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April 28, 2025
Quarterly Opinion
Harold A. Pollack
Marissa “Mari” Mackiewicz
Soham Sinha
Apr 8, 2024
Apr 17, 2023
Back to The Milbank Quarterly Opinion
Age-associated physiological changes, social changes, comorbidities, and increased use of prescription drugs and alcohol put increasing numbers of American older adults at-risk for substance use disorders (SUD). From 2006 to 2020, the number of older adults living with SUD rose from 2.8 million to 7.1 million. Among patients admitted to SUD treatment facilities, the proportion of older adults has correspondingly increased, rising from 9.0% in 2008 to 15.6% in 2018. Exemplifying the trend, a December 2024 Chicago Sun-Times headline exclaimed “Opioids have been killing the same generation of Black men in Chicago for decades,” noting that Black men between the ages of 54 and 74 accounted for nearly 25% of the Chicago area’s opioid overdose deaths.
While SUD diagnoses and drug-related fatalities have been historically concentrated among adults aged 18 – 64, the rise of SUD among older adults has emerged as a surprisingly lethal epidemic, with a quadrupling of drug-related fatalities among older adults over the past two decades. The Substance Abuse and Mental Health Services Administration’s annual Treatment Episodes Data Set (TEDS) includes data for hundreds of thousands of treatment spells involving patients receiving outpatient opioid use disorder (OUD) services. More than 3% of treatment encounters involving older adults are indicated to end in patient death — an age-adjusted mortality rate far higher than that observed in the general population.
Despite growing risks and adverse consequences of increasing substance misuse, many older adults experience long delays in substance use treatment, or never receive any treatment at all. Recent data from the National Survey of Drug Use and Health (NSDUH) indicate that only one-third of the 8.5 million US adults over age 60 in need of SUD treatment received any treatment for such disorders in the past year. Despite rising SUD prevalence and risk among older adults, surprisingly little research has been done to explore low treatment engagement in this population. Further investigation is essential to address barriers to treatment initiation and continued engagement, and to pursue effective policies and interventions that improve treatment options for older adults with SUD.
Older adults are less likely to be assessed or diagnosed with SUD. Many factors reinforce these patterns, and act as barriers to access and continued engagement with treatment for SUD.
First, SUD stigma and ageist misconceptions promote treatment pessimism among many providers. Such misconceptions include the belief that older people do not misuse substances, or the belief that SUD treatment is of low value because older persons already experience low quality of life and are nearer to death. As a result, many older adults with substance-related issues do not receive adequate care for their SUD.
Second, signs and symptoms of substance misuse such as slurred speech, lack of coordination, irritability, mood changes, and memory problems — are commonly misdiagnosed in older adults as the impact of cardiovascular disease, musculoskeletal problems, or age-related cognitive impairment.
Third, improper prescription of opioids for chronic pain management can lead to long-term use of opioids among older adults, with correspondingly greater risks of accompanying SUDs and overdose among older adults.
Finally, standard SUD screening tools may be inappropriate for use in older populations. A standard screening item listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) inquires whether a patient forgoes important social, occupational, or recreational activities secondary to their substance use. Such questions are pertinent for younger adults but may be less informative to evaluate older adults whose life trajectories often entail a reduction in social encounters and in occupational and recreational activities.
Age-appropriate SUD treatment options remain limited, and many health care providers receive insufficient training around SUD, especially in older populations. Older adults deemed to require SUD treatment face difficulties locating programs that meet their distinctive needs. Data from the 2020 National Survey of Substance Abuse Treatment Services (N-SSATS; Table 4.14A) indicate that only one in four SUD treatment facilities have specific programs inclusive to older adults. More research is needed to tailor medication for opioid use disorder (MOUD) treatment programs to the needs of older adults, and, subsequently, to link older adults with MOUD and other age-appropriate, evidence-informed services.
An emerging literature provides valuable insights regarding SUD prevalence among older adults, and patterns of health care use among Medicare beneficiaries who live with SUD. The literature also provides insight into best-practice care models designed to meet older adults’ distinctive needs. Optimizing SUD treatment for older adults should include spaces where older adults have opportunities to receive treatment among their peers, using age-specific approaches. Studies suggest that older adults benefit from more education, and less intensive programs and interventions versus their younger counterparts. However, key research gaps remain. Research regarding strategies to improve older adults’ SUD treatment access is particularly sparse.
Given common physiological and social changes associated with aging, older adults face greater risks of substance-related harms than do younger adults who experience the same patterns of substance use. Social changes, such as retirement, loss of loved ones, and decreased social interaction, further elevate the risks of problematic substance use among older adults, while lack of appropriate treatment options worsens the accompanying harms. At present, most SUD research and policy innovations are designed to meet the needs of adolescents and adults of conventional working age. As the American population ages, any effective response to the opioid epidemic must complement these efforts with the development, evaluation, and deployment of evidence-informed, respectful, and person-centered interventions that meet the distinctive needs of older adults. With tens of thousands of older Americans dying every year from drug-related causes, there is no time to waste.
Harold A. Pollack, PhD, is the Helen Ross Distinguished Service Professor at the University of Chicago. He is faculty codirector of the University of Chicago Health Lab. He researches services for severely disadvantaged populations for individuals at the interface between Medicaid and the criminal justice system.
Marissa “Mari” Mackiewicz is a post-doctoral research fellow in the Center for Health and Social Services at The University of Chicago. Her work focuses on underserved populations of older adults with substance misuse. She completed her master’s and PhD degree from the University of San Diego.
Soham Sinha is a PhD Candidate in Health Services Research at The University of Chicago. He studies how Medicaid policy can be better informed to improve access to care for individuals with opioid use disorders. He completed his undergraduate studies at the University of Manchester and his master’s degrees from the London School of Economics and Cornell University.
