1. Older Adults & Substance Misuse: The Coming Epidemic
Frederic C. Blow, Ph.D.
Professor of Psychiatry, University of Michigan Medical School
Director, University of Michigan Addiction Center
Senior Research Scientist, Center for Clinical Management Research
Ann Arbor VA Healthcare System

2. Disclosure
I receive research grant funding from the US National Institute on Drug Abuse, National Institute on Alcohol Abuse and Alcoholism, National Institute of Mental Health, Department of Defense, and Department of Veterans Affairs. I am the Huss Family/Hazelden Betty Ford Foundation National Research Chair on Older Adults and receive compensation for that role. No other conflicts of interest to disclose.

3. Presentation Outline Aging Population in America
Nature and Extent of the Problem
Drinking Limits
Referral Pathways
Future Workforce Needs

4. Painted in 1890 by Van Gogh inspired by an etching "The Four Ages" by Honoré Daumier

6. The Silver Tsunami
14.5 percent of U.S. population age 65+; expected to increase up to 20 percent by 2030
75 million ‘Baby Boomers’ (born from )
Gen X (now aged 36-51) contains 64 million
Individuals aged 85 and older are the fastest growing segment of the population

7. The Demographic Imperative
‘Baby Boomers’ impact
Roughly 10,000 people will turn 65 today, and about 10,000 more will cross that threshold every day for the next 13 years
By 2030, 1 in 5 Americans will be 65 or older
Enormous pressure on retirement systems, health care facilities, and other services
Major implications for substance abuse and mental health prevention and treatment
Pew Research Center. Baby Boomers Retire. Daily Number December 29, Accessed online at:
U.S. Department of Health and Human Services Administration for Community Living. A Profile of Older Americans: 2015.
Sandra L. Colby and Jennifer M. Ortman The Baby Boom Cohort in the United States: 2012 to 2060: Population Estimates and Projections. 5: p

8. Ethnic/Racial Diversity
Currently, 18% of older adults are members of racial or ethnic minority groups:
8% African American, 6% Latino, 3% Asian or Pacific Islander, and <1% American Indian or Native Alaskans.
By 2030, 26% of older Americans will be members of racial or ethnic minority groups.
Changes in ethnic diversity will affect:
access and barriers to substance abuse prevention and treatment
older adults and care provider dynamics
the need to understand cultural differences in perception of MH/SA problems, care preferences, and response to interventions.
US Administration on Aging

9. What Makes Older Adults Different?
Age-related changes in absorption and metabolism
Interaction of medical conditions, cognitive impairment, functional impairment, and MH/SU conditions
Frequent use of multiple medications both for chronic medical conditions and MH/SU conditions
Goals of care play larger role in health care decisions
Loss and grief are common

10. Substance Use and Misuse in Later Life

11. Rates of Past Month Substance Use in Older Adults
Nicotine - 10%
Alcohol
-Current use (not binge) %
-Binge - 9.1%
-Heavy use (5+ drinks on 5+ days) - 2.1%
Illicit Drugs (Cocaine, marijuana, heroin, hallucinogens, inhalants, and prescribed therapeutic drugs used non- medically) - 3.9%
Substance Abuse and Mental Health Services Administration. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14–4863. Rockville, MD: Substance Abuse and Mental Health Services Administration.

12. Alcohol Use in Older Adults
16.0% of men and 10.9% of women had at-risk drinking (More than 3 drinks on one occasion or more than 7 drinks per week)
1.7% had alcohol use disorder
Up to 22% of older adults have an alcohol use disorder (AUD) within health care settings
Kuerbis, A., Sacco, P., Blazer, D. G., & Moore, A. A. (2014). Substance abuse among older adults. Clinics in geriatric medicine, 30(3),
Choi, N. G., DiNitto, D. M., & Marti, C. N. (2015). Alcohol and other substance use, mental health treatment use, and perceived unmet treatment need: comparison between baby boomers and older adults. The American Journal on Addictions, 24(4),

13. Past Month Illicit Drug Use among Adults Aged 50-64
Illicit drug: cocaine, marijuana, heroin, hallucinogens, inhalants, and prescribed therapeutic drugs used non-medically
Substance Abuse and Mental Health Services Administration. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14–4863. Rockville, MD: Substance Abuse and Mental Health Services Administration.

14. Rate of Past Month Marijuana Use by Age
SAMHSA. Marijuana (Cannabis). Updated Accessed at:

15. Opioid Use and Misuse in Older Adults
Older adults are at the greatest risk of nonmedical use of opioids prescribed directly from their physician because they make more clinic visits and are more likely to be seen for pain than younger patients.
Baby Boomer’s more likely to report the use of psychoactive drugs compared to earlier cohorts.
Increasing suicide rates due to prescription opioid abuse and misuse.
M. Olfson, S. Wang, M. Iza, et al. National trends in the office-based prescription of schedule II opioids. J Clin Psychiatry, 74 (2013), pp. 932–939
Wu, L. T., & Blazer, D. G. (2011). Illicit and nonmedical drug use among older adults: a review. Journal of aging and health, 23(3),
West, N. A., Severtson, S. G., Green, J. L., & Dart, R. C. (2015). Trends in abuse and misuse of prescription opioids among older adults. Drug and alcohol dependence, 149,

16. Substance Abuse Among Older Adults
An estimated one in five older Americans (19%) may be affected by combined difficulties with alcohol and medication misuse.

17. Substance Abuse in Older Adults
The number of adults aged 50 or older with substance use disorders is projected to double from 2.8 million (annual average) in 2002–06 to 5.7 million in 2020.
Substance use disorder among older adults in the United States in Available from: [accessed Oct 28, 2016].

18. Substance Misuse/Abuse in Older Adults
Increased risk of depression and other mental health disorders
Suicide
Falls
Memory problems
Exacerbation of medical conditions (i.e. high blood pressure, diabetes)
Dangerous interactions with prescription medications 

19. Challenges: Substance Abuse in Older Adults
SUD among older adults are often underdiagnosed, misdiagnosed, undertreated or untreated
Insufficient knowledge (mistaken for dementia/Alzheimer’s, depression)
Lack of financial or social support
Denial / social stigma
Diagnostic criteria tend to underestimate prevalence
Shortage of programs designed for older adults
Han, B., Gfroerer, J. C., Colliver, J. D., & Penne, M. A. (2009). Substance use disorder among older adults in the United States in 2020. Addiction,104(1),
Douaihy, A. (2013). Late-Life Substance Use Disorders. Geriatric Psychiatry, 281.

20. Comorbid Mental Health Disorders in Older Adults
Concurrent alcohol use and depression may be more common in late life than in younger adults
Concurrent moderate or at-risk use may be a much greater problem than dependence
Fragmented care is particularly problematic in late life
Blow FC. New findings in alcohol and comorbid mental health disorders in older adults. American Journal of Geriatric Psychiatry, 22(9):851-3, 2014 Sept. (PMID: )

21. Drinking Limits

22. Recommended Drinking Limits for Older Adults
Drinking Limits: no more than one drink per day on average for older men or less than one drink per day on average for older women.
Binge drinking: drinking four or more drinks during a single occasion (drinking day) for men or three or more drinks during a single occasion for women.
*Limits are for healthy individuals who do not have a medical condition worsened by alcoh0l or take any medications that interact with alcohol.
NIAAA; Centers for Disease Control and Prevention, 2006

23. What is a Drink?

24. Referral Pathways

25. Referral Pathways
Admissions aged 55 or older were more likely than younger admissions to enter treatment through self-referral
Elders less likely to be referred through the criminal justice system, yet a quarter are through CJS
Few referred by health care providers in both young and older samples
(OAS, SAMHSA, 2004)

27. Referral Source and Treatment Completion
Referral source most significant completion correlate among older alcoholic men
Legal and self/family referrals much more likely to complete treatment
Health or social services referrals less likely to engage in and complete treatment
(Atkinson et al., 2003)

28. Workforce Needs

29. Committee on the Mental Health Workforce for Geriatric Populations
Institute of Medicine
Committee on the Mental Health Workforce for Geriatric Populations

30. Numbers and Training
The workforce is not prepared—in numbers, knowledge, and skills—to care for the MH/SU needs of a rapidly aging and increasingly diverse population
Current educational, training, certification and licensure requirements are insufficient, vague, and inconsistent
Trainees in MH/SU need training in geriatrics
Trainees in geriatrics need training in MH/SU
Trainees in primary care need training in geriatric MH/SU

31. Workforce Implications of Effective Aging Delivery Models
There is research evidence that an adequately prepared workforce can improve outcomes for substance misuse
Models of care for at-risk drinking/other substance misuse:
Systematic outreach and diagnosis
Team-based care
Patient and family education and self-management
Provider accountability for outcomes
Close follow-up and monitoring to prevent relapse

32. Conclusions
A substantial proportion of older adults have symptoms that warrant the attention of a provider skilled in geriatric MH/SU problems.
Yet only a minority of affected individuals receive specialty care, and the primary care they receive for MH/SU conditions is often inadequate
There is a conspicuous lack of attention to preparing the workforce to care for older adults who have MH/SU conditions
Health care delivery to older adults must be reorganized to reflect the chronic nature of MH/SU and other health conditions

33. Contact Information
Frederic C. Blow, Ph.D.
Director
UM Addiction Center
Professor of Psychiatry
University of Michigan Medical School
2800 Plymouth Road, Bldg. 16, Room 229W
Ann Arbor, MI USA
Phone: 734/ Fax: 734/