Tailoring Treatment for Substance Use Disorders in Older Adults: A Mixed-methods Study

Abstract

Background and Objectives

The number of persons in mid-to-late life with substance use disorders (SUDs) in the United States has tripled over the past 2 decades, with opioid use disorder largely accounting for this increase. Older individuals with SUDs have unique medical, psychological, and social needs. Despite these needs and growing demand for SUD treatment within this age group, little is known regarding availability of specialized SUD treatment programs for older persons and barriers or facilitators to implementing these services.

Research Design and Methods

We conducted a mixed-methods study, first conducting qualitative interviews with counselors at outpatient SUD treatment facilities in Connecticut (N = 10). We then used these qualitative interview findings to guide analysis of quantitative data from SAMHSA’s National Substance Use and Mental Health Services Survey (N-SUMHSS) and the National Survey of Substance Abuse Treatment Services (N-SSATS) survey.

Results

Using the Behavioral Model of Health Services Utilization for Vulnerable Populations and Framework Analysis, we identified predisposing (eg, treatment attitudes), enabling (eg, transportation), need-based (eg, comorbidities; integrated care), and healthcare system-related (eg, insurance) characteristics affecting older adults’ SUD treatment engagement. SUD treatment facilities offering “a tailored program for seniors or older adults” increased steadily in Connecticut, and the United States overall, between 2010 and 2022. Of the 74 (43%) Connecticut facilities offering tailored older adult services, social, structural, and mental health services were offered at high rates (64%–86%), but medical services were offered at lower rates (39%–52%).

Discussion and Implications

Our findings indicate a gap between the treatment needs of older adults with SUDs and available services. Greater attention to integrated medical services, screening for geriatric-specific syndromes that could impede treatment access (eg, cognitive impairment; mobility), and appropriate workforce training is needed to optimize treatment for older adults with SUD, especially considering the opioid use disorder epidemic in the United States.

Translational Significance: Substance use disorder (SUD), particularly opioid use disorder, among persons in mid-to-late life, is an under-recognized public health problem. Little is understood regarding how SUD treatment systems address older adults’ unique needs. Using publicly available data, we found that the percentage of SUD treatment facilities offering older adult programming is increasing. Yet, these data and qualitative interviews with SUD treatment providers indicate minimal training on older adult-specific issues and service gaps that, if addressed, could improve SUD treatment engagement and retention (eg, integrated medical and SUD treatment services).

Substance use disorders (SUDs) among persons in mid-to-late life (age ≥50) are among the fastest-growing health problems in the United States Between 2000 and 2020, those age ≥50 with SUDs increased from 1.7 million to 5.7 million (1). Emergence of SUD as a public health concern in this age group can be at least partly attributed to higher rates of substance use among the baby boom generation (people born between 1946 and 1964) compared with previous generations (1). Thus, many individuals in this age group have experienced persistent drug use throughout the life course. In addition, people live longer with diseases related to drug use such as HIV and Hepatitis C infection (2). Resultingly, demand for SUD treatment for older adults has increased over the past 2 decades, particularly among those with opioid use disorder (OUD) who have seen a 10-fold increase in OUD overdose rates (3,4). Relatedly, a recent study found that persons in mid-to-late life comprised 9% of SUD treatment first-time admissions in 2008 and nearly 16% by 2018 (5), with illicit substances surpassing alcohol as the most common reason for these admissions (5).

Unique Needs of Older Adults in Substance Use Disorder Treatment

The growing number of persons age ≥50 seeking treatment for SUDs is noteworthy for several reasons. First, due to normal consequences of aging, older adults are more likely than young people to have chronic health conditions that are often exacerbated by substance use. Relatedly, age-related physiological changes (eg, slower metabolism, altered fat percentages, reduced muscle mass) are associated with less effective clearing of substances, resulting in greater potency, toxicity, and longer-acting duration (6–8). Thus, when consuming the same dose of a substance as a younger person, older adults may experience more serious adverse effects. Second, growing evidence suggests that substance use accelerates age-related pathophysiological processes such as inflammation and cellular aging, which may translate to earlier onset of chronic conditions (9). Third, older individuals are likely to take prescription medications that can interact negatively with alcohol and drugs (10,11). Finally, older adults with SUD may have experienced stigma over their life course and as part of their treatment experiences, and the combination of aging and drug use may exacerbate social isolation (12,13). Thus, older persons seeking SUD treatment have unique age-related care needs and experiences potentially requiring more complex or intensive intervention. Each of these factors may affect SUD treatment utilization/retention rates and/or effectiveness among older clients.

The Substance Abuse and Mental Health Services Administration (SAMHSA)’s 2020 Treatment Improvement Protocol (TIP 26) (14) is a set of guidelines describing evidence-based practices for treating SUDs in older adults (15). Treatment Improvement Protocol 26 includes recommendations for specialized services such as providing screening and support for cognitive impairment, case management focused on connections to age-related community resources and/or geriatrics specialists, and age-matched peer recovery support providers. Yet, despite growing need for SUD treatment among older persons, as well as these established guidelines, little is known regarding the availability of these types of services and what may or may not affect utilization of these services.

Barriers to Seeking and Completing Treatment Among Persons in Mid-to-late Life

There may be unique factors associated with treatment engagement and treatment completion or retention among older adults with SUD. For example, although pharmacotherapy and counseling are efficacious in older persons with SUD (16), treatment rates are low. Using National Survey of Drug Use and Health (NSDUH) 2008 to 2012 data, Choi et al. (2014) reported that among adults with SUD, 10.6% and 3.6% of those ages 50–64 and age ≥ 65, respectively, received treatment in the prior year (17). Reasons for not getting SUD treatment included lacking readiness to stop using substances, cost of treatment/limited insurance, and not knowing where to go/lack of available programming. It was also hypothesized that those with SUD symptoms that did not include tolerance and/or withdrawal, may not have had the motivation necessary to seek treatment, thus contributing to the low treatment rates (17). An analysis of the 2015–2018 Treatment Episode Data Set—Discharge (TEDS-D) found that factors associated with treatment completion among persons age ≥55 with OUD differed according to level of care (ie, detoxification, residential, or outpatient) and primary substance (ie, heroin or prescription opioids) (18). For example, living arrangement (supervised housing vs homelessness) was associated with increased likelihood of completing detoxification and outpatient treatment among those with heroin use but had no impact on treatment completion in any setting for those in treatment for prescription opioids. In contrast, having a co-occurring psychiatric condition was associated with a lower likelihood of completing detoxification or outpatient treatment among those being treated for prescription opioid use disorder but was not associated with completing treatment for heroin use in any setting. For both conditions, age at first use >30 was associated with increased likelihood of completing outpatient treatment, but not detoxification or residential treatment. These studies, however, did not evaluate the availability of specialized SUD treatment programming for older adults, nor did they evaluate factors that may hinder or facilitate use of these services.

The Current Study

We sought to fill the gap in the literature regarding whether the SUD treatment system addresses the unique needs of older adults and factors associated with availability and use of specialized services for older adults, focusing on SUD treatment providers’ perspectives. We used an exploratory sequential mixed methods design, first conducting qualitative interviews with SUD treatment providers and then analyzing quantitative data from SAMHSA’s National Substance Use and Mental Health Services (N-SUMHSS) and National Survey of Substance Abuse Treatment Services (N-SSATS) surveys.

We used Gelberg & Andersen’s Behavioral Model of Health Services Utilization for Vulnerable Populations to theoretically guide the generation of themes (19). This model, a revision of Andersen’s Behavioral Model (20,21), provides a framework for understanding treatment utilization by considering the impact of predisposing, enabling, and need-related individual-level factors that may hinder or facilitate healthcare services use. Predisposing factors are demographics, health beliefs/attitudes, and social structures. Enabling factors are personal and community resources. Need-related factors are perceived and objective health-related conditions. However, in addition to “traditional” characteristics that affect healthcare services utilization, such as age, health insurance, and individual’s perception of general health conditions, this model includes “vulnerable-specific” precursors such as literacy, transportation, and substance misuse. As persons with SUD often experience societal hardships, the “Vulnerable Populations” model is especially relevant for understanding factors affecting health services utilization in this population. Prior studies have used the Behavioral Model of Health Services Utilization for Vulnerable Populations as a framework for identifying gaps in availability of and access to health services by eliciting the perspectives of healthcare providers who work with vulnerable populations. Providers offer an important perspective and insights regarding services offered. For example, a study of managers of mental health programs used this model to inform data collection regarding gaps in services for sexual and gender minority youth and to determine factors associated with provision of sexual health/HIV services. Other studies have used this model to guide the development of semistructured interviews to gauge opinions of healthcare providers about accessibility of health services such as mobile vans to deliver HIV pre-exposure prophylaxis and to generate themes from provider responses about linkage to HIV treatment clinics and initiation of antiretroviral therapy (22). In the present study, health services use refers to availability and use of outpatient SUD treatment.

We focused our analysis on providers in the state of Connecticut, which has a rate of older adult services similar to the U.S. national rate (23). Our research questions were:

1. What are treatment providers’ views on older adults’ treatment engagement and retention?

2. What are the barriers and facilitators to offering services to older adults in SUD treatment clinics?

3. What percentage of SUD treatment clinics offer programming specifically tailored to older adults and what types of services do they offer in their clinics that may be relevant to this population?

Method

This study was approved by the UConn Health Institutional Review Board (IRB #22-328-1).

Mixed Method Design

An exploratory sequential mixed methods design was used for this study. The key integration points in this mixed methods design occur when qualitative data collected in the initial phase informs the subsequent quantitative data collection and/or analysis by, for example, shaping variable selection and analysis. This approach represents integration of the qualitative and quantitative datasets through a building approach with the integration point primarily at the design and data collection/analysis stages (24). Specifically, we first collected and analyzed qualitative data via interviews, then we used the results of those interviews to drive our selection of variables and content areas to analyze N-SUMHSS data. Using secondary data sources in mixed methods designs has advantages, including using high-quality large national datasets to answer broad research questions that could not be easily answered with primary data collection coupled with more targeted primary data collection to ask focused questions (24–26).

Qualitative Data

Participants and recruitment.

A convenience sample of 6 community-based outpatient clinics in Connecticut from organizations in which the authors had previous relationships were selected for participation. Purposive sampling using the typical case approach (27) was used to recruit individuals from within these clinics to describe what is typical when treating older adults in SUD treatment programs. Inclusion criteria for treatment providers were: (a) provides direct patient care in a counseling role in an outpatient SUD treatment facility (eg, outpatient program; opioid treatment program); (b) has provided this type of care for ≥6 months; and (c) has treated individuals age ≥50. Flyers advertising the study were posted in the clinics and the research team described the study at clinic staff meetings. Interested participants contacted the research assistant and eligibility was confirmed. An investigator (M.O.) obtained verbal informed consent and conducted interviews via Zoom with automatic transcription. Memos with notes and observations from each interview were also created. Participant recruitment stopped once no new information was being provided (ie, reached saturation).

Instrument and approach.

The research team jointly developed a semistructured interview guide. Participants were first asked to describe their role at the outpatient clinic. Then, they were asked to respond to open-ended interview questions regarding their observations and opinions about unique challenges, strengths, and treatment needs affecting SUD treatment engagement and retention among persons aged ≥50; availability of specialized services for this age group; training received or suggested regarding this age group; and factors that may affect implementing specialized services for older adults. Interviews lasted approximately 30 min, and participants received a $75 gift card.

Data management and analysis.

To resolve transcription errors, recordings were reviewed and transcriptions were edited when necessary. We used the framework method for management and analysis, outlined by Gale et al. (2013) (28), which follows 7 stages: transcription, familiarization with the interview, coding, developing a working analytical framework, applying the analytical framework, charting data into a framework matrix, and interpreting the data.

Two members of the research team (M.O., Y.L) developed inductive codes using the Gelberg & Andersen Model (19) to guide the study. Both researchers coded the interviews, discussed the analytical framework, and compared coding. They discussed inconsistencies, further refined the codebook, created additional coding categories following an inductive process, and developed a framework matrix. Data were charted in a matrix of participants by category and codes, summarizing interview content and, at times, direct quotations. The 3 main analytic categories were predisposing characteristics, enabling factors, and need.

Quantitative Data

Dataset and analysis.

We used the SAMHSA-sponsored 2010–2020 N-SSATS and the 2021–2022 N-SUMHSS. N-SSATS was the annual census of SUD treatment facilities, replaced in 2021 by the N-SUMHSS, a combined survey of SUD and mental health treatment facilities. These self-reported surveys, available in both English and Spanish, provide comprehensive data on SUD treatment services; information is collected on the location, organization, structure, services, and utilization of U.S. SUD treatment facilities. Both surveys reported high response rates in all years. For example, the 2022 N-SUMHHS had an overall response rate of 88% (CT response rate: 87%) and included data from 14 854 SUD treatment facilities in the United States (172 in CT) (29).

First, we identified the trend in number/rates of SUD treatment facilities in CT and nationally that reported having older adult-specific programming from 2010 to 2022. The N-SSATS/N-SUMHSS asks facilities to identify categories of clients for whom they currently offer tailored SUD treatment programs or groups (N-SUMHSS Q A15a). Facilities endorsing “seniors or older adults” for this question were coded as offering SUD treatment programming tailored for older persons. Next, we used N-SUMHSS 2022 data to examine services offered by facilities serving seniors/older adults (N-SUMHSS Q A7), utilizing the qualitative findings to guide services selected for examination, where applicable. Services spanned testing, transitions, recovery support, education and counseling, and ancillary (Table 1). All variables were binary (yes/no) response types; we used Chi-square tests to determine services more/less likely to be offered in clinics serving older adults.

Table 1.

Summary of Findings According to the Behavioral Model for Vulnerable Populations

Domains	Predisposing Characteristics	Enabling Characteristics	Need-related Characteristics
Aim 1—Treatment providers’ views on engagement and retention
Traditional	Demographics Older clients bring wisdom, insight, and encouragement to younger clients that can be mutually beneficial	Personal/family resources Lack of social support due to age and/or drug use Engaging in treatment as a motivator for maintaining or repairing social relationships	Evaluated health General population health conditions experienced in older age such as cancer, chronic pain
	Health beliefs Positive attitudes toward treatment that come with age Experience and maturity make them take treatment seriously	State/Federal policies Insurance type affects eligibility for nonemergency medical transport
Vulnerable	Stigma Shame of feeling like addiction is a choice and not a disease Older clients grew up with different social norms around mental health that make it hard to seek treatment/ask for help with addiction	Personal/Family resources Transportation—inability to drive due to age; cognitive or mobility issues precluding public transit use Ability to navigate the system—generational gaps in technology knowledge and use; inability to read small text on mobile phones necessary for scheduling	Evaluated health exacerbated by addiction Vulnerable population health conditions such as Hepatitis C and mental health conditions comorbid with the SUD (eg, anxiety; depression) Geriatric conditions such as mobility disability and cognitive impairment that impede transportation to treatment
	Social structures Homelessness Food insecurity Language barriers Financial challenges
Aim 2—Barriers and facilitators to offering services for older adults
Traditional	Demographics Available programming not specific to older clients. Focus on other demographic groups (eg, younger individuals/emerging adults; pregnant women)	Availability of resources Staff training regarding geriatric-specific topics (eg, dementia; grief/developmental changes happening in older age; trauma/victimization throughout the life course) Provision of technical assistance to clients Staff turnover Caseload size
		Organizational culture Attitudes regarding implementing new programs
Vulnerable		State/Federal policies related to addiction Insurance will not cover Medicare clients being treated by licensed alcohol and drug counselors, thus limiting availability of providers Insurance type affects access to Intensive Outpatient Programming (not covered by Medicare)	Perceptions of health Integrated and coordinated care, overseen by a case manager, is optimal for addressing clients’ co-occurring physical, mental, and social challenges, yet difficult to implement

Results

Qualitative Results

We interviewed 10 participants between January and July 2023. Participants were 26–69 years; 90% were non-Hispanic white, and 9 were female. The gender distribution of this sample is in line with the U.S. workforce of substance use counselors, who are overwhelmingly female (30). When describing the composition of clients at their clinics, 4 participants noted that clients aged ≥50 comprise at least one-third of their clinic population, with 2 of these participants indicating that this age group comprises at least 50%. While the other participants did not specify a percentage, they all agreed that their clinics serve “a lot” or “a large chunk” of clients aged ≥50. Thus, this age group is an important part of their service populations.

Aim 1: treatment providers’ views on older clients’ treatment engagement and retention

Table 1 summarizes findings for Aims 1 and 2 according to the domains of Gelberg & Andersen’s Behavioral Model of Health Services Utilization for Vulnerable Populations. Based on participants’ responses, we identified several subthemes that fit into this framework as predisposing factors that may affect older adults’ engagement and retention in SUD treatment. Subthemes in the traditional domain, which included mature attitudes and beliefs about SUD treatment that comes with age and age as a source of wisdom, were noted as facilitators of engaging in SUD treatment. The following quotes illustrate older age as positively affecting the SUD treatment experience.

“When older adults come in, it seems that they take it a little more seriously…if they made that decision, I do find like they’re ready.” (Participant 8)

“I would definitely say experience is a strength and their motivation. Their motivators be a little bit different such as family like marriages, things like that.” (Participant 9)

Others also indicated that the demographic composition of their clinics (ie, large number of clients aged ≥50) should be recognized and harnessed to facilitate younger clients’ treatment engagement.

“From my experience here, I think that they [older clients] offer a great amount of insight and support to the younger folks, and that, you know, we should be using them more if they were interested, as like peer support and stuff.” (Participant 2)

“I have heard from the groups that it’s the older generation that has been in the program longer that will help the younger crowd that’s like maybe complaining or not wanting to do this… and they’re [older clients] like, no you can do it, I’ve done it, I’ve been here for this long.” (Participant 10)

In contrast, themes of stigma and dealing with social structural hardships, which fall in the vulnerable domain of predisposing factors, emerged as barriers to engaging in treatment. Participants indicated that the intersection of addiction and older age may make treatment seeking more difficult for older generations who grew up with different social norms around mental health.

“I feel like with that population, asking for help is hard because they were taught to grow up, and you know, like you’re an adult. Now take care of yourself versus being vulnerable, asking for that help that they need.” (Participant 1)

“Some of the older people are used to not talking about it.” (Participant 9)

“… I feel like they kind of feel more stigmatized. I feel because it was a very different time when they were going through their addiction… Lot of shame. I feel like, with that generation, addiction was seen as a choice rather than understanding it as a disease.” (Participant 1)

Multiple providers mentioned social structural barriers that affect older adults’ treatment engagement including homelessness, food insecurity, language barriers, and financial precarities, such as being unable to afford phones or computers. Some quotes that exemplify this are:

“Unfortunately, we’re seeing a significant increase [in homelessness], certainly in the [city where clinic is located] area, of folks that are in that age group and well over 50 that are homeless. So dealing with somebody who’s in their sixties who’s homeless and dealing with a variety of medical problems, and they can’t always get treatment.” (Participant 3)

“ …lot of people don’t have phones, they don’t have computers, so they just don’t know the help that’s out there, or even how to get that help, or even want to get help.” (Participant 10).

Participants noted several enabling characteristics affecting older adults’ SUD treatment engagement. These fit into both traditional (social support) and vulnerable (transportation; limited technological knowledge) domains of the Behavioral Model of Health Services Utilization for Vulnerable Populations. Social support, and the lack of, was a traditional factor mentioned by several participants. Isolation as a barrier to treatment engagement and retention was noted as particularly acute for older adults as indicated by the following quotes.

“Older adults sometimes don’t have a solid social community, or they’ve been isolated or damaging [sic] family relations. So social support is a factor that may promote them to even get involved in treatment. So, if they don’t have people in their lives that are supporting them, or they’ve burned bridges, can imagine [sic] less likely to even engage in treatment.” (Participant 4)

“Everything just goes back to that isolation piece. It’s a huge factor in all this…without the community supports, you can have a phenomenal treatment plan, and everything’s going well in the clinic. But then the second they’re out stuff kind of falls apart, because sometimes it really is just them.” (Participant 6)

Participants also suggested that maintaining social relationships, and thus addressing isolation, facilitates treatment seeking among older adults. By staying in treatment, they may get family support, and the treatment program itself provides social support.

Several participants noted transportation as a barrier to treatment retention among older clients. Transportation challenges included inability to drive due to age; cognitive or mobility issues precluding public transit use; unreliable public transit; and not qualifying for nonemergency medical transportation due to insurance type.

“So some of them, like, they get their license taken away. Or maybe their family doesn’t want them to drive anymore. Or maybe it’s just plain old simple, not safe for them to drive anymore. And I think that that’s complicated, because they can’t get here. And then the steps to go through to get either public transportation or [non-emergency medical transportation]. It’s a lot for a person who’s functioning 100% with no other issues. Never mind somebody who’s not feeling well, or maybe starting to decline, like it’s hard. So I think that that’s a problem.” (Participant 2)

“So that’s another big problem we see is getting the transportation to get those people here. I mean, [non-emergency medical transportation provider] will transport you if you have health needs and are in a wheelchair and stuff like that. But some of our older patients…they have Medicare so they don’t qualify for some of those services. So that’s another huge challenge.” (Participant 8)

In addition, as will be described, transportation challenges and mobility disability go hand-in-hand.

Difficulty navigating the current system due to limited technology knowledge (eg, confusion regarding steps involved in online appointment scheduling) also emerged as a barrier.

The following quotes summarize this theme.

“I feel like there’s like a whole generation who don’t feel connected to where the world is moving to now…we may be able to help them with this and that. But if they don’t know the basics of using the phone or using a computer…I feel like they get frustrated, and they give up.” (Participant 10)

“I have to print things out. They don’t know how to use the applications for it. You know there’s no like simple way to explain it, and I have tried, believe me, but I would say, finding locations for things, understanding schedules, you know, navigating their mobile phones. A lot of them have mobile phones they can’t even read, because the text is too small.” (Participant 6)

Several participants noted the high prevalence of comorbid physical and mental health conditions in older clients as compared with younger clients. Health-related conditions are considered need-related factors in the Behavioral Model and managing these conditions can affect engaging in SUD treatment. Some of these, such as obesity, cancer or chronic pain, are more traditional or typical chronic conditions that can occur, regardless of older age or SUD. However, conditions such as Hepatitis C, HIV, anxiety, depression, and PTSD are more common among vulnerable populations. The following quotes are examples how providers described their older clients in SUD treatment.

“…a lot of people are in pain. A lot of them have physical ailments depending on if it’s severe back pain, or if they were in an accident before. I have a few that been into an accident, and to avoid the pain, they seek the fentanyl, and they’re not ready to give it up so they continue using.” (Participant 7)

“Most are 50’s and above, and almost everyone has a co-occurring [mental health disorder], or primarily is there for a substance use disorder of sorts with other various mental health conditions.” (Participant 6)

The intersection between SUD and conditions that occur more frequently with older age can create a vulnerability that complicates SUD treatment for older adults. Several participants mentioned that geriatric conditions including mobility disability, commonly defined as difficulty walking or climbing stairs, and cognitive impairment are barriers to SUD treatment. The following quotes summarize this point.

“A lot of clients will have mobility issues, like wheelchairs that break or electric wheelchairs that don’t go, and it’s always an issue because it complicates it even further in terms of they can’t always get on the bus. They sometimes need a special taxi.” (Participant 2)

“A lot of them have other medical conditions, comorbidities, you know, difficulties with transportation, getting there, even walking up to where the offices [are] in some cases.” (Participant 6)

Regarding cognitive impairment, participants reflected on the challenges of SUD treatment for older persons with cognitive impairment. They stated,

“Today we actually case reviewed somebody who is 71, and he’s got Alzheimer’s and dementia. And it’s just to the point that he can’t participate in our treatment anymore [monthly counseling sessions or groups]. So we’re just like weighing the pros and cons.” (Participant 2)

“One of my nursing home guys has a conservator because he can’t really have a full conversation with me, so I call him [the conservator] to do his [the client’s] session.” (Participant 1)

Aim 2: barriers and facilitators to offering services to older adults in substance use disorder treatment clinics

When asked if their clinics offered specialized services for older adults, 9 of 10 participants indicated that they were unaware of services specifically geared to older persons. However, they acknowledged the need to utilize different treatment approaches for older and younger clients. Participant 6 noted,

“Because the same approach that I use for treating someone who’s in their thirties is not going to be the same approach that I use for someone who’s in their mid-60s, and I’ve tried that…But I haven’t had success…So I really would like to have specialized training.”

Providers indicated that to offer services specific to older adults, several barriers would need to be overcome. As outlined in Table 1, optimal programming would involve providers being trained in what Participant 5 referred to as “developmental milestones that are happening during that time period” that may affect older clients’ treatment engagement and retention.

Most participants had no training specific to older adults’ substance use, health, or treatment needs but indicated interest in receiving such training. To that end, training related to grief and dementia was brought up by several participants as factors that would better enable them to treat older SUD clients. For example,

“The barriers that I ran into is a lot of grief working with the older populations…I’ve had older clients who been taking care of their parents, or even an animal as a social emotional support. Some of these clients have never been married or anything, and those social emotional supports leave. It’s very hard to not have training in and counsel them through that, and to help them not be triggered to use.” (Participant 7)

“And with this population there’s a lot of loss and grief that goes outside of just the death and dying piece of loss and grief, but loss of Jobs, careers in some cases, because many of them have been very successful, health, partners, housing so lots and lots and lots of that.” (Participant 3)

“I think something related to dementia and Alzheimer’s would be helpful. And I also think just basic medical conditions.” (Participant 2)

Relatedly, another suggestion was to approach treatment from a life course perspective.

“Well, one part to address this would be specialize to the large significance of trauma, especially throughout one’s years, and look at all the different aspects of exposure to violence. A family dying from addiction because it is so heritable.” (Participant 4)

Other participants said high caseloads and high staff turnover impeded their ability to provide specialized services. As noted here,

“We had one person here that really specialized with the older clients and then moved on so… Some people that are specialized in it, they either go, and then you’re kind of stuck or you don’t have enough training to provide the services.” (Participant 7)

Participants also felt that older adults may require more staff assistance, but limited staff bandwidth makes it challenging to address their needs. Related to their aforementioned challenges with technology, a participant stated,

“They are not tech savvy. A lot of them don’t know how to use an iPhone or… a computer. We can give them all the brochures to get the help they need. But I feel like it’s just not their comfort level. So, it’s almost like they want someone to do it for them. But unfortunately, we don’t always have the time at our clinic to do that for them, because technically, our counselors are not case managers.” (Participant 10)

Policies at the state and federal level were also mentioned as barriers that could hinder specialized programming for older clients. Medicare, for example, will not bill for certain SUD treatment services as indicated by these examples.

“I am a licensed alcohol and drug counselor… That license is not allowed to see Medicare clients. All they accept is LCSWs and PhDs, which is a very outdated, antiquated process considering that the majority of social workers and psychologists do not work in addictions to begin with…When you start getting into people that are on Medicare, even though I have the skill, the experience, the qualifications, whatever. I’m not allowed to see them because of the insurance.” (Participant 3)

“One of the other challenges is when a patient has Medicare versus Medicaid, because our IOP [Intensive Outpatient] program, Medicare will not cover. We’re kind of missing out on a big chunk of our population because they’re not participating in our IOP.” (Participant 8)

Another barrier mentioned was the system’s inability to innovate and change to address needs of older adult populations. Even when leadership is open to improving or developing new services, logistics and organizational culture can make change onerous and deter implementation.

“It seems like they’re receptive to it, like they’re kind of interested. Oh, this is something new, like, you know, this is something that can improve the agency, but when it comes down to actually implementing it, that’s where we have issues.” (Participant 5)

“Agency culture around decision-making and pace can affect change in services offered… we’re at the mercy of the higher-up to make those determinations. Unfortunately, if it was up to us, we would try to implement a lot of groups, but you know, sometimes it’s just hard to get them started.” (Participant 7)

Given complex vulnerabilities of older clients that may pose barriers to treatment engagement and retention, including high rates of comorbidities combined with challenges related to housing, food linkages, and support in the community, participants highlighted a need for integrated and coordinated care to provide optimal services for older adults. In addition to SUD care, this includes mental health treatment, primary care, coordination with older adult-relevant facilities like nursing homes, and case management to oversee the coordinated treatment plan. The following quotes exemplify these points:

“…we offer an admission physical and things like that and hep C treatment. But we don’t offer, and our patients can’t get, physicals or annuals at the center. So, like it would be good if patients can be assigned to a doctor and have an annual physical appointment at the treatment facility so that they don’t have to go outside of the program.” (Participant 9)

“I feel like a lot of the older adults would just benefit from having a case manager. I know there’s one person that we have who kind of has been helping, …especially for housing, so I just feel like that would be very beneficial.” (Participant 10)

“I think it could be helpful to have… a specialized team, like we have the pregnancy team… like a specialized older adult team who may meet with that person and kind of figure out what their individualized needs are... having a team that follows them within their program to see if their needs are being met and to assess what their needs are.” (Participant 11)

Quantitative Results

Aim 3: percentage of substance use disorder treatment clinics offer programming specifically tailored to older adults and types of services offered in their clinics that may be relevant to this population

The percent of SUD treatment facilities offering programming for older adults has grown substantially over time, both nationally and in Connecticut (Figure 1). In 2010, 8% of clinics in Connecticut and nationwide reported offering programming for older adults. By 2022, over 40% of Connecticut facilities and 30% of facilities across the United States reported offering such programs.

Figure 1.

Percent of SUD treatment facilities reporting that they offer tailored programs or groups for “seniors or older adults” in the United States and Connecticut from 2010 to 2022 using SAMHSA’s National Substance Use and Mental Health Services (N-SUMHSS) and National Survey of Substance Abuse Treatment Services (N-SSATS) surveys.

When examining services provided in the 74 Connecticut clinics offering programming for older adults (Table 2), some services were offered at high rates, including case management (86%), social skills development (78%), housing assistance (75%), peer support (69%), self-help groups (64%), and transportation services (64%). However, other potentially important services were offered at lower rates, including testing for metabolic syndromes (39%), integrated primary care services (45%), hepatitis C screening (51%), and health education (59%).

Table 2.

Services Offered in SUD Treatment Facilities With and Without Tailored Programs for Seniors or Older Adults, NSUMHSS, 2022, Connecticut (N = 175)

Programs Offered		Facility Has a Tailored Program for Seniors or Older Adults (%)		Significance (p Value)
		Yes (n = 74)	No (n = 98)
Testing for metabolic syndrome	Yes	29 (59.18)	20 (40.82)	0.007*
	No	45 (36.59)	78 (63.41)
Screening for hepatitis C	Yes	38 (56.72)	29 (43.28)	0.004*
	No	36 (34.29)	69 (65.71)
Naloxone and overdose education	Yes	68 (43.31)	89 (56.69)	0.719
	No	7 (38.89)	11 (61.11)
Assistance in locating housing for clients	Yes	55 (45.45)	66 (54.55)	0.321
	No	19 (37.25)	32 (62.75)
Assistance with obtaining social services (eg, Medicaid, WIC, SSI, SSDI)	Yes	65 (45.77)	77 (54.23)	0.113
	No	9 (30.00)	21 (70.00)
Mentoring/peer support	Yes	51 (41.13)	73 (58.87)	0.42
	No	23 (47.92)	25 (52.08)
Self-help groups	Yes	47 (47.96)	51 (52.04)	0.132
	No	27 (36.49)	47 (63.51)
Health education	Yes	44 (44.44)	55 (55.56)	0.628
	No	31 (40.79)	45 (59.21)
Case management services	Yes	64 (46.72)	72 (53.28)	0.041*
	No	10 (27.78)	26 (72.22)
Social skills development	Yes	58 (44.27)	73 (55.73)	0.481
	No	16 (38.10)	26 (61.90)
Transportation assistance to treatment	Yes	47 (47.00)	53 (53.00)	0.189
	No	27 (36.99)	46 (63.01)
Mental health services	Yes	68 (41.72)	95 (58.28)	0.257
	No	6 (60.00)	4 (40.00)
Integrated primary care services	Yes	33 (57.89)	24 (42.11)	0.005*
	No	41 (35.34)	75 (64.66)

^* p < .05.

Chi-square analysis results indicated significant relationships between program type (offered older adult programming vs did not) and services offered. Clinics that reported offering tailored services for older persons were more likely to provide metabolic testing, hepatitis C screening, and integrated primary care. The exception to this pattern was that clinics providing case management were less likely to offer programs specifically for older adults.

Overall, a very high percentage of clinics offered mental health services (95%), naloxone and overdose education (91%), and assistance with obtaining social services (83%), and this did not differ by presence of programming for older adults.

Discussion

This exploratory sequential mixed-methods study offered a nuanced approach to evaluating treatment needs of older adults in the United States with SUDs and availability of specialized SUD treatment programming for these persons. Integral to this approach was gathering the attitudes and opinions of healthcare workers employed in counseling roles at outpatient SUD treatment facilities, which are largely OUD treatment programs, as well as examining statewide data on treatment program offerings for older adults. Overall, our qualitative and quantitative findings indicate a disconnect between the treatment needs of older adults with SUDs and available services, thus filling a gap regarding whether the SUD treatment system addresses the unique needs of older adults through specialized services. Further, our findings suggest that providers have minimal training on older adult-specific issues and identify factors associated with service gaps that, if addressed, could improve SUD treatment engagement and retention in this vulnerable population.

Participants in our study indicated generational differences in views on addiction, mental health, and SUD treatment as a predisposing characteristic affecting treatment engagement, with both internalized perceptions (eg, shame of being older and still having SUD) and externalized practices (eg, denying skilled nursing facility admission to individuals with OUD) (31) contributing to these differences. This opinion was shared by participants in a recent qualitative study of healthcare professionals who encounter older people with OUD in varied healthcare settings such as primary care and emergency medicine, in addition to outpatient SUD treatment (32). In contrast, an evaluation of data from the 2008–2012 NSDUH, showed no differences in perceptions of stigma between older and younger individuals seeking SUD treatment (17). As data from this latter study are now more than a decade old and considering the substantial increase in drug overdose deaths among those in mid-to-late life in recent years (33), an updated investigation using more recent NSDUH data is warranted. Despite potential stigmatization, participants in our study also felt that clients’ older ages could be viewed positively, with experience and maturity a source of recovery capital that could both increase treatment retention for the patient themselves and positively influence younger clients.

Social support, considered as an enabling characteristic in the traditional Gelberg–Andersen framework, was mentioned by multiple participants. Lack of social support resulting from SUD (eg, estrangement from family and friends; overdose among peers) was thought to pose a significant barrier to SUD treatment engagement for older adults. This finding is consistent with prior work describing the experience of older adults with OUD from the perspective of the older adults themselves (34) and also suggests that the providers are following the TIP 26 recommendation of assessing their older adult clients’ social connections in terms of number and quality. Yet, how to implement strategies to address a lack of support via age-specific programming, such as helping clients to manage grief, was mentioned by participants in the present study as an area where education and training is needed.

“Vulnerability” factors mentioned by study participants as barriers to treatment engagement and retention included increasing rates of homelessness among older clients, transportation challenges, difficulties navigating the technology that is often necessary to engage in the system, and comorbid medical conditions such as chronic diseases, problems with mobility, and cognitive impairment. While each one of these factors is a barrier, it is unlikely that these vulnerabilities occur in isolation. Prior research indicates that mobility disability is considerably more prevalent among older adults in OUD treatment programs as compared with community-living people of the same age (35). Thus, while transportation challenges have been noted as a barrier to SUD treatment among clients of all ages (36), participants in the present study frequently referred to older clients’ problems with mobility function as exacerbating their difficulties with transportation. Relatedly, SUDs can potentially hasten age-related changes in cognition (14) through biological mechanisms in the brain including premature accumulation of amyloid or accelerated deposition of proteins related to neurodegeneration (37,38). Cognitive impairment, in turn, may make it more difficult for individuals to utilize technology needed to book appointments or safely use public transportation. Participants indicated a need for education and training regarding how to manage issues commonly faced by older clients such as cognitive impairment/dementia as way to optimize existing services. Receiving training in evidence-based principles of geriatrics may help counselors to better identify and address potential barriers and would align with national efforts to establish age-friendly health systems (39,40).

The above-described qualitative findings guided our analysis of the N-SUMHSS data. The quantitative results built upon what we found in the qualitative data and provided additional information about services available for older adults. First, we found that 40% of Connecticut’s SUD treatment facilities reported offering services tailored to older adults. We also found that 30% of facilities nationwide reported offering such programs, which is an increase from about 25% in 2019 and more than 4 times higher than what was reported in 2012 (41–44). These increases indicate responsiveness to the growing rates of SUD among persons age ≥50. However, when asked if the clinics where they worked offered services for older adults, none of the participants in the current study were aware of programming tailored toward this age group. The disconnect between the quantitative and qualitative findings likely highlights an important distinction. While many treatment clinics in Connecticut, and potentially the United States. as a whole, offer social services that can be utilized by older individuals, such as housing assistance and social skills development, and medical services such as hepatitis C screening, programming that specifically addresses the unique needs of older individuals with SUD may be largely unavailable.

Quantitative analysis also determined that facilities reporting having programs tailored for older adults were more likely to offer detoxification services and/or treatment for co-occurring mental illness and SUD. This finding is encouraging, as it indicates that older adults have the opportunity to receive services that address overlap between SUD and other psychiatric illnesses. However, medical services were offered at lower rates, suggesting the need for increased attention to comorbid chronic medical conditions and conditions such as mobility disability or hearing impairment that may occur at earlier ages among individuals with SUD as compared with same-age peers without SUD. This finding aligns with our qualitative results, such that SUD treatment providers reported a need for integrated care that encompasses psychiatric, medical, and social services, with case managers to coordinate care. Our findings also complement prior research where older adults with OUD described a need for more integrated care (34). Furthermore, this need has been shared in appeals for integrated care models for older adults with SUDs (13,45) and is also addressed in SAMHSA’s TIP 26 as an important way to promote person-centered care (14). Yet, as acknowledged by the SUD treatment providers in our study, challenges at the healthcare system level make it difficult to implement integrated care models. In fact, prior research indicates that less than 14% of SUD treatment programs offer OUD medication treatment to older adults using Medicare to pay for treatment (41). Medicare also does not cover IOPs or medical transportation (41).

It is important to consider limitations of this study. Our study participants were a convenience sample comprised of counselors from outpatient SUD treatment facilities in one U.S. state. Thus, although qualitative data provide depth (46,47), generalizability may be limited. Our interviews were limited to counselors who spoke English which may not represent the views of SUD treatment center administrators or non-English speaking counselors. In addition, N-SSATS/N-SUMHSS does not define age categories for SUD treatment facilities, so older adult services may not be uniformly defined. Further, the N-SUMHSS data is only available at the facility level and does not provide detailed demographic information about service recipients. Future research may examine other national datasets that provide information at the patient level (eg, the Treatment Episodes Dataset) to shed more light on treatment admissions and service accessibility for older adults, as well as how this may differ by gender, older age groups, and socioeconomic status. Yet, given the dearth of research focusing on older persons seeking SUD treatment, findings from this study contribute a unique and important perspective and raise awareness of the need for more research to guide best practices regarding SUD treatment for older adults.

In this mixed-methods study, we found that the number of SUD treatment facilities in Connecticut and the United States that have tailored programming for older adults has increased. Yet, our qualitative findings indicate that counselors working at SUD treatment facilities are largely unaware of tailored programming for this population. Thus, despite growing recognition of the need for specialized treatment programs tailored to older adults with SUDs, translating this recognition to practice (ie, to the counselors who are performing direct patient care) may be lagging. Addressing barriers to implementing these types of programs will be essential for expanding access to specialized SUD treatment programming for the growing number of older persons with SUDs in the United States.

Funding

This work was supported by the Aging Research and Criminal Justice Health Network [R24 AG065175].

Conflict of Interest

None.

Data Availability

De-identified data are available upon request. The study was not preregistered.