Despite hopeful news that opioid overdose death rates are declining across the U.S. — a 27% decrease in 2024 from the previous year — older adult populations are still seeing increases in opioid use disorder (OUD), hospitalizations, and deaths, according to recent federal data.
“It’s great to see progress and reductions in overdose among younger adults, but our most vulnerable population isn’t headed in the right direction. This has big implications, especially in terms of where care is delivered, the cost of this care, treatment options, and research,” says Jarratt Pytell, MD, MHS, assistant professor of internal medicine at the University of Colorado School of Medicine, who specializes in addiction medicine and the primary care treatment of substance use disorders.
Medicare data released in 2023 revealed that OUD in older adults has risen significantly over the years, from 4.6 to 15.7 per 1,000 beneficiaries between 2013 and 2018, and treatment rates remain low despite policy changes that expand access to medications.
In a new review in the journal Current Geriatrics Reports, Pytell and his research colleagues write that research and best practices on age-friendly approaches to OUD screening, treatment, and harm reduction remain largely unknown. This creates urgent needs for research and tailored interventions.
“Older adults with OUD are interacting with the health care system, creating touchpoints for evidence-based interventions,” the researchers write. “As the health care system adapts to meet the evolving needs of an aging population, designing age-friendly systems that integrate OUD care across care settings, expand harm reduction efforts, and prioritize research on age-specific treatment strategies can ensure clinicians are equipped to provide comprehensive, evidence-based care to older adults with OUD.”
The role of comorbidities
Among the biggest differences between younger and older adults with OUD is the presence of other health conditions that come with age. Namely, older adults with OUD face higher rates of cardiovascular disease risk factors. The most prominent, the researchers say, is tobacco use.
In one assessment of adults over the age of 50 receiving methadone treatment, 60% had hypertension, 19% had diabetes, 43% had chronic lung disease, and 19% had cancer.
Other conditions, such as falls, chronic pain, and incontinence, were found to be higher in older adults with OUD compared to those without.
These higher rates of comorbidities make care more complex, Pytell says, and creates the need to expand the focus of treatment beyond the substance use disorder to other aspects of a person’s overall health.
“Many of these older adults have other chronic conditions that can be exacerbated by substance use,” he says. “Sometimes substance use is a way to cope with those chronic conditions, be that mental health or other medical conditions, like heart failure, COPD, diabetes, or arthritis. Pain often plays a big a role in addiction treatment and recovery.”
Age-friendly infrastructure
The degree of medical complexity that many older adults with OUD experience is not well suited for the current addiction treatment system, even as some rule changes have sought to increase access to treatment, including the removal of the X-Waiver, which prior to 2023 required doctors to obtain special permission to prescribe buprenorphine for OUD treatment.
Only five years ago did Medicare begin covering opioid treatment program services, which is the only place where methadone — one of the most effective treatments for OUD — can be dispensed. Generally, patients must show up daily or multiple times a week to a methadone clinic for observed dosing.
“It's an onerous task to make it to a clinic three days a week, where you have to stand in line amongst a group of mostly young people,” Pytell says. “We are going to have to really change the way they deliver care for older adults.”
This includes thinking about the physical structure, like accommodating walkers and wheelchairs, and investigating how to best help patients who may have a cognitive impairment and need more help with medication management.
Priming primary care for the task
Primary care may be the best place to start when it comes to effectively screening and treating older patients with OUD, but Pytell says hurdles persist.
“For those of us who are addiction medicine specialists doing integrated primary care, the biggest challenge is not being allowed to prescribe the most effective medication for opioid use disorder, which is methadone,” he says. “This is one of the most effective tools we could have in our toolbox because we are board certified and often fellowship trained. Prescribing and managing that medication is within our scope, within our knowledge, and within our training.”
Federal regulations would have to change to enable physicians like Pytell the ability to prescribe methadone.
For now, Pytell and his research colleagues say investing in additional research that could contribute to a better understanding of effective screening, treatment, and harm reduction efforts is a priority.
“The silver tsunami of older adults who are going to be in our clinic waiting rooms, in our emergency departments, and in our hospital beds will be underrepresented in research, and that’s a shame because that means clinicians are left to their best guess. Without data, we are just flying blind.”
