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. Author manuscript; available in PMC: 2023 Nov 1.
Published in final edited form as: J Psychoactive Drugs. 2021 Nov 25;54(5):440–451. doi: 10.1080/02791072.2021.2009068

Demographic and Clinical Correlates of Treatment Completion among Older Adults with Heroin and Prescription Opioid Use Disorders

Namkee G Choi 1,*, Diana M DiNitto 1, C Nathan Marti 1, Bryan Y Choi 2
PMCID: PMC9130343  NIHMSID: NIHMS1766938  PMID: 34818983

Abstract

In this study using 2015–2018 Treatment Episode Data Set-Discharge (TEDS-D) cases age 55+ for heroin (N=101,524) or prescription opioids (PO; N=25,510) as the primary substance, we examined treatment completion rates and correlates. We fit separate logistic regression models for heroin and PO cases with treatment completion status (completed vs. discontinued due to dropout/termination/other reasons) for each treatment setting (detoxification, residential rehabilitation, and outpatient) as the dependent variable. Results show that detoxification cases had the highest completion rates and outpatient cases had the lowest (14.8% for heroin and 24.0% for PO cases). A consistently significant correlate of treatment completion was legal system referral for heroin cases and having a bachelor’s degree for PO cases. Medication-assisted therapy was associated with higher odds of completing residential treatment for both types of opioids but lower odds of completing detoxification and outpatient treatment. Treatment duration >30 days tended to have higher odds of completion. PO cases age 65+ had higher odds of completing residential treatment than cases age 55–64. Racial/ethnic minorities tended to have lower odds of outpatient treatment completion. Study findings underscore the importance of helping older adults complete treatment, especially those who are racial/ethnic minorities and receiving outpatient treatment.

Keywords: Older adults, heroin, opioid use disorder, substance use treatment, detoxification, medication-assisted therapy

Introduction

Older adults are a significant share of Americans affected by the nonprescription and prescription opioid epidemic. A study based on the 2004–2015 Treatment Episode Data Set-Admissions (TEDS-A) found that the proportion of cases age 55+ admitted for opioid use disorder for the first time rose steadily between 2004 and 2013, then rapidly between 2013 and 2015, during which the increase in older-adult admissions, especially those for heroin as the primary substance, outpaced the increase in younger-adult admissions (Huhn et al., 2018). Treatment admissions age 55+ for heroin as the primary substance nearly tripled between 2007 and 2017, and that the share of those with late onset (i.e., initiation age ≥30) heroin use disorder increased faster than the share of those with typical onset (i.e., initiation age <30) heroin use disorder between 2015 and 2017 (Lynch et al., 2020). Compared to typical-onset cases, late-onset cases used heroin more frequently although they were less likely to inject it (Lynch et al., 2020).

The number of opioid prescriptions for adults decreased after the 2016 release of the Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for chronic pain (Bohnert et al., 2018; CDC, 2020; Dowell et al., 2016). However, prescription rates for older adults remain high, in part due to their higher rates of chronic pain compared to younger age groups (Dahlhamer et al., 2016; Domenichiello & Ramsden, 2019). In 2017, 17.4% of Americans received at least one opioid prescription, with an average of 3.4 opioid prescriptions per patient (CDC, 2019). In comparison, 31% of Medicare beneficiaries received at least one opioid prescription through the Part D program, with an average of 5.4 prescriptions per patient (Office of Inspector General [OIG], 2018). The OIG report also shows that in 2017, one in 10 Part D beneficiaries received opioids for at least 3 months, despite limited evidence supporting long-term opioid use for pain management (O’Brien & Wand, 2020; Volkow et al., 2018). The decrease in opioid prescribing was concentrated among adults with shorter-term rather than longer-term prescriptions (Olfson et al., 2020). Emergency department visit and poison control center call data showed sharp increases in older-adult cases involving prescription opioid misuse between 2006 and 2014 (Carter et al., 2019; West & Dart, 2016). With continued high prescription rates, epidemiologic data, 2015–2018, showed that 6.4% of any prescription opioid users age 50+ misused it and 17.3% of misusers had opioid use disorder (Choi et al., 2021a).

Opioid misuse/use disorder among older adults is associated with an increased number of chronic health conditions, greater injury (e.g., fall) risk, and higher rates of alcohol, cannabis, and other substance use disorders, mental disorders, suicidal ideation, and overdose death (Carter et al., 2019; CDC, 2019; Choi et al., 2021a; Schepis et al., 2019). While previous studies show increasing treatment admissions for opioid use disorder among older adults, research on their opioid use treatment completion, outcomes, and correlates is limited. A systematic review of four studies (all published between 2004 and 2009) did find that older adults had longer opioid use treatment durations and achieved better outcomes (e.g., fewer positive urine results) than younger adults and that older women achieved better outcomes than older men (Carew & Comiskey, 2018). However, another study comparing older (age 50+) and younger adults who received integrated substance use and mental health treatment services at two private facilities offering residential and outpatient services found that older adults remained in treatment for a shorter time and that their treatment retention was negatively associated with psychiatric problems (depression, suicide attempts, hallucinations, cognitive problems) (Morse et al., 2015). Other studies also found that co-occurring psychiatric disorders and polysubstance use, as well as racial/ethnic minority status and treatment at facilities located in regions other than the Northeast, were associated with a lower likelihood of older adults’ substance use treatment completion, but higher education and criminal justice referrals/legal mandate were associated with a higher likelihood (Choi & DiNitto, 2020; Pickard et al., 2020).

Though not specific to older adults, unstable housing has been identified as another barrier to substance use treatment engagement and compliance (Ibabe et al., 2014). TEDS-D data (2015–2017) also showed that medication-assisted therapy (MAT) was associated with an increased likelihood of short-term (length of stay 11–90 days) but a decreased likelihood of long-term (length of stay >90 days) residential treatment completion (Stahler & Mennis, 2020). However, MAT availability and use are sparse in residential addiction treatment facilities (Hyun et al., 2020; Shen et al., 2020; Stahler & Mennis, 2020) despite evidence supporting its efficacy (Bell & Strang, 2019; Coffa & Snyder, 2019; Dong et al., 2020; Moore et al., 2019).

In this study of treatment completion among TEDS-D (Discharge) cases age 55+ with heroin or prescription opioids (PO hereafter) as the primary substance, we examined: (1) treatment completion rates by different treatment settings (detoxification, residential, and outpatient); and (2) demographic factors, substance use patterns, and treatment characteristics associated with treatment completion, as opposed to treatment discontinuation, in each treatment setting. Study hypotheses were: (1) older age (65+), female gender, being married, college degree, supervised or independent housing, legal system referral, opioid initiation ≥age 30, MAT, and longer treatment stays (>30 days) will be positively correlated with treatment completion, while (2) other census regions compared to the Northeast, racial/ethnic minority status, non-oral routes of administration, co-occurring psychiatric disorders, prior substance use treatment and higher frequency use at admission (proxies for addiction severity), and co-use of alcohol or illicit drugs will be negatively correlated with treatment completion. This study fills gaps in research on opioid treatment among older adults by providing insights into correlates of their treatment completion.

Methods

Data and sample

TEDS-D includes annual data on discharges from publicly-funded substance use treatment programs. Programs report data to state substance abuse agencies, which in turn report to the Substance Abuse and Mental Health Services Administration (SAMHSA). Data collected at admission and discharge are included, with treatment discharge status as the unit of analysis (i.e., each case represents a single discharge episode; SAMHSA, 2020). A few states do not participate in TEDS-D every year. Georgia, Oregon, South Carolina, Washington, and West Virginia did not participate in one or all years in 2015–2018.

We included 2015–2018 data to increase the sample size of discharges age 55+. During these four years, a total of 6,205,934 discharges (1,420,316 in 2015; 1,458,045 in 2016; 1,661,207 in 2017; and 1,666,366 in 2018) were recorded. Of them, those age 55+ were 8.0%, 8.5%, 9.2%, and 10.1% in 2015, 2016, 2017, and 2018, respectively. Of the 2015–2018 combined cases, 7.9% (n=492,290) and 1.1% (n=66,128) were ages 55–64 and 65+, respectively. Of discharges age 55+, 18.2% (n=101,524) and 4.6% (n=25,510) involved heroin and PO, respectively, as the primary substance at admission, and these cases were the focus of this study.

Measures

Heroin and PO:

In addition to heroin, PO includes buprenorphine, codeine, hydrocodone, hydromorphone, meperidine, morphine, opium, oxycodone, pentazocine, propoxyphene, tramadol, and any other drug with morphine-like effects.

Treatment setting at discharge:

This included ambulatory detoxification; 24-hour inpatient hospital or free-standing residential detoxification; short-term (≤30 days) and long-term (>30 days) residential rehabilitation; residential rehabilitation; and nonintensive and intensive outpatient treatment. In this study, we grouped these settings into three categories: detoxification; residential rehabilitation; and outpatient treatment.

Reason for discharge:

Reasons included completion of all parts of the treatment plan or program; transfer to another substance use treatment program, provider, or facility within a treatment episode for continuation of treatment; dropout (left against professional advice); treatment terminated by action of facility generally due to client non-compliance or violation of rules, laws, or procedures; incarceration/house confinement; death; and other (moved, illness, hospitalization, or other reason that may have been out of the client’s control) (SAMHSA, 2020). In this study, we grouped these reasons into three categories: (1) treatment completion, (2) transfer, and (3) treatment discontinuation (dropout, termination, and other reasons for not completing treatment).

Census region and demographics at admission:

Census regions were Northeast, Midwest, Southwest, West, and U.S. territories. Demographic factors were age group (55–64 and 65+); gender; race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, Other); marital status (never married, married, separated/divorced/widowed); education (<12 years, 12 years, some college, bachelor’s degree or higher); living arrangement (homeless [no fixed address or living at a shelter], living in a supervised setting, independent living).

Treatment referral sources were self or other individual (e.g., family/friend); alcohol/drug use care provider; other healthcare professional (physician, psychiatrist, other licensed healthcare provider, general or psychiatric hospital, mental health program, or nursing home); employer/employee assistance program (EAP)/school/other community entity, including social service and religious organizations and self-help groups; and legal systems (court/criminal justice referral/DUI [driving under the influence]).

Substance use patterns at admission:

(1) First age of use (≥30 years [oldest age category included in the data set] vs. <30 years); (2) any previous drug and/or alcohol treatment episode (yes, no/missing); (3) usual route of administration (inhalation, injection, oral, smoking, or other); (4) past-month use frequency (no use, some use, daily use, missing); (5) presence of a psychiatric problem (based on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders or the World Health Organization’s International Classification of Diseases [yes, no/missing]); and (6) other substance use (alcohol, cocaine/crack, cannabis, nonprescription methadone, methamphetamine/amphetamine/other stimulants, and benzodiazepines/other tranquilizers).

Treatment characteristics:

(1) MAT (whether medication for opioid use disorder such as methadone, buprenorphine, or naltrexone was part of the client’s treatment plan); and (2) length of stay in treatment (1–30, 31–90, 91–180, 181–365, or 365+ days).

Analysis

All analyses were conducted with Stata 17/MP. We first used χ2 tests to compare heroin and PO cases in terms of: (1) treatment settings, discharge reasons, demographic factors, treatment referral sources, substance use patterns at admission, and treatment-related characteristics; and (2) rates of treatment completion, transfer, and discontinuation in each treatment setting (detoxification, residential rehabilitation, and outpatient). Then, focusing on cases that completed or discontinued treatment, we fit separate logistic regression models for heroin and PO cases with treatment completion status (completed vs. discontinued) for each treatment setting as the dependent variable and demographic factors, use patterns, and treatment characteristics as the independent variables. We excluded transferred cases from multivariable logistic regression models given the possible overlap between them and completed cases in TEDS-D. Logistic regression results are presented as adjusted odds ratios (AOR) with 95% confidence intervals (CI). Statistical significance was set at p<.05.

Results

Treatment settings at discharge, discharge reasons, demographics, and referral sources

Table 1 shows that the number of heroin (80%) or PO (20%) case discharges steadily increased between 2015 and 2018. At discharge, 26.6% of heroin and 19.9% of PO cases were at detoxification settings; 13.7% of heroin and 11.9% of PO cases were at residential rehabilitation; and 62.7% of heroin and 54.8% of PO cases were at outpatient settings. The overall treatment completion rate was 32.9% for heroin and 35.5% for PO cases.

Table 1.

Characteristics of discharge cases age 55+, 2015–2018, with heroin or prescription opioids as the primary substance at admission

Heroin 101,524 (79.92%) Prescription opioids 25,510 (20.08%) p
n % n %
Discharge year <.001
2015 20,530 20.22 4,869 19.09
2016 22,565 22.23 5,569 21.83
2017 29,026 28.59 7,291 28.58
2018 29,403 28.96 7,781 30.50
Treatment setting at discharge <.001
Residential or ambulatory detoxification 27,036 26.63 5,082 19.92
Residential rehabilitation 13,918 13.71 3,043 11.93
Outpatient 60,570 59.66 17,385 68.15
Reason for discharge <.001
Treatment completed 33,436 32.93 9,038 35.43
Transferred for continued treatment 22,022 21.69 6,769 26.53
Treatment discontinuedb 46,066 45.37 9,703 38.04
Census region of residence <.001
Northeast 46,023 45.33 7,318 28.69
Midwest 19,246 18.96 4,175 16.37
South 13,865 13.66 8,251 32.34
West 22,233 21.90 5,766 22.60
US territories 157 0.15 0 0
Age 65+ years 11,079 10.91 2,907 11.40 .028
Male 76,915 75.76 14,608 57.26 <.001
Race/ethnicity <.001
Non-Hispanic White 30,587 30.13 18,925 74.19
Non-Hispanic Black 43,711 43.05 2,972 11.65
Hispanic 21,045 20.73 2,175 8.53
Other 6,181 6.09 1,438 5.64
Marital status <.000
Never married 33,296 32.80 4,649 18.22
Married 9,286 9.15 4,989 19.56
Separated, divorced, or widowed 26,412 26.02 9,185 36.01
Missing 32,530 32.04 6,687 26.21
Education <.001
≥11 years 33,046 32.55 5,137 20.14
12 years or GED 44,235 43.57 11,005 43.14
Some college 16,816 16.56 5,769 22.61
Bachelor’s degree or higher 4,638 4.57 2,475 9.70
Missing 2,789 2.75 1,124 4.41
Living arrangement at admission
Homeless 17,790 17.52 1,715 6.72
Supervised housing 13,723 13.52 2,579 10.11
Independent housing 67,593 66.58 20,003 78.41
Missing 2,418 2.38 1,213 4.75
Treatment referral source <.001
Individual, including self-referral 68,219 67.19 15,455 60.58
Alcohol or drug use care provider 13,826 13.62 2,429 9.52
Other healthcare professional 4,660 4.59 3,137 12.30
Employer/EAP/community program 5,613 5.53 1,590 6.23
Legal systema 7,741 7.62 2,494 9.78
Missing 1,465 1.44 405 1.59
Age at first use <.001
29 years or younger/missing 68,980 67.94 8,225 32.24
30+ years 32,544 32.06 17,285 67.76
Previous substance use treatment episode <.001
None 18,863 18.58 9,747 38.21
One or more times 70,527 69.47 13,635 53.45
Missing 12,134 11.95 2,128 8.34
Past month use frequency at admission <.001
No use 14,966 14.74 5,936 23.27
Some use 14,292 14.08 4,034 15.81
Daily use 63,600 62.65 13,980 54.80
Missing 8,666 8.54 1,560 6.12
Usual route of administration <.001
Inhalation 46,932 46.23 2,116 8.29
Injection 49,792 49.04 1,676 6.57
Oral 1,049 1.03 20,622 80.84
Smoking 2,387 2.35 460 1.80
Other/missing 1,364 1.34 636 2.49
Co-occurring mental and substance use disorders 30,966 30.53 9,635 37.77 <.001
Other substance use reported at admission
Heroin 1,665 6.53
Other opiates 5,385 5.30
Non-prescription methadone 996 0.98 226 0.89 .164
Alcohol 19,438 19.15 5,019 19.67 .056
Cocaine/crack 25,238 24.86 2,100 8.23 <.001
Cannabis 8,218 8.09 2,292 8.98 <.001
Methamphetamine/amphetamines/other stimulants 4,958 4.88 1,053 4.13 <.001
Benzodiazepines/other tranquilizers 4,464 4.40 2,668 10.46 <.001
Medication assisted opioid therapy 48,763 48.03 8,434 33.06 <.001
Length (days) of stay in treatment <.001
1–30 52,164 51.38 13,698 53.70
31–90 13,895 13.69 4,011 15.72
91–180 10,641 10.48 2,864 11.23
181–365 9,518 9.38 2,192 8.59
366+ 15,305 15.08 2,745 20.08
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a

Courts, adjudication process, probation/parole, diversionary programs, prison, DUI, and other legal sources

b

Due to dropout, termination by the facility, or other discontinuation due to incarceration, hospitalization, and death

The highest proportion (45.3%) of heroin cases was in the Northeast, whereas the highest proportion (32.3%) of PO cases were in the South. For both substances, the majority of cases were age 55–64 years and male. Non-Hispanic Whites were 30.1% of heroin cases but 74.2% of PO cases. The majority of heroin cases were non-Hispanic Blacks (43.1%) and Hispanics (20.7%). Compared to heroin cases, higher proportions of PO cases were married, had high school or higher education, and lived in independent housing). Referral sources show that 4.6% of heroin and 12.3% of PO cases were healthcare professional referrals, and 7.6% of heroin and 9.8% of PO cases were legal system referrals.

Substance use patterns and treatment characteristics

Table 1 also shows that 67.9% of heroin cases reported initiation age <30 years, whereas 67.8% of PO cases reported initiation age ≥30 years, with 69.5% of heroin and 53.5% PO cases having at least one prior substance use treatment episode. In the month prior to their admission, 63.7% of heroin and 54.8% of PO cases reported daily use. Inhalation and injection were the two most common routes of administration for heroin cases, while oral intake was the most prevalent for PO cases. Co-occurring psychiatric disorders were reported for 30.5% of heroin and 37.8% of PO cases. Both heroin and PO cases had similar rates of alcohol (one in five) and cannabis (less than one in ten) use; however, heroin cases had a higher rate of cocaine/crack use (24.9% vs. 8.2% of PO cases), and PO cases had a higher rate of benzodiazepine/other tranquilizer use (10.5% vs. 4.4% of heroin cases). MAT was part of the treatment plan for 48.0% of heroin and 33.1% of PO cases. For both heroin and PO cases, slightly more than half were in treatment 1–30 days, while 15.1% of heroin and 20.1% of PO cases were in treatment more than 365 days.

Discharge reason by treatment setting

Table 2 shows that treatment completion rates varied substantially by treatment setting. Completion was highest for detoxification (a little over 60% for both heroin and PO cases), followed by residential rehabilitation (a little over 50% for both heroin and PO cases) and outpatient care (14.8% for heroin and 24.0% for PO cases).

Table 2.

Reason for discharge by treatment setting

Heroin 101,524 (79.92%) Prescription opioids 25,510 (20.08%) p
n % n %
Detoxification .002
Treatment completed 17,165 63.49 3,201 62.99
Transferred 4,066 15.04 807 15.88
Treatment discontinueda 5,805 21.47 1,074 21.23
Residential rehabilitation <.001
Treatment completed 7,323 52.62 1,672 54.95
Transferred 1,946 13.98 526 17.29
Treatment discontinueda 4,649 33.40 845 27.77
Outpatient <.001
Treatment completed 8,948 14.77 4,165 23.96
Transferred 16,010 26.43 5,436 31.27
Treatment discontinueda 35,612 58.79 7,784 44.77
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a

Due to dropout, termination by the facility, or other discontinuation due to incarceration, hospitalization, and death

Correlates of treatment completion among heroin cases by treatment setting

Table 3 shows that compared to cases in the Northeast region, those in the Midwest and South had lower odds of treatment completion in all three treatment settings. Legal system referrals, compared to self/other individual referrals, was associated with higher odds of treatment completion in all three settings (AOR=1.46, 95% CI=1.11–1.91 for detoxification, AOR=1.16, 95% CI=1.01–1.33 for residential settings, and AOR=1.78, 95% CI=1.64–1.94 for outpatient settings); however, referrals from employer/EAP/community sources for residential treatment and from healthcare professionals for outpatient treatment were associated with lower odds of treatment completion. No other factor was significant across all three settings.

Table 3.

Correlates of treatment completion for heroin as the primary substance in each treatment setting

Treatment completion vs. discontinuation
Detoxification AOR (95% CI) Residential treatment AOR (95% CI) Outpatient treatment AOR (95% CI)
Regiona: vs. Northeast
Midwest 0.56 (0.50–0.63)*** 0.41 (0.37–0.46)*** 0.47 (0.44–0.52)***
South 0.77 (0.69–0.87)*** 0.73 (0.63–0.84)*** 0.61 (0.56–0.67)***
West 0.45 (0.34–0.62)*** 1.02 (0.81–1.28) 0.92 (0.83–1.02)
Age 65+ vs. 55–64 1.11 (1.01–1.24)* 0.96 (0.83–1.10) 1.07 (0.98–1.16)
Male vs. female 0.90 (0.83–0.98)* 0.95 (0.85–1.02) 0.96 (0.91–1.02)
Race/ethnicity: vs. Non-Hispanic White
Non-Hispanic Black 1.33 (1.23–1.44)*** 0.99 (0.89–1.10) 0.80 (0.75–0.86)***
Hispanic 1.05 (0.96–1.14) 0.94 (0.83–1.06) 0.77 (0.71–0.83)***
Other 1.87 (1.62–2.16)*** 0.81 (0.69–0.96)* 0.87 (0.76–0.99)*
Marital status: vs. Never married
Married 0.92 (0.80–1.06) 1.24 (1.08–1.42)** 1.17 (1.08–1.27)***
Separated/divorced/widowed 0.95 (0.87–1.05) 1.08 (0.99–1.18) 0.93 (0.87–0.99)*
Missing 1.44 (1.23–1.69)*** 0.84 (0.67–1.04) 0.79 (0.72–0.87)***
Education: vs. <High school
High school/GED 0.95 (0.88–1.02) 1.20 (1.09–1.31)*** 1.22 (1.15–1.30)***
Some college 0.97 (0.88–1.06) 1.20 (1.07–1.35)** 1.11 (1.03–1.21)**
Bachelor’s degree or higher 1.15 (0.98–1.35) 1.13 (0.93–1.38) 1.03 (0.90–1.17)
Missing 1.19 (0.96–1.47) 0.53 (0.36–0.77)** 2.47 (2.09–2.91)**
Living arrangement at admission: vs. Homeless
Supervised housing 1.19 (1.04–1.35)* 1.02 (0.91–1.14) 1.42 (1.28–1.57)***
Independent housing 0.75 (0.69–0.80)*** 1.11 (1.02–1.22)* 0.98 (0.90–1.07)
Missing 0.46 (0.34–0.62)*** 0.63 (0.42–0.96)* 3.88 (3.23–4.67)***
Referral source: vs. Individual or self
Alcohol/drug use care provider 1.11 (0.99–1.25) 0.98 (0.89–1.08) 1.01 (0.92–1.10)
Other healthcare professional 1.28 (1.09–1.51)** 0.98 (0.82–1.17) 0.75 (0.66–0.85)***
Employer/EAP/community program 1.54 (1.29–1.84)*** 0.85 (0.73–0.98)* 0.97 (0.87–1.07)
Legal system 1.46 (1.11–1.91)** 1.16 (1.01–1.33)* 1.78 (1.64–1.94)***
Missing 1.16 (0.92–1.46) 1.14 (0.78–1.68) 1.20 (0.99–1.46)
First use at age 30+ vs. <30 1.02 (0.96–1.09) 1.01 (0.93–1.10) 1.08 (1.02–1.15)**
Prior treatment episode: vs. None
One or more times 1.22 (1.10–1.34)*** 1.01 (0.89–1.14) 0.91 (0.86–0.97)**
Missing 1.03 (0.87–1.22) 2.26 (1.57–3.24)*** 1.00 (0.84–1.19)
Use frequency in month before admission: vs. No use
Some use 1.15 (0.87–1.52) 1.04 (0.89–1.21) 0.61 (0.57–0.66)***
Daily use 0.68 (0.53–0.88)** 0.96 (0.84–1.09) 0.50 (0.47–0.54)***
Missing 2.17 (1.41–3.34)*** 1.26 (1.06–1.50)* 0.59 (0.54–0.65)***
Route of administration: vs. Other
Inhalation 1.13 (0.96–1.33) 0.95 (0.78–1.17) 1.05 (0.94–1.18)
Injection 0.90 (0.77–1.06) 1.02 (0.84–1.25) 1.17 (1.05–1.31)**
Co-occurring psychiatric problem vs. none/missing 1.00 (0.92–1.10) 0.97 (0.90–1.05) 0.95 (0.90–1.01)
Other substance used at admission vs. No use
Other opiates and synthetics 1.19 (1.01–1.39)* 1.18 (0.98–1.42) 1.05 (0.94–1.16)
Alcohol 1.09 (1.01–1.17)* 1.10 (1.01–1.20)* 0.90 (0.84–0.96)**
Cocaine/crack 1.18 (1.09–1.28)*** 1.03 (0.95–1.12) 0.97 (0.92–1.04)
Cannabis 0.92 (0.81–1.05) 0.92 (0.80–1.04) 0.90 (0.83–0.98)*
Methamphetamine/amphetamine/other stimulants 1.01 (0.83–1.23) 1.33 (1.07–1.67)* 0.86 (0.76–0.97)*
Benzodiazepine/other tranquilizers 0.86 (0.77–0.97)* 1.06 (0.90–1.24) 1.03 (0.89–1.20)
Medication-assisted therapy vs. None/missing 0.56 (0.51–0.62)*** 1.13 (1.03–1.25)* 0.30 (0.28–0.32)***
Length of stay in treatmentb: vs. 1–30 days
31–90 days 1.78 (1.59–1.99)*** 1.08 (0.99–1.17)
91–180 days 1.60 (1.37–1.88)*** 1.89 (1.74–2.06)***
181–365 days 1.88 (1.56–2.27)*** 2.00 (1.84–2.19)***
More than a year 2.91 (2.16–3.92)*** 1.81 (1.66–1.97)***
Model statistics N=22,969; Likelihood ratio χ2= 1330.20 (df=39), p<.001 N=11,967 Likelihood ratio χ2= 809.73 (df=43), p<.001 N=44,418 Likelihood ratio χ2= 6033.02 (df=43), p<.001
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a

Due to small numbers, cases from US territories were deleted from multivariable models.

b

Not entered for detoxification because 97.3% were short term (<30 days) stays.

*

p<.05

**

p<.01

***

p<.001

Men had lower odds of completing detoxification than women; being Black or of “Other” race/ethnicity was associated with higher odds of completing detoxification, but all racial/ethnic minority groups had lower odds of completing outpatient treatment. Married status was associated with higher odds of completing residential and outpatient treatment, but divorced/separated or widowed states were associated with lower odds of completing outpatient treatment. Education up to some college was associated with higher odds of completing residential and outpatient treatment; supervised housing was associated with higher odds of completing detoxification and outpatient treatment, and independent housing was associated with higher odds of completing residential treatment.

First use at age 30+ was associated with higher odds of completing outpatient treatment. Prior treatment was associated with higher odds of completing detoxification; however, prior treatment and higher use frequencies were associated with lower odds of completing outpatient treatment. Injection was associated with higher odds of completing outpatient treatment only. Co-use of benzodiazepine was associated with lower odds of completing detoxification. Co-use of alcohol and methamphetamine/amphetamines was associated with higher odds of completing residential treatment, but they and cannabis co-use were associated with lower odds of completing outpatient treatment. MAT was associated with higher odds of completing residential treatment but lower odds of completing detoxification and outpatient treatment. Length of stay >30 days was associated with higher odds of completing residential and outpatient treatment.

Correlates of treatment completion among PO cases by treatment setting

Table 4 shows that cases in the Midwest, compared to those in the Northeast, had lower odds of treatment completion in all three settings. Those in the South also had lower odds in detoxification and residential settings but higher odds in outpatient settings. Those in the West had lower odds in detoxification but higher odds in outpatient settings. Having a college degree was associated with higher odds of treatment completion in all three settings (AOR=1.67, 95% CI=1.16–2.13 for detoxification, AOR=1.50, 95% CI=1.08–2.10 for residential settings, and AOR=1.51, 95% CI=1.29–1.77 for outpatient settings). No other factors were significant for all three settings.

Table 4.

Correlates of treatment completion for prescription opioids as the primary substance in each treatment setting

Treatment completion vs. discontinuation
Detoxification AOR (95% CI) Residential treatment AOR (95% CI) Outpatient treatment AOR (95% CI)
Region: vs. Northeast
Midwest 0.27 (0.21–0.37)*** 0.39 (0.30–0.51)*** 0.53 (0.47–0.61)***
South 0.31 (0.25–0.39)*** 0.48 (0.37–0.62)*** 1.03 (0.92–1.16)***
West 0.35 (0.26–0.46)*** 0.93 (0.65–1.32) 1.29 (1.12–1.49)***
Age 65+ vs. 55–64 0.91 (0.74–1.13) 1.39 (1.03–1.86)* 1.08 (0.95–1.23)
Male vs. female 0.82 (0.70–0.95)* 0.94 (0.78–1.13) 1.13 (1.04–1.23)**
Race/ethnicity: vs. Non-Hispanic White
Non-Hispanic Black 1.21 (0.96–1.53) 0.98 (0.74–1.30) 0.79 (0.69–0.92)**
Hispanic 0.98 (0.76–1.26) 1.44 (1.03–2.01)* 1.03 (0.89–1.18)
Other 0.97 (0.69–1.35) 0.59 (0.41–0.85)** 0.76 (0.62–0.93)**
Marital status: vs. Never married
Married 1.25 (0.95–1.63) 1.43 (1.08–1.90)* 1.42 (1.24–1.61)***
Separated/divorced/widowed 1.11 (0.88–1.39) 1.15 (0.91–1.46) 1.17 (1.04–1.32)*
Missing 1.36 (1.00–1.85) 0.98 (0.69–1.39) 0.69 (0.59–0.81)***
Education: vs. <High school
High school/GED 1.25 (1.02–1.52)* 1.11 (0.88–1.42) 1.29 (1.15–1.45)***
Some college 1.16 (0.92–1.46) 1.27 (0.98–1.66) 1.18 (1.04–1.35)*
Bachelor’s degree or higher 1.57 (1.16–2.13)** 1.50 (1.08–2.10)* 1.51 (1.29–1.77)***
Missing 1.84 (1.18–2.84)** 0.80 (0.42–1.54) 2.40 (1.92–2.99)***
Living arrangement at admission: vs. Homeless
Supervised housing 1.10 (0.80–1.53) 1.21 (0.89–1.64) 0.91 (0.71–1.15)
Independent housing 0.81 (0.63–1.04) 1.40 (1.07–1.82)* 0.87 (0.70–1.07)
Missing 0.44 (0.25–0.77)** 2.42 (1.28–4.58)** 3.37 (2.48–4.57)***
Referral source: vs. Individual or self
Alcohol/drug use care provider 0.99 (0.76–1.28) 0.82 (0.65–1.03) 1.17 (1.00–1.36)*
Other healthcare professional 0.93 (0.72–1.20) 1.25 (0.93–1.69) 0.92 (0.81–1.04)
Employer/EAP/community source 1.54 (1.08–2.19)* 1.08 (0.77–1.51) 1.31 (1.11–1.54)**
Legal system 2.30 (1.36–3.90)** 1.22 (0.86–1.74) 2.02 (1.78–2.30)***
Missing 0.67 (0.38–1.18) 0.77 (0.41–1.43) 0.84 (0.62–1.13)
First use at age 30+ vs. <30 0.95 (0.80–1.13) 1.01 (0.83–1.22) 1.25 (1.14–1.36)***
Prior treatment episode: vs. None
One or more times 0.88 (0.73–1.06) 1.00 (0.81–1.22) 0.93 (0.86–1.02)
Missing 0.67 (0.51–0.88)** 0.63 (0.35–1.13) 0.79 (0.63–0.98)*
Use frequency in the month before admission: vs. No use
Some use 0.94 (0.59–1.50) 0.90 (0.65–1.24) 0.61 (0.54–0.69)***
Daily use 0.84 (0.55–1.27) 0.85 (0.64–1.14) 0.63 (0.57–0.70)***
Missing 2.61 (1.17–5.81)* 1.35 (0.83–2.19) 0.85 (0.72–1.00)
Route of administration: Oral vs. other 1.28 (1.05–1.57)* 1.05 (0.84–1.32) 1.06 (0.95–1.18)
Co-occurring psychiatric problem vs. none/missing 0.77 (0.65–0.91)** 0.89 (0.74–1.08) 0.78 (0.71–0.86)***
Other substance used at admission vs. No use
Heroin 0.97 (0.71–1.33) 0.79 (0.56–1.13) 0.90 (0.77–1.07)
Alcohol 1.09 (0.89–1.34) 1.21 (0.99–1.48) 1.06 (0.96–1.18)
Cocaine/crack 1.02 (0.74–1.40) 0.67 (0.50–0.88)** 0.91 (0.78–1.06)
Cannabis 0.83 (0.61–1.12) 1.34 (1.01–1.78) 0.90 (0.79–1.03)
Methamphetamine/amphetamine/other stimulants 1.24 (0.77–1.99) 0.84 (0.59–1.18) 0.92 (0.75–1.14)
Benzodiazepine/other tranquilizers 1.06 (0.87–1.30) 1.13 (0.88–1.44) 1.06 (0.91–1.23)
Medication-assisted therapy vs. None/missing 0.51 (0.41–0.62)*** 1.33 (1.01–1.77)* 0.47 (0.43–0.52)***
Length of stay in treatmenta: vs. 1–30 days
31–90 days 2.04 (1.56–2.66)*** 1.50 (1.33–1.70)***
91–180 days 3.23 (2.00–5.21)*** 1.99 (1.76–2.26)***
181–365 days 2.37 (1.18–4.78)* 2.33 (2.03–2.66)***
More than a year 0.41 (0.14–1.16) 1.93 (1.69–2.21)***
Model statistics N=4,275 Likelihood ratio χ2=353.31 (df=38), p<.001 N=2,517 Likelihood ratio χ2=252.20 (df=42), p<.001 N=11,948 Likelihood ratio χ2=1702.89 (df=42), p<.001
Open in a new tab
a

Not entered for detoxification because 95.5% were short term (<30 days) stays.

*

p<.05

**

p<.01

***

p<.001

Those age 65+ had higher odds of completing residential treatment. Men had lower odds in detoxification but higher odds in outpatient settings. Hispanics had higher odds of completing residential treatment; Blacks had lower odds in outpatient settings; and “Other” racial/ethnic groups had lower odds in residential and outpatient settings. Those who were married had higher odds of completing residential and outpatient treatment, and those who were divorced/separated or widowed had higher odds of completing outpatient treatment. Those living in independent housing had higher odds of completing residential treatment.

First use at age 30+ was associated with higher odds of completing outpatient treatment. Referral by a substance use service provider was associated with higher odds of completing outpatient treatment, and referral by an employer/EAP/community source or legal system was associated with higher odds of completing detoxification and outpatient treatment. Higher use frequencies were associated with lower odds of completing outpatient treatment. Oral route of administration was associated with higher odds of completing detoxification. Co-occurring psychiatric problems were associated with lower odds of completing detoxification and outpatient treatment. Co-use of cocaine/crack was associated with lower odds of completing residential treatment. MAT was associated with lower odds of completing detoxification and outpatient treatment but higher odds of completing residential treatment. Treatment duration >30 days was associated with higher odds of completing both residential and outpatient treatment.

Discussion

This TEDS-D-based study shows that the number of discharged cases age 55+ with heroin or PO as the primary substance steadily increased between 2015 and 2018, indicating a corresponding increase in treatment admissions. PO cases grew at a faster rate each year than heroin cases. We also found that heroin and PO cases differed significantly by census region, gender, race/ethnicity, and socioeconomic status (i.e., marital status, education, and living arrangement). The results are largely congruent with previous studies of adults of all age groups. For example, a survey of over 60,000 entrants (average age 34.2 [SD=10.5] years) to 114 opioid treatment programs in 37 U.S. states between 2005 and 2016 found that Blacks and Hispanics reported a much higher prevalence of heroin use and much lower prevalence of PO misuse than Whites (Pouget et al., 2018). Pouget et al. also showed that heroin use increased among Whites and decreased among Blacks, while PO misuse prevalence decreased among Whites and increased among Blacks. The National Inpatient Sample for 2000 to 2014 showed that heroin overdose hospitalizations were highest in the Northeast region and grew fastest in the Midwest while PO overdose-related hospitalization rates were highest in the South and lowest in the Northeast (Unick & Ciccarone, 2017). A CDC report showed that 2019 synthetic opioid overdose death rates were higher in the Northeast and Midwest than other regions (Mattson et al., 2021).

Our findings of substance use patterns suggest that heroin cases were more likely to have been chronic cases with previous treatment episodes and had a higher rate of co-use of cocaine/crack, while PO cases had a higher rate of other prescription drug (in particular, benzodiazepines/other tranquilizers) co-use. These findings are congruent with those of previous studies that showed high co-use rates of heroin with alcohol, cannabis, cocaine/crack, methamphetamines, and/or prescription medication in all age groups (Bobashev et al., 2018) and co-misuse of PO and prescription tranquilizers/sedatives among those age 50+ (Schepis et al., 2020). Addiction severity in our study was also reflected in findings that almost two-thirds of heroin cases and more than one-half of PO cases used the substance daily in the month preceding treatment admission.

Heroin cases referred by legal systems and PO case with a college degree had higher odds of completing treatment in all three treatment settings; however, other correlates of treatment completion varied considerably by treatment setting. For example, heroin and PO cases with treatment duration >30 days had, in general, higher odds of completing residential and outpatient treatment, and those with late onset had higher odds of completing outpatient treatment, but not detoxification and residential treatment. MAT was associated with higher odds of completing residential treatment for both substances but lower odds of completing detoxification and outpatient treatment.

Special attention should be paid to factors associated with outpatient treatment completion because these settings had the lowest completion rate but serve the largest number of heroin and PO cases. Our results show that for both substances, race/ethnicity and education are significant factors, indicating that the odds of treatment completion are greater for those of higher socioeconomic status. For both heroin and PO cases, along with MAT, higher frequency use and co-use of other substances were associated with lower odds of treatment completion. Since MAT requires long-term engagement, those who are socioeconomically disadvantaged and use other substances are likely to face more challenges in continuing engagement. Research shows those who discontinued MAT experienced more adverse events (emergency department visits, hospitalizations, and overdose) before and after discontinuation (Williams et al., 2020). The harm reduction approach of methadone treatment, which is being used more by older than younger age groups, has higher potential for abuse (e.g., accidental overdose) than the other MAT (Neighbors et al., 2019; Oesterle et al., 2019). As a long-term treatment, methadone presents an added challenge for older adults with increasing vulnerability due to medical comorbidity/disability, cognitive impairment, and neurobehavioral changes (Cotton et al., 2018).

PO cases with co-occurring mental disorders were less likely to complete outpatient treatment. While not statically significant, heroin cases with co-occurring mental disorders also appeared to have lower odds. It is not clear if treatments addressed co-occurring mental disorders. Some differences in factors associated with outpatient treatment for heroin and PO also need mentioning. While living arrangement was not a significant factor for PO cases, supervised housing was a positive factor for heroin cases, suggesting that heroin cases likely need supportive housing services to succeed. While referrals from substance use service providers and employer/other community sources were not significant factors for heroin cases, they were for PO cases, suggesting that the latter likely have more formal and informal support. Although there were marital status-related differences, we refrain from interpreting them given the high rates of missing marital status data in both types of opioid cases.

The study has limitations due to data constraints. First, though TEDS-D is the largest data set on treatment discharges, it does not include cases from private sources. Second, each state may have different methods and procedures for collecting data from treatment programs, which may have led to differing definitions of discharge status (e.g., transfer vs. termination by the program) and may also explain the large amount of missing data (e.g., marital status). Third, since TEDS-D cases are discharges, not individuals, potential duplication in discharges and overestimation of polysubstance use is likely, although we controlled for prior treatment episodes in logistic regression models.

The findings underscore challenges involved in treating older adults with opioid use problems, likely reflecting the complex nexus of dependence and addiction, medical and psychiatric comorbidities, chronic pain, polysubstance use, long-term psychosocial dysfunction, and lack of stable housing, material resources, and social support among these older adults who entered treatment for opioid use disorder. The findings also underscore the importance of helping older adults complete treatment, whether aimed at harm reduction or abstinence. Clinical and policy implications are: (1) Supportive housing services for heroin cases are needed for facilitating treatment completion. (2) Disparities in outpatient treatment completion by race/ethnicity and socioeconomic status indicate that more resources should be available for those who may face personal and environmental challenges. To reduce racial disparities that do exist in substance use treatment completion among older adults, others also suggest the need to consider and address cultural, historical, and systemic factors that affect voluntary termination (Suntai et al., 2020). More treatment programs that are specific to older adults are also needed, as only 23% of all treatment facilities in the 2019 U.S. National Survey of Substance Abuse Treatment Services had programs dedicated to older adults (age 65+) (Choi & DiNitto, 2021b). (3) Since racial/ethnic disparities appear to be less pronounced in residential treatment, and MAT is positively associated with residential treatment completion, more opportunities for residential treatment and MAT should be made available. (4) For those with co-occurring mental disorders, pharmacotherapy and/or intensive psychosocial interventions should be instituted early in the course of treatment (Murthy et al., 2019). (5) Research is needed to examine reasons for regional differences in treatment completion for different types of opioids in different treatment settings, which may include drug supply issues, treatment-related regulations, and treatment program factors. (6) More research on effective treatments among the growing numbers of older adults with opioid and other substance use problems is needed.

Acknowledgments

Funding source

This research was supported by grant, P30AG066614, awarded to the Center on Aging and Population Sciences at The University of Texas at Austin by the National Institute on Aging. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

Disclosure of interest

The authors report no conflict of interest.

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