Recognizing Substance Abuse and Addiction in Older Adults—And How to Help
When people think about substance abuse and addiction, they often imagine young adults living with this. While it’s true teenagers are at a higher risk for substance abuse as a group, research done on the elderly population is, to say the least, lacking.
Despite the low amount of research, it’s widely believed that substance abuse and addiction in the elderly is a hidden epidemic in the U.S. and worldwide.
While no one wants to imagine their parents or grandparents may have problems with substance abuse or addiction—especially if they have no history—it’s essential to keep an eye out for these challenges. This guide will explain the importance of the issue, how to recognize the signs of use and abuse of different substances, and how to help.
Important Definitions Regarding Substance Abuse, Addiction, and the Elderly
Who Are Considered “Elderly?”
One of the challenges when discussing substance abuse and addiction within the elderly community is the changing definition of the word “elderly.” While most sources say this group is age 65+, some go as young as 55, while others focus on 70 or 75 and older. In general, though, it’s best to assume experts are talking about 65+ unless otherwise specified.
“Elderly” is often used interchangeably with “seniors,” senior citizens,” and “older adults.” You’ll see all of these used in this piece.
Defining Substance Abuse and Addiction
There are many terms used to describe the use of drugs or alcohol. While substance abuse and addiction are grouped into one diagnosis—substance use disorder (SUD)—by the DSM-V, different organizations and professionals still separate them into categories.
The shortest description is: Substance abuse is a coping mechanism developed in response to triggers, while addiction is a disease involving chemical dependency.
Those living with substance abuse generally have more control over the situation, often drinking or using drugs to deal with stress. They sometimes experience minimal disruption to their lives, but this should still be taken seriously because substance use or abuse of any level—especially for the elderly—can exacerbate health problems.
Those who are addicted to substances tend to have their lives overtaken by their conditions. They usually have a chemical need for alcohol or drugs and very little ability to stop themselves from partaking. It affects their daily lives, and relationships are often damaged.
There’s a common misconception that older adults don’t experience substance use disorder. However, as the National Institute on Drug Abuse (NIDA) found in 2014, nearly one million older adults over age 65 were living with such a disorder.
Unfortunately, there aren’t many more recent studies investigating substance abuse among older adults. We’ll discuss possible reasons why in the next section.
According to the 2015-2016 Medical Expenditure Panel Survey, 9.8 million elderly adults (65+) in the U.S.—19.3% of older adults in the country—filled at least one opioid prescription, and 3.6 million (7.1%) had four or more opioid prescriptions that year. The survey also found that as the patient’s health condition declined, opioid use increased to 39.4% for patients in poor health compared to 8.8% for those in excellent health.
As people age, their need for pain relief is likely to increase. But because opioids are highly addictive, those taking it at any age run the risk of abuse of, or addiction to, these drugs.
Researchers from the Johns Hopkins School of Medicine found that first-time opioid treatment admissions of adults aged 55 and older grew by 25%each year between 2013 and 2015. Perhaps the most alarming of the findings was the increase in heroin addiction in this age group, which doubled between 2012 and 2015.
Similarly, Healthcare Cost and Utilization Project (H-CUP) discovered between 2010 and 2015, opioid-related treatment increased most substantially in older adults aged 65-74, inpatient hospital stays increased by 71.9%, and opioid-related emergency department visits increased by 131.7%.
For alcohol use and abuse, the Substance Abuse and Mental Health Services Administration (SAMHSA) collects data to illuminate the crisis. Their 2018 National Survey on Drug Use and Health found 10.7% of seniors (60+) reported binge drinking in the past month, 2.5% reported heavy drinking, and 1.6% were diagnosed with alcohol abuse disorder. But, as the American Addiction Centers reminds us, alcohol abuse among older adults is often neither recognized nor reported.
There’s likely a lot more below the surface, between lack of reporting and recent research on substance use disorder in older adults, than these statistics show us.
Despite the statistics cited above, there is simply very little research on seniors and substance abuse compared to the number of studies using younger subjects.
American Addiction Centers boils the possible cause of the lack of data down to this: if someone doesn’t seek out or receive appropriate treatment, they don’t get a diagnosis. If they don’t get a diagnosis, they can’t become part of the data. They further explain why they believe treatment isn’t sought by older adults:
First, American Addiction Centers posits social isolation as a cause for under-recognition and underreporting of substance abuse in elderly Americans. When people are no longer working, they don’t necessarily see others every day. This is especially true for those who live alone, far away from family, and whose friends pass away as they age. If no one sees substance issues growing, no one can attempt to intervene.
Ageism In the Medical Field
Second, they suggest healthcare practitioners may be under-diagnosing the issue due to unconscious ageism. While “ageism” is often thought of as negative beliefs or actions—e.g., older adults being fired due to age—it includes anything involving treating an older person differently than a younger one.
Many actions taken based on age can be harmful, even if well-intentioned—like not bringing up substance abuse because of a belief that older adults have earned certain indulgences. No one, not even a medical professional, is immune to unconscious biases.
Concerns About Quality of Life
Third, loved ones and caregivers may worry about taking substances away from seniors. This could be because they want to avoid negative interactions or be afraid that taking away their substance may lower their quality of life. These fears often mean getting help won’t be encouraged.
Years of Misinformation
And of course, years of misinformation have led to misunderstanding and, consequently, possibly lack of treatment.
Many substance abuse issues begin with casual use and normal prescription schedules. Both senior citizens and their caregivers may not realize there’s an issue because no one told them what to look for—or they don’t see the problems even if they were told.
Additionally, many older adults grew up watching anti-drug propaganda films and being taught misinformation about addiction. These films and lessons emphasized that morality and substance use are connected, possibly making older adults believe having substance abuse problems makes them bad people. They also usually showed over-the-top, panic-inducing portrayals of people with addictions—typical addiction behaviors often weren’t portrayed.
How Substance Abuse Affects Older Adults
Because of the natural physical and mental health challenges that come with aging, substance abuse can disproportionately negatively affect older adults.
The National Institute on Drug Abuse notes that we metabolize things we ingest, such as medications or alcohol, more slowly as we age. This means older adults can be more sensitive to such substances.
Mental health illnesses or challenges also often become bigger issues as we age, which could be exacerbated by inappropriate drug use. For example, the accidental misuse of prescription drugs could worsen mental health issues. A 2019 study showed 25% of patients over 50 who misuse prescription opioids or benzodiazepines (benzos) experience suicidal ideation, compared to 2% who don’t use them.
For alcohol addiction, slower metabolization of alcohol in older adults can lead to higher blood alcohol concentration (BAC), making them impaired more quickly than younger adults. Studies have shown heavy alcohol use (three or more drinks per day), especially among older adults, can lead to faster cognitive decline and a higher risk of dementia. Older adults can be at even greater risk if they’re on medications that interact poorly with alcohol.
Substance use disorder could also increase the risk of heart and lung issues, mood disorders, memory issues, or stroke. Alcohol abuse is linked to cancer, liver damage, compromised immune systems, osteoporosis, diabetes, high blood pressure, ulcers, and stroke. Additionally, studies have linked the treatment of insomnia with benzos to Alzheimer’s disease.
Finally, any impairments caused by substance use increase the risk of injury or accidents, to greater detriment to the average older individual. For example, a fall is more likely to result in a hip fracture or other serious injury in the elderly.
Causes of Substance Abuse and Addiction in Seniors
The following are causes of substance use disorder in older individuals:
Chronic pain or illness
Chronic illnesses or pain are often treated with potentially addictive medications.
Abuse and neglect
Elder abuse takes many forms, including physical abuse, sexual abuse, financial exploitation, or neglect by a designated caregiver. Living in abusive situations could cause people to turn to substances to cope, and neglect could result in medication misuse and eventual dependency.
Retirement, bereavement, loss of mobility, increased isolation and feelings of loneliness, or the requirement for long-term care can all lead to the desire to seek out coping mechanisms such as alcohol use. Additionally, the changes could lead to mental health challenges that lead to substance use disorder.
Mental health challenges
Stressors and conditions linked to aging can also be linked to substance abuse. As noted above, the rapid rate of life changes can often lead to depression and anxiety, and those living with these or other mental health challenges are more prone to developing substance use disorders. However, nearly any mental or cognitive health challenge can be comorbid with or lead to substance abuse.
Substances Commonly Abused by the Elderly
It’s important to understand the different substances that could take hold of our loved ones. Below is a list of the most common substances abused by older adults, including the potential risks of abuse, signs of abuse or addiction, and how they might access the substances.
Among older adults, alcohol is the most commonly abused substance. The legal accessibility of alcohol could be a big factor, as it’s available in grocery and liquor stores. Additionally, alcohol abuse can be hard to recognize, leading many to call it a “hidden epidemic.” Part of the challenge is that signs of alcohol abuse are very similar to signs of aging, making it particularly difficult to identify the issue. Nonetheless, here are some signs an older adult you know might have an alcohol abuse disorder, according to SAMHSA and Rehab Spot:
- Frequent injuries
- Increased tolerance for other medications
- An overabundance of empty beer, wine, or liquor bottles
- Displaying signs of cognitive impairment (e.g., forgetfulness, unsteadiness, confusion, memory loss, etc.)
- Slurred speech
- Symptoms of depression or anxiety
- Unpredictable mood swings
Synthetic opioids—such as oxycodone (Percocet and OxyContin), hydrocodone (Vicodin), codeine, morphine, and fentanyl—are commonly prescribed for severe or chronic pain. With an estimated 65% of older adults suffering from pain and 30% reporting chronic pain, many could be prescribed opioids—which are highly addictive. While most opioid abusers receive prescriptions from their physicians, frequent requests may cause their doctors to decrease dosages or find non-opioid pain management options. This has led to opioid diversion—more commonly known as “dealing”—by people who have access to prescriptions becoming more common. Some signs of opioid addiction include:
- Hiding prescriptions
- Running out of opioid medications quickly
- Showing withdrawal symptoms (e.g., nausea, vomiting)
- Signs of cognitive impairment
- Using multiple pharmacies to fill prescriptions
Benzodiazepines—such as diazepam (Valium), lorazepam (Ativan), alprazolam (Xanax), midazolam (Versed)—are psychoactive drugs that function as relaxers. They’re commonly prescribed for people experiencing depression, anxiety, insomnia, muscle spasms, or seizures. However, it should be noted benzos are no longer recommended for treating insomnia in older adults because of the risk of Alzheimer’s disease. The Mayo Clinic and Addiction Center explain some signs of potential abuse, including the following:
- Decreased attention span
- Memory loss
- Profuse sweating
- Running into objects or walls frequently (difficulty with spatial reasoning)
- Slurred speech
Cocaine is often considered a “party drug,” so it may seem odd that it’s on a list of substances commonly abused by seniors. For some, it could be due to a history of use—one study hypothesized that Baby Boomers “…having lived through the cultural changes associated with the 1960s onward… they are bringing new views, acceptance, and, at times, habits of drug use with them.” They further explain that this group aging into the senior citizen category is changing the landscape of drug use—cocaine wasn’t a widely used one in previous generations when they hit this age range.
Cocaine is popular because it makes many people feel great—for a little while. They may have increased self-confidence, euphoria, and desire to be social, all things older adults may miss from their youth. But, the crash is hard, and the long-term effects are simply not worth the short-term feelings.
People either snort the powder form of cocaine or smoke the “freebase” version, termed “crack.” Because it’s illegal for non-doctors to get—and even doctors can only use it in very specific situations, with no prescriptions allowed—the only way users can get cocaine is through dealers. Some signs your loved one could be addicted to cocaine include:
- Dilated pupils
- Excess energy and over-excitement
- Experiencing paranoia
- Little appetite
- Not sleeping
- Runny or red nose and sniffling often
Marijuana is from the dried flower of a Cannabis sativa plant that can be either smoked or ingested by being mixed with foods (edibles). The legal availability of cannabis varies by state, from fully legal to legal for medical purposes to completely illegal. Medical marijuana is commonly prescribed to older adults because it’s believed to help treat Alzheimer’s, cancer, glaucoma, and pain, among other things that frequently affect this population.
For states where it’s legal to sell and purchase, you can walk into a cannabis shop or dispensary. For states where the drug is illegal, regular users would likely purchase from a dealer.
You’ll often hear “marijuana isn’t addictive.” However, there’s a relatively new diagnosis known as “marijuana use disorder.” This new term may have become necessary because marijuana has more THC than it used to, meaning users’ brains get higher doses than ever before, so dependency is more likely. Whether or not this dependency can lead to addiction remains controversial, but there are cases where this dependency mimics addiction because it interferes with everyday life.
Some signs your loved one might have a marijuana dependency include:
- Consistent bloodshot eyes
- Decrease in coordination
- Lethargy and lack of motivation
- Loss of memory
- Using it every day or multiple times a day, especially if their doctors have recommended a lower frequency
Heroin is a natural opioid made from the opium poppy plant that is turned into a fine powder or black sticky substance. People addicted to prescription opioids are often at risk of turning to heroin, especially if it gets too difficult to procure prescriptions. This drug can ease their pain the way the opioids did.
Heroin users can take the drug through injection, sniffing, snorting, or smoking. It’s often used in combination with other drugs, making it particularly dangerous. Heroin is usually acquired through a dealer.
Signs of heroin use include:
- Constricted pupils
- Sleepiness while on it; inability to sleep when it wears off
- Slowed thoughts or movements
- Visible injection marks on their skin, often called “track marks”
- Pain, chills, vomiting, itchiness, and nervousness when the heroin wears off
Other Abused Substances
About 85% of people in the U.S. consume at least one caffeinated drink per day, mostly coffee. Effects include jitteriness, insomnia, and a quick heartbeat. It can exacerbate heart problems, raise blood pressure, and increase the risk of osteoporosis.
Nicotine is the addictive chemical in tobacco products like cigarettes. The U.S. Centers for Disease Control (CDC) estimates 34.2 million U.S. adults smoke cigarettes, 8.4% of whom are 65+. Smoking causes health problems like lung cancer, COPD, heart disease, and stroke, often leading to death
75% of Americans consume too much sugar. While the recommended daily amounts of sugar are 6 tsp for women and 9 tsp for men, many processed foods contain far more sugar. Excess sugar can cause weight gain and increase the risk of heart disease, diabetes, depression, cellular aging, and cancer.
How to Help Seniors With Substance Abuse or Addiction Problems
Knowing your loved one might be suffering from addiction can be painful. But acknowledging there is a problem can be the first step to helping them overcome it. Both caregivers and medical professionals can have important roles in getting assistance to someone suffering from substance use disorder.
If You’re a Caregiver or Loved One
Show love, compassion, and honesty. By rooting your discussion in your love for the person, they might be more open to hearing your concern. The Hazelden Betty Ford Foundation has tips on how to talk to your loved one about addiction.
Don’t blame the person.
The addiction isn’t a choice; it’s a disease that can be treated and should be addressed as such.
If they’re in a long-term care facility, keep an eye on the situation.
Talk with their caregivers, find out what supports are available, and decide whether it’s the right place for them.
Consult a doctor or substance abuse counselor.
While there are limits about what your loved one’s doctor can disclose to you, you may want to consult a physician or substance abuse professional specializing in older adults. They may help you ask the right questions about prescriptions and counsel you on approaching your loved one.
Consider becoming a legal caregiver.
If your loved one has diminished mental capacity, becoming a legal caregiver in order to receive all medical information may be a necessary course of action.
Research alternative pain management options.
Chronic pain for older adults can be a very real concern, especially if prescription opioids seem to be the only intervention that works. Open up a discussion about what alternatives they’ve tried, help them talk with their doctor, and see if there’s a way you can work together to manage the situation.
If You’re a Medical Professional
Begin with pre-treatment counseling.
If you’re worried a patient may be abusing or addicted to a substance, open the discussion by acknowledging your concern and engaging in motivational counseling.
Be compassionate and non-confrontational.
Older adults, or anyone with a substance use disorder, can feel a great deal of shame about their addiction. So, be calm and supportive in your approach.
Recommend age-specific and supportive treatment strategies.
Understand the needs of your patient. Identify treatment and recovery programs that can build self-esteem, help cope with depression or loneliness, and link them with people and resources to help them through the recovery process.
Discuss bringing a loved one or caregiver into the discussion.
While HIPAA generally prohibits healthcare professionals from talking about health details to anyone but the patient without consent, talk to your patient about getting that consent. A supportive community can be an important part of recovery.
Ensure the long-term care facility has clear instructions for care.
If your patient lives in a long-term care facility, provide specific instructions to the care team to ensure they provide the appropriate recovery support for your patient.
How to Get Help if You Have a Substance Abuse or Addiction Issue
If you recognize the signs of substance use disorder in yourself, it’s important to know addiction isn’t your fault. You’re not alone; it’s a disease thousands of people live with. And you’re also not alone in your recovery. Here are some ways to get the help you need:
Do some research to understand more about addiction.
Knowing is the first step to getting better. If you’re concerned, learn about substance abuse in older adults. As we age and our body change, substance abuse symptoms can be masked even to ourselves. Learning more can help you identify if you might have a problem.
Talk to a trusted healthcare professional.
If you’re concerned, talk to a doctor or nurse you trust to learn more about how you can get help.
Talk to your loved ones.
Enlist the support from the people you love so they can walk alongside you during this recovery.
Call a substance abuse helpline.
If you’re hesitant to reach out to people you know, there are anonymous resources available to you via 24-hour helplines to information and treatment facilities.
Resources to Help Older Individuals With Substance Abuse
This site provides a wealth of information about substance use disorder and addiction in general, as well as help you find rehabilitation centers or other treatment options.’
National Institute on Drug Abuse
This government resource provides answers to nearly every question you’ve ever had about drug and alcohol abuse.
Opioid Treatment Program Directory
If opioids are causing struggles, this directory helps you find treatment in your state.
This rehabilitation organization is specifically for seniors living with drug and alcohol abuse or addiction. They provide a great deal of resources specific to this population and a 24/7 hotline.
SAMHSA National Helpline
This 24/7, confidential hotline is available to people living with or who care about someone with a substance use disorder. They can provide referrals to local assistance and send publications.