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. Author manuscript; available in PMC: 2012 Apr 6.
Published in final edited form as: Am J Addict. 2010 Sep 21;19(6):515–522. doi: 10.1111/j.1521-0391.2010.00080.x

Prescription Use Disorders in Older Adults

Raj K Kalapatapu 1,✉, Maria A Sullivan 2
PMCID: PMC3320720  NIHMSID: NIHMS365173  PMID: 20958847

Abstract

The number of older adults needing substance abuse treatment is projected to rise significantly in the next few decades. This article will focus on the epidemic of prescription use disorders in older adults. Particular vulnerabilities of older adults to addiction will be considered. Specifically, the prevalence and patterns of use of opioids, stimulants, and benzodiazepines will be explored, including the effects of these substances on morbidity and mortality. Treatment intervention strategies will be briefly discussed, and areas for future research are suggested.

Keywords: prescription, abuse, older, geriatric

Aging Population

When the “baby boomers” start turning 65 in 2011, 10,000 people will turn 65 every day and will continue to do so for the next 20 years 1. All of the baby boomers will be 50 and older in 20202, 3 and 65 and older in 2030, when nearly one in five U.S. residents is expected to be 65 and older 1. The 65 and older age group is projected to increase to 88.5 million in 2050, more than doubling the number in 2008 (38.7 million). The 85 and older population is expected to more than triple, from 5.4 million to 19 million between 2008 and 20504. Such projected numbers of older adults will likely have a significant impact on the healthcare workforce required in the future 5, 6.

Unique Features of Older Adults

Older adults, generally defined in most developed countries as adults age 65 and older 7, have unique features that recommend particular focus on the study of medical and psychiatric disorders in this population. Older adults are distinct from younger adults in at least 4 domains: cognitive function, biological factors, psychological factors, and social factors.

Cognitively, older adults often have a loss in speed and efficiency of information processing, show decreases on tests of visuoperceptual, visuospatial, and constructional functions, and show decreases on motor speed and response time 8, 9. Neuropathological changes consistent with early stage Alzheimer’s disease, such as neuritic plaques and neurofibrillary tangles, can be seen in cognitively normal older adults 10. Biologically, older adults generally have a decreased volume of distribution, are more pharmacodynamically sensitive to medications, and can have a higher prevalence of chronic medical comorbidities that overload the aging body 8. Psychologically, older adults may use different coping strategies to resolve problems, such as using reminiscence, looking more inward, or taking mortality into consideration 11. Socially, older adults tend to experience a decrease in the size and change in composition of social networks 12, are more likely to experience widowhood and deaths of family members/friends, and can have losses in occupational domains 13. Also, older adults often have a sense of fewer responsibilities due to freedom from children and a career, which may decrease previous self-imposed controls 14. Such features particular to later life can potentially impact the etiology, presentation, course, treatment outcomes, and prevention strategies for substance use disorders in older adults.

Defining an Older Adult with a Substance Use Disorder

Among individuals with substance use disorders, defining an older adult is problematic. Chronologic age may not reflect biologic age, which depends on the cumulative illness burden 15, 16. With respect to substance use disorders, it may be reasonable to define an older adult as an adult age 50 and older, since the overall health condition of a 50-year-old adult with a substance use disorder may be more similar to that of an adult in his or her 60s without a substance use disorder 17. For example, individuals with substance abuse have higher mortality rates than age-matched individuals without substance abuse 18–20, reflecting more rapid biologic aging. Older patients in methadone maintenance treatment have worse general health and poorer physical and social functioning, compared with age- and sex-matched population norms 17, 21. Substance abuse can also exacerbate neurological, respiratory, and other age-associated diseases 22, 23. Patients with substance abuse have elevated rates of blood-borne diseases such as hepatitis and C and HIV, and a higher medical burden can be present in older adults 24, 25. Overall, there is considerable evidence that older patients with drug dependence have higher rates of medical morbidity than younger patients with drug dependence 17, 21, 26, 27.

Thus, given the accelerated rate of biologic aging among individuals with substance use disorders, for purposes of this review we have defined an older adult with a substance use disorder as an adult age 50 and older. This definition is consistent with definitions employed by other researchers who have conducted studies among older adults with substance use disorders 3, 21, 28, 29.

Substance Use Disorders in Older Adults

The number of older adults (age 50 and older) in need of substance abuse treatment has been estimated to be increasing from 1.7 million in 2000/2001 to 4.4 million in 2020, due to a 50% increase in the number of older adults and a 70% increase in the rate of treatment need among older adults 3. Table 1 shows the increasing admission rate from 2005–0730–32 for older adults in the Treatment Episode Data Set, which tracks federal and state funded substance abuse treatment admissions. Local mortality data in the New York/New Jersey/Pennsylvania area from the Drug Abuse Warning Network also show an overall increase in the drug-related death rate among adults age 55 and over, from 49.5/1,000,000 population in 200333 to 66/1,000,000 population in 200734. Such data provide examples of the significant impact of substance abuse in older adults.

Table 1.

Admission Rates for Older Adults in the Treatment Episode Data Set (TEDS) by Year.

Age Group 200532 200631 200730
50–54 5.9% 6.2% 6.7%
55–59 2.5% 2.8% 3.0%
60–64 1.0% 1.0% 1.1%
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The aging process itself can potentially affect the underlying neurobiological systems involved in substance use disorders 22. The neurotransmitter systems and neural circuits involved in the reward system can be affected by aging, but the consequences of these effects have not been well characterized 22. For example, during reward anticipation, young adults (age 25 +/− 3.7 years) reportedly recruit the ventral striatum, the anterior cingulate cortex, and the left intraparietal region, compared to only the left intraparietal region in older adults (age 65 +/− 5 years) 35. An age-related change in the direction of the relationship between midbrain dopamine synthesis and prefrontal cortex activity has been noted 35. Dopamine transporter binding has been found to decrease with age (range 21–63 years) 36. Dopaminergic (range 24–86 years) and serotonergic (range 21–49 years) receptor loss within the prefrontal cortex and striatum have been observed during aging 37–39. N-methyl-D-aspartate (NMDA) glutamate receptor density and function have shown age-related decreases in the cortex, striatum, and hippocampus 22, 40–42. Implications of these changes warrant further investigation and suggest a possible role for age-specific treatment interventions. The clinical picture may be further confounded by an older adult’s past substance abuse history 22.

Hence, epidemiological data have suggested the growing scope of substance use disorders in older adults, but additional clinical research is needed to elucidate the specific features of illness presentation and course of substance use disorders in older adults. Such research efforts would permit the development of more targeted treatment interventions for this population.

Prescription Use Disorders

One area of particular clinical concern in older adults is the abuse of prescription drugs, which is part of an “invisible epidemic” of alcohol, prescription, and over-the-counter drug abuse 43, 44. Polypharmacy can be common in older adults (age 65 and older) who have multiple underlying medical disorders 45, and approximately one third of all prescription drugs in the U.S. are used by older adults (age 65 and older) 46. Various classes of prescription drugs are subject to abuse and dependence by older adults (age 50 and older), including opioids, stimulants, and benzodiazepines 47. As the availability and accessibility of prescription drugs continue to increase, and as the “baby boom” cohort ages, it appears likely that the proportion of older adults using these drugs and experiencing substance abuse associated problems will also increase 18, 22. Some data suggest that patterns of prescription drug abuse may differ by gender in older adults. For example, older women have been found to be at greater risk for prescription drug abuse than older men or younger women 47–49. Possible explanations for this finding include the higher rate of psychoactive drug use among older women than older men 47, psychoactive drug use associated with recent divorce and widowhood among older women 47, and men’s preference for alcohol 47.

1. Opioids

The overall societal cost of prescription opioid abuse in the U.S. has been estimated at $9.5 billion in 200550. The prevalence of prescription opioid use disorders in older adults should not be underestimated. In an analysis of the Treatment Episode Data Set, the percentage of admissions in 1992 for prescription opioids was 0.7% for ages 50–54 and 55 and older, compared to 3.2% for ages 50–54 and 2.8% for age 55 and older in 200517. Codeine was the second highest abused prescription drug in a program targeting high-risk, community-based elderly individuals through the Elderly Services for Spokane 51.

One study examining the course of prescription opioid use disorders during an older adult’s lifetime found that in 92% of subjects, the duration of prescription opioid abuse was greater than 5 years 51. Regarding risk factors for prescription opioid abuse in older adults, the risk of addiction to prescription opioids appears to be minimal in individuals without a previous substance abuse history 52. Several studies (mean age range 51–62) have also failed to find a relation between previous substance abuse history and the risk of current prescription opioid abuse in older adults (studies had mean age ranges from 51 to 62) 53–55.

Regarding the actual source of opioids, in a center for individuals seeking opioid detoxification, physician prescriptions were the primary source of prescription opioids, particularly for older patients (age group of 55 and older greater than all younger age groups) 56. An important note is the potential for drug diversion among older adults. In a study of prescription drug diversion in Wilmington, Delaware, many older adults engaged in deceiving their physician by using pain complaints to obtain desired opioid prescriptions. Although older adults did not self-identify as drug dealers, some reported filling their prescriptions and selling some or all to a few abusers known to them, as well as to dealers or pill brokers for much less than the street value of the drugs 57.

However, it is equally important to emphasize that persistent pain can have significant consequences on an older adult’s quality of life 58, such as depression, anxiety, and falls 59, 60. The aging process affects neurotransmitter systems and neural circuits not only involved in the reward system, but also in pain processing pathways. Examples include a decreasing density of myelinated and unmyelinated peripheral fibers and a loss of serotonergic and noradrenergic neurons in the dorsal horn 61. Yet, opioid analgesics can serve an important role in the management of persistent pain in older adults 62, 63, and clinicians need to distinguish pseudoaddiction (drug-seeking due to poorly managed persistent pain) from true prescription opioid abuse 49. An inappropriate “opiophobia” 59 in the clinician does not legitimize inadequate management of an older adult’s persistent pain. Systematic strategies to evaluate for prescription opioid abuse include monitoring requests for early refills and asking about opioid prescriptions from other clinicians 59, 60. Screening tools 64–68 that can be valuable in the assessment of opioid abuse in patients with persistent pain are included in Table 2. A written “medication agreement” can also be a valuable tool during the management of persistent pain 59, 60. Nonpharmacological interventions, such as biofeedback, relaxation techniques, and acupuncture, may need to be concomitantly used to achieve effective pain control 69. The American Geriatrics Society has an entire panel dedicated to improving the pharmacological management of persistent pain in older adults 59, 60.

Table 2.

Examples of Screening Tools in the Assessment of Opioid Abuse in Patients with Persistent Pain.

Pain Assessment and Documentation Tool (PADT) 64
Prescription Drug Use Questionnaire (PDUQ) 65 –age 20 to 66
Screener and Opioid Assessment for Patients with Pain (SOAPP) 66 –age 18 to 88
Current Opioid Misuse Measure (COMM) 67 –age 21 to 89
Opioid Risk Tool (ORT) 68 –age 17 to 82
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2. Stimulants

Some data on prescription stimulant use disorders exist in older adults, although stimulants are generally abused by younger individuals 70. Data are beginning to emerge in the older adult age group (age 50 and older) 3, 71. NSDUH data from 2000–01 revealed that among the estimated 244,000 older adults (age 50 and older) abusing or dependent on illicit drugs, the prevalence of stimulants was 18% 3. In 2007, an analysis of the Treatment Episode Data Set found that methamphetamine/amphetamine was the primary substances for 7.87% (142,832 admissions) of all admissions, of which 2.7% were age 50–54, 0.8% age 55–59, 0.2% age 60–64, and less than 0.05% age 65 and older. Other stimulants were the primary substances for 896 admissions, of which 4.4% were age 50–54, 2.6% age 55–59, 0.7% age 60–64, and 0.7% age 65 and older 30. In a prospective cross-sectional study that assessed the pattern of drugs of abuse among patients admitted for acute poisoning over a 1-year period in a Medicine department, 8% of patients (age 50 and older) had positive amphetamine samples 72. In a prospective 4-year study of older Medicare patients with substance use disorders (mean age 72.9 years), 9% of the drug-related diagnoses by clinicians specified barbiturate, sedative, or stimulant abuse/dependence 73. Thus, while not as prevalent as alcohol abuse or perhaps even benzodiazepine abuse, stimulant abuse is present in a significant minority of older patients, and may complicate medical diagnosis and treatment.

Neuroimaging studies have suggested a possible underlying reason for low rates of prescription stimulant use disorders. An investigation of reinforcing effects of amphetamine in stimulant-naïve healthy volunteers (age range 19 to 53) found that increasing age was associated with decreased potency of dopamine to elicit positive reinforcing effects 74. Studies on the subjective effects of amphetamines in older patients 75–77 (mean age 78.477) have also found that increasing age is associated with reduced euphoric effects; this may be related to age-related cortical gray matter volume reductions 76, possibly reflecting a reduction in cortical dopamine levels 76,78. These findings suggest that older adults may be relatively protected from developing new onset stimulant use disorders. A small case series has shown that those older adults who already have a long history of prescription stimulant use disorders may have significant morbidity, such as severe withdrawal symptoms 79. Older adults (age range 57 to 66) with chronic methamphetamine abuse often display a number of psychiatric symptoms, such as depressed mood, psychomotor slowing, loss of interest and suicidal ideations, as well as resistance to antidepressant medications 80. In spite of these sequelae of stimulant use disorders, it is important to remember that stimulants may have an appropriate therapeutic role in the treatment of depression in older adults 81, 82.

Prescription stimulant use disorders can lead to medical morbidity in older adults. Pulmonary emphysema 83 and pulmonary talcosis (resulting in lower lobe panacinaremphysema) 84 have been reported in adults over the age of 50 intravenously injecting methylphenidate. In older adults presenting with symptoms of heart failure, stimulant abuse may have an etiologic role 85. Amphetamine abuse may even accelerate skin wrinkling, a hallmark of aging 86. Thus, the medical history and physical examination may offer clues to stimulant abuse not reported by the older patient.

3. Benzodiazepines

Many older adults fear becoming addicted to benzodiazepines, even when they have no personal history of past addiction problems 87. The prevalence of prescription benzodiazepine use disorders can be significant. The 2007 Treatment Episode Data Set found that sedatives were the primary substances for 4,197 admissions, of which 6.4% were age 50–54, 3.1% were age 55–59, 1.7% were age 60–64, and 3.5% were age 65 and older 30. Among older patients admitted to the Mayo Inpatient Addiction Program in 1974–93, prescription drugs accounted for 16% of annual admissions, the most frequent being sedatives/hypnotics 88. In a retrospective analysis of older patients (age 60 and older) presenting to an outpatient geriatric psychiatry clinic, the prevalence of benzodiazepine dependence was 11.4% 89. Diazepam was the most commonly abused prescription drug in the Elderly Services of Spokane study, whereas flurazepam ranked fourth 51. Underdiagnosis of benzodiazepine abuse in older adults is still a concern, even though the prevalence may be lower than the prevalence in younger age groups 90.

Some risk factors for prescription benzodiazepine abuse in older adults have been identified: increasing age, medical disorders where multiple medications are used, and comorbid depression and alcohol dependence 91, 92. In a retrospective chart review of psychiatrically hospitalized older adults (age 65 and older), the abuse of benzodiazepines was more frequently unrecognized among older women than older men 93. In the study of older patients admitted to the Mayo Inpatient Addiction Program in 1974–93, female gender appeared to be a risk factor for prescription drug dependence 88. Persistent pain, depression, and isolation can predispose older adults to benzodiazepine use and dependence 94, 95. Benzodiazepine dependence can be a complication among older adults with alcohol dependence 91. Benzodiazepine abuse is rarely an isolated practice and more generally occurs with alcohol or other substances 49.

Prescription benzodiazepine use disorders can lead to neuropsychiatric and medical morbidity in older adults. The cognitive effects of benzodiazepines are well known 96, such as anterograde amnesia, diminished short-term recall, increased forgetfulness 95, confusion 97, and deficits in visuospatial learning, processing speed, and verbal learning 96. Benzodiazepine dependence can lead to dementia, depression, and anxiety 94, 95. Symptoms such as agitation, anxiety, confusion, delirium, and seizures can occur during withdrawal after a sudden cessation or decrease in dosage among patients with benzodiazepine dependence 95. Thus, either acute/chronic intoxicating effects or withdrawal symptoms from benzodiazepine use disorders may complicate medical and psychiatric assessment in older adults.

Intervention Strategies

The above findings highlight the need to develop intervention strategies aimed at older adults with prescription use disorders. Table 3 summarizes strategies for the screening, evaluation, and management of prescription abuse in this population. Barriers to effective substance abuse screening include limitations imposed by the clinician (lack of time, lack of knowledge, discomfort discussing the problem) and the patient (denial, discomfort discussing the problem) 98. For example, in a medical setting, the Severity of Dependence Scale may be a useful screen for identifying benzodiazepine dependence in current benzodiazepine users 49, 99, although further evidence specifically in older adults is needed 94. In the context of a psychiatric setting, it is important for clinicians to be aware that the DSM-IV-TR criteria for substance abuse/dependence may suffer from lower diagnostic sensitivity in older adults 100. For example, as we have seen, a sense of fewer responsibilities due to freedom from children and a career 14, may mean that older adults may not meet the criterion of a failure to fulfill major role obligations at work or home, as listed in the DSM-IV-TR 100.

Table 3.

Intervention Strategies for Older Adults with Prescription Use Disorders.

1. Be aware that barriers to effective substance abuse screening include limitations imposed by the clinician and the patient 98.
2. Be aware that the DSM-IV-TR criteria for substance abuse/dependence may have lower sensitivity in older adults 100.
3. For atypical or nonspecific presentations of medical illnesses, consider substance abuse in the differential diagnosis 101.
4. Urine toxicology screening can be helpful as a screening tool and as a confirmation of self- report 13.
5. Optimize treatment of comorbid psychiatric and medical illnesses and age-related functional limitations 101.
6. Detoxification management may be needed in a safe inpatient medical setting 13, for which the threshold should be lower in older adults due to safety concerns.
7. Psychotherapeutic interventions can include individual, family, and group therapies, and the comprehensive SBIRT model (Screening, Brief Intervention, Referral to Treatment) has been developed for use in medical settings 100.
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Medical illnesses such as pneumonia, congestive heart failure, and transient ischemic attacks, can present atypically or nonspecifically in older adults, and substance abuse must be considered in the differential diagnosis of such presentations 101. Recognizing the possibility of occult prescription use disorders in any setting is also important. For example, institutionalized older adults in skilled nursing facilities can have substance use disorders 101, and the “visitor supplier” should not be missed 101. Urine toxicology screening can also be helpful as a screening tool and as a confirmation of self-report 13.

Treatment interventions for the prescription substance use disorder(s) should take place within the context of a biopsychosocial treatment plan. Comorbid psychiatric and medical illnesses and age-related functional limitations, such as vision or hearing loss, should be considered when designing a treatment plan 101, and treatment of such illnesses should be optimized. Pharmacological interventions can include a gradual tapering strategy, which may be appropriate for benzodiazepines, to prevent acute withdrawal symptoms 95, 102. In the case of opioids or benzodiazepines, physiological dependence may require a medical management of withdrawal symptoms 13, and the threshold for choosing an inpatient setting should be lower in older adults because of safety concerns. Psychotherapeutic interventions can include individual, family, and group therapies 100. Self-help groups such as the 12-Step peer support model can also be beneficial 13. The comprehensive SBIRT model (Screening, Brief Intervention, Referral to Treatment) has been developed for use in medical settings 100. The “Screening” component involves assessing the severity of substance use and identifying the appropriate level of intervention/treatment 100. The “Brief Intervention” component involves a focus on increasing insight and awareness of substance use and motivation for behavioral change 100. The “Referral to Treatment” component involves providing patients identified as needing more treatment access to specialized care as necessary 100.

Future Directions

Prescription use disorders are prevalent in older adults and lead to significant neuropsychiatric and medical morbidity. Yet, in many clinical settings, these substance use disorders are inadequately assessed. Structured screening tools represent an important strategy to enhance clinical detection of such disorders in this age group. Guidelines for appropriate use of structured clinical instruments to detect prescription use disorders might lead to revised estimates of the prevalence of these disorders in clinical settings such as primary care, pain, and psychiatric clinics. Such revised population-based and clinic-based estimates could further inform efforts to develop targeted treatment strategies for prescription use disorders in older adults.

We have reviewed a number of studies which have identified risk factors and consequences of prescription opioid and benzodiazepine use disorders in older adults. Comparable data on such features for prescription stimulant use disorders in this older population are largely lacking, warranting further study.

Future areas of focus for prescription stimulant use disorders in older adults include further delineation of the course and pattern of use during an older adult’s lifetime, careful characterization of comorbid neuropsychiatric and medical disorders, and age-specific pharmacological and nonpharmacological interventions. For example, diagnoses such as attention-deficit/hyperactivity disorder (ADHD) are prevalent in adults and may warrant the use of stimulant medications 103. To date, there are quite limited data on ADHD in older adults; the question of whether this diagnosis represents a risk factor for stimulant abuse in older age remains to be explored. Older adults continue to undergo hormonal changes, such as a decrease in total and free testosterone, and an increase in parathyroid hormone 104; whether hormonal changes have any role in stimulant use disorders in older adults is not fully known. Various cognitive deficits occur with stimulant use disorders 105. Given the importance of cognitive function in older adults, it is not fully known whether pharmacological and/or nonpharmacological interventions specific to older adults are necessary to remediate such cognitive deficits.

The projected numbers of older adults in the U.S. will likely have a significant impact on the healthcare workforce in the future, and the number of older adults in need of substance abuse treatment has been estimated to be increasing. Symptoms of substance abuse/dependence may be less evident in older adults due to the decreased demands for functional role performance, and it is important for clinicians and researchers to be alert for the presence of substance abuse in older adults. Commitment to including older adults in substance abuse treatment and non-treatment research trials can help in generating evidence-based guidelines for the growing problem of substance use disorders in older adults.

Footnotes

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Contributor Information

Raj K. Kalapatapu, Email: kalapat@pi.cpmc.columbia.edu, New York State Psychiatric Institute, Columbia University, Substance Use Research Center, Unit 66, 1051 Riverside Drive, New York, NY 10032, Phone: 212-543-5447, Fax: 212-543-6018.

Maria A. Sullivan, New York State Psychiatric Institute, Columbia University, Substance Use Research Center, Unit 66, 1051 Riverside Drive, New York, NY 10032.

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