KM, Saranathan M, et al: Hippocampal subfield CA2+3 exhibits
accelerated aging in alcohol use disorder: a preliminary study. Neuroimage Clin 22:101764, 2019 30904825
SAMHSA, 2020
systemic bias and implications for care. Cureus 10(12):e3733,
Abus 26(1):33–42, 2005 16492661
dependent patients in methadone maintenance
_suppl):24S–34S, 2018 30426871
Rockville, MD, SAMHSA, 2019
treatment outcome over nine years. J Stud Alcohol
e data, 2013–2018. Am J Prev Med 60(6):850–855, 2021
CHAPTER 8
Sedative, Hypnotic,
and Anxiolytic Use
and Use Disorder
Among Older Adults
Seetha Chandrasekhara, M.D.
Sue-Jean Sylvia Yu, M.D.
There are many clinical indications for the use of sedatives, hypnot-
ics, and anxiolytics, including anxiety and insomnia. Historically, older
ts were prescribed sedatives, hypnotics, and anxiolytics more fre-
adul
quently than younger adults (Olfson et al. 2015), although recently, use
by 50- to 64et al. 2019a). Caution must be used when prescribing sedative-hypnotics
to older adults, given changes in metabolism associated with aging,
drug–drug interactions, and increased risk of falls, cognitive impairment, and respiratory suppression. In addition to problematic side ef-
year-olds has surpassed use by adults 65 and older (Maust
213
214 Substance Use in Older Adults
fects at therapeutic doses, older adults may develop sedative, hypnotic,
or anxiolytic use disorder, with its associated complications and comorbidities, and may be at risk of withdrawal, which can be deadly. In this
chapter, we discuss the presentation and treatment of sedative, hypnotic,
or anxiolytic use disorder, as well as the appropriate use of these medications in older adults. Deprescribing is discussed in Chapter 4.
EPIDEMIOLOGY
Many older adults take sedatives, hypnotics, and anxiolytics. This heterogeneous category of medications includes benzodiazepines, nonbenzodiazepine hypnotics, barbiturat
with sedative effects (Table 8–1). Note that some of the literature also includes skeletal muscle relaxants (e.g., carisoprodol) as sedatives or tranquilizers, but they are not discussed here. In this chapter, we touch on
some clinical indications for medications (both ap
and off-label), but a full discussion is beyond our scope. For the most
part, we discuss use and misuse of benzodiazepines and nonbenzodiazepine hypnotics.
Adults ages 50–64 are more likely to use benzodiazepines in a given
year than those ≥ 65 (14.3%
. Of course, those in middle age will soon be older adults, raising
2019a)
the concerning possibility that use among older adults will rise in the
near future. The vast majority of benzodiazepine prescriptions to older
adults are written by nonpsychiatrists, with psychiatrists accounting
for just 5.7% of prescriptions (Olfson et al. 2015). Older adults’ visits to
primary care providers and psychiatrists for anxiety and insomnia
have increased over time, as have prescriptions of benzodiazepines by
primary care providers (although prescribing benzodiazepines by psychiatrists has decreased) (Maust et al. 2017). Despite warnings that benzodiazepines should be used only for short duration, nearly a third of
older benzodiazepine users reported long-term use (≥ 120 days)
(Olfson et al. 20
Older women are about twice as likely to use benzodiazepines as
older men (Olfson et al. 2
scription of benzodiazepines. Older women are at more risk for social
isola
tion and in turn prolonged prescription of benzodiazepines, increasing their risk for a substance use disorder (Schutte et al. 2015).
Older adults th
cial isolation and barriers to treatment (American Psychological Association Committee on Aging 2009).
15).
015). Social factors can also increase the pre-
at belong to a minority group can also have increased so-
es, and various other medications
proved by the FDA
and 12.9%, respectively) (Maust et al.
Sedative, Hypnotic, and Anxiolytic Use 215
Table 8–1. Sedatives, hypnotics, and anxiolytics by drug class
Drug class Medications
Benzodiazepine Alprazolam, chlordiazepoxide, clonazepam,
clorazepate, diazepam,
midazolam, oxazepam, temazepam, triazolam
Nonbenzodiazepine
hypnotic
Barbiturate Butabarbital, pentobarbital, phenobarbital,
Orexin antagonist Daridorexant, lemborexant, suvorexant
Melatonin agonist Melatonin, ramelteon, tasimelteon
Antihistamine Diphenhydramine, doxylamine, hydroxyzine
Antidepressant Doxepin, mirtazapine*, trazodone*
Anticonvulsant Gabapentin*
Antipsychotic Quetiapine*
*Off-label use.
Source. American Geriatrics Society Beers Criteria Update Expert Panel 2023; U.S.
Food and Drug Administration 2019b.
Eszopiclone, zaleplon,
secobarbital
lorazepam,
zolpidem
Misuse of benzodiazepines is less common in older adults than in
younger adults: the prevalence of past-year misuse is 0.6% for those 65
and older versus 1.4% for ages 50–64 and 5.2% for ages 18–25 (Maust et
al. 2019a). The most common reason for misuse reported by older adults
was to help with sleep; the most commonly misused medications were
alprazolam, diazepam, and lorazepam; and the most common source
was from a friend or relative (Maust et al. 2019a).
Older adults are high consumers of sleep products. About 60% of
benzodiazepine use among older adults is f
or insomnia (Tannenbaum
et al. 2014). A survey of older adults found that 35.4% reported at least
occasional use of over-the-counter (OTC) sleep aids (e.g., diphenhydramine-containing products, 21.9% of all respondents), herbal/natural
sleep aids (e.g., melatonin or valerian, 12.5%), prescription hypnotics
(e.g., zolpidem or temazepam, 8.3%), or prescription pain medication
for sleep (e.g., oxycodone, 5.0%) (Maust et al. 2019b). Non-Hispanic
Black older adults were less likely to use herbal/natural aids than
White older adults; other than that, no demographic variables were associated with use of these products (Maust et al. 2019b).
Especially concerning is the combined use of sedatives, hypnotics, or
anxiolytics with other substan
ces. A systematic review with studies from
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