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Ageism, stigma hinders response to senior alcohol use disorder

Ageism, stigma hinders response to senior alcohol use disorder
Problem is poised to get worse as the population ages: By 2040, some 20.5 percent of the U.S. will be 65 or older

Roll Call
By Jessie Hellmann
April 20, 2023

Older adults are increasingly drinking excessively and dying of alcohol-related deaths, and the problem has been compounded by ageism, stigma, a lack of interest from policymakers and health care providers and few age-appropriate treatment options, experts say.

“There is such a need to help this population,” said Nicole MacFarland, the executive director of Senior Hope Counseling, the only freestanding outpatient clinic in New York that exclusively treats people 50 and older. The nonprofit specializes in geriatric addiction, leading group sessions focused on trauma, finding purpose later in life, and other issues geared toward older adults. They also connect patients with local services and entitlement programs.

Programs like MacFarland’s are rare, despite evidence that age-specific treatment can be beneficial: Only 25 percent of facilities surveyed by the Substance Abuse and Mental Health Services Administration have programs that specialize in older adults.

And only 11 percent of the facilities have those programs and accept Medicare, the insurance program for people 65 and older.

“There are many older adults suffering silently, and not enough programs geared toward their age group and their need,” MacFarland said.

The numbers

According to the 2021 National Survey on Drug Use and Health, 7.6 percent of adults 50 and older had an alcohol use disorder in the past year — a lower rate than other adult age groups, but one that, like other adult age groups, has increased in recent years.

Older adults are more likely to die from alcohol-related causes, mostly from chronic diseases associated with years of drinking. In 2020, the rate of alcohol-induced deaths among 55- to 64-year-old men was higher than in any other age group, according to the CDC, and was second highest among men aged 65-74. Rates among older women are also increasing.

A broader measure used by the CDC to estimate how many people die from alcohol-related causes, including cancer and car accidents, found an average of 48,000 people 65 and older died every year between 2015 and 2019 — more than any other age group.

The problem is poised to get worse as the population ages: By 2040, some 20.5 percent of the U.S. population will be 65 or older.

But with fewer medical professionals specializing in geriatrics, and even fewer of those professionals specializing in addiction training, the U.S. is not prepared to treat this growing need, experts say.

“The number of specialists is declining, and the number of older adults is increasing,” said Erin Emery-Tiburcio, an associate professor of geriatric and rehabilitation psychology at Rush University in Chicago.

Screening and treatment

While older adults have some of the greatest exposure to the health care system, physicians often fail to screen for excessive drinking. When they do, experts say, they rarely make referrals for treatment or prescribe medications that can treat alcohol use disorder.

Signs of excessive drinking can mimic symptoms of aging, like sleep problems, memory loss, depression or anxiety, meaning the problem often goes undetected.

“Ageism plays a massive role in substance use in particular for older adults because health care providers don’t screen,” Emery-Tiburcio said. “If you don’t think that the 80-year-old in front of you is drinking a bottle of wine at night, you’re not likely to ask him. You’re not likely to do anything about it.”

While the U.S. Preventive Services Task Force recommends screening for unhealthy alcohol use in primary care settings in all adults, more than half of adults age 65 and older who used alcohol and had a recent health care visit were not asked about their alcohol use, according to a study published in the journal Alcoholism in 2021.

Excessive alcohol use poses unique risks to older adults. As adults age, their tolerance for alcohol decreases, putting them at higher risk for falls, car crashes and other accidents. And alcohol can exacerbate diseases like diabetes, high blood pressure and memory problems and interfere with medications older adults are likely to take for those issues.

While medication-assisted treatment is an option for people diagnosed with alcohol use disorder, “I think if you were to ask a physician to name the three medications approved by the FDA to treat alcohol use disorder, they couldn’t,” said George Koob, director of the National Institute on Alcohol Abuse and Alcoholism, which is part of the National Institutes of Health.

In 2021, about 1 percent of people who had alcohol use disorder said they received medication for it, according to the National Survey on Drug Use and Health. In comparison, 22 percent of people with opioid use disorder said they received medication treatment.

But there’s evidence medication helps. According to a study published in 2021 the International Journal of Environmental Research and Public Health adults aged 65 and older admitted for alcohol use disorder were less likely than middle-aged and 50-64 year olds to be prescribed naltrexone, one of the drugs approved to treat AUD.

“I think we need to do a better job of identifying older patients and offering them treatment,” said Benjamin Han, a geriatrician, addiction medicine physician and researcher at University of California San Diego, who said he offers naltrexone to any patient who meets the criteria for alcohol use disorder.

Despite evidence that naltrexone works, “we’re not using it or offering it to patients,” he said.

Meanwhile, in emergency departments, data shows physicians are slightly more likely to screen for excessive alcohol use, with one in six doing so consistently. But less than half used that information to provide interventions, like medication assisted treatment.

“It would be like having somebody come in with diabetes and not offering them insulin on discharge,” said Cara Poland, an internal medicine doctor and associate professor at Michigan State University.

Part of the problem, she said, is that medical schools struggle to incorporate addiction treatment into their curricula.

Poland leads a program called MI CARES that aims to prepare students for residencies by incorporating SUD training into all four years of medical school, including through introducing them to people in recovery. The curriculum includes a section on older adults to teach students how substance use disorders present differently in that population.

The goal, she said, is to “get them to the point where they’re kind of questioning some of the things that they hear on rotations.”

Funding age-specific programs

While Congress has focused in recent years on the drug overdose epidemic, which killed 107,000 people in 2021, advocates have pushed for more attention on alcohol, which contributes to the deaths of 140,000 people every year. Alcohol is the number one substance used by older adults, and costs society about $249 billion every year, according to a CDC estimate.

“If we could fix this challenge, we would probably save an enormous amount of money in health care costs,” Koob said. “But it’s something that’s often overlooked.”

Federal grants aim to train the health care workforce and fill in the gaps in access to care for behavioral and mental health services, particularly for populations that might not otherwise get that care.

Grant funding primarily comes from SAMHSA, which had a $6.4 billion discretionary budget in 2022.

But while federal grants for treating opioid use disorder are widely available, funding for programs focused specifically on alcohol use disorder and older adults can be hard for nonprofits to find.

SAMHSA doesn’t have any grants currently awarded to organizations focusing on alcohol use and older adults, a spokesperson said, despite the growing need for services in that population and lackluster coverage of those services by Medicare.

“If more money were allocated to help clinics across the nation work with older adults who struggle with substance use disorder, that would be extremely helpful,” MacFarland said.

SAMHSA is currently accepting applications for a $1.5 million program that would provide training, guidance and mentoring on the use of medications for alcohol use disorder. But it doesn’t target a specific population.

“SAMHSA needs to be required to include older adults in their funding stream,” said Emery-Tiburcio of Rush.

The focus has primarily been on opioids.

State Opioid Response Grants, created by Congress in 2018, have become one of the main funding sources for providers helping with substance use disorders, totaling more than $1 billion in funding each year. The Government Accountability Office has found that some states can’t spend all the money they are awarded, partly because it is limited for treatment of OUD and stimulants.

Some advocates have asked Congress to broaden eligibility for the grants to include alcohol; Congress recently expanded eligibility to treatment of stimulants like meth and cocaine.

“Alcohol Use Disorder appears to be overlooked,” Appalachian Recovery Alliance in West Virginia, a coalition of providers treating substance use disorders, wrote in a March letter to Democratic Sen. Joe Manchin III. “Unlike so-called ‘hard’ drugs, immoderate drinking — the kind of drinking that can kill — is normalized in our culture.”