One crisis, many ages: investigating opioid use disorder across the life course

Rhetoric condemning the opioid epidemic has become a familiar refrain in every sector of society. Despite arguments about the imprecision of numbers, the staggering rates of opioid use disorder and deaths from opioid overdose have fueled increased research attention on the prevalence, correlates, and consequences, as well as a variety of programs and initiatives to reduce inappropriate opioid use and avoid preventable deaths. In this special issue of Innovation in Aging, we examine a group frequently neglected in the veritable mountain of data describing the opioid epidemic, older adults.

Through the life course, the aging process introduces physiologic, interpersonal, social, and structural factors that may augment the experience of opioid use disorder and both the availability and appropriateness of services for older adults. Opioid use disorder is growing rapidly among older adults when compared to other segments of the population (SAMHSA, 2024). The rate of opioid use disorder among older adults tripled from 2013 to 2018, coupled with staggering rates of hospitalization, social isolation, and overdose deaths (Shoff et al., 2021; Stumbo et al., 2017; Zullo, et al., 2020). Notably, while overall mortality rates remain highest among adults aged 26 to 64 years, recent years have seen substantial increases among older adults, even as rates decreased in other age groups. (Saunders et al., 2024). Current knowledge of opioid use disorder and opioid related deaths among older adults likely underestimates the scope of the issue and its impacts on older adults, their families, and communities at large.

This special issue offers several innovations by focusing on a previously “invisible” population and providing an overview of the dynamic evolution of the nation’s response to the opioid epidemic. The articles demonstrate why settings and populations matter, showing how care must extend beyond clinical walls to address the lived experiences of persons with opioid use disorder. They also examine family dynamics, surrounding community contexts, data gaps, transitional care, and policy challenges—underscoring the value of diverse research methodologies for providing new insights.

The article by Rottnek (2025) provides a clinical orientation to the past, present, and future of opioids and older adults. It provides an understanding of how we got to the current opioid crisis, the current state of opioids and analgesia for older adults, and promising opportunities for improvement. Rottnek issues a passionate call to action to do better to meet the needs of older adults and create more effective and safer ways to deal with older adults’ pain.

The approaches to solving the opioid epidemic have been extremely diverse, ranging from individual and community interventions to policy changes on a national level. To fully conceptualize the needed breadth of intervention required to combat a complex challenge like the opioid epidemic, we contend that the Social Ecological Model (SEM) offers an elegant framework to organize and consider the available options.

The work presented in Figure 1 by Jalali et al. (2020) offers an apt application of the model.

Figure 1.

Social-ecological framework of the opioid crisis.

Note. Reprinted from Jalali et al. (2020).

Policy and systems

The SEM offers various concentric rings to represent the levels at which an intervention or program may address the issue of concern, in this case, the opioid epidemic. By acknowledging the interplay between an individual, their community, and the policies that shape everyday life, we can best match our research and programmatic efforts to the prime targets. The SEM framework also provides an organizational schema for highlighting the contributions of each selected article.

Individual and interpersonal perspectives

Individual perspectives are the most common in patient-centered health research. Health professionals’ attempts to deal with patients’ pain are often cited as one of the triggers for the first wave of the opioid epidemic (CDC, n.d.), yet chronic pain remains a major health concern for many older adults. Breder and Yu (2025) make a unique contribution by examining the prevalence of opioid use disorder, pain, and cognitive functionality among current and formerly homeless older adults. This exploratory study provides a characterization of the health and functioning of this especially vulnerable population and implications for care needs.

Social isolation and loneliness are also viewed as major public health problems and reflect the importance of interpersonal connections for healthy living (Office of the Surgeon General, 2023). Lam et al. (2025) address a related concept, social withdrawal, and how it is related to prescription misuse in older adults, and given the interrelationships, how attention to either or both could mitigate negative effects for older adults. While social interactions are typically seen as leading to positive outcomes for older adults, family ties and interpersonal connections can also be detrimental. Comparing case data reports of elder abuse cases by substance use involvement, Roberto and colleagues (2025) reveal how opioid misuse among family members or paid caregivers amplifies elder abuse through exploitation, mistreatment, or neglect among vulnerable older adults. Individual and interpersonal perspectives must be understood with broader health care and societal perspectives.

Community and health systems

As we move to the next layer, we explore the role communities and health systems may play in addressing the opioid epidemic. The decision whether to continue prescription opioids often rests with the patient and their clinician. Clinicians may recommend tapering of an opioid to work toward discontinuation, which may or may not occur in the context of a shared decision-making framework. Understanding patterns and predictors of tapering can help inform who, when, and how this type of transition occurs. Ramachandran et al. (2025) used Medicare claims data to explore this, specifically covering the period of transition before and after the change in guidance for opioid prescribing in 2016. In 2016, the CDC issued updated guidance regarding prescription opioids that was aimed at reducing the adverse outcomes from opioid therapy (Dowell et al., 2016). The CDC recommendation included critical evaluation of opioid dosing over 50 morphine milligram equivalents (MME) and avoidance of dosages at or above 90 MME. This change in guidance from the CDC is contemporaneous with a 44% increased hazard in any tapering and a 64% increase in rapid tapering.

Approaches to reducing prescription opioid use, such as tapering doses, may have improved outcomes when tailored to the individual’s needs. O’Grady et al. (2025) highlight the challenges of customizing opioid reduction plans to best support patients when resources are not designed for the specific needs of older adults. The availability of medical services for older adults, who are more likely to have comorbid conditions requiring more complex management, was significantly limited compared to social, structural, and mental health services. These community and health systems level challenges will require the attention of clinicians, administrators, and patients to address these gaps.

Society

Lastly, various authors consider the societal structures encompassing the care systems, communities, and individual experiences of opioid use. The SEM underscores the importance of public policy, cultural attitudes, and infrastructure in shaping how older adults access and engage with opioids and related care. Mackiewicz and colleagues (2025) sought the perspectives of low-income, minoritized older adults to understand the drivers of and treatment gaps for problematic opioid use. They identified social isolation as a driver of opioid use disorder for older adults, as well as peer support as a protective factor in navigating highly stigmatized and poorly understood addiction. Themes of widespread stigma and healthcare infrastructure barriers are echoed by Ritter and colleagues (2025) through qualitative interviews with skilled nursing staff responsible for making admission decisions for aging adults with opioid use disorder, with continued needs for skilled care following hospitalizations. Song et al. (2025) eloquently illustrate the experiences of aging heroin users in China, highlighting the importance of the life course in their methodology and societal factors that reiterate societal neglect in social, medical, and judicial systems of older adults who use drugs. Collectively, these authors highlight practical approaches to shift societal attitudes and systems to acknowledge opioid use disorder among older adults as a distinct experience with shared responsibility to ensure inclusivity across sectors.

Cross-cutting issues

This special issue expounds on two critical issues in our understanding of how the current opioid crisis intersects with the aging population: (a) addressing data gaps in opioid overdose reporting and (b) identifying opportunities to shape policy to improve access to and quality of care. Alonzo and colleagues (2025) lament that significant gaps in data reporting limit our understanding of the full impact of the evolving opioid crisis on older adults. However, these challenges can be overcome by actionable solutions to improve the standardization and integration of opioid data monitoring solutions. One concrete recommendation is to examine overdose events in light of available prevention, harm reduction, or treatment services, utilizing diverse datasets to tailor interventions based on geographically based population needs. Lowenstein and colleagues (2025) reiterate the multitude of policy barriers facing older adults seeking opioid use disorder treatment across institutional, state, and federal landscapes. They describe how policy strategies can be leveraged to enhance age-friendly care by adapting current care models. The optimal solution is to create care models that provide accessible, high-quality care for opioid use disorder across the continuum of acute, postacute, and outpatient care settings.

Summary

This special issue has taken stock of what is known about how older adults are defining and are being defined by the current opioid crisis. It has identified novel themes, conceptualizations, research questions, and methods in advancing knowledge on the interconnections between aging and opioid use. In addition to focusing on older adults, many of the articles emphasize the unique situations of especially vulnerable populations, by considering physical and cognitive challenges, socioeconomic or minority status, limited social engagement, unhoused living arrangements and abusive environments, and a dearth of accessible, affordable, and quality mental health and behavioral community resources.

The scope of issues presented by opioid use disorder in later life are best identified and understood by people with lived experience of opioid use disorder, their support networks, and the systems of care they interact with and rely upon. Further, it is important to track how the evolution in the opioid epidemic, from prescription drugs to heroin use to illicitly manufactured fentanyl and multiple drug combinations, will continue to impact older adults. Increased attention on the impacts of opioid use disorder for aging fuels inquiry and investment into solutions best suited to meet the unique needs of this underrecognized and growing population. When considering next steps, levers for change at the individual, community, and societal level offer opportunities to improve personalized care delivery to meet intersecting needs for older adults at risk of, or living with, opioid use disorder.

Funding

None.

Conflicts of interestA. Z. Ritter was the first author on Ritter et al. (2025) and a coauthor on Lowenstein et al. (2025), and M. Ory was a coauthor on Alonzo et al. (2025). Neither were involved in the review or decision process for these articles, which are included in this special issue.