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6 Substance Use in Older Adults
tive salience play a role in the transition from isolated use of substances
to the problematic patterns of use in addiction. Note that the following
describes how addiction may arise in adults in general, as the pathophysiology of SUDs in older adults has not been well studied.
Binge/intoxication involves the replication of phasic dopamine firing
when substances are administered and the associated sensation of attaining a “high.” An intricate reward circuit involving dopamine, opioid, GABA, glutamate, serotonin, acetylcholine, and endocannabinoid
systems are implicated in this stage. In response to chronic drug exposure, neuroadaptations are made via these and even more neurotransmitters (norepinephrine, enkephalins, and corticotrophin-releasing
factor, to name a few) to previously balanced circuits of executive functioning, decision-making, inhibitory control, mood regulation, and
ress reactivity. These changes set the stage for both conditioned rein-
st
forcement (response to previously neutral stimuli that have become
paired with use
ward, based on one’s physiological state and previously learned asso-
re
ciations). Exposure to drug cues or to negative emotional states may
lead to craving, the intense desire for the drug (characterized later in this
chapter).
Withdrawal/negative affect is characterized by decreased reward
sensation brought about by ever-increasing reward thresholds during
chronic drug exposure. The brain responds to chronic drug exposure
via within-system and between-system neuroadaptation. Withinsystem neuroadaptation opposes the effects of the drug; in the absence of the drug, the opposing effects persist, resulting in the experience of withdrawal. Between-system neuroadaptation includes
upre
gulation of various “anti-reward” circuits that are thought to
limit reward; when the substance of use is not available, dysregulation
of the hypothalamic-pituitary-adrenal axis (HPA axis) leads to negative emotional states such as dysphoria, malaise, irritability, and increased stress. This drives drug-seeking and compulsive goal-directed
behavi
ors.
Preoccupation/anticipation helps us understand how relapse occurs
after periods
the prefrontal cortex to seek out the drug and impairment of the executive function required to avoid inappropriate behavior. Koob and Volkow (2016) hypothesized that opposing “go” and “stop” systems are
active during this stage. The go system in the dorsal prefrontal cortex
and cingulate cortex drives craving and engages habits related to substance use, whereas the stop system in the ventromedial prefrontal cortex inhibits impulsivity and responses to negative emotional states.
of the substance) and incentive salience (motivation for
of abstinence. Craving seems to involve both activation of
Introduction to Substance Use Among Older Adults 7
Research on genetics and epigenetics varies among SUDs. More
studies have been conducted to understand the genetics and epigenetics of alcohol and tobacco than of cocaine, methamphetamines, or
opioids. Such studies have used genomewide association studies, large
biobank samples, and large meta-analysis consortia (Deak and Johnson
2021; Gelernter and Polimanti 2021; Kaplan et al. 2022). There is evidence that SUDs are polygenic in nature, with each variant across the
genome having a small effect with respect to risk. For example,
entire
variants in the alcohol dehydrogenase genes ADH1B and ALDH2 have
been associated with both alcohol intake and AUD (Gelernter and Polimanti 2021). Because these enzymes are directly involved in the process
of alcohol metabolism, it makes sense that genetic variations confer risk
of developing AUD. With respect to epigenetics, the best studied substance is tobacco, use of which results in widespread epigenetic modification across the genome; fortunately, these modifications appear to be
re
versible with smoking cessation (Gelernter and Polimanti 2021).
The effect of the use of various substances on the aging brain is not
completely understood, but
nergic neurotransmitter systems, which are also altered by drugs of abuse,
have been noted to change with age in individuals without SUDs (Dowling et al. 2008). For example, the effects of expected decreases in dopaminergic cell bodies in the substantia nigra and decreases in dopamine
receptor binding in the striatum may be worsened by specific SUDs.
Chronic cocaine use was found to arrest maturation of the frontal and temporal lobe between ages 20 and 50, with an even more profound reduction
hite matter volume later in age than would be expected compared
in w
with healthy counterparts (Dowling et al. 2008). A neuroimaging study of
people ages 25–58 without cerebrovascular symptoms who were dependent on cocaine found “age-related risk of white matter neurovascular
toxicity
ter regions compared with the control group (Bartzokis et al. 1999). There
is also evidence that several
damage and inflammation, which may contribute to disruption of the
blood–brain barrier (stimulants in particular), inhibition of necessary enzymes of detoxification such as monoamine oxidases (nicotine in particular), and leukocyte telomere wear and shortening (opioids in particular),
hastening th
noted to bring about a proinflammatory state due to chronic immune system activity, and there is a possibility that the use of methamphetamines
leads to cognitive decline in some users (Dean et al. 2013).
tetrahydro
,” including severe lesions in the cortical and subinsular white mat-
e aging process (Bachi et al. 2017). Opioid use disorder is also
Conversely, substances may have neuroprotective effects. Delta-9-
cannabinol, a component of marijuana, decreases proinflam-
the cannabinoid, glutamatergic, and seroto-
substances bring about greater oxidative
8 Substance Use in Older Adults
matory cytokine production and may confer an antioxidant role against
reactive oxygen species similar to or greater than that of standard antioxidants, although cannabis has also been associated with decreased
hippocampal volume (Bachi et al. 20
Age-related pharmacokinetic and pharmacodynamic changes such
as decre
tion, changes in drug–receptor interactions, and related downstream effects are normal and may lead to longer duration of action as well as
greater sensitivity to drugs (Lehmann and Fingerhood 2018). These normal changes confer an even greater risk of drug–disease and drug–drug
inte
bidities and take more medications as they age (Lehmann and Fingerhood 2018).
ased renal elimination of drugs, decreased volume of distribu-
ractions in older adults, who are more likely to have medical comor-
17; Dowling et al. 2008).
Psychosocial, Psychological, and
Personality Factors
Aging is associated with a number of psychosocial and psychological
risk factors for SUDs, including loneliness, social isolation, stressful life
events (e.g., the death of loved ones), being a caregiver, and changes in
living situations (Koechl et al. 2012; Yarnell et al. 2020). Although the
impact of the COVID-19 pandemic on older adults’ use of substances is
not yet clear, the social isolation resulting from the pandemic portends
negative health consequences for older adults.
Adverse childhood experiences (ACEs) such as physical abuse, sexual abuse, neglect, exposure to domestic violence, household mental illness or substance use, and parental separation are strongly associated
with misuse of substances and development of SUDs, including in
older adults (Grummitt et al. 2022). Using substances as a coping mechanism to avoid negative feelings (avoidance coping) arising from childhood adversity may link ACEs with SUDs (Grummitt et al. 2022).
Avoidance
use in a 20-year, longitudinal study of middle-aged adults (ages 55 to 65
at the start of the study; Brennan et al. 2012). Other mediators of the relationship between ACEs and SUDs may include psychiatric disorders
such
and interactions with peers (Grummitt et al. 2022). Personality traits
such as sensation-seeking or impulsivity may contribute to the development of SUDs, although this association is not well studied in older
adults (Liu et
Denial of substance use or its severity contributes to difficulties with
re
cognizing and diagnosing SUDs (Yarnell et al. 2020). In particular,
coping has in fact been associated with problematic alcohol
as major depressive disorder and PTSD, behavioral disinhibition,
al. 2020).
Introduction to Substance Use Among Older Adults 9
older adults’ attitudes regarding the use of alcohol (e.g., linking alcohol
use with social life and social engagement; adopting or sharing the
drinking habits of partners, family members, or peers; doubting health
risks and citing health benefits of alcohol use; drinking alcohol to help
deal with stressful events) may be barriers to identifying and addressing problematic alcohol use (Kelly et al. 2018).
Social Determinants and Structural Factors
Care for older adults with SUDs must be holistic and thorough, encompassing social, spiritual, financial, and other factors that may enhance
re
covery or conversely prevent engagement (SAMHSA 2020b). Structural and social determinants of health contribute to differences in the
prevalence of SU
tive care. Social determinants are the conditions in which people live
and age, includin
cess to affordable health services (World Health Organization 2023).
For example, 50% of older adults who live alone lack the money to pay
for basic needs (Mutchler et al. 2019).
There are no direct studies on how SUDs in older adults directly
contribute to other social determinants of health. Some correlations can
be drawn, however, in terms of which social determinants of health put
people at risk for having a substance use disorder in late life. For example, one study using latent profile analysis found that older adults who
considered “connected and active” had the lowest odds of ciga-
were
rette use; the “alone but not lonely” group had the highest risk of cigarette use, alcohol use, and high-risk drinking; and the “alone and
lonely” group had the highest odds of nonmedical drug use (Farmer et
al. 2022). These results suggest that both social isolation and loneliness
are significant risk factors for developing an SUD in older adults. Major
life changes such as involuntary loss of a job, losing a partner, and
health problems were all risk factors for poorer SUD treatment outcomes (Satre et al. 2012). Other risk factors related to substance use in
late life include white ethnicity, chronic pain, transitions in living situation, avoidant coping style, affluence, and bereavement. Housing status
is an im
in a nursing home correlates with late-life drinking (Kuerbis et al. 2014).
people from racial or
in younger adults, and these disparities are likely to continue, if not accelerate, in older cohorts. Religion and spirituality have generally been
associated with decreased substance use in older adults; for example,
portant factor, with studies showing that homelessness or living
Structural disparities (e.g., poor access to SUD treatment services in
Ds across populations and may affect access to effec-
g income, education, food security, housing, and ac-
ethnic minorities) exist in the treatment of SUDs
10 Substance Use in Older Adults
frequent attendance at religious services is correlated with lower alcohol and tobacco use (Lucchetti et al. 2018). For a much more in-depth
di
scussion of this critical topic, we refer you to Chapter 11, “Cultural,
Structural, and Ethical Considerations in the Care of Older Adults With
Substance Use Disorders.”
EPIDEMIOLOGY
The population of the United States is getting older. By 2029, all members of the Baby Boomer generation (born from mid-1946 to mid-
1964)—almost 20% of the population—will be ≤65 years old (Colby and
Ortman 2014
ethnically diverse than subsequent generations: in 2012, 72% of Baby
Boomers were non-Hispanic white versus 63% of the total population,
and this difference will grow over time (Colby and Ortman 2014).
Compared with previous geriatric cohorts, Baby Boomers have increased life expectancy, higher rates of substance use when younger,
and a gr
stance use (Yarnell et al. 2020). Thus, there has been and will continue
to be an incr
seeking treatment for an SUD (SAMHSA 2020b). Some parts of the
country (e.g., Maine, Florida, West Virginia, Vermont) have increased
numbers of aging adults, which will intensify the demand for SUD services for older adults in those areas (U.S. Census Bureau 2020).
We discuss the epidemiology of specific SUDs in Chapters 5–10; we
sent a summary here. Although the prevalence of SUDs tends to be
pre
lower in older adults than those who are younger, prevalence among
older adults has been increasing. For example, binge drinking (see “Defining Limits, Use, and Misuse” in Chapter 5 for definitions), overall
past-year alcohol use, and incidence of A
to 2013–2014 (Han et al. 2017a). About 2.3% of older adults meet criteria
for past-year AUD, and 13.4% meet criteria for lifetime AUD (Grant et al.
2015). Nearly 12% of community-dwelling older adults smoke cigarettes;
the total number of older adults in the United States who smoke is expected to double by 2050 (Blazer and Wu 2012; U.S. Department of
Health and Human Services 2016). Exposure to opioids is common
among older adults, and the prevalence of opioid use disorder tripled
from 2013 to 2018, including an increase in the use of heroin and, more
recently, fentanyl (Huhn et al. 2018; Shoff et al. 2021; Simoni-Wastila et
al. 2005). Nearly 13% of older adults have been prescribed a benzodiazepine in the last year; although the prevalence of misuse is low (0.6% in
), up from 13% in 2010. Baby Boomers are less racially and
eater acceptance of and more positive attitude toward sub-
ease in the total number of individuals meeting criteria and
UD increased from 2005–2006
Introduction to Substance Use Among Older Adults 11
the past year), there are many concerns about the safety of this medication class in older adults (Maust et al. 2019). The prevalence of methamphetamine use and use disorder have increased to 0.8% and 0.4% of
older adults, r
adults; 0.12% of older adults use cocaine (SAMHSA 2020a). Among
older adults, past-year cannabis use increased dramatically to 4.2% in
2018, with 6.9% of cannabis users meeting criteria for cannabis use disorder (Han et al. 2017b; Hasin and Walsh 2021).
Of particular concern in older adults is the increasing simultaneous
use of two
(Hasin and Walsh 2021) or benzodiazepines and opioids (Park et al.
2015). Clinicians can play a critical role in addressing this issue by reducing coprescription of the latter classes of medication.
espectively, with the highest increase in Black older
or more substance categories, such as alcohol and cannabis
CONSEQUENCES AND COMPLICATIONS
The consequences and complications of substance use are especially apparent in older adults, who may have multiple medical conditions and
substance use that has gone on for decades
ularly vulnerable to the well-known long-term consequences of substance use such as lung and heart disease, stroke, and cancer. These
consequences can also exacerbate and increase the risk of aging-related
health conditions such as dementia and proneness to falls. For example,
long-term tobacco smoking can increase vascular risk, which in turn increases risk of developing certain types of dementia (Peters et al. 2008).
Older adults are prescribed more medications than any other age
grou
p: a 2015–2016 study showed that 87.5% of older adults took at
least one prescription medication, and 39.8% took five or more prescription medications in the previous 30 days (National Center for Health
Statistics 2019). Taking more medication and having more co-occurring
conditions means that older adults are at higher risk for experiencing
medication–medication, medication–substance, and substance–health
condition interactions than their younger counterparts (American Geriatrics Society Beers Criteria Update Expert Panel 2023). Additionally,
changes in metabolism that occur with aging can cr
For example, adults generally have less lean muscle mass and more
body fat as they age, resulting in fat-soluble substances such as benzodiazepines having a longer effect (Kuerbis et al. 2014). Older adults may
therefore become more sensitive to substances as they age.
Older adults are also susceptible to the general health risks of sub-
stance use that younger adults are. For example, older adults may con-
. Older adults may be partic-
eate complications.
12 Substance Use in Older Adults
tinue to use substances through many methods, including intravenous
injection. They are therefore susceptible to both the acute and long-term
consequences of intravenous drug injection including infectious viral
diseases (e.g., HIV, hepatitis B and C), other infections (e.g., sepsis, cellulitis, endocarditis), and overdose (Cornford and Close 2016). Older
adults also continue to be vulnerable to tolerance, dependence, and
withdrawal, although these may be more difficult to recognize if a substance is a prescribed medication being misused. Withdrawal in older
adults may be even more life-threatening than in younger adults;
guidelines for treatment of opioid use disorder in older adults suggest
having a lower threshold to admit for opioid withdrawal management
than in younger adults (Rieb et al. 2020).
The various consequences and complications of specific substance
use are di
substances, such as “Effects of Alcohol on Older Adults” in Chapter 5.
scussed in greater detail in the chapters dedicated to those
COMORBIDITIES
Older adults with SUDs have higher rates of medical comorbidities
compared with older adults without SUDs and also younger patients
with SUDs (Lofwall et al. 2005; Yarnell et al. 2020). Medical comorbidities are wide-ranging and vary depending on the substance. Table 1–2
outlines some common medical comorbidities and the substance they
are
most associated with. Substances used for treatment, such as opioids and benzodiazepines, can have unwanted and sometimes increased adverse effects in this population. Cannabis, which is used as
an adjunctive treatment for many medical conditions in older age, also
has adverse effects in this population (Han et al. 2017b; Yarnell et al.
2020). Substance use also can worsen certain preexisting comorbidities
or cause disease processes to progress more quickly. Older age, health
problems, and substance use are all associated with increased risk of
mortality, which in turn decreases with abstinence (Scott et al. 2011).
Although the relationship between medical conditions and SUDs in
r adults is well established, there is far less data on the relationship
olde
between psychiatric disorders and SUDs in older adults. Most studies
looking at substance use disorder in older adults and psychiatric comorbidities focus on depression alone (Wu and Blazer 2014). One crosssectional study in Canada of older adults with past-year benzodiazepine dependence showed that about a third also had mood or anxiety
disorders in the last year (Préville et al. 2008). The most robust information on psychiatric comorbidity in older adults with SUDs comes from
Introduction to Substance Use Among Older Adults 13
Table 1–2. Substances of abuse and common medical comorbidities
Substance Common medical comorbidities
Alcohol Intracranial hemorrhage
Cognitive impairment/dementia
Liver disease
Cerebrovascular accidents
Cardiovascular disease
Cardiac Events
Hypertension
Upper gastrointestinal bleeding/perforation
Pancreatitis
Cancer (breast, colon, head and neck, esophageal)
To ba cc o H yp er t en si on
Atherosclerosis
Cerebrovascular accidents
Coronary events and cardiac death
Decline in pulmonary function
Chronic obstructive pulmonary disease
Smoking-related cancers
Erectile dysfunction
Osteoporosis and related complications
Cocaine Cardiovascular disease
Pulmonary disease
Gastrointestinal disease
Cerebrovascular disease
Bleeding dysfunction
Immune dysfunction
Cannabis Increased heart rate, respiratory rate, and blood
pressure
Cardiac events
Short-term memory impairment
Source. Mannelli et al. 2007; Yarnell et al. 2020.
papers analyzing the National Epidemiologic Survey on Alcohol and
Related Conditions. One study looking at older adults with varying alcohol use from this data set showed that past-year major depression,
anxiety disor
der, and antisocial personality disorder were significantly
increased in those with high-risk alcohol use compared with moderate
or low-risk alcohol use (Sacco et al. 2009). Another study of this data set
showed that PTSD was associated with elevated odds of alcohol or
drug use disorders (Pietrzak et al. 2012).
Psychiatric and medical comorbidities of specific SUDs are de-
scribed in further detail in Chapters 5–10.
14 Substance Use in Older Adults
SUBSTANCE USE AND COGNITIVE
IMPAIRMENT
The prevalence of mild neurocognitive disorder (cognitive impairment
without functional impairment; also known as mild cognitive impairment) and major neurocognitive disorder (both cognitive and functional impairment; also known as dementia) increases with age.
Substances
bacco, contribute to both reversible and irreversible cognitive impairment in older adults.
While there is some evidence that moderate alcohol use (perhaps
one s
dementia, higher alcohol use is associated with increased risk in a dosedependent fashion, with heavy use resulting in irreversible WernickeKorsakoff syndrome and the risk of delirium tremens (SAMHSA 2020b;
Walaszek 2019). The use of alcohol, a neurotoxin, may accelerate the
progression of mild cognitive impairment to dementia and can exacerbate dementia (SAMHSA 2020b). Alcohol may also contribute to behavioral and psychological symptoms of dementia (Bessey and Walaszek
2019). W
Cognition” in Chapter 5 for a more detailed discussion.
As noted earlier in “Epidemiology,” clinicians prescribe benzodiazepines to older adults at an alarming rate, despite a number of concerns
about their use, including cognitive impairment. Older adults who
have taken benzodiazepines (whether recently, previously, for long periods of time, or ever) may be at increased risk of developing dementia
(SAM
Chapter 8, “Sedative, Hypnotic, and Anxiolytic Use and Use Disorder
Among Older Adults” goes into this topic in greater detail.
Smoking tobacco increases the risk of dementia, whereas smoking
cess
never smoked (Zhong et al. 2015). A relationship between cannabis and
dementia has not been established, but it should be noted that cannabis
can cause problems with memory and that the increasing potency of
cannabis may make it even riskier cognitively (SAMHSA 2020b).
, especially alcohol, sedatives, hypnotics, anxiolytics, and to-
tandard drink per day) is associated with decreased risk of
e refer the reader to “Alcohol Use, Cardiovascular Disease, and
HSA 2020b). Antihistaminergic hypnotics also affect cognition.
ation reduces the risk to the level experienced by those who have
SUMMARY
The number of older adults with SUDs is increasing rapidly. SUDs in older
adults also increase health care costs in older adults by increasing the
Introduction to Substance Use Among Older Adults 15
number of comorbid illnesses and complications of substance use, hastening disease progression, and leading to other poor health-related outcomes such as increasing falls. Additionally, many substances of abuse can
also contribute to wors
Even so, SUDs in older adults are often underdiagnosed and undertreated for a variety of r
get older adults with SUDs, but they can benefit from screening and
treatment interventions such as SBIRT. Advocating for public policy to
help fund research, public health interventions, and treatment for older
adults with SUDs will be key as our population ages.
It matters what terms we use with our patients when discussing
SUDs.
promoting ageism or stigma.
pared with younger age groups. Therefore, our best understanding of
the pa
diction arises in adults in general. Addiction can be conceptualized as a
re
negative affect, and preoccupation/anticipation. Each stage is associated with adaptations of the neural circuitry of reward and of executive
function. Gene
current evidence suggests that SUDs are polygenic in nature, with each
variant having a small effect with respect to risk. The effect of the use of
various substances on the aging brain is not completely understood, but
some are shown to hasten aging of the brain. Additionally, normal agerelated pharmacokinetic and pharmacodynamic changes increase the
risk of adverse effects from substance use in older adults.
fa
ing is associated with a number of psychosocial and psychological risk
factors f
and difficulty coping contribute to development of SUDs. Denial of the
issue by the patient, family, or caregivers contributes to the difficulty in
recognizing SUDs in older adults. Structural and social determinants of
health contribute to differences in the prevalence of SUDs across populations and also may affect access to effective care. Within our population of focus, there is even less research about the impact of SUDs in
women, racial
As the proportion of older adults in the United States grows and diversifies, more research needs to be done to discover potential nuances of
SUD treatment in these different populations, with the goal of providing evidence-based care.
Care should be taken to use person-first language that avoids
There is an overall dearth of research on SUDs in older adults com-
thophysiology of addiction in older adults comes from how ad-
curring cycle of stages including binge/intoxication, withdrawal/
tic and epigenetic studies vary widely among SUDs, and
In addition to biological factors, there are psychological and social
ctors contributing to etiology of substance abuse in older adults. Ag-
or SUDs, such as loneliness. Psychological factors such as ACEs
and ethnic minorities, and individuals with disabilities.
ening cognitive impairment in older adults.
easons. Few public health prevention efforts tar-
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