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Author Topic: Old Farts2: Substance Abuse Among Older Adults  (Read 4007 times)

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Old Farts2: Substance Abuse Among Older Adults
« on: October 23, 2019, 11:51:36 AM »

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Some excerpts:

Substance Abuse Among Older Adults

2014 Jun 12

The initial wave of the baby boom generation turned 65 years old in 2011, a generation that comprises 30% of the total US population.1 The size of this generation and their longer life expectancies2 led the US Census Bureau to project that the number of older adults will increase from 40.3 million to 72.1 million between 2010 and 2030.3 Historically, older adults have not demonstrated high rates of alcohol or other drug use compared with younger adults4,5 or presented in large numbers to substance abuse treatment programs.6 These facts have helped to perpetuate a misconception that older adults do not use or abuse mood-altering substances. Indeed, substantial evidence suggests that substance use among older adults has been underidentified7,8 for decades. The aging of the baby boom generation creates a new urgency to effectively identify and treat substance use among older adults.

Baby boomers are distinct compared with past generations as they came of age during the 1960s and 1970s, a period of changing attitudes toward and rates of drug and alcohol use.9,10 The prevalence rates of substance use disorder (SUD) have remained high among this group as they age,5 and both the proportions and actual numbers of older adults needing treatment of SUD are expected to grow substantially. SUD rates among people older than 50 years are projected to increase from about 2.8 million in 2006 to 5.7 million in 2020.11 There is, therefore, widespread recognition among both generalists and specialists in gerontology and psychiatry,3,12,13 and health care overall, of the need for more information about assessment and interventions related to problematic substance use among older adults.


Alcohol Use

Despite increasing rates of illicit and prescription drug misuse among adults older than 65 years,5,6,10 alcohol remains the most commonly used substance among older adults.6,10 Therefore, most of the research on substance use among and treatment of older adults has centered on alcohol use disorders (AUD). Among the population at large, older adults reduce their alcohol use as they age.14–17 As of 2002, among individuals aged 65 years and older in the general population, the estimated prevalence is 1.2% for the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) alcohol abuse and 0.24% for DSM-IV alcohol dependence.18 Prevalence estimates inclusive of those older than 50 years are higher (2.98% for all AUD). Within heath care settings, the rates of AUD among older adults ranges up to a proportion of 22%.19–21 Although these rates are lower than for younger adults, they are likely impacted by the underreporting of heavy drinking,7 difficulties with differential diagnoses of AUDs in older adults, and unidentified comorbidities.22

At-risk drinking is more prevalent among older adults than AUD and is likely responsible for a larger share of the harm to the health and well-being of older adults. Guidelines provided by the American Geriatrics Society and the National Institute for Alcohol Abuse and Alcoholism recommend that older adults drink no more than 7 standard drinks (12-oz beer, 4- to 5-oz glass of wine, 1.5 oz of 80-proof liquor) per week.10,16 Prevalence rates for older-adult at-risk drinking (defined as more than 3 drinks on one occasion or more than 7 drinks per week) are estimated to be 16.0% for men23,24 and 10.9% for women.20,21 There is also a substantial proportion of the older-adult population who are binge drinkers (generally defined as 5 or more standard drinks in one drinking episode, though definitions vary for older adults).25 Rates of older-adult binge drinking are 19.6% for men and 6.3% for women using data from the 2005–2006 National Survey on Drug Use and Health.20,26 In a study of community-based older adults who reported drinking one or more drinks in the previous 3 months, 67% reported binge drinking in the last year.25

Tobacco Use

Tobacco use is quite prevalent among older adults, with about 14% of those aged 65 years and older reporting tobacco use in the last 12 months,10 and just more than 6% used tobacco and alcohol together in the last 12 months. Clinical trials examining smoking cessation interventions demonstrate that older-adult smokers tend to be long-term, heavy smokers who are also physiologically dependent on nicotine.27–29

Illicit Substance Use

Illicit drug use is more prevalent among American older adults than among older adults in almost any other country in the world.30 Results from the 2012 National Survey on Drug Use and Health revealed that rates of past month use of illicit substances doubled on average (from 1.9%–3.4% to 3.6%–7.2%) among 50 to 65 year olds between 2002 and 20125—a statistically significant increase driven by the baby boom generation.5,11 Generally, individuals aged 50 to 64 years report more psychoactive drug use than older groups.24,31,32 For example, in 2012, 19.3% of adults aged 65 years and older reported having ever used illicit drugs in their lifetime, whereas 47.6% of adults between 60 and 64 years of age reported lifetime drug use. Among those that do use illicit substances, 11.7% meet the criteria for past-year SUD.31 There are no recommendations for safe levels of illicit drug use among older adults.33

Cannabis use by older adults is considerably more prevalent than other drugs. Among adults aged 50 years and older in 2012, 4.6 million reported past-year marijuana use, and less than one million reported cocaine, inhalants, hallucinogens, methamphetamine, and/or heroin use in the past year. These rates are consistent with those reported by other studies.24,31 With the passage of medical marijuana legislation and relaxed enforcement of drug possession related to marijuana, the prevalence rate of use among older adults may increase as they use it to cope with illness-related side effects,20 potentially facilitating an increase in recreational use.

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

Older adults take more prescribed and over-the-counter medications than younger adults,22,34 increasing the risk for harmful drug interactions, misuse, and abuse. A cross-sectional community-based study of 3005 individuals aged 57 to 85 years found that 37.1% of men and 36.0% of women used at least 5 prescription medications concurrently.35 The study also found that about 1 in 25 of the participants were at risk for a major drug interaction, and half of these situations involved nonprescription medications. In 2012, 2.9 million adults aged 50 years and older reported nonmedical use of psychotherapeutic medications in the past year.5 Estimates of prescription medication misuse among older women are 11%.36 Blazer and Wu32 reported that 1.4% of adults aged 50 years and older used prescription opioids nonmedically in the last year, which was higher than sedatives, tranquilizers, and stimulants (all <1%). Actual prescription opioid use disorder among this same group was 0.13%, yet dependence was more common than abuse.31 Benzodiazepines are the most commonly prescribed psychiatric medication among all adults. Despite contraindications for use with older adults, they are widely prescribed37 and are disproportionately prescribed to older adults.38 Rates of benzodiazepine use among older adults have ranged from 15.2% to 32.0%.39 It is important to note that the rates of benzodiazepine use may be impacted by overprescription, misdiagnosis, or polypharmacy rather than intentional misuse or abuse.


Although the rates of SUD and use of drugs and alcohol are generally lower among older adults than the general population, aging itself presents specific risks for harm when considering even minimal amounts of substance use among older adults. Risk factors may vary considerably by substance and the specific clinical presentation of a patient (eg, age, medical comorbidities, current medications, and health history). Understanding substance-specific risks can help practitioners to recognize and respond to unhealthy use that does not meet the narrow definition of problem use.


Alcohol has a unique physical impact on the body in late life as compared with adults in young to middle age.40 As one ages, the percentages of lean body mass and total body water decrease, and the ability of the liver to process alcohol is also diminished; blood-brain barrier permeability and neuronal receptor sensitivity to alcohol in the brain increase.22 Because of these changes, older adults experience higher blood alcohol concentrations and increased impairment compared with younger adults40 at equivalent consumption levels and with less awareness of their impairment,41–43 thus, rendering them more vulnerable to the ill effects of alcohol even in moderate amounts. Compared with moderate drinkers, older-adult at-risk drinkers are more likely to experience alcohol-related problems14,25 and basic functional impairment, such as impaired instrumental activities of daily living (eg, shopping, cooking, responsibility for medication).25 The increased rate of comorbid medical and psychiatric conditions and the medications used to treat them create a complicated picture of risk and unique vulnerabilities for older adults.10 Even healthy drinking levels established in young to middle age and then sustained through older age may be a risk factor for health problems among older adults.44

Despite the older person’s increased vulnerability to alcohol, moderate alcohol consumption is associated with decreased morbidity and mortality among older adults.45,46 A large body of research suggests that those older adults who are moderate drinkers (no more than one standard drink per day) experience better health than their heavier drinking and abstinent peers.47–49 For example, moderate-drinking older adults have been discovered to have fewer falls, greater mobility, and improved physical functioning when compared with nondrinkers.40

It is important to note that many of the health benefits of moderate alcohol use for older adults may come with negative trade-offs. For example, moderate drinking may decrease the risk of ischemic stroke but increase the risk of hemorrhagic stroke50 and have many potential interactions with medications.51 As with other age groups, it would seem that the benefits of alcohol for older adults varies across individuals and depends on each person’s unique biopsychosocial context, including age, comorbid illnesses, sex, and genetics.

Medications and Illicit Drugs

The same biologic changes that increase the effect of alcohol among older adults also increase the effect of medications and illicit drugs, causing an increased vulnerability to drug effects and drug interactions.22 For example, older adults process benzodiazepines and opiates differently than younger adults; these medications should be prescribed with caution. Benzodiazepines with long half-lives are contraindicated for older adults as they can cause excessive sedation.36 Benzodiazepines are fatsoluble drugs; as adults have less lean muscle mass and more body fat as they age, these drugs have a longer duration of action. Other risks associated with medication use in older adults occur because they may see multiple doctors, each of who may prescribe them medications that may interact with each other and/or with alcohol or other substances. Alcohol and marijuana increase the sedative effects of drugs such as barbiturates, benzodiazepines, and opiates.52 Older adults may also unintentionally misuse a medication by borrowing a prescribed medication from another person (eg, taking a dose of another person’s lorazepam or zolpidem for sleep), taking more than intended, or confusing pills.

The increasing acceptance of marijuana use, both medicinally and recreationally, may also pose unique risks in an aging population. Marijuana is known to cause impairment of short-term memory; increased heart rate, respiratory rate, elevated blood pressure; and a 4-time increase in the risk for heart attack after the first hour of smoking marijuana.53 These risks may be pronounced in older adults whose cognitive or cardiovascular systems may already be compromised. Additionally, tobacco use among older adults is associated with greater mortality, risks of coronary events and cardiac deaths, smoking-related cancers, chronic obstructive pulmonary disease, decline in pulmonary function, development of osteoporosis, risk of hip fractures, loss of mobility, and poorer physical functioning.54,55 Incidentally, smoking also impairs or inhibits effective treatments for these conditions.56 It is unclear which of these correlates to smoking tobacco also appear for marijuana.53


Most research on the correlates and predictors of substance use in late life has been conducted on alcohol use. Individual, social, and familial factors that contribute to or are associated with late-life unhealthy drinking may also apply to other substances. Box 1 lists some of the potential risk factors for older adults associated with use of alcohol and, where known, other substances.

Box 1 Risk factors related to substance use in late life:

Physical risk factors

  • Male sex (for alcohol), female sex (for prescription drug)
  • Caucasian ethnicity
  • Chronic pain
  • Physical disabilities or reduced mobility
  • Transitions in care/living situations
  • Poor health status
  • Chronic physical illness/polymorbidity
  • Significant drug burden/polypharmacy

Psychiatric risk factors

  • Avoidance coping style
  • History of alcohol problems
  • Previous and/or concurrent SUD
  • Previous and/or concurrent psychiatric illness

Social risk factors

  • Affluence
  • Bereavement
  • Unexpected or forced retirement
  • Social isolation (living alone or with nonspousal others)

This continues at the source link (too long) to edit for me


The myth that older adults do not use substances and/or do not use substances problematically has been dispelled. Older-adult substance users may not present with the same symptoms as their younger counterparts and, therefore, may be more difficult to identify. Treatment options remain generally limited, as few programs or health care settings offer tailored interventions for older adults. Health care professionals need to continue to do as thorough of assessments as possible and enlist the help of formal measures, Web-based assessment, and build in the questions outlined earlier as routine. As the baby boom generation ages, the health care system will be challenged to provide culturally competent services to this group, as they are a unique generation of older adults. Knowledge about older-adult substance use and the issues that contribute to late onset or maintained addiction in late life will need to be continually updated as we learn how and why this generation of adults uses substances. Furthermore, the advancement and development of interventions that may be more useful for, effective for, and desired by this incoming generation of older adults than previous generation, such as mobile interventions, will be crucial to alleviating the projected pressures on the health care system.


  • Although the current proportions of older adults with substance use disorders remain low compared with the general population, a growing proportion and number of older adults are at risk for hazardous drinking, prescription drug misuse, and illicit substance use and abuse.
  • The identification of problematic substance use with older adults can be difficult because of overlapping symptoms with medical disorders that are common in older age.
  • The assessment should include a respectful and nonstigmatizing approach along with direct questions about drinking, prescription medication, and illicit drug use.
  • Several brief interventions centered on education about the harms of substance use have been shown to be effective with older adults.
  • For older adults with more severe substance use problems, more intensive treatments geared toward a general population have been shown to be effective for older adults; however, treatments tailored for older adults have shown particular promise.

see the source link for References

« Last Edit: October 23, 2019, 12:03:04 PM by Chip »
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