To Care For Older Adults With Substance Use Disorder, Create Age-Friendly Health Systems
While the United States continues to experience a worsening of the drug overdose crisis, addiction among older adults often remains overlooked. There were more than 30,000 unintentional drug overdoses among adults ages 65 and older between 1999 and 2020, a nearly 700 percent relative increase during this period. Increased use of psychostimulants has also contributed to recent rising overdoses deaths among this population.
Due to aging-related physiological changes and greater number of chronic diseases medications used, older adults are particularly vulnerable to the harms of psychoactive substance use. For example, they are at increased risk of psychomotor effects of substances, which further heightens risk for mobility and cognitive impairment.
Substance use disorders among older adults are expected to continue to sharply increase nationally, likely representing a combination of two cohorts. The first comprises adults who have a history of substance use disorder (SUD) from a younger age, whether continuous or interrupted at times. The second encompasses older adults who are newly diagnosed and whose substance use is often driven by co-occurring mental illness, later-life stress and traumatic events, exposure to prescription psychoactive medications that may lead to misuse, and continuation of unhealthy substance use from middle age.
Despite this, older adults are often not screened or offered evidence-based treatment for substance use disorder. For opioid use disorder, this would include behavioral treatment and one of three Food and Drug Administration-approved medications——methadone, buprenorphine, and naltrexone. Current treatment systems, influenced by structural ageism and racism, limit the ability of older adults to access evidence-based treatment that is age-friendly. Additionally, there are stark racial and ethnic disparities seen among older adults. They reflect unequal access to buprenorphine for opioid use disorder and fewer investments in providing addiction treatment and harm-reduction interventions for minority populations, the homeless, and justice-involved persons.
An Opportunity: Deliver Age-Friendly Care For The Growing Number Of Older Adults Entering Substance Use Disorder Treatment
Despite the barriers to accessing treatment for substance use disorder, there has been over the past two decades a sharp increase in the proportion of older adults entering evidence-based treatment for opioid use disorderincluding in opioid treatment programs. These programs are strictly regulated and are the only way patients with opioid use disorder can be treated with methadone. Patients can receive buprenorphine and naltrexone through opioid treatment programs, but they can also receive these medications in primary care settings.
Older adults who receive care from opioid treatment programs frequently have multiple and complex conditions including arthritis and chronic pain that may limit mobility. Despite this, most opioid treatment programs are separate from primary care, do not offer integrated care, and generally deliver services that are limited to substance use disorder treatment. Additionally, many programs operate in a manner that presents challenges for people who have mobility problems or other limitations requiring special accommodations.
Others include challenges strict federal and state regulations that require in-person evaluations to initiate methadone treatment, frequent and often daily in-person medication dosing, and limited flexibility to adjust dosing schedules such as to two or three times a day. Also, the fee-for-service reimbursement structure often incentivizes opioid treatment programs that are based on in-person dosing, counseling, and lab monitoring.
We need to transform how opioid treatment programs operate to deliver age-friendly care for the growing number of older adults entering substance use disorder treatment. During the COVID-19 pandemic, temporary partial solutions to reduce the spread of infection and maintain substance use disorder treatment services allowed the use of telemedicine for methadone monitoring as well as programs that provide treatments from vans parked in disadvantaged neighborhoods and others that deliver medications to people’s homes. Making these COVID-19-related changes permanent could enhance care for older adults. They can help improve access to methadone for patients with functional impairments who may be home-bound or who have difficulties with transportation.
However, much more needs to be done to deliver age-friendly care to older adults with substance use disorder. Opioid treatment programs could provide care that integrates the principles of geriatric-based care for their aging population, particularly since many with substance use disorders may not feel comfortable in traditional health care settings due to the stigma that exists in primary care settings.
While much must be done in traditional primary care settings to remedy that, a current priority should be for opioid treatment programs to focus on the 4Ms (Matters Most, Medication, Mentation, and Mobility) in the care of older adults as a standard of care. For this population, the goal should be integrated and coordinated geriatric-based care that focuses on maintaining function and managing chronic conditions, including geriatric conditions, in coordination with substance use disorder treatment. Fragmented care for older patients on methadone, especially for patients with multiple chronic conditions who take many medications, is not age-friendly and increases the likelihood of drug-drug and drug-disease interactions, common among people living with multimorbidity.
As opioid treatment programs increasingly care for an aging population, integrating other needed services (for example, medical care, psychiatric care, nursing care, physical therapy, adult day services) into existing treatment programs could mitigate social isolation and reduce hospitalization and institutionalization. Ensuring the continuation of adequate Medicare bundled payment reimbursement for opioid treatment programs will be critical; before 2020, Medicare did not cover methadone treatment for opioid use disorder.
It is important to also recognize that these changes in opioid treatment programs need to occur simultaneously with expanded access to buprenorphine treatment for older adults wherever they receive care. Buprenorphine may overcome many barriers that methadone restrictions pose for age-friendly treatment and may be safer for some older adults with certain chronic diseases. However, age-friendly access to both forms of treatment must be prioritized as buprenorphine does not work for all patients with opioid use disorder. Changes in the x-waiver training requirement such as exempting certain clinicians from certification requirements for prescribing buprenorphine for opioid use disorder are a step forward. However, many barriers still exist that prevent buprenorphine access for all patientsespecially older adults who often receive care in multiple treatment settings.
Delivering Evidence-Based Substance Use Disorder Treatment In All Locations Where Older Adults Receive Care
The care of older adults with chronic conditions spans a variety of additional clinical settings beyond traditional outpatient and inpatient settings including postacute, long-term, and home-based care. Therefore, health systems providing care for older adults must be able to deliver evidence-based substance use disorder treatment in skilled nursing facilities, assisted living centers, and adult day programs, especially given the frequency with which this population is hospitalized.
Unfortunately, regulatory, financial, and institutional barriers prevent older adults with substance use disorder from receiving the treatment they need in the care locations they require. Stigmatization of addiction treatment likely contributes to difficulties that older adults with substance use disorder encounter when seeking admission to skilled nursing facilities for both postacute and long-term care and in receiving evidence-based addiction treatment in such settings.
The barriers to postacute care for those with substance use disorder in skilled nursing facilities are well-documented. Patients with opioid use disorder have been excluded from skilled nursing facilities due to the systematic stigmatization of SUDs. For example, some facilities have not accepted patients taking methadone despite the Americans with Disabilities Act of 1990 recognizing SUDs as a protected disability and barring such discrimination. Changes in federal regulations to facilitate methadone use in postacute and long-term care settings should be prioritized.
Clinicians for older adults must be comfortable in screening, recognizing, and diagnosing substance use disorder and be able to provide a timely referral to specialty addiction treatment when needed. Furthermore, geriatricians and other geriatric care clinicians should prescribe evidence-based medications such as buprenorphine for opioid use disorder or naltrexone for alcohol use disorder. Continuing such medications is especially critical during transitions of care that many patients with multiple chronic diseases experience.
Just as clinicians would not withhold insulin for patients with diabetes who are discharged from the hospital to a skilled nursing facility or to home-based care, withholding medications for substance use disorder should not be tolerated, either. Policy makers and regulators must make clear that all older adults living with substance use disorder must have access to lifesaving, evidence-based treatment in all settings where they receive clinical care.
The Demand For Treatment Will Continue To Increase
The current treatment model for substance use disorders in the United States is neither age-friendly nor designed to care for a population with multimorbidity and functional impairments. As the harms related to drugs and alcohol among older adults continue to arise, the demand for substance use disorder treatment among an older population with high levels of medical and social complexity will continue to sharply increase.
In addition to several regulatory and policy changes that are urgently needed, age-friendly care must be integrated into the broader addiction treatment health care setting. Along with that, the medical community must be comfortable managing older adult patients with substance use disorder. Older adults with substance use disorder must be able to access evidence-based treatment in age-friendly settings wherever they receive clinical care.
Dr. Han is funded by a grant from the National Institute on Drug Abuse (K23DA043651). Dr. Levander is funded by a grant from the Agency for Healthcare Research and Quality (K12 HS026370).