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56 Substance Use in Older Adults
interventions are available and should be offered to all older adults
with SUDs and modified as needed (e.g., lower doses and slower titration of medication). It is essential to manage comorbid medical and psychiatric conditions, monitor for suicidal ideation, and mitigate risk of
suicide. Cognitive impairment among older adults may interfere with
the ability to effectively engage in treatment, but successful treatment
may result in improved cognition. Older adults with late-life onset may
not have the same chronic medical and psychiatric comorbidities as
those with early-life onset, who may require more intensive treatment
(Substance Abuse and Mental Health Services Administration [SAMHSA] 2020). Finally, as the role of trauma in the development of SUDs
is increasingly recognized and as our population becomes more diverse, clinicians should be equipped to provide trauma-informed care
to older adul
ts with SUDs.
OVERVIEW OF MANAGEMENT
Older adults with at-risk substance use or SUDs may benefit from a
wide range of interventions. At-risk use refers to substance use behaviors that increase the risk of developing problems and complications.
For example, thos
alcohol use disorder may require only a brief intervention that involves
education about the harms of alcohol use and motivational interviewing to guide them to reduced alcohol use or abstinence. Conversely, an
older adult with severe
tion in an inpatient setting, followed by residential or intensive outpatient treatment and pharmacotherapy with buprenorphine.
Referrals of older adults to treatment programs most commonly
come from the justice s
while intoxicated or other criminal situations), health care professionals, or themselves (Sahker et al. 2015). Because older adults are more
likely than younger people to see health care professionals, health care
visits offer an excellent opportunity to address at-risk substance use
and SUDs (SAMHSA 2020).
In general, older adults have better outcomes of SUD treatment than
younger adults. Unfo
treatment programs offer programs specifically for older adults
(SAMHSA 2020), and only 11% of people who receive Medicare and have
an SUD receive treatment for their condition (Parish et al. 2022). Barriers
to care include skepticism about the ill effects of substance use, the link between substance use (especially alcohol) and social life, lack of access to
e with at-risk alcohol use who do not meet criteria for
opioid use disorder may first require detoxifica-
ystem (after they are cited for operating a vehicle
rtunately, in the United States, only ~ 23% of SUD
Management of Substance Use Disorders in Late Life 57
care, problems with finances and/or insurance coverage, lack of transportation, lack of motivation, and stigma (Kelly et al. 2018; Parish et al. 2022).
Older adults have unique challenges t
cluding the loss of spouse/partner or friends; changes in roles with respect to family and work; normal aging-related cognitive changes; or the
velopment of a neurocognitive disorder (SAMHSA 2020). On the other
de
hand, older adults may be motivated to address substance use due to a desire to maintain independence, improve physical or mental health, or
maintain or improve cognition (Lehmann and Fingerhood 2018).
In the wake of the COVID-19 pandemic, concern has been increasingly expressed about the ill effects of social isolation, especially in
older adults. Clinicians should include family members and caregivers
to the extent that patients are willing to have them involved. Successful
treatment may also entail engaging and expanding patients’ social networks and referring to community-based services such as mutual-help
ps and faith-based communities (SAMHSA 2020).
grou
More treatment—of greater intensity or longer duration or both—
re
sults in better outcomes for older adults with SUDs (SAMHSA 2020).
Combinations of treatments tend to be more effective than individual
therapies alone (National Institute on Drug Abuse 2018). We believe
that primary care clinicians and psychiatrists should have the skills necessary to conduct brief interventions (including motivational interviewing), manage uncomplicated withdrawal syndromes, initiate
pharmacotherapy (specifically for alc
orders), treat comorbid psychiatric disorders, and refer to specialized
treatment pr
In this chapter, we cite general principles (Table 3–1) and summarize
inte
rventions (Table 3–2). For more details, we refer readers to Chapter
5 (“Alcohol Use and Use Disorder Among Older Adults”), Chapter 6
(“Tobacco Use Among Older Adults”), Chapter 7 (“Opioid Use and Use
Disorder Among Older Adults”), Chapter 8 (“Sedative, Hypnotic, and
Anxiolytic Use and Use Disorder Among Older Adults”), Chapter 9
(“Stimulant Use Disorder in Older Adults”), and Chapter 10 (“Cannabinoid Use and Use Disorder Among Older Adults”).
As the older adult population becomes increasingly diverse, it will
be criti
to race, ethnicity, sexual orientation, and gender identity, as discussed
in Chapter 11, “Cultural, Structural, and Ethical Considerations in the
Care of Older Adults With Substance Use Disorders.” Recognition of
role of trauma in the development of SUDs has also improved, and
the
we close this chapter with a discussion of trauma-informed care of
older adults with SUDs.
ograms if necessary.
cal for treatment to acknowledge and address disparities related
hat can complicate treatment, in-
ohol, tobacco, and opioid use dis-
58 Substance Use in Older Adults
Table 3–1. Principles of effective treatment of SUDs in older adults
1. Addiction is a complex but treatable disease that affects brain function and
behavior.
2. No single treatment is appropriate for everyone.
3. Treatment needs to be readily available. Primary care providers and psychiatrists should be able to provide basic treatment and refer to specialty care
as needed.
4. Effective treatment attends to multiple needs of the individual, not just alcohol or drug use.
5. Remaining in treatment for an adequate period of time (at least 3 months to
significantly reduce or stop alcohol or drug use) is critical.
6. Behavioral therapies (individual, family, group therapy) are the most commonly used forms of drug abuse treatment. Involvement of family may be
especi
7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.
8. An individual’s treatment and services plan must be assessed continually
and mod
9. Comorbid psychiatric and medical disorders must be addressed. Clinicians
should be especially mindful of alcohol or drugs that can contribute to
cognitive impairment and of cognitive impairment interfering with treatment.
10. Alcohol and drug use during treatment must be monitored continuously,
as lapses
Source. Adapted from National Institute on Drug Abuse 2018.
ally relevant in the care of older adults with SUDs.
ified as necessary to ensure that it meets their changing needs.
during treatment do occur.
BRIEF INTERVENTIONS
Older adults with at-risk alcohol or substance use may benefit from brief
interventions. These interventions may take place in primary care clinics,
behavioral health settings,
vices agencies. Typically, screening first takes place to identify those
with at-risk use or an SU
sional offers feedback to the person about their alcohol or substance
ves advice for making changes, and provides options for treat-
use, gi
ment. Lehmann and Fingerhood’s adaptation (2018) of the FRAMES
approach summarizes bri
vational interviewing (see Table 3–3). We discuss motivational interviewing in greater detail later in the “Psychosocial Interventions”
section.
pharmacies, or senior living or aging ser-
D. Then, a health care or social services profes-
ef interventions, using the principles of moti-
Table 3–2. Overview of interventions for substance use in older adults
Management of Substance Use Disorders in Late Life 59
Maintenance
Substance Intoxication Withdrawal
Alcohol Supportive care; address
CNS and respiratory
suppression, electrolyte
disturbances; may
require inpatient care
Tobacco — NRT NRT, varenicline, bupropion;
Opioids Naloxone; address
CNS and r
suppression; may
require inpatient care,
including intubation and
mechanical ventilation;
see Chapter 7 section
“Screening and
A
ssessment”
espiratory
Benzodiazepines on a
tapering schedule or based
on CIWA protocol; may
require inpatient care;
see Chapter 5 section
“Detoxification”
Buprenorphine, clonidine,
antidiarrh
medications, analgesics,
hypnotics; may require
inpatient care; see Chapter 7
section “Detoxification”
eal and antiemetic
pharmacotherapy
Naltrexone, acamprosate,
and disulfiram are FDA
approved; gabapentin
and topiramate could be
considered; see Chapter 5
section “Maintenance
Pharmacotherapy”
see Chapter 6 section
“Pharmacotherapy”
Buprenorphine, methadone,
naltrexone; see Chapter 7
section “Pharmacological
Inte
rventions”
Psychosocial
interventions
SBIRT, mutual-help
groups (e.g., Alcoholics
Anonymous), CBT,
MI/MET; see Chapter 5
section “Psychosocial
Interven
Tobacco quitlines, coping
skills training; see Chapter 6
section “Psychotherapeutic
and Psychosocial
Interventions”
MI/MET, CBT, contingency
management, mutua
groups (e.g., Narcotics
Anonymous); see Chapter 7
section “Psychotherapeutic
and Psychosocial
Interve
tions”
l-help
ntions”
Table 3–2. Overview of interventions for substance use in older adults (continued)
60 Substance Use in Older Adults
Substance Intoxication Withdrawal
Sedatives,
hypnotics,
anxiolytics
Address CNS and
respiratory suppression;
may require inpatient
care, including
intubation and
Benzodiazepine, with
eventual plan to taper off;
see Chapter 8 section
“Pharmacological
Interventions”
Maintenance
pharmacotherapy
Slowly taper off medication;
see Chapter 8 section
“Pharmacological
Interventions”
Psychosocial
interventions
MI/MET, CBT, CBT-I;
see Chapter 8 section
“Psychotherapeutic and
Psychosocial Interventions”
mechanical ventilation
Stimulants Supportive care; manage
agitation, psychosis,
cardiovascular effects,
hyperthermia; see
Chapter 9 sections
“Methamphetamine”
and “Cocaine”
Monitor for and address
suicidality
No FDA-approved
treatments, but a number
of agents are being studied;
see Chapter 9 section
“Pharmacological
Interventions for
Methamphetamine
Contingency management,
CBT, MI/MET, mutual-help
groups; see Chapter 9
section “Psychosocial
Interven
tions”
Use Disorder”
Cannabis Supportive care; manage
anxiety, agitation,
psychosis, hyperemesis
Note. For all substance use disorders, comorbid psychiatric issues, including risk of suicide, should be addressed.
CBT=cognitive-behavioral therapy; CBT-I=cognitive-behavioral therapy for insomnia; CIWA=Clinical Institute Withdrawal Assessment for Alcohol;
CNS= central nervous system; MI/MET=motivational interviewing or motivational enhancement therapy; NRT=nicotine replacement therapy;
SBIRT=screening, brief intervention, and referral to treatment.
Psychoeducation, coping
skills training; see Chapter
10 section “Management”
No FDA-approved
treatments; see Chapter 10
section “Management”
CBT, MI/MET, contingency
management; see Chapter
10 section “Management”
Management of Substance Use Disorders in Late Life 61
Table 3–3. FRAMES model of motivational interviewing in older adults
with SUDs
Feedback is provided from screening assessments*
Responsibility for change comes from the patient
Advice for making a change comes from the clinician
Menu of options is given to the patient
Empathy characterizes the clinician’s approach
Self-efficacy will enable the patient to pursue ongoing follow-up
*See Chapter 2 for detailed discussion of screening assessments.
Source. Lehmann and Fingerhood 2018.
One of the first clinical trials of a brief intervention in older adults
with excessive alcohol use involved physicians, over the course of two
10- to 15-minute visits a month apart, giving patients feedback on their
health behaviors, education about adverse effects of alcohol use, and a
“drinking agreement in the form of a prescription” and “drinking diary
cards” (Fleming et al. 1999). Older adults randomly assigned to the intervention drank less alcohol and had fewer episodes of binge drinking
than those in
the control group.
Since roughly 2000, the U.S. Substance Abuse and Mental Health
Services Ad
ministration (SAMHSA) has promoted SBIRT (Schonfeld et
al. 2015). SBIRT focuses on getting patients into treatment early through
universal screening for alcohol or substance misuse, offering a brief outpatient intervention, and referring patients to SUD or mental health
rams (SAMHSA 2020). SBIRT may take place in primary care set-
prog
tings, emergency departments, and aging services agencies. A modification called SBI focuses on just the screening and brief intervention
steps, which can be implemented in a variety of organizations that
serve older adults.
The Brief Intervention and Treatment of Elders (BRITE) project is
the largest implementation of SBIRT in older adults, with 85,000 people
screened (Schonfeld et al. 2015). Health educators in 18 Florida counties
approached older adults in a variety of settings (e.g., senior housing, aging services) and screened them for the use of alcohol, tobacco, and
other drugs;
excessive use of prescription medications; and depression.
Based on screening results, older adults were provided a brief intervention over one to five sessions, brief treatment (16 sessions of cognitivebehavioral and self-management methods), or referral to an SUD treatment program (Schonfeld et al. 2010). At the 6-month follow-up of those
62 Substance Use in Older Adults
who received services, drinking decreased from 46.7% to 23.3%, and the
use of illegal drugs decreased from 36.2% to 11.8% (Schonfeld et al.
2015). SBIRT thus is a low-cost, effective strategy for addressing risky
alcohol and substance use in older adults.
A detailed guide for implementing SBI/SBIRT in older adults at a
systems level is listed in the Resources section at the end of this chapter.
MANAGING INTOXICATION AND
WITHDRAWAL
Intoxication
Older adults may be more prone than younger people to the effects of
alcohol and substance use, and thus may have more medical or psychiatric symptoms when intoxicated. Any change in mental status in older
adults should rais
cause or may be contributing. Clinicians should have a low threshold
for hospitalizing older adults who are intoxicated, especially if they
have medical comorbidities, since they will be at higher risk of central
nervous system and respiratory suppression, as well as renal, hepatic,
and metabolic complications. Of particular concern is intoxication with
alcohol, opioids (which may require repeated reversal with naloxone),
sedatives, hypnotics, anxiolytics, and stimulants (which may result in
agitation, psychosis, hyperthermia, or cardiovascular effects). Critical
care, including intubation and mechanical ventilation, may be necessary in severe intoxication.
Cannabis intoxication is generally not life-threatening in older
adults but may result in anxiety, agitation, psychosis, hypotension, or
hypertension (Schmid et al. 2022). Older adults may be more susceptible to the intoxicating effects of cannabis than when they were younger,
both because they have more medical comorbidities and because modern cannabis is generally more potent. Hyperemesis may be of particular concern and might be difficult to identify as due to cannabis
intoxication because of medical comorbidities (Senderovich et al. 2022).
Hallucinogen intoxication, especially in unprepared individuals,
esult in high levels of distress and even agitation, aggression, or
may r
suicidality. Patients should be given emotional support; if that is ineffective, a low dose of a benzodiazepine such as lorazepam could be
considered (Dakwar 2021). With the increased experimental use of psychedelics for the treatment of psychiatric disorders, we should expect to
e the concern that alcohol or substance use may be the
Management of Substance Use Disorders in Late Life 63
see more older adults experiencing adverse effects. Given the extremely
limited literature on hallucinogens in older adults, we do not otherwise
cover hallucinogen use in this book.
Withdrawal
Withdrawal syndromes may present with confusion or other nonspecific symptoms in older adults and so may be more difficult to detect
(Lehmann an
possibility of withdrawal from alcohol or another substance in any
older adult with new-onset confusion.
The course of withdrawal may also be different in older adults. For
ple, alcohol withdrawal syndrome (AWS) may not start until sev-
exam
eral days after stopping drinking; confusion may be more prominent
than tachycar
longer duration (Lehmann and Fingerhood 2018) compared with
younger people. Supplementation with thiamine to prevent WernickeKorsakoff encephalopathy, while important at all ages, is especially critical in older adults, given their higher risk of neurocognitive disorders
(Thomson et al. 2012). As in younger adults, benzodiazepines are used
to address withdrawal and prevent seizures; supervised detoxification
may need to take place in an inpatient setting, especially when older
adults are frail or have medical comorbidities. Please see Chapter 5 section “Detoxif
managing AWS.
Older adults who are prescribed long-term benzodiazepines are at
risk of withdrawal, abrupt or too-rapid discontinuation, the development of tolerance, or loss of effect over the course of the day with
shorterresulting in seizures. Withdrawal should be considered in any older
adult taking a benzodiazepine who has a sudden change in physical or
mental status or who has unexplained medical symptoms. The mainstay of treatment is a gradual taper off of benzodiazepines. We discuss
the identification an
withdrawal in Chapter 8 section “Pharmacological Interventions” and
illust
rate it in Case Example 8–1.
Opioid withdrawal in younger adults is usually not life-threatening,
but old
more susceptible to the negative effects of autonomic instability and dehydration. Older adults may have difficulty tolerating the combination
of medications (for example,
ondansetron, acetaminophen, nonsteroidal anti-inflammatory drugs)
d Fingerhood 2018). In fact, clinicians should consider the
dia or tremor; and withdrawal may be more severe and of
ication” for a more detailed discussion of assessing and
acting agents. Abrupt cessation can be particularly dangerous,
d management of sedative, hypnotic, or anxiolytic
er adults, especially those with medical comorbidities, may be
buprenorphine, clonidine, loperamide,
64 Substance Use in Older Adults
used to manage opioid withdrawal. Thus, older adults with opioid use
disorders are more likely to require inpatient care. See Chapter 7 section
“Detoxifica
tion” for a discussion of managing opioid withdrawal.
TREATING SUBSTANCE USE DISORDERS
IN OLDER ADULTS
SUDs can be effectively treated in older adults. The relevant literature
is sparse, but in general interventions are as effective in older adults as
in younger adults (Barrick and Connors 2002; Doolan and Froelicher
2008; Lemke and Moos 2003). Some evidence suggests that older adults
might even have better outcomes than younger adults (Weiss and Petry
2013).
Older adults can receive care for SUDs in a variety of settings. The
erican Society of Addiction Medicine (ASAM) defines four levels of
Am
specialty care for those with SUDs: outpatient, intensive outpatient, or
partial hospitalization; residential or medically monitored inpatient
care; and medically managed inpatient care (e.g., for severe or unstable
withdrawal) (Gastfriend and Mee-Lee 2022). Older adults also have
good outcomes when treated in integrated primary care/mental health
programs, with some evidence of greater engagement in such programs
than in specialty care (Bartels et al. 2004; Oslin et al. 2006). Group therapy and family therapy may be especially helpful for older adults,
given the emphasis on increasing social support (Sullivan 2021).
SAMHSA recommends that treatment should be matched to older
adults’ needs and functioning. For example, one
program specific to older adults resulted in marked reduction in alcohol
use (Blow et al. 2000). Unfortunately, as noted earlier in “Overview of
Management,” only about a quarter of treatment centers offer programs
or groups specifically for older adults (SAMHSA 2020). Clinicians may
also need to challenge their own ageist assumptions that older adults
may not be good candidates for SUD treatment. See Table 3–4 for modi-
ions that SUD treatment programs should make to ensure effective
ficat
care of older adults.
Clinicians in the United States should be aware of 42 CFR Part 2, the
federal regulation enacted in 1975 to protect the confidentiality of people receiving SUD treatment (Karway et al. 2022). Subsequent revisions
in 2017
into general medical practice and to better align 42 CFR Part 2 with
Health Insurance Portability and Accountability Act (HIPAA) privacy
, 2018, and 2020 recognized the need to integrate SUD treatment
inpatient treatment
Management of Substance Use Disorders in Late Life 65
Table 3–4. How SUD treatment programs can effectively care for older
adults
Clinicians and staff should use a slow pace, repeat information, and allow
enough time for patients to ask questions and integrate new information.
The treatment setting must be able to accommodate older adults who have vi-
sion or hearing impairment, problems with mobility, and mild cognitive impairment.
To promote access to services, especially for homebound older adults, pro-
grams should assist with transportation and offer telehealth services.
Older adults may be more private and less willing to share personal informa-
tion in group settings. Clinicians and staff should emphasize privacy and
confidentiality, especially when groups include both younger and older
adults.
Match older adults to treatments based on their preferences, needs, and goals.
For exam
and loss, loneliness, social isolation, social or familial pressures to drink, role
transitions, and trauma.
Source. SAMHSA 2020.
ple, groups specifically for older adults may need to focus on grief
protections. Still, SUD treatment records often remain separate from the
rest of the electronic medical record, raising concerns about safely and
effectively coordinating the care of older adults with SUDs and comorbid medical and psychiatric conditions. Clinicians can advocate for
their patients by ensuring that their organizations have updated procedures in accordance with the latest revisions to 42 CFR Part 2.
Psychosocial Interventions
At the heart of assessing and addressing substance use is motiva-
tional interviewing, a “respectful counseling style that focuses on helping
s resolve ambivalence about and enhance motivation to change
client
health-risk behaviors, including substance misuse” (SAMHSA 2019, p.
1). One can think of motivation as the combination of the ability to make
a change, the willingness or desire to make a change, and the readiness
to change (SAMHSA 2019). The role of the clinician caring for a person
with at-risk substance use or an SUD is to elicit and enhance motivation
to move through the stages of change: precontemplation, contemplation, preparation, action, and maintenance (see Table 3–5) (SAMHSA
2019).
With motivational interviewing, a clinician uses the core skills of
asking open-ended ques
tions, affirming, reflectively listening, and
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