Treating Substance Use Disorder 

in Older Adults 

UPDATED 2020 

TREATMENT IMPROVEMENT PROTOCOL 

TIP 26 
TIP 26

Please share your thoughts about this publication by completing a brief online survey at: 

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Contents 

Foreword ix 

Executive Summary xi 

Introduction xi

 Overall Key Messages xi 

Content Overview xii 

TIP Development Participants xxi

 Consensus Panel xxi

 Stakeholder Meeting Participants xxii 

Field Reviewers xxiii 

Publication Information xxv 

Chapter 1—Older Adults and Substance Misuse: Understanding 

the Issue (For All Audiences) 1

 Organization of This TIP 1

 Who Can Beneft From This TIP and How? 4

 Overview and Scope of the Substance Misuse Problem 5

 Screening and Diagnosis 12

 Treatment 13

 Summary 17

 Chapter 1 Appendix 19 

Chapter 2—Principles of Care for Older Adults 

(For Providers, Supervisors, and Administrators) 25

 Organization of Chapter 2 of This TIP 25 

General Principles of Care 28

 Summary 36

 Chapter 2 Resources 36 

Chapter 3—Identifying, Screening for, and Assessing Substance 

Misuse in Older Adults (For Providers) 37

 Who Can Beneft From Chapter 3 of This TIP and How? 37

 Organization of Chapter 3 of This TIP 38 

Challenges to Identifcation, Screening, and Assessment 41

 Screening for Substance Misuse in Older Adults 41 

Screening for Co-Occurring Disorders and Conditions 46

 Communicating Screening Results 57

 Conducting Brief Assessments and Interventions 59

 Conducting Full Assessments for Substance Misuse 62 

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Treating Substance Use Disorder in Older Adults 

Treatment Planning, Referrals, and Treatments 71

 Summary 75

 Chapter 3 Resources 76

 Chapter 3 Appendix 77 

Chapter 4—Treating Alcohol Misuse in Older Adults (For Providers) 87

 Organization of Chapter 4 of This TIP 87 

Alcohol Misuse Among Older Adults 90

 Screening and Assessment 94

 Continuum of Care 100

 Treatment Approaches Suited to Older Adults 101

 Recovery Management 112 

Clinical Scenarios 116 

Summary 123

 Chapter 4 Resources 123 

Chapter 4 Appendix 125 

Chapter 5—Treating Drug Use and Prescription Medication Misuse 

in Older Adults (For Providers) 131

 Organization of Chapter 5 of This TIP 131 

Drug Use and Prescription Medication Misuse Among Older Adults 134

 Screening and Assessment 137

 Continuum of Care 140

 Treatment Approaches Suited to Older Adults 142

 Recovery Management 149

 Clinical Scenarios 151

 Summary 156

 Chapter 5 Resources 156 

Chapter 6—Substance Misuse and Cognitive Impairment (For Providers) 157

 Who Can Beneft From Chapter 6 of This TIP and How? 157

 Organization of Chapter 6 of This TIP 158 

Substance Misuse in Older Adults 161

 Links Between Substance Misuse and Cognitive Disorders 163

 Substance Misuse and Co-Occurring Mental Disorders That Afect Cognition 168

 How Providers Can Help 170

 Addressing Caregiver Concerns 172

 Summary 175

 Chapter 6 Resources 175 

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 Chapter 6 Appendix 177 

Chapter 7—Social Support and Other Wellness Strategies 

for Older Adults (For Providers) 181

 Organization of Chapter 7 of This TIP 181

 Social Support: The Key to Health, Wellness, and Recovery 183

 Promoting Wellness Strategies for Older Adults 188

 Chapter 7 Resources 200 

Chapter 7 Appendix 203 

Chapter 8—Drinking as an Older Adult: What Do I Need To 

Know? (For Older Adults, Caregivers, and Family Members) 207

 Organization of Chapter 8 of This TIP 207

 Drinking Guidelines and Alcohol Misuse in Older Adults 209 

Alcohol’s Efects on Older Adult Health 213

 Tips and Cautions for Addressing Drinking on Your Own 217

 When It’s Time To Get Help 220

 Information for Family and Caregivers 225

 Chapter 8 Resources 228 

Chapter 9—Resources for Treating Substance Use Disorder in 

Older Adults (For All Audiences) 229

 Organization of Chapter 9 of This TIP 229

 General Resources 229

 Resources for Supervisors and Administrators 238

 Resources for Providers 239

 Resources for Clients and Families 246 

Provider Tools 253 

Appendix—Bibliography 285 

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Exhibits 

Exhibit 1 1 Key Terms 2 

Exhibit 1 2 What Is a Standard Drink? 7 

Exhibit 1 3 Potential AI Medications 8 

Exhibit 1 4 Common Forms of Opioids 9 

Exhibit 1 5 Common Benzodiazepines 10 

Exhibit 1 6 Substance Misuse Risk Factors in Older Adults 11 

Exhibit 1 7 Substance Misuse Protective Factors in Older Adults 11 

Exhibit 1 8 Barriers to Seeking Treatment 12 

Exhibit 1 9 Characteristics of Early-Onset Versus Late-Onset Alcohol Misuse 14 

Exhibit 1 10 Range of Intervention and Treatment Strategies for Older Adults 16 

Exhibit 2 1 Key Terms 24 

Exhibit 2 2 How Administrators Can Create a Treatment Environment 

Responsive to Older Adults 29 

Exhibit 3 1 Key Terms 39 

Exhibit 3 2 Drug and Alcohol Screening Tools 43 

Exhibit 3 3 Screening Tools for Co-Occurring Mental and Cognitive Disorders 47 

Exhibit 3 4 Geriatric Depression Scale (GDS)–Short Form 48 

Exhibit 3 5 Geriatric Anxiety Scale (GAS) 51 

Exhibit 3 6 PTSD Checklist for DSM-5 (PCL-5) 54 

Exhibit 3 7 Successfully Applying SBIRT Principles to Older Adults 62 

Exhibit 3 8 Key Objectives of a Full Assessment for Substance Misuse 63 

Exhibit 3 9 Verbal Descriptor Scales (VDS) 66 

Exhibit 4 1 Key Terms 88 

Exhibit 4 2 Preventing Alcohol Misuse Among Older Adults 96 

Exhibit 4 3 DSM-5 Criteria for AUD and Considerations for Older Adults 97 

Exhibit 4 4 Risk Factors Related to Alcohol Misuse in Late Life 99 

Exhibit 4 5 Continuum of Care Pathways for Older Adults 100 

Exhibit 4 6 Characteristics of Age-Sensitive Alcohol Treatment for Older Adults 101 

Exhibit 4 7 Brief Alcohol Intervention Parts for Older Adults 103 

Exhibit 4 8 Drinking Behavioral Chain of Events 106 

Exhibit 4 9 Alcohol Health-Related Risk and Treatment Response Pyramid 117 

Exhibit 5 1 Key Terms 132 

Exhibit 5 2 DSM-5 Criteria for SUD and Considerations for Older Adults 139 

Exhibit 5 3 SUD Treatment Continuum of Care 141 

Exhibit 5 4 Chronic Pain Assessment and Treatment Approaches for Older Adults 145 

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Exhibit 5 5 Age-Specifc SUD Treatment for Older Adults 148 

Exhibit 6 1 Key Terms 158 

Exhibit 6 2 Understanding Classes of Medications 161 

Exhibit 7 1 Key Terms 182 

Exhibit 7 2 SAMHSA Wellness Wheel 189 

Exhibit 7 3 Identifying Wellness Activities 190 

Exhibit 7 4 Writing a SMART Goal 200 

Exhibit 8 1 Key Terms 208 

Exhibit 8 2 How Aging Afects the Body’s Response to Alcohol 210 

Exhibit 8 3 What Is a Standard Drink? 211 

Exhibit 8 4 Some Health Risks of Alcohol Misuse 214 

Exhibit 8 5 Common Prescription Medication–Alcohol Interactions 215 

Exhibit 8 6 Writing a Change Plan 218 

Exhibit 8 7 Four-Week Drinking Tracker Card 219 

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Foreword 

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the U.S. Department of 

Health and Human Services agency that leads public health efforts to reduce the impact of substance 

abuse and mental illness on America’s communities. An important component of SAMHSA’s work is 

focused on dissemination of evidence-based practices and providing training and technical assistance to 

healthcare practitioners on implementation of these best practices. 

The Treatment Improvement Protocol (TIP) series contributes to SAMHSA’s mission by providing sciencebased, best-practice guidance to the behavioral health feld. TIPs refect careful consideration of all 

relevant clinical and health service research, demonstrated experience, and implementation requirements. 

Select nonfederal clinical researchers, service providers, program administrators, and patient advocates 

comprising each TIP’s consensus panel discuss these factors, offering input on the TIP’s specifc topics in 

their areas of expertise to reach consensus on best practices. Field reviewers then assess draft content and 

the TIP is fnalized. 

The talent, dedication, and hard work that TIP panelists and reviewers bring to this highly participatory 

process have helped bridge the gap between the promise of research and the needs of practicing 

clinicians and administrators to serve, in the most scientifcally sound and effective ways, people in need of 

care and treatment of mental and substance use disorders. My sincere thanks to all who have contributed 

their time and expertise to the development of this TIP. It is my hope that clinicians will fnd it useful and 

informative to their work. 

Elinore F. McCance-Katz, M.D., Ph.D. 

Assistant Secretary for Mental Health and Substance Use 

U.S. Department of Health and Human Services 

Substance Abuse and Mental Health Services Administration 

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Executive Summary 

Treatment Improvement Protocol (TIP) 26 provides a wide range of guidance in the latest evidencebased screening and assessment approaches, interventions, and services for substance misuse, including 

substance use disorders (SUDs), in older adults. It is intended for behavioral health service providers, 

healthcare professionals, and older adults, as well as those people who are signifcant in their lives. 

Introduction 

Older adults are a special group because they are particularly vulnerable to the negative effects of 

substances and therefore substance misuse. Further, providers, professionals, and family and caregivers 

tend to overlook substance misuse in older people, meaning they are less likely than younger adults to be 

correctly diagnosed and offered treatments, services, or referrals. This oversight makes SUDs particularly 

dangerous for this population in terms of possible effects on mortality and comorbid conditions (including 

physical, cognitive, and mental disorders). This TIP is designed to help providers and others better 

understand how to identify, manage, and prevent substance misuse in older adults. This publication 

describes the unique ways in which SUD signs and symptoms manifest in older adults; drug and alcohol 

use disorder (AUD) screening tools, assessments, and treatments specifcally tailored for older clients’ 

needs; the interaction between SUDs and dementia and other cognitive disorders; and strategies to help 

providers improve their older clients’ social functioning and overall wellness—both of which are critical to 

successful recovery. 

A consensus panel developed the TIP’s content based on a review of the most up-to-date literature 

and on their extensive experience in the feld of geriatric alcohol and drug addiction treatment. Other 

professionals also generously contributed their time and commitment to this publication. 

This publication is an update of the original TIP. The content addresses many of the same key topics and 

messages, as well as new ones. Revisions refect the most recent scientifc knowledge, clinical advances, 

and guidance pertaining to preventing and treating substance misuse among older adults. 

Overall Key Messages 

Substance misuse in older adults is often overlooked and undertreated. In part, this is because of false 

beliefs among providers, professionals, and the general public that older adults do not develop or need 

treatment for drug and alcohol use disorders. Providers and professionals can beneft from an improved 

awareness about substance misuse in older clients, including how to approach screening, assessment, and 

treatment. Similarly, family members/caregivers can beneft from information and resources to help them 

recognize, prevent, and respond to substance misuse in their older loved ones. 

Empirical evidence supports the use of SUD treatment for older adults—especially when tailored 

to their age-related needs. The notion that older adults are not interested in or do not respond well to 

treatment for substance misuse is simply untrue. In fact, when interventions are adapted to the physical, 

cognitive, and psychosocial needs of older clients, they are likely to be effective. It is critical that providers 

and professionals learn about available interventions and local resources so they can treat, serve, or 

otherwise refer older clients appropriately. 

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Like treatments and services, screening and 

assessment techniques can and should be 

adapted to older adults. Many instruments have 

been developed specifcally to detect possible 

SUDs and common comorbid mental and physical 

conditions (e.g., depression, anxiety, pain) in 

this population. Age-appropriate screening 

tools and interventions are available for older 

adults struggling with alcohol use, illicit drug 

use, or nonmedical prescription medication use. 

Comprehensive assessments should explore other 

areas relevant to older adults and substance 

misuse, such as their trauma history and risk of 

current elder abuse, fall risk, cognitive decline, 

and ability to perform activities of daily living 

and other functions. 

Nearly all of us will experience changes in our 

thinking as we age, but substance misuse can 

potentially worsen normal age-related changes 

in cognition. Further, older people already 

experiencing cognitive conditions, including 

dementia or mild cognitive impairment (MCI), may 

have diffculty using substances like alcohol and 

prescription medications safely and according to 

recommended guidelines. 

Alcohol is the most widely used substance 

among older adults with substance misuse. 

It is vital that older adults and their family and 

caregivers receive information about moderate 

versus high-risk drinking, harmful effects of alcohol 

misuse, and available treatments for AUD. 

Providers, professionals, and family and caregivers 

should be especially watchful for signs and 

symptoms of nonmedical prescription drug use, 

including that of opioids and benzodiazepines. 

Most older adults take at least one prescription 

medication, and many take more than one. This 

increases their risk for potentially dangerous drug– 

drug interactions and drug–alcohol interactions. 

Older adults often experience reductions in their 

social network and social functioning as a part 

of normal aging, but among older individuals 

with substance misuse, this can be especially 

problematic. Social support is a critical piece of 

achieving and sustaining long-term recovery 

from substance misuse for all people, including 

Treating Substance Use Disorder in Older Adults 

older adults. Providers and professionals should be 

mindful of this and work closely with older clients 

to help them enhance the size and diversity of their 

social network, increase their social functioning, 

and engage in meaningful, recovery-oriented social 

activities (e.g., mutual-aid support programs, peer 

recovery support). 

Recovery is just one part of wellness. To help 

older clients achieve true health and well-being, 

be sure to help them address any areas in which 

functioning may be lacking. This includes their 

physical functioning, mental health, emotional 

well-being, intellectual activities, spirituality, work 

or volunteer activities, and social life. All of these 

aspects of wellness play a role in recovery and in 

overall health. 

Many older adults consume alcohol, but how 

does one know whether an older adult’s alcohol 

use is a problem? Part of your role is to provide a 

wide range of education and resources to help 

older adults and their family or caregivers better 

understand the risk factors for, signs and symptoms 

of, and treatments and services available for 

alcohol misuse. 

This TIP is divided into nine chapters designed to 

thoroughly cover all relevant aspects of the ways in 

which SUDs affect older adults and how providers, 

professionals, and family members and caregivers 

can offer treatment, services, support, and 

resources to help older adults prevent or overcome 

substance misuse. 

Content Overview 

The TIP is divided into chapters to make the 

material more accessible according to the reader’s 

interests. Below is a summary of each TIP chapter’s 

main messages and key content areas. 

Chapter 1: Older Adults and Substance 

Misuse: Understanding the Issue 

This chapter lays the foundation for understanding 

the scope and importance of substance misuse 

as a problem among older aged populations. 

It is for a variety of audiences (e.g., providers, 

professionals, administrators, informal and formal 

caregivers, family). 

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This chapter emphasizes the fact that substance 

misuse is indeed a serious—and increasing— 

problem among older adults. SUDs tend to be 

underrecognized by providers, professionals, 

and family and caregivers in part because of false 

beliefs that drug and alcohol addiction is only a 

“young person’s disease” and that older clients are 

not interested and willing to engage in treatment 

or services. These myths contribute to low rates of 

diagnosis, treatment, and service provision among 

older persons and interfere with their chances for 

recovery. Most providers and professionals do not 

have specialized training in geriatric substance 

misuse, and most family members and caregivers 

do not know how to recognize and respond to 

these problems in older adults. This chapter helps 

fll these knowledge gaps by laying out the facts 

and statistics, many from large-scale surveys 

and empirical research, that underscore how 

problematic drug and alcohol addiction truly is for 

older adults. 

In Chapter 1, you will learn that: 

• Even though rates of drug and alcohol addiction 

are higher among adolescents and younger 

adults, SUDs can and do occur in older persons. 

Substance misuse is not something that only 

occurs in younger people. These ageist beliefs 

are a large reason why we see low rates of 

diagnosis and treatment/services in the older 

adult population. 

• Substance misuse among older individuals 

is very dangerous and can increase their 

risk of death and other physical harms. 

Older persons are vulnerable to negative drug 

and alcohol interactions with prescription 

medications, adverse reactions from illicit drugs 

and prescription medications, and the harmful 

effects of alcohol. 

• Not only are rates of illicit drug use among 

older adults growing, rates of co-occurring 

mental disorders are also high. As the number 

of older individuals in the U.S. population 

increases, the need for treatment providers and 

programs that understand and can respond to 

the needs of older adults with SUDs also will 

likely rise over time. 

• Older adults with SUDs are more likely to 

misuse alcohol than any other substance. This 

is concerning because older individuals’ bodies 

do not metabolize alcohol as effciently as 

those of younger people, increasing their risk of 

cognitive and physical problems, like confusion 

and falls. 

• Most older adults take at least one 

medication, and many take more than one. 

This makes substance use and misuse even 

more dangerous because of potentially deadly 

or otherwise harmful interactions between 

prescription medications and drugs and alcohol. 

Like their younger counterparts, some older 

adults do engage in nonmedical prescription 

medication use, including nonmedical use of 

opioids and benzodiazepines. 

• Providers and professionals may struggle 

to identify SUDs in older clients because 

symptoms can be hard to recognize and do 

not necessarily mirror diagnostic criteria. For 

example, changes in thinking attributable to 

alcohol misuse may appear similar to normal 

age-related changes in cognition. 

• Although the idea that older adults are 

unwilling to seek treatment or services for 

substance misuse is false, certain barriers 

can make this population less likely to seek 

treatment. These barriers include negative 

attitudes among providers, professionals, or 

family/caregivers; denial on the part of the 

older adult; lack of knowledge about substance 

misuse among family and caregivers; and lack of 

provider awareness about available and effective 

treatment and services. 

• Multiple treatment approaches for SUDs 

exist that are effective for older adults. 

These include screening, brief intervention, 

and referral to treatment; brief structured 

treatment; patient education; relapse prevention 

techniques; formal SUD treatment programs; 

and pharmacotherapy (e.g., methadone, 

buprenorphine, naloxone). 

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Chapter 2: Principles of Care for Older 

Adults 

This chapter describes guiding principles for 

evidence-based, effective, and safe treatments and 

services for older adults with substance misuse. 

This chapter will most beneft providers. 

Older adults are a diverse and unique population, 

and their SUD treatment and service needs 

typically differ somewhat from those of 

younger adults. Providers should understand 

developmental differences but also generational 

differences (e.g., baby boomers versus earlier 

cohorts) among their older clients. Age-sensitive 

and age-specifc interventions can help increase 

older adults’ chances of achieving and sustaining 

long-term recovery. The treatment/service 

environment itself also should be adapted to this 

population, for example, through organizationwide training and encouragement of staff attitudes 

responsive to older clients’ needs. Consider each 

older client’s cultural background, gender, and 

age of onset of an SUD, all of which can infuence 

treatment needs and recovery outcomes. 

In Chapter 2, you will learn the following: 

• To give older clients the best opportunities 

to access and beneft from substance 

use treatment and services, you must 

acknowledge, respect, and respond to 

differences among populations of older 

individuals. This includes differences in 

generation, age of and reason for substance 

misuse onset, gender, recovery needs and 

wishes, attitudes about substance use/misuse, 

available support network, and more. In short, 

providers must remember that no two older 

clients are alike. 

• Organizations should create a treatment/ 

service environment that gives older clients 

the best chances for successful recovery. 

This means considering how the physical 

environment, as well as staff skills, services, 

abilities, and policies, can be tailored to 

overcome any age-related barriers. 

• Older adults are diverse in gender, race/ 

ethnicity, and sexual orientation. Bias and 

discrimination can occur as easily as in any 

other age group. Take time to learn how such 

Treating Substance Use Disorder in Older Adults 

diversity may infuence your clients’ late-life 

substance misuse, health disparities, and 

access to care. 

• Early identifcation, education, and intervention, 

even if brief and informal, are important 

because substance misuse in older adults is 

often unrecognized by older adults themselves, 

as well as by their family members, friends, 

and healthcare and social service providers. 

As a provider, you should learn the signs and 

symptoms of SUDs in older adults and be 

prepared to respond appropriately when 

they appear. This includes performing routine 

screening and assessment for substance misuse. 

For older adults uninterested in abstinence, 

provide health risk reduction services, such as 

education on the health benefts of reducing 

alcohol use. 

• Person-centered care is the preferred 

approach for this population and emphasizes 

older clients’ values, needs, and preferences 

from among a menu of care options. 

• Age-sensitive approaches include those that 

are tailored to older clients’ physical needs 

(e.g., diffculties with mobility, hearing, vision, 

or a combination of these), cognitive problems 

(e.g., memory and attention diffculties), learning 

needs (e.g., using a slower pace, repeating 

information), and age-related preferences (e.g., 

desiring age-specifc rather than mixed-age 

group treatment). 

• Investing time and money in developing an 

age-sensitive workforce throughout your 

organization is important. Staff recruitment, 

hiring, retention, supervision, and professional 

development strategies should include a focus 

on understanding evidence-based approaches 

that are effective and appropriate for older 

adults. 

• Older adults with substance misuse can 

beneft greatly from social support and 

community resources. Keep on hand a listing 

of resources and referrals, and help older clients 

access and engage in these services. 

• Including caregivers throughout treatment 

and services (as appropriate) and providing 

them with education and resources (including 

access to case managers) can improve older 

clients’ recovery chances. Not only will this 

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help them better understand the nature of 

SUDs and the recovery process, it can help 

reduce caregiver burden and stress, which, if 

unaddressed, can affect their own health as well 

as that of the older adult with the SUD. 

Chapter 3: Identifying, Screening for, 

and Assessing Substance Misuse in Older 

Adults 

This chapter addresses how, when, and why to use 

screening and assessment for substance misuse 

in older clients. This chapter will most beneft 

behavioral health service providers, social service 

providers, and other healthcare professionals and 

paraprofessionals. 

Identifcation, screening, and assessment are 

critical steps to linking older adults with substance 

misuse to needed treatment and services. Older 

adults’ signs and symptoms of SUDs can be 

diffcult to spot, however. By learning the steps to 

accurate and effective screening and assessment, 

you increase the chances of older adults 

receiving timely and appropriate care. This means 

taking a comprehensive approach that not only 

focuses on specifc drug and alcohol use disorders 

but also on related conditions that infuence (or are 

infuenced by) substance misuse. These conditions 

include co-occurring mental disorders (e.g., 

depression, anxiety), certain physical problems 

(like chronic pain and sleep disorders), cognitive 

impairment, falls, trauma, and abuse (history and 

current experiences), and everyday functioning. 

In Chapter 3, you will learn the following: 

• Screening and assessment for SUDs in older 

persons can be challenging because the signs 

and symptoms are not necessarily the same 

as those in younger adults and do not always 

mirror diagnostic criteria. To ensure proper and 

timely identifcation of problems, you should 

learn how to recognize and overcome these 

challenges. 

• As a provider, you should regularly screen your 

older clients for substance misuse, at least 

annually. Also consider screening if the client 

displays signs or symptoms that are concerning, 

if the client or family/caregiver reports 

substance-related diffculties, or if you otherwise 

suspect substance misuse may be present. 

• Numerous screening instruments are available 

that have been developed for or tested and 

approved for use with older persons. These 

include instruments to help you screen for 

alcohol misuse, illicit drug use, and nonmedical 

prescription medication use. Older adult 

screeners are also available to help you explore 

related areas, such as depression, posttraumatic 

stress disorder (PTSD), anxiety, cognition, pain, 

and daily functioning. 

• When communicating screening results, you 

should praise clients for fndings that indicate 

abstinence, and follow up on fndings that 

indicate substance-related problems. Be sure 

to also occasionally rescreen older clients even if 

their fndings suggest no problems are present. 

• You should follow up on screening that 

indicates a potential substance-related 

problem by conducting an assessment. Brief 

assessments can occur immediately after 

screening. More thorough, comprehensive 

assessments are lengthier and may require a 

separate appointment. 

• Comprehensive assessment for SUDs is a 

multistep process that will help you determine 

whether substance misuse is truly present and 

differentiate SUDs from possible co-occurring 

disorders (CODs), physical conditions common 

in older populations, and signs of normal aging. 

• You should fully explore older clients’ 

psychological, medical, family, vocational or 

retirement-related, social, sexual, fnancial, 

legal, substance use, and substance-related 

treatment histories. Also ask about older clients’ 

fall risk, abuse potential, skills and abilities, and 

functional status. 

• Not all clients who screen positive will need 

formal substance use treatment. For older 

clients with or at risk for mild or moderate 

substance misuse, a brief intervention may 

be suffcient (e.g., education, motivational 

interviewing). For older adults with moderateto-severe SUDs, formal treatment may be 

necessary. 

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Chapter 4: Treating Alcohol Misuse in 

Older Adults 

This chapter discusses key aspects of alcohol 

misuse and the screening, assessment, and 

treatment of/services for binge drinking and AUD. 

It will most beneft healthcare, behavioral health, 

and social service providers working with older 

adults (physicians, nurse practitioners, physician 

assistants, nurses, social workers, psychologists, 

psychiatrists, mental health counselors, alcohol and 

drug counselors, and peer providers). 

Alcohol is the most commonly used substance 

among older individuals with an SUD or 

substance-related problems. Although 

widespread screening is an effective method 

of detecting alcohol-related problems in this 

population, many providers and professionals fail 

to screen because of false beliefs (e.g., that older 

people do not experience AUD or would not be 

interested in treatment) and lack of knowledge 

about the importance of widespread screening. 

For older clients in need of treatment, services, 

referrals, or some combination thereof, you should 

use age-sensitive and age-specifc approaches 

to care that respect and respond to the 

unique needs of older adults. A wide range of 

interventions are available to draw from, including 

pharmacologic and nonpharmacologic options. 

In Chapter 4, you will learn about: 

• The ways in which older adults are at risk 

for harm from alcohol misuse, including agespecifc health effects as well as negative cooccurring mental and social conditions. 

• The need to screen all older adults for 

alcohol misuse and alcohol-related problems. 

Screening is especially important in primary care 

and emergency department settings, where 

older adults are often seen for co-occurring 

conditions like chronic pain and falls. Screening 

is necessary in certain situations, like following 

major life changes (e.g., retirement [especially if 

forced or unwanted], loss of a signifcant other), 

when starting a new medication, and as part of 

an annual physical exam. 

• Measures developed and approved for use 

with older populations, such as the Alcohol 

Treating Substance Use Disorder in Older Adults 

Use Disorders Identifcation Test and the Short 

Michigan Alcoholism Screening Test-Geriatric 

Version. 

• The ways to respond appropriately to older 

clients who screen positively for alcohol misuse 

or alcohol-related problems. As a provider, 

remember that not all diagnostic criteria for 

AUD apply to older adults in the same way 

they apply to younger adults. For instance, 

older adults may report reduced socialization, 

but this is common with aging and not 

necessarily a sign that drinking is interfering with 

social abilities. 

• The ways in which prescription medications can 

interact negatively with alcohol. This is critical 

information for providers and professionals 

because most of your older clients will be taking 

at least one prescription medication. Older 

adults taking numerous prescriptions or taking 

certain medications (e.g., benzodiazepines, 

antidepressants, blood thinners) are especially 

at risk for potentially harmful alcohol–drug 

interactions. 

• The steps to guiding older clients through 

the continuum of care for substance misuse, 

including brief interventions, prevention 

strategies, outpatient care, inpatient 

rehabilitation, follow-up services, referrals, 

and recovery management. 

• Adapting treatment and services for agespecifc needs of older adults, including clinical 

approaches (e.g., nonconfrontational and 

supportive approaches), treatment and service 

structure (e.g., fexible scheduling, shorter 

sessions), and content needs (e.g., focus on 

increasing behavioral change, quality of life, 

and social connectedness). You also should be 

aware of pharmacologic and nonpharmacologic 

interventions and their effectiveness and safety 

for use with older adults. 

Chapter 5: Treating Drug Use and 

Prescription Medication Misuse in 

Older Adults 

This chapter discusses age-appropriate 

interventions and services for older adults with 

substance misuse (non-alcohol-related), including 

illicit drug use and nonmedical prescription 

medication use. This chapter will most beneft 

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healthcare, behavioral health, and social service 

providers who work with older adults (e.g., 

physicians, nurse practitioners, physician assistants, 

nurses, social workers, psychologists, psychiatrists, 

mental health counselors, alcohol and drug 

counselors, peer recovery support specialists). 

Older adults can and do develop SUDs involving 

illicit drugs and nonmedical use of prescription 

medication. Many older adults take multiple 

medications and may be unaware of potential 

harms arising from substance misuse (e.g., 

overdose; dangerous interactions with alcohol and 

with other medications; increased risk of physical, 

mental, and cognitive problems). Age-specifc, 

evidence-based treatments and services are 

available for older clients with these conditions, 

including SUDs involving opioids, cannabis, 

stimulants, and benzodiazepines and other 

sedative-hypnotics. 

There is no “wrong door” by which older 

adults access care for drug addiction, and as a 

provider, you should ensure education, formal 

and informal treatment, services, and referrals 

are available throughout the entire course of 

care, from prevention through continuing care and 

recovery management. 

In Chapter 5, you will learn that: 

• Prescription medication misuse can be 

unintentional, underscoring the importance of 

educating your older clients about how to 

take medication correctly (including avoiding 

harmful interactions). 

• Older adults are at risk for opioid addiction, 

given the high prevalence of chronic pain in 

this population. Opioid overdose prevention 

strategies, detoxifcation, and medication can be 

used safely and effectively with this population. 

• Illicit substance use (e.g., opioids, cannabis, 

stimulants) does occur among older adults 

and can be treated using behavioral and 

pharmacological methods. 

• Routine screening and assessment will help 

you detect substance misuse early and 

accurately. Thoroughly explore not just the 

client’s substance misuse (current and past) but 

also other health behaviors (e.g., exercise, diet), 

changes in physical and mental functioning, and 

major life events that may put the person at risk 

for substance misuse (e.g., retirement, moving, 

loss of a loved one). 

• A full assessment should cover topics like cooccurring medical and mental conditions, sleep 

problems, occurrence of pain, fall risk, and daily 

functioning. 

• Diagnostic criteria for SUDs may not fully 

apply to older clients. Older clients’ substancerelated signs and symptoms may differ from 

those in the diagnostic criteria and in younger 

adults. 

• Older adults with SUDs can beneft from a 

wide range of age-sensitive and age-specifc 

treatment and services across the continuum 

of care, including prevention strategies, 

early and brief interventions, formal inpatient 

and outpatient treatment, and recovery 

management techniques. 

• Mutual-aid support programs and family 

involvement are important components of the 

continuum of care for older adults with SUDs. 

Social support and connectedness are often 

lacking in older adults and can help those with 

substance misuse achieve and sustain recovery, 

optimal functioning, and good quality of life. 

Chapter 6: Substance Misuse and 

Cognitive Impairment 

This chapter outlines the ways in which substance 

misuse can affect (and be affected by) declines in 

thinking, including the occurrence of dementia. 

This chapter will most beneft behavioral health, 

healthcare, and primary care service providers 

and prevention specialists who offer direct care to 

clients in behavioral health and healthcare settings 

and care for older adults who misuse substances. 

Changes in thinking, like diffculties with memory, 

attention, and learning, are a normal part of 

aging for most of us. But for older adults with 

substance misuse, these changes in thinking can 

be more severe and may develop faster than in 

the absence of substance misuse. Substance 

misuse can increase the risk of certain cognitive 

problems and can make managing those 

cognitive problems more diffcult. Furthermore, 

problems with thinking may make it harder for 

some older adults to remember how to take 

xvii 
TIP 26

prescription medication appropriately or keep track 

of their alcohol consumption to ensure it does not 

exceed recommended guidelines. In other words, 

cognitive disorders can increase older adults’ 

chances of experiencing substance-related 

problems. The key to offering timely and effective 

treatment is to engage in routine screening 

and assessment to detect potential cognitive 

impairment, like dementia and MCI, as soon as 

possible. 

There are many age-appropriate interventions 

and services you can offer (or offer referrals 

for) to help maintain or improve older clients’ 

mood, functioning, and quality of life. Involving 

caregivers is also important to make sure clients 

struggling with their thinking take prescription 

medication correctly, avoid or consume safe 

amounts of alcohol, avoid illicit drugs, and stay 

engaged in treatment and services. 

In Chapter 6, you will learn about: 

• Facts that show substance misuse can and does 

occur in older adults, particularly alcohol misuse. 

• The latest research on the effects of 

substances and certain medications (e.g., 

benzodiazepines) on cognition and brain 

functioning in general. 

• The link between substance misuse and the 

risk of developing cognitive disorders in the 

future, such as dementia and MCI. 

• The many mental disorders/symptoms 

that co-occur with substance misuse and 

that negatively infuence thinking, such as 

depression and depressive symptoms, anxiety, 

and PTSD and trauma. If offering treatment or 

services for older clients’ substance misuse, it 

is critical to screen and assess for these mental 

disorders/symptoms because, if present and 

untreated, cognitive problems may persist. 

• Screening instruments developed for and 

tested in populations of older individuals 

are available. These tools will help you detect 

possible co-occurring mental disorders as well 

as cognitive impairment. 

• The numerous interventions for older clients 

with substance misuse and co-occurring 

behavioral health and cognitive disorders, 

Treating Substance Use Disorder in Older Adults 

including education, drug and alcohol counseling, 

brief counseling, referral to mutual-aid support 

programs and peer-recovery programs, 

and other interventions that do not involve 

pharmacotherapy. 

• Why including caregivers is essential for 

successfully treating older adults with 

substance misuse and co-occurring dementia 

or MCI. Additionally, your role is to help ensure 

caregivers have the support and resources 

they need to maintain their own health and 

well-being (including avoiding substance misuse 

themselves). 

Chapter 7: Social Support and Other 

Wellness Strategies for Older Adults 

This chapter outlines ways to help older clients 

with substance misuse leverage social supports 

and other wellness strategies to improve their 

chances of achieving and maintaining long-term 

recovery. This chapter will most beneft healthcare, 

behavioral health, and social service providers 

who work with older adults (physicians, nurse 

practitioners, physician assistants, nurses, social 

workers, psychologists, psychiatrists, mental health 

counselors, alcohol and drug counselors, and peer 

recovery support specialists). 

Strong social networks are an essential part of 

older adults’ health and well-being. You can help 

increase older adults’ chances of recovery by 

offering interventions, services, and resources 

that target social supports and other aspects of 

wellness, like health literacy, illness management, 

and relapse prevention. Social isolation is 

unfortunately common among many older 

individuals and has been linked to risky behaviors, 

including substance misuse, as well as poor 

physical, cognitive, and mental health. But you can 

help older clients enhance their social functioning 

as a part of recovery treatment/services through 

interventions that expand your clients’ social 

network, increase their feelings of connectedness, 

promote neighborhood/community supports, and 

engage their family members in recovery activities. 

In addition to addressing socialization, do not 

overlook other areas of health and well-being 

that may help enhance recovery efforts and 

xviii 
TIP 26

improve quality of life. This includes the older 

adult’s physical health, emotional well-being, 

spirituality, vocational or volunteer work, and more. 

In Chapter 7, you will learn that: 

• Declines in social functioning are a normal 

part of aging for many individuals, but you can 

(and should) help older clients with substance 

misuse do something about this. By helping 

older adults increase and enhance their social 

network and feelings of connectedness, 

you are at the same time also helping 

them improve their chances of overcoming 

substance misuse. 

• You should help older clients with substance 

misuse expand the size and diversity of their 

social network, engage neighborhood and 

community supports, and involve family 

members or caregivers in their recovery. Be 

sure to offer recovery-specifc social supports, 

like mutual-aid support programs and peer 

support programs, among your services and 

referral options. 

• Area Agencies on Aging are wonderful sources 

of information, support, and services to help 

your older clients engage in social support and 

other healthy activities. Online social networks, 

though often associated only with adolescents 

and young adults, also are a potential useful 

resource for older adults. Explore whether your 

older clients are interested in and need help 

accessing social media and related technologies; 

they can be an asset for older individuals who 

experience barriers to establishing or growing a 

social network of support. 

• In addition to focusing on social functioning, 

help older clients with substance misuse 

establish all-around wellness by addressing 

multiple areas of functioning, like their 

physical health, spirituality, emotional health, 

fnances, work, and cognition. All of these can 

play an important role in recovery. 

• Wellness recovery activities keep your older 

clients engaged in all aspects of life, health, 

and well-being. Brainstorm ideas together 

and link your clients to a wide range of 

wellness activities, like exercising, joining a 

spiritual or religious fellowship, creating a safe 

and welcoming living environment, enrolling in 

adult education or senior college courses, and 

volunteering. 

• Complementary therapies and activities, like 

animal-assisted therapy, may help your older 

clients improve certain aspects of their physical, 

social, and emotional health. But be sure 

to discuss with them both the benefts and 

potential limitations of these strategies. 

• Older adults should learn self-management 

techniques to independently monitor and 

improve their health. This is important for 

addressing chronic illnesses, like heart disease 

and chronic pain, which often affect older 

individuals and, if unmanaged, can lead to 

signifcant impairments in functioning and 

quality of life. By learning to independently 

track and manage their symptoms, clients feel 

empowered and gain control of their health. 

This also applies to recovery; by continuing 

to engage in recovery activities, use relapse 

prevention techniques, and rely on social 

supports, older clients can strengthen their 

resilience and maintain a sense of control over 

their recovery. 

Chapter 8: Drinking as an Older Adult: 

What Do I Need To Know? 

This chapter focuses on older adults’ alcohol 

consumption and key facts and information they 

(and family members/caregivers) should know 

about alcohol use and misuse. This chapter is 

for older adults who drink (including those with 

questions about how much they should drink), their 

caregivers, and their families. 

Many older adults drink alcohol but do not develop 

alcohol misuse or other alcohol-related problems. 

Understandably, they may have questions about 

what defnes a “safe” level of consumption; the 

signs, symptoms, and effects of alcohol misuse; and 

how, why, and when to seek professional treatment 

or services. Family and caregivers should be 

similarly armed with this information so they can 

offer support to an older signifcant other in need 

of care for alcohol misuse. 

In Chapter 8, you will learn about: 

• Guidelines that defne “moderate” and 

“at-risk/high-risk” amounts of alcohol for 

xix 
TIP 26

adults, including what counts as one drink. Keep 

in mind that what is high risk for older adults is 

often different than what is high risk for younger 

individuals, because older adults experience the 

negative effects of alcohol at lower amounts. 

• The causes of older adults’ alcohol misuse, 

such as certain stressful major life events 

(e.g., forced retirement, death of a signifcant 

other), increased isolation, physical disability, 

and boredom/lack of meaningful activities or 

hobbies. 

• The signs and symptoms of alcohol misuse 

in older adults, including cognitive, physical, 

emotional, social, and behavioral conditions. 

• Aspects of alcohol use that can lead to or 

worsen health conditions. 

• How to make sense of media reports that 

suggest light or moderate drinking is healthy. 

• Which medications can have harmful interactions 

with alcohol and what those interactions include. 

• Tips and strategies for older adults who want 

to try to manage their alcohol misuse on their 

Treating Substance Use Disorder in Older Adults 

own and how to tell when it is time to seek help 

from a professional. 

• The steps that occur when a person accesses 

professional treatment or services, such as 

screening, assessment, and follow-up visits. 

Also, you will learn about treatment options 

across the continuum of care, including formal 

and informal interventions, and how to select 

the best-ftting treatment. 

• Ways to engage family and friends in support of 

recovery, as well as self-motivation strategies. 

• Vital information for family and caregivers, 

like warning signs of alcohol misuse, helping an 

older adult access professional care, and the 

importance of self-care. 

Chapter 9: Resources for Treating 

Substance Use Disorder in Older Adults 

Chapter 9 provides a compendium of resources 

described in all other portions of the TIP, plus 

additional resources. 

xx 
TIP 26

TIP Development Participants 

Consensus Panel 

Each Treatment Improvement Protocol (TIP) 

consensus panel is a group of primarily 

nonfederal addiction-focused clinical, research, 

administrative, and recovery support experts 

with deep knowledge of the TIP’s topic. With the 

Substance Abuse and Mental Health Services 

Administration’s (SAMHSA) Knowledge Application 

Program (KAP) team, they develop each TIP via a 

consensus-driven, collaborative process that blends 

evidence-based, best, and promising practices 

with the panel’s expertise and combined wealth of 

experience. 

Note: The information below indicates each 

participant’s position and affliation when the panel 

was convened and may not be current. 

Consensus Panel Chair 

Frederic C. Blow, Ph.D. 

Director, Addiction Center and Substance Abuse 

Section 

Professor, Department of Psychiatry 

University of Michigan 

Ann Arbor, MI 

Senior Research Investigator 

Center for Clinical Management Research 

Department of Veterans Affairs 

Ann Arbor, MI 

Consensus Panelists 

Kimberly Burton 

Director, Older Adult Programs 

Chair, Maryland Coalition on Mental Health and 

Aging 

Mental Health Association of Maryland 

Lutherville, MD 

Sarah L. Canham, Ph.D., M.A. 

Aging, Alcohol, and Addictions Interest Group 

Convener 

Gerontologists Giving Back Founder and 

Co-Coordinator 

Gerontological Society of America 

Washington, DC 

Senior Lecturer and University Research Associate 

Gerontology Research Centre 

Simon Fraser University 

Vancouver, BC, Canada 

Alexis Kuerbis, Ph.D., LCSW 

Assistant Professor, Silberman School of Social 

Work 

Member, Advisory Committee on LGBT Social 

Science & Public Policy Center 

Member, Health and Mental Health Field of 

Practice Committee 

Member, Clinical Practice with Individuals, Families, 

and Groups Committee 

Hunter College 

City University of New York 

New York, NY 

Sharon A. Matthew, LPC, ACRPS, CCS, CSAT, 

CMAT 

Clinical Director, Addiction Rehab for Older Adults 

Program 

Caron Treatment Centers 

Wernersville, PA 

David W. Oslin, M.D. 

Professor, Geriatric and Addiction Psychiatry 

Treatment Research Center 

Perelman School of Medicine 

University of Pennsylvania 

Philadelphia, PA 

Chief of Behavioral Health 

Philadelphia VA Medical Center 

Philadelphia, PA 

xxi 
TIP 26 Treating Substance Use Disorder in Older Adults 

Derek D. Satre, Ph.D. 

Associate Professor of Psychiatry, In Residence - 

Step 4 

School of Medicine 

Medical Staff Psychologist 

Langley Porter Hospital and Clinics 

University of California, San Francisco 

San Francisco, CA 

Stakeholders Meeting 

Participants 

Stakeholders represent a cross-section of key 

audiences with a deep interest in a TIP’s subject 

matter. Stakeholders review and comment on the 

draft outline and supporting materials for the TIP 

to ensure that its focus is clear, its stated purpose 

meets an urgent need in the feld, and it will not 

duplicate existing resources produced by the 

federal government or other entities. 

Note: The information below indicates each 

participant’s position and affliation when the 

meeting was convened and may not be current. 

Chair 

Frederic C. Blow, Ph.D. 

Director, Addiction Center and Substance Abuse 

Section 

Professor, Department of Psychiatry 

University of Michigan 

Ann Arbor, MI 

Senior Research Investigator 

Center for Clinical Management Research 

Department of Veterans Affairs 

Ann Arbor, MI 

Stakeholders Meeting 

Candi Byrne 

Alternate Contracting Offcer’s Representative 

Center for Substance Abuse Treatment (CSAT) 

SAMHSA 

Rockville, MD 

Melinda Campopiano von Klimo, M.D. 

Senior Medical Adviser 

CSAT 

SAMHSA 

Rockville, MD 

Anita Everett, M.D. 

Chief Medical Offcer 

Offce of Planning, Policy and Innovation (OPPI) 

SAMHSA 

Rockville, MD 

Deborah Goodman 

Publications Manager 

Offce of Communications 

SAMHSA 

Rockville, MD 

Kimberly Johnson, Ph.D. 

Director 

CSAT 

SAMHSA 

Rockville, MD 

Melinda Lantz, M.D. 

Member, Board of Directors 

American Association of Geriatric Psychiatry 

McLean, VA 

Eunice Park-Lee, Ph.D. 

Survey Statistician 

Center for Behavioral Health Statistics and Quality 

SAMHSA 

Rockville, MD 

Ron Pritchard, B.S. 

Veterans Affairs Subcommittee Chairperson 

NAADAC, the Association for Addiction 

Professionals 

Alexandria, VA 

Patricia Santora, Ph.D. 

Public Health Advisor 

Division of Service Improvement 

CSAT 

SAMHSA 

Rockville, MD 

Jennie Simpson, Ph.D. 

Special Assistant to the Administrator 

OPPI 

SAMHSA 

Rockville, MD 

Jennifer Solomon, M.A. 

TIP Product Champion 

Public Health Analyst 

Center for Substance Abuse Prevention 

SAMHSA 

Rockville, MD 

xxii 
TIP 26

Ivette Torres, M.Ed., M.S. 

Associate Director for Consumer Affairs 

Offce of the Director 

CSAT 

SAMHSA 

Rockville, MD 

Sherrill Wayland, M.S.W. 

National Projects Manager 

National Resource Center on LGBT Aging 

Services & Advocacy for GLBT Elders (SAGE) 

New York, NY 

Eric Weakly 

Chief, State Grants Western Branch 

Division of State and Community Systems 

Development 

Center for Mental Health Services 

SAMHSA 

Rockville, MD 

Marissa Whitehouse, M.Ed. 

Senior Program Specialist 

Center for Healthy Aging 

National Council on Aging 

Arlington, VA 

Field Reviewers 

Field reviewers represent each TIP’s intended 

target audiences. They work in addiction, mental 

health, primary care, and adjacent felds. Their 

direct frontline experience related to the TIP’s topic 

allows them to provide valuable input on a TIP’s 

relevance, utility, accuracy, and accessibility. 

Note: The information below indicates each 

participant’s position and affliation when the 

review was requested and may not be current. 

Constance Coogle, Ph.D., M.S. 

Associate Director for Research and Administrator 

for Alzheimer’s and Related Diseases Research 

Award Fund, Virginia Center on Aging 

Director of Evaluation, Virginia Geriatric Education 

Center 

Associate Professor, Department of Gerontology 

Associate Research Professor, Department of 

Psychology 

Virginia Commonwealth University 

Richmond, VA 

Brandi Cotton, Ph.D., M.S.N., APRN 

Assistant Professor, College of Nursing 

University of Rhode Island 

Kingston, RI 

Larry Dupree, Ph.D., M.S., M.A. 

Chair Emeritus 

Department of Aging and Mental Health, Louis de 

la Parte Florida Mental Health Institute 

University of South Florida 

Tampa, FL 

John Dyben, D.H.S., M.S., M.A. 

Chief Clinical Offcer 

Origins Behavioral Healthcare 

West Palm Beach, FL 

Stephen Ferrante, Ph.D., M.S.W. 

Adjunct Professor 

Barry University School of Social Work 

Miami Shores, FL 

Michael Fingerhood, M.D., FACP 

Associate Professor, Department of Medicine 

Johns Hopkins University School of Medicine 

Associate Professor, Department of Mental Health 

Johns Hopkins University Bloomberg School of 

Public Health 

Attending Physician and Director, Division of 

Chemical Dependence 

Johns Hopkins Bayview Medical Center 

Baltimore, MD 

Benjamin Han, M.D., M.P.H. 

Assistant Professor, Department of Medicine, 

Division of Geriatric Medicine 

Assistant Professor, Department of Population 

Health 

New York University School of Medicine 

Primary Care Physician, Geriatric Medicine 

Bellevue Hospital Center 

New York, NY 

Robert Hazlett, Ph.D., M.S. 

Consultant/Trainer 

National Screening, Brief Intervention, and Referral 

to Treatment Addiction Technology Transfer Center 

Pittsburgh, PA 

Chris Herman, M.S.W., LICSW 

Senior Practice Associate for Aging 

National Association of Social Workers 

Washington, DC 

xxiii 
TIP 26 Treating Substance Use Disorder in Older Adults 

Brenda Iliff, M.A., LADC, CAC, CMAT 

Executive Director 

Hazelden Betty Ford Foundation 

Naples, FL 

Susan Lehmann, M.D. 

Associate Professor, Department of Psychiatry and 

Behavioral Sciences 

Director, Psychiatry Clerkship and Geriatric 

Psychiatry Outpatient Clinic 

Clinical Director, Division of Geriatric Psychiatry 

and Neuropsychiatry 

Johns Hopkins University School of Medicine 

Director, Geriatric Psychiatry Day Hospital 

Johns Hopkins Hospital 

Baltimore, MD 

Nicole MacFarland, Ph.D., M.S.W., LCSW-R, 

CASAC 

Executive Director 

Senior Hope Counseling, Inc. 

Albany, NY 

Alison Moore, M.D., M.P.H., FACP, AGSF 

Chief of Geriatric Medicine and Gerontology, 

Professor of Medicine, and Adjunct Professor of 

Psychiatry, University of California–San Diego 

La Jolla, CA 

Co-Director, Center for Health Improvement 

for Minority Elders Mentorship Core, 

Resource Centers for Minority Aging Research, 

University of California–Los Angeles/ 

Charles R. Drew University of Medicine and Science 

Los Angeles, CA 

Cynthia Munshell, Ph.D., M.A. 

Partner and Managing Member, Director of 

Psychotherapy Services 

PsychoGeriatric Services 

Silver Spring, MD 

Collegiate Professor of Psychology 

University of Maryland University College 

Adelphi, MD 

Joseph Pickard, Ph.D., LCSW 

Associate Professor and Gerontology 

Concentration Coordinator 

University of Missouri–St. Louis School of Social 

Work 

St. Louis, MO 

Lawrence Schonfeld, Ph.D., M.A. 

Professor Emeritus, Department of Mental 

Health Law and Policy, College of Behavioral and 

Community Sciences, Louis de la Parte Florida 

Mental Health Institute 

University of South Florida 

Tampa, FL 

Harvey Sterns, Ph.D., M.A. 

Director, Institute for Life-Span Development and 

Gerontology 

Professor of Psychology 

University of Akron 

Akron, OH 

Research Professor of Gerontology, Family and 

Community Medicine 

Northeast Ohio Medical University 

Rootstown, OH 

Ming Wang, M.D., FASAM 

Addiction Medicine Specialist and Medical 

Director, Caron Older Adult Treatment Program 

Caron Treatment Centers 

Wernersville, PA 

Clinical Assistant Professor of Psychiatry 

Penn State College of Medicine 

Hershey, PA 

Kimberly Williams, M.S.W. 

President and CEO 

Vibrant Emotional Health 

Executive Committee Chair 

National Coalition on Mental Health and Aging 

Adjunct Lecturer 

Columbia University School of Social Work 

New York, NY 

Faika Zanjani, M.S.W., LICSW 

Associate Professor, Department of Gerontology, 

College of Health Professionals 

Associate Director of Academic Programs and 

Research Training, Institute for Inclusion, Inquiry, 

and Innovation 

Virginia Commonwealth University 

Richmond, VA 

xxiv 
TIP 26

Publication Information 

Acknowledgments 

This publication was prepared under contract 

numbers 270-14-0445 and 283-17-4901 by the 

Knowledge Application Program (KAP) for the 

Center for Substance Abuse Treatment, Substance 

Abuse and Mental Health Services Administration 

(SAMHSA), U.S. Department of Health and Human 

Services (HHS). Suzanne Wise served as the 

Contracting Offcer’s Representative (COR), Candi 

Byrne as the Alternate COR, and Jennifer Solomon, 

M.A., as the Product Champion. 

Disclaimer 

The views, opinions, and content expressed 

herein are the views of the consensus panel 

members and do not necessarily refect the offcial 

position of SAMHSA or HHS. No offcial support 

of or endorsement by SAMHSA or HHS for these 

opinions or for the instruments or resources 

described is intended or should be inferred. The 

guidelines presented should not be considered 

substitutes for individualized client care and 

treatment decisions. 

Public Domain Notice 

All materials appearing in this volume except those 

taken directly from copyrighted sources are in the 

public domain and may be reproduced or copied 

without permission from SAMHSA or the authors. 

Citation of the source is appreciated. However, this 

publication may not be reproduced or distributed 

for a fee without the specifc, written authorization 

of the Offce of Communications, SAMHSA, HHS. 

Electronic Access and Copies of 

Publication 

This publication may be ordered or downloaded 

from SAMHSA’s Publications and Digital Products 

webpage at https://store.samhsa.gov. Or, please 

call SAMHSA at 1-877-SAMHSA-7 (1-877-726-

4727) (English and Español). 

Recommended Citation 

Substance Abuse and Mental Health Services 

Administration. Treating Substance Use Disorder 

in Older Adults. Treatment Improvement Protocol 

(TIP) Series No. 26, SAMHSA Publication No. 

PEP20-02-01-011. Rockville, MD: Substance Abuse 

and Mental Health Services Administration, 2020. 

Originating Ofce 

Quality Improvement and Workforce Development 

Branch, Division of Services Improvement, Center 

for Substance Abuse Treatment, Substance Abuse 

and Mental Health Services Administration, 5600 

Fishers Lane, Rockville, MD 20857. 

Nondiscrimination Notice 

SAMHSA complies with applicable federal civil 

rights laws and does not discriminate on the basis 

of race, color, national origin, age, disability, or 

sex. SAMHSA cumple con las leyes federales 

de derechos civiles aplicables y no discrimina 

por motivos de raza, color, nacionalidad, edad, 

discapacidad, o sexo. 

SAMHSA Publication No. PEP20-02-01-011 

First printed 1998 

Updated 2020 

xxv 
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TIP 26 TREATING SUBSTANCE USE DISORDER 

IN OLDER ADULTS

Chapter 1—Older Adults and Substance 

Misuse: Understanding the Issue 

KEY MESSAGES Chapter 1 of this Treatment Improvement 

Protocol (TIP) benefts all audiences (providers, 

supervisors, administrators, older adults, 

caregivers, and family members). It summarizes 

the extent of substance use and substance misuse, 

including substance use disorders (SUDs), among 

older adults. Chapter 1 will help you understand 

the current situation and trends to gain an overall, 

broad understanding of this critical issue. This TIP is 

for all audiences who provide care and support to 

older adults, including older adults themselves as 

well as individuals who are connected to an older 

adult, such as family members, friends, formal and 

informal caregivers, behavioral health service and 

healthcare providers, and aging services providers. 

Organization of This TIP 

Chapter 1 contains information of value to all 

audiences: it is an overview of substance misuse 

and addiction treatment among older adults. 

Chapter 1 also defnes terms and summarizes 

issues to help clients and providers communicate 

more clearly with each other. 

Exhibit 1.1 defnes important terms this TIP uses. 

• Estimated rates of substance misuse in 

older adults vary widely. Substance misuse 

by this population is underrecognized and 

undertreated. 

• Substance misuse can be very dangerous for 

older adults. They are affected by substances 

differently than younger adults, and smaller 

amounts of substances can have more of an 

impact. Substance misuse by older adults 

can worsen any chronic medical conditions 

they may have. Older adults also often take 

more than one medication, which increases 

their odds of being exposed to harmful drug 

interactions. 

• It is never too late to stop misusing substances, 

no matter one’s age. Treatment for older 

adults is available. Providers need to learn 

about effective interventions for older adults 

so that they can offer treatment or referrals for 

treatment quickly and appropriately. 

1 
TIP 26 Treating Substance Use Disorder in Older Adults 

EXHIBIT 1.1. Key Terms 

• Addiction*: The most severe form of SUD, associated with compulsive or uncontrolled use of one or more 

substances. Addiction is a chronic brain disease that has the potential for both recurrence (relapse) and 

recovery. 

• Age-specifc: Treatment approaches and practices specifcally developed for older adults (e.g., an older 

adult specialty group in a mixed-age SUD treatment program). 

• Alcohol misuse: The use of alcohol in any harmful way, including heavy drinking, binge drinking, and 

alcohol use disorder (AUD). 

• At-risk/high-risk drinking: Drinking alcohol in excessive amounts. This defnition encompasses both 

binge drinking and heavy drinking. Additionally, any alcohol consumption is considered risky when 

carried out by individuals with certain medical conditions that are worsened by alcohol, those taking 

medicine that can interact harmfully with alcohol, those driving a car or engaged in other activities that 

require alertness, or people recovering from AUD.1,2 Note that for purposes of this TIP, at-risk drinking and 

high-risk drinking are synonymous and either term is acceptable to describe an older adult’s drinking 

patterns. 

• Binge drinking: A drinking pattern that leads to blood alcohol concentration levels of 0.08 grams per 

deciliter or greater. This usually takes place after four or more drinks for women and fve or more drinks 

for men.3,4 However, older adults are more sensitive to the effects of alcohol, and treatment providers 

may need to lower these numbers when screening for alcohol misuse.5

 Additionally, other factors such as 

weight, decrease in enzyme activity, and body composition (e.g., amount of muscle tissue present in the 

body) can also affect alcohol absorption rates. 

• Caregivers: Informal caregivers provide unpaid care. They assist others with activities of daily living, 

including health and medical tasks. Informal caregivers may be spouses, partners, family members, 

friends, neighbors, or others who have a signifcant personal relationship with the person who needs care. 

Formal caregivers are paid providers who offer care in one’s home or in a facility.6

 Most older adults do not 

need caregivers and are as able to address their own needs as younger adults, whether or not substance 

misuse is a factor in their lives. 

• Drug–drug interaction: The interaction of one substance (e.g., alcohol, medication, an illicit drug) with 

another substance. Drug–drug interactions may change the effectiveness of medications, introduce 

or alter the intensity of side effects, and increase a substance’s toxicity or the concentration of that 

substance in a person’s blood. Potentially serious interactions can also occur with certain foods, 

beverages, and dietary supplements.7 

• Heavy drinking: Consuming fve or more drinks for men and four or more drinks for women in one period 

on each of 5 or more days in the past 30 days.8 

• Illicit substances: Illicit substances include cocaine, heroin, hallucinogens, inhalants, methamphetamine, 

and prescription medications that are taken other than as prescribed (e.g., pain relievers, tranquilizers, 

stimulants, sedatives). 

• Moderate drinking: According to the 2015–2020 Dietary Guidelines for Americans, moderate drinking 

is defned as up to two drinks per day for men and up to one drink per day for women.9,10 However, the 

Centers for Disease Control and Prevention (CDC) notes that these numbers apply to any given day and 

are not meant as an average over several days.11 Additionally, individuals who don’t metabolize alcohol 

well may need to consume even lower quantities. Some people, particularly those with certain alcoholrelated illnesses or engaging in tasks requiring concentration, should not consume alcohol at all. The 

Dietary Guidelines stipulate that those who don’t drink should not begin drinking for any reason.12 

Continued on next page 

2 Chapter 1 
Chapter 1—Older Adults and Substance Misuse: Understanding the Issue TIP 26

Continued 

• Psychoactive substances: Substances that can alter mental processes (e.g., cognition or affect; in other 

words, the way one thinks or feels). Also called psychotropic drugs, such substances will not necessarily 

produce dependence, but they have the potential for misuse or abuse.13 

• Recovery*: A process of change through which individuals improve their health and wellness, live a selfdirected life, and strive to reach their full potential. Even individuals with severe and chronic SUDs can, 

with help, overcome them and regain health and social function. This is called remission. When those 

positive changes and values become part of a voluntarily adopted lifestyle, that is called being in recovery. 

Although abstinence from all substance misuse is a cardinal feature of a recovery lifestyle, it is not the 

only healthy, prosocial feature. 

• Relapse*: A return to substance use after a signifcant period of abstinence. 

• Remission: A medical term meaning a disappearance of signs and symptoms of the disease or disorder. 

The ffth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defnes remission 

as present in people who previously met SUD criteria but no longer meet any SUD criteria (with the 

possible exception of craving).14 Remission is an essential element of recovery. 

• Sensitivity: The extent to which a substance affects someone physiologically. Aging causes people to 

develop increasing sensitivity to substances. As a person ages, a given dose of a substance will have a 

greater physiological impact than it did when the person was younger. 

• Substance misuse*: The use of any substance in a manner, situation, amount, or frequency that can 

cause harm to users or to those around them. For some substances or individuals, any use would 

constitute misuse (e.g., underage drinking, injection drug use). 

• Substance use disorder*: A medical illness caused by repeated misuse of a substance or substances. 

According to DSM-5,15 SUDs are characterized by clinically signifcant impairments in health and social 

function, and by impaired control over substance use. They are diagnosed through assessing cognitive, 

behavioral, and psychological symptoms. SUDs range from mild to severe and from temporary to chronic. 

They typically develop gradually over time with repeated misuse, leading to changes in brain circuits 

governing incentive salience (the ability of substance-associated cues to trigger substance seeking), 

reward, stress, and executive functions like decision making and self-control. Multiple factors infuence 

whether and how rapidly a person will develop an SUD. These factors include the substance itself; the 

genetic vulnerability of the user; and the amount, frequency, and duration of the misuse. Note: A severe 

SUD is commonly called an addiction. A mild SUD is generally equivalent to what previous editions of 

DSM called substance abuse; a moderate or severe SUD is generally equivalent to what was formerly 

called substance dependence. 

* The defnitions of all terms marked with an asterisk correspond closely to those given in Facing Addiction 

in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. This resource provides a great 

deal of useful information about substance misuse and its impact on U.S. public health. The report is 

available online (https://addiction.surgeongeneral.gov/sites/default/fles/surgeon-generals-report.pdf). 

Chapter 1 3 
TIP 26

Who Can Beneft From This TIP 

and How? 

The demand for services to address substance 

misuse in older adults is increasing. All 

healthcare, behavioral health, and aging service/ 

long-term care providers need training in 

working on substance misuse–related problems 

with older adults, their families and friends, and 

formal and informal caregivers.16,17 Such providers 

include primary and specialty healthcare providers, 

case workers, social workers, psychologists, drug 

and alcohol counselors, peer recovery support 

specialists, clergy, providers of aging-related 

services, and direct care workers. 

~23% of SUD 

treatment programs in the 

U.S. offer services tailored to 

OLDER ADULTS.18 

Caregivers and families need resources to 

help navigate initial identifcation, screening, 

assessment, and treatment options for older 

people who misuse substances or have SUDs. Key 

societal changes have made this a critical time to 

address substance misuse in the aging population: 

• Substance use and SUDs among older adults are 

rising: 

- Illicit drug use is more common among 

current older adults than among previous 

generations of older adults. Current 65-andolder individuals and aging baby boomers 

(those born between 1946 and 1964) are 

more likely than members of previous 

generations to use illicit drugs. 

- SUDs among older adults are expected 

to continue increasing. Rapidly growing 

numbers of older adults will need substance 

misuse prevention and counseling, and 

sometimes SUD treatment services, 

particularly to address nonmedical use of 

prescription medication. 

Treating Substance Use Disorder in Older Adults 

• Substance use and chronic health conditions 

have compound effects on older individuals. 

Chronic health conditions in older adults can 

complicate the effects of their substance use, 

increasing their need for comprehensive, 

integrated services.19 Likewise, substance use 

can complicate the management of chronic 

conditions.20 

• Older adults are increasingly willing to seek 

services. Baby boomers tend to view addiction 

treatment as more acceptable than previous 

generations have.21,22 As baby boomers continue 

to enter old age, the number of older people 

needing treatment will continue to increase— 

and so therefore will the overall percentage 

willing to seek treatment. However, feelings 

of shame and stigma linked to SUD treatment 

settings cause many older adults to seek 

addiction care from providers who do not 

specialize in addiction treatment, including 

primary care and emergency department 

providers.23 

• Older adults are affected by co-occurring 

mental disorders and SUDs. In the 2019 

National Survey on Drug Use and Health 

(NSDUH):24 

- 1.5 percent of Americans ages 50 and older 

(1.7 million) had any past-year mental illness 

and SUD; an estimated 0.5 percent (607,000) 

reported both a past-year serious mental 

illness (SMI) and a past-year SUD. 

- 37 percent with a past-year SUD also had any 

mental illness; 13 percent, an SMI. 

- 11 percent of older adults with any mental 

illness in the past year also had an SUD. 

- 18 percent of older adults with an SMI in the 

past year also had an SUD. 

• Few providers specialize in dealing with 

geriatric substance use. 

Much research has been done with older adult 

populations, but guidance has lagged on 

implementing research fndings in ways that will 

improve services. This TIP flls gaps in the feld by 

focusing on ways to implement and improve the 

delivery of SUD treatment based on evidence 

and promising practices specifcally for older 

adults. Current gaps include: 

4 Chapter 1 
Chapter 1—Older Adults and Substance Misuse: Understanding the Issue TIP 26

• A science-to-service gap in resources for 

providers. Few service improvement resources 

focus on tailoring treatment services for 

older clients with SUDs who may also have 

co-occurring physical disabilities or mental 

disorders. 

• A gap in addiction treatment resources 

for clients, their families and friends, and 

caregivers. Free, user-friendly publications that 

inform older clients and those close to them 

about substance use and addiction services are 

diffcult to fnd. 

When reading this TIP, remember that some 

misuse is accidental or inadvertent. For example, 

individuals who are unaware of a medication’s 

potential to cause dependence or other harms 

may consume more than prescribed. Other 

individuals may have diffculty in monitoring 

when they have taken their medication and 

take more than the recommended dose. Some 

individuals may become substance dependent 

even though they take their medication as 

prescribed. The pathway to misuse helps guide 

the selection of interventions and, if necessary, 

treatment. Accidental misuse stills requires a 

response. 

Overview and Scope of the 

Substance Misuse Problem 

Older Adults Today 

The Older Adult Population 

The older adult population is becoming more 

diverse. In the coming decades, the percentage 

of non-Hispanic White older adults in the U.S. 

population is projected to drop, whereas the 

percentages of Hispanics and races other than 

White are expected to increase. Gender ratios are 

also changing. The gap between the number of 

women and men is beginning to narrow because 

of the increased life expectancy of men, especially 

among men ages 85 years and older.25 

Healthcare and behavioral health service 

providers and caregivers must understand 

this diversity to provide culturally responsive 

services, including interventions and treatments 

for alcohol and other substance misuse.26 Providers 

should also recognize differences between 

generations of older adults that may make some 

older adults more willing than others to discuss 

addiction and mental illness with their healthcare 

providers. 

The number of older adults with SUDs is 

increasing. The U.S. population of older adults 

increasingly consists of baby boomers. Baby 

boomers came of age at a time when substance 

use tended to be more culturally acceptable, 

making them more open to and less judgmental 

about substance use than prior generations. (Not 

all subgroups of baby boomers experienced this 

openness and freedom from judgment about 

substance use, such as racially and ethnically 

diverse populations.) Because of baby boomers’ 

exposure to drugs and alcohol at a younger age, 

their generation has higher rates of past or current 

SUDs compared with previous generations.27,28 

These changes in older adult demographics will 

have major consequences for SUD prevention 

and treatment programs. Shifts in the older 

population will strain retirement systems, 

healthcare facilities, and other services. A rapidly 

increasing number of older adults will need 

comprehensive, integrated, age-specifc SUD 

screening, assessment, and treatment services.29 

Substance Misuse Among Older Adults 

Substance misuse in older adults is dangerous 

and potentially deadly. They have increased 

vulnerability to alcohol and to adverse drug 

reactions (whether the drugs are prescription 

or illicit)30 because of physiological and mental 

changes associated with aging. Such changes 

include slower metabolism and lower body fat. This 

increased vulnerability makes identifying SUDs in 

older adults especially critical. 

Chapter 1 5 
TIP 26

SUDs do occur in older adults, although less 

often than in younger people. Of adults ages 65 

and older in the 2012–2013 Wave of the National 

Epidemiologic Survey on Alcohol and Related 

Conditions (NESARC III): 

• 2.3 percent had a 12-month AUD, and 13.4 

percent had a lifetime AUD.31 

• 0.8 percent had a past-year drug use disorder, 

and 2 percent had any lifetime drug use 

disorder.32 

Substance misuse rates in older adults vary by 

gender, race/ethnicity, and education level: 

• In NESARC III, past-year cannabis use was 

reported by about 4 percent of non-Hispanic 

Whites, 6 percent of non-Hispanic Blacks, 3 

percent of Hispanics, 0.7 percent of Asians, and 

11 percent of American Indians/Alaska Natives 

ages 50 and older.33 

• In the 2004–2005 Wave of NESARC, past-year 

prevalence of any SUD in adults 55 and older 

was:34 

- 3.9 percent for non-Hispanic Whites, 3.6 

percent for African Americans, 3.3 percent 

for Hispanics, 3.0 percent for American 

Indians/Alaska Natives, and 1.7 percent for 

Asian/Native Hawaiian/other Pacifc Islanders. 

- 2.9 percent for individuals with less than 

a high school education, 3.1 percent for 

individuals with a high school education, 

and 4.5 percent for those with at least some 

college. 

Older adults are often willing to seek help for 

substance misuse or SUDs, as they are tending 

to take more accepting views about addiction 

treatment.35 Yet negative attitudes (sometimes 

termed “ageism”) about older adults’ ability to 

recover from addiction persist, despite evidence 

that treatment is effective in reducing or stopping 

substance misuse and improving older adults’ 

health and quality of life.36,37,38,39,40,41 

Treating Substance Use Disorder in Older Adults 

Substance misuse, including SUDs, among older 

adults often goes unrecognized and untreated. 

Societal norms, values, and biases play a large role 

in this phenomenon. Some people hold the ageist 

false belief that SUDs do not exist or need no 

treatment in this age group. Others—even some 

healthcare providers—mistake SUD symptoms 

for normal age-related changes. Some healthcare 

providers may focus more on older adults’ reports 

of physical/medical complaints. Similarly, some 

older adults may deny or hide their substance userelated problems from their healthcare providers.42 

Current cultural biases tend to minimize the scope 

of substance misuse among older adults, but this 

public health concern is more urgent than ever. 

Prevalence and Characteristics of 

Substance Use Among Older Adults 

Alcohol 

Alcohol is the substance that older adults use 

and misuse most frequently. The 2019 NSDUH43 

found that, in individuals ages 65 and older, an 

estimated 5.6 million (10.7 percent) engaged in 

past-month binge alcohol use and an estimated 

1.5 million (2.8 percent) engaged in past-month 

heavy alcohol use. 

The survey also showed that 903,000 adults ages 

60 to 64 and 1.04 million adults ages 65 and older 

met Diagnostic and Statistical Manual of Mental 

Disorders, 4th Edition (DSM-IV) criteria for alcohol 

dependence or abuse in the past year. These 

numbers were similar among slightly younger 

groups of older adults, with 939,000 adults ages 50 

to 54 and 1.02 million adults ages 55 to 59 meeting 

DSM-IV criteria for alcohol dependence or abuse in 

the past year. 

Exhibit 1.2 shows what constitutes a standard drink 

by type of alcohol. 

6 Chapter 1 
Chapter 1—Older Adults and Substance Misuse: Understanding the Issue TIP 26

EXHIBIT 1.2. What Is a Standard Drink? 

Image adapted from material in the public domain. 44 

In healthcare settings, up to 15 percent of 

older patients may meet criteria for at-risk 

drinking.45,46,47 For example, one study48 of 24,863 

adults ages 65 and older in military and civilian 

healthcare clinics found that 9.2 percent of men 

and 2.1 percent of women regularly drank in excess 

of federal guidelines. The study found that 21.5 

percent of patients drank moderately, 4.1 percent 

engaged in at-risk drinking, and 4.5 percent drank 

heavily or engaged in binge drinking. Among those 

who drank moderately, 10.2 percent had engaged 

in heavy episodic drinking one to three times in the 

past 3 months. 

The Dietary Guidelines defne moderate drinking 

as consuming up to one drink a day for women 

and up to two drinks a day for men. Exceeding 

these numbers can lead to high-risk drinking. 

Older adults who drink at all in the following 

situations are also engaging in high-risk drinking:49 

• While taking certain prescription medications 

(such as opioids or sedatives) 

• Despite having a medical condition that drinking 

could worsen (like diabetes or heart disease) 

• When planning to drive a car or engage in other 

activities that require alertness 

• While recovering from AUD 

Older clients who engage in heavy drinking are 

at risk for worsening of existing health problems 

(e.g., diabetes, high blood pressure, mood 

disorders, cancer).50,51,52 In addition, certain life 

stressors53,54 are linked to increased risk of alcohol 

misuse in older adults and could cause existing 

health problems to worsen. Such life stressors 

include: 

• Financial strain. 

• Job loss/retirement. 

• Housing changes. 

• Bereavement. 

• Being a victim of theft. 

As adults age, they metabolize alcohol 

differently and become more sensitive to its 

effects even when they drink less.55 This increases 

risk of confusion, falls, and injury, and worsens 

existing health issues. 

Chapter 1 7 
TIP 26

Establishing clients’ history of use can help 

providers recognize possible substance use 

concerns in the future. Taking a history is also 

an opportunity to offer prevention messages 

and encouragement to individuals maintaining 

abstinence or very low use. 

Older adults are more likely to take medications 

that interact badly with alcohol. Exhibit 1.3 

lists some of these “alcohol-interactive” (AI) 

medications. In a review of 20 studies on reported 

use of alcohol and AI medication, more than half 

of individuals who used AI medication reported 

drinking alcohol.56 Another study found that 77.8 

percent of older adults who drank alcohol also took 

AI medications.57 

EXHIBIT 1.3. Potential AI 

Medications58 

• Medications to control heart or circulatory 

problems like arrhythmia or high blood 

pressure 

• Diuretics, sometimes called water pills 

• Seizure medications 

• Antianxiety medications 

• Muscle relaxers 

• Pain medications, including opioids (e.g., 

oxycodone, hydrocodone) and nonsteroidal 

anti-infammatory medications (e.g., ibuprofen) 

• Medications to control diabetes 

• Antidepressants 

Older adults who drink and regularly take AI 

medications may experience severe negative 

reactions (e.g., falls, gastrointestinal bleeding, 

low blood pressure, drowsiness, heart problems, 

liver damage).59 Drinking can also make these 

medications less effective in treating health 

conditions. Healthcare and behavioral health 

service providers should discuss the risks of 

combining alcohol and AI prescription medications 

with older clients, especially those with a history of 

alcohol use. 

Treating Substance Use Disorder in Older Adults 

Prescription Medications 

Most older adults take at least one prescription 

medication. Many take more than one. According 

to national estimates released in 2019,60 87.5 

percent of older adults in the United States have at 

least one prescribed medication, and 39.8 percent 

take fve or more prescription medications at the 

same time. From 2015 to 2016, the percentage 

of adults taking a prescription medication was 

greater for the 65 and older age group (87.5 

percent) than for any other adult age group. 

High prescription medication use puts older 

adults at greater risk than the general population 

for harmful side effects and drug–drug 

interactions, especially when they use over-thecounter (OTC) medications in addition to their 

prescriptions.61 Many prescription medications may 

interact badly with alcohol (Exhibit 1.3) and other 

substances, compounding this risk. Additionally, 

older individuals are more likely to experience 

negative side effects from prescription medications 

because of aging-related changes that alter how 

the body processes such substances.62 

# of older adults who 

VISITED the ER 

because of the 

prescription opioid 

TRAMADOL 

increased 481% 

from 2005 to 2011.63 

In addition, older adults may make medication 

errors (e.g., take too much, forget to take 

medications) because they have diffcult or 

complex medication regimens. According to the 

Agency for Healthcare Research and Quality,64 

50 percent of emergency department visits for 

adverse drug events in Medicare recipients are 

caused by four medication types: medications for 

diabetes (e.g., insulin), oral blood thinners (e.g., 

warfarin), anti-blood-clotting medications (e.g., 

aspirin, clopidogrel), and opioid pain relievers. 

Many older adults take numerous medications, thus 

increasing their chances of making errors. 

8 Chapter 1 
Chapter 1—Older Adults and Substance Misuse: Understanding the Issue TIP 26

Adults 65 and older are particularly vulnerable to 

misusing prescription medications. Prescription 

medication misuse involves taking a medication 

other than as prescribed, whether accidently or on 

purpose. 

In 2019, the most commonly misused medications 

were pain relievers, with an estimated 1.7 percent 

(900,000) of adults ages 65 and older misusing 

them in the past year.65 In 2019, pain reliever 

misuse was the fourth most common type of 

substance misuse among adults ages 65 and 

older in the United States.66 Some older adults do 

use prescription medications to “get high,” but 

many develop SUDs from misusing prescription 

medications to address sleep problems, chronic 

pain, or anxiety.67,68,69 

The medications of most concern are 

psychoactive medications such as opioids and 

central nervous system (CNS) depressants. Opioids 

are medications that relieve pain. CNS depressants 

include antianxiety medications, tranquilizers, 

sedatives, and hypnotics. These medications affect 

brain function, which can result in changes in 

consciousness, behavior, mood, pain, perception, 

and thinking. 

Nonmedical use of prescription medications by 

older adults will likely increase in the future. 

Most misused medications (e.g., pain relievers, 

stimulants, tranquillizers, sedatives) are obtained by 

prescription.70 

Opioids 

Older adults are at risk for nonmedical use of 

opioids, given the high prevalence of chronic pain 

in this population.71 Chronic pain is among the most 

common reasons for taking opioid medications, but 

for some individuals, prescription opioids do not 

relieve pain.72 

Older adults are also at risk for alcohol–opioid 

interactions. When taken with opioids, alcohol 

increases the risk of negative outcomes in older 

adults, including death.73, 74,75 

Rates of death and suicide caused by 

prescription opioid misuse are increasing.76 

In 2016, the Food and Drug Administration 

(FDA) issued a warning about serious risks, 

including death, from combining opioids with 

benzodiazepines or other CNS depressants, 

and required boxed warnings for prescription 

opioids and benzodiazepines. FDA’s action was 

not meant to suggest that providers withhold 

buprenorphine or methadone, which treat opioid 

use disorder (OUD), from patients also prescribed 

benzodiazepines, although FDA recommends 

careful medication management of these 

patients.77 Exhibit 1.4 lists common opioids. 

EXHIBIT 1.4. Common Forms 

of Opioids 

• Hydromorphone • Fentanyl 

• Oxycodone • Meperidine 

• Codeine • Hydrocodone 

• Methadone • Morphine 

Older adults may receive prescriptions for 

opioids to help manage their pain. For some, 

this creates a desire to get more pain medication 

than prescribed, because of tolerance. Having 

staff trained in the administration of naloxone is 

important in case clients experience an overdose 

of opioid medication. Providers should also learn 

about and offer older adults nonopioid pain 

medications (e.g., acetaminophen, antidepressants) 

and nonpharmacological pain management options 

(e.g., cognitive–behavioral therapy, relaxation 

training, exercise). 

Opioids can be appropriate in the short term 

and for specifc uses, such as postsurgical 

discomfort or cancer-related pain. But for many 

older adults with chronic (e.g., greater than 3 to 

6 months) noncancer pain, nonopioid options are 

appropriate, effective, and well tolerated. 

Chapter 1 9 
TIP 26

Benzodiazepines 

Benzodiazepines are frequently prescribed 

to older adults to treat anxiety and insomnia, 

despite having a high dependence potential. 

Benzodiazepines interact with alcohol, increasing 

the risk of negative outcomes. Recent research 

shows that, frequently, benzodiazepines are 

prescribed long term for older adults without a 

clear need for ongoing treatment.78 

Benzodiazepines are linked with a number of 

risks in older adults, including falls,79 problems 

with thinking,80 motor vehicle accidents,81 and 

overdose death.82 Exhibit 1.5 lists common 

benzodiazepines. 

EXHIBIT 1.5. Common 

Benzodiazepines 

• Lorazepam 

• Clonazepam 

• Diazepam 

• Alprazolam 

Cannabis 

Cannabis is illegal at the federal level, although 

an increasing number of states have legalized the 

recreational and medical use of cannabis. In 2019, 

about 2.7 million adults ages 65 and older (5.1 

percent) engaged in past-year cannabis use.83 

The number of older adults using prescribed 

cannabis is unknown. From 2013 to 2014, 

12-month prevalence of medical cannabis use 

among U.S. adults ages 50 and older was only 0.6 

percent.84 

Older adults using medical cannabis are at risk for 

misuse and diversion (including forced or coerced 

diversion by others).85 Other adverse effects can 

include psychomotor slowing (e.g., gait instability 

leading to fall risk), cognitive problems (e.g., 

short-term memory impairment), and increased 

risk of heart attack, stroke, psychotic episodes, and 

suicide.86 Studies have shown limited benefts of 

cannabis for medical purposes, with, for example, 

Treating Substance Use Disorder in Older Adults 

some evidence suggesting possible improvements 

in neuropathic pain and spasticity from multiple 

sclerosis in older adults;87 also, certain components 

of cannabis have demonstrated some medical value 

when treating seizure disorders (Dravet’s syndrome, 

Lennox-Gastaut syndrome), wasting illnesses, and 

lack of appetite.88 Other medications can treat these 

conditions, but they do not always work for older 

adults and may have unpleasant side effects. 

Little is known about interactions of cannabis with 

specifc medications.89 Cannabis affects the CNS. 

The substance is associated with memory and 

thinking problems, diffculties with motor skills, 

depression, and anxiety, among other negative 

effects.90,91,92,93 Moreover, the increasing potency 

of cannabis in recent decades may make cannabis 

use riskier.94 

Illicit Drugs 

Older adults are much less likely to use illicit 

drugs than younger adults. However, the pattern 

of drug use in older adults is changing. According 

to national survey data, use of illicit drugs among 

adults ages 50 to 64 rose from 2.7 to 10.4 percent 

from 2002 to 2019.95,96 Baby boomers are more 

likely than earlier generations to report use of 

heroin and psychoactive drugs like cocaine or 

methamphetamine.97 

OTC Medications and Dietary Supplements 

According to a 2016 analysis of national survey 

data,98 about 38 percent of older adults take at 

least one OTC medication; more than 63 percent 

take a dietary supplement (e.g., herbal products, 

vitamins). Among those who take prescription 

medications, 71.7 percent also take OTC 

medication or dietary supplements. 

OTC medications, including OTC pain 

medications like acetaminophen and ibuprofen, 

and dietary supplements can interact harmfully 

with prescription medications, illicit substances, 

and alcohol. Older adults may lack awareness of 

side effects and possible negative interactions, 

because information that comes with OTC 

medications often does not include warnings 

specifcally for older adults. 

10 Chapter 1 
Chapter 1—Older Adults and Substance Misuse: Understanding the Issue TIP 26

Providers should routinely discuss OTC 

medication use with older clients and advise 

them of possibly harmful interactions with 

prescribed medications, alcohol, and other 

substances.99 

Older adults (and their families and caregivers) 

should inform their healthcare providers of any 

OTC medications and dietary supplements, 

including herbal products, they take. Asking 

for guidance on safety is crucial when taking 

multiple OTC medications or using them in 

combination with alcohol or a prescribed 

medication. 

Risk and Protective Factors for Substance 

Misuse in Aging 

The unique physical, emotional, and cognitive 

challenges older adults face tend to mask SUD 

symptoms, making it harder for providers to 

identify and address SUDs. 

The aging process often includes major life 

changes and transitions. Some older adults turn 

to drugs or alcohol to cope.100 Older adults also 

face many aging-related physical and mental health 

issues that may increase their risk of substance 

misuse and make detection and treatment diffcult. 

The aging process can cause changes in and 

problems with thinking. Symptoms of cognitive 

decline and symptoms of substance misuse 

may be similar. This makes it harder for family 

members, caregivers, and healthcare and 

behavioral health service providers to recognize 

when older adults misuse substances. 

Many older adults who misuse substances have 

a history of co-occurring mental disorders, which 

suggests that mental illness is a risk factor for 

this population. Older adults with co-occurring 

mental and substance use disorders are at risk for 

negative outcomes like greater need for behavioral 

health services and higher rates of homelessness 

and suicidal thoughts.101,102,103 

Exhibit 1.6 lists risk factors for substance misuse in 

older adults. 

EXHIBIT 1.6. Substance Misuse 

Risk Factors in Older Adults104,105 

• Retirement (when not voluntary) 

• Loss of spouse, partner, or family member 

• Environment (e.g., relocation to assisted living) 

• Physical health (e.g., pain, high blood pressure, 

sleep and mobility issues) 

• Previous traumatic events 

• Mental disorders (e.g., disorders related to 

depression and anxiety) 

• Cognitive decline (e.g., Alzheimer’s disease) 

• Social changes (e.g., less active, socially 

disconnected from family and friends) 

• Economic stressors (rising medication and 

healthcare costs, living on reduced income) 

• Lifetime or family history of SUDs 

• High availability of substances 

• Social isolation 

Protective factors help prevent or reduce 106,107,108 substance misuse in older adults. Exhibit

1.7 lists protective factors against substance misuse 

in older adults. 

EXHIBIT 1.7. Substance Misuse 

Protective Factors in Older 

Adults 

Protective factors are factors that can reduce 

substance misuse or make it less likely to 

occur. They include a person’s strengths, skills, 

and abilities as well as environmental factors. 

Protective factors include: 

• Resiliency. 

• Marriage or committed relationship. 

• Supportive family relationships. 

• Retirement (when voluntary). 

• Ability to live independently. 

• Access to basic resources such as safe housing. 

• Positive self-image. 

• Well-managed medical care and proper use of 

medications. 

• Sense of identity and purpose. 

• Supportive networks and social bonds. 

Chapter 1 11 
TIP 26 Treating Substance Use Disorder in Older Adults 

EXHIBIT 1.8. Barriers to Seeking Treatment 

• Negative attitudes. Some families, caregivers, and service providers don’t feel comfortable addressing 

substance misuse because of their negative views about SUDs. They may also be afraid of “making waves” 

or feel that asking about the issue would intrude on the older adult’s life or independence. 

• Denial of the problem. Family and friends often either ignore or accept older adults’ substance misuse, 

especially if the problem is long standing. 

• Accepting attitudes. Some adults live in settings where family and peers have accepting attitudes 

toward alcohol and drugs. Even caregivers and medical professionals may view substance use as okay for 

older adults (e.g., viewing substances as older adults’ “one last pleasure”).109,110 

• Lack of knowledge. Family and friends may not realize that older adults undergo physiological changes 

that make the effects of alcohol or drugs more dangerous. 

• Misinformation about treatment. Some people hold the false belief that older adults cannot be treated 

for SUDs. However, evidence shows that addiction treatment for older adults has positive outcomes, can 

reduce or stop substance use, and improves health and quality of life.111,112,113,114,115,116 

See the Chapter 1 Appendix for a more detailed list of barriers to seeking treatment. 

Barriers to Seeking Treatment 

Exhibit 1.8 lists some of the barriers that prevent 

older adults from getting the SUD treatment they 

need. Understanding these barriers is a key step 

in reducing substance misuse in the older adult 

population. Such misuse limits one’s ability to 

function and to achieve the best possible quality of 

life, regardless of age. 

The following two sections will be of greater 

interest to healthcare providers. These sections 

give overviews of basic information on screening, 

diagnosis, and treatment as they apply to older 

clients from the provider’s point of view. 

Screening and Diagnosis 

Screening, brief intervention, and referral to 

treatment (SBIRT) is the overall model for and 

approach to screening and intervening with 

individuals who misuse, or are at risk for misusing, 

substances. Older adults with SUDs may receive 

screening, diagnosis, and treatment for SUDs 

in many different settings and from a variety 

of professionals. Few older adults seek help in 

specialized addiction treatment settings. 

All healthcare, behavioral health, and aging 

service providers must know the signs/symptoms 

of SUDs and substance misuse in older adults 

and have protocols for screening, treatment, or 

referral.117,118 

See Chapters 3, 4, and 5 of this TIP for more 

information about screening, assessment, 

and SBIRT. 

Screening 

Universal screening is key in SBIRT. Providers 

should screen all older clients for substance use 

(type of substance, frequency, quantity), misuse 

(including of prescriptions), consequences, and 

drug–drug interactions. 

UNIVERSAL SCREENING119 

Healthcare and social service providers should 

give all older clients a brief prescreen. Most 

will screen negative, but prescreening helps 

identify substance misuse that may otherwise be 

overlooked. 

Settings in which older adults may receive screening 

for substance-related problems include: 

• Healthcare clinics. 

• Hospitals. 

• SUD treatment programs. 

• Home health care. 

• Nursing homes. 

• Social service agencies. 

12 Chapter 1 
Chapter 1—Older Adults and Substance Misuse: Understanding the Issue TIP 26

• Senior centers. 

• Assisted living facilities. 

• Faith-based organizations. 

The TIP consensus panel recommends yearly 

screening for all adults ages 60 and older and 

when major life changes occur (e.g., retirement, 

loss of partner/spouse, changes in health). For 

more accurate histories, ask questions about 

substance use in the recent past while asking 

about other health behaviors (e.g., exercise, 

smoking, diet). Asking straightforward questions 

in a nonjudgmental manner is the best approach. 

Providers should also ask about medical marijuana 

prescriptions or use. 

Screening helps fully determine which 

substances (including alcohol) and medications 

a client takes and what, if any, interactions 

these substances, prescription medications, 

OTC medications, and dietary supplements may 

have with each other. Many providers fail to ask 

about OTC medications. However, some OTC 

medications (particularly anticholinergic agents, like 

diphenhydramine [Benadryl], doxylamine [Unisom], 

and acetaminophen/diphenhydramine [e.g., Tylenol 

PM]) can be problematic in combination with 

alcohol or prescription medications as well as 

illicit drugs. 

Screening for older adults can be verbal (e.g., by 

interview), with paper-and-pencil forms, or with 

computerized forms. All three methods are reliable 

and valid.120 Any positive responses should lead to 

further questions constituting full assessment (or 

referral for full assessment by a qualifed provider). 

Chapter 3 of this TIP offers further information 

about substance misuse screening measures and 

how to follow up with clients who screen positive 

as well as those who screen negative. 

Diagnostic Issues in Working With 

Older Adults 

Some DSM-5 SUD criteria may not apply to older 

adults with substance use problems, even though 

DSM-5 criteria generally determine SUD diagnoses. 

For example, in retired older individuals with fewer 

familial and work obligations, substance use may 

not cause failure to fulfll major obligations at work, 

school, or home. Even so, it may negatively affect 

health, daily activities, or functioning.121 

Older adults have unique risk factors that 

increase their vulnerability to substance 

misuse, but signs and symptoms of SUDs often 

resemble those of other health issues, making 

detection diffcult. Bodily changes (e.g., slower 

metabolism, reduced muscle mass, altered body 

fat percentages and organ functions) make older 

adults more sensitive to the effects of alcohol and 

drugs. Because of such changes, smaller amounts 

of substances may cause more harmful effects. 

These changes can occur gradually, which may 

make them harder to notice. 

Older individuals who misuse substances may 

require treatment even if they do not meet 

DSM-5 criteria for an SUD. Quantity-frequency 

measures may be less effective than assessment of 

impact on overall well-being and quality of life in 

identifying substance misuse for this population. 

Healthcare and behavioral health service providers 

must determine these effects before focusing on 

interventions and treatments. 

Treatment 

Addiction treatment programs have begun to 

see an increase in admissions among older adults 

because of the population increase and the higher 

prevalence of lifetime substance use among baby 

boomers.122,123 Although alcohol use remains the 

primary reason for admission, the years 2000 to 

2012 saw a decrease in alcohol-related admissions 

and steep increases in admissions for prescription 

opioids as well as illicit drugs such as cocaine, 

crack, and heroin.124 

Early- and Late-Onset Substance Misuse 

SUD diagnosis and treatment planning depend, 

in part, on when substance use began in older 

adults. “Early onset” substance use is present in 

those with a history of at-risk or harmful substance 

use that began before age 50.125 “Late-onset” 

substance use is present in those who began to 

misuse substances only later in life. Exhibit 1.9 

shows early- versus late-onset aspects of alcohol 

misuse as an example. 

Chapter 1 13 
TIP 26 Treating Substance Use Disorder in Older Adults 

EXHIBIT 1.9. Characteristics of Early-Onset Versus Late-Onset 

Alcohol Misuse126 

• Early onset: 

- Risky or harmful drinking patterns prior to age 50 

- Long-term denial, which complicates treatment 

- Multiple medical comorbidities, limited social support, poor emotional skills, and cognitive impairment 

- More common, making up two-thirds of older adults127 

• Late onset: 

- Began misusing alcohol later in life (possibly following alcohol problems at various periods earlier in life) 

- May have begun misusing alcohol because of age-related stressors (e.g., retirement, loss of income or 

partner) 

- Preceded by stable periods of abstinence or low-level drinking over a long period of time 

- May appear “too healthy” to raise concerns 

People with late-onset misuse may seem “too 

healthy” to raise concern. Providers should 

ask older clients about lifetime substance use 

patterns. Problems can arise with stressors in older 

adulthood.128,129 

Medication Interventions 

AUD 

Acamprosate, disulfram, and naltrexone are 

approved to treat AUD. They can improve 

outcomes130 but are not usually used for long-term 

treatment of older adults with AUD. 

Acamprosate 

Acamprosate is approved by FDA to treat 

AUD.131 Clinical evidence suggests that 

acamprosate can help people with alcohol 

dependence maintain abstinence by reducing 

cravings and the pleasurable effects associated 

with alcohol.132,133 It may also lessen symptoms 

of prolonged abstinence such as anxiety and 

insomnia.134 To date, research on acamprosate use 

in older adults is not readily available. Because 

acamprosate is removed from the body through 

the kidneys and older adults are at elevated risk of 

diminished kidney function, this population should 

have baseline and frequent renal function tests as 

part of acamprosate treatment.135 

Disulfram 

Disulfram is approved by FDA to treat AUD.136 

Disulfram triggers an acute physical reaction to 

alcohol, including fushing, fast heartbeat, nausea, 

chest pain, dizziness, and changes in blood 

pressure.137,138 These reactions are supposed to 

motivate a person to avoid drinking alcohol. 

Because the effects of taking this medication in 

combination with alcohol can be harmful to older 

people, it is generally not recommended for use 

in this population and, if used, is done so only 

with great caution.139,140 

Also, for disulfram to be useful, clients must 

stick to strict medication protocols.141 Doing so 

may be hard for older adults who have cognitive 

impairment or live alone and have no one to 

support them in taking medication as prescribed. 

A meta-analysis suggests that when compliance 

with disulfram is not monitored, its effcacy is 

no different from that of control conditions.142 

Monitoring for adherence is essential for 

disulfram to be effective. People taking disulfram 

may also need to be observed, as some may stop 

taking it on a day during which they want to drink. 

14 Chapter 1 
Chapter 1—Older Adults and Substance Misuse: Understanding the Issue TIP 26

Naltrexone 

Naltrexone is approved by FDA to treat AUD.143 

It reduces craving for alcohol and decreases the 

rate of relapse to heavy drinking. Some research 

suggests that naltrexone is tolerable in adults 

ages 50 and older, but widespread data on its 

tolerability in older individuals are lacking.144 

Naltrexone is an opioid blocker and cannot be 

used in clients who require prescription opioids for 

pain relief. Giving naltrexone to a client who takes 

opioid medication for pain may cause signifcant 

opioid withdrawal symptoms. 

OUD 

Medication treatment for OUD can reduce risk of 

relapse.145,146 Three medications can treat older 

adults with OUD: naltrexone, buprenorphine, 

and methadone. The opioid overdose medication 

naloxone is also safe and effective in older 

adults. Learn more about medication for OUD 

in the Substance Abuse and Mental Health 

Services Administration’s (SAMHSA) TIP 63, 

Medications for Opioid Use Disorder (https:// 

store.samhsa.gov/product/TIP-63-Medicationsfor-Opioid-Use-Disorder-Full-Document/ 

PEP20-02-01-006). 

Naltrexone 

Naltrexone can prevent relapse after medically 

supervised opioid withdrawal.147 It is not a 

pain medication. It is a medication that reduces 

cravings for and effects of opioids and alcohol. 

Research on its use in older adults with OUD is not 

readily available, but some studies have shown it 

to be safe and acceptable in older adults with 

AUD.148,149 

Buprenorphine 

Buprenorphine can treat opioid withdrawal or 

provide long-term medication maintenance 

for OUD. It is so effective that the World Health 

Organization (WHO) lists it as “an essential 

medication.”150,151 Compared with methadone, 

less is known about use of buprenorphine in 

older adults with OUD. It may be preferable 

to methadone, because it is less likely to cause 

withdrawal symptoms, erectile dysfunction, and 

prolonged QT interval (see “Methadone” section). 

It may be safer than methadone for older adults 

with cardiovascular/respiratory disorders.152 A study 

of short-term use of low-dose buprenorphine for 

older adults with depression found the medication 

to be safe and well tolerated.153 However, more 

studies are needed to fully understand the benefts 

and side effects of buprenorphine in older adults 

with OUD. 

Certain buprenorphine formulations are FDA 

approved to treat chronic pain. One such 

formulation is the buprenorphine transdermal 

system,154 which appears safe for pain treatment 

among older adults.155 

Methadone 

Methadone is used to prevent opioid withdrawal 

symptoms and reduce cravings for people with 

OUD.156 As with buprenorphine, it is considered 

so effective that WHO lists it as “an essential 

medication.”157,158 Methadone is available through 

federally certifed and accredited opioid treatment 

programs. It can be effective on its own, but 

research shows that it is often more effective in 

treating OUD when used with behavioral, social, 

and other medical services.159 Methadone can 

also be prescribed to treat chronic pain in older 

adults.160,161 

Older adults taking methadone may experience 

certain side effects, some of which can be 

serious.162 Methadone is associated with higher 

risk of prolonged QT interval, which can cause a 

potentially deadly cardiac arrhythmia.163 This risk is 

even greater when methadone is taken at higher 

doses, with other QT-prolonging medication, or 

by someone with congestive heart failure. Many 

medications negatively interact with methadone.164 

This is an important consideration in older adults, 

who are likely to take multiple medications. As with 

other opioids, methadone can increase the risk of 

falls in older adults.165 

Chapter 1 15 
TIP 26

RESOURCE ALERT: METHADONE 

SAFETY 

See Methadone Safety: A Clinical Practice 

Guideline From the American Pain Society and 

College on Problems of Drug Dependence, in 

Collaboration With the Heart Rhythm Society 

(www.jpain.org/article/S1526-5900(14)00522-7/ 

fulltext). 

This guideline provides recommendations on 

the safe use of methadone and addresses the 

potential risks related to overdose and cardiac 

arrhythmias. 

Naloxone 

Naloxone does not treat OUD or pain by itself, 

but it can reverse potentially fatal opioid 

overdoses. It is so effective that WHO lists it as 

“an essential medication.”166 Older adults are at 

increased risk of opioid overdose. Bodily changes 

that occur normally in aging cause older adults 

to experience a higher concentration of opioid 

metabolites than younger adults when the same 

dose is consumed.167 Low-dose naloxone is safe 

and effective in older adults in case of opioid 

overdose. 

Formal and Informal SUD Treatment 

Approaches 

People can change their substance use at any 

age. Once substance misuse becomes apparent, 

hope for recovery should always follow. A wide 

range of professionals and providers across a 

variety of settings share the responsibility to help 

older clients achieve recovery. 

Some studies suggest that older adults who 

enter specialized SUD treatment have better 

outcomes than younger adults.168,169,170,171 

However, many traditional SUD treatment 

programs do not serve many older adults 

(compared with the number of younger people 

they serve). In 2019, only about 23 percent of 

SUD treatment facilities had older adult-specifc 

Treating Substance Use Disorder in Older Adults 

programming.172 Thus, few studies with signifcant 

older populations have examined effectiveness of 

residential programming in this age group. 

Older adults do best in SUD treatment 

programs that offer age-appropriate care 

with providers who are knowledgeable 

about aging issues.173 In the community-based 

Geriatric Addictions Program, for older adults 

with SUDs and co-occurring mental disorders, 

a multidimensional approach connected more 

older adults to outpatient and inpatient treatment 

than did traditional assessment and referral. The 

multidimensional approach included geriatric care 

management assessment, motivational counseling, 

in-home counseling, and referral to aging services 

and addiction treatment.174 

Many pathways lead to recovery, and many 

treatment options work for older adults 

(Exhibit 1.10). 

EXHIBIT 1.10. Range of 

Intervention and Treatment 

Strategies for Older Adults 

• Minimal advice 

• Structured brief intervention protocols 

(e.g., SBIRT) 

• Structured brief treatments 

• Formal specialized treatments 

• Relapse prevention programs 

Few older adults who screen positive for 

substance misuse need specialized addiction 

treatment. Many can change their misuse 

through less intensive approaches,

175,176 such as: 

• Professional and personal advice and 

discussions. 

• Education about alcohol misuse, drug use, and 

prescription medication misuse. 

• Brief structured interventions and treatments 

(both individual and group). 

16 Chapter 1 
Chapter 1—Older Adults and Substance Misuse: Understanding the Issue TIP 26

Each older adult has an individual history and 

unique needs. Each older client’s intervention or 

treatment path will also be unique. The path to 

improving outcomes is determined, in part, by the 

severity of the problem, the individual’s willingness 

to get help with reducing or stopping substance 

misuse, the types of programs available, and the 

cost of care. 

Summary 

Evidence-based screening techniques, brief 

interventions or treatments, and specialized 

care options give older adults the best chances 

of improving their physical and emotional 

health. Identifcation and treatment of SUDs 

can be challenging, but is possible with the right 

knowledge and tools. 

This TIP will guide SUD treatment providers, 

supervisors, and administrators; mental 

health service providers; state and community 

behavioral health service agencies; healthcare 

providers; caregivers; families; and older adults 

in understanding and accessing evidence-based 

screening, intervention, and treatment options to 

address substance misuse in a number of settings. 

Chapter 1 17 
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Chapter 1—Older Adults and Substance Misuse: Understanding the Issue TIP 26

help all older clients receive the best possible care 

for substance misuse. 

The following table shows the many types of

barriers older adults potentially face in addressing 

substance misuse. The table includes citations of 

supporting research; access these references to 

learn more about each barrier and how it affects 

older adults. 

Chapter 1 Appendix 

Older Adults and Barriers to SUD 

Treatment and Mental Health Services 

Older adults face barriers at many levels in 

accessing SUD treatment and mental health 

services. Barriers can be personal, interpersonal, 

structural, or a combination. Recognizing, 

understanding, and working to remove barriers will 

Barriers Older Adults Face in Addressing Substance Misuse 

BARRIER DEFINITION, DESCRIPTION, OR EXAMPLE OF BARRIER 

SAMPLES OF 

RESEARCH 

Common myths 

and negative 

beliefs 

Myths and negative beliefs include “Drug addiction is only a ‘young 

person’s problem’” or “Once an alcoholic, always an alcoholic.” 

Providers or family members with these beliefs might not offer to 

help an older person who misuses substances. 

Similarly, an older person who fears stigma that comes from 

hearing other people express these negative beliefs might not ask 

for help. 

Choi et al. 

(2014)177 

Blais et al. 

(2015)178 

Crome (2013)179 

Co-occurring 

physical and 

mental health 

conditions 

Symptoms of substance misuse can seem similar to symptoms of 

other conditions common in older adults, including depression, 

anxiety, posttraumatic stress disorder, chronic pain, and sleep 

problems. Providers, family members, and clients themselves can 

easily mistake the symptoms of substance misuse for one or more 

of these conditions. 

Little research clarifes barriers for older adults with co-occurring 

mental and substance use disorders. But in adults in general, these 

co-occurring disorders (CODs) are associated with several barriers 

to treatment access: stigma, negative beliefs about addiction and 

mental health services, lack of specialized services for people with 

CODs, and providers’ failure to recognize both conditions in a client 

with CODs. 

Royal College 

of Psychiatrists 

(2015)180 

Crome (2013)181 

Center for 

Behavioral Health 

Statistics and 

Quality (2020)182 

Priester et al. 

(2016)183 

Continued on next page 

Chapter 1 19 
TIP 26 Treating Substance Use Disorder in Older Adults 

Continued 

BARRIER DEFINITION, DESCRIPTION, OR EXAMPLE OF BARRIER 

SAMPLES OF 

RESEARCH 

Lack of 

awareness on 

the part of older

clients 

Older clients may not realize how much they are drinking or that 

their substance misuse is a problem. 

For instance, older people are affected by alcohol differently than 

when they were younger. This is because of changes in the body 

that are a normal part of aging, like losing lean mass. For example, 

a woman in her 70s might think she can safely drink the same 

amount of alcohol that she drank in her 30s. This is not necessarily 

so. 

Some older adults think the amount of alcohol they drink is not 

risky although it exceeds recommendations for low-risk drinking. 

Sometimes a client’s lack of awareness can result from cognitive 

impairment, making it hard for the client to self-monitor alcohol 

intake. 

Sacco & Kuerbis 

(2013)184 

Borok et al. 

(2013)185 

Kuerbis et al. 

(2014)186 

Family members’ 

lack of awareness 

of older adults’ 

misuse 

Adult children may not know how much their parent is drinking or 

that his or her substance misuse is harmful. 

Even when aware of an older adult’s substance misuse, family 

members may not seek help as quickly as needed. They may have 

thoughts such as “Alcohol is my father’s last pleasure in life. I’d 

hate to take that away from him.” 

Royal College 

of Psychiatrists 

(2015)187 

Briggs et al. 

(2011)188 

Ageism “Ageism” refers to negative beliefs or attitudes about older people 

that lead to stereotyping or discrimination. 

An example of ageism is failing to screen a client in her 80s for 

SUDs because “people her age don't beneft from treatment.” 

Royal College 

of Psychiatrists 

(2015)189 

Chrisler et al. 

(2016)190 

Views of SUDs as 

a moral failure or 

weakness 

An older client who believes that having an SUD is a sign of being 

“weak” or a “bad person” might feel too ashamed to ask for help. 

Royal College 

of Psychiatrists 

(2015)191 

Financial 

problems, 

insurance issues 

Examples of this barrier include low income or no income, as well 

as having no insurance or insurance that does not cover SUD 

treatment and mental health services. 

Choi et al. 

(2014)192 

Osborn et al. 

(2017)193 

Limited mobility, 

transportation, or 

both 

Examples of these barriers are having diffculty walking or not 

having access to mobility assistance devices (like a walker or 

wheelchair). 

This barrier also includes being unable to travel to appointments 

(e.g., not having a car, not having access to public transportation). 

Choi et al. 

(2014)194 

Hadley Strout et 

al. (2016)195 

Continued on next page 

20 Chapter 1 
Chapter 1—Older Adults and Substance Misuse: Understanding the Issue TIP 26

Continued 

BARRIER DEFINITION, DESCRIPTION, OR EXAMPLE OF BARRIER 

SAMPLES OF 

RESEARCH 

Living situations 

and social 

settings that 

“normalize” 

substance 

misuse 

A home setting or social network that supports older adults’ 

misuse of substances can hinder diagnosis and treatment. For 

instance, in some assisted living facilities, residents frequently 

use alcohol. This could make it harder for staff to identify an older 

client who misuses alcohol because drinking is seen as “normal.” 

In some nursing homes, staff do not regularly ask about alcohol 

use at intake and may fail to recognize when residents are 

misusing alcohol. 

Many long-term care facilities have no policies on illicit drug use. 

This suggests that staff members may not be fully prepared to 

recognize and respond to residents’ drug use. 

Older adults with spouses/friends who misuse alcohol or support 

drinking may be at more risk for alcohol misuse because they 

are surrounded by people who make their alcohol misuse seem 

“normal.” 

Castle et al. 

(2012)196 

Klein & Jess 

(2002)197 

White et al. 

(2015)198 

Moos et al. 

(2011)199 

Lack of social 

support, 

including 

social isolation 

or low social 

connectedness 

Older adults with few or weak social relationships (like being 

single, widowed, or divorced) may be less likely to visit healthcare 

providers compared with older adults with stronger social ties (like

being married or living with someone else). 

Older adults who are socially connected and feel positive about 

their social network appear to have better access to healthcare 

services and better health and well-being than older people who 

are not socially well connected. 

Bremer et al. 

(2017)200 

Graham et al. 

(2014)201 

Limited numbers

of providers 

with knowledge 

of and 

commitment 

to working with 

older adults 

Too few healthcare providers and behavioral health service 

providers are trained to work with older adults who misuse 

substances. Without this training, providers are less likely to 

screen, assess, diagnose, and treat older clients who misuse 

substances. 

Institute of 

Medicine (2012)202 

Bartels et al. 

(2014)203 

No coordinated 

services; 

limited access 

to behavioral 

health or social 

services across 

care settings 

or geographic 

regions 

Older adults who misuse substances, have other problems related 

to behavioral health, or both need coordinated, person-centered 

care. Coordinated care helps address all of clients’ physical, mental,

and social service needs. 

Many older clients who misuse substances do not receive 

coordinated care. Healthcare providers (including physicians, 

nurses, and physician assistants) and behavioral health service 

providers should be appropriately trained and working together 

closely when providing SUD treatment or mental health services. 

Institute of 

Medicine (2012)204 

Gage & Melillo 

(2011)205 

Continued on next page 

Chapter 1 21 
TIP 26 Treating Substance Use Disorder in Older Adults 

Continued 

BARRIER DEFINITION, DESCRIPTION, OR EXAMPLE OF BARRIER 

SAMPLES OF 

RESEARCH 

Lack of case 

management 

or care 

management 

Case managers (or “care managers”) coordinate healthcare and 

behavioral health services across providers. When care is not 

coordinated, clients might not get access to the full range of 

treatments they need. 

The workforce needs to identify and include in coordinated 

services case managers or care managers who are specially 

trained in older adults’ unique substance misuse and mental 

health issues. Providers who do not understand the particular 

ways that older adults experience substance misuse may be less 

likely to screen, assess, diagnose, and treat older clients for SUDs, 

as needed. 

Institute of 

Medicine (2012)206 

Ambivalence 

about changing 

a health behavior

Like young and middle-aged adults, older adults may feel 

ambivalent about changing a long-standing health behavior. This 

can be a barrier to entering treatment or following a provider’s 

recommendations. 

National 

Research Council 

(2006)207 

Normal life 

changes 

Older adults commonly experience life changes that increase their 

risk of misusing substances. Such changes include moving into 

assisted living or other long-term care facility, retiring from work, 

and losing a family member (such as a spouse or adult child). 

It might be easy to “normalize” or make light of an older person’s 

substance misuse in one of these situations. (“He doesn’t really 

have a drinking problem. He’s just drinking because he lost his 

wife. Who can blame him?”) But substance misuse in these 

situations is just as serious and potentially harmful as in any other 

situation. 

Kuerbis et al. 

(2014)208 

Loss, especially 

death of children, 

spouse, siblings, 

or close friends; 

also, loss of 

employment 

(e.g., forced 

retirement) 

The death of a family member or friend can be extremely 

distressing. In some older adults, grief can increase the risk of 

substance misuse, especially alcohol misuse and tobacco use. 

Grieving older adults may misuse substances as a way of coping 

with their loss. If this is their main method of coping, it can be a 

barrier to entering treatment, as they likely will not want to quit. 

Some older people consider retirement a form of loss, especially 

when the retirement is unwanted. Many people defne themselves 

by their work. For them, leaving their job represents a loss of their 

identity and can lead to negative self-esteem. People may misuse 

substances as a way of coping, which could be a barrier to entering

treatment. 

Stahl & Schulz 

(2014)209 

Kelly et al. 

(2018)210 

Continued on next page 

22 Chapter 1 
Chapter 1—Older Adults and Substance Misuse: Understanding the Issue TIP 26

Continued 

BARRIER DEFINITION, DESCRIPTION, OR EXAMPLE OF BARRIER 

SAMPLES OF 

RESEARCH 

Lack of health 

literacy 

“Health literacy” is a person’s ability to access, understand, and 

communicate about health-related information. 

Older people with low health literacy may have trouble talking 

about substance misuse with their providers. They may also not 

understand, for example, what amount of alcohol is considered 

low risk versus harmful. In these instances, these individuals may 

not seek treatment. 

Levy & Janke 

(2016)211 

Geboers et al. 

(2016)212 

Findley (2015)213 

Cultural norms Cultural norms can infuence a person’s help-seeking behavior. 

For example, an older person whose culture discourages talking 

about mental illness or substance misuse may not seek help. 

In some cultures, it is more acceptable to talk about physical 

symptoms, such as aches and pains or sleep problems, than it is 

to talk about symptoms of addiction or mental illness, like feeling 

depressed or wanting to hurt oneself. This can make it hard 

for a provider to know when a client from this kind of cultural 

background has a problem related to substance misuse or mental 

illness. 

Royal College 

of Psychiatrists 

(2015)214 

Barrio et al. 

(2008)215 

Jimenez et al. 

(2013)216 

Racial and 

cultural 

differences 

among older 

clients 

Racial and cultural factors can affect how a person thinks and 

speaks about his or her behavioral health, seeks help for addiction 

or mental illness, and receives treatment. 

For instance, an older individual who does not speak English 

fuently may feel uncomfortable asking for help from a provider 

who speaks only English. 

De Guzman et al. 

(2015)217 

Barrio et al. 

(2008)218 

Sorkin et al. 

(2016)219 

Gender and 

sexual identity 

Like race and culture, older adults’ gender and sexual identity can 

affect whether they seek and receive help for substance misuse or 

mental illness. 

For example, older lesbian, gay, bisexual, transgender, and 

questioning adults may be slow to seek treatment out of fear 

that providers will refuse to care for them or because they are 

uncomfortable with physical exams. 

Older women are especially vulnerable to some barriers, like 

stigma, low income, or providers not recognizing their substance 

misuse. 

Auldridge et al. 

(2012)220 

Koenig & Crisp 

(2008)221 

Chrisler et al. 

(2016)222 

Chapter 1 23 
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TIP 26 TREATING SUBSTANCE USE DISORDER 

IN OLDER ADULTS

Chapter 2—Principles of Care for 

Older Adults 

KEY MESSAGES 

• Incorporating age-sensitive and age-specifc

treatment practices into your program is

important for engaging older clients and

improving their retention in treatment.

• The older adult population is culturally, racially,

and ethnically diverse. Recognize and address

diversity and health disparity issues related to

aging.

• Collaboration among service providers across

settings is essential when working with older

adults who misuse substances, particularly for

those with co-occurring medical conditions

and mental disorders.

• Hiring, training, and retaining staff

who demonstrate high motivation and

commitment to serving older adults are vital

to successfully implementing substance

use disorder (SUD) treatment programs and

services for this population.

Chapter 2 of this Treatment Improvement 

Protocol (TIP) will most beneft healthcare, 

mental health, addiction treatment, and social 

service providers who work with older adults. It 

addresses principles of care for older clients who 

present across settings with substance misuse. 

By tailoring traditional treatment methods and 

adopting age-specifc, age-sensitive, scienceinformed interventions, providers can better fulfll 

the needs of a growing population of older adults 

who misuse substances. Older adults receive 

services in many settings besides SUD treatment 

programs: mental health service programs, 

primary care practices, emergency departments, 

senior centers, adult day programs, faith-based 

organizations, and assisted living and residential 

care facilities. Across settings, early identifcation, 

universal screening, and education for substance 

misuse can facilitate brief intervention and referral 

to treatment. 

Organization of Chapter 2 of 

This TIP 

Chapter 2 addresses the general principles of 

care—across service settings—for older adults 

with a history of substance misuse. The following 

are essential principles of care: 

• Understand the developmental issues of aging.

• Acknowledge and address the diversity among

older adults.

• Recognize the difference between early- and

late-onset SUDs among older adults.

• Emphasize client education, early identifcation,

screening, and brief treatment.

• Engage in health risk reduction practices.

• Provide person-centered care.

• Build alliances with older clients; use agesensitive strategies to engage/retain them in

treatment.

• Help older clients use social networks and

community-based services.

• Encourage family and caregiver involvement.

• Coordinate care and develop service linkages.

• Make programmatic changes to effectively serve

older adults with SUDs.

• Invest in age-sensitive workforce development.

Chapter 2 concludes with a list of targeted 

resources to support the delivery of older adult– 

focused services to address substance misuse. 

A more detailed resource guide is available in 

Chapter 9 of this TIP. 

Exhibit 2.1 provides defnitions for key terms that 

appear in Chapter 2. 

25 
TIP 26 Treating Substance Use Disorder in Older Adults 

EXHIBIT 2.1. Key Terms 

• Addiction*: The most severe form of SUD, associated with compulsive or uncontrolled use of one or more 

substances. Addiction is a chronic brain disease that has the potential for both recurrence (relapse) and 

recovery. 

• Age-sensitive: Adaptations to existing treatment approaches that accommodate older adults’ unique 

needs (e.g., a large-print handout on the signs of substance misuse). 

• Age-specifc: Treatment approaches and practices specifcally developed for older adults (e.g., an older 

adult specialty group in a mixed-age SUD treatment program). 

• Alcohol misuse: The use of alcohol in any harmful way, including heavy drinking, binge drinking, and 

alcohol use disorder (AUD). 

• At-risk/high-risk drinking: Drinking alcohol in excessive amounts. This defnition encompasses both 

binge drinking and heavy drinking. Additionally, any alcohol consumption is considered risky when 

carried out by individuals with certain medical conditions that are worsened by alcohol, those taking 

medicine that can interact harmfully with alcohol, those driving a car or engaged in other activities that 

require alertness, or people recovering from AUD. 223,224 Note that for purposes of this TIP, at-risk drinking 

and high-risk drinking are synonymous and either term is acceptable to describe an older adult’s drinking 

patterns. 

• Binge drinking: A drinking pattern that leads to blood alcohol concentration levels of 0.08 grams per 

deciliter or greater. This usually takes place after four or more drinks for women and fve or more drinks 

for men.225,226 However, older adults are more sensitive to the effects of alcohol, and treatment providers 

may need to lower these numbers when screening for alcohol misuse.227 Additionally, other factors such 

as weight, decrease in enzyme activity, and body composition (e.g., amount of muscle tissue present in 

the body) can also affect alcohol absorption rates. 

• Caregivers: Informal caregivers provide unpaid care. They assist others with activities of daily living 

(ADLs), including health and medical tasks. Informal caregivers may be spouses, partners, family 

members, friends, neighbors, or others who have a signifcant personal relationship with the person who 

needs care. Formal caregivers are paid providers who offer care in one’s home or in a facility.228 Most older 

adults do not need caregivers and are as able to address their own needs as younger adults, whether or 

not substance misuse is a factor in their lives. 

• Drug–drug interaction: The interaction of one substance (e.g., alcohol, medication, an illicit drug) with 

another substance. Drug–drug interactions may change the effectiveness of medications, introduce 

or alter the intensity of side effects, and increase a substance’s toxicity or the concentration of that 

substance in a person’s blood. Potentially serious interactions can also occur with certain foods, 

beverages, and dietary supplements.229 

• Drug use: The full range of severity of illicit drug use, from a single instance of use to meeting criteria for a 

drug use disorder. 

• Heavy drinking: Consuming fve or more drinks for men and four or more drinks for women in one period 

on each of 5 or more days in the past 30 days.230 

• Moderate drinking: According to the 2015–2020 Dietary Guidelines for Americans, moderate drinking is 

defned as up to two drinks per day for men and up to one drink per day for women.231,232 However, the 

Centers for Disease Control and Prevention (CDC) notes that these numbers apply to any given day and 

are not meant as an average over several days.233 Additionally, individuals who don’t metabolize alcohol 

well may need to consume even lower quantities. Some people, particularly those with certain alcoholrelated illnesses or engaging in tasks requiring concentration, should not consume alcohol at all. The 

Dietary Guidelines stipulate that those who don’t drink should not begin drinking for any reason.234 

Continued on next page 

26 Chapter 2 
Chapter 2—Principles of Care for Older Adults TIP 26

Continued 

• Mutual-help groups: Groups of people who work together on obtaining and maintaining recovery. Unlike

peer support (e.g., the use of recovery coaches or peer recovery support specialists), mutual-help groups

consist entirely of people who volunteer their time and typically have no offcial connection to treatment

programs. Most are self-supporting. Although 12-Step groups such as Alcoholics Anonymous and

Narcotics Anonymous are the most widespread and well researched type of mutual-help groups, other

groups may be available in some areas. They range from groups affliated with a religion or church (e.g.,

Celebrate Recovery, Millati Islami) to purely secular groups (e.g., SMART [Self-Management and Recovery

Training] Recovery, Women for Sobriety).

• Peer support: The use of peer recovery support specialists (e.g., someone in recovery who has lived

experience in addiction plus skills learned in formal training) to provide nonclinical (i.e., not requiring

training in diagnosis or treatment) recovery support services to individuals in recovery from addiction and

to their families.

• Recovery*: A process of change through which individuals improve their health and wellness, live a selfdirected life, and strive to reach their full potential. Even individuals with severe and chronic SUDs can,

with help, overcome them and regain health and social function. This is called remission. When those

positive changes and values become part of a voluntarily adopted lifestyle, that is called being in recovery.

Although abstinence from all substance misuse is a cardinal feature of a recovery lifestyle, it is not the

only healthy, prosocial feature.

• Relapse*: A return to substance use after a signifcant period of abstinence.

• Remission: A medical term meaning a disappearance of signs and symptoms of the disease or disorder.

The ffth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defnes remission

as present in people who previously met SUD criteria but no longer meet any SUD criteria (with the

possible exception of craving).235 Remission is an essential element of recovery.

• Substance misuse*: The use of any substance in a manner, situation, amount, or frequency that can

cause harm to users or to those around them. For some substances or individuals, any use would

constitute misuse (e.g., underage drinking, injection drug use).

• Substance use disorder*: A medical illness caused by repeated misuse of a substance or substances.

According to DSM-5,236 SUDs are characterized by clinically signifcant impairments in health and social

function, and by impaired control over substance use. They are diagnosed through assessing cognitive,

behavioral, and psychological symptoms. SUDs range from mild to severe and from temporary to chronic.

They typically develop gradually over time with repeated misuse, leading to changes in brain circuits

governing incentive salience (the ability of substance-associated cues to trigger substance seeking),

reward, stress, and executive functions like decision making and self-control. Multiple factors infuence

whether and how rapidly a person will develop an SUD. These factors include the substance itself; the

genetic vulnerability of the user; and the amount, frequency, and duration of the misuse. Note: A severe

SUD is commonly called an addiction. A mild SUD is generally equivalent to what previous editions of

DSM called substance abuse; a moderate or severe SUD is generally equivalent to what was formerly

called substance dependence.

* The defnitions of all terms marked with an asterisk correspond closely to those given in Facing Addiction

in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. This resource provides a great

deal of useful information about substance misuse and its impact on U.S. public health. The report is

available online (https://addiction.surgeongeneral.gov/sites/default/fles/surgeon-generals-report.pdf).

Chapter 2 27 
TIP 26 Treating Substance Use Disorder in Older Adults 

General Principles of Care 

Older adults tend to do as well as or better than 

younger adults in mixed-age SUD treatment.237,238 

Moreover, growing evidence links age-specifc 

treatment to better treatment adherence and 

long-term outcomes for many older adults.239 

Even so, only about 23 percent of SUD treatment 

programs in the United States offer a program or 

group specifcally tailored to older adults.240 

Few SUD treatment approaches are designed 

specifcally for older adults. Therefore, this TIP 

provides general principles of care that can 

inform a fexible approach for age-sensitive, 

age-specifc treatment of substance misuse 

among older adults. The principles are a framework 

to guide your work with older adults across 

settings to address issues related to their misuse of 

substances. 

Understand the Developmental 

Issues of Aging 

Older adults are not a homogenous group. As 

with any group, older adults may hold a diverse 

range of opinions and attitudes toward alcohol 

and drug use. For example, within the older adult 

population, people in various age ranges differ 

from one another in signifcant ways that may 

infuence which approaches will most successfully 

address substance misuse. 

Earlier cohorts of older adults (e.g., adults born 

before or during World War II) are more likely 

to have moralistic attitudes about drinking and 

drug use—attitudes that, for some, were shaped 

by Prohibition and the Temperance Movement.241 

They may feel deeply ashamed about alcohol 

misuse or drug use. If they attribute their substance 

misuse to a moral failing, they may be less likely to 

seek SUD treatment.242 These cohorts are likelier 

to beneft from screening and brief intervention 

with a healthcare provider when questions about 

drinking and drug use are part of an overall 

approach to health assessments. 

Baby boomers (i.e., adults born between 1946 

and 1964) grew up in a time when substance use 

was more culturally acceptable. They may have 

more permissive attitudes toward drinking and 

drug use. They are also more likely to be willing 

to seek and agree to specialized addiction 

treatment.243 

Older adults have unique developmental 

challenges that younger adults may not have. 

These include possibly losing a spouse or partner, 

as well as experiencing: 

• Increasing numbers of deaths of friends in the

same age cohort.

• Role changes in families and work-related

activities.

• Reduced opportunities for increasing or

maintaining income levels.

• Normal age-related cognitive and physical

decline leading to loss of functioning and

reduced capacity to carry out ADLs.244 

Providing age-sensitive, age-specifc treatment 

approaches helps older adults feel more 

comfortable discussing personal issues and agerelated changes than they would feel doing so in 

mixed-age treatment programs.245 Whether or not 

you can offer age-specifc treatment options, your 

program needs to create an environment that 

responds to older adults’ needs (Exhibit 2.2). 

28 Chapter 2 
Chapter 2—Principles of Care for Older Adults TIP 26

EXHIBIT 2.2. How Administrators Can Create a Treatment Environment 

Responsive to Older Adults246 

Older adults have specifc developmental needs. To create an environment that is responsive to older 

adults’ needs, the entire organization, not just providers, must be committed to this purpose. Some of the 

strategies administrators can use to create an age-sensitive treatment or service environment include: 

• Make a commitment to understanding the developmental needs and cohort differences. 

• Review and update your vision and mission statement to refect your commitment to older adults. 

• Conduct an organizational self-assessment of attitudes, knowledge, and skills needed to effectively 

respond to older adults in your program. 

• Conduct an organizational self-assessment of the physical environment and other barriers to access that 

must be addressed to provide services to older adults. 

• Address organization-wide competence in the developmental needs of older adults and cohort 

differences in your strategic planning process. 

• Assign one staff member to oversee the development of age-specifc practices and services. 

• Develop an advisory board or task group with older adult members from the community. 

• Engage clients, staff, and community members in planning/developing age-specifc services and 

programs. 

• Develop and review policies and procedures to ensure that all staff are responsive to older adults’ needs. 

• Create an older adult-friendly environment that enhances engagement and retention of clients. 

• Develop outreach strategies to improve access to care. 

The consensus panel recommends that you 

engage your clients in discussions about their 

attitudes toward substance misuse, create an 

age-sensitive treatment environment that is 

responsive to older adults, and offer age-specifc 

treatment options when possible. 

Acknowledge and Address Older Adults’ 

Diversity 

The older adult population is as culturally diverse 

as other age groups. Yet older adults who are 

members of racial/ethnic and other minority 

groups are often at greater risk of poor health, 

disability, social isolation, and poverty than 

are their younger counterparts. Older adults 

from diverse racial and ethnic backgrounds are 

also more likely to be underinsured and receive 

fewer routine screenings for health concerns.247 

Therefore, they face more barriers to accessing 

health care and experience greater health 

disparities.248 These disparities increase risk 

for developing SUDs and increase barriers to 

treatment. 

Higher rates of deaths, disability, and chronic 

illness are more common among older adults 

who identify with diverse racial and ethnic 

groups.249 

Lesbian, gay, bisexual, transgender, and 

questioning (LGBTQ) older adults may 

experience poor health care and lack of access to 

services. Given discrimination and prejudice, they 

may have to hide, or feel the need to hide, their 

LGBTQ identity to receive care.250 

Gender-related disparities can create or 

compound health disparities in older adults. 

Older women are at higher risk for co-occurring 

mental disorders and social isolation than older 

men.251 They are also more likely to be prescribed 

medications (e.g., benzodiazepines) that negatively 

interact with alcohol and to be prescribed them 

for longer periods of time, increasing the risk of 

SUDs.252 

Chapter 2 29 
TIP 26 Treating Substance Use Disorder in Older Adults 

OLDER WOMEN

are at higher risk for 

CO-OCCURRING 

mental disorders and 

social isolation than

older men. 

Providers and program administrators must learn 

how older clients’ race, ethnicity, sexual 

orientation, gender identity, and socioeconomic 

status infuence overall health, substance misuse, 

and availability of healthcare and behavioral health 

services.253 They should also recognize that older 

adults can draw on their cultural heritage in ways 

that improve health and well-being.254 

As people age, they shape their 

world in ways that maximize 

their well-being ... within the 

confnes and defnitions of their 

respective cultures.” 

—H. H. Fung (2013), p. 375255 

The consensus panel recommends that you 

maintain awareness of older adults’ racial, ethnic, 

gender, and LGBTQ diversity when addressing 

late-life substance misuse, health disparities, 

and barriers to access to care. Provide culturally 

responsive screening, assessment, and treatment 

for clients across settings. 

RESOURCE ALERT: IMPROVING 

CULTURAL COMPETENCE 

The Substance Abuse and Mental Health Services 

Administration’s (SAMHSA) TIP 59, Improving 

Cultural Competence (https://store.samhsa.gov/ 

product/TIP-59-Improving-Cultural-Competence/ 

SMA15-4849), helps providers and administrators 

understand the role of culture in the delivery of 

mental health services and SUD treatment. 

Recognize the Diference Between Earlyand Late-Onset Substance Misuse 

Diagnosis and treatment planning differ for older 

adults who have a history of substance misuse 

(early onset) and those who develop problems 

only later in life (late onset). For example, older 

adults who begin to drink because of late-life 

stressors (e.g., loss of a signifcant other) may 

not have the same chronic, co-occurring medical 

conditions or mental disorders that older adults 

who have been drinking since adolescence or early 

adulthood have. Late-onset substance misuse 

may respond well to brief interventions. Older 

adults who exhibit chronic misuse may need more 

intensive SUD treatment.256 

The consensus panel recommends that, as 

part of regular screening and assessment, you 

determine whether clients have a history of 

substance misuse or are using in response to 

more recent stressors. Use this information to 

identify appropriate treatment options. Discuss 

these options with clients. 

Emphasize Client Education, Early 

Identifcation, Screening, and Brief 

Treatment 

Substance misuse in older adults is often 

unrecognized by older adults themselves, as well 

as by their family members, friends, and healthcare 

and social service providers. To ensure that older 

adults receive education, screening, assessment, 

and treatment, all who have regular contact 

with them—whether in the home, at healthcare 

visits, at community-based senior services, or in 

long-term care facilities—must recognize the signs 

of substance misuse (including prescription drug 

misuse) in older adults. 

Older adults are less likely to get referrals to 

specialized SUD treatment from healthcare 

providers than other sources (e.g., self-referral, 

referrals from legal incidents related to driving and 

substance misuse).257 Yet healthcare providers 

are well positioned to identify and screen for 

substance misuse in older adults. 

30 Chapter 2 
Chapter 2—Principles of Care for Older Adults TIP 26

Older adults are more likely than younger adults 

to see their healthcare providers to discuss 

and receive treatment for numerous medical and 

health-related concerns. Healthcare visits are 

opportunities to discuss substance use and 

related health risks and consequences. Healthcare 

providers can also take these opportunities to talk 

with older clients about drug–drug interactions 

with alcohol, prescription medications, and other 

substances in the context of routine medical 

care.258 

If you are a healthcare or social service provider 

who has contact with older adults in home-care 

situations, residential care facilities, communitybased programs, or emergency departments, 

you should be aware of the signs of substance 

misuse among this population. Within your 

scope of practice, you should engage in routine 

screening of older adults for substance misuse 

in accordance with your program’s policies and 

procedures. 

A home healthcare nurse noticed empty beer 

bottles and the smell of alcohol on Joe’s breath 

during one of her regularly scheduled home visits 

to monitor Joe’s management of his diabetes. Joe 

also seemed unsteady on his feet. She recognized 

the signs of a potential problem and had a 

friendly conversation with him about his health 

in which she embedded screening questions 

about his drinking. Joe agreed to let her call his 

daughter to arrange for a ride for him to see his 

healthcare provider for an assessment. 

A growing body of research demonstrates that 

different kinds of brief interventions delivered in 

a variety of healthcare and social service settings 

can effectively reduce alcohol consumption and 

substance misuse and lower health-related risk 

among older adults.259,260,261,262,263 Brief interventions 

can also facilitate entry into more intensive 

treatment.264 

The consensus panel recommends that providers 

across settings in which older adults may seek 

care: 

• Promote early identifcation, education, 

outreach, and prevention in their programs/ 

communities. 

• Promote universal screening for alcohol misuse, 

drug use, and prescription medication misuse 

for older adults. 

• Develop and expand brief interventions for 

older adults who misuse substances. 

Engage in Health Risk Reduction Practices 

Older adults who misuse substances may 

not want to set abstinence as their goal. 

Engaging in health risk reduction practices is 

an important and viable option for older adults 

and is consistent with age-sensitive treatment 

practices.265 For example, medical providers can 

slowly taper older adults to the lowest possible 

doses of benzodiazepines without withdrawing 

them completely. Another health risk reduction 

approach specifcally designed for older adults is 

the BRITE project, an adaptation of screening, brief 

intervention, and referral to treatment (SBIRT). It 

has demonstrated lowered alcohol severity and 

depression in older adults and improvements in 

medication misuse.266 (See Chapter 3 of this TIP for 

more information on screening and assessment.) 

Risk reduction strategies lower health-related 

risk for older adults and can boost functioning. 

Risk reduction can also be a frst step toward 

abstinence. For example, once older adults who 

misuse alcohol begin to experience the health 

benefts of less drinking, they may be more willing 

to stop completely. 

The consensus panel recommends engaging 

in health risk reduction practices to lessen the 

impact of substance misuse on the physical and 

mental health of older adults. 

Provide Person-Centered Care 

Based on a literature review and qualitative 

research, a consensus panel convened by the 

American Geriatrics Society determined that a 

Chapter 2 31 
TIP 26 Treating Substance Use Disorder in Older Adults 

person-centered approach to care for older 

adults puts older adults’ values and preferences 

at the center of the decision-making process 

regarding healthcare options and treatment 

goals.267 

‘Person-centered care’ means 

that individuals’ values and 

preferences are elicited and, once 

expressed, guide all aspects of 

their health care, supporting their 

realistic health and life goals. 

Person-centered care is achieved 

through a dynamic relationship 

among individuals, others 

who are important to them, 

and all relevant providers. This 

collaboration informs decisionmaking to the extent that the 

individual desires.” 

—American Geriatrics Society (2015), 

p. 16268 

Consider client needs and preferences when 

deciding treatment intensity (e.g., inpatient or 

outpatient), method (i.e., group or individual 

treatment), and goal choice (i.e., abstinence or 

reduction in use). 

Collaborating with clients to develop treatment 

goals enhances positive outcomes.269 Offer clients 

a menu of treatment options that ft their needs 

and preferences. Options should include the least 

intensive treatment approaches that are medically 

appropriate as well as more intensive alternatives. 

More treatment leads to better outcomes, 

regardless of the level of care (e.g., residential 

versus outpatient treatment) or whether treatment 

is greater in intensity or greater in length of overall 

treatment. The more attention older clients receive, 

the more likely they are to improve.270 

Continually reassess older clients’ needs, 

treatment goals, priorities, and intensity of 

care throughout treatment. Maintaining clients at 

the center of the conversation is essential to this 

process. 

The consensus panel recommends that you 

engage older clients in a comprehensive, personcentered, trauma-informed approach to SUD 

treatment that emphasizes their values, needs, 

and preferences. Offer a menu of care options, 

including the least intensive treatment approach. 

Build Alliances With Age-Sensitive 

Engagement and Retention Strategies 

Building a strong treatment alliance with each 

client fosters engagement and retention in 

treatment. The treatment alliance is a collaborative 

process based on agreement on treatment 

goals and tasks and a bond between you and 

your client.271 A large body of research shows 

the alliance as signifcant in all kinds of helping 

relationships across a variety of treatment methods, 

including SUD treatment.272 

Retention in SUD treatment predicts good 

outcomes for older adults regardless of treatment 

approach.273 Retention refers to a client’s length of 

time in treatment and adherence to treatment. 

To engage and retain older adults in treatment, 

the following practices are helpful: 

• Recognize the importance of establishing

a collaborative relationship as the primary

mechanism for engaging clients in treatment

and supporting behavior change.

• Create a culture of respect, which is

nonconfrontational, focuses on building older

clients’ sense of value and worth, acknowledges

the wisdom of their own lived experience,

and expresses confdence in their ability to

participate in treatment and accomplish their

treatment and recovery goals. Respect the

customary social conventions of older adults’

age cohort (e.g., refrain from swearing or using

slang) and ask clients how they would like to be

addressed and introduced to others.

• Use proven treatment approaches that have

demonstrated effectiveness or shown promise

with older adults in addressing substance misuse

across a variety of settings. Such approaches

include brief advice and brief interventions,

SBIRT, motivational interviewing, supportive

therapy, problem-solving therapy, individual

therapy, and cognitive–behavioral therapy.274,275 

32 Chapter 2 
Chapter 2—Principles of Care for Older Adults TIP 26

• Match treatment to older adults’ needs and

levels of functioning.

- Outpatient programs should provide services

during daytime hours and assist clients with

transportation. Offer in-home or telehealth

support services to homebound older adults.

- Inpatient and residential treatment programs

should create an environment that is easy

for older adults to navigate. Facilities should

be well lighted and accessible to individuals

with disabilities, and should have other

accommodations as needed for older clients.

- Programs should modify design and delivery

of services to accommodate vision, hearing,

and mild cognitive problems that develop or

increase in later life.

- A slower program pace, repetition of

information and instructions, and allowing

time for clients to integrate and respond

to information and questions can enhance

their learning and participation in program

activities.

• Implement age-sensitive group treatment

approaches to meet older adults’ needs

and preferences. Older adults, regardless of

gender, tend to be more private and concerned

about how much personal information they will

share in a mixed-age group setting. They may

not relate to or feel comfortable sharing their

problems with younger adults.276 

• Use age-sensitive adaptions if your program

only has mixed-age groups: Emphasize privacy/

confdentiality, accommodate physical needs,

establish group norms for respect, and ensure

older adults’ voices are heard by creating

opportunities to share without pressure to

disclose.

• Work with older clients to explore pros and

cons of age-specifc and mixed-age groups,

and honor their preferences if possible in your

program. Age-specifc groups for older adults

should focus on topics such as grief and loss,

trauma, social isolation, social pressure to drink,

life-stage and role transitions, and coping skills

specifc to older adults (e.g., strategies for

coping with loneliness).

• Match older adults to groups based on

availability, primary substance use concerns,

age-related issues, and client preference.

If possible, match older adults who have 

experienced trauma to gender-specifc groups 

and those with chronic pain to groups that 

address pain and medication misuse. 

The consensus panel recommends incorporating 

into your program age-sensitive and age-specifc 

treatment practices that engage clients and 

improve retention in treatment. (See Chapters 4 

and 5 for additional information on treatment of 

older adults for AUD and other SUDs, respectively.) 

Help Older Clients Use Social Networks 

and Community-Based Services 

Older adults in long-term recovery from SUDs 

demonstrate better outcomes when they have 

social supports that promote abstinence.277,278 

Social networks for older adults in recovery include 

caregivers, family, friends, faith-based communities, 

peer recovery support services, and mutual-help 

groups. 

Older adults’ social networks frequently narrow 

because of retirement, loss of spouses or friends, 

or reduced ability to engage in activities outside 

the home. This can increase some older adults’ 

isolation and contribute to substance misuse.279 

Assess older adults’ current social networks. Help 

them improve and use social supports to reduce 

isolation and support recovery from substance 

misuse. 

CASE MANAGEMENT SERVICES 

Case and care management (CCM) services are 

often the keys to better outcomes, particularly for 

older adults with SUDs or co-occurring medical 

conditions or mental disorders.280 The CCM 

provider helps clients gain access to healthcare, 

addiction treatment, mental health, social, 

fnancial, education, employment, and other 

community-based services. CCM services can be 

provided by a nurse care manager, social worker, 

addiction treatment or mental health counselor, 

or a peer recovery support specialist. Programs 

serving older adults should either provide CCM 

or actively link clients to a CCM provider who 

can connect older adults and their families to 

community-based resources and services. 

Chapter 2 33 
TIP 26

The consensus panel recommends that SUD 

treatment programs help older clients connect 

with social networks that promote recovery. 

Use a CCM approach to link clients actively to 

community services. 

Encourage Family and Caregiver 

Involvement 

Involving caregivers throughout treatment 

and ongoing recovery enhances retention and 

improves treatment outcomes for people with 

SUDs.281 Include caregivers (e.g., family members 

or guardians) in the entire treatment and recovery 

process, with the permission of the older client. 

Caregivers and family members can be essential 

partners in helping older adults participate fully 

in treatment and recovery activities. For example, 

they can assist older adults who have mobility 

challenges and cognitive impairments that make 

it diffcult to follow treatment and recovery plans 

without support. 

Educate caregivers about how substance misuse 

can affect older adults’ physical and mental 

health, as well as their relationships. Include them 

in counseling sessions that focus on recognizing 

relapse triggers, improving communication, and 

teaching constructive problem-solving skills. This 

knowledge will help them more effectively support 

the recovery of your older clients. 

Family members are often both caregivers and 

case managers for older adults with SUDs. The 

stress of this responsibility and resulting neglect of 

their self-care can put them at risk for developing 

SUDs, worsening chronic medical conditions, or 

increasing vulnerability to stress-related illnesses.282 

Help caregivers reduce their stress levels and 

maintain their own mental, emotional, and physical 

health.283 Encourage family members to take care 

of their own emotional, mental, and health needs 

and participate in community-based supports such 

as caregiver groups. 

The consensus panel recommends that, with 

older clients’ consent, providers across service 

settings involve caregivers in all aspects of older 

clients’ treatment and recovery. 

Treating Substance Use Disorder in Older Adults 

Coordinate Care and Develop Service 

Linkages 

Develop linkages to appropriate services and 

maintain ongoing relationships with other 

providers to coordinate care across settings for 

older adults with SUDs. Doing so will increase 

successful referral outcomes.284 Coordinated care 

involves establishing and strengthening referral 

streams and partnering with community-based 

resources serving older adults (e.g., local Area 

Agencies on Aging). 

Referring older clients to other services is 

not a once-and-done event. It requires actively 

connecting clients to appropriate providers or 

services (e.g., a “warm handoff” in which you 

make a referral to another agency in person with 

the client present) and following up with clients to 

ensure that referral was successful. 

Care coordination and management are 

especially important for older adults with 

co-occurring medical or mental disorders. For 

example, a client with an SUD in a healthcare 

setting who screens positive for anxiety or 

depression should receive a referral for further 

assessment and treatment to a mental health 

service clinician experienced in working with older 

adults who have co-occurring disorders. Consider 

availability, accessibility, and client preferences 

when making referrals to other providers or 

community-based services. In addition, stay 

informed of available services. Treatment options 

within a given agency may change frequently. 

RESOURCE ALERT: DEVELOPING 

REFERRAL RESOURCES 

SAMHSA’s Toolkit GET CONNECTED: Linking 

Older Adults With Resources on Medication, 

Alcohol, and Mental Health (https://store.samhsa. 

gov/product/Get-Connected-Linking-OlderAdults-with-Resources-on-Medication-Alcoholand-Mental-Health-2019-Edition/SMA03-3824) 

addresses developing and actively linking to 

referral resources for alcohol misuse prevention 

and treatment among older adults. 

34 Chapter 2 
Chapter 2—Principles of Care for Older Adults TIP 26

The consensus panel recommends that you 

establish ongoing relationships with providers 

across services and community-based programs 

to ensure active linkage of clients to older adult 

services, healthcare professionals who specialize 

in geriatrics, addiction treatment services, 

mental health services, and recovery resources. 

Make Programmatic Changes To 

Efectively Serve Older Adults With SUDS 

Before administrators and clinical supervisors 

can focus on workforce development, they 

must establish their organizations’ vision and 

commitment to making programs more accessible 

to older clients and to creating new or adapting 

existing programs to accommodate older adults’ 

unique needs. Start with an organizational selfassessment and change plan that includes: 

• A rationale for providing age-sensitive and agespecifc services.

• An assessment of the organization’s strengths

and needs for improving services for older

adults.

• A review of priorities, goals, and tasks to help

develop or augment existing services for older

adults.

• A plan for adapting facilities and programs

to accommodate the unique needs of older

adults throughout the continuum of care. This

includes establishing age-sensitive and agespecifc policies and practices for outreach,

universal screening for substance misuse, and

enhancing access and fow of clients through

the continuum of care from screening to brief

intervention and referral or admission to SUD

treatment and continuing care.

• A plan for identifying and developing linkages

to community-based resources serving older

adults.

• A plan for involving staff, older clients, and

members of older adult programs and recoveryfocused organizations in the planning and

implementation of services.

• Guidelines for implementing organizational

change that describe roles, responsibilities,

timeframes, and specifc activities for each step

of the change process.285 

In addition, administrators need to be aware of 

state-level variance in policies and practices, which 

can dictate the parameters and limitations of a 

program’s features and implementation process. 

The consensus panel recommends that you do an 

organizational self-assessment and have a plan 

in place before implementing any organizationwide changes to policies and practices. 

Invest in Age-Sensitive Workforce 

Development 

To implement older adult-specifc SUD treatment 

programs and services successfully, program 

administrators must hire and retain highly 

motivated staff who are committed to serving 

older adults. To ensure staff are knowledgeable 

and have the skills to care for older adults 

with SUDs, engage in ongoing workforce 

development practices:286,287 

• Develop staff recruitment, retention, and

promotion strategies that engage clinical and

program staff who are knowledgeable about

older adult health, mental health, and substance

misuse and are motivated to work with this

population.

• Recruit older peer recovery support providers

and create a work environment that recognizes

lived experience as a valuable source of

knowledge.

• Develop pathways for integrating older peer

recovery support providers into service teams

and provide them with ongoing supervision and

professional development opportunities.

• Create training plans and curriculums that

address ageism, health disparities, and cultural

diversity among older adults; the culture of

aging; physical and mental health needs of older

adults; and treatment practices and evidencebased approaches that are effective with older

adults.

• Provide ongoing clinical and administrative

supervision that emphasizes the attitudes,

knowledge, and skills required to care for older

adults.

• Evaluate staff performance on the attitudes,

knowledge, and skills required to care for older

adults.

Chapter 2 35 
TIP 26

The consensus panel recommends that you 

implement workforce development strategies for 

building or improving age-sensitive and agespecifc treatment for older adults with SUDs. 

Summary 

The principles of care this TIP describes will 

support efforts to develop and improve agesensitive and age-specifc services for older 

adults with SUDs. The key to implementing these 

principles is to work collaboratively with staff, 

older clients, other providers, and community 

stakeholders to foster awareness and commitment 

to providing quality services to older adults and 

their families. 

Chapter 2 Resources 

Provider Resources 

American Psychological Association (APA)— 

Guidelines for Psychological Practice With Older 

Adults (www.apa.org/pubs/journals/features/olderadults.pdf): These guidelines provide information 

on evaluating psychologists’ readiness for working 

with older adults; this information is also applicable 

to other behavioral health service providers. 

APA—Multicultural Competency in 

Geropsychology (www.apa.org/pi/aging/ 

programs/pipeline/multicultural-competency.pdf): 

This report describes behavioral health service 

providers’ multicultural competencies for working 

with older adults. 

Treating Substance Use Disorder in Older Adults 

Council on Social Work Education—Gero-Ed 

Center (www.cswe.org/Centers-Initiatives/ 

CSWE-Gero-Ed-Center.aspx): The center’s website 

provides resources, educational materials, and a 

curriculum to enhance social work competencies, 

which apply to all behavioral health service 

providers caring for older adults. 

Institute of Medicine (IOM)—The Mental Health 

and Substance Use Workforce for Older Adults: 

In Whose Hands? (www.nap.edu/download/13400; 

download for free as a guest): The IOM provides 

this report as an overview of the eldercare 

workforce and workforce development barriers 

and needs. (IOM is now the National Academy of 

Medicine.) 

Offce of Minority Health—National Standards 

for Culturally and Linguistically Appropriate 

Services in Health and Health Care (https:// 

thinkculturalhealth.hhs.gov/clas): These standards 

describe principles of culturally appropriate 

services applicable to treating culturally diverse 

older adults in healthcare and behavioral health 

service settings. 

Understanding Issues Facing LGBT Older Adults 

(www.lgbtmap.org/fle/understanding-issuesfacing-lgbt-older-adults.pdf): This report from the 

Movement Advancement Project and SAGE helps 

providers and others better understand the social 

isolation and health challenges that affect many 

LGBT older adults. 

36 Chapter 2 
TIP 26 TREATING SUBSTANCE USE DISORDER 

IN OLDER ADULTS

Chapter 3—Identifying, Screening for, and 

Assessing Substance Misuse in Older Adults 

KEY MESSAGES 

• Behavioral health service and healthcare 

providers in any setting should screen older 

clients for substance misuse. Many different 

healthcare providers can play a role in this. 

There is no “wrong door” through which older 

adults can arrive at the right diagnosis and 

care. 

• The main reason for screening and assessment 

is to help you decide whether, where, and how 

to address substance misuse. 

• Substance misuse affects older adults 

differently than it does middle-aged and 

younger adults. Providers across settings 

should be trained in giving age-appropriate 

care. They also need to have the skills to 

recognize substance misuse in older clients. 

Chapter 3 of this Treatment Improvement 

Protocol (TIP) will most beneft providers. It 

discusses identifying, screening for, and assessing 

substance misuse in older clients. In the United 

States and elsewhere, more and more people ages 

50 and older struggle with substance misuse, but 

many providers do not screen for, diagnose, or 

treat substance use disorders (SUDs) among this 

population. 

OLDER ADULTS are 

less likely to be screened for 

SUBSTANCE MISUSE 

and more likely to be taking 

MULTIPLE medications. 

Older adults are less likely than younger adults to 

receive screening and assessment for substance 

misuse.288 This is potentially dangerous because, 

as people age, they are more likely to feel the 

negative effects of drugs and alcohol. Older adults 

are also more likely to take multiple medications, 

which means they may face dangerous and 

potentially fatal drug–drug interactions. 

Furthermore, identifying substance misuse in older 

adults is not simple. The signs and symptoms of 

substance misuse can be easily mistaken for normal 

aging or physical or mental disorders common in 

older populations. 

Even so, substance misuse is detectable and 

treatable among older adults. Yet if left untreated 

or poorly treated, it can shorten their lives and 

keep them from living healthily and independently. 

For example, substance misuse increases the risk 

of falls, cognitive impairment, overdose, heart 

disease, high blood pressure, certain cancers, HIV, 

hepatitis, cirrhosis, and mental disorders.289,290 

This chapter of TIP 26 will help behavioral health 

service providers, social service providers, and 

other healthcare providers who work with older 

adults better understand how, when, and why 

to use screening and assessment to address 

substance misuse in their older clients. 

Who Can Beneft From Chapter 3 

of This TIP and How? 

Chapter 3 will support behavioral health service 

and healthcare providers who work with older 

adults in overcoming barriers to identifying, 

screening for, and assessing substance misuse in 

older clients by helping these providers: 

• Recognize early warning signs of substance 

misuse in older adults. 

37 
TIP 26 Treating Substance Use Disorder in Older Adults 

• Understand the relationship between substance 

misuse and depression, anxiety, trauma, and 

problems with thinking (also called cognitive 

impairment). 

• Become more aware of common myths about 

substance misuse in older adults. 

Who in the geriatric workforce should be 

identifying, screening for, or assessing substance 

misuse in older adults? Nearly everyone! The 

Institute of Medicine report The Mental Health 

and Substance Use Workforce for Older Adults: 

In Whose Hands?291 notes that the full range of 

providers should help meet the needs of older 

adults who misuse substances. These providers 

include: 

• Mental health service and SUD treatment 

providers, including psychiatrists, psychologists, 

social workers, psychiatric nurses, and addiction 

counselors. 

• Primary care providers, general internists, family 

medicine practitioners, trained pharmacists, 

advanced practice registered nurses, and 

physician assistants. 

• Geriatricians, geriatric nurses, geriatric 

psychiatrists, geropsychologists, and 

gerontological social workers. 

• Direct care workers who provide in-home 

support services. 

• Peer recovery support service providers. 

• Informal and formal caregivers. 

• Supports within the faith community. 

• Social service providers. 

Chapter 3 will be useful across settings in which 

these workers encounter older adults. No single 

service provider or setting is solely responsible for 

making sure older adults receive the substance 

use-related care they need. However, all providers 

and settings can fulfll an important role. 

Organization of Chapter 3 of 

This TIP 

Chapter 3 offers a wide range of information and 

strategies to help you screen, assess, and treat 

older clients for substance misuse. 

The frst section of Chapter 3 is about the 

challenges to screening and assessing older 

clients for substance misuse. It also discusses 

why you need to screen and assess these clients. 

You will be more likely to use screening and 

assessment once you understand why they are so 

important. In the end, this will help your clients 

increase their chances for recovery. 

The second section discusses how to screen 

for substance misuse in older adults. Screening 

for substance misuse also includes screening for 

co-occurring mental and neurocognitive disorders 

that can affect (and are affected by) substance use, 

such as depression, anxiety, posttraumatic stress 

disorder (PTSD), and dementia. Knowing why, how, 

and whom to screen for substance misuse and 

co-occurring mental or neurocognitive disorders 

will help you provide more complete care. It also 

increases the chances of clients receiving the 

correct diagnosis and needed treatment. 

The third section describes how to use brief 

assessments—an important follow-up to 

screening—for clients who screen at risk for 

substance misuse and co-occurring mental or 

neurocognitive disorders. Brief assessment helps 

make or rule out diagnoses and aids you and your 

clients in making appropriate shared treatment 

decisions. 

The fourth section describes how to fully assess 

older adults who screen positive for moderate-tosevere substance misuse. A full assessment does 

more than just ask clients about substance use. It 

also asks about their overall health and well-being. 

This will give you a more complete picture of your 

clients’ substance-related issues and will help you 

understand how substance misuse affects them. 

The ffth section guides providers in treatment 

planning, treating, or referring for treatment. 

Knowing how and why to screen and assess is only 

half the picture. Understanding what steps to take 

in offering effective care or referral for care is a 

cornerstone of good clinical practice. 

The fnal section identifes targeted resources to 

support your practice, from screening to referral. 

A more detailed resource guide is available in 

Chapter 9 of this TIP. 

38 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

For defnitions of key terms you will fnd in Chapter 3 of this TIP, see Exhibit 3.1. 

EXHIBIT 3.1. Key Terms 

• Addiction*: The most severe form of SUD, associated with compulsive or uncontrolled use of one or more 

substances. Addiction is a chronic brain disease that has the potential for both recurrence (relapse) and 

recovery. 

• Age-specifc: Treatment approaches and practices specifcally developed for older adults (e.g., an older 

adult specialty group in a mixed-age SUD treatment program). 

• Alcohol misuse: The use of alcohol in any harmful way, including heavy drinking, binge drinking, and 

alcohol use disorder (AUD). 

• At-risk/high-risk drinking: Drinking alcohol in excessive amounts. This defnition encompasses both 

binge drinking and heavy drinking. Additionally, any alcohol consumption is considered risky when 

carried out by individuals with certain medical conditions that are worsened by alcohol, those taking 

medicine that can interact harmfully with alcohol, those driving a car or engaged in other activities that 

require alertness, or people recovering from AUD.292,293 Note that for purposes of this TIP, at-risk drinking 

and high-risk drinking are synonymous, and either term is acceptable to describe an older adult’s 

drinking patterns. 

• Binge drinking: A drinking pattern that leads to blood alcohol concentration levels of 0.08 grams per 

deciliter or greater. This usually takes place after four or more drinks for women and fve or more drinks 

for men.294,295 However, older adults are more sensitive to the effects of alcohol, and treatment providers 

may need to lower these numbers when screening for alcohol misuse.296 Additionally, other factors such 

as weight, decrease in enzyme activity, and body composition (e.g., amount of muscle tissue present in 

the body) can also affect alcohol absorption rates. 

• Caregivers: Informal caregivers provide unpaid care. They assist others with activities of daily living 

(ADLs), including health and medical tasks. Informal caregivers may be spouses, partners, family 

members, friends, neighbors, or others who have a signifcant personal relationship with the person who 

needs care. Formal caregivers are paid providers who offer care in one’s home or in a facility.297 Most older 

adults do not need caregivers and are as able to address their own needs as younger adults, whether or 

not substance misuse is a factor in their lives. 

• Drug–drug interaction: The interaction of one substance (e.g., alcohol, medication, an illicit drug) with 

another substance. Drug–drug interactions may change the effectiveness of medications, introduce 

or alter the intensity of side effects, and increase a substance’s toxicity or the concentration of that 

substance in a person’s blood. Potentially serious interactions can also occur with certain foods, 

beverages, and dietary supplements.298 

• Heavy drinking: Consuming fve or more drinks for men and four or more drinks for women in one period 

on each of 5 or more days in the past 30 days.299 

• Illicit substances: Illicit substances include cocaine, heroin, hallucinogens, inhalants, methamphetamine, 

and prescription medications that are taken other than as prescribed (e.g., pain relievers, tranquilizers, 

stimulants, sedatives). 

• Moderate drinking: According to the 2015–2020 Dietary Guidelines for Americans, moderate drinking is 

defned as up to two drinks per day for men and up to one drink per day for women.300,301 However, the 

Centers for Disease Control and Prevention (CDC) notes that these numbers apply to any given day and 

are not meant as an average over several days.302 Additionally, individuals who don’t metabolize alcohol 

well may need to consume even lower quantities. Some people, particularly those with certain alcoholrelated illnesses or engaging in tasks requiring concentration, should not consume alcohol at all. The 

Dietary Guidelines stipulate that those who don’t drink should not begin drinking for any reason.303 

Continued on next page 

Chapter 3 39 
TIP 26 Treating Substance Use Disorder in Older Adults 

Continued 

• Psychoactive substances: Substances that can alter mental processes (e.g., cognition or affect; in other 

words, the way one thinks or feels). Also called psychotropic drugs, such substances will not necessarily 

produce dependence, but they have the potential for misuse or abuse.304 

• Recovery*: A process of change through which individuals improve their health and wellness, live a selfdirected life, and strive to reach their full potential. Even individuals with severe and chronic SUDs can, 

with help, overcome them and regain health and social function. This is called remission. When those 

positive changes and values become part of a voluntarily adopted lifestyle, that is called being in recovery. 

Although abstinence from all substance misuse is a cardinal feature of a recovery lifestyle, it is not the only 

healthy, prosocial feature. 

• Relapse*: A return to substance use after a signifcant period of abstinence. 

• Remission: A medical term meaning a disappearance of signs and symptoms of the disease or disorder. 

The ffth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defnes remission 

as present in people who previously met SUD criteria but no longer meet any SUD criteria (with the 

possible exception of craving).305 Remission is an essential element of recovery. 

• Screening: A process for evaluating the possible presence of a specifc problem. The outcome is normally 

a simple yes or no. 

• Screening, brief intervention, and referral to treatment (SBIRT): An evidence-based, comprehensive, 

integrated public health approach to identify, reduce, and prevent misuse of and dependence on alcohol 

and illicit drugs. 

• Substance misuse*: The use of any substance in a manner, situation, amount, or frequency that can 

cause harm to users or to those around them. For some substances or individuals, any use would 

constitute misuse (e.g., underage drinking, injection drug use). 

• Substance use disorder*: A medical illness caused by repeated misuse of a substance or substances. 

According to DSM-5,306 SUDs are characterized by clinically signifcant impairments in health and social 

function, and by impaired control over substance use. They are diagnosed through assessing cognitive, 

behavioral, and psychological symptoms. SUDs range from mild to severe and from temporary to chronic. 

They typically develop gradually over time with repeated misuse, leading to changes in brain circuits 

governing incentive salience (the ability of substance-associated cues to trigger substance seeking), 

reward, stress, and executive functions like decision making and self-control. Multiple factors infuence 

whether and how rapidly a person will develop an SUD. These factors include the substance itself; the 

genetic vulnerability of the user; and the amount, frequency, and duration of the misuse. Note: A severe 

SUD is commonly called an addiction. A mild SUD is generally equivalent to what previous editions of 

DSM called substance abuse; a moderate or severe SUD is generally equivalent to what was formerly 

called substance dependence. 

* The defnitions of all terms marked with an asterisk correspond closely to those given in Facing Addiction 

in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. This resource provides a great 

deal of useful information about substance misuse and its impact on U.S. public health. The report is 

available online (https://addiction.surgeongeneral.gov/sites/default/fles/surgeon-generals-report.pdf). 

40 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

Challenges to Identifcation, 

Screening, and Assessment 

Some health experts have called older 

adults who misuse substances an “invisible” 

population.307,308 Although older adults have 

frequent medical visits, behavioral health or 

healthcare providers often do not recognize 

substance misuse in their older clients. 

Older clients are less likely than younger clients 

to tell you that they are having a problem with 

substance use and are less likely to ask for 

treatment.309 Some barriers older adults face 

are unique to their population. Older adults’ 

substance misuse can stay “hidden” when:310 

• Providers believe that older clients do not 

have alcohol or drug problems later in life. 

(“Drug use is a young person’s problem.” Or, 

“No one starts abusing alcohol in their 60s.”) 

• Providers have negative thoughts and 

attitudes about aging. This is also called 

ageism. (“Talking about drugs and alcohol with 

someone who is older is a waste of time.” Or, 

“He’s 83 years old and has been drinking his 

whole life. He’s never going to change, so why 

bother?” Or, “Older people are less likely to 

change or beneft from treatment.”) 

• Providers feel uncomfortable talking about 

substance use and misuse with older adults. 

(“Given his age, I don’t want to be disrepectful 

or tell him what to do.”) 

• Family members feel uncomfortable asking 

an older relative to stop using substances— 

especially alcohol. (“I’d rather not ask Mom to 

stop drinking. I’d be taking away her one last 

pleasure in life.”) 

• Providers lack knowledge about drug and 

alcohol screening and assessment tools. (“I 

don’t know the frst thing about how to look for 

addiction problems in older clients.”) 

• Providers and family members misunderstand 

the difference between symptoms of 

substance misuse and similar symptoms of 

physical and cognitive decline or mental illness 

common in older populations. Such problems 

include dementia, pain, anxiety, and depression. 

(“At her age, it’s normal to forget people’s 

names. Drinking has nothing to do with it,” or, 

“Dad’s not depressed; he just lost his ‘pep’ in 

getting older.”) 

• Providers believe that they don’t have enough 

time to give screening and assessment measures. 

(“I barely have time to see all my clients. There’s 

just no time for screening and assessment.”) 

• Older adults experience substance-related 

functional impairment, which providers may 

have a hard time detecting in older clients 

who no longer work, drive, or have signifcant 

obligations to others professionally or at home. 

• Older adults seek services in nontraditional 

addiction treatment settings. 

• Providers spend too little time with clients (and 

older adults in particular). 

To remove these barriers, providers need education 

and skills training aimed at helping them better 

recognize possible substance misuse in their older 

clients. 

To spot substance misuse in older clients 

as early as possible, tailor your approach to 

working with them: 

• Be aware of your beliefs about/attitudes toward 

older clients that make you not screen for 

substance misuse. 

• Choose a method for drug and alcohol 

screening that you can use with all older clients. 

• Use an interview style that older clients will fnd 

comfortable (e.g., supportive). 

• Train counselors on how to spot substance 

misuse early. 

Screening for Substance Misuse in 

Older Adults 

Substance misuse is common among clients seen 

in healthcare311 and behavioral health service 

settings. Although most older adults do not misuse 

substances, some do. Consider these facts, which 

show that substance misuse does occur in older 

people: 

• In 2019, estimates showed that 4.7 million adults 

ages 50 and older had a past-year SUD.312 

Chapter 3 41 
TIP 26 Treating Substance Use Disorder in Older Adults 

• In 2019, an estimated 8.8 million adults ages 50 

and older reported using an illicit drug in the 

past month.313 

• In 2019, more than 56 million adults ages 50 

and older were estimated to have engaged in 

past-month alcohol use.314 

• The rate of prescription opioid misuse among 

older adults (ages 60 and older) is lower than 

among younger adults (ages 20 to 59), but from 

2006 to 2013, older adults increasingly misused 

prescription opioids with suicidal intent and 

showed an increasing trend in death rate.315 

Know the different types of prescription 

medications older clients may misuse. These 

include: 

• Sedative-hypnotics: These medications are 

often used to help people relax or sleep. They 

include barbiturates (like amobarbital and 

secobarbital) as well as benzodiazepines (like 

lorazepam and alprazolam). 

• Opioid analgesics: These medications are often 

prescribed to provide pain relief by attaching to 

opioid receptors in the brain. Examples include 

oxycodone and hydrocodone. 

Why, When, and How To Screen 

The TIP consensus panel recommends that 

addiction treatment, other behavioral health 

service, and healthcare providers screen for 

alcohol, tobacco, prescription drug, and illicit 

drug use in all older clients at least annually. The 

TIP consensus panel recommends performing 

universal screening during health visits. 

Screening and assessment are very important 

steps in diagnosing substance misuse and making 

the right care decisions. Screening can help you 

answer the following important questions: 

• Does my client need an assessment? 

Although the two terms are often confused for 

one another, “screening” is not the same as 

“assessment.” 

• Screening is the process of evaluating whether

symptoms of substance misuse are present. 

Screening helps you decide whether further 

assessment is necessary. 

• Assessments give detailed information for 

diagnosis, treatment decisions, and treatment 

planning. 

• Is my client’s substance use potentially 

harmful? Screening can help you learn whether 

a client’s alcohol or drug use could be harmful 

because of an existing condition or use of 

prescription medications. In some cases, any 

substance use at all may be harmful. Many 

older clients have chronic medical illnesses and 

take more than one prescription medication. 

Combining drugs and alcohol with medications 

can be dangerous and even lead to death. Drug 

and alcohol use can also make certain illnesses 

worse and keep clients from feeling their best. 

• Does my client seem afraid to ask for help? 

Screening is necessary because older clients 

are less likely than younger clients to ask 

directly for help.316 However, older adults are 

diverse, and older adults from the baby boomer 

generation (birth dates 1946 through 1964) 

may be more willing to discuss SUD and mental 

illness with their healthcare providers than 

earlier generations. Screening is helpful when 

clients feel afraid or ashamed of revealing their 

problem spontaneously. 

SUDs are chronic conditions. You can help older 

clients feel less shame and stigma by talking 

about substance misuse in the same way you 

would a mental disorder, like depression or 

anxiety. Use basic terms rather than confusing or 

judgmental language. Be sure to also ask about 

their overall health, functioning, and well-being. 

This shows clients that you are concerned and 

feel empathy for them rather than making them 

feel like their substance use is a consequence of 

weak willpower or a personal faw. 

• My client doesn’t seem to meet diagnostic 

criteria for an SUD. Could this person still be 

misusing substances? Screening is initially more 

useful than relying solely on DSM-5 diagnostic 

criteria. Most older adults who misuse 

substances do not meet full DSM-5 criteria for 

a specifc SUD but may be engaging in risky 

use of substances. This is because several key 

criteria are not typically present in older adults. 

42 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

For example, older adults have lower tolerance 

for substances like alcohol than younger and 

middle-aged adults and may experience harmful 

effects at lower amounts of consumption 

than younger adults. Compared with younger 

and middle-aged adults, older adults are 

signifcantly less likely to endorse the Diagnostic 

and Statistical Manual of Mental Disorders, 

4th Edition (DSM-IV) alcohol abuse criterion 

for alcohol use in “physically hazardous” 

situations.317 

• Does my client need SUD treatment? 

Screening can lead to earlier treatment, and 

thus, better health.318 

The U.S. Preventive Services Task Force (USPSTF) 

recommends that healthcare providers screen 

for unhealthy alcohol use in adults age 18 years 

or older and provide people engaged in risky 

or hazardous drinking with brief behavioral 

counseling interventions to reduce unhealthy 

alcohol use (www.uspreventiveservicestaskforce. 

org/Page/Document/UpdateSummaryDraft/ 

unhealthy-alcohol-use-in-adolescents-andadults-screening-and-behavioral-counselinginterventions). 

Chapter 3 will help you decide which screening 

tools to use, how and when to administer them, 

and who should do so. Every practice should 

select screening tools and develop procedures 

for who will give the screenings and when to give 

them. You can select screening measures based on 

which substances you want to ask about (Exhibit 

3.2). Be aware that not all of these measures 

have been validated—in other words, tested and 

approved for use—in older adults. Your practice 

should also identify steps to take when screening 

tests are positive (see the section “Communicating 

Screening Results”). 

No screeners have been statistically validated 

for assessing prescription or over-the-counter 

(OTC) medication misuse that would identify 

accidental misuse or noncompliance issues. 

Nevertheless, healthcare and behavioral health 

service providers should assess how older adults 

use such medications, with an eye toward potential 

adverse reactions and interactions. The American 

Geriatrics Society’s 2019 Beers Criteria® address 

medications that are potentially inappropriately 

prescribed for older adults.319 See the Chapter 6 

text box on the 2019 Beers Criteria®. 

EXHIBIT 3.2. Drug and Alcohol 

Screening Tools 

Alcohol: 

• Alcohol Use Disorders Identifcation Test 

(AUDIT) 

• Alcohol Use Disorders Identifcation Test-C 

(AUDIT-C) 

• Short Michigan Alcoholism Screening TestGeriatric Version (SMAST-G) 

• Senior Alcohol Misuse Indicator (SAMI) 

Cannabis: 

• Cannabis Use Disorder Identifcation TestRevised (CUDIT-R) 

Multiple substances: 

• Alcohol, Smoking, and Substance Involvement 

Screening Test (ASSIST) 

• Brief Addiction Monitor 

• CAGE Adapted to Include Drugs (CAGE-AID) 

• National Institute on Drug Abuse (NIDA) Quick 

Screen V1.0 

Screen older clients for substance misuse at 

intake. Screen regularly, before starting new 

medication, and when potentially substancerelated problems arise, such as injury or accidents. 

Have clinical assistants administer screening 

instruments in an interview or as part of other 

health screenings. Provide a paper or digital 

tablet version for clients to complete by 

themselves. USPSTF recommends electronic 

screening and brief intervention as an effective 

strategy to prevent excessive alcohol use.320 

Some older adults may not be comfortable using 

computers or tablets. Others may have diffculty 

reading or writing. Be sensitive to each client’s skills 

and abilities when selecting screening formats. 

Chapter 3 43 
TIP 26 Treating Substance Use Disorder in Older Adults 

Review screening results and discuss them with 

clients. Help clients understand their risk levels 

and the consequences of substance misuse. Gauge 

motivation and readiness for change. Keeping an 

open, nonjudgmental attitude will help your clients 

feel more comfortable sharing more information 

with you. 

Make sure you have the required training and 

credentials or licensure before performing 

screening, assessment, or diagnosis. If no 

providers in your program have appropriate 

licenses or credentials to screen, assess, or 

diagnose clients for mental disorders, refer clients 

to another program for those needs. Also make 

sure you review the training requirements on 

administration and scoring; formal training may 

be required prior to using some instruments. 

When formal training is unnecessary, learn how 

to give each screening measure and assessment; 

instructions and scoring may vary depending 

on population demographic features and other 

factors. 

Federal guidelines for moderate drinking are 

as follows:321,322,323 

Overall consumption that minimizes risk and can 

help avoid alcohol-related problems includes: 

• No more than one standard drink a day for 

women and no more than two standard drinks 

a day for men. 

• These numbers apply to any given day and are 

not meant as an average over multiple days. 

However, guidelines do not recommend that 

individuals who do not drink alcohol start 

drinking for any reason.324 

Older adults should not drink any alcohol if they: 

• Are taking alcohol-interactive prescription 

medications, especially psychoactive 

prescription medications (e.g., opioid 

analgesics, benzodiazepines). 

• Have medical conditions that can be made 

worse by alcohol (e.g., diabetes, heart disease). 

• Are planning to drive a car or participate in 

other activities requiring alertness and skill. 

• Are recovering from AUD. 

Substance Misuse Screening Measures 

Appropriate for Use With Older Adults 

This section discusses examples of substance 

misuse screening instruments useful for older 

adults. A full selection of screening resources 

appears in the Chapter 3 Appendix. Many tools 

described here were developed specifcally for 

older adults. Some are self-report tools (i.e., clients 

complete the tools themselves); a behavioral health 

service provider must deliver others. Older clients 

may have limited vision or diffculty writing and 

may need help completing screens. 

Alcohol Screening 

USPSTF recommends screening adults for alcohol 

misuse,325 including screening for risky drinking 

and AUD with brief instruments like the AUDIT-C. 

USPSTF also recommends brief counseling for 

clients who engage in risky drinking.326,327 

A very brief “prescreen,” especially for alcohol 

misuse, can be easily incorporated into healthcare 

clinic or social service agency screening 

protocols. A short prescreen is not burdensome 

as a universal screening tool. However, many 

clients will be ruled negative for problematic 

use. If results are positive, more comprehensive 

assessments can be administered to determine 

severity and make treatment recommendations. 

For more information about alcohol screening, 

see the “Screening and Assessment” section in 

Chapter 4 of this TIP. 

AUDIT 

The AUDIT was developed to screen for heavy 

alcohol use. It can reveal alcohol misuse in people 

ages 65 and older.328 The frst three AUDIT 

questions measure alcohol intake and are known 

as the AUDIT-C. Use the AUDIT or the AUDIT-C 

to get more detailed information from clients 

who use alcohol. The AUDIT has demonstrated 

reliability in studies of AUD screening.329 The 

AUDIT (self-report version) and the AUDIT-C are 

available in the Chapter 3 Appendix. 

44 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

SAMI 

The SAMI330 is a fve-item questionnaire for older 

adults who may engage in risky alcohol use. This 

questionnaire includes a checklist of symptoms 

and open-ended questions about alcohol use.331 A 

score of 1 or higher suggests problem alcohol use. 

The SAMI is available in the Chapter 3 Appendix. 

SMAST-G 

The SMAST-G is the frst brief alcohol misuse 

screener developed for older adults. If a client 

marks two or more items on the SMAST-G with a 

“yes” response, that suggests potential alcohol 

misuse.332 The SMAST-G is available in the Chapter 

3 Appendix. 

Cannabis Screening 

CUDIT-R 

The CUDIT-R333 measures cannabis misuse in 

the past 6 months. Developed from the AUDIT 

measure, it is a short version of the 20-item 

CUDIT screener. A score of 12 or higher means 

you should assess for cannabis use disorder. Yet 

this cutoff score has not been tested thoroughly. 

Do not assume that a score below 13 means the 

client does not misuse cannabis.334 The CUDIT-R is 

available in the Chapter 3 Appendix. 

Screening for Multiple Substances 

ASSIST 

ASSIST screens clients for all categories of 

substance misuse, including alcohol and tobacco 

(see “Resource Alert: The ASSIST Screener”). This 

World Health Organization (WHO) screener also 

measures substance-specifc risk. Many providers 

do not use the ASSIST because it is long and 

somewhat hard to score. A computer version and 

a shorter version (ASSIST-Lite; see https://eassist. 

adelaide.edu.au/#/eassist-lite for a computer 

version) are available and easier to use.335,336,337 

RESOURCE ALERT: THE ASSIST 

SCREENER 

The full version of WHO’s ASSIST screener, scoring 

system, and client feedback guidance can be 

downloaded in multiple languages (www.who.int/ 

substance_abuse/activities/assist_test/en). 

Brief Addiction Monitor 

The Brief Addiction Monitor is a 17-item 

scale originally made for the Veterans Health 

Administration healthcare system.338 It can indicate 

the severity of a client’s substance misuse and 

show how people in treatment or recovery 

are doing.339 The Brief Addiction Monitor asks 

about risk factors for substance misuse (e.g., 

craving, family or social problems) as well as 

factors that protect against substance misuse 

(e.g., social supports for recovery, religion or 

spirituality). This instrument is available at www. 

mentalhealth.va.gov/communityproviders/docs/ 

bam_continuous_3-10-14.pdf. 

CAGE-AID 

The CAGE (Cut down, Annoyed, Guilty, Eye 

opener) Questionnaire is widely used to screen 

for risk of alcohol misuse. A similar version, the 

CAGE-AID,340 asks about substance misuse. 

A “yes” response on any of the questions can 

mean substance misuse is present. However, the 

CAGE-AID does not ask about certain important 

aspects of substance use, including past substance 

use, frequency of use, and effects of using the 

substance. The CAGE-AID should be used with, 

but not in place of, longer and more detailed 

alcohol and drug screeners. It is available at www. 

hiv.uw.edu/page/substance-use/cage-aid. 

Chapter 3 45 
TIP 26

NIDA Quick Screen V1 0 

The NIDA Quick Screen V1.0 is a brief screener 

that asks about a client’s past-year use of 

alcohol, tobacco, prescription drugs (nonmedical 

use), and illegal drugs. If a client answers “yes” 

to the question about using illegal drugs, follow 

up by giving a slightly longer screening tool called 

the NIDA-Modifed ASSIST V2.0. Both tools are 

available on NIDA’s website (www.drugabuse.gov/ 

sites/default/fles/pdf/nmassist.pdf). 

Screening for Co-Occurring 

Disorders and Conditions 

Co-Occurring Mental Disorders 

Many older people who misuse substances also 

have co-occurring mental disorders. Some of 

these disorders, like major depressive disorder 

(MDD), anxiety, and PTSD, have symptoms 

similar to those seen in substance misuse and in 

cognitive impairment. You might at times have 

diffculty telling these conditions apart from one 

another. Co-occurring mental disorders can make 

substance misuse worse or result from substance 

misuse. You might be surprised to learn that: 

• In 2019, approximately 1.7 million U.S. adults 

ages 50 and older had an SUD and a mental 

disorder.341 

• Approximately 36.8 percent of adults older than 

age 50 with SUDs also have mental disorders, 

and 10.7 percent of adults over 50 with mental 

disorders also have SUDs.342 

• SUDs in older adults often occur alongside 

depression and other affective disorders, 

psychosis, and cognitive disorders (e.g., 

dementia).343,344 

• Older people with serious mental illness (SMI; 

complex mental disorders like bipolar disorders 

and schizophrenia) are especially likely to 

misuse substances compared with older adults 

without SMI,345 but more research is needed. For 

example, of more than 7,000 adults ages 50 and 

older receiving inpatient services for SMI, 26 

percent also met criteria for an SUD.346 The most 

common SUD was for cocaine (9.5 percent). 

Treating Substance Use Disorder in Older Adults 

In 2019, approximately 1.7M 

Americans 50 and older 

were living with an SUD & a 

MENTAL DISORDER. 

• For older adults with both an SUD and 

a mental disorder, alcohol misuse and 

depression are a common combination. 

347 

Having these two co-occurring disorders (CODs) 

may lead to negative physical and behavioral 

health consequences. For example, in a study 

of adults ages 65 and older who were receiving 

inpatient treatment for depression, those with 

co-occurring alcohol misuse had higher rates of 

drug use, liver disease, and suicidality than older 

adults with depression who did not also misuse 

alcohol.348 

Be sure to screen older clients who misuse 

substances for co-occurring mental and cognitive 

disorders as well. Exhibit 3.3 indicates which 

screening measure to use by specifc disorder, 

plus it lists a screening instrument for elder abuse. 

Older adults may also be at risk for negative 

outcomes, including: 

• Increased mortality.349 

• Increased risk of unintentional injuries leading to 

emergency department service use.350 

• Increased risk of self-harm.351 Older adult men 

are at especially high risk for suicide. Older 

adults with CODs may also have an increased 

risk of suicide attempt, but this requires more 

research.352 

• Self-medication through substance misuse. 

46 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

EXHIBIT 3.3. Screening Tools for Co-Occurring Mental and Cognitive 

Disorders 

Co-occurring conditions in general • Comorbidity Alcohol Risk Evaluation Tool (CARET) 

Depression • Geriatric Depression Scale (GDS)–Short Form 

• Patient Health Questionnaire-9 (PHQ-9) 

Anxiety • Geriatric Anxiety Scale (GAS) 

• Penn State Worry Questionnaire (PSWQ) 

PTSD, trauma symptoms, and elder abuse • PTSD Checklist for DSM-5 

• Primary Care PTSD Screen for DSM-5 

• Elder Abuse Suspicion Index© (EASI©) 

Cognitive impairment • Mini-Cog© 

CARET 

You can screen for CODs using the CARET, 

which was developed from the short version of 

the Alcohol-Related Problems Survey.353 Research 

supports using the CARET with older adults354,355 to 

identify those at risk for alcohol misuse. The CARET 

asks about alcohol-related risk factors and risky 

behaviors—many of which you may see in older 

clients. Such risk factors and risky behaviors include 

using alcohol while also: 

• Having physical conditions negatively affected 

by drinking (like high blood pressure and 

diabetes). 

• Having a history of falls or accidents. 

• Having memory problems. 

• Having trouble sleeping. 

• Feeling sad or “blue.” 

• Taking medications that can be harmful when 

mixed with alcohol. These include arthritis and 

pain medications, depression medications, 

blood thinners, antiseizure medications, and 

sleep medications. 

• Driving a car or other vehicle. 

For more information about the items in the 

CARET and how to score them, please see Barnes 

et al., 2010.356 

Depression Screening 

Make sure to screen for depression. Depression is 

both a risk factor for and an outcome of substance 

misuse in older individuals.357 Approximately 4.7 

percent of adults in the United States ages 50 and 

older have depression.358 MDD is commonly found 

in older clients who misuse substances.359,360 

GDS–Short Form 

One of the most commonly used depression 

screeners for older adults is the short form of 

the GDS361 (Exhibit 3.4). Clients with a GDS score 

of 6 or higher need further assessment and may 

need treatment for MDD.362 Clients with a GDS 

score below 6 should be screened again in 1 month 

if symptoms of depression are still present.363 If a 

client’s depressive symptoms are no longer present 

in 1 month, give the depression screener again in 6 

months.364 

Chapter 3 47 
TIP 26

 

 

 

Treating Substance Use Disorder in Older Adults 

EXHIBIT 3.4. Geriatric Depression Scale (GDS)–Short Form 

Client Version 

Client’s Name: Date: 

Instructions: Circle the best answer for how you felt over the past week. 

1. Are you basically satisfed with your life? Yes No 

2. Have you dropped many of your activities and interests? Yes No 

3. Do you feel that your life is empty? Yes No 

4. Do you often get bored? Yes No 

5. Are you in good spirits most of the time? Yes No 

6. Are you afraid that something bad is going to happen to you? Yes No 

7. Do you feel happy most of the time? Yes No 

8. Do you often feel helpless? Yes No 

9. Do you prefer staying at home, rather than going out and doing new things? Yes No 

10. Do you feel you have more problems with memory than most people? Yes No 

11. Do you think it is wonderful to be alive now? Yes No 

12. Do you feel pretty worthless the way you are now? Yes No 

13. Do you feel full of energy? Yes No 

14. Do you feel that your situation is hopeless? Yes No 

15. Do you think that most people are better off than you are? Yes No 

Scoring Version 

Client’s Name: Date: 

Scoring: Count boldface responses for a total score. A score of 0–5 is normal. A score of 6 or above suggests 

depression. 

Instructions: Circle the best answer for how you felt over the past week. 

1. Are you basically satisfed with your life? Yes No 

2. Have you dropped many of your activities and interests? Yes No 

3. Do you feel that your life is empty? Yes No 

4. Do you often get bored? Yes No 

5. Are you in good spirits most of the time? Yes No 

6. Are you afraid that something bad is going to happen to you? Yes No 

7. Do you feel happy most of the time? Yes No 

8. Do you often feel helpless? Yes No 

Continued on next page 

48 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

Continued 

9. Do you prefer staying at home, rather than going out and doing new things? Yes No 

10. Do you feel you have more problems with memory than most people? Yes No 

11. Do you think it is wonderful to be alive now? Yes No 

12. Do you feel pretty worthless the way you are now? Yes No 

13. Do you feel full of energy? Yes No 

14. Do you feel that your situation is hopeless? Yes No 

15. Do you think that most people are better off than you are? Yes No 

The Client Version and Scoring Version of the GDS–Short Form were both adapted from material in the public 

domain.365 

PHQ 

The nine-item PHQ-9 is commonly used to 

screen for depression in adults of any age.366 

It is tested and approved for use with older 

clients.367 The PHQ-9 is also useful for monitoring 

depression severity and treatment response in 

clients who already screened positive for or are 

diagnosed with depression. The PHQ-9 is available 

via https://cde.drugabuse.gov/instrument/ 

f226b1a0-897c-de2a-e040-bb89ad4338b9. 

A two-item version of the PHQ-9 is available (the 

PHQ-2) that includes only the frst two questions 

from the PHQ-9. However, compared with the 

PHQ-9, the PHQ-2 has a higher likelihood of 

giving older adults a false positive (that is, 

incorrectly rating a person as depressed when they 

are not).368 To get more reliable results, you should 

give the full PHQ-9. If you give the PHQ-2, be sure 

to give the full PHQ-9 to older adults who have a 

total score of 3 or higher.369 

Scoring: The total score for the PHQ-9 is derived 

by frst summing each column (e.g., each item 

chosen in column “More than half the days” = 2), 

then summing the column totals. Total scores range 

from 0 to 27 and indicate the following levels of 

depression severity: 

0–4: None-minimal 

5–9: Mild depression 

10–14: Moderate depression 

15–19: Moderately severe depression 

20–27: Severe depression 

In addition to the total score, review responses 

to Question #9 (suicidality) and the unnumbered 

question below it (the effect of symptoms on 

the client’s daily functioning) when determining 

whether to initiate or refer for further 

assessment and treatment.370,371,372 

Screening for Anxiety 

About 10 to 11 percent of older adults have had 

an anxiety disorder in the past year.373,374 About 

15 percent have had an anxiety disorder in their 

lifetime.375 Older women may be especially at risk 

for anxiety. The number of women ages 55 and 

older with any anxiety disorder in the past year has 

been estimated to be almost double that of older 

men (about 14 percent versus nearly 8 percent).376 

Anxiety is underdiagnosed in the older adult 

population.377 Providers may view older clients’ 

worries and concerns as a normal part of aging.378 

Older adults’ symptoms of anxiety can also be 

mistaken for physical conditions common in older 

age, as well as depression.379 

Chapter 3 49 
TIP 26

Yet different types of anxiety disorders can and do 

occur in older people. Some of these include: 

• Generalized anxiety disorder (GAD), panic 

disorder, and social phobia.380 In the National 

Comorbidity Survey Replication, the 12-month 

prevalence of GAD in people ages 65 and 

older was 1.2 percent.381 In the same study, 

0.7 percent of adults ages 65 and older had 

past-year panic disorder, and 2.7 percent had 

past-year social phobia. 

• PTSD. Estimates of past-year PTSD prevalence 

for those 65 or older range from 0.4 percent to 

2.6 percent.382,383 

Symptoms of anxiety that are present but do not 

meet full criteria for an anxiety disorder are more 

common than full anxiety disorders. As many as 

half, or possibly slightly more, of older adults in 

the community and in treatment settings may 

have anxiety symptoms.384 

It is not unusual for older people with anxiety 

to misuse substances, especially alcohol and 

tobacco: 

• In the National Epidemiologic Survey on Alcohol 

and Related Conditions, adults 65 and older 

with any anxiety disorder in their lifetime had 

a 1.5 times greater chance of having a lifetime 

AUD, when compared with adults 65 and older 

without anxiety disorders.385 They also had a 

1.6 times greater chance of having a lifetime 

tobacco use disorder.386 

Treating Substance Use Disorder in Older Adults 

• Among older people assessed for treatment for 

alcohol misuse,387 the most commonly reported 

reason for using alcohol among women (24 

percent) was “to reduce tension or anxiety.” 

This was also the second-most-common reason 

reported by men (20 percent). 

• Adults ages 55 and older with GAD in the past 

year were 2.2 times more likely to have had an 

SUD in the past year.388 Adults ages 50 to 64 

who had an anxiety disorder in the past year 

were 1.7 times more likely to have smoked 

cigarettes in the past year.389 

A review of anxiety assessment tools created for 

or approved for use with older people390 found the 

PSWQ and the Geriatric Mental Status Examination 

are useful and strongly supported by scientifc 

evidence. The Geriatric Mental Status Examination 

is a somewhat lengthy semistructured interview, 

not a brief screening tool. For that reason, it is 

not included here. Another valid and reliable 

self-report anxiety scale designed specifcally 

for older people is the GAS (Exhibit 3.5).391 The 

original GAS has 30 items. A short form of only 10 

items was developed and, like the full measure, 

was found to be valid for use in older people.392 

Higher scores on the GAS indicate higher 

anxiety. More research in larger clinical samples 

is needed to determine the optimal cutoff score, 

although in the 30-item scale, a cutoff of 16 may 

be clinically useful.393 

50 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

EXHIBIT 3.5. Geriatric Anxiety Scale (GAS) 

Below is a list of common symptoms of anxiety or stress. Please read each item in the list carefully. 

Indicate how often you have experienced each symptom during the PAST WEEK, INCLUDING TODAY, 

by checking under the corresponding answer. 

Not at all 

(0) 

Sometimes 

(1) 

Most of 

the time 

(2) 

All of 

the time 

(3) 

1. My heart raced or beat strongly. 

2. My breath was short. 

3. I had an upset stomach. 

4. I felt like things were not real or like I was 

outside of myself. 

5. I felt like I was losing control. 

6. I was afraid of being judged by others. 

7. I was afraid of being humiliated or 

embarrassed. 

8. I had diffculty falling asleep. 

9. I had diffculty staying asleep. 

10. I was irritable. 

11. I had outbursts of anger. 

12. I had diffculty concentrating. 

13. I was easily startled or upset. 

14. I was less interested in doing something I 

typically enjoy. 

15. I felt detached or isolated from others. 

16. I felt like I was in a daze. 

17. I had a hard time sitting still. 

18. I worried too much. 

19. I could not control my worry. 

20. I felt restless, keyed up, or on edge. 

21. I felt tired. 

22. My muscles were tense. 

23. I had back pain, neck pain, or muscle 

cramps. 

24. I felt like I had no control over my life. 

Continued on next page 

Chapter 3 51 
TIP 26

 

Treating Substance Use Disorder in Older Adults 

Continued 

Not at all 

(0) 

Sometimes 

(1) 

Most of 

the time 

(2) 

All of 

the time 

(3) 

25. I felt like something terrible was going to 

happen to me. 

26. I was concerned about my fnances. 

27. I was concerned about my health. 

28. I was concerned about my children. 

29. I was afraid of dying. 

30. I was afraid of becoming a burden to my 

family or children. 

GAS Scoring Instructions 

Items 1 through 25 are scorable items. Each item ranges from 0 to 3. Each item loads on only one scale. 

Items 26 through 30 are used to help clinicians identify areas of concern for the respondent. 

They are not used to calculate the total score of the GAS or any subscale. 

Total Score = sum of items 1 through 25. 

Somatic subscale (9 items) = sum of items 1, 2, 3, 8, 9, 17, 21, 22, 23 

Cognitive subscale (8 items) = sum of items 4, 5, 12, 16, 18, 19, 24, 25 

Affective subscale (8 items) = sum of items 6, 7, 10, 11, 13, 14, 15, 20 

© Daniel L. Segal, Ph.D., 2014. Reprinted with permission.394 

The PSWQ395 is a self-report instrument with 16 

items, each rated on a 5-point scale. Items 1, 3, 8, 

10, and 11 are reverse scored as follows: 

• Very typical of me = 1 (circled 5 on the sheet) 

• Circled 4 on the sheet = 2 

• Circled 3 on the sheet = 3 

• Circled 2 on the sheet = 4 

• Not at all typical of me = 5 (circled 1 on the 

sheet) 

The remaining items are scored regularly. The item 

scores are added to produce a total score ranging 

from 16 to 80, with higher scores refecting more 

worry. A score of 50 or higher by an older person 

could mean signifcant worries are present, but 

research on cutoff scores in older people is too 

limited to know for certain.396 Do not assume that 

an older client who scores below 50 does not have 

anxiety. The PSWQ is available in the Chapter 3 

Appendix. 

Screening for PTSD, Trauma Symptoms, and 

Abuse 

People with PTSD are at high risk for substance 

misuse.397 People with PTSD may use substances 

to help themselves cope and feel better. Even 

if a person does not meet criteria for PTSD, 

experiencing a traumatic event at any point in 

one’s life raises the risk for substance misuse.398,399 

As with any other clients, explore whether older 

clients have a history of trauma. 

About 52 percent of people 50 and older have 

had at least one adverse childhood experience,400 

such as sexual abuse, physical abuse, neglect, or 

extremely stressful family events including: 

• Seeing the abuse of a family member. 

• Living in the home with someone who misuses 

substances or has a mental disorder. 

• Experiencing the death of a parent or 

abandonment by one’s parents. 

52 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

• Having a household member in the criminal 

justice system. 

PTSD in older adults is not very common. 

Past-year PTSD occurs in only about 0.4 percent 

to 2.6 percent of people ages 65 and older.401,402 

Many people with trauma do not meet criteria for 

PTSD but do meet criteria for depression.403 Thus, 

depression screening is important in older clients 

who misuse substances. 

Trauma in older clients can include being a 

current victim of elder abuse. According to 

CDC, 1 in 10 adults (ages 60 or older) who live 

at home is a victim of elder abuse each year.404 

Elder abuse can manifest as emotional (or mental) 

abuse, fnancial abuse (or exploitation), physical 

abuse, sexual abuse, and neglect.405 Of women 

over age 65, 20 to 30 percent have been victims 

of intimate partner violence.406 Older adults who 

experience abuse are more likely to:407 

• Have depression or anxiety. 

• Have thoughts of suicide. 

• Attempt suicide. 

• Need emergency department care. 

• Be hospitalized. 

• Die prematurely. 

Some research shows that older adults from 

minority ethnic or racial groups may be more 

likely to experience abuse.408 The most recent 

nationally representative study of elder abuse 

found that lack of social support is a primary 

risk factor for experiencing elder abuse and for 

having negative outcomes following such abuse.409 

Cognitive disorders are a major risk factor for 

experiencing abuse. Older adults with dementia 

are almost fve times more likely to be victims of 

abuse as older people without dementia.410 

Ask all older clients with ongoing or past 

substance misuse about their history of trauma, 

including trauma in childhood and current trauma. 

Be sure to ask about any current abuse, including 

intimate partner abuse. Use brief screening 

measures to further explore these areas. Screening 

for trauma and abuse in older clients is important, as 

older adults with PTSD may have different or milder 

symptoms than younger clients. PTSD can thus be 

harder to recognize in older people.411 

Trauma is a sensitive topic for many clients. You 

need to know not just what to ask but how to 

ask it. Otherwise, clients might “shut down” or 

feel uncomfortable sharing private details with you. 

Some tips to help you assess trauma fully but in a 

gentle, sensitive manner include the following:412 

• Remind the client you are there as a support. 

Explain what will take place during and after the 

screening and assessment so that the individual 

knows what to expect. 

• Use screening and assessment tools that have 

been well researched and approved for use 

with older adults. 

• Remember that trauma can come in many 

forms. Use a checklist or question list to 

make sure you cover all possible traumas 

and not just ones that are commonly thought 

of (like physical and sexual abuse). You 

can fnd more information about Adverse 

Childhood Experiences (ACEs) on the CDC’s 

website (www.cdc.gov/violenceprevention/ 

childabuseandneglect/acestudy/index.html). 

• Tell clients that they can answer whichever 

questions they wish, however they wish. If 

they choose to only partly answer a question, 

that’s okay. If they choose not to answer a 

question at all, that’s also fne. 

• Remind them that they are safe. Sometimes 

talking about a trauma can feel scary, as if the 

traumatic event is happening again. You don’t 

want clients to feel that talking about their 

trauma is dangerous. This could lead them to 

avoid talking about it altogether, and that is not 

helpful. 

• Do not ask clients to “relive” their trauma by 

describing it in detail. Let your clients answer 

questions about their trauma in the ways that 

are most comfortable to them. There’s no “right 

or wrong way” for them to talk about their 

experiences. 

• Ask how the client’s trauma symptoms affect 

functioning. This includes ability to complete 

daily activities, engage in self-care, and maintain 

intimate relationships and a healthy social life. 

• Screen clients with histories of trauma for CODs 

and suicide risk. 

• Some people naturally feel more comfortable 

sharing information in writing than verbally. 

Chapter 3 53 
TIP 26 Treating Substance Use Disorder in Older Adults 

Have paper-and-pencil or computerized selfreport trauma measures on hand for clients who 

would rather not take part in a clinical interview. 

• Share resources and information with clients 

as needed to keep them safe and feeling 

supported. 

• End positively. After assessment, ensure that the 

client feels safe and ready to leave the session. 

PTSD Checklist for DSM-5 

The PTSD Checklist for DSM-5 (PCL-5; Exhibit 

3.6) is an updated version of the widely used 

and researched PTSD Checklist (PCL), which was 

based on DSM-IV criteria. Not much research has 

yet been conducted on the use of the PCL-5 with 

older adults. The PCL-5 has been used to screen 

for PTSD in some studies of older veterans,413,414,415 

but these studies were not designed to look at the 

validity of the PCL-5 in aging populations. More 

research is needed in this area. 

The optimal PCL-5 cutoff score in older adults 

is unclear. One study of Vietnam veterans (thus, 

mostly older men) found a PCL-5 score of 37 

made the best cutoff for PTSD screening.416 The 

Department of Veterans Affairs (VA) instructions 

on the PCL-5 (www.ptsd.va.gov/professional/ 

assessment/adult-sr/ptsd-checklist.asp) note a 

cutoff score of 33 as “reasonable” to use until 

further research is published on the best cutoff 

scores in different groups of people (such as 

veterans versus civilians).417 The VA warns that 

cutoff scores from the original PCL and those for 

the PCL-5 are neither equal nor interchangeable 

given that the PCL-5 contains changes in rating 

scales and number of items. You should not use 

PCL cutoff scores when interpreting scores from 

the PCL-5. 

EXHIBIT 3.6. PTSD Checklist for DSM-5 (PCL-5) 

Instructions: Below is a list of problems that people sometimes have in response to a very stressful 

experience. Please read each problem carefully and then circle one of the numbers to the right to indicate 

how much you have been bothered by that problem in the past month. 

In the past month, how much 

were you bothered by: Not at all 

A little 

bit Moderately 

Quite 

a bit Extremely 

1. Repeated, disturbing, and 

unwanted memories of the 

stressful experience? 

0 1 2 3 4 

2. Repeated, disturbing dreams 

of the stressful experience? 0 1 2 3 4 

3. Suddenly feeling or acting 

as if the stressful experience 

were actually happening 

again (as if you were actually 

back there reliving it)? 

0 1 2 3 4 

4. Feeling very upset when 

something reminded you of 

the stressful experience? 

0 1 2 3 4 

5. Having strong physical 

reactions when something 

reminded you of the stressful 

experience (for example, heart 

pounding, trouble breathing, 

sweating)? 

0 1 2 3 4 

Continued on next page 

54 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

Continued 

In the past month, how much 

were you bothered by: Not at all 

A little 

bit Moderately 

Quite 

a bit Extremely 

6. Avoiding memories, thoughts, 

or feelings related to the 

stressful experience? 

0 1 2 3 4 

7. Avoiding external reminders 

of the stressful experience 

(for example, people, places, 

conversations, activities, 

objects, or situations)? 

0 1 2 3 4 

8. Trouble remembering 

important parts of the 

stressful experience? 

0 1 2 3 4 

9. Having strong negative beliefs 

about yourself, other people, 

or the world (for example, 

having thoughts such as: I 

am bad, there is something 

seriously wrong with me, no 

one can be trusted, the world 

is completely dangerous)? 

0 1 2 3 4 

10. Blaming yourself or someone 

else for the stressful 

experience or what happened 

after it? 

0 1 2 3 4 

11. Having strong negative 

feelings such as fear, horror, 

anger, guilt, or shame? 

0 1 2 3 4 

12. Loss of interest in activities 

that you used to enjoy? 0 1 2 3 4 

13. Feeling distant or cut off from 

other people? 0 1 2 3 4 

14. Trouble experiencing positive 

feelings (for example, being 

unable to feel happiness or 

have loving feelings for people 

close to you)? 

0 1 2 3 4 

15. Irritable behavior, angry 

outbursts, or acting 

aggressively? 

0 1 2 3 4 

Continued on next page 

Chapter 3 55 
TIP 26 Treating Substance Use Disorder in Older Adults 

Continued 

In the past month, how much 

were you bothered by: Not at all 

A little 

bit Moderately 

Quite 

a bit Extremely

16. Taking too many risks or 

doing things that could cause 

you harm? 

0 1 2 3 4 

17. Being “superalert” or watchful 

or on guard? 0 1 2 3 4 

18. Feeling jumpy or easily 

startled? 0 1 2 3 4 

19. Having diffculty 

concentrating? 0 1 2 3 4 

20. Trouble falling or staying 

asleep? 0 1 2 3 4 

Reprinted from material in the public domain.418 A digital, fllable form is available online (www.ptsd.va.gov/professional/ 

assessment/documents/PCL5_Standard_form.PDF). 

Primary Care PTSD Screen for DSM-5 

The Primary Care PTSD Screen for DSM-5419 

(PC-PTSD-5) is a fve-item questionnaire that 

identifes clients likely to have PTSD. It was 

approved for use in a sample of older veterans 

(mostly male; mean age 63 years).420 All questions 

are yes/no. A score of 3 or more “yes” responses is 

considered positive.421 More information on using 

this tool is available online (www.ptsd.va.gov/ 

professional/assessment/documents/pc-ptsd5-

screen.pdf). The PC-PTSD-5 is available in the 

Chapter 3 Appendix. 

Elder Abuse Suspicion Index© 

The Elder Abuse Suspicion Index©422 is a six-item 

yes/no questionnaire. You should ask the client 

Questions 1 through 5. You can answer Question 

6 yourself. Questions apply to the last 12 months. 

A “yes” response on one or more questions (other 

than on Question 1) is considered a positive screen. 

This measure appears in the Chapter 3 Appendix. 

Screening for Co-Occurring Cognitive 

Disorders 

You should also screen older clients who misuse 

substances for cognitive impairment, which 

includes dementia and mild cognitive impairment 

(MCI). Dementia is a brain disorder affecting 

mental ability and personality that gets worse 

over time. Several types of dementia exist, such 

as Alzheimer’s (the most common form) and 

Parkinson’s dementia. People with dementia have 

diffculties in at least one area of thinking, such as 

memory, learning, language, or attention. These 

diffculties make it hard for people to live their 

everyday lives without help from others (e.g., 

needing help getting dressed, bathing, feeding 

themselves, or managing their money). Current 

research suggests almost 9 percent of Americans 

ages 65 and older have dementia.423 That includes 

over 3 percent of people ages 65 to 74, roughly 

10.5 percent of people ages 75 to 84, and almost 

30 percent of people ages 85 and older.424 

MCI is a milder form of cognitive impairment that 

often represents early brain changes that may 

precede and lead to dementia. In MCI, defcits in 

thinking from a previous level of performance are 

present but are not severe enough for a person 

to need help from others in their everyday life. A 

person with MCI is at increased risk of developing 

Alzheimer’s or another type of dementia. About 10 

percent to 20 percent of adults in the United States 

ages 65 and older have MCI, with the likelihood 

increasing with age.425,426,427 (Chapter 6 of this 

TIP provides more information about cognitive 

disorders and older adults who misuse substances.) 

56 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

Substance misuse, especially heavy alcohol use, 

can negatively affect thinking. Keep in mind that: 

• Heavy alcohol use can harm the brain, heart, 

liver, and other organs.428,429 

• Alcohol’s negative effects on the brain can 

lead to memory problems, diffculty learning 

new information, and diffculty thinking 

quickly.430,431,432 

• Heavy alcohol use can also cause brain cells and 

tissues to shrink or no longer work properly.433 

• In some people, even moderate alcohol use can 

harm the brain.434 

• Heavy drinking may do more harm to older adults’ 

cognitive abilities than those of younger adults.435 

Less research has been done on how substances 

other than alcohol can affect one’s chances 

of having a cognitive disorder like dementia 

or MCI. However, the long-term use of 

benzodiazepines,436,437,438 cannabis,439,440,441 

cocaine,442 and tobacco does seem to carry a 

somewhat greater risk of cognitive problems.443 

Mini-Cog© 

The Mini-Cog© is a brief screening tool that was 

created to detect dementia in older adults. It 

takes about 3 minutes to complete and involves 

a verbal memory task and a clock drawing task. 

The Alzheimer’s Association endorses using the 

Mini-Cog© in primary care settings to screen for 

cognitive impairment, and the National Institute 

on Aging lists it as an instrument to consider using 

for this purpose.444,445 Several reviews have found 

the Mini-Cog© to have acceptable-to-good test 

characteristics (e.g., sensitivity, specifcity, negative 

predictive value), although research suggests that it 

is better at detecting dementia than MCI.446,447,448 

The Mini-Cog© and its administration and scoring 

instructions are freely available to individual 

clinicians at https://mini-cog.com/mini-coginstrument/standardized-mini-cog-instrument. 

Two brief screening tools for cognitive impairment 

that have been more widely administered—the 

Montreal Cognitive Assessment (which was created 

to screen for MCI) and the Mini-Mental State 

Examination—now have costs associated with their 

use.449,450 

Communicating Screening Results 

Knowing what to do after screening is as important 

as knowing why and how to screen in the frst place. 

Whether negative or positive, you should inform all 

clients of their screening results. Read further to 

learn the specifc steps to take next, which will differ 

based on the client’s screening results. 

Negative Results 

No formal intervention is needed for people who 

screen negative. Instead: 

• Acknowledge clients who are substance free. 

(“I see that it’s important to you not to smoke.”) 

• Offer positive comments about the benefts 

of drug- and alcohol-free living. (“You know, 

people who don’t smoke generally live longer, 

healthier lives than people who do.”) 

• Reinforce attitudes, behaviors, and strategies 

that promote health. Think about asking 

whether their lack of substance use is new or 

lifelong, or whether it is because they are in 

recovery. (“Not drinking is a healthy decision. 

What made you decide not to drink?”) 

For older adults who screen negative or at low 

risk for substance misuse, be sure to: 

• Use positive language to urge them to continue 

using substances appropriately. 

• Give brief education, such as reminding them of 

low-risk alcohol intake levels for older adults. 

• Continue monitoring them for future signs and 

symptoms of possible at-risk substance use. 

Even if a screener is negative, the TIP consensus 

panel recommends that you occasionally 

rescreen clients. Why is that necessary? Because 

substance use can change over an individual’s 

lifetime. Substance use patterns can also change 

with life events, cognitive functioning, and mental 

health status. 

Chapter 3 57 
TIP 26 Treating Substance Use Disorder in Older Adults 

No clear scientifc data indicate exactly how 

often you should rescreen clients. The TIP 

consensus panel recommends that you use your 

clinical judgment to determine how often to 

rescreen. You might consider screening more often 

(at least once a year) if the client has repeatedly 

requested prescription drugs or has certain 

conditions, such as: 

• Physical conditions that are often alcohol 

or drug related (e.g., high blood pressure, 

insomnia). 

• Diabetes or ulcers unresponsive to treatment. 

• Staph infection on face, arms, or legs. 

• Repeated fractures, lacerations, or burns. 

• Depression. 

• Unexplained weight loss. 

• Frequent falls. 

• Repeated trauma suggesting domestic violence. 

• Sexually transmitted diseases. 

When doing an SUD screen, if the depression 

screener is negative but the client has some 

symptoms of depression, you will want to give 

another depression screen in 1 month. Symptoms 

to look for include low mood, diffculty making 

decisions, loss of interest in pleasurable activities, 

and feelings of hopelessness. You should continue 

to monitor the client’s symptoms over time. You 

may want to give another depression screen earlier 

if the client reports worsening symptoms or if the 

client seems to be feeling worse. If the depression 

screen is negative and the client has few or 

no symptoms of depression, you can continue 

screening on a yearly basis. If the client reports 

new symptoms or you suspect the person may be 

feeling depressed at any time, you should give a 

depression screener again. 

When doing an SUD screen, if trauma or elder 

abuse screeners are negative, continue with 

routine clinical care. Rescreen any time you 

suspect that trauma or abuse has occurred. For 

instance, if a client reports disagreements with her 

husband and has visible bruises, screen for possible 

abuse. 

You can also give a substance-related, 

depression, or trauma screener again if the client 

experiences major changes that could lead to 

substance misuse, depression, anxiety, or PTSD. 

Such changes include the death of someone 

signifcant to the client, a transition to an assisted 

living residence or nursing home, or retirement. 

Positive Results 

For clients who screen positive for potential 

substance misuse, three possible approaches 

exist. These are based on the severity of the 

problem and possible risk of having substance 

misuse. (None of the three approaches listed below 

is appropriate for an intoxicated client, who may 

need an immediate and specifc response [e.g., 

referral to detoxifcation].) The three approaches 

are: 

• Immediately give a brief assessment during 

the same visit in which you gave the screening 

measure. (See the section “Conducting Brief 

Assessments and Interventions” below.) 

• Give a full assessment if the screening results 

are unclear. You may need to schedule another 

visit for this longer assessment. 

• Refer the client to another provider for 

assessment. Refer high-risk clients to a program 

where specialized SUD treatment services are 

available, if possible. 

If a cognitive screener is positive, you should 

refer the client for further testing by a behavioral 

health service provider with special training 

in diagnosing clients with dementia and MCI. 

Making such diagnoses requires additional, 

indepth cognitive testing. Do not give a diagnosis 

of dementia or MCI based solely on a positive 

cognitive screen. 

If a depression, anxiety, PTSD, or trauma 

screener is positive, give a full assessment using 

DSM-5 diagnostic criteria to determine whether 

a disorder is present (or refer the client for further 

evaluation if you do not have the training and 

credentials to make a mental disorder diagnosis). 

58 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

This may mean giving a full diagnostic interview, 

perhaps at another appointment. Even if full 

diagnostic criteria are not met, the client may still 

beneft from treatment if symptoms are upsetting 

or interfere with daily living. 

If an elder abuse screener is positive, follow 

your state’s laws on reporting suspected abuse. 

Unless you work in private practice, you frst 

need to contact your immediate supervisor 

to ensure that you are following program 

procedures and abiding by state laws. You 

may need to consult with social services or Adult 

Protective Services on next steps. The Department 

of Justice provides a list of online resources to help 

you learn your state’s laws about reporting abuse 

and involving Adult Protective Services (www. 

justice.gov/elderjustice/elder-justice-statutes-0). 

The National Center on Elder Abuse links to statespecifc reporting numbers and other agencies 

(https://ncea.acl.gov/Resources/State.aspx). Make 

sure you are familiar with these laws and resources 

before giving abuse screeners so that you can act 

right away if a screener is positive. 

Present the results of positive screens to clients 

in a gentle manner. For example, you might say, 

“After reviewing your answers on the screening 

questionnaire, there are some things I’d like to 

follow up on with you,” or, “Your answers are 

similar to the answers of people who may be 

having a problem with alcohol.” 

Conducting Brief Assessments 

and Interventions 

Positive screens for substance misuse require 

follow-up, but next steps may not be immediately 

clear. Decisions about follow-up care depend on 

how much time and effort you can expend, how 

much training and experience you have in drug and 

alcohol counseling, and your program’s treatment 

abilities. Also essential are the client’s agreement, 

engagement level, and preferences. 

Starting Of on the Right Foot 

A successful assessment starts by creating a 

welcoming environment. This is key to helping 

older clients “open up” and feel safe talking 

about substance misuse. You can do this by 

keeping a gentle, respectful, and empathetic 

attitude. Many clients who misuse substances 

feel uncomfortable talking about their substance 

use in medical settings. A friendly, nonjudgmental 

atmosphere can put clients at ease and help them 

share information they may fnd embarrassing, 

like feeling depressed or being abused.451 Using 

motivational interviewing approaches, such as 

asking open-ended questions, is more helpful 

than asking basic yes/no questions.452 (See the 

Substance Abuse and Mental Health Services 

Administration’s [SAMHSA] update of TIP 35, 

Enhancing Motivation for Change in Substance 

Use Disorder Treatment [https://store.samhsa. 

gov/product/TIP-35-Enhancing-Motivation-forChange-in-Substance-Use-Disorder-Treatment/ 

PEP19-02-01-003]). 

What is motivational interviewing (MI)? Per 

SAMHSA, it is a clinical approach to helping 

clients make positive changes in their behavior. 

MI involves techniques like showing concern and 

empathy, avoiding arguing, and supporting a 

client’s self-effcacy (a person’s belief that he or 

she can successfully make a change). 

Keep in mind that almost all clients will have 

mixed feelings about their substance use. They 

will fnd some aspects of it pleasant and benefcial 

but other aspects diffcult, painful, or harmful. You 

can help clients discover their own reasons for 

wanting to change by talking about these mixed 

feelings and pointing out problem areas. 

SAMHSA’s TIP 34, Brief Interventions and Brief 

Therapies for Substance Abuse, offers more 

guidance on how to make assessment and 

interviews successful.453 

Chapter 3 59 
TIP 26

Looking for a simple way to help clients “open 

up”? Avoid asking yes/no questions. Openended questions are more thought-provoking 

and help clients share their own experiences in 

a more meaningful way. Start by asking broad 

questions about a client’s health in general, such 

as: 

• “How would you rate your health overall?” 

• “Compared with other people your age, how 

would you say you are doing?” 

• “What health problems do you have?” 

Next, move into more specifc questions about 

the client’s substance misuse. Try asking 

questions like: 

• “What concerns do you have about your alcohol 

use?” 

• “In what ways might your life be different were 

you not using tobacco?” 

• “How has using opioids affected your 

relationships?” 

Questions that can be answered with a simple 

“yes” or “no” can seem harsh or judgmental. 

Older clients might already feel ashamed and 

uncomfortable talking about their substance 

use. Closed-ended questions could make those 

feelings even worse and cause clients to “shut 

down.” On the other hand, open-ended questions 

can help clients become aware of and express 

their own experiences and motivations related to 

substance use. 

Brief Assessments 

If a client’s screening results show mild substance 

misuse, conduct a brief assessment to get more 

information. Assessment questions should cover: 

• The severity of substance use (including what, 

how often, and how much the client uses). 

• The types of problems connected with the 

client’s use. 

• The frequency of problems that occur with the 

client’s use. 

• Other special physical and mental factors (e.g., 

whether a mental or physical disorder is present 

that could be making the person’s substancerelated symptoms worse). 

Treating Substance Use Disorder in Older Adults 

If the client’s responses suggest an SUD diagnosis 

per DSM-5 criteria, you should conduct or provide 

a referral for an indepth assessment. However, you 

can give a brief outpatient therapeutic intervention 

if: 

• Only mild or mild-to-moderate substance misuse 

is present. 

• The client appears to be at risk for harm 

because of current substance use. 

• Co-occurring illnesses or conditions may be 

made worse by continuing to drink or use drugs. 

• The client declines referral for further 

assessment or treatment. 

Brief Interventions: SBIRT 

SBIRT is an approach to providing brief 

interventions after screening, referrals for further 

assessment, or treatment. SBIRT approaches are 

focused on getting clients into treatment early. 

They include: 

• Screening for possible substance misuse and 

level of risk. 

• Offering a brief outpatient intervention to 

help clients understand the need to change 

their substance misuse and help them increase 

their desire to change. 

• Referrals to SUD treatment programs or mental 

health services for clients who need more 

indepth assessment or intervention. 

Behavioral health service and healthcare providers 

can easily incorporate brief interventions into 

standard practices. Brief interventions: 

• Give you the chance to: 

- Explain screening results to clients. 

- Provide information about low-risk substance 

use. 

- Give advice about changing substance 

misuse habits. 

- Assess clients’ desire for change. 

- Work with clients to set goals and strategies 

for change. 

- Figure out how best to make sure clients are 

sticking with their treatment plan. 

60 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

• Are usually only 10 to 15 minutes long and 

include a limited number of sessions. 

• May require at least one follow-up visit. 

However, even more follow-up sessions may be 

needed depending on the setting, the severity 

of the substance misuse, and clients’ responses. 

• Are usually inexpensive and quick to conduct. 

Most older adults at risk for substance misuse 

do not need formal specialized SUD treatment. 

However, many clients can beneft from education 

to prevent problems before they occur. They 

can also beneft from SBIRT techniques. For 

instance, SBIRT that involves basic education as an 

intervention has been shown to help reduce older 

adults’ risky alcohol use.454,455 Educate clients on 

risky alcohol use as a prevention measure and an 

intervention. Boston University School of Public 

Health provides helpful information and resources 

(e.g., demonstration videos) on screening and 

brief intervention techniques successfully used 

in primary care and emergency department 

settings (www.bu.edu/bniart/sbirt-in-health-care/ 

sbirt-brief-negotiated-interview-bni/). 

Why do your clients want to change their 

substance misuse? Knowing the answer to 

this question is more useful than just knowing 

whether clients are ready to change. Helping 

clients explore their reasons for wanting to 

change their substance use can help them feel 

more positive and confdent about making 

this change. It also helps better support them 

during assessment and treatment. It is okay if 

the reasons for change are initially attributable 

to outside forces rather than the clients’ own 

desires. Clients pressured into treatment—such 

as through parole and probation or drug courts— 

are as or sometimes more likely to succeed in 

treatment as clients who enter on their own.456 

SBIRT services must meet the special age-related 

needs of older adults to give them the greatest 

chance for success (Exhibit 3.7). You can make 

your SBIRT services age sensitive by: 

• Using supportive language in your discussions 

so that older clients do not feel shame or fear. 

• Using clear, basic terms with older clients 

rather than confusing terms or medical 

language. 

• Sharing information that is specifc to older 

clients, such as guidelines about low-risk levels 

of substance use for older adults or physical 

effects of substance misuse. 

• Including strategies and materials that are 

culturally sensitive to clients and to the unique 

issues that older adults face. For example, your 

older adult clients may be: 

- Worrying about not being able to live 

independently, without help from others. 

- Coping with grief (over loss of a partner, 

spouse, child, or another signifcant person). 

- Adapting to major life changes, like retiring 

or moving into an assisted living residence. 

• Thinking about the role of chronic physical 

conditions in older clients’ misuse of 

substances (e.g., use of substances to manage 

chronic pain). Such conditions can also affect 

symptoms of substance misuse and treatment 

response. 

• Using tailored screening and assessment 

measures that were made specifcally for older 

adults or are approved for use with them. 

• Giving interventions that meet older clients’ 

needs. For instance, if possible, in-home 

treatment is helpful if clients cannot travel to 

your program. 

• Keeping referral information on hand about 

local providers who specialize in addiction 

treatment and are skilled at working with older 

adults who misuse substances. 

Chapter 3 61 
TIP 26 Treating Substance Use Disorder in Older Adults 

EXHIBIT 3.7. Successfully Applying SBIRT Principles to Older Adults 

The Florida Brief Intervention and Treatment for Elders (BRITE) pilot project457 was funded by the Center for 

Substance Abuse Treatment and modeled on SBIRT. In this program, older adults who screened as needing 

a brief SUD intervention received: 

• Education to help reduce substance misuse, develop healthier habits, and improve quality of life. 

• MI to increase their desire to change substance misuse-related behaviors. 

• Age-appropriate information designed to address high-risk situations, coping with urges to use 

substances, and preventing return to substance misuse. 

Results from the program were positive.458 Specifc outcomes included the following:459 

• Clients who completed the program had lower SMAST-G scores. 

• At the end of the study, nearly 30 percent of clients in the BRITE program had fewer fags in their medical 

chart for prescription medication misuse. 

• People in the BRITE program had large decreases in depression (measured by the GDS) and suicide risk 

scores. 

• The number of older adults getting treatment in the program was three times greater than the number 

who were getting SUD services before BRITE began. 

RESOURCE ALERT: DESIGNING 

AND IMPLEMENTING SBIRT 

PROGRAMS FOR OLDER ADULTS 

SAMHSA’s A Guide to Preventing Older Adult 

Alcohol and Psychoactive Medication Misuse/ 

Abuse: Screening and Brief Interventions is a 

manual to assist addiction treatment providers 

and administrators in designing, implementing, 

and delivering screening and brief intervention 

programs to prevent substance misuse in older 

adults. It is available online (www.ncoa.org/wpcontent/uploads/SBIRT-Older-Adult-Manual-Final. 

pdf). SAMHSA has other resources to help you 

integrate SBIRT into your program (www.samhsa. 

gov/sbirt/resources). 

The National Council on Aging also offers an 

instruction manual and workbook for effective 

screening and brief intervention strategies for 

risky alcohol use in older adults (www.ncoa. 

org/wp-content/uploads/BI_OlderAdults_ 

ImplementationManual.pdf). 

Conducting Full Assessments for 

Substance Misuse 

Conduct a full assessment for any client 

whose screening suggests moderate-to-severe 

substance misuse. Full assessments gather not 

just substance-related information, but information 

about overall functioning and health (Exhibit 3.8). 

This information will help you differentiate among 

substance misuse, CODs, physical conditions 

common in older populations, and symptoms of 

normal aging. Common physical conditions and 

symptoms of normal aging that can be confused 

for substance misuse include low energy, memory 

changes, sleep problems, and decreased appetite. 

62 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

EXHIBIT 3.8. Key Objectives of a 

Full Assessment for Substance 

Misuse 

Key objectives of giving a full assessment for 

substance misuse can include: 

• Getting older clients’ substance use history 

(including prescription and OTC medications). 

• Checking clients for CODs that can affect 

substance misuse, such as depression, anxiety, 

and PTSD. 

• Checking clients for other trauma or abuse. 

• Learning older clients’ physical conditions 

and physical and medication history. This is 

especially important for physical conditions 

that can lead to or result from substance 

misuse, like sleep problems and pain. 

• Asking about social supports available to older 

clients who misuse substances. 

• Referring clients with cognitive problems 

for a full cognitive assessment by a 

neuropsychologist or neuropsychiatrist to see 

whether dementia, MCI, or delirium is present. 

• Understanding clients’ unique substance 

misuse. This means asking them about: 

- When and with whom they misuse 

substances. 

- Why they misuse substances. 

- How misusing substances fts into their life. 

- How they feel and what they believe about 

their misuse of substances. 

Full assessments often involve several members 

of the care team, depending on the setting and 

available resources of your program. Which care 

team members contribute to the full assessment 

depends on the qualifcations and level of expertise 

needed to address the client’s problems. For 

instance, the assessment may start with a certifed 

drug and alcohol counselor or other licensed 

provider taking a complete psychosocial history. 

Other licensed providers may need to complete 

a psychological evaluation (e.g., if the intake 

interview is given by someone not licensed to 

diagnose mental disorders) and look for withdrawal 

indicators or educate the client on the need for 

medical withdrawal. A medical staff member may 

take a medical history and perform a physical 

exam. Nurses or occupational therapists, rather 

than behavioral health service providers, usually 

give assessments of ADLs and fall risk. If your 

program does not have any medical staff members, 

you should refer clients elsewhere for this part of 

the assessment. A physician, nurse, or pharmacist 

may be consulted to determine risk for medication 

misuse, whether accidental or intentional. 

Determining risk for medication misuse involves 

reviewing the client’s: 

• Current prescriptions and OTC medications. 

• Management of these medications. 

• Ability to obtain prescriptions (referring to cost 

as well as accessibility). 

• Potential adverse reactions to medications. 

Full assessments help the treatment team: 

• Make the right diagnosis (whether it be an 

SUD, a mental disorder, or a cognitive disorder). 

• Learn the severity of the substance misuse. 

• Guide treatment planning, including giving 

clients the right level of care in the right setting. 

• Decide whether medical conditions are present 

that need to be addressed during treatment. 

• Decide whether other conditions are present 

that need to be addressed during treatment. 

The Assessment Process 

A complete assessment has several parts. These 

include: 

• Full mental health, medical, family, vocational, 

social, sexual, fnancial, legal, substance use, 

and SUD treatment histories. 

• A health history and physical exam for common 

co-occurring physical conditions that affect 

mental health as well as physical conditions that 

suggest the client has substance misuse (e.g., 

sleep problems, chronic pain). This part of the 

assessment also sometimes includes biological 

screening measures, like urine screens (for 

benzodiazepines and opiates), breath alcohol 

testing (i.e., breathalyzer), and laboratory 

tests. Medical professionals should also check 

Chapter 3 63 
TIP 26 Treating Substance Use Disorder in Older Adults 

the Prescription Drug Monitoring Program for 

additional information about clients’ prescribed 

medications. 

• Further assessment for CODs. Sometimes 

referral to an outside provider (e.g., licensed 

psychologist, clinical social worker) is needed, 

depending on the expertise of the staff 

members in your program. 

• Assessment of skills used in everyday living, 

like dressing, bathing, shopping, and managing 

money. 

• Assessment of the client’s fall risk. (For example, 

see the CDC’s fall prevention program, 

“Stopping Elderly Accidents, Deaths, and 

Injuries,” at www.cdc.gov/steadi/.) 

• Assessment of the client’s basic needs (e.g., 

housing, nutrition), support network, and 

strengths/resources. 

The most important parts of your full assessment 

are gathering information about the client’s 

substance use, mental health, physical health, 

and SUD treatment histories, as well as a listing 

of prescribed and OTC medications. It may take 

multiple visits to complete the assessment. 

Clients will feel safe sharing detailed information as 

their trust in you builds. 

The following sections describe some of the 

most common parts of a full assessment, 

targeting only those parts that are most 

appropriate for older clients who misuse 

substances. The sections do not cover questions 

about a client’s recreational, military, occupational, 

or avocational/retirement history. 

The section on health history and the physical 

exam discusses disordered sleep and pain because 

these are common physical conditions seen in 

older people who misuse substances. But other 

health and physical assessments may be needed 

beyond what is listed in that section. 

Make sure you have the required training and 

qualifcations before assessing for or diagnosing 

SUDs. If no providers in your program have the 

necessary licenses and qualifcations to assess for 

and diagnose mental disorders, make referrals as 

necessary to providers who can do so. 

Health History and Physical Exam 

Taking a complete physical history of clients is 

very important. Asking about clients’ physical 

history can help you learn about: 

• The medical effects of their substance use 

(e.g., soft tissue infection, hepatitis B or C, HIV 

infection) that may need treatment. 

• Consequences of substance misuse that might 

get clients to change (e.g., elevated blood 

pressure, worsening acid refux symptoms, 

increased risk of falls). 

• Physical health issues (e.g., severe liver disease) 

that affect whether medications can be given for 

certain SUDs, such as opioid use disorder. 

• Possible drug–drug interactions. 

Sleep problems 

Sleep quality is closely linked to substance 

misuse in adults in general. For instance: 

• Alcohol misuse and withdrawal can lead to many 

types of sleep problems. These include:460,461 

- Increased awakening during the night. 

- Insomnia. 

- Excessive daytime sleepiness. 

- Less total sleep time. 

- Worsening of sleep apnea and other 

breathing-related sleep conditions. 

• Adults ages 50 and older who binge drink are 

at an increased risk of insomnia compared 

with adults in this age group who do not binge 

drink.462 

• Compared with people who have never smoked 

cigarettes, people who smoke report having 

worse sleep quality, taking longer to fall asleep, 

sleeping less than 6 hours, and having disturbed 

sleep.463 

• Cocaine use is linked to taking longer to fall 

asleep and having decreased total sleep time.464 

• Chronic opioid use is associated with an 

increased risk of central sleep apnea and other 

breathing-related sleep problems.465 

64 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

RESOURCE ALERT: SAMHSA 

GUIDANCE ON TREATING SLEEP 

DISORDERS IN CLIENTS WITH 

SUDS 

SAMHSA’s Treating Sleep Problems of People 

in Recovery From Substance Use Disorders 

offers tips on how to manage clients who have 

SUDs and sleep problems.466 It is available online 

(https://store.samhsa.gov/product/TreatingSleep-Problems-of-People-in-Recovery-FromSubstance-Use-Disorders/sma14-4859). 

Sleep is an important part of clients’ physical 

history. Sleeping less and waking earlier are normal 

parts of aging. But it is abnormal for older clients 

to be very tired in the day or not sleep through the 

night. These problems can increase risk of negative 

events like falls and even death.467,468,469 

If symptoms of poor sleep are present, also ask 

about the client’s:470 

• Sleep history. 

• Leg movements during sleep. 

• Grief or recent loss. 

• Level of physical activity during the day. 

• Caffeine intake. 

• Alcohol consumption. 

• Need to use the bathroom during the night. 

Several medication and nonmedication treatments 

can improve sleep problems. Depending on 

symptom severity, the medical provider conducting 

this part of the assessment may consult with a 

sleep medicine specialist for an indepth assessment 

or with a psychologist for behavioral management 

of symptoms. A full assessment of sleep should 

include an assessment for sleep apnea, which may 

involve an in-home or in-clinic overnight sleep 

study. Sleep problems that result from a physical 

condition or medication can usually be treated by 

addressing the medical illness and by switching 

medication or adjusting the dose. 

Chronic pain 

Chronic pain can be hard to manage in any 

client. But in clients who misuse or are at risk 

of misusing substances, managing chronic pain 

becomes even more diffcult. This is because 

substance use can often affect chronic pain 

in positive ways, even though the substance 

itself is harmful. For example, many older clients 

start taking pain medication to reduce physical 

discomfort. However, they may continue taking 

the medication to also manage emotional pain or 

to reduce withdrawal symptoms that occur when 

they try to stop taking it. Clients may misuse both 

prescribed and nonprescribed substances, such as 

alcohol, for such reasons. 

People with chronic pain may be at risk for 

substance misuse. This is not surprising given 

that substances like opioids, alcohol, and cannabis 

can help reduce physical pain. The following are 

fndings from several studies of older adults: 

• In Wave 3 of the National Epidemiologic Survey 

on Alcohol and Related Conditions, adults 

ages 50 and older who engaged in nonmedical 

cannabis use were signifcantly more likely 

also to report past-year injuries, greater pain 

interference, and nonmedical pain reliever use 

compared with those not using cannabis.471 

The study authors suggest that, in some older 

adults, nonmedical substance use and misuse 

may refect their efforts to reduce pain without 

help from doctors. 

• Having numerous painful medical conditions, 

or more severe pain, was associated with a 

15-percent to 20-percent increased chance 

of having physical, mental, or social problems 

related to drinking.472 Older adults with 

pain severe enough to interfere with ADLs 

were especially likely to have alcohol-related 

problems.473 

• Using alcohol to self-medicate pain is associated 

with greater pain intensity, greater pain 

interference with everyday activities, and higher 

levels of depression and anxiety compared with 

not using alcohol to self-medicate pain.474 

Chapter 3 65 
TIP 26

Older clients are likely to underreport their 

pain.475 Using a two-step approach will help you 

thoroughly assess for chronic pain in older clients: 

• First, ask your clients directly about their pain. 

- Self-report is the most reliable method of 

assessing pain in older people.476 Even most 

clients with mild-to-moderate cognitive 

impairment can accurately tell you about 

their pain.477 

- Open-ended questions (“Tell me about your 

aches and sores,” or “Tell me about any 

discomfort you are having”) may be more 

useful than yes/no questions (“Are you 

feeling any pain?”).478 

- You should try using words other than “pain,” 

because some older adults will not report 

feeling pain.479 Instead, you can use words 

like “discomfort,” “aches,” “hurt,” and 

“sore.” 

• Second, use a pain rating scale to learn the 

intensity of your client’s pain. 

- The revised Iowa Pain Thermometer (IPT-R; 

see the Chapter 3 Appendix) and the 

revised Faces Pain Scale (see the Chapter 

3 Appendix) are approved for use in older 

adults, including those from diverse racial 

and ethnic populations.480 The IPT-R can also 

be used with older adults with cognitive 

impairment.481 

- Verbal descriptor scales (VDS; Exhibit 3.9) can 

be used with older adults with and without 

cognitive impairment.482 These scales come 

in two main types.483 One type asks clients 

to rate their pain only using words, such as 

“none,” “mild,” “moderate,” or “extreme.” 

The second type asks clients to rate their 

pain using a number scale. The number scale 

usually ranges from 0 to 5 or 0 to 6. 

All three of these tools (the IPT-R, the revised Faces 

Pain Scale, and VDS instruments) are easy to use 

and easy for older clients to understand. Although 

pain scales can be useful, do not rely on them 

alone. Assessment and treatment planning should 

consider not just how a client rates on a pain 

scale but also his or her level of functioning in the 

presence of pain. 

Treating Substance Use Disorder in Older Adults 

EXHIBIT 3.9. Verbal Descriptor 

Scales (VDS)484,485 

(Word-based scale) Please describe your pain 

from “no pain” to “slight,” “mild,” “moderate,” 

“severe,” “extreme,” or “pain as bad as it could be.” 

(Number-based scale) Please describe your pain 

using these numbers: 0 for no pain, 1 for slight 

pain, 2 for mild pain, 3 for moderate pain, 4 for 

severe pain, 5 for extreme pain, and 6 for the most 

intense pain imaginable. 

Older clients with chronic pain can be treated 

effectively. However, giving older clients 

prescription opioid medications to treat chronic 

pain raises concerns. That’s because: 

• Little evidence exists that opioids offer 

long-term relief of chronic noncancer pain in 

older adults.486 Nonopioid medications, like 

acetaminophen and topical nonsteroidal antiinfammatory drugs (NSAIDs), can be effective 

for certain conditions and are alternatives to 

opioid medications.487 

• Compared with younger adults, older adults 

have a higher risk of harmful drug–drug 

interactions because they often take one 

or more prescribed medications for chronic 

illnesses. The combination of opioid medications 

and alcohol is also very dangerous in older 

people. (See the CDC’s factsheet on screening 

for alcohol use before prescribing opioids at 

www.cdc.gov/drugoverdose/pdf/prescribing/ 

AlcoholToolFactSheet-508.pdf.) 

• Long-term opioid use can increase the risk for 

certain negative physical conditions. These 

conditions include breathing problems and 

hormone changes for older adults.488 

• This age group is also at risk for opioid misuse 

and addiction.489 In 2018, more than 9,200 

opioid overdose deaths occurred among people 

ages 55 and older.490 From 2017 to 2018, opioid 

overdose deaths among people ages 65 and 

older increased by 14.3 percent, and deaths 

from prescription opioid overdose among this 

same age group increased by 7.4 percent.491 

66 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

• Some nonmedication treatments may be 

benefcial and carry less risk of harm to older 

adults than opioid medications, although more 

research is needed on these management 

approaches.492,493 

Healthcare providers and prescribers must carefully 

weigh the possible benefts of opioid treatment 

with its risks. For instance, healthcare prescribers 

should:494 

• Try using nonmedication treatments in place of 

or along with opioid treatment. 

• Use a “start low and go slow” approach to 

dosing. 

• Check for possible drug–drug interactions with 

clients’ other medications. 

• Discuss with clients the benefts and possible 

harms of taking opioids. 

• Screen and assess clients for factors that 

increase the odds of misuse and addiction. 

• Carefully monitor clients for harmful reactions. 

• Educate clients about opioid-related safety 

issues. These include drug–drug interactions, 

fall risk, driving risks, and safe storage of opioid 

medications. 

• Periodically review the ongoing need for the 

opioid medication, and consider whether the 

dose can be reduced, tapered, or discontinued. 

Nonmedication and medication treatments 

are available to help older adults reduce their 

pain and improve their everyday activities and 

quality of life while keeping their risk of opioid 

misuse and addiction low. Nonopioid medication 

treatments for pain recommended by CDC in its 

2016 CDC Guideline for Prescribing Opioids for 

Chronic Pain495 include: 

• Acetaminophen. 

• NSAIDs. 

• Antidepressants. 

• Anticonvulsants. 

• Epidural injections. 

In some instances, opioid medication may be 

appropriate and can be used safely if used within 

CDC guidelines for safe practices.496 However, 

proven nonmedication approaches to pain 

management exist, such as acupuncture, cognitive– 

behavioral therapy, physical therapy, massage, 

biofeedback, and chronic pain self-management 

programs. 

Of note, if medication is used, acetaminophen 

or oral NSAIDs in older adults can increase their 

risk of hepatic, cardiovascular, or gastrointestinal 

toxicity, especially when used long term, in 

excess, or in combination with certain other 

medications.497,498 

Psychosocial History 

Substance use history 

Substance use histories can help you learn the 

severity of a client’s substance misuse, make SUD 

treatment plans, discover whether potential drug 

interactions are present, and understand the 

negative consequences of the substance misuse. 

Asking about the client’s history of substance use 

will help you learn about the individual’s severity of 

use and effects of that use on life. This may include 

asking about: 

• Choice of substances used. 

• Age at frst use. 

• The person who frst introduced the client to the 

substance. 

• Routes of taking the substance (e.g., injection, 

smoking). 

• History of tolerance, withdrawal, mixing drugs, 

and overdose. 

• Reasons for starting and continuing to use the 

substance, which may change over time. 

Be sure to also ask about current patterns of use, 

which will help you make treatment decisions. Such 

questions could include: 

• “How much do you drink when you do use 

alcohol?” 

• “How often do you smoke or use tobacco?” 

• “When was the last time you had a drink?” 

• “Have you ever wondered whether your 

substance use is affecting your life or health in 

any way? Have you ever had a DUI?” 

• “Does drinking alcohol help you feel better? (If 

yes) In what ways does it help you feel better? 

How do you feel after you have stopped 

drinking?” 

Chapter 3 67 
TIP 26

• “Which prescription and over-the-counter 

medications do you take? Do any of them 

interact with alcohol in a way that could harm 

you?” 

SUD treatment history 

Clients’ history of seeking SUD treatment or 

stopping use on their own can help guide 

treatment planning. Also ask clients about what 

led to their return to substance use after having 

stopped for a period. Successful and unsuccessful 

quit attempts can help you make treatment 

planning decisions. Taking an SUD treatment 

history could include asking clients about: 

• Specifc settings in which they were treated 

(e.g., inpatient versus outpatient, criminal justice 

versus non-criminal justice). 

• Their history of using support groups and 

community support and in what ways such 

supports were (or were not) helpful. 

• Previous SUD treatments that were and were 

not successful. In addition, ask about periods 

following treatment where clients were 

successful (e.g., what worked for them). 

• Previous attempts at stopping use, why they 

attempted to stop, and how many times they 

have tried to stop. 

• Circumstances that led to the clients’ starting 

treatment. (Was it voluntary? Why start 

treatment now, today?) 

• Relapse prevention and recovery strategies that 

worked in the past. 

• How treatment ended. (Did they complete 

treatment or leave treatment early? If the latter, 

why?) 

History of mental illness and mental health 

services 

Co-occurring mental illness is very common 

among people who misuse substances.499,500 The 

2019 National Survey on Drug Use and Health 

estimates that 49.2 percent of adults with an 

SUD in the past year also had a mental illness,501 

whereas only about 16.8 percent of adults without 

an SUD in the past year also had a mental illness.502 

The survey also estimates that 10.7 percent of 

Treating Substance Use Disorder in Older Adults 

adults ages 50 and older with any mental illness 

also have an SUD.503 Meanwhile, an estimated 36.8 

percent of adults ages 50 and older with an SUD 

have a co-occurring mental disorder.504 

Depression, anxiety, and PTSD are 

especially likely to co-occur with substance 

misuse.505,506,507,508 Keep the following points in 

mind when you assess for these conditions:509 

• Older clients may be more likely to talk about 

physical symptoms than emotional ones. 

• You should ask about any medications the 

client is taking. Some medications can cause 

side effects that are similar to symptoms of 

depression (like trouble sleeping or feeling low 

energy). 

• Depending on the client’s cognitive abilities, 

you may need to speak with a family member or 

a family caregiver to get information about the 

client’s mental health and history. Be sure to get 

permission from the client before doing this. 

• Older women in particular can be easily 

mistaken as having depression or other mental 

disorders (like anxiety) instead of PTSD.510 

• Remember the importance of helping clients 

feel safe physically and emotionally. 

- Trauma and abuse can occur at any point 

in a person’s life. Suicide also can occur in 

older people. Before assessing for depression 

and PTSD, make sure you have a safety 

plan in place. This will help you respond 

appropriately to any client’s reports of abuse 

and self-harm. 

- Keeping your clients safe isn’t just the right 

thing to do—it’s the law. Make sure you know 

your state’s laws about responding to reports 

of abuse and self-harm. 

The co-occurrence of a mental disorder and SUD 

can make treatment diffcult and is associated 

with negative events. In older adults, such events 

include increased mortality, an increased chance 

of experiencing harmful medication–substance 

interactions, the co-occurrence of complex 

medical conditions (like dementia), and an 

increased risk of suicide.511 Be sure to ask clients 

about psychosocial symptoms they have during 

periods of substance misuse and abstinence. 

68 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

Social history 

Learning about a client’s social environment 

and relationships can guide you in treatment 

planning. That is because social factors can affect 

whether a client stays in treatment or leaves 

treatment early, as well as treatment outcomes. 

Valuable information about the social environment 

includes the client’s: 

• Transportation. 

• Caregiver needs. 

• Caregiving responsibilities (e.g., whether the 

client cares for a child or other dependent). 

• Cohabitating status (i.e., living alone versus with 

someone). 

• Regular access to safe, secure, and stable 

housing. 

• Criminal justice involvement. 

• Employment status and quality of work setting. 

• Relationships with family, friends, or close others 

who themselves use substances. (Get the client’s 

consent before speaking to any of these people 

directly.) 

• Sexual orientation, identity, and history, 

including risk factors for HIV and sexually 

transmitted infections. 

• Level of safety at home, especially in terms of 

potential for violence. Note that substance use 

greatly increases the risk of intimate partner 

violence. Screen all women who seek SUD 

treatment for intimate partner abuse, regardless 

of their age.512 Substance use increases the 

risk of abuse toward older adults,513 and 

experiencing elder abuse can contribute to 

substance misuse among older adults. If you 

suspect an older adult is misusing substances, 

screen for elder abuse. 

Family history 

Family can play a major role in whether a 

person is at risk for substance misuse. Always 

ask clients about the substance use histories 

of their parents, siblings, and partners. Familyrelated factors that can increase the risk of having 

substance misuse include:514,515 

• Genetic factors. 

• The home environment in which a person was 

raised—specifcally, whether the client was 

exposed to substance use in the household 

during childhood. 

• Having a frst-degree relative (i.e., a parent, 

child, sister, or brother) who misuses substances. 

For instance, a person has fve times the risk 

of developing alcohol dependence if he or 

she has any frst-degree relative with alcohol 

dependence.516 The client’s misuse may have a 

basis in genetic factors, modeling of behavior of 

others, or both. 

• Having negative or low-quality parent–child 

relationships in adolescence that were 

unsupportive and featured a lot of arguing or 

fghting.517 

Activities of Everyday Living 

As people age, many sooner or later have 

problems completing everyday tasks on their 

own, like bathing, cooking, shopping, and driving. 

Substance misuse can make everyday living even 

more diffcult, including ADLs and instrumental 

activities of daily living (IADLs). ADLs are basic 

everyday tasks like dressing, using the toilet, using 

the phone, and feeding oneself. IADLs are more 

complex tasks that need more skills to complete. 

They include balancing a checkbook, shopping, 

cooking, and driving. As part of assessing 

substance misuse, measure clients’ ability to 

complete ADLs and IADLs without help. This will 

paint a full picture of the effects of substance 

misuse. 

Katz Index of Independence in Activities of 

Daily Living 

The Katz Index of Independence in Activities 

of Daily Living (Katz ADL; see the Chapter 3 

Appendix)518 is one of the most commonly used 

measures of ADLs. It assesses performance in six 

areas: bathing, dressing, toileting, transferring, 

continence, and feeding. 

Chapter 3 69 
TIP 26

Barthel Index 

Like the Katz ADL, the Barthel Index is a brief, 

widely used screener for ADLs.519,520 It measures a 

person’s ability to perform the following: feeding, 

bathing, grooming, dressing, toileting, controlling 

bladder and bowels, transfers, mobility, and using 

the stairs. Unlike the Katz ADL, the Barthel Index 

collects information from three sources—clients, 

their caregivers, and direct observation—to see 

whether older adults can complete activities 

without help. 

Functional Activities Questionnaire 

The Functional Activities Questionnaire is a 

measure of IADLs.521,522 It is completed by a person 

(usually an adult family member) who knows the 

client well, has seen the client’s behavior, and can 

assess the client’s ability to complete IADLs and 

how much assistance the client needs to complete 

them, if any. 

Fall Risk Assessment 

Older people are at an increased risk of falling, 

and substance misuse can increase this risk. 

Falling is the number one cause of injury among 

people ages 65 and older.523 Each year, more 

than 800,000 adults are hospitalized for a fall.524 

Between 30 and 40 percent of adults in the 

community (that is, not in a hospital) ages 65 and 

older fall at least once each year. In 2014 alone, 

older Americans had approximately 29 million 

falls, which resulted in roughly 7 million injuries.525 

Falls are not only potentially dangerous, they can 

be expensive as well. The direct cost of care for 

nonfatal fall-related injuries in older adults in the 

United States is estimated to be more than $31 

billion a year.526 

Physical and mental conditions (including substance 

misuse) that can increase an older person’s fall risk 

include:527,528,529,530,531,532 

• Dementia. 

• Delirium. 

• Cognitive problems in general. 

• Depression. 

• Poor sleep. 

Treating Substance Use Disorder in Older Adults 

• Use of multiple medications, especially 

antidepressants. 

• Benzodiazepine use. 

• Excessive alcohol use. 

How do you know which client does and does 

not need a fall assessment? The American 

Geriatrics Society and the British Geriatrics 

Society533 suggest you ask yourself three simple 

questions: 

• Has the client had two or more falls in the past 

year? 

• Has the client had a recent fall? 

• Does the client have trouble with walking or 

balance? 

If you answered “yes” to any of these questions, 

you may want to assess the client for fall risk. 

Timed Up & Go Test 

The CDC’s Timed Up & Go is one of the easiest 

ways to assess a client’s fall risk. This test measures 

a person’s ability to stand from a sitting position, 

walk a short distance (10 feet), turn around, and 

walk back to where the individual was sitting. 

Instructions for how to give the Timed Up & Go 

are available online (www.cdc.gov/steadi/pdf/ 

TUG_Test-print.pdf). 

Determining Diagnosis and Severity 

of an SUD 

Because diagnosing SUDs in older adults differs 

from diagnosing SUDs in younger adults, try: 

• Using DSM-5 criteria to make an SUD 

diagnosis.534 Using an SUD assessment 

instrument based on DSM-5 criteria will improve 

diagnostic accuracy. However, not all DSM-5 

diagnostic criteria apply to older adults. Always 

use clinical judgment when making an SUD 

diagnosis. 

• Using diagnostic decision trees made specifcally 

for SUD in older clients. 

• Making a treatment plan only after getting a 

positive substance misuse screen, completing a 

full assessment, and making a diagnosis of SUD. 

70 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

• Knowing how to keep older adults interested 

and willing participants in the screening and 

assessment process (e.g., knowing what to say 

to older clients and how to say it). 

If diagnostic criteria are met, also fnd out the 

severity of the diagnosis. You can do this by 

counting the number of DSM-5 SUD criteria met by 

the client’s symptoms.535 

• A mild SUD is present when 2 or 3 of the 11 

SUD diagnostic criteria are met. 

• A moderate SUD is present when 4 or 5 criteria 

are met. 

• A severe SUD is present when 6 or more criteria 

are met. 

Keep in mind that DSM-5 criteria should be 

interpreted in an age-appropriate manner. 

(See Chapter 4 for examples of how DSM-5 

criteria for AUD might not be age appropriate.) 

For instance, tolerance is a DSM-5 criterion for 

an SUD diagnosis. But older people are more 

likely to achieve tolerance faster and on smaller 

amounts of the substance than younger adults. 

Therefore, tolerance in an older individual does not 

necessarily mean that they are dependent on the 

substance. Also remember that symptoms of SUDs 

are often the same as symptoms of other physical 

diseases and mental disorders. You must rule out 

these other mental and physical disorders before 

making an SUD diagnosis. 

Remember that not every addiction treatment 

provider is qualifed to make a mental disorder 

diagnosis. If you do not have the training and 

licensure to make diagnoses, send the client 

to another provider in your program who can. 

If no one in your program has the required 

qualifcations, refer the client to another program 

that does. Integrated programs can be particularly 

effective at meeting older adults’ full range of 

biopsychosocial needs and may be a suitable 

referral option. When possible, help facilitate these 

referrals by offering a “warm handoff” of clients 

to the referred provider, which helps ensure that 

clients are able to successfully access mental health 

services. 

Treatment Planning, Referrals, 

and Treatments 

Treatment Planning 

Treatment planning includes preparing to 

provide treatment or refer to the most 

appropriate treatment provider. You should start 

with treatment planning, and then either give the 

treatment or refer to an outside provider if your 

program cannot provide the services or level of 

care the client needs. Although rare, age-specifc 

treatment settings and programs may provide the 

most effective care for older clients. 

The foundation of treatment planning is 

individualized assessment. This should be done 

systematically with a tool such as the Level of Care 

Utilization System for Psychiatric and Addiction 

Services (LOCUS 20).536 LOCUS allows the user to 

characterize the following dimensions based on 

client strengths, challenges, resources, and risks 

and produce a specifc rating: 

• Risk of Harm 

• Functional Status 

• Medical, Addictive and Psychiatric Co-Morbidity 

• Recovery Environment both in terms of level of 

stress and level of support 

• Treatment and Recovery History 

• Engagement and Recovery Status 

For older adults, be sure to think also about agerelated factors when making decisions about where 

to place the client for treatment. For example, if 

a client uses a wheelchair, you will want to select 

a treatment setting that the individual can access. 

Clients who are Deaf or Hard of Hearing may need 

individual therapy, small-group therapy tailored to 

their hearing needs, or both. LOCUS 20 describes 

six broadly defned levels of care and provides 

a decision tree and grid to help you map the 

multidimensional assessment of the client to the 

level of care most likely to meet their needs. The 

six levels of care are: 

Chapter 3 71 
TIP 26 Treating Substance Use Disorder in Older Adults 

• Recovery Maintenance/Health Management. 

• Low Intensity Community Based Services. 

• High Intensity Community Based Services. 

• Medically Monitored Non-Residential Services. 

• Medically Monitored Residential Services. 

• Medically Managed Residential Services. 

The LOCUS 20 tool can be downloaded for free 

from www.communitypsychiatry.org/resources/ 

locus. 

Using Shared Decision Making 

Shared decision making helps people who are 

receiving treatment for or in recovery from an SUD 

feel more involved in their own care. Decision 

making should involve the client in determining 

preferences for treatment. Statements like those 

below can help clients participate in the shared 

decision-making process: 

• “I want to work with you to fnd the best 

treatment setting possible for you and your 

needs.” 

• “Let’s see what your spouse and brother think 

about these treatment options.” (Be sure to get 

the client’s consent before speaking with family.) 

• “Let’s review your smoking cessation options 

so that you know everything that is available to 

you.” 

• “Many people do not understand what 

‘intensive outpatient addiction treatment’ 

means. Let’s talk about that so I can clear up any 

misunderstandings and answer any questions 

you might have.” 

• “You said you would like to hear more about 

inpatient detoxifcation. Let me review with you 

the admission requirements so we can fgure out 

whether this type of setting is best for you.” 

• “I know we talked about many treatment 

options today. Why don’t you tell me what you 

think would be the best ft, and then I can share 

with you my thoughts about the best option. I’ll 

bet we can fnd something we both agree on.” 

When cognitive impairment is present, you 

may need to adapt these statements to elicit 

an older adult’s feedback. Nonetheless, best 

practices suggest that service providers, healthcare 

professionals, and guardians maximize each 

individual’s input in the healthcare decision-making 

process.537,538 

Research supports involving clients with SUDs 

in treatment decision-making processes.539 In 

some cases, matching clients’ substance-related 

treatment preferences has led to improved 

outcomes.540 However, shared decision making in 

the context of SUDs can be challenging. Clients 

who have SUDs may have mixed feelings about 

whether they can, or even want to, stop using 

substances. This is where MI can be a useful tool. 

MI 

Motivational interviewing is a client-centered 

approach to treatment planning that can be used 

with shared decision making. Combined, these 

methods can help clients feel confdent in their 

treatment decisions and ability to change their 

substance misuse.541 

MI has been reported to be effective for people 

with many different health conditions, including 

SUDs.542 It has been used successfully with older 

adults to help improve physical health and healthrelated behaviors (e.g., weight loss, exercise) as 

well as substance misuse (including alcohol misuse 

and tobacco use).543 MI can help clients:544 

• Address any mixed feelings they have about 

entering treatment. 

• Explore their thoughts about changing their 

behaviors, such as cutting down on alcohol use 

or monitoring their prescription medication 

intake. 

• Develop personal and meaningful reasons for 

wanting to change their behaviors. 

• Create an action plan for how they will change 

their behaviors. 

Referrals 

If your program cannot offer treatment for SUDs, 

refer your clients to counseling and tailored 

psychosocial supports that have the capacity 

to meet older adults’ unique needs. You should 

refer to the level of care that is the least intense 

yet will address all the client’s needs. The following 

paragraphs describe several options. 

72 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

A safe withdrawal is the frst order of business. 

If detoxifcation is needed, that will be the frst 

referral indicated, whether inpatient or outpatient. 

Develop a plan for seamless transitions between 

services and warm patient handoffs. 

Refer for SUD treatment and mental health 

services as needed. You may need to refer the 

client to an outside provider for SUD treatment 

if your setting cannot offer the level of care or 

types of services the client’s symptoms warrant. 

For example, a client may need inpatient drug and 

alcohol rehabilitation, but your program only offers 

outpatient care. 

Referral to mental health services is appropriate 

if the severity or type of mental illness is beyond 

what you can treat. Clients with depression, PTSD, 

or other mental disorders may be more likely to 

succeed in addiction treatment if those conditions 

are managed. 

When considering referral for treatment, 

frst consider the client’s thinking abilities. 

Problems with thinking could affect a client’s 

ability to participate in treatment. The client 

might need a treatment provider who has 

experience working with older clients with 

cognitive problems. Individual treatment rather 

than group treatment might also be a better 

choice. 

Even if you refer to formal SUD treatment 

elsewhere, you can still support the client. Follow 

up with him or her by periodically asking about 

current substance use and progress in treatment. 

Use these questions as an opportunity to identify 

clients at risk for relapse while offering positive 

reinforcement in a warm and nonjudgmental 

manner. Addiction treatment providers can also 

provide ongoing support and encouragement 

to older clients who enter the formal treatment 

system by: 

• Learning about treatment resources in the 

community that offer appropriate services. 

(See “Resource Alert: Making the Most of Your 

Referral Resources.”) 

• Keeping in touch with the client’s specifc 

treatment program. This can help you make 

sure the program is offering appropriate care. 

It will also help you understand the approach 

and services the program offers so you can 

appropriately refer future clients there. 

• Asking the treatment program to share with you, 

from time to time, reports about the treatment 

plan and how the client is doing in treatment. 

(Get the client’s written permission before doing 

so.) 

• Stressing the importance of continuing with 

treatment when discussing progress with the 

client. 

Make referrals to medical services that provide 

respectful, consistent physical health care. This 

can help clients recover from substance misuse. 

As with any client, you should make appropriate 

referrals for medical care that is beyond what your 

practice setting offers. 

Make referrals to mutual-help groups for clients 

who wish to join such groups in addition to receiving 

addiction treatment or mental health services. 

These programs can offer clients social support 

and encouragement to help them avoid substance 

misuse. (See “Mutual-Help Programs” below.) 

Make referrals to additional services that meet 

clients’ needs. In addition to SUD treatment, mental 

health, and medical services, older adults who have 

SUDs may need additional support in certain areas. 

They may beneft from help in areas like: 

• Case management. 

• Food access. 

• Housing. 

• Transportation. 

• Legal assistance. 

• In-home services and supports to facilitate 

completing ADLs and IADLs. 

• Insurance-related needs (e.g., assistance 

enrolling in Medicare, Medicaid, or both). 

Chapter 3 73 
TIP 26 Treating Substance Use Disorder in Older Adults 

RESOURCE ALERT: MAKING THE MOST OF YOUR REFERRAL RESOURCES 

Having a collection of substance-related treatment referral resources on hand will help you give clients 

more options and better access to care. Ask yourself the following questions to help make the most of the 

available referral resources. 

What specialized SUD treatment programs are in my community? 

Most communities have a public or private agency that keeps a directory of SUD treatment programs. This 

directory can give useful information about program facilities (e.g., type, location, hours, accessibility to 

public transportation), services, eligibility criteria, cost, and staff experience, including languages spoken. 

Each state also has a single state-level alcohol and drug agency that oversees the licensing and program 

review for all SUD treatment programs in that state. This agency often offers a statewide directory of all SUD 

treatment programs licensed in the state. 

• You can fnd SUD treatment facilities by using https://fndtreatment.gov/. 

• SAMHSA offers a Behavioral Health Treatment Services Locator (https://fndtreatment.samhsa.gov/) and 

a National Directory of Drug and Alcohol Abuse Treatment Facilities (https://www.samhsa.gov/data/sites/ 

default/fles/reports/rpt23267/National_Directory_SA_facilities.pdf). 

Who are my local resources and points of contact? Reach out to local resources and introduce yourself. 

Learn what services they offer. This will help you get clients into the system of care more quickly. 

What mutual-help groups are in my community? What do they offer older clients specifcally? Keep on 

hand names of mutual-help groups that can meet older clients’ age-related needs. For instance, Seniors In 

Sobriety (SIS) (www.seniorsinsobriety.com) is a part of Alcoholics Anonymous (AA). SIS maintains an online 

list of SIS and senior-friendly AA meetings in several states (http://www.seniorsinsobriety.com/wp-content/ 

uploads/2019/03/SISMeetings-Mar2019.pdf). 

Treatments 

Older adults can and do beneft from SUD 

treatment, although less is known about what 

works for older adults than for other age groups.545 

Older adults who get SUD treatment may 

show the same levels of abstinence as younger 

adults.546 In some cases, older adults have had 

even more success than younger adults.547,548 

More treatment (e.g., more outpatient sessions, 

longer inpatient stays) can improve older adults’ 

treatment outcomes. 

Mental Health Services 

A range of mental health interventions exist for 

older adults who misuse substances. Effective 

psychosocial treatments and levels of care that 

have worked for older clients include:549,550,551,552 

• Motivational enhancement. 

• Cognitive–behavioral therapy. 

• Individual and group therapy. 

• Supportive therapy. 

• Pharmacological treatments. 

• Couples and family therapy. 

• Brief advice or targeted education. 

• Telephone-based brief interventions. 

• Relationship enhancement therapy. 

• Case management. 

• Outpatient treatment. 

• Inpatient treatment. 

Many of these treatments can also address 

MDD, PTSD, and other CODs in older clients 

who misuse substances. To get the best results, 

recommend mental health services that meet older 

adults’ special needs. Age-related needs often 

relate to the unique stressors and life events, like 

retirement, death of a signifcant individual, or 

moving into a nursing home, that older adults are 

likely to experience. 

74 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

Mutual-Help Programs 

Well-known mutual-help programs include the 

12-Step programs AA and Narcotics Anonymous. 

Many other peer-recovery support groups are 

available as well, like: 

• Women for Sobriety. 

• SMART (Self-Management and Recovery 

Training) Recovery. 

• LifeRing Secular Recovery. 

• Secular Organizations for Sobriety/Save Our 

Selves. 

• Celebrate Recovery. 

• Double Trouble in Recovery (for people with 

CODs). 

• Dual Recovery Anonymous (for people with 

CODs). 

Mutual-help programs offer older adults a 

network of peers with whom they can relate. 

These groups help older adults share common 

experiences in substance misuse and recovery. 

Mutual-help programs also help keep clients 

socially active and reduce loneliness. These groups 

and their availability vary greatly in various parts 

of the county. Some will not be available in many 

localities, but online and telephone meetings may 

be available. 

Finding local mutual-help programs that are only 

for older adults can be diffcult. Instead, try to 

fnd local groups that are open to adjusting their 

sessions toward older clients and their needs 

(e.g., using a slower pace, being willing to discuss 

life-stage changes and loss). You should also 

look for local groups that already have older-age 

attendees.553 

RESOURCE ALERT: AA AND 

OLDER ADULTS 

AA offers a large-print handout for older adults 

interested in attending an AA meeting. This 

handout is titled A.A. for the Older Alcoholic— 

Never Too Late. Consider sharing this with older 

clients who misuse alcohol and express an 

interest in learning more about 12-Step programs. 

(Available at www.aa.org/assets/en_US/p-22_ 

AAfortheOlderAA.pdf) 

Summary 

A well-thought-out approach to comprehensive 

screening and assessment will help you identify 

older adults with or at risk for substance misuse 

and related conditions. This is an important step 

in making sure clients get the right diagnosis 

and timely treatment (or treatment referral). The 

many screening tools approved for use with older 

adults can help you detect substance misuse. In 

addition, numerous measures can help you identify 

conditions common in older people with substance 

misuse. These conditions include problems with 

thinking, depression, anxiety, PTSD, elder abuse, 

sleep problems, chronic pain, struggles with 

ADLs, and risk of falling. Indepth assessments 

allow you to better understand the full range of 

factors in clients’ substance misuse. Screening and 

assessment results contribute to client-centered 

care by helping you offer treatment options that 

meet clients’ individual symptoms, risk factors, 

treatment needs, and treatment preferences. 

Remember that a wide range of providers in 

many different settings can be involved in helping 

to identify, screen, and assess older clients for 

substance misuse. There’s no “wrong door” 

through which older adults can receive a diagnosis 

and the treatment they need. 

Chapter 3 75 
TIP 26

Chapter 3 Resources 

Alcohol and Drug Use Screening 

National Institute on Alcohol Abuse and 

Alcoholism (NIAAA)—Professional Education 

Materials (www.niaaa.nih.gov/publications/ 

clinical-guides-and-manuals): NIAAA offers links 

to screening, treatment planning, and general 

information for clinicians in outpatient programs. 

NIDA—NIDAMED: Clinical Resources (www. 

drugabuse.gov/nidamed-medical-healthprofessionals): This webpage offers resources for 

healthcare professionals on the effects of substance 

misuse on clients’ health and on ways to identify 

substance use early and prevent it from turning 

into misuse. 

Tobacco Screening and Cessation 

Agency for Healthcare Research and Quality—Five 

Major Steps to Intervention (www.ahrq.gov/ 

prevention/guidelines/tobacco/5steps.html): The 

agency provides guidance to clinicians for using 

the “5 A’s” approach (Ask, Advise, Assess, Assist, 

Arrange) for determining whether clients are ready 

and willing to quit tobacco use. 

CDC—Smoking & Tobacco Use (www.cdc.gov/ 

tobacco/index.htm): CDC offers resources and 

information for clients and clinicians, including links 

to factsheets, tobacco prevention and control data, 

and clinical tools. 

HHS—BeTobaccoFree.gov (https://betobaccofree. 

hhs.gov/): People with nicotine addiction can use 

this website to connect with counselors, get free 

text messages supporting their efforts to quit, and 

download smartphone apps to help them stay 

smoke free. The site also links to federal reports and 

research on tobacco use. 

HHS—Million Hearts Initiative: Tobacco Use 

(https://millionhearts.hhs.gov/tools-protocols/tools/ 

tobacco-use.html): Providers can use the tools on this 

webpage to improve the tobacco use interventions 

they undertake as part of clinical care. 

MaineHealth Center for Tobacco Independence— 

Provider Tobacco Treatment Tools (https://ctimaine. 

org/resources/provider-tools/): The center makes 

available the Fagerström screening tools for nicotine 

dependence, including dependence on smokeless 

Treating Substance Use Disorder in Older Adults 

tobacco. The center’s webpage also includes other 

assessment tools, motivational documents, and 

information on tobacco treatment medications and 

treatment in group settings. 

University of California, San Francisco Smoking 

Cessation Leadership Center—Toolkits (https:// 

smokingcessationleadership.ucsf.edu/resources/ 

toolkits): This webpage has downloadable provider 

toolkits on tobacco screening and cessation from 

a variety of sources, including the American Lung 

Association and CDC. 

Referral and Treatment Locators 

FindTreatment.gov (https://fndtreatment.gov): 

People seeking treatment for SUDs can use this 

federal locator maintained by SAMHSA to fnd 

treatment facilities based on location, availability 

of treatment for co-occurring mental disorders, 

availability of telemedicine care, payment option, 

age, languages spoken, and access to medication 

for OUD. The site also links to information on 

understanding addiction, understanding mental 

illness, and paying for treatment. 

SAMHSA—Behavioral Health Treatment 

Services Locator (https://fndtreatment.samhsa. 

gov): SAMHSA offers people seeking treatment 

for addiction or mental illness a confdential, 

anonymous information source about treatment 

facilities in the United States and U.S. Territories. 

SAMHSA—Opioid Treatment Program Directory 

(https://dpt2.samhsa.gov/treatment/directory. 

aspx): SAMHSA provides a state-by-state directory 

of opioid treatment programs. 

SAMHSA—Your Recovery Is Important: Virtual 

Recovery Resources (www.samhsa.gov/sites/ 

default/fles/virtual-recovery-resources.pdf): This 

listing of virtual recovery resources includes mutualhelp groups with online meetings. 

Treatment Planning 

SAMHSA—Decisions in Recovery: Treatment 

for Opioid Use Disorder (https://mat-decisionsin-recovery.samhsa.gov/): People with opioid use 

disorder can use this website’s interactive tool to 

make informed decisions about their care. The site 

also includes links to a video library, recovery tools, 

and other recovery-related resources. 

76 Chapter 3 
TIP 26

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chapter 3—Identifying, Screening for, and Assessing Substance Misuse 

Chapter 3 Appendix 

Alcohol Use Disorders Identifcation Test (AUDIT): Interview Version 

Read questions as written. Record answers carefully. Begin the AUDIT by saying “Now I am going to ask 

you some questions about your use of alcoholic beverages during this past year.” Explain what is meant by 

“alcoholic beverages” by using local examples of beer, wine, vodka, etc. Code answers in terms of “standard 

drinks.” Place the correct answer number in the box at the right. 

1. How often do you have a drink containing 

alcohol? 

(0) Never [Skip to Qs 9-10] 

(1) Monthly or less 

(2) 2 to 4 times a month 

(3) 2 to 3 times a week 

(4) 4 or more times a week 

6. How often during the last year have you needed a frst drink in the morning to get yourself 

going after a heavy drinking session? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

2. How many drinks containing alcohol do you 

have on a typical day when you are drinking? 

(0) 1 or 2 

(1) 3 or 4 

(2) 5 or 6 

(3) 7, 8, or 9 

(4) 10 or more 

7. How often during the last year have you had 

a feeling of guilt or remorse after drinking? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

3. How often do you have six or more drinks on 

one occasion? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

Skip to Questions 9 and 10 if Total Score 

for Questions 2 and 3 = 0 

8. How often during the last year have you been 

unable to remember what happened the 

night before because you had been drinking? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

4. How often during the last year have you 

found that you were not able to stop 

drinking once you had started? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

9. Have you or someone else been injured as a 

result of your drinking? 

(0) No 

(2) Yes, but not in the last year 

(4) Yes, during the last year 

5. How often during the last year have you 

failed to do what was normally expected 

from you because of drinking? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

10. Has a relative or friend or a doctor or 

another health worker been concerned 

about your drinking or suggested you 

cut down? 

(0) No 

(2) Yes, but not in the last year 

(4) Yes, during the last year 

Record total of specifc items here 

Scoring: The cutoff score indicating hazardous and harmful alcohol use for the AUDIT is generally 8; however, for older 

adults a score of 5 indicates a need for clarifying questions and further assessment.554 

Adapted from Barbor et al. (2001).555 

Chapter 3 77 
TIP 26 Treating Substance Use Disorder in Older Adults 

Alcohol Use Disorders Identifcation Test-C (AUDIT-C) 

Patient Name: ___________________________________________________________ Date: ______________________ 

1. Ho

□

w often do you have a drink containing alcohol?

a. Never 

□ b. Monthly or less 

□ c. 2-4 times a month 

□ d. 2-3 times a week 

□ e. 4 or more times a week 

2. How many drinks containing alcohol did you have on a typical day when you were drinking in 

th

□

e past year?

a. 0 drinks 

□ b. 1 or 2 

□ c. 3 or 4 

□ d. 5 or 6 

□ e. 7 to 9 

□ f. 10 or more 

3. 

□

How often do you have six or more drinks on one occasion?

a. Never 

□ b. Less than monthly 

□ c. Monthly 

□ d. Weekly 

□ e. Daily or almost daily 

The AUDIT-C is a much shorter version of the AUDIT that can help you identify alcohol misuse in your 

clients. It contains only three questions, which add up to a total score of 0–12. A higher score usually 

means the client is engaging in more hazardous alcohol use. The AUDIT-C is scored as follows: 

• For Questions 1 and 3, assign 0 points to response a, 1 point to response b, 2 points to response c, 3 

points to response d, and 4 points to response e. 

• For Question 2, assign 0 points to responses a and b, 1 point to response c, 2 points to response d, 3 

points to response e, and 4 points to response f. 

A total score of 3 or higher for women and 4 or higher for men means problematic alcohol use. In such 

cases, you should assess further (or refer for formal assessment) to learn more about the client’s drinking 

habits and determine whether AUD is present. Learn more about the AUDIT-C, including how to score 

and interpret results, at www.queri.research.va.gov/tools/alcohol-misuse/alcohol-faqs.cfm#top. 

Adapted from material in the public domain.556,557 

78 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G) 

Yes (1) No (0) 

1. When talking with others, do you ever underestimate how much you drink? 

2. After a few drinks, have you sometimes not eaten or been able to skip a meal 

because you didn’t feel hungry? 

3. Does having a few drinks help decrease your shakiness or tremors? 

4. Does alcohol sometimes make it hard for you to remember parts of the day or night? 

5. Do you usually take a drink to relax or calm your nerves? 

6. Do you drink to take your mind off your problems? 

7. Have you ever increased your drinking after experiencing a loss in your life? 

8. Has a doctor or nurse ever said they were worried or concerned about your drinking? 

9. Have you ever made rules to manage your drinking? 

10. When you feel lonely, does having a drink help? 

TOTAL SMAST-G-SCORE (0-10) _________ 

SCORING: 2 OR MORE “YES” RESPONSES IS INDICATIVE OF AN ALCOHOL PROBLEM. 

Ask the extra question below but do not calculate it in the fnal score. 

Extra question: Do you drink alcohol and take mood or mind-altering drugs, including prescription 

tranquilizers, prescription sleeping pills, prescription pain pills, or any illicit drugs? 

© The Regents of the University of Michigan, 1991. Source: University of Michigan Alcohol Research 

Center.558 Adapted with permission. 

Chapter 3 79 
TIP 26

 

Treating Substance Use Disorder in Older Adults 

Senior Alcohol Misuse Indicator (SAMI) 

1a. Have you recently (in the last few months) experienced problems with any of the following

 (if yes, please check box): 

Changes in sleep? Changes in appetite or weight? Dizziness? 

Drowsiness? Diffculty remembering things? Poor balance? 

Falls? 

1b. Have you recently (in the last few months) experienced problems with any of the following 

(if yes, please check box): 

Feelings of sadness? Lack of interest in daily activities? Feelings of 

worthlessness? Loneliness? Feelings of anxiety? 

2. Do you enjoy wine/beer/spirits? Which do you prefer? 

3. As your life has changed, how has your use of [selected] wine/beer/spirits changed? 

4. Do you fnd you enjoy [selected] wine/beer/spirits as much as you used to? 

(For clinical use. Not included in scoring.) Yes No 

5. You mentioned that you have diffculties with_______________ (from answers to questions 1a and b). 

I am wondering if you think that [selected] wine/beer/spirits might be connected? Yes No 

SCORING KEY 

Single responses (a score of 1 for each response): Multiple responses (a score of 1 for each 

combination of responses): 

Question 2: 

Question 2 & 3: I enjoy all three of wine/beer/spirits OR 

Yes, I do enjoy alcohol I enjoy a combination of any two There has been no change in alcohol consumption from wine/beer/spirits 

=> If both responses provided, check box => 

Question 3: 

Question 1, 2 & 3: I have increased alcohol consumption 

Yes, I have experienced 5 or more symptoms from when I was younger 

Yes, I do enjoy alcohol 

Question 5: Indicates any current alcohol consumption Yes, there may be a connection between (regardless of any change in pattern) my alcohol use and health => If all three responses provided, check box => 

SUBTOTAL 1 = ____________ /3 SUBTOTAL 2 = ____________ /2 

TOTAL SCORE = SUBTOTAL 1 + SUBTOTAL 2 = ________________ 

Developed by B. Purcell. © Centre for Addiction and Mental Health, 2003. The Senior Alcohol Misuse Indicator is licensed 

for reuse under the terms of Creative Commons Attribution-NonCommercial-NoDerivs CC BY-NC-ND.559 

80 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

Cannabis Use Disorder Identifcation Test-Revised (CUDIT-R) 

Reprinted from material in the public domain.560 

Chapter 3 81 
TIP 26 Treating Substance Use Disorder in Older Adults 

Penn State Worry Questionnaire (PSWQ) 

Instructions: Rate each of the following statements on a scale of 1 (“not at all typical of me”) to 5 (“very 

typical of me”). Please do not leave any items blank. 

Not at Very 

all typical typical 

of me of me 

1. If I do not have enough time to do everything, 

I do not worry about it. 1 2 3 4 5 

2. My worries overwhelm me. 1 2 3 4 5 

3. I do not tend to worry about things. 1 2 3 4 5 

4. Many situations make me worry. 1 2 3 4 5 

5. I know I should not worry about things, but 

I just cannot help it. 1 2 3 4 5 

6. When I am under pressure I worry a lot. 1 2 3 4 5 

7. I am always worrying about something. 1 2 3 4 5 

8. I fnd it easy to dismiss worrisome thoughts. 1 2 3 4 5 

9. As soon as I fnish one task, I start to worry 

about everything else I have to do. 1 2 3 4 5 

10. I never worry about anything. 1 2 3 4 5 

11. When there is nothing more I can do about a 

concern, I do not worry about it anymore. 1 2 3 4 5 

12. I have been a worrier all my life. 1 2 3 4 5 

13. I notice that I have been worrying about things. 1 2 3 4 5 

14. Once I start worrying, I cannot stop. 1 2 3 4 5 

15. I worry all the time. 1 2 3 4 5 

16. I worry about projects until they are all done. 1 2 3 4 5 

Developed by Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. Reproduced under the terms of the Creative 

Commons Attribution-NonCommercial 3.0 license (https://creativecommons.org/licenses/by-nc/3.0).561 

Scoring: Each of the 16 items is rated on a 5-point scale. Items 1, 3, 8, 10, and 11 are reverse scored as follows: 

• Very typical of me = 1 (circled 5 on the sheet) 

• Circled 4 on the sheet = 2 

• Circled 3 on the sheet = 3 

• Circled 2 on the sheet = 4 

• Not at all typical of me = 5 (circled 1 on the sheet) 

The remaining items are scored regularly. The item scores are added to produce a total score ranging from 16 to 

80, with higher scores refecting more worry. A score of 50 or higher by an older person could mean signifcant 

worries are present, but research on cutoff scores in older people is too limited to know for certain.562 Do not assume 

that an older client who scores below 50 does not have anxiety. 

82 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) 

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. 

For example: 

• a serious accident or fre 

• a physical or sexual assault or abuse 

• an earthquake or food 

• a war 

• seeing someone be killed or seriously injured 

• having a loved one die through homicide or suicide. 

Have you ever experienced this kind of event? 

YES NO 

If no, screen total = 0. Please stop here. 

If yes, please answer the questions below. 

In the past month, have you... 

1. had nightmares about the event(s) or thought about the event(s) when you did not want to? 

YES NO 

2. tried hard not to think about the event(s) or went out of your way to avoid situaitons that reminded 

you of the event(s)? 

YES NO 

3. been constantly on guard, watchful, or easily startled? 

YES NO 

4. felt numb or detached from people, activities, or your surroundings? 

YES NO 

5. felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) 

may have caused? 

YES NO 

Reprinted from material in the public domain.563 This tool and additional information on it can be found online (www. 

ptsd.va.gov/professional/assessment/documents/pc-ptsd5-screen.pdf). 

Scoring: A score of 3 or more “yes” responses is considered positive.564 

Chapter 3 83 
TIP 26 Treating Substance Use Disorder in Older Adults 

Elder Abuse Suspicion Index© (EASI©) 

EASI© Questions 

Q.1-Q.5 asked of patient; Q.6 answered by doctor 

(Within the last 12 months) 

1) Have you relied on people for any of the following: 

bathing, dressing, shopping, banking, or meals? YES NO Did not 

answer 

2) Has anyone prevented you from getting food, clothes, 

medication, glasses, hearing aids or medical care, or 

from being with people you wanted to be with? 

YES NO Did not 

answer 

3) Have you been upset because someone talked to you in 

a way that made you feel shamed or threatened? YES NO Did not 

answer 

4) Has anyone tried to force you to sign papers or to use 

your money against your will? YES NO Did not 

answer 

5) Has anyone made you afraid, touched you in ways that 

you did not want, or hurt you physically? YES NO Did not 

answer 

6) Doctor: Elder abuse may be associated with findings 

such as: poor eye contact, withdrawn nature, 

malnourishment, hygiene issues, cuts, bruises, 

inappropriate clothing, or medication compliance 

issues. Did you notice any of these today or in the last 

12 months?

YES NO Not sure 

Reprinted with permission. Yaffe MJ, Wolfson C, Weiss D, Lithwick M. Development and validation of a tool to assist 

physicians’ identifcation of elder abuse: The Elder Abuse Suspicion Index (EASI©). Journal of Elder Abuse and Neglect, 

2008; 20 (3): 276-300. This tool is available online (www.mcgill.ca/familymed/research/projects/elder). 

Mark J. Yaffe, MD, McGill University, Montreal, Canada, mark.yaffe@mcgill.ca 

Maxine Lithwick, MSW, CSSS Cavendish, Montreal, Canada, maxine.lithwick.cvd@ssss.gouv.qc.ca 

Christina Wolfson, PhD, McGill University, Montreal, Canada, christina.wolfson@mcgill.ca 

84 Chapter 3 
Chapter 3—Identifying, Screening for, and Assessing Substance Misuse TIP 26

Revised Iowa Pain Thermometer (IPT-R) 

Revised Iowa Pain Thermometer (IPT-R, 2011) printed with permission. © Keela Herr, The University of Iowa.565 

Revised Faces Pain Scale 

In the following instructions, say “hurt” or “pain,” whichever seems right for a particular client. “These 

faces show how much something can hurt. This face [point to face on far left] shows no pain. The faces 

show more and more pain [point to each from left to right] up to this one [point to face on far right]—it 

shows very much pain. Point to the face that shows how much you hurt [right now].” 

Score the chosen face 0, 2, 4, 6, 8, or 10, counting left to right. Therefore, “0” = “no pain” and “10” = 

“very much pain.” Do not use words like “happy” or “sad.” This scale is intended to measure how a client 

feels inside, not how his or her face looks. 

Faces Pain Scale – Revised, ©2001, International Association for the Study of Pain [ www.iasp-pain.org/FPSR ] 

Chapter 3 85 
TIP 26 Treating Substance Use Disorder in Older Adults 

Katz Index of Independence in Activities of Daily Living (Katz ADL) 

Activities Independence (1 Point) 

No supervision, direction, or 

personal assistance 

Dependence (0 Points) 

With supervision, direction, 

personal assistance, or total 

care 

BATHING 

Points: __________ 

(1 POINT) Bathes self completely or 

needs help in bathing only a single 

part of the body, such as the back, 

genital area, or disabled extremity. 

(0 POINTS) Needs help with 

bathing more than one part of the 

body, getting in or out of the tub, 

or shower. Requires total bathing. 

DRESSING 

Points: __________ 

(1 POINT) Can get clothes from closet 

and drawers and put on clothes 

and outer garments complete with 

fasteners. May have help tying shoes. 

(0 POINTS) Needs help with 

dressing self or needs to be 

completely dressed. 

TOILETING 

Points: __________ 

(1 POINT) Goes to the toilet, gets on 

and off, arranges clothes, and cleans 

genital area without help. 

(0 POINTS) Needs help transferring 

to the toilet or cleaning self or uses 

bedpan or commode. 

TRANSFERRING 

Points: __________ 

(1 POINT) Moves in and out of bed or 

chair unassisted. Mechanical transfer 

aids are acceptable. 

(0 POINTS) Needs help in moving 

from bed to chair or requires a 

complete transfer. 

CONTINENCE 

Points: __________ 

(1 POINT) Exercises complete selfcontrol over urination and defecation. (0 POINTS) Is partially or totally 

incontinent of bowel or bladder. 

FEEDING 

Points: __________ 

(1 POINT) Gets food from plate into 

mouth without help. Preparation of 

food may be done by another person. 

(0 POINTS) Needs partial or total 

help with feeding or requires 

parenteral feeding. 

Total Points: ________ 

A score of 6 indicates full function; 4, moderate impairment; and 2 or less, severe functional impairment. 

Adapted from Katz, S., Down, T. D., Cash, H. R., & Grotz, R. C. Progress in the development of the index of ADL. 

Gerontologist 1970, 10(1):20‒30. By permission of The Gerontological Society of America.566 

86 Chapter 3 
TIP 26 TREATING SUBSTANCE USE DISORDER 

IN OLDER ADULTS

Chapter 4—Treating Alcohol Misuse 

in Older Adults 

KEY MESSAGES 

• Older adults are more likely than younger 

adults to feel the negative effects of alcohol 

and are at risk for alcohol–drug interactions. 

Therefore, widespread screening for alcohol 

use and misuse in all healthcare settings and 

emergency departments is recommended. 

• Screening and assessment tools and 

treatment options for alcohol misuse among 

older adults should be senior friendly and 

meet their unique physical, emotional, and 

social needs. 

• Education about low-risk levels of alcohol 

use and about alcohol–drug interactions can 

be a powerful brief intervention as well as a 

prevention tool in keeping seniors safe. 

• You can help increase your older clients’ 

chances of success by offering many different 

treatment choices based on their symptoms 

and needs; addressing all co-occurring health 

conditions; and using a stepped-care approach 

to the management of referrals and ongoing 

coordination of care. 

Chapter 4 of this Treatment Improvement 

Protocol (TIP) will beneft healthcare, behavioral 

health service, and social service providers 

working with older adults. It addresses alcohol 

use and misuse among older adults. National 

survey data show that alcohol use, binge drinking, 

and alcohol use disorder (AUD) are increasing in 

this population at a concerning rate.567 Addiction 

counselors and other healthcare providers should 

understand the unique needs of older adults when 

addressing alcohol-related issues. Although older 

adults generally have lower rates of alcohol misuse, 

including AUD, than younger adults, baby boomers 

(born between 1946 and 1964) are more likely 

to drink and have alcohol-related problems than 

earlier generations of older adults. Even low levels 

of drinking can lead to negative health effects 

in older adults because of age-related physical 

changes, negative interactions between alcohol 

and commonly used medications, and decreases 

in physical and cognitive functioning (thinking 

abilities). 

Organization of Chapter 4 of 

This TIP 

This chapter of TIP 26 presents facts about 

alcohol misuse, including AUD, among older 

adults. It also addresses screening and assessment, 

co-occurring health conditions and mental 

disorders often related to alcohol misuse, and 

treatment and recovery management approaches 

for older adults. 

The frst section of Chapter 4 describes alcohol 

misuse among older adults. It includes defnitions; 

numbers and fgures; and the physical, mental, 

social, and economic effects of AUD. It also 

addresses co-occurring health conditions and 

mental disorders in older adults who drink. 

87 
TIP 26

 

Treating Substance Use Disorder in Older Adults 

The second section addresses screening and 

assessment of alcohol misuse in older adults. 

It covers screening tools for alcohol misuse, 

limitations of the ffth edition of the Diagnostic 

and Statistical Manual of Mental Disorders (DSM-5) 

diagnostic criteria for AUD as applied to older 

adults, signs of late-onset AUD, and misuse of 

alcohol with prescription medications. This section 

also addresses screening for and assessing 

commonly co-occurring health conditions and 

mental disorders among older adults who drink. 

The third section briefy describes the 

continuum of care for older adults, including 

brief interventions for alcohol misuse and inpatient 

detoxifcation or rehabilitation. 

The fourth section discusses specifc treatment 

approaches for older adults with AUD. These include 

brief interventions, cognitive–behavioral therapy 

(CBT), problem-solving therapy (PST), skill-building and 

relapse prevention therapy (RPT), 12-Step Facilitation 

(TSF) therapy, age-specifc inpatient and outpatient 

rehabilitation, and pharmacotherapy. 

EXHIBIT 4.1. Key Terms 

The ffth section explores recovery management 

strategies for older adults. It covers strategies for 

including family members in treatment; addressing 

caregiver needs; and linking older adults to 

evidence-supported, community-based recovery 

support groups such as Alcoholics Anonymous 

(AA) and SMART (Self-Management and Recovery 

Training) Recovery. 

The sixth section presents clinical scenarios to 

show how to match treatment approaches to a 

client’s level of alcohol misuse, from those who 

are abstinent (not drinking at all) for health reasons 

to those with AUD requiring inpatient rehabilitation 

and ongoing recovery management. 

The fnal section offers targeted resources 

to support your practice. For more resources 

related to addressing substance misuse among 

older adults, including misuse of alcohol, see the 

Chapter 4 Appendix and the additional resources 

in Chapter 9 of this TIP. 

For defnitions of key terms you will see throughout 

Chapter 4, refer to Exhibit 4.1. 

• Addiction*: The most severe form of substance use disorder (SUD), associated with compulsive or 

uncontrolled use of one or more substances. Addiction is a chronic brain disease that has the potential for 

both recurrence (relapse) and recovery. 

• Age-sensitive: Adaptations to existing treatment approaches that accommodate older adults’ unique 

needs (e.g., a large-print handout on the signs of substance misuse). 

• Age-specifc: Treatment approaches and practices specifcally developed for older adults (e.g., an older 

adult specialty group in a mixed-age SUD treatment program). 

• Alcohol misuse: The use of alcohol in any harmful way, including heavy drinking, binge drinking, and 

AUD. 

• At-risk/high-risk drinking: Drinking alcohol in excessive amounts. This defnition encompasses both 

binge drinking and heavy drinking. Additionally, any alcohol consumption is considered risky when 

carried out by individuals with certain medical conditions that are worsened by alcohol, those taking 

medicine that can interact harmfully with alcohol, those driving a car or engaged in other activities that 

require alertness, or people recovering from AUD.568,569 Note that for purposes of this TIP, at-risk drinking 

and high-risk drinking are synonymous and either term is acceptable to describe an older adult’s drinking 

patterns. 

• AUD: DSM-5 defnes this disorder.570 An AUD diagnosis is given to people who use alcohol and meet at 

least 2 of the 11 DSM-5 symptoms in a 12-month period. Key aspects of AUD include tolerance, withdrawal, 

loss of control, and continued use despite negative consequences. AUD covers a range of severity and 

replaces what the previous edition of DSM termed alcohol abuse and alcohol dependence. 

Continued on next page 

88 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

Continued 

• Binge drinking: A drinking pattern that leads to blood alcohol concentration levels of 0.08 grams per 

deciliter or greater. This usually takes place after four or more drinks for women and fve or more drinks 

for men.571,572 However, older adults are more sensitive to the effects of alcohol, and treatment providers 

may need to lower these numbers when screening for alcohol misuse.573 Additionally, other factors such 

as weight, decrease in enzyme activity, and body composition (e.g., amount of muscle tissue present in 

the body) can also affect alcohol absorption rates. 

• Caregivers: Informal caregivers provide unpaid care. They assist others with activities of daily living 

(ADLs), including health and medical tasks. Informal caregivers may be spouses, partners, family 

members, friends, neighbors, or others who have a signifcant personal relationship with the person who 

needs care. Formal caregivers are paid providers who offer care in one’s home or in a facility.574 Most older 

adults do not need caregivers and are as able to address their own needs as younger adults, whether or 

not substance misuse is a factor in their lives. 

• Drug–drug interaction: The interaction of one substance (e.g., alcohol, medication, an illicit drug) with 

another substance. Drug–drug interactions may change the effectiveness of medications, introduce 

or alter the intensity of side effects, and increase a substance’s toxicity or the concentration of that 

substance in a person’s blood. Potentially serious interactions can also occur with certain foods, 

beverages, and dietary supplements.575 

• Harmful drinking: Alcohol use that worsens or complicates current alcohol-related problems.576 

• Hazardous drinking: Alcohol use that increases the risk of future harm.577 

• Heavy drinking: Consuming fve or more drinks for men and four or more drinks for women in one period 

on each of 5 or more days in the past 30 days.578 

• Moderate drinking: According to the 2015–2020 Dietary Guidelines for Americans, moderate drinking 

is defned as up to two drinks per day for men and up to one drink per day for women.579,580 However, the 

Centers for Disease Control and Prevention (CDC) notes that these numbers apply to any given day and 

are not meant as an average over several days.581 Additionally, individuals who don’t metabolize alcohol 

well may need to consume even lower quantities. Some people, particularly those with certain alcoholrelated illnesses or engaging in tasks requiring concentration, should not consume alcohol at all. The 

Dietary Guidelines stipulate that those who don’t drink should not begin drinking for any reason.582 

• Mutual-help groups: Groups of people who work together on obtaining and maintaining recovery. Unlike 

peer support (e.g., the use of recovery coaches or peer recovery support specialists), mutual-help groups 

consist entirely of people who volunteer their time and typically have no offcial connection to treatment 

programs. Most are self-supporting. Although 12-Step groups such as AA and Narcotics Anonymous are 

the most widespread and well researched type of mutual-help groups, other groups may be available in 

some areas. They range from groups affliated with a religion or church (e.g., Celebrate Recovery, Millati 

Islami) to purely secular groups (e.g., SMART Recovery, Women for Sobriety). 

• Peer support: The use of peer recovery support specialists (e.g., someone in recovery who has lived 

experience in addiction plus skills learned in formal training) to provide nonclinical (i.e., not requiring 

training in diagnosis or treatment) recovery support services to individuals in recovery from addiction and 

to their families. 

• Recovery*: A process of change through which individuals improve their health and wellness, live a selfdirected life, and strive to reach their full potential. Even individuals with severe and chronic SUDs can, 

with help, overcome them and regain health and social function. This is called remission. When those 

positive changes and values become part of a voluntarily adopted lifestyle, that is called being in recovery. 

Although abstinence from all substance misuse is a cardinal feature of a recovery lifestyle, it is not the 

only healthy, prosocial feature. 

• Relapse*: A return to substance use after a signifcant period of abstinence. 

Continued on next page 

Chapter 4 89 
TIP 26 Treating Substance Use Disorder in Older Adults 

Continued 

• Remission: A medical term meaning a disappearance of signs and symptoms of the disease or disorder. 

DSM-5 defnes remission as present in people who previously met SUD criteria but no longer meet any 

SUD criteria (with the possible exception of craving).583 Remission is an essential element of recovery. 

• Stepped care: A science-based approach that matches an individual’s treatment needs to different levels 

of care, from least intensive to most intensive. 

• Substance misuse*: The use of any substance in a manner, situation, amount, or frequency that can 

cause harm to users or to those around them. For some substances or individuals, any use would 

constitute misuse (e.g., underage drinking, injection drug use). 

• Substance use disorder*: A medical illness caused by repeated misuse of a substance or substances. 

According to DSM-5,584 SUDs are characterized by clinically signifcant impairments in health and social 

function, and by impaired control over substance use. They are diagnosed through assessing cognitive, 

behavioral, and psychological symptoms. SUDs range from mild to severe and from temporary to chronic. 

They typically develop gradually over time with repeated misuse, leading to changes in brain circuits 

governing incentive salience (the ability of substance-associated cues to trigger substance seeking), 

reward, stress, and executive functions like decision making and self-control. Multiple factors infuence 

whether and how rapidly a person will develop an SUD. These factors include the substance itself; the 

genetic vulnerability of the user; and the amount, frequency, and duration of the misuse. Note: A severe 

SUD is commonly called an addiction. A mild SUD is generally equivalent to what previous editions of 

DSM called substance abuse; a moderate or severe SUD is generally equivalent to what was formerly 

called substance dependence. 

* The defnitions of all terms marked with an asterisk correspond closely to those given in Facing Addiction in 

America: The Surgeon General’s Report on Alcohol, Drugs, and Health. This resource provides a great deal of useful 

information about substance misuse and its impact on U.S. public health. The report is available online (https://addiction. 

surgeongeneral.gov/sites/default/fles/surgeon-generals-report.pdf). 

Alcohol Misuse Among Older 

Adults 

Age-Specifc Efects of Alcohol Use 

More older adults are misusing alcohol than in 

earlier years. An estimated 23.2 million adults 

ages 65 and older drank alcohol in the past month, 

5.6 million engaged in past-month binge drinking, 

and 1.5 million engaged in past-month heavy 

drinking.585 

The signs and effects of alcohol misuse, including 

binge drinking and AUD, often differ between 

older and younger adults. Understanding the 

differences will help you identify, assess, and treat 

older adults. 

Older adults metabolize alcohol less effciently 

than younger adults. Older adults have less lean 

body mass and less total body water than younger 

adults. This smaller water volume is one reason why 

an older adult and a younger adult can drink similar 

amounts of alcohol, but the older adult’s blood 

alcohol level will be higher and stay high longer. 

In addition, older adults’ central nervous system 

(CNS) is more sensitive to alcohol’s effects, leading 

to lower tolerance.586 These differences can lead 

to or worsen chronic illnesses common in older 

adults (e.g., high blood pressure).587 

Drinking also increases health-related risks for 

older adults who take medications that may 

interact negatively with alcohol. Older adults are 

more likely than younger adults to take multiple 

90 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

medications, further increasing this risk. Moreover, 

up to 19 percent of older adults in the United 

States use alcohol and prescription medications in 

a way that could be considered misuse.588 

Alcohol Misuse 

Older adults can meet the defnition of alcohol 

misuse at lower levels of alcohol use than adults 

younger than 60. Older adults who have been 

drinking for years may face more alcohol-related 

problems—and those problems may be more 

severe—even if their use has not increased over 

time. A review of survey data indicates that 4 percent 

to 14 percent of older adults may misuse alcohol.589 

The rate of alcohol misuse among older adults 

increases when including health status and 

overall functioning, rather than just amount of 

alcohol used and frequency of use. For instance, a 

study on alcohol-related health risk in older adults 

in the United States found that among older adults 

who drink, 53.3 percent had harmful or hazardous 

use.590 This number was more than three times 

greater than the number of older adults consuming 

alcohol above federal guideline limits. The 

discrepancy in the consumption rate and the rate 

of harmful or hazardous use is explained by the 

health status of older adults. 

RESOURCE ALERT: A CONSUMER 

WEBSITE FOR CALCULATING 

ALCOHOL CONSUMPTION 

Rethinking Drinking: Alcohol & Your Health 

(www.rethinkingdrinking.niaaa.nih.gov) is 

a National Institute on Alcohol Abuse and 

Alcoholism (NIAAA) interactive website that 

provides individuals with accurate information 

about what a standard drink is and how to calculate 

their level of alcohol use based on the types and 

amounts of alcoholic beverages they drink. 

Low-risk drinking guidelines at this website 

are for all adults; they are not reduced for older 

adults. Discuss why older adults may need to 

adhere to lower numbers before referring your 

clients to this website. 

Alcohol misuse among older adults is likely 

responsible for a large portion of the damage 

some experience to their health and wellbeing.591 For the older adult population, drinking 

even small amounts of alcohol can have serious 

physical, mental, and social effects. For example, 

one or two drinks a day may lead to increased 

cognitive impairment (problems with thinking) for 

individuals who already have dementia, or sleep 

problems (e.g., sleep apnea).592 

The economic costs of alcohol misuse among 

older adults are signifcant. Older adults who 

misuse alcohol are at greater risk for injury and 

falls. Certain events among older adults that can be 

related to alcohol use—such as injury deaths, falls 

treated in emergency departments, hospitalized 

falls, and fall-related traumatic brain injury deaths— 

have risen signifcantly in the past decade.593 

Older adults who misuse alcohol are at risk for:594 

• Liver disease. 

• Sleep problems. 

• Cancer. 

• Diabetes. 

• Congestive heart failure. 

• Lowered general health functioning. 

Older adults who drink beyond recommended 

guidelines have higher rates of tobacco use 

disorder and are at risk for:595,596,597 

• Depression, anxiety, and mood disorders. 

• Memory problems. 

• Cognitive changes such as dementia. 

• Sleep disorders. 

• Agitation or violent behavior. 

• Suicide. 

Chapter 4 91 
TIP 26

DRINKING IN RETIREMENT 

COMMUNITIES 

Participating in social activities with family and 

friends who drink reinforces alcohol use and 

misuse. This is particularly true in retirement 

communities, where drinking and socializing 

often go hand in hand.598 A recent study of a 

large retirement community in Florida found 

that 15.4 percent of the respondents to a survey 

on drinking reported hazardous drinking levels. 

However, when asked about health-related 

concerns and quality of life, most responded that 

drinking was a part of their social lives, did not 

report many health concerns, and reported a 

high quality of life.599 

This result suggests that some older adults 

whose social drinking exceeds recommended 

limits may improve their quality of life, which 

could balance out any potential health risks. 

However, subjective measures of health-related 

effects of heavy alcohol use are not always as 

trustworthy as objective measures, such as lab 

results for medical conditions. When you assess 

the health risks of an older adult’s drinking, 

keep in mind the cultural context of his or 

her drinking, the amount and frequency of 

drinking, and any objective measures of health 

effects in addition to self-report fndings. 

Binge Drinking 

Binge drinking is a drinking pattern that leads 

to blood alcohol concentration levels of 0.08 

grams per deciliter or greater. On average, this 

occurs after fve or more drinks for men and four 

or more drinks for women.600,601 However, for 

older adults, who have increased sensitivity to 

alcohol, lower alcohol consumption levels may be 

considered binge drinking. 

According to the National Survey on Drug Use 

and Health (NSDUH), 10.7 percent of adults 

ages 65 and older binge drink (defned as fve or 

more drinks for men and four or more drinks for 

women, per event).602 This percentage would be 

even higher if the survey could factor in that binge 

drinking occurs at lower alcohol consumption levels 

for some older adults. Binge drinking appears to 

Treating Substance Use Disorder in Older Adults 

be more of an issue for older men than older 

women.603 Yet binge drinking among older women 

is rapidly increasing.604 

Binge drinking creates additional health problems 

for older adults. Binge drinking is related to a 

number of health and safety issues, including 

accidents, an increased chance of physical injury 

(e.g., falls), and higher death rates.605,606 Binge 

drinking is also related to a higher risk of AUD in 

both men and women as they age.607,608 

AUD 

Baby boomers drink more than earlier 

generations, which is likely to lead to a large 

increase in the number of older adults with 

AUD as this generation ages. 

609 Furthermore, the 

number of adults ages 65 and older in the U.S. 

population is predicted to increase from about 

56 million in 2020 to more than 85 million by 

2050.610,611 

In the general population, only an estimated 1.52 

percent of adults ages 60 and older report AUD 

in the past 12 months; 16.1 percent report AUD 

in their lifetime.612 Conversely, up to 30 percent of 

older adults hospitalized in general medical units 

and up to 50 percent hospitalized in psychiatric 

units have AUD.613 This is signifcant, because 

older adults with AUD who are hospitalized might 

not report their level of drinking to healthcare 

providers and could be at risk for alcohol 

withdrawal during their hospitalization. So too, 

these percentages may not capture the actual 

prevalence of AUD in this population, as DSM 

diagnostic criteria do not always accurately identify 

AUD in older adults.614 

According to the 2019 NSDUH, 

10.7% of adults ages 65 and 

older BINGE DRINK. 

92 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

Co-Occurring Health Conditions and 

Mental Disorders 

Alcohol use can worsen the effects of many 

co-occurring mental health and health conditions 

(e.g., depressive disorders, high blood pressure, 

and diabetes). In addition, many physiological 

changes naturally take place during the aging 

process; clients need to understand that drinking 

can accelerate these health-related changes. 

Anxiety 

Anxiety symptoms and anxiety disorders 

are common in adults ages 60 and older in 

community and treatment settings.615 Older adults 

also have a high rate of co-occurring anxiety 

disorders and AUD.616 Anxiety causes high personal 

distress, reduces life satisfaction, and increases the 

risk for disability among older adults. Anxiety also 

increases the risk of death among older adults from 

suicide and from heart disease.617 Older adults 

who drink to lessen their anxiety increase their 

health-related risks. 

Depression 

Depression is one of the most common 

co-occurring mental disorders among older 

adults with AUD. Approximately 4.5 percent of 

older adults (ages 50 and older) met past-year 

prevalence of major depression.618 This estimate 

does not include those who meet either DSM-5 

diagnostic criteria for other depressive disorders 

or have symptoms of depression that interfere 

with everyday functioning. The negative effects 

of depression in older adults include suicide risk, 

increased cognitive impairment, a higher risk of 

dementia, and poorer physical health.619 

Alcohol is a depressant drug (meaning it 

reduces activity of the CNS). Drinking alcohol can 

worsen depression or increase the risk of late-life 

depression.620 In approximately 30 percent of older 

adults with co-occurring AUD and depression, the 

depression is not directly linked to drinking but 

instead was present before the onset of AUD or 

developed separately from AUD.621 

RESOURCE ALERT: TREATING 

DEPRESSION IN OLDER ADULTS 

See SAMHSA’s Evidence-Based Practices KIT 

(Knowledge Informing Transformation) The 

Treatment of Depression in Older Adults (https:// 

store.samhsa.gov/product/Treatment-DepressionOlder-Adults-Evidence-Based-Practices-EBP-Kit/ 

SMA11-4631) for more information and treatment 

strategies. 

Diagnosing depression in older adults with AUD 

is challenging. Depression may be underdiagnosed 

because its symptoms are similar to those of 

dementia and common complaints of older adults, 

such as loss of interests, slowed thinking, lack 

of energy, or general aches and pains.622 Assess 

depression and other mood disorders at the start 

of AUD treatment, and reassess from time to 

time to learn whether abstinence or a reduction in 

alcohol use reduces symptoms of depression. 

Serious Mental Illness 

People with serious mental illness (SMI), like 

schizophrenia, typically have higher levels of stress, 

tobacco use, and alcohol use than the general 

population. They are also more likely to have 

poor overall health, an inactive lifestyle, and an 

increased risk of death.623 About 19 percent of 

older adults with SMI have a co-occurring SUD, 

and AUD is one of the most common.624 

Co-occurring AUD and SMI among older adults 

has not been studied widely. However, alcohol use 

is a factor in people not taking their psychotropic 

medication as prescribed, and co-occurring AUD is 

related to longer length of psychiatric stay and an 

increase in co-occurring medical conditions. 

See Chapter 6 of this TIP for details on the links 

between alcohol use and dementia among older 

adults. 

Chapter 4 93 
TIP 26

Pain 

Chronic pain is a common condition in older adults 

that reduces their ability to move and perform 

ADLs. A study of U.S. older adults estimated that 

52.9 percent, or as many as 18.7 million, have pain 

that makes their daily functioning diffcult.625 

Older adults with chronic pain who drink to 

reduce their pain are at risk for late-onset 

AUD.626 Drinking while taking pain medications 

also increases other health-related risks (e.g., 

serious liver disease, overdose death). Common 

pain medications older adults may take include 

nonsteroidal anti-infammatory drugs (NSAIDs) and 

opioids (e.g., hydrocodone, oxycodone). 

Screening and Assessment 

Many older adults who misuse alcohol do not 

need specialized addiction treatment services. 

Still, screening and brief educational and 

motivational interventions can help older adults 

reduce alcohol use and health-related harms 

when delivered in healthcare and mental health 

service settings.627 

AUD is often underdiagnosed in older adults. 

Some DSM-5 diagnostic criteria may not apply to 

them. For example, the criterion of failing to fulfll 

major duties at work will not apply to an older 

adult who is retired. Furthermore, providers may 

mistake AUD symptoms for other conditions that 

are commonly, yet often incorrectly, thought to be 

normal signs of aging, such as:628 

• Sleep problems. 

• Memory loss. 

• Depression. 

• Anxiety. 

• Aches and pains. 

• Poor diet. 

• Loss of interest in sex. 

Treating Substance Use Disorder in Older Adults 

Older adults in long-term care settings, such as 

assisted living and nursing homes, are often not 

diagnosed or treated for AUD.629 The key to fnding 

the right interventions for alcohol misuse, including 

AUD, is to adapt screening, assessment, and 

diagnostic criteria to older clients, regardless of 

the settings in which they receive health or social 

services. 

Widespread Screening 

Widespread screening in healthcare and behavioral 

health service settings is an opportunity for 

brief intervention and, when needed, referral to 

addiction-specifc treatment services.630 

Older adults are often not screened for alcohol 

misuse because providers hold incorrect beliefs 

about alcohol use in this population. They may 

think that older adults don’t drink much or, if they 

do drink, they should be allowed this “one last 

pleasure” of life.631 Providers also may choose not 

to ask older adults about their drinking history 

and current alcohol use for fear that asking these 

questions will hurt their relationship with these 

clients. However, baby boomers tend to be more 

accepting than earlier generations of the idea of 

talking about and seeking help for mental disorders 

and SUDs. 

Challenge false beliefs by educating your fellow 

providers and supporting widespread alcohol 

screening as a normal, ongoing practice. Doing 

so can help reduce any mixed feelings providers 

have about screening older adults. It can also 

increase the chances of identifying alcohol misuse 

early in older clients. (Chapter 3 of this TIP offers 

more information on screening and assessing for 

substance misuse in older adults.) 

94 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

WHEN TO SCREEN OLDER ADULTS 

FOR ALCOHOL MISUSE632 

• As part of every annual physical exam 

• As part of the initial assessment in behavioral 

health service settings 

• As part of the initial intake or admission process 

to older adult–focused social service programs 

• When the older adult starts a new medication 

• When the older adult has major stressful life 

changes (e.g., death of a signifcant other, 

retirement, major illness or declining health, 

loss of social supports) 

• When potential signs and symptoms of an 

alcohol-related problem are present, such as 

sleep diffculties, falls, injuries, depression, and 

problems with daily living skills 

• When the older adult has multiple healthcare 

providers or uses more than one pharmacy 

• When the older adult reports that a medication 

is not working as well over time 

• When the older adult reports a past personal 

or family history of substance use or mental 

disorders 

The consensus panel recommends widespread 

screening of older adults for alcohol misuse 

and alcohol-related problems in all healthcare 

settings and emergency departments, where 

older adults are frequently seen because of 

accidents and falls related to alcohol use. Also 

screen older adults for alcohol misuse at the 

initial intake or assessment when admitted to 

social services agencies and behavioral health 

service programs. 

Screening Tools 

The Alcohol Use Disorders Identifcation Test 

(AUDIT) and the Short Michigan Alcoholism 

Screening Test-Geriatric Version (SMAST-G) are two 

common, easy-to-use, brief instruments that can 

successfully screen older adults for alcohol misuse 

and signs of AUD.633 

AUDIT 

The AUDIT is a 10-item screening instrument 

for heavy drinking from the World Health 

Organization. The AUDIT collects information 

about alcohol use, drinking behaviors, and 

alcohol-related problems over the past year.634 It 

is a validated (tested and approved) measure of 

alcohol-related risk in people of different genders, 

ages, and cultures.635 There are two versions—one 

given by clinicians and one that clients complete by 

themselves. (See the Chapter 4 Appendix for both.) 

A cutoff score of 8 generally indicates hazardous 

and harmful alcohol use. For older adults, however, 

a score of 5 means you should assess further.636 

SMAST-G 

Researchers at the University of Michigan 

developed the MAST-G, a 24-item screening 

instrument specifcally for use with older adults. 

The MAST-G can be used to identify alcohol misuse 

in older adults. 

The SMAST-G is a shorter, 10-item, validated 

version of MAST-G.637 The SMAST-G does not ask 

about amount and frequency of alcohol use; it 

focuses more on the older adult’s relationship to 

alcohol and effects of drinking. The SMAST-G is 

about as reliable and accurate for older adults as 

the AUDIT. Two or more “yes” responses indicate 

possible alcohol misuse.638 (See the Chapter 4 

Appendix for the SMAST-G.) 

Considerations When Using AUD Screening 

Instruments 

Although screening instruments can help you 

quickly identify potential alcohol misuse in older 

adults and offer a chance to use prevention 

strategies (Exhibit 4.2), they can sometimes be 

overly sensitive and lead to false positives.639 

Some questions on alcohol screening instruments 

refer to physical complaints that are often age 

associated. Conversely, brief screening does not 

always capture symptoms that may indicate AUD. 

Always follow up positive screens with more 

questions and indepth assessment (or referral to 

assessment) for AUD. 

Chapter 4 95 
TIP 26 Treating Substance Use Disorder in Older Adults 

EXHIBIT 4.2. Preventing Alcohol Misuse Among Older Adults 

You can support prevention efforts by helping older adults develop the knowledge, attitudes, and skills they 

need to make good choices about alcohol use before their drinking puts their physical and mental health 

at risk. The key to prevention is identifying early which older adults drink alcohol. You can often help older 

adults to reduce their drinking, or to seek help if their alcohol use begins to affect their health, simply by 

giving them information about standard drink sizes, guidelines for low-risk drinking, health risks of alcohol 

misuse, and health risks of mixing medication with alcohol. 

Early identifcation and prevention begin with widespread prescreening in all healthcare and communitybased senior service settings.640 The following decision tree shows the early identifcation and prevention 

process. 

Adapted from material in the public domain.641 

Assessment and Diagnosis of AUD 

It is essential that you, or another provider 

with suffcient qualifcations, perform indepth 

assessments for AUD in your older adult clients. 

Older adults with AUD are often underdiagnosed 

because DSM-5 criteria do not always capture AUD 

in older adults. Also, some signs of AUD may be 

mistaken for symptoms of co-occurring medical or 

mental disorders or natural aging processes. If you 

only use DSM-5 diagnostic criteria to diagnose 

AUD, you may miss many older adults with 

alcohol-related problems, which means they may 

not receive proper treatment.642 

A full assessment should address the client’s: 

• History of alcohol use. 

• Age of onset of alcohol-related problems. 

• Past and current amount and frequency of 

alcohol use (with attention to periods of binge 

drinking). 

• Relationship between his or her drinking and 

daily functioning. 

• Co-occurring medical conditions. 

• Past attempts to limit or control alcohol intake. 

96 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

• Co-occurring mental disorders, particularly 

depression and anxiety. 

• Current medications. 

• Use of alcohol to cope with sleep problems, 

depression, anxiety, stressful life events, or pain. 

For information on how to give an indepth 

assessment for AUD, refer to Chapter 3 of this TIP. 

Understanding DSM-5 Diagnostic Criteria 

Versus Alcohol-Related Risk Criteria 

For an AUD diagnosis, your client must have 

at least 2 out of 11 symptoms listed in DSM-5. 

However, as noted before, some of these 

symptoms may not apply to older adults. Exhibit 

4.3 summarizes the physical, cognitive, and social 

aspects of aging you should think about when 

using these criteria to assess and diagnose AUD in 

older adults. 

EXHIBIT 4.3. DSM-5 Criteria for AUD and Considerations for Older Adults 

DSM-5 CRITERIA FOR AUD643 CLINICAL CONSIDERATIONS644,645,646,647,648 

Criterion A1 Older adults may need less alcohol to feel physical effects. Cognitive 

impairment can make it hard for older adults to keep track of their 

drinking. 

Criterion A2 No special considerations for older adults. 

Criterion A3 Effects of alcohol can result from drinking even small amounts, so 

relatively less time may be spent getting and drinking alcohol and 

recovering from using it. 

Criterion A4 No special considerations for older adults. 

Criterion A5 Older adults may have different role responsibilities because of life-stage 

changes, such as retirement. Role responsibilities more common in older 

adulthood include caregiving for a spouse or another family member, 

such as a grandchild. 

Criterion A6 Older adults may not realize that social or interpersonal problems they are 

experiencing are connected to their alcohol use. 

Criterion A7 Older adults may take part in fewer activities generally, making it more 

diffcult to discover when drinking is causing them to withdraw from 

activities. 

Criterion A8 Older adults may not understand that their alcohol use is hazardous, 

especially when they are drinking the same as or less than before. In 

addition, older adults may not realize the physical dangers of drinking in 

certain situations (e.g., before using a step stool). 

Criterion A9 Older adults experiencing physical or psychological problems may not 

realize that drinking could be a factor. 

Criterion A10 Changes in tolerance occur because of increased sensitivity to alcohol 

with age. Previously manageable quantities of alcohol may cause greater 

impairment. 

Criterion A11 Withdrawal symptoms in older adults can last longer, be less obvious, or 

be mistaken for age-related illness. 

Chapter 4 97 
TIP 26 Treating Substance Use Disorder in Older Adults 

DSM-5 diagnostic criteria related to physical and 

emotional effects (e.g., craving, desire to cut 

down) may be key signs of AUD in older adults.649 

When deciding whether an older individual’s 

alcohol misuse meets DSM-5 criteria for AUD, 

remember older adults’ lowered tolerance to 

alcohol and the unique aspects of withdrawal from 

alcohol and other sedative-hypnotic drugs, like 

benzodiazepines. 

To diagnose AUD in older adults, use alcoholrelated risk criteria in addition to DSM-5 

diagnostic criteria. For example, alcohol-related 

risk criteria for older adults in the Comorbidity 

Alcohol Risk Evaluation Tool (CARET), based on the 

Alcohol-Related Problems Survey,650 include:651 

• Amount and frequency of alcohol use (e.g., 

drinking more than recommended guidelines). 

• Brief periods of excessive drinking (e.g., binge 

drinking). 

• Driving after drinking. 

• Others being concerned about the older adult’s 

drinking. 

• Co-occurring medical and mental disorders. 

• Symptoms caused or worsened by drinking 

(e.g., cognitive impairment). 

• Medications that interact negatively with alcohol 

or that do not work properly if taken with 

alcohol. 

The amount and frequency of drinking described 

as “at-risk” for older adults is paired with specifc 

drinking behaviors, use of medications, and cooccurring conditions in the past 12 months. For 

more information about the items in the CARET 

and how to score them, please see Barnes et al., 

2010.652 

For example, if an older adult has chronic liver 

disease and drinks any alcohol or even binge drinks 

just once a week, he or she may not meet DSM-5 

criteria for AUD. Still, his or her drinking is a risk 

for serious alcohol-related health consequences. 

Using age-adjusted DSM-5 criteria and CARET 

health-related risk criteria will more accurately 

gauge severity of AUD and the degree to which 

your client may exhibit behavioral or health-related 

effects of drinking that should be a focus of 

treatment. 

In assessing and diagnosing AUD in older adults, 

the consensus panel recommends that you think 

through all aspects of health-related risk in 

addition to age-specifc issues. 

Late-Onset Alcohol Misuse and AUD 

Most older adults meeting criteria or receiving 

treatment for AUD began drinking earlier in their 

lives. However, some older adults begin to misuse 

alcohol later in life (called late-onset alcohol 

misuse or, if severe enough to meet criteria for 

AUD, late-onset AUD). Older adults who begin 

misusing alcohol late in life may not realize their 

increased risk for health-related harms related to 

drinking. They may start misusing alcohol to cope 

with co-occurring medical or mental disorders, 

grief and isolation upon the loss of a loved one, 

or the stress of life changes, such as retirement.653 

Stress, role or identity loss, and approval of 

drinking by members of older adults’ social groups 

are linked to an increased risk of late-onset AUD.654 

Assessments should address risk factors related to 

late-life alcohol misuse among older adults (Exhibit 

4.4). Assessment is a chance for you to use 

education as a prevention and early intervention 

tool. 

~78% of older adults 

in the U.S. who drink also 

take MEDICATIONS 

that INTERACT with 

ALCOHOL. 

98 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

EXHIBIT 4.4. Risk Factors Related to Alcohol Misuse in Late Life655 

Physical risk factors: 

• Long-lasting pain 

• Physical disabilities or problems getting around 

• Changes in care or living situations 

• Poor health status 

• Chronic physical illness 

• Multiple prescription drugs 

Mental risk factors: 

• Avoidance coping style (e.g., drinking to cope with stressful events) 

• History of alcohol misuse 

• Past or co-occurring SUDs (including tobacco use disorder) 

• Past or co-occurring mental disorders 

Social risk factors: 

• Financial stress, including having a fxed income and having diffculty obtaining Medicare/Medicaid and 

other health benefts 

• Bereavement 

• Unexpected or forced retirement 

• Social isolation 

Assessing Alcohol–Drug Interactions 

Alcohol–drug interactions are a major factor 

in the overall health risk for older adults who 

drink.656 Changes in older adults’ ability to absorb 

and metabolize alcohol and medications (i.e., 

higher sensitivity) can increase the risk of negative 

alcohol–drug interactions. Alcohol can also increase 

or reduce a medication’s therapeutic effect and 

interfere with its effectiveness in treating medical 

illnesses commonly seen in older adults, like high 

blood pressure, depression, gout, and insomnia.657 

Some older adults may also be at greater risk for 

negative alcohol–drug interactions because of 

the number and types of medications they take. 

Approximately 78 percent of older adults in the 

United States who drink also take medications that 

interact with alcohol.658,659 Emergency department 

visits are increasing for dangerous alcohol–drug 

reactions in older adults. 

Many classes of prescription medications can 

interact negatively with alcohol, including:660 

• Antibiotics. 

• Antidepressants. 

• Antihistamines. 

• Barbiturates. 

• Benzodiazepines. 

• Muscle relaxants. 

• Nonopioid pain medications. 

• Anti-infammatory agents. 

• Opioids. 

• Anticoagulants. 

Learn more about commonly used prescription 

and over-the-counter medications and how they 

interact with alcohol in NIAAA’s publication 

Harmful Interactions (www.niaaa.nih.gov/ 

publications/brochures-and-fact-sheets/harmfulinteractions-mixing-alcohol-with-medicines). 

Chapter 4 99 
TIP 26

 

 

Treating Substance Use Disorder in Older Adults 

RESOURCE ALERT: ALCOHOL AND 

DRUG INTERACTION CHECKERS 

a

Learn more about interactions between alcohol 

and specifc medications by using a drug 

interaction checker (e.g., the one available at 

www.drugs.com/drug_interactions.html). Check 

for interactions between ethanol (the type of 

alcohol in alcoholic beverages) and medications 

(prescription and over-the-counter) and dietary 

supplements (e.g., vitamins, herbal products). 

With permission, you can also check with 

your client’s pharmacist about alcohol–drug 

interactions for the specifc medications your 

client takes. 

Always learn which medications your client takes. 

Nonjudgmentally offer information about the 

ways alcohol can interfere with a medication’s 

effectiveness and increase the risk of harmful 

effects. 

The consensus panel recommends that you 

educate older adults about negative alcohol– 

drug interactions and work with your clients to 

help them reduce or abstain from alcohol use 

while taking these medications. 

Continuum of Care 

A continuum of care exists for older adults with 

lcohol misuse, including AUD. It ranges from 

least to most intensive: from brief interventions, 

to outpatient or intensive outpatient treatment 

(IOP) in programs that specialize in mental 

health services or SUD treatment, to inpatient 

detoxifcation and rehabilitation. 

Continuing care should focus not only on 

achieving abstinence from or reducing alcohol 

use but also on improving quality of life. AUD 

treatment goals are like treatment goals for any 

other chronic condition. They include:661 

• Respectfully helping older adults participate in 

treatment throughout the continuum. 

• Helping them stay motivated to change risk 

behaviors to improve their health and quality of 

life throughout treatment and recovery. 

• Using multiple treatments as needed, 

including pharmacotherapy and psychosocial 

interventions. 

• Reducing the risk of relapse. 

Apply a stepped-care approach that starts with 

the least intensive treatment option that meets 

the needs of the older adult, and then increase 

the level of intensity as needed. Exhibit 4.5 

shows the possible treatment pathways along the 

continuum of care for older adults with alcohol 

misuse. 

EXHIBIT 4.5. Continuum of Care Pathways for Older Adults 

Brief Intervention Follow-Up

Inpatient Detoxification

Inpatient Detoxification and Rehabilitation

Outpatient or IOP

Referral Management 

Outpatient Recovery Management*

Recovery Management*

Outpatient Recovery Management*

Note: Pharmacological interventions may be started at any time across the continuum of care to meet 

clients’ needs. 

*For more about recovery management, see the “Recovery Management” section of this chapter.

Based on Severity

100 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

Treatment Approaches Suited to 

Older Adults 

Despite common stereotypes, older adults are 

generally open to and accepting of alcohol 

treatment, especially when programs offer 

age-specifc groups, age-sensitive treatment 

(i.e., treatments that meet their special needs), 

and providers trained in issues unique to older 

adults.662,663 Older men and women who participate 

in alcohol treatment:664 

• Are successful in reaching treatment goals of 

abstinence or risk reduction. 

• Have nearly the same or better outcomes than 

younger adults. 

• Are more likely to complete treatment than 

younger adults. 

• Beneft greatly from age-specifc treatment. 

The consensus panel recommends that all 

treatment providers adopt the age-sensitive 

practices in Exhibit 4.6. (For more information on 

principles of care for older adults, see Chapter 2 of 

this TIP.) 

EXHIBIT 4.6. Characteristics of Age-Sensitive Alcohol Treatment for 

Older Adults665 

Regardless of the settings and modalities in which you offer treatment services to older adults, they are 

more likely to be open to and respond to treatment if interventions are: 

• Supportive and nonconfrontational (e.g., forming a respectful partnership with your clients, which is the 

primary way to support behavior change). 

• Flexible (e.g., supplying services at home or over the phone if clients cannot get to you). 

• Sensitive to gender differences (e.g., addressing in AUD treatment the fact that women are more likely 

to be prescribed psychoactive medications than men). 

• Sensitive to cultural differences (e.g., using print materials in your clients’ primary language). 

• Sensitive to the client’s level of physical and cognitive functioning (e.g., using shorter sessions; 

meeting in a room close to the building entrance; giving information in multiple formats, like verbally and 

in writing). 

• Holistic and thorough (e.g., addressing cognitive, physical, social, mental, fnancial, emotional, and 

spiritual factors that may inhibit treatment engagement or enhance recovery). 

• Focused on helping older adults develop and improve coping and social skills (i.e., instead of focusing 

on internal mental processes, using treatment that focuses on behavioral change to reduce their alcoholrelated risk and increase quality of life, such as developing problem-solving strategies to manage triggers 

for drinking and strengthening social connections with nondrinking friends or members of mutual-help 

groups). 

Brief Interventions for Alcohol Misuse 

Brief interventions can support AUD prevention 

and risk reduction (e.g., helping clients to reduce 

or abstain from drinking to decrease health-related 

risks). Brief intervention also can be a starting point 

for entry into more intensive AUD treatment. (See 

Chapter 3 of this TIP for more information.) Older 

adults are likely to participate in and accept this 

approach to addressing alcohol misuse.666,667,668 

Brief interventions are a good ft for many 

different treatment settings, including primary 

care, emergency departments, older adult-focused 

social service settings, and outpatient behavioral 

health service programs. They are cost effective, 

low intensity,669,670 and effcient, generally 

consisting of one to four sessions that last from 15 

to 60 minutes.671,672 Brief interventions may include: 

Chapter 4 101 
TIP 26

• Referral as needed to medical specialists. 

• Inpatient/outpatient addiction-specifc 

treatment. 

• Older adult–focused social services. 

• Community-based mutual help and recovery 

support groups, such as AA. 

RESOURCE ALERT: SCREENING 

AND BRIEF INTERVENTIONS FOR 

OLDER ADULTS 

See SAMHSA’s A Guide to Preventing Older Adult 

Alcohol and Psychoactive Medication Misuse/ 

Abuse: Screening and Brief Interventions at www. 

ncoa.org/wp-content/uploads/SBIRT-Older-AdultManual-Final.pdf for more information about 

prevention strategies and brief interventions. 

You can use the guide’s “Health Promotion 

Workbook” (included as an appendix) when 

conducting brief interventions for alcohol misuse. 

Motivational Interviewing 

Motivational interviewing (MI) strategies are a 

cornerstone of brief interventions for alcohol 

misuse. You can combine these strategies with 

longer therapeutic approaches to treat AUD 

in older adults.673 MI can help people of many 

different ages and ethnic, racial, and cultural 

backgrounds participate in treatment. MI is fexible 

and focuses on empathetic, refective listening 

and a respectful, client-centered approach.674 MI 

strategies may be particularly useful with older 

adults who may not be aware of the health risks 

related to their alcohol use. Because MI is a 

nonjudgmental and nonconfrontational approach, 

it may also be useful with clients who have mixed 

feelings about changing their drinking. 

MI can help older adults change risk behaviors, 

such as reducing or abstaining from alcohol 

use.675,676,677 However, not many studies have 

looked at MI’s usefulness in getting older adults to 

reduce or stop alcohol use. Some of the ways in 

which MI affects behavior change may be different 

for older adults than for younger adults.678 

Treating Substance Use Disorder in Older Adults 

KEY ASPECTS OF MI 

• Being willing to collaborate with the client 

• Being accepting and nonjudgmental 

• Offering compassionate and empathetic 

responses to client concerns 

• Asking clients about their concerns and goals 

for treatment instead of forcing your own 

agenda for change on them679 

The mnemonic “FRAMES” outlines the most 

common MI strategies used in brief interventions 

to address alcohol misuse: 

• F: Give specifc and nonjudgmental, objective 

Feedback to your clients about their drinking, 

including information about health risk and 

potential effects. This feedback is often 

based on results of alcohol misuse screening 

instruments. 

• R: Point out to your clients their personal 

Responsibility for change and emphasize that 

it is up to them to decide what, if anything, 

to change about their drinking. Responsibility 

for change also means respecting your clients’ 

independence and decisions about behavior 

change. 

• A: Give clear Advice and recommendations 

to your clients about changing their drinking. 

In the spirit of a client-centered approach, 

ask permission to give advice, and then ask 

your clients about their understanding of the 

recommendations you offered. 

• M: Offer a Menu of options for changing 

drinking behaviors if your clients choose to 

change. Options may include altering drinking 

behaviors, abstaining, or accepting referral 

to more intensive mental health services or 

addiction-specifc treatment. 

• E: Use an Empathetic communication style 

that is respectful, supportive, and focused on 

listening to your clients’ views and concerns 

about their drinking. 

• S: Support Self-effcacy by recognizing 

clients’ knowledge about and ability to 

change behaviors in support of their health 

and well-being, including changing drinking 

behaviors.680,681 

102 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

MI generally focuses on:682 

• Helping clients deal with any mixed feelings 

they may have about changing their drinking. 

• Asking clients about their own reasons for 

change. 

• Having a respectful and joint conversation about 

behavior change based on clients’ stated goals. 

Exhibit 4.7 shows a brief intervention developed 

specifcally for older adults that builds on the 

FRAMES model and uses MI strategies, such as 

discussing the client’s reasons to reduce or quit 

drinking and summarizing the discussion at the 

session’s end. 

EXHIBIT 4.7. Brief Alcohol Intervention Parts for Older Adults683 

After you fnd that an older adult is misusing alcohol, use a semistructured brief intervention, including the 

following steps: 

1. Ask the client about future goals for health, activities, hobbies, relationships, and fnancial stability. 

2. Adapt your feedback based on the client’s responses to screening questions relating to drinking 

patterns and other health habits (which may also include smoking, nutrition, and tobacco use). 

3. Discuss how the client’s drinking compares with that of others in his or her age group; review defnitions 

of standard drinks (one standard drink equals 12 ounces of beer or ale, one 1.5 ounce shot of distilled 

spirits, 5 ounces of wine, 3–4 ounces of sherry, or 2–3 ounces of liqueur684). 

4. Discuss the “pros and cons” of drinking if appropriate. Doing so can help you understand the role of 

alcohol in the older adult’s life, including its role in coping with loss and loneliness, without infuencing 

the client to move toward any specifc change. 

5. Give information about the effects of heavier drinking in a nonjudgmental way. Some older adults may 

have problems in physical, mental, or social abilities despite drinking within recommended limits. 

6. Discuss the client’s reasons to cut down or quit drinking. Staying independent, having good physical 

health, and keeping mental abilities can be key motivators in this age group. 

7. Offer information about drinking limits and ways to cut down or quit (e.g., participating in social 

activities that do not involve alcohol, taking up hobbies and interests from earlier in life, fnding 

volunteer activities). 

8. Create a drinking agreement. Agreed-upon drinking limits that are signed by the client and the provider 

are particularly helpful in changing drinking patterns. 

9. Discuss ways to cope with risky situations when the client may feel tempted to drink beyond agreedupon limits. Social isolation, boredom, and negative family interactions can be problems in this age 

group. 

10. Summarize the session. 

If clients are already motivated to change their drinking, exploring their mixed feelings can accidentally lead 

to “sustain talk” (i.e., talk about reasons for not changing) instead of “change talk” (i.e., talk about reasons for 

changing). Sustain talk can keep clients from making improvements. You should assess clients’ readiness 

to change at the beginning of a brief intervention. If clients appear ready to make changes, urge them to 

talk more about the positive reasons for changing their alcohol use instead of focusing on the “pros 

and cons” of changing.685,686,687,688 

Chapter 4 103 
TIP 26

Treatment of Co-Occurring Conditions 

and Disorders 

Co-occurring medical conditions and mental 

disorders can contribute to or worsen AUD. They 

can also complicate treatment of AUD in older 

adults. These conditions should be addressed at 

the same time as AUD, either by the same provider 

or provider team or through active referral to and 

care coordination with other medical or behavioral 

health services.689 Factors that will help you decide 

how to address co-occurring conditions include:690 

• The severity and duration of AUD and any cooccurring conditions. 

• Client preference. 

• Availability of services in the community. 

• The availability of care coordination among 

different providers. 

You can address co-occurring health conditions 

and mental disorders in older adults by: 

• Helping clients who do not have a primary 

healthcare provider fnd one, and referring 

them to healthcare for an indepth physical, 

including screening and assessment for: 

- High blood pressure. 

- Liver disease. 

- Osteoporosis. 

- Sleep disorders. 

- Cancer. 

- Diabetes. 

- Heart disease. 

• Screening for cognitive impairment and, 

if needed, referring for an indepth geriatric 

assessment. (See Chapter 6 of this TIP for more 

information.) 

• Providing emotional support and behavioral 

interventions instead of standard CBT for older 

adults with cognitive impairments.691 

• Assessing for other SUDs, including tobacco 

use disorder and opioid use disorder. 

• Giving clients treatment and intervention 

options for tobacco use disorder, pain 

management, and sleeping diffculties (e.g., 

CBT, relaxation training, exercise, physical 

Treating Substance Use Disorder in Older Adults 

therapy).692 Options should be scientifcally 

supported and nonpharmacological whenever 

possible. 

• Screening, assessing, and treating mental 

disorders (including depression and anxiety) 

within the scope of your practice, or referring to 

mental health services. 

• Referring for pharmacotherapy for SUDs 

or mental disorders as needed to a medical 

provider trained in older adult care. 

• Addressing mental disorders in age-sensitive/ 

age-specifc co-occurring treatment programs. 

• Following up with other providers regularly 

and keeping track of clients’ treatment 

progress together with the clients. (See the 

“Referral Management and Care Coordination” 

section.) 

The consensus panel recommends that you treat 

co-occurring medical conditions and mental 

disorders among older adults while you treat the 

AUD. 

Referral Management and Care 

Coordination 

The keys to positive outcomes in a steppedcare approach are effective management of 

referrals to the right level of treatment and 

ongoing coordination of care. You can adapt to 

many different settings the following strategies 

for referral management and care coordination for 

older adults: 

• Identify a provider (e.g., nurse manager, case 

manager, social worker) in your organization 

who can help older adults with referral and 

follow-up after referral. This provider should 

be knowledgeable of older adults’ needs and 

of age-sensitive/age-specifc resources in the 

community. 

• Identify and develop linkages to ageappropriate medical, mental health, addiction 

treatment, recovery support, and social service 

resources and programs in your community.693 

In areas where no age-specifc treatment is 

available, work with programs to offer such 

services. 

104 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

• Gather information about programs’ eligibility 

criteria, treatment length, type of treatment, 

philosophy, and continuing-care options so you 

can match clients to the right program.694 

• Keep an updated referral list of contacts and 

phone numbers of treatment resources. Keep 

on hand current information on services offered, 

cost, schedule, and accessibility.695 Contact key 

individuals in that organization, and maintain an 

ongoing relationship with them. 

• Match the referral to treatment with your 

clients’ stated goals, treatment needs, problem 

severity and available resources. 

• Include family members and caregivers in 

conversations about treatment planning, with 

clients’ permission. 

• Address your clients’ hopes for treatment by: 

- Describing the type of program to which you 

are referring clients. 

- Asking and responding to any questions they 

may have. 

- Acknowledging their worries through 

refective listening. 

- Clearing up incorrect beliefs with information 

about treatment and its usefulness. 

- Offering hope by describing other older 

adults’ positive outcomes with AUD 

treatment. 

• Address clients’ concerns about confdentiality, 

and get all necessary paperwork signed so you 

can communicate with other providers while 

your clients are in treatment. 

• Offer a “warm handoff” (i.e., introduce clients 

directly) to the care coordinator or behavioral 

health service provider in your integrated care 

organization. 

• Be prepared to take on the responsibility of 

managing the referral and coordinating care if 

you are not part of an integrated care team.696 

• Follow up with clients to make sure referral 

was successful or to make another referral if 

needed.697 

• Keep track of clients’ progress in treatment; 

work closely with other providers to offer 

ongoing care as needed. 

Higher Intensity Treatment Approaches 

for AUD 

Several scientifcally supported approaches to 

AUD treatment are a good ft for older adults 

in outpatient, intensive outpatient, or inpatient 

residential settings. Treatment approaches that 

work best for older adults with AUD who need 

more intensive treatment than a brief intervention 

include CBT, TSF, pharmacological interventions, 

and inpatient AUD treatment tailored to older 

adults. 

CBT for Older Adults 

CBT is a well-established and scientifcally 

supported approach for treating AUD as well as 

co-occurring conditions often present in older 

adults, such as depression, anxiety, pain, insomnia, 

physical disability, and other SUDs.698,699,700 

CBT includes both cognitive and behavioral 

interventions applied separately or together. CBT 

is effective for individual and group sessions. Its 

fexibility and adaptability are pluses for treating 

the complex medical and mental health concerns 

of older adults.701 Although CBT can be adapted 

to healthcare, outpatient, inpatient, and residential 

settings in which SUD treatment is available, older 

adults may have better outcomes with CBT in 

outpatient settings.702 

CBT for AUD focuses on helping clients fnd 

and change thoughts, feelings, and behaviors 

that lead to alcohol misuse. CBT assumes that 

thoughts and feelings that occur before drinking 

behaviors take place are set in motion by situations 

or cues (e.g., attending a wedding where alcohol 

is served, smelling a favorite alcoholic beverage). 

In CBT, the client learns to identify these thoughts, 

feelings, and cues and then applies skills and 

coping methods to manage them.703 

Strong evidence supports CBT’s usefulness in 

helping a wide range of client populations and 

ages, including older adults, reduce alcohol 

misuse and support and continue abstinence.704 

For older adults with memory problems, CBT 

provides a structured and educational approach.705 

Treatment programs using CBT report improved 

Chapter 4 105 
TIP 26

This chain of events is for a 72-year-old woman who recently lost her spouse. She is having trouble sleeping. 

Antecedents

Situations/Thoughts

“A drink before bed will help me 

sleep.” 

+

Feelings/Emotions

Feels lonely at night 

+

Cues/Urges

Remembers drinking brandy with her 

spouse after dinner; feels an urge to

get the brandy from the liquor cabinet 

Behavior

Alcohol Consumption

Has a glass of brandy 

before bed every night 

Consequences

Immediate/Short-Term (positive or 

negative)

Dozes off quickly; wakes up at 3 a.m.; can’t 

get back to sleep; is tired and sleepy the 

next day

Long-Term (negative)

Insomnia increases; unsteady on her feet;

falls and breaks her wrist 

Treating Substance Use Disorder in Older Adults 

drinking outcomes for older veterans with 

signifcant co-occurring medical, mental health, and 

social problems and for women with late-life onset 

of heavy drinking.706 

Given common age-related cognitive changes, CBT 

can be useful with older adults when you:707 

• Make sure the older adult remembers the

information and skills learned in counseling

sessions.

• Summarize and repeat information, cognitive

and behavioral change strategy steps, and the

client’s new awareness and insights several times

throughout and at the end of each session.

• Urge the older adult to take notes on key

points of the session, or you can take notes

and give a copy to the client at the end of the

session. Once permission is obtained from the

client, you may want to arrange for a family

member or signifcant person to attend and

learn information and skills.

• Offer handouts, forms, and reminder calls to

increase the chances that the older client will

complete between-session assignments and

tasks.

Skills-based approaches, relapse prevention, and 

PST are CBT adaptations that have been used 

successfully in the treatment of AUD among older 

adults. 

Skills-based approaches and relapse prevention 

Skills-based approaches may work well with 

older adults. Skills-based interventions focus on 

reducing health-related risks for alcohol use and 

continuing abstinence if the client decides that 

abstinence is the goal. The most commonly used 

skills-based approaches in AUD treatment that 

can be adapted for use with older adults are social 

skills training and coping skills training. 

Social skills training helps older adults grow or 

improve social networks to decrease the effects 

of substance use, loneliness, and depression in 

their lives. Social skills training helps clients keep 

existing or create new social networks that support 

reduced drinking or abstinence. A key element for 

clients with AUD is learning skills for turning down 

drinks when in social situations. 

Coping skills training helps older adults learn 

about and avoid or manage high-stress or 

high-risk situations they used to cope with by 

drinking. Key elements of coping skills training 

adapted for older adults with AUD are learning the 

ABCs (antecedents, behaviors, and consequences) 

of alcohol use, breaking down this chain of events, 

then identifying and practicing other ways of 

coping in high-risk situations.708,709 Exhibit 4.8 

depicts an example of an AUD behavioral chain for 

a 72-year-old woman. 

EXHIBIT 4.8. Drinking Behavioral Chain of Events 

Adapted from material in the public domain.710 

106 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

RPT combines social skills and coping skills 

training into a structured program that can 

be used in group or individual treatment. One 

16-week group treatment approach designed 

for older adults includes the following structured 

sections that can be repeated as needed:711 

• Identifying individual-specifc behavioral chains 

for drinking 

• Managing social pressures to drink 

• Developing coping strategies for being home 

and alone 

• Coping with negative thoughts and emotions 

related to drinking (e.g., anxiety, anger, 

depression, loneliness) 

• Managing cues that lead to drinking (e.g., 

seeing a beer commercial on television) 

• Coping with urges to drink 

• Preventing a return to drinking after a period 

of abstinence (also known as a “slip”) from 

becoming a full return to past levels of alcohol 

use and negative effects 

PST 

Older adults face many everyday stressors, 

including chronic medical illnesses and cognitive 

and physical limitations. PST is a simple approach 

that older adults can learn easily, including those 

who have mild cognitive impairment.712 PST 

assumes that fnding the best solution to everyday 

problems reduces stress. Reducing stress improves 

people’s functioning and well-being. Teaching 

people problem-solving skills helps them identify 

and apply solutions to current and future problems 

of living.713 

PST includes the following steps: 

• Identify the client’s view of the problem (i.e., 

a positive or negative view of the problem or of 

the possibility of identifying solutions). 

• Defne the problem in specifc terms. 

• Brainstorm possible solutions to the problem. 

• Review the possible solutions. 

• Select the best possible solution. 

• Use the chosen solution, and track whether it is 

useful. 

• Adjust the solution, if needed, and then use 

and review the new solution.714 

PST is widely used in many settings, including 

healthcare settings, outpatient addiction treatment, 

and home care. It is useful across age groups, 

including older adults, and across many mental 

disorders.715 

MINING THE WISDOM OF AGE AND 

LIVED EXPERIENCE 

When you work with older adults, remember that 

they have a great deal of wisdom from their life 

experience. This experience is like gold; mine it 

to help them solve their current problems. After 

you help clients defne a problem, ask, “How 

have you dealt with a similar challenge in the 

past?” or “What are some of the ways you solved 

similar problems in your life?” Talking with older 

adults about their skills and abilities empowers 

them and is a respectful and supportive way to 

help them recognize their own knowledge and 

wisdom. 

TSF 

Twelve-Step recovery support groups such as 

AA, as well as other mutual-help groups, can 

deliver positive outcomes for people with AUD. 

Such outcomes including a greater likelihood 

of stopping alcohol use, improved psychosocial 

functioning, and greater levels of self-effcacy.716 

Factors related to these improved outcomes 

include: 

• Participating in 12-Step meetings held at the 

treatment facility. 

• Attending 12-Step meetings while participating 

in outpatient or inpatient addiction treatment. 

• Attending and actively participating in 12-Step 

meetings consistently, early in the recovery 

process, and frequently (e.g., three or more 

meetings per week). 

• Participating in other 12-Step group activities 

(e.g., doing service at meetings, reading 12-Step 

literature, doing “step work,” getting a sponsor, 

calling other AA members for support).717 

• Creating nondrinking social networks.718 

• Increasing spirituality and participating 

in spiritual practices like prayer and 

meditation.719,720 

Chapter 4 107 
TIP 26 Treating Substance Use Disorder in Older Adults 

TSF therapy is a structured therapeutic approach 

that links people to, and helps them stick with, 

community-based 12-Step recovery support 

groups. TSF interventions range from 4 to 12 

sessions of individual or group treatment in 

inpatient or outpatient settings. During sessions, 

the provider: 

• Explores different 12-Step themes (e.g., 

powerlessness, personal responsibility, 

spirituality). 

• Explores the client’s attitudes about those 

themes and other aspects of 12-Step support 

groups. 

• Identifes solutions to barriers hindering the 

client’s active participation in 12-Step support 

groups. 

Some evidence exists that TSF therapy is effective 

with older adults and, like CBT, gives support, 

structure, goal direction, and opportunities for 

older adults to develop positive coping skills and 

a social network that values abstinence and a 

recovery focus.721 

RESOURCE ALERT: TSF THERAPY 

MANUAL 

The Twelve Step Facilitation Therapy Manual— 

found at https://pubs.niaaa.nih.gov/publications/ 

projectmatch/match01.pdf—was designed to 

standardize TSF therapy as a 12-session treatment 

approach for the original Project MATCH multisite 

clinical research trial. The manual, published 

by NIAAA, offers an overview of Project MATCH 

and the trial’s standardized TSF modules. The 

TSF manual is the basis for other types and 

adaptations of TSF interventions. Adapt the 

confrontational interventions described in this 

manual for older adults, who respond better to 

and are more accepting of nonconfrontational 

approaches. 

Pharmacological Interventions 

Options for pharmacological interventions 

to treat AUD are more limited for older than 

younger adults.722 Although these medications 

may work well and be safe for older adults, 

the risk of negative reactions is higher because 

older adults are more likely to have co-occurring 

medical problems, take multiple medications, and 

have a decreased ability to eliminate medications 

given age-related changes in liver and kidney 

functions.723,724 

To avoid harmful drug–drug interactions, 

prescribers must review all medications an older 

adult uses before giving a new prescription to 

treat AUD and consider a lower dose of the AUD 

medication when appropriate. 

Three medications are approved by the 

Food and Drug Administration to treat AUD, 

but clinicians should note for each of these 

the effectiveness and safety profle in older 

adults specifcally. Furthermore, none of these 

medications have been studied across numerous 

long-term, randomized, controlled trials of 

older populations.725 This limits understanding of 

their true benefts and drawbacks to older clients. 

Nonetheless, potential pharmacologic options and 

some of their considerations include: 

• Acamprosate, which reduces symptoms of 

protracted withdrawal from alcohol, such as 

sleep and mood problems, by altering brain 

changes related to alcohol use.726 It can also 

reduce craving and the pleasurable effects of 

alcohol.727,728 Not enough research exists on 

the effcacy and safety of acamprosate in older 

adults. Because it is removed from the body 

through the kidneys, healthcare providers 

should frst evaluate and then monitor renal 

function in older clients.729,730 

• Naltrexone, which reduces craving and the 

pleasurable effects of alcohol.731 It comes in 

an oral formulation that is taken daily or an 

injectable formulation that requires a monthly 

visit to a healthcare provider. A very small 

number of studies suggest that naltrexone may 

be tolerable in adults ages 50 and older, but 

widespread data on its tolerability in older aged 

108 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

individuals are missing.732 Prescribers should 

consider the following: 

- Naltrexone is removed from the body 

through the liver and should be used 

cautiously in older adults with possible liver 

problems.733 

- Naltrexone blocks the effects of opioids 

used to treat chronic pain, which is common 

in older adults.734 A client who begins 

naltrexone treatment while still taking opioids 

can suffer acute opioid withdrawal serious 

enough to require hospitalization.735,736 

Ask older adults about their use of 

opioid pain medication before starting 

naltrexone treatment. (See SAMHSA's TIP 

63, Medications for Opioid Use Disorder 

[https://store.samhsa.gov/product/TIP-63-

Medications-for-Opioid-Use-Disorder-FullDocument/PEP20-02-01-006], for more 

information about naltrexone.) 

- Naltrexone can trigger symptoms of major 

depression, including suicidal ideation.737 

Closely watch older adults with a history of 

depression who take naltrexone.738 

- Although naltrexone’s potential side effects 

are relatively benign (e.g., dizziness, nausea, 

reduced appetite, increased daytime 

sleepiness), they can be signifcant in older 

adults.739 Clinicians should monitor older 

clients appropriately. 

• Disulfram, which triggers an acute physical 

reaction to alcohol, including fushing, fast 

heartbeat, nausea, chest pain, dizziness, and 

changes in blood pressure. It is prescribed 

to motivate people to abstain from alcohol. 

Because these effects can be harmful to 

older people, disulfram is generally not 

recommended for use with older adults and, if 

used, is done so only with great caution.740,741 

Physicians and other providers must closely 

monitor older clients taking disulfram for the 

occurrence of these effects. Additionally, family/ 

caregivers may need to supervise older adults 

taking disulfram to make sure they take it 

correctly and do not take it while continuing 

to use alcohol, which can lead to serious 

complications.742 

RESOURCE ALERT: MEDICATIONS 

FOR AUD 

For more information about medications for AUD, 

including dosing considerations for older adults, 

see SAMHSA’s Medication for the Treatment 

of Alcohol Use Disorder: A Brief Guide (https:// 

store.samhsa.gov/product/Medication-for-theTreatment-of-Alcohol-Use-Disorder-A-BriefGuide/SMA15-4907). 

Medical Management Counseling 

Older adults with AUD who have no access 

to addiction-specifc treatment and do not 

need medically supervised withdrawal can get 

treatment in general healthcare settings with 

pharmacological interventions and brief treatment. 

Medical management counseling for this approach 

includes: 

• Providing feedback on lab tests that show 

potential drinking-related health issues. This 

feedback can help increase motivation to 

change drinking habits. 

• Recommending abstinence as the safest 

course while supporting movement toward that 

goal. 

• Frequently checking that the older adult is 

taking his or her medication as prescribed, 

then reducing the frequency of visits after an 

appropriate period of abstinence. 

• Actively linking the older adult to supports, 

such as to AA or other mutual-help and recovery 

support groups (see the “Recovery Support 

Groups” section) that welcome older adults. 

• Urging and supporting active participation in 

recovery activities. 

Brief medical management counseling and 

following clients to make sure they take AUD 

medications as prescribed can help individuals with 

AUD stop drinking and remain alcohol free.743 

Chapter 4 109 
TIP 26

The consensus panel recommends using 

medications to treat AUD in older adults when 

necessary. Key parts of pharmacotherapy for older 

adults include: 

• Carefully reviewing potentially harmful drug– 

drug interactions. 

• Using lower doses of medications. 

• Following up with clients and making sure they 

take medications as prescribed. 

• Linking clients to recovery supports. 

Inpatient AUD Treatment for Older Adults 

Inpatient treatment can be a good ft for older 

adults who: 

• Meet criteria for AUD. 

• Have co-occurring health and mental health 

concerns. 

• Need medically supervised withdrawal. 

• Chose abstinence as their primary treatment 

goal. 

Inpatient treatment may be limited to medically 

supervised withdrawal followed by active referral 

and immediate start of outpatient or IOP specialty 

treatment or can include a longer residential stay 

for an indepth recovery-oriented rehabilitation 

program.744 All inpatient treatment programs 

should use age-sensitive practices for older 

adults (Exhibit 4.6). 

Medically supervised withdrawal 

Alcohol withdrawal symptoms in older adults can 

differ in severity, may occur 7 days or longer after 

the last drink, and are more likely to happen in 

people who have had withdrawal symptoms in the 

past.745 Detoxifcation, also known as medically 

supervised withdrawal, should consider the unique 

aspects of alcohol withdrawal in older adults: 

• Older adults are more likely to have delirium 

(i.e., rapid onset of a confused mental state) 

during withdrawal, which may be mistaken for 

early signs of dementia.746 

• Typical withdrawal symptoms may be less 

obvious yet last longer in older adults.747 Typical 

withdrawal symptoms include: 

- Autonomic hyperactivity (e.g., increased 

pulse rate, blood pressure, and temperature). 

Treating Substance Use Disorder in Older Adults 

- Restlessness. 

- Sleep problems. 

- Anxiety. 

- Nausea. 

- Tremor (shaking/shivering). 

• Withdrawal may worsen other medical issues 

(e.g., heart disease, diabetes) and mental 

disorders (e.g., depression, anxiety) in older 

adults.748 

• Older adults are at greater risk than younger 

adults for alcohol withdrawal-related medical 

and neurological problems. This is because 

older adults have higher rates of co-occurring 

physical and mental disorders and cognitive 

impairments and an increased sensitivity to 

medications used to treat withdrawal symptoms 

(e.g., benzodiazepines).749 Watch older adults 

closely for signs of delirium or seizures during 

withdrawal. 

Older adults may be at greater risk for harmful 

drug events during medically supervised 

withdrawal if they are taking medications 

to treat other medical conditions. Conduct 

an indepth assessment and continue to follow 

clients to learn: 

• Which medications are being taken for other 

medical conditions. 

• The client’s risk of falls while being treated with 

common medications for managing withdrawal 

symptoms (e.g., benzodiazepines). 

• Which co-occurring medical conditions are 

present (e.g., heart disease, breathing problems, 

diabetes, cognitive impairment). See Chapter 6 

for more information about assessing cognitive 

impairment in older adults. 

RESOURCE ALERT: TIP 45, 

DETOXIFICATION AND 

SUBSTANCE ABUSE TREATMENT 

SAMHSA’s TIP 45 offers guidance for medically 

supervised alcohol withdrawal and additional 

information about older adults (https://store. 

samhsa.gov/product/TIP-45-Detoxifcation-andSubstance-Abuse-Treatment/SMA15-4131). 

110 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

To reduce the risk of complicated withdrawal, 

older adults should complete medically 

supervised withdrawal in a medically supervised 

inpatient facility.750 The revised Clinical Institute 

Withdrawal Assessment of Alcohol Scale–Revised 

(CIWA-Ar) is an objective measure of alcohol 

withdrawal and shows the use and dosage of 

medications (e.g., short-acting benzodiazepines) 

to ease withdrawal symptoms. See “Resource 

Alert: Clinical Institute Withdrawal Assessment of 

Alcohol Scale–Revised (CIWA-Ar).” However, the 

CIWA-Ar may not be as accurate for older adults 

with co-occurring medical conditions that hide or 

increase withdrawal symptoms.751 Treatment during 

withdrawal should be based on your knowledge 

of the unique physiology of older adults, clinical 

judgment, and close tracking of clients. 

RESOURCE ALERT: CLINICAL 

INSTITUTE WITHDRAWAL 

ASSESSMENT OF ALCOHOL 

SCALE–REVISED (CIWA -Ar) 

The CIWA-Ar is available for download at https:// 

umem.org/fles/uploads/1104212257_CIWA-Ar.pdf. 

Age-specifc treatment 

Age-specifc treatment for older adults helps 

support clients in seeking, entering, and staying 

in treatment. It also improves their treatment 

experience.752 Whereas some older adults beneft 

from mixed-age treatment, other older adults are 

more likely to beneft from age-specifc treatment, 

such as those with more chronic co-occurring 

health conditions and problems with functioning, 

and those ages 75 and older.753 Research shows 

positive outcomes; for instance, 60 percent to 85 

percent of older adults who participated in agespecifc inpatient treatment programs were still 

abstinent 12 months after leaving treatment.754 

These programs offered:755 

• Individual and group therapy and community 

activities. 

• Adaptations for older adults (e.g., slower pace; 

adaptations for vision, hearing and cognitive 

needs). 

• Special topic groups for older adults that 

focused on grief, loss, isolation, physical health 

issues, recreation, and life changes. 

• A nonconfrontational therapeutic approach 

highlighting the therapeutic alliance while using 

CBT, MI, and a 12-Step philosophy. 

PARTS OF A SUCCESSFUL INPATIENT 

REHABILITATION PROGRAM FOR 

OLDER ADULTS 

Positive outcomes have been achieved by 

inpatient SUD rehabilitation programs for older 

adults that use: 

• Nonconfrontational group therapy for grief, 

denial, anger, shame, age-related loss, and 

loneliness. 

• CBT and dialectical behavioral therapy (DBT) 

focusing on: 

- Teaching clients how to manage distress, 

how to control emotions, and how to improve 

relationship skills. 

- Allowing people to rebuild social-support 

networks. 

- Using self-awareness to deal with grief, 

loneliness, and depression. 

• Medical and mental health services, including 

24-hour access to nursing care. 

• Personal care aides, if needed. 

• Health and wellness activities, including: 

- Massage. 

- Acupuncture. 

- Hydrotherapy. 

- Movement therapy. 

- Meditation. 

- Mindfulness practice. 

• Family involvement in treatment. 

• Active links to medical, social, and case 

management services. 

Chapter 4 111 
TIP 26

Recovery Management 

Per SAMHSA, recovery is “a process of change 

through which individuals improve their health and 

wellness, live a self-directed life, and strive to reach 

their full potential.”756 Recovery management is an 

organizing philosophy for addiction treatment and 

recovery support services to help individuals and 

family members achieve and continue long-term 

addiction recovery. Not everyone who misuses 

alcohol needs ongoing recovery management 

support, but some older adults may beneft from 

ongoing tracking and recovery support, including 

those with:757 

• Co-occurring medical conditions or mental 

disorders. 

• Social isolation. 

• Little support from family and friends. 

Recovery support for older adults who misuse 

alcohol can begin after a brief intervention in a 

healthcare setting or while the older adult is in 

mental disorder or AUD treatment (Exhibit 4.5). 

However, ongoing recovery management is most 

like the continuing care approach to addiction 

treatment and to the philosophy of ongoing illness 

management in the treatment of chronic medical 

illnesses like diabetes. In the addiction treatment 

research, some of the continuing care interventions 

that work well for older adults and show positive 

effects include:758 

• Home visits. 

• Telephone counseling. 

• Recovery checkups. 

• Linkages to community resources, such as 

recovery support groups. 

In addition, using case management services and 

helping supportive family members participate in 

the older adult’s treatment can support ongoing 

recovery. 

Case and Care Management Services 

Case and care management (CCM) services focus 

on helping older adults reduce the health-related 

risks of alcohol misuse and enter addictionspecifc treatment when necessary. CCM models 

can be particularly helpful to older adults who 

Treating Substance Use Disorder in Older Adults 

are isolated, because the CCM provider can offer 

services: 

• In the client’s home. 

• By phone. 

• Through videoconferencing. 

• At the healthcare provider’s offce. 

• In community-based social service settings. 

• In residential or long-term care facilities. 

For older adults, whose social networks tend 

to get smaller with age, CCM strategies should 

focus on connecting them to age-related 

resources in the community that support 

recovery. The CCM provider helps clients access 

medical, mental health, social, fnancial, education, 

work-related, and other community-based services. 

Nurse care managers, social workers, addiction 

treatment or mental health counselors, or peer 

recovery supporters can offer CCM. CCM services 

often lead to positive outcomes for older adults 

with AUD or co-occurring medical conditions or 

mental disorders.759 

CCM models may be particularly good at 

supporting and keeping older adults in treatment 

and offering a complete approach to addressing 

the needs of older adults with complex medical 

and mental health issues. CCM services are part of 

a comprehensive approach. They focus on overall 

health improvement, which is a common goal 

among older adults, rather than just addressing 

AUD (which may feel uncomfortable or shameful 

to older adults).760 Program reviews of CCM 

approaches support case management as a key part 

of a long-term recovery management approach for 

older adults with AUD.761 

Caregiver Involvement 

Involving caregivers throughout treatment 

and ongoing recovery can help improve an 

individual’s chances of staying in AUD treatment. 

It can also improve AUD treatment outcomes.762 

However, the client must give permission for you 

to involve others in their treatment. Issues of 

confdentiality and protection of dignity are highly 

important. You should know whom the older 

adult trusts or prefers for support. Caregivers 

may include a spouse or partner, adult children, 

112 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

siblings, or extended family members, friends, or 

neighbors. Caregivers may be family members or 

individuals signifcant to the older adult who might 

be involved in the older adult’s health decisions. 

Caregivers: 

• Often make the frst contact with treatment 

services and should be involved in the initial 

assessment of the older adult (with the older 

adult’s permission). 

• Often supply strong motivation for the older 

adult to enter treatment. 

• Can also offer important details about the older 

adult’s drinking history and health-related risks 

related to current alcohol use. 

• Should also be involved throughout 

treatment, including during development of a 

posttreatment recovery plan for the older adult 

and ongoing recovery support. 

Ways to involve a caregiver in AUD treatment 

include helping the caregiver: 

• Develop contingency contracts for specifc 

AUD behaviors (e.g., taking AUD treatment 

medication, attending mutual help and 

recovery support groups, effects of returning to 

drinking).763 

• Improve daily interactions and reinforce positive 

communication. 

• Find caregiver education groups where 

caregivers learn and share with others. 

• Develop and engage in shared recreational 

activities as alternatives to drinking. 

• Reinforce positive change (e.g., praising steps to 

reduce or stop alcohol use). 

• Develop constructive problem-solving skills 

(e.g., how to identify relapse triggers and 

respond with coping skills or strategies to 

prevent relapse, how to reengage with the 

recovery plan). 

• Respond more effectively to the older adult’s 

drinking (e.g., make sure the older adult is safe, 

then follow through with the consequences 

agreed to in the contingency contract instead of 

arguing or judging; encourage reengagement 

with the recovery plan and return to treatment if 

needed). 

RESOURCE ALERT: HOW TO TALK 

TO AN OLDER PERSON WHO HAS 

A PROBLEM WITH ALCOHOL OR 

MEDICATIONS 

This easy-to-read online article for family 

members and concerned others offers 

information about how to identify signs that the 

older adult may be misusing alcohol, how to talk 

with the older adult in a nonconfrontational way, 

and how to get help (www.hazeldenbettyford.org/ 

articles/how-to-talk-to-an-older-person-who-hasa-problem-with-alcohol-or-medications). 

A legal guardian (who may or may not be 

a family member) should participate in the 

treatment and recovery process for an older 

adult with cognitive impairment who cannot 

manage his or her own affairs. When a guardian 

has the healthcare power of attorney, the guardian 

should sign releases to speak with all providers 

involved in the older adult’s treatment. 

Addressing Caregiver Needs 

Family members and others signifcant to older 

adults with AUD often take on the role of 

caregivers and case managers, particularly when 

co-occurring chronic medical conditions (e.g., 

diabetes) or mental/neurocognitive disorders (e.g., 

depression, dementia) are involved. Caregivers 

often get left out of treatment decisions and 

recovery planning, despite their commitment to 

and important role in the care and ongoing health 

management of these older adults.764 

Because of the stress of this responsibility and 

lack of support, caregivers can develop healthrisk behaviors, such as sleep disorders, poor diet, 

smoking, alcohol use, and substance misuse. 

Caregivers may ignore their own care, which may 

worsen their own chronic medical conditions or 

increase their risk of stress-related illnesses.765 You 

can help address caregivers’ needs by:766 

• Identifying primary caregivers by reviewing 

clients’ medical records.767 Make sure all 

necessary paperwork is signed to allow family 

members and other providers to speak with one 

another. 

Chapter 4 113 
TIP 26 Treating Substance Use Disorder in Older Adults 

• Involving them in the treatment and recovery 

planning process. 

• Asking them about their own use of alcohol 

and other substances and history of mental 

disorders. 

• Screening, assessing, and referring them to 

treatment for SUDs or mental disorders as 

needed. 

• Supporting their use of healthy self-care 

activities, such as: 

- Getting enough sleep. 

- Eating a healthy diet. 

- Quitting smoking. 

- Exercising moderately. 

- Getting an annual physical with their primary 

care provider. 

- Reducing or avoiding alcohol use. 

• Reminding them to ask for help from other 

family, friends, community members, or social 

service agency representatives who may be able 

to offer respite care. 

• Exploring available caregiver supports in the 

community, such as the local Area Agency on 

Aging. (See “Resource Alert: Community-Based 

Supports for Caregivers.”) 

• Urging them to participate in mutual-help 

groups (e.g., Al-Anon, caregiver support 

groups). 

• Reminding them to take breaks from the 

caregiver role. 

• Pointing out that they are still the relative, 

spouse, or partner of the older adult, and that 

relationship has meaning and can still give them 

satisfaction. 

RESOURCE ALERT: COMMUNITY -

BASED SUPPORTS FOR 

CAREGIVERS 

For more information on Al-Anon family groups 

and fnding local/online meetings, go to https:// 

al-anon.org. 

For more information about local and online 

caregiver support groups for family members 

of older adults with dementia, go to www.alz.org/ 

events/event_search?etid=2&cid=0. 

Recovery Support Groups 

Older adults who have social supports that 

reinforce abstinence from alcohol have better 

outcomes in long-term AUD recovery than older 

adults without those social supports. 

768 Two key 

factors for older adults in continuing recovery over 

time are having people in their lives who support 

their recovery and not having people in their social 

networks who encourage or enable alcohol use.769 

A key factor in long-term recovery for older 

adults is not having people in their social 

networks who encourage alcohol use. 

Community-based recovery support groups 

highlight the importance of developing social 

relationships that support recovery rather than 

drinking.770 Although a growing range and number 

of recovery support groups are available to adults 

who have AUD, AA and SMART Recovery are 

widely available and may be the most useful 

supports for older adults. 

AA 

AA is the most well known and widely available 

recovery support group for older adults with 

AUD. It offers a community-based, long-term 

recovery management approach to treating 

AUD. AA meetings and activities following 

treatment can be cost-effective sources of 

ongoing social support.771 Key elements of AA 

especially well suited to older adults include:772,773 

• Decreasing social ties that support drinking. 

• Increasing social ties that support abstinence. 

• Providing social support, goal direction, and 

structure. 

• Offering opportunities to participate in 

substance-free social activities. 

• Helping participants improve their self-effcacy 

and coping skills. 

Research on AA has found that older adults 

who attend more group meetings and have a 

sponsor have better 1-year alcohol-related and 

mental stress outcomes and less alcohol use at 

114 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

5-year follow-up than those who do not.774 The 

structured social support of AA may help older 

adults whose social networks have become smaller 

by improving their interpersonal and social coping 

skills.775,776 

Some research has found that older adults are 

less likely to attend AA meetings than younger 

adults. Results are mixed on older adults’ level of 

involvement in AA meetings compared with that 

of younger AA members.777,778 Sometimes older 

adults feel shut out by the culture, language, and 

experiences of younger adults in AA meetings. 

However, other evidence indicates that older 

adults’ membership in AA is increasing. The AA 

Membership Survey showed increases from 2007 to 

2014 in members ages 61 to 70 (from 12.3 percent 

to 18 percent) and in members ages 71 and older 

(from 5.3 percent to 7 percent).779 

Starting and staying in AA may be challenging 

for older adults with AUD, but not participating 

may put older adults at increased risk for return to 

alcohol use and negative long-term outcomes.780 

When older adults do participate in AA, they 

beneft by:781,782 

• Having better drinking-related outcomes. 

• Feeling less stress. 

• Participating in more spiritual practices. 

• Increasing social interactions and support. 

• Having improved recovery. 

BARRIERS TO AA ATTENDANCE FOR 

OLDER ADULTS783 

• Lacking transportation 

• Facing physical limitations 

• Feeling uncomfortable going to meetings at 

night 

• Having smaller social networks because of 

aging 

• Having less interest than younger adults in 

increasing their social networks 

• Relying on a spouse for recovery support 

SMART Recovery 

SMART Recovery is a network of local and online 

abstinence-focused recovery support groups that 

is based on principles of CBT and MI. Unlike AA 

meetings, SMART Recovery meetings are run by 

trained volunteers. The SMART program784 is based 

on helping people: 

• Build and keep motivation. 

• Cope with urges. 

• Manage thoughts, feelings, and behaviors. 

• Live a balanced life. 

The principles and structured format of SMART 

Recovery follow CBT and MI approaches to 

treating older adults. Research suggests that it 

is as effective as other community-based mutualhelp approaches in supporting abstinence and 

in reducing the severity of the effects of alcohol 

misuse, particularly for people with less severe 

AUD.785 SMART Recovery may also be an important 

option for those who feel uncomfortable with the 

spiritual underpinnings of AA and the 12-Step 

approach. Although the mutual-help group is less 

available in some areas of the country, online or 

telephone meetings are becoming more popular in 

all recovery support groups. 

The program does not support use of labels such 

as “alcoholic,” which may beneft older adults who 

feel shame and fear discrimination or judgment 

because of having AUD. SMART Recovery, like 

AA, offers chances for older adults to improve 

their recovery and quality of life by serving as 

volunteers. 

RESOURCE ALERT: SMART 

RECOVERY WEBSITE 

The SMART Recovery website (www. 

smartrecovery.org) gives information about 

SMART Recovery principles and training 

opportunities, including how to become a 

facilitator for meetings. It also has a searchable 

database of local and online meetings. 

Chapter 4 115 
TIP 26

You can help older adults become involved in 

mutual-help groups by: 

• Actively linking clients to available mutual-help 

groups, and supporting them in trying different 

groups so that they can fnd the one that best 

fts their needs. 

• Asking clients about their understanding of and 

any past participation in mutual-help groups. 

• Discussing the benefts of being involved in 

mutual-help groups as a part of recovery. 

• Exploring ways to overcome barriers to joining 

and participating in mutual-help groups. 

• Contacting local, regional, or state AA groups 

or other mutual-help groups or recovery 

community organizations (RCOs; see text box) 

to ask about community outreach efforts for 

older adults. 

• Helping older clients fnd an age-friendly home 

group with older adult participants or a Seniors 

in Sobriety meeting (see “Resource Alert: 

Seniors in Sobriety”). 

• Linking older adults to mutual-help group 

volunteers/peer recovery support specialists 

who can introduce them to the group, attend 

some meetings with them, and introduce them 

to other older members. 

• Teaching them about sponsorship and how 

clients can fnd an AA sponsor or mutual-help 

group mentor who can guide them in the 

recovery process. 

RESOURCE ALERT: SENIORS IN 

SOBRIETY 

Since 1990, AA has actively reached out to older 

adults with AUD. Efforts include urging local 

meetings to be senior friendly and starting 

Seniors in Sobriety (SIS) meetings. The SIS 

website (www.seniorsinsobriety.com/) has 

information on SIS’s history, focus, and annual 

conference and other meetings. 

Treating Substance Use Disorder in Older Adults 

WHAT IS AN RCO? 

“A recovery community organization (RCO) 

is an independent, nonproft organization 

led and governed by representatives of local 

communities of recovery. These organizations 

organize recovery-focused policy advocacy 

activities, carry out recovery-focused community 

education and outreach programs, and supply 

peer-based recovery support services (P-BRSS).”786 

Search for an RCO near you (https:// 

facesandvoicesofrecovery.org/arco/arcomembers-on-the-map/). 

The consensus panel recommends that you 

actively link older clients to age-sensitive case 

management and ongoing recovery supports for 

older adults. Family, caregivers, and communitybased mutual-help groups are key elements of 

recovery support for older adults. 

Clinical Scenarios 

The level of intensity of clinical interventions 

for older adults should match the severity 

of alcohol misuse. Interventions range from 

healthcare providers asking clients about their 

alcohol use during an annual screening to inpatient 

treatment for older adults who have AUD. Exhibit 

4.9 shows how to match levels of health-related 

risk associated with alcohol misuse with different 

clinical interventions. 

The higher up the pyramid, the higher the level of 

risk and the more intense the intervention. In this 

graphic, the level of health-related drinking risk is 

defned as follows: 

• Abstinence: Does not currently use alcohol. 

• Low-Risk Drinking: Drinks within recommended 

limits. 

• Moderate-Risk Drinking: Drinks above 

recommended limits. 

• High-Risk Drinking: Binge drinks or drinks 

above recommended limits and has a cooccurring health condition or mental disorder. 

• AUD: Meets DSM-5 diagnostic criteria for AUD. 

116 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

The following clinical case scenarios are examples 

of different levels of alcohol misuse. They show 

how to use prevention strategies and clinical 

interventions that match risk levels in Exhibit 4.9. 

EXHIBIT 4.9. Alcohol Health-Related Risk and Treatment Response 

Pyramid787,788,789 

Clinical Scenario: Abstinence 

During the initial screening for alcohol misuse, 

ask about earlier alcohol use even if the older 

adult reports that he or she does not drink at all. 

The older adult may have always abstained from 

alcohol, identify as being in recovery, or have 

stopped drinking for health-related reasons, which 

is common as people age. The following clinical 

scenario shows the importance of asking about 

earlier alcohol use when deciding which treatment 

to offer. 

• Abstinence: An older adult reports no alcohol 

use in the past 3 years. 

• Treatment Setting: Outpatient healthcare clinic 

• Provider: Nurse practitioner (NP) 

• Prevention/Treatment Strategies: Ask about 

earlier alcohol use; support abstinence using a 

brief problem-solving intervention. 

George is 76 years old and has been divorced 

for 5 years. He recently moved to a retirement 

community near his oldest daughter. He goes 

to see a new primary care provider for an initial 

medical exam. As part of the health history 

questionnaire, which includes the AUDIT, George 

says that he does not currently drink, but he was 

injured earlier because of his drinking. His primary 

care provider reviews George’s questionnaire and 

Chapter 4 117 
TIP 26

sees that George does not meet the AUDIT criteria 

for alcohol misuse but fags the item about alcoholrelated injury. 

During the clinical interview, the provider 

asks about an item on the AUDIT in a curious, 

nonjudgmental way. The NP says, “I noticed on 

the health questionnaire that you may have been 

injured after drinking. Can you tell me more about 

that?” George says that he used to drink from 

time to time, but 3 years ago he twisted his ankle 

badly after having a couple of drinks and had to 

use a walker for several weeks. He tells the NP that 

he decided not to drink at all because he didn’t 

want to risk any more injuries. The NP praises 

his commitment to his health and urges him to 

continue to avoid drinking. 

George feels comfortable opening up to the NP 

and says that since he moved to the retirement 

community, he has participated in a lot of social 

activities with alcohol. He likes socializing but 

feels uncomfortable when people offer him drinks 

all the time. He says, “I know they are just being 

friendly, but sometimes they just don’t give up.” 

George states that he does not want to drink but 

does want to keep going to the social activities. 

The NP uses brief problem-solving by asking 

George, “How have you dealt with a challenge like 

this in the past?” The NP then invites George to 

brainstorm some solutions to the current problem, 

including ideas from his earlier struggles. George 

decides that he can say “no” frmly and tell people 

that alcohol doesn’t agree with him when they 

continue to urge him to drink. George states that 

he feels good about that solution and will try 

it out at the next social event. The NP writes a 

treatment note about George’s chosen solution 

in the electronic medical record and gives him a 

copy, telling him that if this plan doesn’t work to 

schedule a follow-up visit soon. 

Clinical Scenario: Low-Risk Drinking 

For many older adults, the relationship with 

their primary care provider is often one of their 

strongest and most stable. The annual physical 

is a chance to screen for alcohol misuse and any 

changes in alcohol use related to life events, such 

as a death in the immediate family. The following 

Treating Substance Use Disorder in Older Adults 

REMINDER ABOUT DRINKING IN 

RETIREMENT COMMUNITIES 

Hazardous drinking may be more common 

among older adults in age-separated residential 

settings (e.g., continuing care and planned 

retirement communities) than communitydwelling older adults. A recent survey reported 

that 15.4 percent of people who took the survey 

and live in a large retirement community had 

hazardous drinking compared with around 10 

percent in the general older adult population.790 

Although older adults in these settings may 

drink to cope with problems, they usually drink 

because they want to socialize, and they believe 

that their peers affect their drinking.791 Avoiding 

alcohol in these settings can be a challenge for 

older adults. 

scenario addresses the importance of conducting 

an annual screen for alcohol misuse with older 

adults and shows how to actively link clients to a 

referral for grief counseling and care coordination. 

• Low-Risk Drinking: An older adult drinks 

within recommended guidelines and has no 

co-occurring physical or mental illness that limits 

daily functioning. 

• Treatment Setting: Integrated outpatient 

medical and behavioral health clinic 

• Providers: Primary care provider (PCP); licensed 

clinical social worker 

• Prevention/Treatment Strategies: Screen for 

alcohol misuse, depression, and stressors that 

may put the older adult at risk for increased 

alcohol use; supply information on drinking 

guidelines for older adults; offer a menu 

of options for addressing grief; coordinate 

follow-up care. 

Lily is 80 years old. Her husband of 60 years died 

6 months ago. Lily goes to her doctor for her 

annual physical. Her PCP tells Lily that she is sorry 

to hear about her husband’s death. They talk for 

a few minutes about how she is doing and what 

kinds of recreational activities and social support 

she has in her life right now. Lily tells her PCP that 

she belongs to the local church and is still active 

118 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

in volunteer activities there. Her son and her 

granddaughter live nearby and visit on a regular 

basis. She goes to an arts and crafts class on 

Wednesday afternoons at the local senior center. 

The PCP then tells Lily that she wants to ask her 

a few more questions about her health, including 

alcohol use, if that is okay with her. Lily feels 

comfortable talking with her PCP and agrees. The 

PCP mixes in questions from both the AUDIT and 

the SMAST-G with her general health questions. 

Lily says that she drinks one 5-ounce glass of white 

wine two to three times a week (an AUDIT score of 

three) and sometimes has another drink when she 

feels lonely (an SMAST-G score of one), but she has 

not used more alcohol since her husband died. She 

says, “If I drink too much, I feel lightheaded, and I 

worry that I’ll fall and break something.” 

The PCP offers information on drinking guidelines 

and praises Lily for staying within those guidelines. 

The PCP then tells her that sometimes when older 

people lose a spouse, they may start drinking a 

bit more when they feel sad or lonely or they may 

simply lose track of how much they are drinking. 

The PCP tells Lily to call her if that happens. Lily 

says she will, then states, “You know, I have been 

feeling a bit blue in the past few weeks, and I 

haven’t been sleeping well. I really miss him.” 

The PCP follows up on Lily’s statement by saying, 

“It seems like you are keeping busy and have a lot 

of good support in your life. At the same time, I am 

wondering if it would be helpful to have someone 

other than your family to talk to about how you 

have been feeling recently. I can suggest a few 

options if you are interested.” Lily says that she 

doesn’t like to burden her family and that talking 

to someone might be good. The PCP offers two 

suggestions: “There is a grief support group at the 

same senior center where you take your arts and 

crafts class. Or, I can introduce you to a counselor 

right here at the clinic who knows a lot about 

helping folks with loss.” Lily says she wouldn’t feel 

comfortable talking in a group. The PCP describes 

the counselor with whom she would like Lily to 

talk. Lily agrees to meet her after the appointment 

with the PCP. The PCP also conducts an initial 

depression screening. 

The PCP arranges a follow-up phone call for Lily 

from the nurse care manager who will coordinate 

care with the PCP and the counselor. The PCP then 

walks Lily over to the licensed clinical social worker 

at the clinic and does a “warm handoff.” The 

licensed clinical social worker talks briefy with Lily, 

gives her a large-print handout that explains the 

grieving process, and schedules a follow-up visit 

that includes a depression assessment. (See the 

Chapter 4 Appendix for a large-print handout on 

grief for older adults.) 

Clinical Scenario: Moderate-Risk 

Drinking 

All too often, spouses of people who misuse 

alcohol drink as a shared social activity with their 

spouse. For older spouses, this can easily turn into 

their own health risk behavior, particularly if, to 

reduce the stress of being a caregiver, they take 

medication that negatively interacts with alcohol. 

The following scenario focuses on the importance 

of assessing family members’ alcohol and 

medication use while at the same time addressing 

their needs as caregivers. 

• Moderate-Risk Drinking: An older adult drinks 

above recommended limits while also taking a 

sedating medication. 

• Treatment Setting: Outpatient behavioral 

health program 

• Provider: Behavioral health service provider 

(provider) 

• Prevention/Treatment Strategies: Supply 

information about drinking guidelines; screen 

for anxiety; give information about risks for 

alcohol and medication use; explore strategies 

for family members to address the spouse’s 

drinking and to address caregiver needs. 

Rose is 69 years old. She is married to Ed, who is 

78 years old. Ed drinks heavily daily, has a history 

of bipolar disorder, and recently was diagnosed 

with early-stage dementia. Ed sees the same PCP 

as Rose and also sees a psychiatrist for medication 

management for bipolar disorder. Rose is growing 

more worried about Ed’s drinking and is unsure of 

how to take care of him as his dementia worsens. 

Chapter 4 119 
TIP 26 Treating Substance Use Disorder in Older Adults 

Rose calls an outpatient behavioral treatment 

program after a friend of hers tells Rose that she 

is worried about Rose’s health. The friend also 

recommends a counselor she had seen there. 

At the initial appointment, the provider assesses 

Rose’s substance use. Rose reports that she drinks 

one to three standard glasses of wine about 

three to four times a week when she and Ed go 

out to dinner or to social events. She also tells 

the counselor that she takes a benzodiazepine 

prescribed by her PCP about one to two times a 

week when she can’t sleep. Rose states, “When 

Ed drinks at night, he becomes aggressive and 

sometimes gets very confused. I worry about him 

so much that I can’t get to sleep.” 

The counselor acknowledges Rose’s distress about 

Ed’s drinking, then asks her if it would be okay to 

talk with her briefy about her drinking and use 

of benzodiazepines. Rose agrees. The counselor 

offers this personalized feedback to Rose: “Based 

on what you have told me about your own 

drinking, it looks like you are drinking over the 

recommended guidelines on the days you have 

more than one drink a day. Also, you may not be 

aware that the sleep medication you are taking can 

increase the depressant effect of alcohol in your 

body and could put you at risk for oversedation, 

memory loss, and even overdose if you forget how 

much you had to drink or mistakenly take too many 

pills.” The counselor asks Rose what she makes 

of this information. Rose says, “I had no idea that 

drinking and taking sleep medication might be so 

dangerous. It also makes me think that I might not 

be helping Ed with controlling his drinking if I drink 

with him.” 

After exploring possible strategies to address her 

own health risks, Rose decides that she will stop 

drinking completely while she is taking the sleep 

medication and tell Ed why she can’t drink with him 

when they go out. The counselor supports Rose’s 

decision and suggests that one way she can help 

Ed is to fnd positive recreational activities that they 

can share without drinking. Rose becomes excited 

and says she can think of several things they can do 

together that they both enjoy without drinking, like 

going to lectures at the local senior adult education 

program. 

The counselor then asks Rose to tell her more 

about her diffculties with worry and sleep, and 

conducts an anxiety screening. They also explore 

self-care strategies for managing worry and getting 

to sleep. Rose decides she can tell Ed that she is 

going to sleep in another room if he is up late and 

has been drinking. The counselor then teaches 

Rose a relaxation exercise she can do before bed, 

and Rose practices it in the session. Rose agrees to 

talk with her doctor about less risky medication for 

sleep. 

RESOURCE ALERT: OLDER 

ADULTS AND SLEEP 

The National Institute on Aging has a webpage 

with information and useful tips for helping older 

adults get a good night’s sleep (www.nia.nih.gov/ 

health/good-nights-sleep). 

The counselor shifts the conversation to what 

further support Rose may need to address Ed’s 

drinking while taking care of herself. Rose identifes 

her PCP and Ed’s psychiatrist as potential supports. 

She states that Ed has given permission for her 

to talk with both. The counselor suggests she ask 

both to discuss Ed’s drinking with him, state frmly 

that Ed should not drink at all, and then put their 

recommendations in writing. Both Ed and Rose 

can then refer to the recommendations instead of 

getting into an argument about his drinking. Rose 

likes this idea and feels confdent that she can 

express her concerns to both of Ed’s providers and 

ask for their help in addressing Ed’s alcohol misuse. 

The counselor explores other self-care and 

recovery strategies with Rose, including Al-Anon 

and a dementia caregiver support group. Rose 

is not sure that she wants to try Al-Anon but 

then agrees to talk with a peer recovery support 

specialist the counselor knows at the local 

recovery community center who is Rose’s age and 

helps family members. The counselor sets up a 

series of sessions with Rose. She will continue to 

track Rose’s drinking, benzodiazepine use, and 

strategies for self-care. 

120 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

Clinical Scenario: High-Risk Drinking 

Older adults may not know that their drinking 

is negatively affecting their physical and mental 

health. The following scenario focuses on the 

importance of screening for alcohol misuse in 

settings where older adults are being treated 

for mental disorders and shows how a brief 

intervention focused on alcohol use can improve 

physical and mental health. 

• High-Risk Drinking: An older adult drinks above 

recommended limits, including binge drinks, and 

has a co-occurring mental disorder (depression) 

and health condition (high blood pressure). 

• Treatment Setting: Hospital-based mental 

health clinic 

• Provider: Geriatric psychiatrist 

• Prevention/Treatment Strategies: Supply 

feedback on AUDIT score; give information 

about the risks of taking medications for 

depression and high blood pressure while 

drinking; offer nonjudgmental advice about 

abstaining from alcohol use; continue to watch 

alcohol and medication use. 

Carl is 68 years old. His PCP refers him to a 

geriatric psychiatrist for medication management 

of his major depression. Carl currently takes one 

tricyclic antidepressant—which, when taken with 

alcohol, increases his risk for oversedation and low 

blood pressure—and a blood pressure medication, 

which can lower his blood pressure even more. The 

psychiatrist gives Carl the clinical interview version 

of the AUDIT as part of the initial psychiatric 

evaluation. Carl’s score on the AUDIT is a 9 and 

includes positive responses to daily drinking and 

binge drinking about once a month. 

The psychiatrist offers Carl nonjudgmental 

feedback about his AUDIT score and says that 

Carl’s drinking may be worsening both his 

depression and his high blood pressure. At frst, 

Carl makes light of his drinking by saying, “I 

really don’t drink that much. And besides, I have 

been drinking the same amount for years, and it’s 

never been a problem before.” The psychiatrist 

acknowledges Carl’s mixed feelings, then asks if he 

would be interested in more information. After Carl 

agrees, the psychiatrist describes the health risks 

of drinking while taking antidepressants and blood 

pressure medication, stating in a nonjudgmental, 

factual tone that alcohol can keep his medications 

from working correctly. He also states that the type 

of antidepressant Carl is taking can lead to low 

blood pressure when he drinks, especially when 

taken with his blood pressure medication, and can 

cause harmful effects like increased depression, 

dizziness, and fatigue. Carl responds, “Now that 

you mention it, I have noticed feeling very tired in 

the afternoon. I really don’t like feeling that way. 

It’s like the depression is getting worse.” 

The psychiatrist supports Carl’s ability to make 

his own decisions, then gives him clear advice: 

“Although it is up to you in the end, I think that 

in your situation you are better off not drinking at 

all while you are being treated for depression and 

high blood pressure. What do you think you would 

like to do about the drinking?” Carl agrees to stop 

drinking to see whether abstinence improves his 

health. The psychiatrist supports Carl’s decision; 

summarizes their conversation; writes out a brief 

alcohol use agreement that supports Carl’s decision 

to remain abstinent but also tracks his alcohol use 

if he does drink; and schedules a follow-up visit in a 

month. (See the Chapter 4 Appendix for an alcohol 

use agreement and drinking tracking cards.) 

At the next visit, Carl says that his depression has 

gotten better and that he no longer feels tired 

or gets dizzy. Carl says that he wants to continue 

not drinking because he feels so much better. 

The psychiatrist supports Carl’s efforts to avoid 

drinking and, after discussion with Carl, prescribes 

a different antidepressant medication for him. 

In future medication management visits, the 

psychiatrist tracks Carl’s depression, his response 

to the new medication, his blood pressure, and his 

success in avoiding alcohol. 

Clinical Scenario: AUD 

Older adults with a long history of heavy drinking, 

multiple past periods of treatment, or co-occurring 

mental disorders often need medically supervised 

withdrawal and age-sensitive, age-specifc 

treatment to address multiple co-occurring 

Chapter 4 121 
TIP 26

conditions at the same time. This scenario focuses 

on age-specifc treatment, RPT, and recovery 

support for an older adult with AUD and cooccurring disorders. 

• AUD: An older adult has a long history of heavy 

drinking and meets criteria for AUD. 

• Treatment Setting: Inpatient detox and 

rehabilitation program 

• Provider: Licensed alcohol and drug counselor 

on a multidisciplinary treatment team 

• Treatment Strategies: Offer CBT, RPT adapted 

for older adults, trauma-informed counseling 

strategies to address emotional dysregulation, 

and recovery management strategies. 

Barb is 72 years old and enters an inpatient 

treatment program after her three adult children 

intervene. She has a long history of heavy drinking 

and brief periods of treatment followed by a return 

to drinking. Barb has been married four times and 

was recently divorced from her fourth husband. 

She has been diagnosed with anxiety, depression, 

posttraumatic stress disorder, and binge eating 

disorder, for which she had gastric bypass surgery. 

This is her fourth treatment for AUD. Her pattern of 

returning to drinking tends to happen when she is 

having diffcult relationships, intense emotions, and 

traumatic stress reactions. Barb is carefully watched 

throughout detoxifcation at the facility; she is then 

transferred to the rehabilitation program, which 

includes an age-specifc track for older adults. 

Barb’s primary counselor offers relapse prevention 

approaches, which are focused on identifying 

and managing relapse triggers. Barb’s CBT 

counseling focuses on strategies to address the 

communication issues between Barb and her 

daughter and to help her identify and replace 

negative automatic thoughts about drinking 

triggered by relationship problems. For example, 

when Barb’s daughter criticizes her, Barb feels 

ashamed. Barb replaces the negative thought, “I 

drink because I can’t stand to feel ashamed” with a 

more positive thought, “I can stand to feel shame 

for a while, until the urge to drink goes away.” 

Barb’s group counseling at the older adult program 

includes focused topic groups for older adults, 

relapse prevention coping skills groups, and a DBT 

group. The DBT group teaches her mindfulness 

Treating Substance Use Disorder in Older Adults 

skills for distress tolerance, emotional regulation, 

and effective interpersonal interactions. With 

permission, Barb’s counselor keeps contact with 

her family. They attend family group sessions, too. 

During an individual session, Barb and her 

counselor discuss her improvement in treatment. 

The counselor opens the conversation: “I know 

this is your fourth time in treatment. How would 

you say this time has been different for you?” 

Barb says, “I really like the group discussions on 

topics that are important to me at this stage in my 

life. Staying here for such a long time has helped 

a lot, too. I needed the extra time to let all this 

information about recovery and all the skills I have 

learned really sink in.” 

Near the end of her time at the treatment facility, 

Barb’s counselor actively links her to a continuing 

care group and individual outpatient counseling at 

an addiction treatment program in her community, 

as well as women’s and senior-friendly AA 

meetings. Staying in treatment longer allows Barb 

to improve her emotional regulation, work on 

relapse prevention, and improve her interpersonal 

skills in a safe, supportive place. It also helps her 

get connected to community-based support before 

she ends treatment. 

RESOURCE ALERT: DBT 

DBT, a variation of CBT, was developed for adult 

women with chronic suicidal behavior who meet 

the diagnostic criteria for borderline personality 

disorder.792,793 More recently, adaptations of 

DBT skills training have been shown to help 

adults with borderline personality disorder and 

SUDs, adults with binge eating disorder, older 

adults with depression, and family caregivers 

of older adults with dementia.794,795 DBT uses 

mindfulness practices and helps people manage 

overwhelming emotions. This skill-building 

approach shows promise in treating older 

adults with emotional dysregulation and poor 

interpersonal skills. 

For more information about DBT, the latest 

research, and training opportunities, go to the 

website of the Behavioral Research and Therapy 

Clinics at the University of Washington (http:// 

depts.washington.edu/uwbrtc/). 

122 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

Summary 

As older adults’ levels of alcohol use and related 

risk of negative health effects increase, more 

complex and intense interventions are needed. MI 

and adaptations of CBT (including PST and RPT) 

are useful in brief interventions and long-term 

treatment. Whichever strategy you use, take a 

nonconfrontational, age-sensitive approach when 

working with older adults with alcohol misuse, 

including AUD. Ongoing recovery management 

strategies increase the chance that improvements 

will continue over time and not only help older 

adults reduce negative alcohol-related health and 

mental health outcomes, but also help improve 

their quality of life. 

Chapter 4 Resources 

Provider Resources 

A Clinician’s Guide to CBT With Older People 

(www.uea.ac.uk/documents/246046/11919343/ 

CBT_BOOKLET_FINAL_FEB2016%287%29. 

pdf/280459ae-a1b8-4c31-a1b3-173c524330c9): 

This workbook explores age-sensitive strategies for 

adapting CBT for older adults. 

BNI-ART Institute—Tools for the Brief 

Negotiated Interview (BNI) (www.bu.edu/bniart/ 

sbirt-in-health-care/sbirt-educational-materials/ 

sbirt-brief-intervention/): This webpage includes an 

algorithm, or script, that guides providers through 

an intervention for substance misuse with carefully 

phrased key questions and responses. 

Motivational Interviewing Network of Trainers 

(https://motivationalinterviewing.org): This website 

includes references, articles, videos, and links to 

training opportunities in the theory and practice of 

MI. 

National Council on Aging—Resources (www. 

ncoa.org/audience/professional-resources/?post_ 

type=ncoaresource): This webpage contains a 

searchable database of articles, webinars, and 

manuals. 

Consumer Resources 

AA—A.A. for the Older Alcoholic—Never Too 

Late (large print) (www.aa.org/assets/en_US/p-22_ 

AAfortheOlderAA.pdf): This brochure describes the 

stories of men and women who became involved 

with AA as older adults and includes comments 

from AA speakers at meetings. 

National Association of Area Agencies on Aging 

(n4a) (www.n4a.org): This national association 

provides searchable services, resources, and 

advocacy for older adults and professionals who 

work with them. 

National Council on Aging—Resources (www. 

ncoa.org/audience/older-adults-caregiversresources/?post_type=ncoaresource): This 

webpage contains a searchable database of articles 

and webinars. 

National Institute on Aging—Alcohol Use or 

Abuse (www.nia.nih.gov/health/topics/alcohol-useor-abuse): This webpage contains links to older 

adult-specifc information on alcohol misuse. 

NIAAA Alcohol Treatment Navigator (https:// 

alcoholtreatment.niaaa.nih.gov): In addition to 

helping visitors fnd the best alcohol misuse 

treatment options, this treatment navigator details 

a step-by-step process for understanding AUD. 

Chapter 4 123 
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Chapter 4—Treating Alcohol Misuse in Older Adults 

Chapter 4 Appendix 

Alcohol Use Disorders Identifcation Test (AUDIT): Interview Version 

Read questions as written. Record answers carefully. Begin the AUDIT by saying “Now I am going to ask 

you some questions about your use of alcoholic beverages during this past year.” Explain what is meant by 

“alcoholic beverages” by using local examples of beer, wine, vodka, etc. Code answers in terms of “standard 

drinks.” Place the correct answer number in the box at the right. 

1. How often do you have a drink containing 

alcohol? 

(0) Never [Skip to Qs 9-10] 

(1) Monthly or less 

(2) 2 to 4 times a month 

(3) 2 to 3 times a week 

(4) 4 or more times a week 

6. How often during the last year have you needed a frst drink in the morning to get yourself 

going after a heavy drinking session? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

2. How many drinks containing alcohol do you 

have on a typical day when you are drinking? 

(0) 1 or 2 

(1) 3 or 4 

(2) 5 or 6 

(3) 7, 8, or 9 

(4) 10 or more 

7. How often during the last year have you had 

a feeling of guilt or remorse after drinking? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

3. How often do you have six or more drinks on 

one occasion? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

Skip to Questions 9 and 10 if Total Score 

for Questions 2 and 3 = 0 

8. How often during the last year have you been 

unable to remember what happened the 

night before because you had been drinking? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

4. How often during the last year have you 

found that you were not able to stop 

drinking once you had started? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

9. Have you or someone else been injured as a 

result of your drinking? 

(0) No 

(2) Yes, but not in the last year 

(4) Yes, during the last year 

5. How often during the last year have you 

failed to do what was normally expected 

from you because of drinking? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

10. Has a relative or friend or a doctor or 

another health worker been concerned 

about your drinking or suggested you 

cut down? 

(0) No 

(2) Yes, but not in the last year 

(4) Yes, during the last year 

Record total of specifc items here 

Scoring: The cutoff score indicating hazardous and harmful alcohol use for the AUDIT is generally 8; however, for older 

adults a score of 5 indicates a need for clarifying questions and further assessment.796 

Adapted from Barbor et al. (2001).797 

Chapter 4 125 
TIP 26

 

Treating Substance Use Disorder in Older Adults 

Alcohol Use Disorders Identifcation Test (AUDIT): Self-Report Version 

CLIENT: Alcohol use can affect your health and interfere with some medications and treatments, so it’s 

important that we ask some questions about your alcohol use. Your answers will remain confdential; please 

be honest. 

Place an X in one box that best describes your answer to each question. 

Questions 0 1 2 3 4 

1. How often do you have a drink 

containing alcohol? 

Never Monthly 

or less 

2-4 times 

a month 

2-3 times 

a week 

4 or more 

times a week 

2. How many drinks containing 

alcohol do you have on a typical 

day when you are drinking? 

1 or 2 3 or 4 5 or 6 7 to 9 10 or more 

3. How often do you have six or more 

drinks on one occasion? 

Never Less 

than 

monthly 

Monthly Weekly Daily or 

almost 

daily 

4. How often during the last year have 

you found that you were not able to 

stop drinking once you had started? 

Never Less 

than 

monthly 

Monthly Weekly Daily or 

almost 

daily 

5. How often during the last year 

have you failed to do what was 

normally expected of you because 

of drinking? 

Never Less 

than 

monthly 

Monthly Weekly Daily or 

almost 

daily 

6. How often during the last year 

have you needed a frst drink in the 

morning to get yourself going after 

a heavy drinking session? 

Never Less 

than 

monthly 

Monthly Weekly Daily or 

almost 

daily 

7. How often during the last year have 

you had a feeling of guilt or remorse 

after drinking? 

Never Less 

than 

monthly 

Monthly Weekly Daily or 

almost 

daily 

8. How often during the last year 

have you been unable to remember what happened the night 

before because of your drinking? 

Never Less 

than 

monthly 

Monthly Weekly Daily or 

almost 

daily 

9. Have you or someone else been 

injured because of your drinking? 

No Yes, but 

not in the 

last year 

Yes, 

during the 

last year 

10. Has a relative, friend, doctor, or 

other health care worker been 

concerned about your drinking 

or suggested you cut down? 

No Yes, but 

not in the 

last year 

Yes, 

during the 

last year 

Total 

Adapted from Barbor et al. (2001).798 

Provider Note: The self-report version should be given to older clients to fll out. Ask them to 

return it to you, and then discuss the results with them. A cutoff score of 5 means you need to 

assess further.799 

126 Chapter 4 
Chapter 4—Treating Alcohol Misuse in Older Adults TIP 26

Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G) 

Yes (1) No (0) 

1. When talking with others, do you ever underestimate how much 

you drink? 

2. After a few drinks, have you sometimes not eaten or been able to skip a meal 

because you didn’t feel hungry? 

3. Does having a few drinks help decrease your shakiness or tremors? 

4. Does alcohol sometimes make it hard for you to remember parts of the day or night? 

5. Do you usually take a drink to relax or calm your nerves? 

6. Do you drink to take your mind off your problems? 

7. Have you ever increased your drinking after experiencing a loss in your life? 

8. Has a doctor or nurse ever said they were worried or concerned about your drinking? 

9. Have you ever made rules to manage your drinking? 

10. When you feel lonely, does having a drink help? 

TOTAL SMAST-G-SCORE (0-10) _________ 

SCORING: 2 OR MORE “YES” RESPONSES IS INDICATIVE OF AN ALCOHOL PROBLEM. 

Ask the extra question below but do not calculate it in the fnal score. 

Extra question: Do you drink alcohol and take mood or mind-altering drugs, including prescription tranquilizers, 

prescription sleeping pills, prescription pain pills, or any illicit drugs? 

© The Regents of the University of Michigan, 1991. Source: University of Michigan Alcohol Research Center.800 Adapted with 

permission. 

Chapter 4 127 
TIP 26 Treating Substance Use Disorder in Older Adults 

Large-Print Grief Handout 

What Is Grief? 

Grief is a natural response to loss. It’s the emotional suffering 

you feel when something or someone you love is taken away. 

Whatever your loss, it’s personal to you. 

Coping With Grief 

Although loss is a part of life that cannot be avoided, there 

are ways to help cope with the pain, come to terms with your 

grief, and eventually, fnd a way to move on with your life. This 

doesn’t mean you will forget your loved one, but you can fnd 

a way to hold that individual in your heart and your memories 

while continuing to live your life. This includes: 

•	 Acknowledging your pain. 

•	 Accepting that grief can bring up many different and 

unexpected feelings. 

•	 Understanding that your grieving process will be unique to 

you. 

•	 Seeking out face-to-face support from people who care 

about you. 

•	 Supporting yourself emotionally by taking care of yourself 

physically. 

•	 Learning the difference between grief and depression. 

The Grieving Process 

Grieving is highly individual; there’s no right or wrong way 

to grieve. The grieving process takes time. Healing happens 

gradually; it can’t be forced or hurried—and there is no 

“normal” timetable for grieving. Some people start to feel 

better in weeks or months. For others, the grieving process is 

measured in years. Whatever grief is like for you, it’s important 

to be patient with yourself and allow the process to naturally 

unfold. 

Reprinted with permission.801 

128 Chapter 4 
TIP 26

__________________________________________________________________________________________________________ 

__________________________________________________________________________________________________________ 

__________________________________________________________________________________________________________ 

Chapter 4—Treating Alcohol Misuse in Older Adults 

Alcohol Use Agreement and Drinking Diary Cards 

The purpose of this step is to decide on a drinking limit for yourself for a particular period of time. 

Negotiate with your healthcare provider so you can both agree on a reasonable goal. A reasonable 

goal for some people is abstinence—not drinking any alcohol. 

As you develop this agreement, answer the following questions: 

• How many standard drinks? 

• How frequently? 

• For what period of time? 

Agreement 

Date ______________ 

Client signature __________________________________ 

Clinician signature ________________________________ 

Drinking Diary Card 

One way to keep track of how much you drink is the use of drinking diary cards. One card is used for each 

week. Every day record the number of drinks you had. At the end of the week add up the total number of 

drinks you had during the week. 

Card A 

Keep Track of What You Drink Over The Next 

7 Days 

Keep Tra

Card B 

ck of What You Drink Over The Next 

7 Days 

Starting Date ________________________________ Starting Date ________________________________ 

Beer Wine Liquor Number Beer Wine Liquor Number 

Sunday Sunday 

Monday Monday 

Tuesday Tuesday 

Wednesday Wednesday 

Thursday Thursday 

Friday Friday 

Saturday Saturday 

WEEK’S TOTAL: WEEK’S TOTAL: 

Adapted from material in the public domain.802 

Chapter 4 129 
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TIP 26 TREATING SUBSTANCE USE DISORDER 

IN OLDER ADULTS

Chapter 5—Treating Drug Use and Prescription 

Medication Misuse in Older Adults 

KEY MESSAGES 

• Illicit drug use and prescription medication 

misuse do occur in older adults, but they are 

treatable. 

• Regular screening and assessment can help 

you learn whether an older client is struggling 

with drug use or prescription medication 

misuse. 

• Education and brief interventions are often 

enough to help older adults prevent, reduce, 

or stop drug use and prescription medication 

misuse. Most older clients who use illicit drugs 

or misuse prescription medication do not need 

care from programs or providers that specialize 

in substance use disorder (SUD) treatment. 

• Age-specifc and age-sensitive treatments are 

useful in reducing drug use and prescription 

medication misuse and related health risks. 

These treatments are designed to meet the 

special physical, cognitive, and social needs of 

older individuals. For many older adults, these 

adaptations can make all the difference in 

helping them start, stay in, and beneft from 

treatment. 

Chapter 5 of this Treatment Improvement 

Protocol (TIP) will beneft healthcare, behavioral 

health service, and social service providers who 

work with older adults (e.g., physicians, nurse 

practitioners [NPs], physician assistants, nurses, 

social workers, psychologists, psychiatrists, mental 

health counselors, drug and alcohol counselors, peer 

recovery support specialists). It addresses drug use, 

prescription medication misuse, and SUDs other 

than alcohol use disorder among older adults. 

Prescription medications are some of the most 

commonly misused substances in this population,803 

and rates of substance misuse in general are 

increasing. These increases result, in part, from the 

size of the aging baby boomer generation (those 

born from 1946 to 1964) and the fact that baby 

boomers are living longer and have higher rates 

of lifetime substance misuse, including SUDs, than 

past generations. 

Many older adults who misuse substances do 

not need specialized SUD treatment. Prevention 

strategies and brief interventions are often enough. 

Even so, research shows that older adults do beneft 

from addiction treatment.804,805,806 In fact, older adults 

in addiction treatment programs are more likely than 

younger adults to complete treatment, and older 

adults have nearly as good or better outcomes.807,808 

Thus, as the older population in the United States 

grows, the need for a full range of treatment 

approaches that meet the unique requirements of 

older adults will continue to increase. 

Organization of Chapter 5 of 

This TIP 

This chapter of TIP 26 addresses rates of 

drug use and prescription medication misuse, 

including drug use disorders, among older adults 

as well as treatment and recovery management 

approaches that meet older adults’ specifc 

needs. 

The frst section of Chapter 5 describes illicit 

drug use and prescription medication misuse, 

including drug use disorders, among older 

adults. Defnitions and facts are discussed as well 

as the physical, mental, social, and economic 

effects of drug use disorders. 

The second section describes how to identify, 

screen, and assess for drug use disorders in older 

adults. The parts of screening, brief intervention, 

and referral to treatment (SBIRT) are discussed, 

along with specifc tips for screening older adults. 

131 
TIP 26 Treating Substance Use Disorder in Older Adults 

The third section describes the continuum of care 

for older adults with drug use disorders, which 

ranges from brief interventions for prescription 

medication misuse to inpatient detoxifcation 

and rehabilitation for older adults with drug use 

disorders. 

The fourth section discusses specifc treatment 

approaches for older adults with drug use 

disorders. These approaches include acute 

care, overdose treatment, medically supervised 

withdrawal, medication maintenance therapy, 

psychosocial approaches, age-specifc treatment 

options, referral management, and care 

coordination. 

The ffth section provides an overview of 

recovery management strategies for older 

EXHIBIT 5.1. Key Terms 

adults with drug use disorders. It covers topics 

such as family member involvement in treatment 

and linking older adults to evidence-supported, 

community-based recovery support groups such 

as Narcotics Anonymous (NA) and Alcoholics 

Anonymous (AA). 

The sixth section provides clinical scenarios. This 

section uses clinical case material to show how 

to apply approaches and strategies discussed in 

Chapter 5 to older clients. 

The seventh section identifes targeted resources 

to support your practice. A more detailed resource 

guide is in Chapter 9 of this TIP. 

For defnitions of key terms you will see throughout 

Chapter 5, refer to Exhibit 5.1. 

• Addiction*: The most severe form of SUD, associated with compulsive or uncontrolled use of one or more 

substances. Addiction is a chronic brain disease that has the potential for both recurrence (relapse) and 

recovery. 

• Age-sensitive: Adaptations to existing treatment approaches that accommodate older adults’ unique 

needs (e.g., a large-print handout on the signs of substance misuse). 

• Age-specifc: Treatment approaches and practices specifcally developed for older adults (e.g., an older 

adult specialty group in a mixed-age SUD treatment program). 

• Caregivers: Informal caregivers provide unpaid care. They assist others with activities of daily living 

(ADLs), including health and medical tasks. Informal caregivers may be spouses, partners, family 

members, friends, neighbors, or others who have a signifcant personal relationship with the person who 

needs care. Formal caregivers are paid providers who offer care in one’s home or in a facility.809 Most older 

adults do not need caregivers and are as able to address their own needs as younger adults, whether or 

not substance misuse is a factor in their lives. 

• Diversion: A medical and legal term describing the illegal sharing of a legally prescribed, controlled 

medication (e.g., an opioid) with another individual. 

• Drug–drug interaction: The interaction of one substance (e.g., alcohol, medication, an illicit drug) with 

another substance. Drug–drug interactions may change the effectiveness of medications, introduce 

or alter the intensity of side effects, and increase a substance’s toxicity or the concentration of that 

substance in a person’s blood. Potentially serious interactions can also occur with certain foods, 

beverages, and dietary supplements.810 

• Drug use: The full range of severity of illicit drug use, from a single instance of use to meeting criteria for a 

drug use disorder. 

• Illicit substances: Illicit substances include cocaine, heroin, hallucinogens, inhalants, methamphetamine, 

and prescription medications that are taken other than as prescribed (e.g., pain relievers, tranquilizers, 

stimulants, sedatives). 

Continued on next page 

132 Chapter 5 
Chapter 5—Treating Drug Use and Prescription Medication Misuse in Older Adults TIP 26

Continued 

• Mutual-help groups: Groups of people who work together on obtaining and maintaining recovery. Unlike 

peer support (e.g., the use of recovery coaches or peer recovery support specialists), mutual-help groups 

consist entirely of people who volunteer their time and typically have no offcial connection to treatment 

programs. Most are self-supporting. Although 12-Step groups such as AA and NA are the most widespread 

and well researched type of mutual-help groups, other groups may be available in some areas. They range 

from groups affliated with a religion or church (e.g., Celebrate Recovery, Millati Islami) to purely secular 

groups (e.g., SMART [Self-Management and Recovery Training] Recovery, Women for Sobriety). 

• Peer support: The use of peer recovery support specialists (e.g., someone in recovery who has lived 

experience in addiction plus skills learned in formal training) to provide nonclinical (i.e., not requiring 

training in diagnosis or treatment) recovery support services to individuals in recovery from addiction and 

to their families. 

• Prescription medication misuse: The full range of severity of problematic use of prescription medication 

(meaning using a medication to feel good, using more than prescribed or in a way not prescribed, or 

using medication prescribed to someone else), from mild misuse to meeting criteria for an SUD. 

• Psychoactive substances: Substances that can alter mental processes (e.g., cognition or affect; in other 

words, the way one thinks or feels). Also called psychotropic drugs, such substances will not necessarily 

produce dependence, but they have the potential for misuse or abuse.811 

• Recovery*: A process of change through which individuals improve their health and wellness, live a selfdirected life, and strive to reach their full potential. Even individuals with severe and chronic SUDs can, 

with help, overcome them and regain health and social function. This is called remission. When those 

positive changes and values become part of a voluntarily adopted lifestyle, that is called being in recovery. 

Although abstinence from all substance misuse is a cardinal feature of a recovery lifestyle, it is not the 

only healthy, pro-social feature. 

• Relapse*: A return to substance use after a signifcant period of abstinence. 

• Remission: A medical term meaning a disappearance of signs and symptoms of the disease or disorder. 

The ffth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defnes remission 

as present in people who previously met SUD criteria but no longer meet any SUD criteria (with the 

possible exception of craving).812 Remission is an essential element of recovery. 

• Substance misuse*: The use of any substance in a manner, situation, amount, or frequency that can 

cause harm to users or to those around them. For some substances or individuals, any use would 

constitute misuse (e.g., underage drinking, injection drug use). 

• Substance use disorder*: A medical illness caused by repeated misuse of a substance or substances. 

According to DSM-5,813 SUDs are characterized by clinically signifcant impairments in health and social 

function, and by impaired control over substance use. They are diagnosed through assessing cognitive, 

behavioral, and psychological symptoms. SUDs range from mild to severe and from temporary to chronic. 

They typically develop gradually over time with repeated misuse, leading to changes in brain circuits 

governing incentive salience (the ability of substance-associated cues to trigger substance seeking), 

reward, stress, and executive functions like decision making and self-control. Multiple factors infuence 

whether and how rapidly a person will develop an SUD. These factors include the substance itself; the 

genetic vulnerability of the user; and the amount, frequency, and duration of the misuse. Note: A severe 

SUD is commonly called an addiction. A mild SUD is generally equivalent to what previous editions of 

DSM called substance abuse; a moderate or severe SUD is generally equivalent to what was formerly 

called substance dependence. 

* The defnitions of all terms marked with an asterisk correspond closely to those given in Facing Addiction in 

America: The Surgeon General’s Report on Alcohol, Drugs, and Health. This resource provides a great deal of useful 

information about substance misuse and its impact on U.S. public health. The report is available online (https://addiction. 

surgeongeneral.gov/sites/default/fles/surgeon-generals-report.pdf). 

Chapter 5 133 
TIP 26 Treating Substance Use Disorder in Older Adults 

Drug Use and Prescription 

Medication Misuse Among Older 

Adults 

Drug use and prescription medication misuse are 

growing problems among older adults. In the next 

decade, approximately 20 percent of the U.S. 

population will be over age 65.814 As the large 

baby boomer population ages up, drug use and 

prescription medication misuse will likely increase. 

This group has higher rates of illicit drug use than past 

generations,815,816 and their misuse of pain medication 

and other prescription medication is signifcant. 

Taking opioids for pain is one pathway to drug 

use or prescription medication misuse for older 

adults. They may start taking opioids for pain and 

become physically dependent. 

Other than alcohol and tobacco, the most 

commonly misused substances among older 

adults are psychoactive prescription medications, 

such as opioids and benzodiazepines (i.e., 

medications for sleep, pain, and anxiety). Research 

shows that older adults also use cannabis, cocaine, 

and heroin. For example, past-year cannabis use 

by older adults increased from 2006 to 2013 by 

57.8 percent for adults ages 50 to 64 and by 250 

percent for adults ages 65 and older.817 

Drug use and prescription medication misuse can 

lead to many negative health outcomes for older 

adults, such as: 

• Increased risk of injury and falls. 

• Problems with thinking (also called cognitive 

impairment). 

• Harmful drug–drug interactions. 

Prescribed medication is not always misused on 

purpose. Older adults: 

• Can accidentally take more of a prescribed 

medication than they meant to. 

• Can accidentally mix up medications. 

• May not know the potential risk of harmful 

effects of using certain substances (e.g., 

over-the-counter [OTC] medications, dietary 

supplements) while taking medication, even 

when taking it as prescribed. 

• Overdose, which can be fatal. 

• Suicide. 

• Liver and heart disease. 

• Sleep problems. 

Drug use and prescription medication misuse have 

negative economic effects. They cost the United 

States billions of dollars each year, including $193 

billion for illicit substances in 2007818 (the last year 

in which those numbers were reported) and $78.5 

billion for prescription opioids in 2013819 (the last 

year in which those numbers were reported). Drug 

use and prescription medication misuse also lead to 

greater healthcare costs. Older adults already use 

more healthcare resources than younger adults. As 

older adults with drug use disorders age, they are at 

an increased risk of co-occurring medical conditions, 

which means they will use more healthcare 

services.820,821,822 

Drug use and prescription medication misuse 

among older adults negatively affect relationships, 

families, and friends. Many family members, 

friends, and caregivers recognize but minimize 

drug use or prescription medication misuse 

among older adults. Well-meaning family and 

friends may assume that drug use and prescription 

medication misuse in older adults cannot be treated, 

especially if the behavior has been going on for a 

while. They may feel that the time for treatment has 

passed or that previous attempts at treatment make 

trying again pointless.823,824 Often, friends and family 

view the use of certain substances by older adults as 

one of their “last pleasures” or distractions in life.825 

Ageist, incorrect beliefs about drug use and 

prescription medication misuse among older 

adults can prevent older adults from getting 

treatment. Treatment access for older adults is key, 

as research increasingly shows that SUD treatment 

for older adults can reduce or stop drug use and 

prescription medication misuse and improve health/ 

quality of life.826,827,828,829,830 

Prescription Medication Misuse 

Prescription medication misuse includes: 

• Taking larger doses of a medication than 

prescribed. 

• Changing the dose without guidance from the 

prescriber. 

134 Chapter 5 
Chapter 5—Treating Drug Use and Prescription Medication Misuse in Older Adults TIP 26

• Taking a medication for reasons other than its 

intended purpose. 

• Taking someone else’s medications. 

Older adults are prescribed and use more 

medication than any other age group. From 2015 

to 2016:831 

• An estimated 87.5 percent of adults ages 65 and 

older took at least one prescription medication 

in the past 30 days, versus 67.4 percent of adults 

ages 45 to 64 and 35.3 percent of those ages 18 

to 44. 

• Adults ages 65 and older were the largest 

group of people taking fve or more prescription 

medications in the past 30 days (39.8 percent) 

compared with adults ages 45 to 64 (19.1 

percent) and adults ages 18 to 44 (3.9 percent). 

Age-related changes to metabolism and body fat 

affect the medication dosage that older adults 

need and increase the risk of older adults feeling 

negative effects of medication. For example, 

older adults are very likely to feel memory-related 

and psychomotor effects of benzodiazepines and 

opioids. Also, older adults have a higher rate of 

co-occurring conditions than do younger adults, 

which means they take more medication and are 

more likely to experience harmful drug–drug, 

alcohol–drug, and drug–co-occurring condition 

interactions.832,833 

Providers face challenges when prescribing for 

older adults in general and need to exercise extra 

caution. One challenge is that a medication may 

not have a recommended dosage for older adults, 

in which case providers should prescribe the 

minimum dosage needed to achieve a positive 

outcome. Prescribers also need to think about 

what formulation of a medication will work best 

for an older patient and what dosing schedule 

will be easiest to follow. Yet another common 

challenge is that older patients may be taking 

unnecessary medication given their specifc 

clinical conditions. Such medication should be 

discontinued, consulting with the patient and 

using tapering as appropriate.834,835 Also, some 

medications are potentially inappropriate for 

older adults: see the Chapter 6 text box on the 

American Geriatrics Society Beers Criteria®. 

Younger people tend to misuse psychoactive 

prescription medication for mood effects 

(i.e., wanting to feel very happy or euphoric), 

but older adults tend to develop drug use 

disorders because they are using drugs or 

misusing prescription medication to treat their 

chronic pain, anxiety, depression, and sleep 

issues.836,837,838 

Opioids 

The United States is facing an opioid use 

and overdose crisis. (See SAMHSA’s TIP 63, 

Medications for Opioid Use Disorder, for more 

information; https://store.samhsa.gov/product/ 

TIP-63-Medications-for-Opioid-Use-Disorder-FullDocument/PEP20-02-01-006). The years 2006 to 

2013 saw an increase in calls to U.S. poison control 

centers about older adults’ misuse of prescription 

opioids, including misuse of prescription opioids 

for self-harm.839 

Chronic pain is one of the most common reasons 

for taking medication. Older adults have the 

highest rate of chronic pain of any age group,840 

leading to more clinic visits and increased 

prescribing of opioid medication. Older adults with 

opioid use disorder (OUD) and chronic pain may 

have a hard time accepting that they have OUD. 

Benzodiazepines 

Benzodiazepines (e.g., lorazepam, alprazolam, 

clonazepam) are mainly used to treat sleep and 

anxiety disorders. Benzodiazepines are thought 

to be safer than barbiturates and nonbarbiturate 

sedative-hypnotics.841 However, the physical 

dependence potential for benzodiazepines 

is very high. Long-term use or misuse of 

benzodiazepines in older adults has many risks. 

Results from more than 68 clinical trials show that 

benzodiazepines, no matter how long they are 

used (either short-, intermediate-, or long-acting) 

can lead to cognitive impairment. The greater the 

dose, the greater the impairment.842 

Chapter 5 135 
TIP 26

 

Many older adults experience adverse drug 

reactions because they are managing numerous 

prescribed medications (sometimes from 

multiple prescribing physicians). Adverse 

drug reactions are not necessarily the result of 

intentional or accidental misuse; rather, they 

result from complying with a dangerous regimen 

of drugs. 

Multiple Medications 

The aging process causes changes to the body 

that increase the chances of older adults feeling 

negative effects of medication. For example, 

older adults have decreased ability to metabolize 

drugs. Older adults often take more than one 

medication.843 Negative effects are more likely 

to occur when older adults take many OTC or 

prescription medications.844 Taking more than one 

medication that affects the central nervous system 

(CNS) increases the risk of:845 

• Problems with daily functioning. 

• Cognitive impairment. 

• Falls. 

• Death. 

Coprescribing of opioid and benzodiazepine 

medications is a concern. The risk of death increases 

with the dose of benzodiazepine prescribed.846 In 

2016, the Food and Drug Administration (FDA) 

issued a Drug Safety Communication warning about 

serious risks, including respiratory depression and 

death, from combining opioids with benzodiazepines 

or other CNS depressants (e.g., alcohol), and 

requiring boxed warnings for prescription opioids 

and benzodiazepines. FDA also cautioned that 

healthcare professionals “should limit prescribing 

opioid pain medicines with benzodiazepines or 

other CNS depressants only to patients for whom 

alternative treatment options are inadequate. If 

these medicines are prescribed together, limit the 

dosages and duration of each drug to the minimum 

possible while achieving the desired clinical effect.” 

FDA further advised healthcare professionals to 

screen these patients for SUDs, plus listed other 

precautions.847 Note that even greater caution should 

be used with older patients because of their higher 

risk of experiencing negative effects from medication. 

Treating Substance Use Disorder in Older Adults 

FDA in 2017 advised against withholding 

buprenorphine or methadone treatment for OUD 

from patients taking benzodiazepines or other 

CNS depressants, but recommended careful 

medication management of these patients. 

Although combining these OUD medications with 

CNS depressants increases the risk of serious side 

effects, FDA noted that this risk can be outweighed 

by the risk and harm of untreated OUD.848 For 

strategies on caring for these patients, see the 

FDA Drug Safety Communication at www.fda. 

gov/drugs/drug-safety-and-availability/fda-drugsafety-communication-fda-urges-caution-aboutwithholding-opioid-addiction-medications and 

the section “Concurrent Substance Use Disorders 

(SUDs) Involving Benzodiazepines or Alcohol” 

in SAMHSA’s TIP 63 (https://store.samhsa.gov/ 

product/TIP-63-Medications-for-Opioid-UseDisorder-Full-Document/PEP20-02-01-006). Again, 

keep in mind the need for using extra caution with 

older patients. 

Illicit Substances 

Illicit substances include cocaine, heroin, 

hallucinogens, inhalants, methamphetamine, and 

prescription medications that are taken other than 

as prescribed (e.g., pain relievers, tranquilizers, 

stimulants, sedatives). Because federal law bans 

the recreational and medical use of cannabis, 

this publication considers it an illicit substance 

(although in some states, medical use of cannabis is 

legal and in others, both recreational and medical 

use are legal). 

In 2019, 3.7 million adults ages 65 and older had 

used illicit substances in the past year.849 Of these 

drugs, older adults most commonly used:850 

• Cannabis: 2.6 million adults. 

• Prescription pain relievers: 900,000 adults. 

• Tranquilizers or sedatives: 325,000 adults. 

From 2000 to 2012, SUD treatment admissions for 

illicit substance use increased for adults ages 55 or 

older.851 

Rates of cannabis use among older adults are 

likely to continue rising. This is a major concern as 

baby boomers, who tend to be more accepting 

of cannabis use than previous generations, enter 

136 Chapter 5 
Chapter 5—Treating Drug Use and Prescription Medication Misuse in Older Adults TIP 26

3.7 MILLION ADULTS 

ages 65 and older used ILLICIT 

SUBSTANCES in 2019. 

900K 

2.6M 

325K 

Cannabis Prescription Tranquilizers or 

Pain Relievers Sedatives 

the later stages of life. From 2000 to 2019, the 

percentage of adults ages 50 to 64 who had ever 

used cannabis increased from approximately 24 

percent to around 54 percent.852,853 

The effects of using cannabis while also taking 

specifc prescription medications are not known. 

However, cannabis use is related to an increased 

risk of injury and short-term memory problems. 

Cannabis affects central and peripheral nervous 

system processes in ways such as:854,855,856,857 

• Increasing symptoms of anxiety and depression. 

• Increasing problems with cognition and learning. 

• Worsening motor coordination (i.e., the ability 

to use and control muscle movements). 

Moreover, the increasing potency of cannabis in 

recent decades may make cannabis use riskier.858 

Screening and Assessment 

If you think a client might be using drugs or 

misusing prescription medication, screening 

measures will help you identify and address this 

behavior.859 Screening older adults for drug use 

and prescription medication misuse and providing 

education about health risks related to interactions 

between prescribed medication, alcohol, and illicit 

substances are prevention strategies you can use in 

many different settings. 

Screen and assess older adults for substance use 

and co-occurring medical and mental disorders 

(e.g., cognitive impairment) that can mask SUDs 

or appear similar to SUDs. 

CO-OCCURRING CONDITIONS 

AMONG OLDER ADULTS 

Older adults with SUDs have high rates of mental 

disorders and co-occurring health conditions. 

In 2019, an estimated 36.8 percent of adults 

older than age 50 with SUDs also had mental 

disorders.860 Co-occurring mental disorders 

and SUDs among older adults are probably 

underdiagnosed, so the rates of co-occurring 

disorders (CODs) may actually be higher.861 

Compared with older adults who have only an 

SUD or a mental disorder, those with both are at 

risk for:862,863 

• Higher rates of inpatient and outpatient 

behavioral healthcare service use. 

• Thoughts of suicide and of death in general. 

• Certain physical conditions related to 

substance misuse (e.g., heart disease, organ 

damage, some cancers). 

Given high rates of CODs in older adults with 

SUDs, you should use holistic, detailed approaches 

to screening, assessment, and treatment. 

Screening Strategies 

To successfully make routine screening for drug use 

disorders a part of your clinical practice with older 

adults, use simple, consistent approaches that 

can be added to screening practices you already 

have in place. Screening questions can be asked 

verbally, on paper, or electronically. Make sure print 

is large enough for older adults to read easily. Ask 

about drug use:864 

• In a straightforward and nonjudgmental manner. 

• While asking about other health behaviors (e.g., 

exercise, weight, smoking, alcohol use). 

• While keeping the focus on helping clients 

improve their overall health, functioning, 

independence, and quality of life. 

Screen adults ages 60 and older: 

• Yearly, as part of the annual checkup in both 

healthcare and behavioral health service 

settings. 

• When changes in physical or mental health 

status occur (e.g., falls, memory issues). 

Chapter 5 137 
TIP 26

• During major life events or changes (e.g., 

retirement, moving, loss of a signifcant person). 

The consensus panel recommends screening all 

adults ages 60 and older yearly and when life 

changes occur (e.g., retirement, loss of a partner 

or spouse, changes in health). 

Several measures can help you screen for 

substance misuse, but few are validated (tested 

and approved for use) with older adults.865 (See 

Chapter 3 of this TIP for an indepth discussion of 

substance use screening tools that can be used 

with older adults.) 

One option is to use screening questions 

developed for the general adult population. For 

example, open your conversation with older 

clients by asking, “Have you taken a prescription 

medication differently than prescribed by your 

healthcare provider?” You can also use a singlequestion screener for drug use, such as, “How 

many times in the past year have you used an 

illegal drug or taken a prescription medication for 

nonmedical reasons?”866 If the client says “yes” to 

the frst question or answers the second question 

with one or more, begin more indepth screening. 

Indepth screening includes asking clients about: 

• Use of prescription and OTC medications. 

• Use of other substances (e.g., alcohol, cannabis, 

tobacco). 

• Amount/frequency of past-month substance use. 

• Effects of using substances. 

• Concerns about their substance use as well as 

concerns of family members or friends. 

RESOURCE ALERT: NATIONAL 

INSTITUTE ON DRUG ABUSEMODIFIED ALCOHOL, SMOKING, 

AND SUBSTANCE INVOLVEMENT 

SCREENING TEST 

This screening tool (www.drugabuse.gov/sites/ 

default/fles/pdf/nmassist.pdf) offers a helpful way to 

organize your questions about types of substances 

used, lifetime and recent amount and frequency of 

substances used, and substance use concerns. 

Treating Substance Use Disorder in Older Adults 

SCREENING FOR USE OF MULTIPLE 

MEDICATIONS: A BROWN BAG 

MEDICINE REVIEW 

Older adults often take a number of prescribed 

medications as well as OTC medications and 

dietary supplements. As part of an annual 

physical, or given signs that the older client is 

misusing medications (e.g., benzodiazepines, 

opioids), urge the client (or a family member, 

with consent) to bring in all prescribed and 

OTC medications and dietary supplements in a 

bag so that you and the client can review them 

together. This is known as a “brown bag medicine 

review.” This is a chance to discuss the health 

risks of taking multiple medications, of drug– 

drug interactions, and of misuse.867,868 Brown bag 

medicine reviews can improve client reporting 

of medication use and improve provider–client 

discussions about medication use.869 

When using verbal, electronic, or printed screeners: 

• Be empathetic and nonconfrontational. 

• Make the screening questions easy to 

understand. 

• Speak clearly and repeat instructions or questions 

as needed, especially if the client has cognitive 

impairment or problems with vision or hearing. 

Make sure the client can hear and understand you. 

• Use large type for printed questions and screen 

reader–friendly adaptations for computer 

screening. 

• Ask questions about the client’s illicit substance 

use or prescription medication misuse as a part 

of assessing overall health status. 

• Assess and reassess if the client is having 

problems using a computer, tablet, or writing on 

a printed form. If needed, offer a verbal interview 

in which you read the screening questions. 

Assessment and Diagnosis of Drug Use 

Disorders 

Screening is the frst step in performing an 

indepth assessment of substance misuse. Some 

signs of drug use disorders in older adults may 

be mistaken for symptoms of co-occurring 

138 Chapter 5 
Chapter 5—Treating Drug Use and Prescription Medication Misuse in Older Adults TIP 26

LINKING SCREENING QUESTIONS 

ABOUT SUBSTANCE USE TO HEALTH 

STATUS 

You can help older adults understand 

the reason for your asking substance use 

questions by giving them information about 

age-related changes in metabolism and how 

specifc medications, such as sedatives and 

antianxiety medications, can negatively interact 

with alcohol. You can also help older adults 

understand the relationship between substance 

use and health outcomes by discussing their 

substance use and other health problems, such 

as falls, high blood pressure, and depression. 

medical or mental disorders. Using DSM-5 

diagnostic criteria alone may underdiagnose 

older adults who have drug use-related and 

prescription medication misuse-related health and 

functioning problems. This can keep clients from 

getting needed treatment. 

A full assessment should include questions about a 

client’s: 

• History of substance use (including alcohol and

tobacco use).

• Age at which substance misuse issues began.

• Amount and frequency of substance use.

• Current prescription medications, OTC

medications, and dietary supplements.

• Co-occurring medical conditions.

• Relationship between substance use and daily

functioning.

• Co-occurring mental disorders, particularly

depression and anxiety.

• Use of substances to cope with sleep problems,

depression, anxiety, stress, or pain.

• Management of daily medication regimens.

Note any signs that clients may be under the 

infuence of substances. Although clients who 

appear to be so may give incomplete answers, 

current infuence of substances is by itself a clear sign 

that further assessment and intervention are needed. 

DSM-5 Diagnostic Criteria 

A formal SUD diagnosis is based on your client 

meeting 2 out of 11 DSM-5 diagnostic criteria. 

However, some of the physical and social 

factors described in DSM-5 may not apply to 

older adults because of age-related changes in 

tolerance to substances, cognitive functioning, 

role responsibilities, or social isolation.870 Exhibit 

5.2 summarizes the physical, mental, and social 

aspects of aging you should consider when using 

these criteria to diagnose SUD in older adults. 

EXHIBIT 5.2. DSM-5 Criteria for SUD and Considerations for Older Adults 

DSM-5 CRITERIA FOR SUD871 CLINICAL CONSIDERATIONS872,873,874 

Criterion 1 Older adults may need less of a substance to feel its physical effects. 

In addition to age-related or co-occurring medical-related decline in 

cognitive functioning, use of many substances can increase cognitive 

impairment and the ability to keep track of the amount and frequency of 

substance use. 

Criterion 2 This is the same as in the general adult population. There are no special 

considerations for older adults. 

Continued on next page 

Chapter 5 139 
TIP 26 Treating Substance Use Disorder in Older Adults 

Continued 

DSM-5 CRITERIA FOR SUD CLINICAL CONSIDERATIONS 

Criterion 3 Effects from substance use can occur from using relatively small amounts 

compared with the general adult population. 

Criterion 4 Although older adults may have cravings, they may not recognize 

substance cravings in the same way as the general adult population (e.g., 

cognitive decline may increase confusion about physiological cues related 

to craving). 

Criterion 5 Role responsibilities may be different for older adults because of life-stage 

changes, like retirement. Role responsibilities more common among 

older adults include caregiving for a spouse with a chronic illness and 

parenting a custodial grandchild. 

Criterion 6 Older adults may not realize their substance use is related to social or 

interpersonal problems. 

Criterion 7 Older adults may participate in fewer activities than younger adults, 

making it diffcult to know whether a reduction in activities is related to 

substance use. However, social isolation is related to substance use and 

should be noted and addressed. 

Criterion 8 Older adults may not understand that their use is harmful, especially 

when using substances in smaller amounts. Older adults may not identify 

certain situations (e.g., using a step stool or taking medications together) 

as physically dangerous. 

Criterion 9 Older adults may not realize their substance use is related to physical (e.g., 

gastrointestinal distress) or mental problems (e.g., anxiety). 

Criterion 10 Because of increased sensitivity to substances with age, older adults 

may have lowered rather than increased tolerance depending on the 

substance used. 

Criterion 11 Withdrawal symptoms among older adults can be less obvious and 

more drawn out. Older adults may not develop physical dependence if 

they started using the substance in late life; if prescribed and correctly 

using medications like benzodiazepines, they may develop physical 

dependence. 

Biopsychosocial Assessment and 

Placement 

The Level of Care Utilization System for Psychiatric 

and Addiction Services (LOCUS 20) is an 

assessment and placement tool that supports 

adoption of a systematic approach to these 

important steps in meeting the needs of older 

adults. The tool can be downloaded for free from 

www.communitypsychiatry.org/resources/locus. 

Continuum of Care 

The SUD treatment continuum of care has many 

points of intervention where older adults can 

receive services (Exhibit 5.3). Treatment for drug 

use disorders can be delivered in many different 

settings using behavioral and pharmacological 

methods. 

140 Chapter 5 
TIP 26

 

Chapter 5—Treating Drug Use and Prescription Medication Misuse in Older Adults 

EXHIBIT 5.3. SUD Treatment Continuum of Care 

PREVENTION EARLY INTERVENTION TREATMENT RECOVERY 

MANAGEMENT 

Address individual and 

environmental risk 

factors for substance use 

through science-informed 

prevention strategies 

aimed at individuals, 

families, and communities. 

Identify and screen for 

substance misuse; provide 

psychoeducation and 

brief interventions to 

reduce health risk; refer to 

treatment as needed. 

Adapted from material in the public domain.875 

More than 14,500 specialized treatment facilities in 

the United States provide SUD services, such as:876 

• Counseling. 

• Rehabilitation. 

• Behavioral therapy. 

• Case management. 

• Medication therapy. 

• Psychoeducation. 

• Peer recovery support services. 

Early intervention for an older adult’s drug use 

or prescription medication misuse can take place 

in a healthcare offce, a hospital, an emergency 

department (ED), an outpatient behavioral health 

clinic, or an older adult-focused social service 

Provide medication as 

needed, psychosocial 

interventions, and 

supportive services to 

achieve recovery and 

maximize functioning. 

Levels of Care: 

Outpatient 

Intensive outpatient/ 

partial hospitalization 

Residential/inpatient 

Medically managed 

intensive inpatient 

services 

Offer comprehensive 

discharge planning, 

referral management, 

continuing care, 

and linkage to 

community-based 

services (e.g., mutualhelp groups; medical 

care; social, legal, 

educational, and 

fnancial services) 

that support ongoing 

recovery and improve 

wellness and quality 

of life. 

agency. Primary care providers (PCPs) are often the 

entry point for brief interventions and referral to 

drug use disorder-specifc treatment. 

Different levels of care include: 

• Outpatient individual, group, and family 

counseling. 

• Intensive outpatient care (i.e., daily or weekly 

individual and group counseling for many 

weeks/months). 

• Residential care (i.e., 24-hour supervision and 

clinical monitoring). 

• Medically managed inpatient care (i.e., 

treatment services in a medical or mental 

hospital setting). 

Chapter 5 141 
TIP 26

When you work with clients to develop a 

treatment and recovery plan based on their 

preferences, as well as on the accessibility and 

appropriateness of the chosen treatment, clients 

are more likely to follow your recommendations. 

Unless clients present with active suicidal ideation, 

withdrawal risks, or an acute health concern (e.g., 

overdose, signifcant impairment, delirium, falls), 

let them choose their preferred treatment method. 

Offer options and discuss the benefts of each as 

they apply to each client. 

Recovery management, including discharge 

planning and continuing care, is an important 

part of the continuum of care. Older adults 

leaving intensive addiction treatment should:877 

• Have routine medical care for co-occurring, 

chronic medical conditions. 

• Be linked with older adult-focused, communitybased services. 

• Be introduced and referred to recovery groups 

to support their ongoing recovery but also 

to reduce isolation and loneliness, which are 

common among older adults. (See Chapter 7 

of this TIP for more information about social 

isolation.) 

Treatment Approaches Suited to 

Older Adults 

Many safe and effective interventions exist for 

older adults who use drugs, misuse prescription 

medication, or have drug use disorders. You 

should approach decisions about treatment by 

considering: 

• The drug being used or the prescription 

medication being misused. 

• The level of care needed (e.g., brief 

intervention, detoxifcation, maintenance). 

• Overdose prevention and treatments. 

• Psychosocial approaches adapted to older 

adults. 

This section describes general approaches that 

work with older adults who misuse prescription 

medications and use illicit substances. It also 

describes treatment strategies for specifc kinds of 

substances. 

Treating Substance Use Disorder in Older Adults 

ENDING, CHANGING, OR CONTINUING 

TREATMENT878 

Clients’ progress in treatment, as gauged by 

clearly defned, agreed-upon goals, should 

determine their length of time in treatment. 

The main criterion for discharge is that clients 

have met treatment goals. If clients are making 

progress and that progress is likely to continue, 

treatment should continue. If clients cannot 

meet treatment goals or they develop new 

treatment-related challenges, they should receive 

recommendations for different types of services 

or treatments. 

SBIRT 

Many older adults who use illicit drugs or 

misuse prescription medication do not need 

specialized addiction treatment. Education is 

often enough to help older adults change their 

behaviors. Older adults often respond well to 

nonjudgmental, brief education about: 

• Medications they are taking. 

• Potential drug–drug interactions. 

• Negative effects of using medications in ways 

other than as prescribed. 

SBIRT is an indepth approach to screening and 

brief intervention with older adults who may 

exhibit at-risk drug use, misuse of prescription 

medications, or use of illicit substances.879 

• Screening helps you quickly assess the severity 

of drug use or prescription medication misuse 

and identifes the right type and intensity of 

treatment. 

• The brief intervention focuses on helping older 

adults increase awareness of their drug use or 

prescription medication misuse and motivation 

for changing health risk behaviors. 

• Referral to treatment secures access to 

assessment and treatment by providers who 

specialize in addiction, when needed.880 

Providers can implement SBIRT in many settings, 

including behavioral health service programs 

and healthcare clinics. 

142 Chapter 5 
Chapter 5—Treating Drug Use and Prescription Medication Misuse in Older Adults TIP 26

Chapter 3 offers indepth discussion of SBIRT, 

research on its usefulness, and adaptations for 

older adults. 

Treatment for OUD 

Opioid Overdose Treatment 

Because of physiological changes, older adults 

show higher blood concentrations of opioid 

metabolites. This results in greater substance 

potency, toxicity, and longer duration of action 

than in younger adults.881,882 These factors may 

increase older adults’ risk of opioid overdose, 

which should be treated as a life-threatening 

emergency. 

Follow recommended guidelines for naloxone 

administration, and offer overdose prevention 

education and emergency naloxone kits to 

clients, caregivers, and families in case of 

overdose.883,884 

Medically Supervised Opioid Withdrawal 

Older adults are likely to have intense opioid 

withdrawal symptoms, especially related to 

chronic pain. 

ACUTE CARE: MEDICAL 

STABILIZATION AND SUPERVISED 

MEDICAL WITHDRAWAL 

Individuals must be medically and mentally 

stabilized if they:885 

• Are acutely intoxicated. 

• Are having an overdose. 

• Are in withdrawal. 

• Return to substance use. 

Acute inpatient treatment may also be needed 

for individuals who: 

• Are frail. 

• Have multiple addictions. 

• Have suicidal ideation. 

Medically supervised withdrawal in a monitored 

or managed setting is recommended for older 

adults who have been taking high doses of a 

substance (e.g., opioids) or using for a long time. 

Inpatient treatment will ensure that individuals 

are medically monitored for a safe withdrawal 

process. This is especially important for older 

adults with co-occurring mental and medical 

conditions. Monitoring reduces risk of severe 

negative effects, including death, as older adults 

have more clinical risks related to withdrawal and 

medical stabilization. 

Medication To Treat OUD 

Three FDA-approved medications886 can treat OUD 

in older adults: 

• Buprenorphine. Buprenorphine carries less 

risk for overdose than methadone.887,888 

Buprenorphine’s risk of respiratory depression 

or sedation is low,889 and the medication doesn’t 

produce the euphoria caused by heroin or 

synthetic opioids. Buprenorphine: 

- Is a good option for patients with repeated 

return to opioid use. 

- Is usually more convenient and cost-effective 

than methadone, because it can be provided 

in offce-based settings by qualifed 

physicians, NPs, physician assistants, and, 

until October 1, 2023, qualifed clinical 

nurse specialists, certifed registered nurse 

anesthetists, and certifed nurse midwives. 

- Is available as an implant, in sublingual 

and transmucosal formulations, and as an 

injection. This makes it a good option for 

older adults with mobility or transportation 

issues, as it reduces the need for frequent 

visits to the provider.890 

Chapter 5 143 
TIP 26 Treating Substance Use Disorder in Older Adults 

• Methadone. Methadone can prevent opioid 

withdrawal symptoms and reduce drug 

cravings. Methadone is available in almost 

every state from specially licensed opioid 

treatment programs. Methadone is a benefcial 

intervention.891 

• Naltrexone. Naltrexone is best for clients 

who want to stop all opioid use. Research 

on naltrexone for OUD treatment in older 

adults is not readily available. It is less useful 

for individuals needing long-term medication 

maintenance therapy for SUDs or for those with 

chronic pain. Naltrexone must not be prescribed 

to individuals who are currently using opioid 

medications. 

Nonopioid Treatments for Chronic Pain 

Older adults may develop OUD because 

of chronic pain. Given the complexities of 

managing the care of older clients with chronic 

pain, a comprehensive treatment approach is 

recommended.892 Chronic pain in older adults is 

best managed by a multidisciplinary team that 

includes (when possible) a:893 

• Geriatrician. 

• Rheumatologist. 

• Physical medicine and rehabilitation physician. 

• Psychiatrist or psychologist. 

• Physical therapist. 

• Occupational therapist. 

• Pharmacist. 

Nonpharmacological treatments can successfully 

treat chronic pain in older adults. These 

include:894 

• Meditation. 

• Relaxation. 

• Cognitive–behavioral therapy (CBT). 

• Exercise therapy. 

• Physical therapy/occupational rehabilitation. 

Exhibit 5.4 shows the general approach to 

managing chronic pain in older adults. 

RESOURCE ALERT: VETERANS AFFAIRS CLINICAL DECISION TOOLS FOR 

OPIOID USE AND CHRONIC PAIN 

The Department of Veterans Affairs/Department of Defense Clinical Practice Guideline for Opioid 

Therapy for Chronic Pain (www.healthquality.va.gov/guidelines/Pain/cot) describes the critical decision 

points in the management of opioid therapy for chronic pain. It provides clear and comprehensive 

evidence-based recommendations using current information and practices for practitioners throughout 

the Department of Defense and Department of Veterans Affairs healthcare systems. It includes special 

dosing considerations for older adults. 

The Opioid Safety Initiative Toolkit (www.va.gov/PAINMANAGEMENT/Opioid_Safety_Initiative_OSI.asp), 

created by the Veterans Health Administration National Pain Management Program, can aid in clinical 

decisions about starting, continuing, or tapering opioid therapy and other challenges related to safe opioid 

prescribing. Clinical teams caring for older adult veterans with chronic pain may fnd this useful. 

144 Chapter 5 
Chapter 5—Treating Drug Use and Prescription Medication Misuse in Older Adults TIP 26

EXHIBIT 5.4. Chronic Pain 

Assessment and Treatment 

Approaches for Older Adults895,896 

Assessment. An indepth assessment should 

review the client’s: 

• Cognitive and functional status. 

• Social support. 

• Co-occurring medical and psychiatric 

conditions and SUDs. 

• History of pharmacological and 

nonpharmacological treatments. 

• Current medication and alcohol use. 

• ADLs. (See Chapter 3 for more information 

about assessing these.) 

• Goals and hopes for treatment. 

Treatment. An indepth approach should include: 

• Building a treatment alliance with the older 

adult by asking about his or her preferences 

and goals. 

• Providing consistent and prompt follow-up to a 

client’s requests and phone calls. 

• Providing backup coverage with providers who 

understand the unique treatment needs of 

older adults. 

• Providing/actively linking the client to physical 

or occupational therapy and other communitybased resources. 

• Offering pharmacological (when needed) and 

other treatments (e.g., CBT, physical therapy, 

mindfulness). 

• Using praise and positive reinforcement when 

the client meets treatment tasks and goals. 

• When necessary, adapting treatment 

approaches to meet the needs of the older 

adult. 

• Including family and caregivers in treatment 

planning and recovery/rehabilitation activities 

(with the older adult’s permission). 

If you are treating older adults with opioids for 

chronic pain, do not stop treatment suddenly. 

This can cause serious withdrawal effects. In 

addition, the return of pain may lead older adults 

to misuse or use other prescribed medications, 

alcohol, OTC medications, and illicit drugs. 

The consensus panel recommends that you 

slowly titrate older adults off of opioids, 

while at the same time offering them other 

pharmacological and nonpharmacological 

treatment options. 

Treatment of Drug Use Disorders Other 

Than OUD 

Benzodiazepines 

Given the potential risks and harmful effects, 

medical providers are cautioned against 

prescribing benzodiazepines to older adults. If 

a benzodiazepine is needed, prescribe the lowest 

dose for the shortest amount of time. Harmful 

effects of benzodiazepines can include:897 

• Residual sedation. 

• Decreased attention. 

• Decreased memory and cognitive function. 

• Changes in motor coordination. 

• Increased risk of falls. 

• Drug dependence and withdrawal. 

• Increased risk of car accidents. 

Although life-threatening benzodiazepine 

overdoses are rare, the risk is higher in 

older adults because of age-related declines 

in medication metabolism. In the event of 

a benzodiazepine overdose, low doses of a 

benzodiazepine antagonist are safe for older 

adults.898 

Medically supervised withdrawal from 

benzodiazepines for older adults should include:899 

• Counseling. 

• A stepped withdrawal schedule. 

• Client education about benzodiazepine use and 

withdrawal. 

Chapter 5 145 
TIP 26 Treating Substance Use Disorder in Older Adults 

Benzodiazepine withdrawal symptoms can 

be similar to alcohol withdrawal symptoms. 

Withdrawal symptoms can include anxiety, sleep 

disturbances, and life-threatening complications 

such as seizures. A gradual, tapered approach to 

medically supervised withdrawal is best. 

Because older adults can have withdrawal 

symptoms even after taking the medication for 

relatively short periods of time, tapering should 

be gradual. It should last for a minimum of 4 

weeks, although most clients need longer.900 

One study using a 22-week tapering protocol 

and education about the tapering process 

found that 27 percent of clients stopped taking 

benzodiazepines within 6 months, compared 

with 5 percent in the control group.901 A review 

of 28 studies of older adults tapering off 

benzodiazepines reported positive outcomes 

and no serious harmful effects with tapering only 

(32 percent), tapering and CBT (32 percent), and 

tapering plus other medication (36 percent).902 

Other Sedative-Hypnotics 

Medical providers often prescribe sedativehypnotic medication to older adults for insomnia. 

Sedative-hypnotics should not be frst-line 

treatment for insomnia. Some older adults can 

beneft from benzodiazepines and other sedativehypnotics as short-term solutions to sleep issues. 

However, long-term use of these medications 

increases the risk of physical dependence. Be 

very cautious prescribing them to older adults 

because of the increased risk of:903 

• Memory impairment. 

• Falls. 

• Fractures. 

• Car accidents. 

The consensus panel discourages treatment of 

insomnia with sedative-hypnotics for more than 

7 to 10 days. Patients need frequent monitoring 

and reassessment if treatment continues past 2 

to 3 weeks. Intermittent dosing at the lowest 

possible dose is best. Prescribe no more than a 

30-day supply. 

SLEEP HYGIENE TO REDUCE 

INSOMNIA IN OLDER ADULTS 

The aging process can cause changes in sleep 

that lead to increased awakenings during the 

night. Older clients who practice good sleep 

hygiene and receive CBT can retrain their 

bodies and brains for better, more restful sleep. 

Sleep-related best practices that combine 

principles of sleep hygiene with CBT include the 

following:904,905,906,907 

• Avoid alcohol and caffeine, especially before 

bed. 

• Take medications in the morning if possible, 

especially if they are stimulating or cause 

alertness. 

• Don’t take daytime naps. 

• Follow a regular bedtime. 

• Use the bedroom only for sleep and sexual 

activity; remove TVs, electronics, and items 

unrelated to sleep. 

• Limit exercise to earlier in the day. 

• Avoid heavy meals before bedtime. 

• Learn relaxation techniques and use them 

before bed and during night wakening. 

• If awake for 10 to 15 minutes, get out of bed and 

do something quiet and relaxing (e.g., read a 

book in some place other than bed). Go back to 

bed only when sleepy. This helps the brain link 

the bedroom to sleep only. 

• Keep a sleep diary to track habits and changes 

in sleep over time. 

Cannabis 

The widening legalization, availability, and social 

acceptance of cannabis has led to more frequent 

recreational and medicinal use of this drug by 

older adults. Sometimes, this results in cannabis 

use disorder (CUD). According to DSM-5, CUD 

includes symptoms such as:908 

• Taking cannabis in larger amounts or over a 

longer period than was planned by the person. 

• Having an ongoing desire to cut down or control 

use or past unsuccessful efforts to do so. 

146 Chapter 5 
Chapter 5—Treating Drug Use and Prescription Medication Misuse in Older Adults TIP 26

• Failing to fulfll major role responsibilities at 

work, school, or home because of cannabis use. 

• Experiencing tolerance or withdrawal. 

Withdrawal symptoms can lead to a return to use 

and include:909 

• Irritability. 

• Depression. 

• Anxiety. 

• Sleep problems. 

• Dysphoria (sad mood). 

Evidence-based treatments for CUD are lacking 

for the general population and for older adults. 

More studies and interventions designed for older 

adults are needed. 

The National Institute on Drug Abuse 

recommends three behavioral approaches to 

treat CUD:910 motivational interviewing (MI), CBT, 

and contingency management. 

Stimulants 

Stimulant intoxication (e.g., from cocaine or 

amphetamines) is linked to mental symptoms (e.g., 

anxiety, agitation, psychosis) as well as autonomic 

hyperactivity (i.e., high blood pressure, rapid 

heart rate). Benzodiazepines or neuroleptics may 

be prescribed for withdrawal-related symptoms, 

such as agitation and sleep issues (e.g., insomnia, 

extreme sleepiness).911 Other withdrawal symptoms 

can include: 

• Depression. 

• Irritability. 

• Anxiety. 

• Psychosis. 

At this time, there are no FDA-approved, 

evidence-based pharmacological treatment 

options for individuals with cocaine use 

disorder912 and no approved treatments specifc 

to older adults with stimulant use disorders. 

However, some pharmacotherapies have shown 

success in adult populations, including disulfram, 

bupropion, and naltrexone.913 CBT remains the 

gold-standard treatment for stimulant cravings 

and return to stimulant use.914 

Psychosocial Treatment Approaches 

Psychosocial interventions are generally 

effective in reducing and even stopping drug 

use and prescription medication misuse. Some 

interventions, such as CBT, MI, and relapse 

prevention therapy, are effective for many 

types of drug use.915 Medication treatments for 

drug use may be more effective in combination 

with psychosocial treatment, compared with 

either medication or psychosocial interventions 

alone.916,917 

It is unclear which psychosocial treatments are 

most effective for older adults with drug use 

disorders. Some psychosocial approaches, like 

problem-solving therapy and CBT, have effectively 

treated older adults for other behavioral health 

issues (e.g., depression, tobacco addiction) that 

often co-occur with drug use disorders.918,919,920 A 

systematic review found that older adults do as 

well as or better than younger adults across SUD 

treatment approaches.921 

You can adapt standard psychosocial counseling 

methods for use with older adults by: 

• Repeating information. 

• Using a slower pace. 

• Offering shorter sessions. 

• Giving information in different ways (e.g., verbally, 

in large print) to match clients’ level of physical 

and cognitive functioning. 

• Using age-sensitive approaches with structured 

(not open-ended) questions. Such approaches are: 

- Supportive. 

- Nonconfrontational. 

- Responsive to gender/cultural differences. 

- Flexible (e.g., provide in-home or phone 

service for clients without transportation). 

- Focused on helping older adults learn/ 

improve coping and social skills. (Chapter 

4 of this TIP discusses CBT, MI, relapse 

prevention therapy, and problem-solving 

therapy treatment approaches for older 

adults in more detail.) 

Chapter 5 147 
TIP 26

Age-Specifc Treatment 

Age-specifc treatment approaches and practices 

help older adults seek, participate in, and complete 

treatment. Such approaches also improve older 

adults’ treatment experience (Exhibit 5.5). Whereas 

some older adults beneft from mixed-age addiction 

treatment, those ages 75 and older or with more 

chronic co-occurring health conditions and functional 

limitations beneft from age-specifc treatment.922 

Regardless of the treatment approach, older adults 

prefer age-specifc, age-sensitive approaches that are 

nonconfrontational, person centered, and fexible. 

Age-specifc programming923,924 improves treatment 

completion and improves older adults’ 12-month 

rates of abstinence. It also results in higher rates 

of attendance at group meetings compared with 

mixed-age treatment. Age-specifc programs that 

have been studied have featured:925 

• An emphasis on individual and group counseling 

and community activities. 

• Adaptations such as slower pace and 

accommodations for vision, hearing, and cognitive 

impairment. 

Treating Substance Use Disorder in Older Adults 

• Special topic groups for older adults focusing on: 

- Grief. 

- Loss. 

- Isolation. 

- Physical health issues. 

- Recreation. 

- Life changes. 

- Purpose. 

- Support. 

• An emphasis on the therapeutic alliance while 

using CBT and MI, and a 12-Step philosophy. 

Exhibit 5.5 highlights important characteristics 

of age-specifc treatment for older adults 

recommended by the consensus panel. 

Referral Management and Care 

Coordination 

Limited time and resources may keep you from 

treating older adults with drug use disorders. 

However, as part of care coordination, you should 

develop linkages with treatment providers who 

EXHIBIT 5.5. Age-Specifc SUD Treatment for Older Adults 

Accessibility 

• Use a larger font on print and electronic client 

screening, assessment, and educational materials. 

• Offer adaptations for individuals with cognitive, 

vision, or hearing impairments. 

• Offer transportation, in-home services, and 

telephone checkups. 

• Offer a sliding scale for self-paying clients. 

• Use adaptations for individuals with physical 

disabilities and problems getting around. 

• When needed, supply linkages to: 

- Food, clothing, and shelter. 

- Specialized medical services. 

- Older adult-focused social services. 

- Employment services. 

- Financial and housing assistance. 

Program Specifc 

• Use a nonconfrontational manner emphasizing 

the therapeutic alliance while using therapeutic 

approaches that have been shown to work with 

older adults (e.g., CBT, MI, problem-solving therapy). 

• Focus on building self-esteem and coping skills. 

• Use a slower pace and adaptations for vision, 

hearing, and mild cognitive problems. 

• Offer individual, group, and family counseling. 

• Offer special topic groups for older adults. 

• Give individual counseling and one-on-one 

attention. 

• Ensure that staff are trained in the unique concerns 

and treatment needs of older adults. 

• Use gender-specifc content. 

• Offer counseling with providers who specialize in 

geriatrics. 

• Offer age-specifc linkages to services within the 

community. 

• Offer peer recovery support services geared to 

older adults. 

148 Chapter 5 
Chapter 5—Treating Drug Use and Prescription Medication Misuse in Older Adults TIP 26

can do so and with other resources within the 

community.926 (See “Resource Alert: Developing 

Referral Resources” in Chapter 2 of this TIP.) 

Referring older clients to the right level of 

treatment and offering ongoing coordination of 

care are the keys to getting positive outcomes 

for older adults in addiction treatment. 

Effective referral starts with matching your referral 

to the client’s stated goals and available resources. 

You must also address the client’s outlook and 

hopes for the referral. 

Once you make a referral, follow up with both 

the client and the other provider to make 

sure that the client is continuing in treatment. 

Work together with the other provider to offer 

ongoing care as needed. (See Chapter 4 of this 

TIP for more strategies for referral management 

and care coordination.) 

Recovery Management 

Recovery management is an organizing philosophy 

for addiction treatment and recovery support 

services. Recovery management can help 

individuals and family members participate in 

treatment and achieve long-term recovery.927 Not 

everyone who uses illicit substances or misuses 

prescription medication needs ongoing recovery 

management support. However, some older adults 

may need ongoing monitoring and recovery 

support, especially if they have co-occurring 

medical conditions or mental disorders, experience 

social isolation, or receive little support from family 

and friends.928 

Continuing care interventions that suit older adults 

and positively affect addiction treatment include: 

• Home visits. 

• Telephone counseling. 

• Recovery checkups. 

• Active linkage to community resources, such as 

recovery support groups. 

Offering case management services and including 

supportive family members in the older adult’s 

treatment can also support ongoing recovery. (See 

also the “Family Involvement” section.) 

Case and Care Management Services 

Case and care management (CCM) services can 

help older adults reduce health-related risks of 

drug use or prescription medication misuse. The 

CCM approach to addiction treatment is broad. 

It addresses clients’ overall health and connects 

them to recovery resources within the community, 

such as NA and AA. CCM services focus on getting 

clients into addiction treatment programs when 

needed and linking them to other services, like: 

• Housing support. 

• Employment services. 

• Financial services. 

• Specialty medical treatment. 

CCM services are commonly available in 

community-based agencies, healthcare offces, and 

residential or long-term care facilities.929 Addiction 

treatment programs and comprehensive behavioral 

health programs also may have care coordination 

and resource linkage services, which are increasingly 

offered by peer recovery support specialists. 

CCM models can help older adults enter and stay 

in treatment, possibly because this approach 

seeks to reduce feelings of shame older adults 

often feel about entering treatment, and it 

provides support to the individual. CCM does 

this by focusing on older adults’ overall health 

rather than just their drug use.930,931 CCM strategies 

should help older adults gain access to agerelated resources in the community that support 

recovery.932,933 

Family Involvement 

Involving family throughout treatment and 

ongoing recovery can help improve older clients’ 

chances of staying in addiction treatment. 

It can also improve treatment outcomes. Family 

members: 

• Often make frst contact with treatment services. 

• Can motivate the older adult to participate in 

treatment. 

Chapter 5 149 
TIP 26 Treating Substance Use Disorder in Older Adults 

• Can help the older adult overcome barriers to 

access. 

• Can help the older adult with the diffculties of 

the medical and specialized addiction treatment 

systems. 

• Can provide important details about the client’s 

history of and current substance use. 

With the client’s permission, involve family 

members and caregivers who support the older 

adult’s recovery efforts: 

• In the initial evaluation of the older adult. 

• Throughout treatment. 

• During ongoing recovery support. 

• In posttreatment recovery plan development. 

Although family members and caregivers can 

be key in providing support, they may also feel 

shame related to their family member’s drug 

use disorder. You can help them feel more open 

to being involved by stressing that addiction 

is a chronic illness, like heart disease, and 

reminding them of the confdential nature of 

treatment. Without meaning to, sometimes family 

members exacerbate the older adult’s drug use or 

prescription medication misuse by helping him or 

her get access to illicit substances or supporting 

the misuse of prescribed medication. Family 

members may beneft from psychoeducation, 

delivered in a nonjudgmental way, about the health 

risks of drug use and prescription medication 

misuse. (See Chapter 4 of this TIP for more 

information about family involvement in treatment 

and caregiver support resources.) 

Mutual-Help Groups 

Twelve-Step recovery support groups offer 

community-based support for individuals who 

have drug use disorders, including people who 

are in continuing care following brief interventions 

or specialized addiction treatment.934 A growing 

body of research suggests that mutual-help 

group participation improves long-term recovery, 

psychosocial outcomes, and self-effcacy.935,936 

However, no systematic studies address outcomes 

for older adults. Even so, mutual-help group 

participation may improve recovery and help 

older adults reduce social isolation, shame, and 

the effects of discrimination associated with drug 

use disorders.937 

The key to linking older adults to mutual-help 

groups is fnding available resources in your 

community and matching clients to specifc 

groups that may be a better ft for older adults. 

For example, when an older client cannot easily 

access an NA meeting, the client may beneft from 

attending AA meetings instead.938 Older clients 

may feel more comfortable going to AA than NA, 

where participants are typically younger and use 

multiple substances.939 

Key elements of 12-Step groups that are especially 

well suited to older adults include:940 

• General social support, goal direction, and 

structure. 

• Participation in substance-free social activities. 

• Activities to improve participants’ self-effcacy 

and coping skills. 

These strategies can help you link older clients to 

community-based recovery support groups: 

• Become familiar with age-friendly mutual-help 

groups available in your community. 

• Contact local support group offces and ask 

which meetings are accessible to people with 

disabilities and have active members who are 

older adults. 

• Ask groups to provide contact information for 

older adult members who can act as temporary 

sponsors or provide transportation. 

• Link clients to peer recovery support specialists 

in your own organization or in the community. 

• Urge older clients to attend several different 

meetings before they decide whether mutual 

help is something they want to pursue, because 

each meeting has its own tone and feeling. 

150 Chapter 5 
Chapter 5—Treating Drug Use and Prescription Medication Misuse in Older Adults TIP 26

RESOURCE ALERT: SMART 

RECOVERY 

SMART stands for Self-Management and 

Recovery Training. SMART Recovery is a network 

of local and online abstinence-focused addiction 

recovery support groups based on evidencesupported principles of CBT and MI approaches, 

which are appropriate for treating older adults. 

Unlike AA, NA, and Cocaine Anonymous, SMART 

Recovery meetings are run by trained volunteers 

and do not include a spiritual component. The 

SMART Recovery website (www.smartrecovery. 

org) offers information about SMART Recovery 

principles and training opportunities, including 

how to become a facilitator for meetings. It 

includes a searchable database of local and 

online meetings. You can also learn more about 

SMART Recovery in Chapter 4 of this TIP. 

Clinical Scenarios 

The clinical cases that follow give examples of 

substance misuse by older adults and ways to 

apply clinical interventions in these situations. 

Interventions and treatments can range from 

PCPs asking the older adult about personal use 

of substances (e.g., benzodiazepines, cannabis, 

cocaine, alcohol use with medication misuse 

or illicit substance use) to inpatient addiction 

treatment. The level of intensity of interventions 

and treatments for older adults depends on: 

• The substance used. 

• The level of use. 

• Effects on and risks to client. 

Clinical Scenario: Benzodiazepine Misuse 

and Polypharmacy 

For many older adults, the relationship with their 

PCP is often one of their strongest and most 

stable. Visits to their PCP provide an opportunity 

to screen for substance use and misuse, including 

substance use related to late-life changes (e.g., 

retirement, moving, grieving a death). This 

scenario demonstrates thorough screening of 

a new client and strategies for problem-solving 

and referral. 

• Sedative, Hypnotic, or Anxiolytic Use 

Disorder: An older adult woman becomes 

physically dependent on benzodiazepines after 

long-term use and increases her health risk by 

taking benzodiazepines with other sedativehypnotic medications. 

• Treatment Setting: Outpatient healthcare clinic 

• Providers: PCP; clinical social worker (CSW) 

• Treatment Strategies: Screen for alcohol 

misuse; discuss history of sedative use; provide 

information on risks of taking substances 

together; explore tapering off benzodiazepines; 

refer to CSW who uses CBT strategies for 

anxiety; follow up with the client. 

Joan is a 70-year-old widow who has two grown 

children who live far away from her. She started 

to have signifcant anxiety in her 50s, when the 

company she worked for closed and her job 

ended. She was never able to look for or fnd 

a job again. At that time, she was prescribed a 

benzodiazepine by her PCP and she has taken it 

for many years. In the past year, her husband died, 

and she moved from her house to an apartment 

because she could not afford to stay in the house. 

She became more anxious and started taking extra 

doses of the benzodiazepine. Her sister also has a 

benzodiazepine prescription and has given Joan 

extra pills when she runs out, which happens more 

often lately. Joan has arthritis pain, making sleep 

diffcult. To help with this, her doctor prescribed 

sleeping pills on a short-term basis. Joan stopped 

drinking alcohol when her husband stopped 

drinking 10 years before his death. 

Her long-term PCP retired recently—another 

signifcant loss for Joan. She started seeing a new 

PCP at the same group practice after the nurse 

care manager reached out by phone to set up an 

initial consultation. Her new provider is screening 

all new clients for a variety of health behaviors. The 

PCP asks Joan about her alcohol use and notes 

that she has been taking benzodiazepines for more 

than a decade. Joan states, “I have been taking 

Xanax for years for my ‘nerves.’ It made it easier 

for me to go to social events and church after 

Jake died.” Joan also says that the pills make it a 

little easier to sleep but that she has recently had 

to take more sleeping pills to get any sleep at all. 

Joan likes her new doctor, so she is willing to talk 

Chapter 5 151 
TIP 26

about her benzodiazepine dosage. She discusses 

how she gets some extra pills from her sister 

because she runs out before the prescriptions are 

ready to be flled and starts to feel “bad.” 

At this meeting, the new PCP discusses 

Joan’s anxiety and, in a nonjudgmental way, 

gives information about the risks of taking 

benzodiazepines for a long time, taking more than 

prescribed, and adding sleeping pills to the mix. 

She says, “You know, many people who take this 

medication for a long time, even as prescribed, 

start to need a higher dose just to keep the 

anxiety at bay or then add a sleeping pill because 

the tranquilizer isn’t working anymore. There are 

some options we can talk about that could help 

you feel better without all of this medication. Can 

we discuss some options and fgure out together 

what might work best for you?” Joan says that she 

would like not to have to take so many pills, and 

she worries that if her sister isn’t around, she won’t 

be able to get more tranquilizers from her. 

The PCP and Joan discuss several options, 

including a long-term taper from the 

benzodiazepines, and work together to fnd 

the best option for Joan. The PCP explains the 

tapering process and explains how Joan can 

manage anxiety and sleep problems as she tapers 

off the medication. Initially, Joan is a bit nervous 

about tapering off the medication but agrees to 

this option after the PCP reassures her that she 

will work closely with her to make sure the taper is 

adjusted correctly for her situation. 

The PCP then asks Joan whether she would 

be willing to talk to the clinic’s social worker 

about connecting with age-friendly activities 

in the community and learning to manage her 

anxiety without medication. Joan says “yes.” 

The PCP walks Joan over to the social worker’s 

offce and introduces Joan to her. They set up an 

appointment for an initial visit. 

The social worker is trained in CBT strategies to 

manage anxiety and introduces them to Joan 

at her initial visit. In their next session, the social 

worker discusses with Joan how the CBT is affecting 

her ability to manage anxiety. The social worker 

continues to see Joan weekly. Each week, Joan gets a 

structured, between-session assignment and a quick 

telephone reminder about practicing the exercise. 

Treating Substance Use Disorder in Older Adults 

CBT FOR ANXIETY AMONG OLDER 

ADULTS 

A review of psychosocial treatments for anxiety 

among older adults found that CBT had the 

strongest research support.941 The authors 

reported that CBT could be even more useful for 

older adults when adapted to their needs. Some 

of these adaptations include:942 

• Simpler CBT interventions. 

• Between-session reminder phone calls. 

• A weekly review of concepts discussed. 

• At-home assignments. 

The social worker also helps Joan connect with 

social activities she enjoys. With support, Joan 

feels she can improve how she feels physically and 

emotionally. Her PCP is in contact with Joan’s social 

worker and sees Joan on a regular basis to assess 

how well the taper is going and whether it needs 

adjustment. 

Clinical Scenario: Use of Opioids and 

Alcohol for Pain Management 

When older adults taking pain medication use 

alcohol, they can experience additional negative 

health effects. Older adults who live in retirement 

communities and long-term residential care 

facilities often fnd themselves in social situations 

where drinking is supported.943 Visits to the PCP 

provide a chance to screen for alcohol misuse as 

well as offer new options for pain management. 

This scenario demonstrates screening 

thoroughly before prescribing additional pain 

medication, educating clients on the dangers 

of using alcohol with medication, and providing 

nonpharmacological pain management 

strategies. 

• OUD and Alcohol Misuse: An older adult 

living in a retirement community who drinks 

to socialize becomes physically dependent on 

opioids after surgery. 

• Treatment Setting: Outpatient healthcare clinic 

• Providers: PCP; NP 

152 Chapter 5 
Chapter 5—Treating Drug Use and Prescription Medication Misuse in Older Adults TIP 26

• Treatment Strategies: Screen for prescription 

drug and alcohol use; discuss current health 

status of the client; provide information on risks 

of using alcohol while taking opioids; perform 

initial brief interventions; suggest physical 

therapy and a tapering program; conduct 

multiple follow-up brief interventions and calls 

with the client. 

Louise is a 75-year-old retired middle school 

teacher who is married. She and her husband, a 

retired high school principal, just celebrated their 

50th wedding anniversary. They have a son, a 

daughter, and three grandchildren. For the past 5 

years, they have lived in a retirement community. 

They have made friends in the community and take 

part in activities, including golf, exercise classes, 

card games, and book clubs. Many of these 

events include alcohol. In addition, the community 

sponsors regular happy hour gatherings at the 

clubhouse that Louise and her husband also attend. 

One month ago, Louise had knee replacement 

surgery. She began taking opioids for pain in the 

hospital and was sent home with a prescription 

so that she could continue to use the medication 

during rehabilitation. She was still having pain 

during the day, with greater pain at night. To 

add to the effects of the opioids and make them 

“go further,” she drank wine at the usual gettogethers with friends and had additional drinks 

in the evening before bed. A neighbor, Pat, had 

prescription opioids from a past surgery. She 

offered them to Louise to help “tide her over” 

until she saw her doctor. Louise waited to make 

an appointment until she was almost out of her 

neighbor’s opioid medication. 

Louise makes an appointment with her PCP to see 

whether she can get more pain medication. She 

tells her PCP that the pain is not going away, and 

that she is almost out of medication. The PCP talks 

with Louise about her pain and screens for amount 

and frequency of alcohol use and medication use. 

He discovers that she is drinking while taking the 

opioids and has been using more opioids than 

recommended. He then gives her nonjudgmental 

feedback about the results of the screens. He says, 

“Based on your answers to my questions about 

your alcohol use and use of pain medication, it 

looks like you are at risk for some serious health 

problems if you continue drinking alcohol and 

taking medication in this way. We know that when 

people your age drink and take the kind of pain 

medication you are on, they can have problems 

with their breathing, ability to move around, or 

memory. Are any of those happening to you?” 

Louise starts to become concerned and responds, 

“You know, I have been getting more confused 

about things lately and feeling like I sometimes 

have a hard time breathing easily. But I am worried 

about the pain and how I will manage without pain 

medicine or extra alcohol.” 

The PCP acknowledges her concerns by stating 

that maintaining her health and level of activity is 

important. The PCP asks whether she would be 

willing to work with him and an NP to come up 

with a plan to manage her pain while lowering the 

health risks she faces by drinking and using pain 

medication at the same time. Louise says, “Well, 

what’s most important to me is to get my knee in 

good shape again.” 

The PCP supports Louise’s goal and calls in the 

NP, who is trained in giving substance-related brief 

interventions and has worked with other clients 

to help them cut back on alcohol and reduce or 

stop their use of opioids. The NP schedules Louise 

for two face-to-face meetings and two follow-up 

phone calls between visits. She and Louise develop 

a treatment plan that includes Louise going to 

physical therapy and a rehabilitative exercise 

class in her community to help her knee heal and 

improve her range of motion so she can get back 

to golfng with her group. Louise also agrees to 

keep track of her alcohol use and to follow an 

opioid taper plan over the next month to get off 

the pain medication. 

Clinical Scenario: Screening, Assessment, 

and Referral to Addiction Treatment 

Older adults with a history of substance misuse 

have increased risk of return to substance use when 

they have additional stressors (e.g., injury, divorce, 

family confict). Heavy substance use also leads to 

many health problems; these are often the primary 

reason a client seeks treatment or winds up in the 

ED. A study found that SBIRT in an ED setting was 

a factor in reducing substance use at follow-up, 

suggesting that an ED visit for another medical 

Chapter 5 153 
TIP 26

problem may be a “turning point” for many 

individuals with substance misuse concerns.944 This 

scenario shows the importance of the ED as a 

setting for screening, assessment, and referral; it 

also demonstrates strategies providers can use 

to take advantage of “teachable moments” with 

clients. 

• Cannabis and Alcohol Misuse: An older adult 

with a long history of alcohol and cannabis 

misuse has co-occurring medical conditions. 

• Treatment Setting: ED of a community hospital 

• Provider: ED attending physician 

• Treatment Strategies: Get the client medically 

stable; order a blood test screen for alcohol; 

order a urine screen for cannabis; discuss the 

current state of the client; provide information 

on the risks of using alcohol with cannabis; 

conduct a brief intervention; recommend shortstay, inpatient detoxifcation and treatment 

followed by outpatient care. 

Walter is 69 years old and divorced. He lives 

with his girlfriend. He has an adult son and a 

granddaughter. Walter likes to hunt and fsh with 

his male friends but has little other social contact. 

Walter had some problems with alcohol when he 

was younger, including being arrested for driving 

under the infuence. He cut back on drinking 

but started smoking cannabis daily. After he got 

married, he stopped using cannabis and drank only 

occasionally for several years. He started drinking 

heavily and smoking cannabis again after an 

on-the-job back injury in his early 50s. He divorced 

10 years ago and retired the next year. He met 

Sally, his long-term girlfriend, 5 years ago. Walter 

drinks heavily and uses cannabis daily. In the past 

year, there have been many times when he did not 

remember what he did when he was intoxicated. 

His girlfriend used to enjoy smoking cannabis and 

drinking with him, but as he increased his use, she 

is no longer comfortable living with him and has 

threatened to move out if he keeps using. 

Walter has been having some health problems, 

including high blood pressure, diabetes, and 

chronic back pain. He sometimes forgets to take 

his medications. He was stopped by the police 

for unsafe driving recently but was not arrested. 

Treating Substance Use Disorder in Older Adults 

In addition, he had a falling out with his son and 

daughter-in-law. They do not want him spending 

time with his granddaughter because he is often 

drunk and high. 

A week later, he starts drinking and smoking 

cannabis when he wakes in the morning and 

continues to use all day, passing out in the late 

afternoon. When he awakens a few hours later, he 

has chest pain, nausea, and sweating. Worried of 

a heart attack, his girlfriend takes him to the ED. 

The attending physician sees him immediately, 

takes a medical history, and orders lab tests to rule 

out a heart attack. However, a blood draw shows 

his blood alcohol level is 0.18. A urine screen 

is positive for cannabis. The ED physician then 

performs a more indepth screen and assessment 

of Walter’s substance use history and, with Walter’s 

permission, invites Sally to discuss the effects of 

Walter’s drinking and cannabis use. 

Once Walter is less intoxicated, the ED physician 

talks with him about his medical status. In a 

nonjudgmental and nonconfrontational tone, he 

says, “Walter, the good news is that you did not 

have a heart attack. Based on your other lab tests, 

your age, and other medical conditions and what 

you and Sally have told me about your drinking and 

cannabis use, I want you to think about a short stay 

at an inpatient treatment program so you can get 

a handle on your substance use.” At frst, Walter is 

not sure, but then Sally supports him. He then says, 

“I feel so sick, and thinking I was having a heart 

attack really scared me. I guess it’s the best thing 

for me to do.” The ED physician introduces Walter 

and Sally to the nurse care manager and assures 

them that she can answer any questions they have 

about the treatment process and will help transfer 

his care to the inpatient program. 

Clinical Scenario: Polysubstance Misuse 

With Co-Occurring Medical Conditions 

More and more older adults with a history of illicit 

drug use, particularly heroin and cocaine, are 

being admitted to inpatient addiction treatment 

programs.945,946 Cocaine use in older adults is 

related to multiple medical problems, including 

higher rates of high blood pressure, breathing 

issues, heart attack, stroke, and cognitive 

154 Chapter 5 
Chapter 5—Treating Drug Use and Prescription Medication Misuse in Older Adults TIP 26

impairment.947 Older adults with a long history 

of polysubstance misuse (misuse of multiple 

substances at the same time) and co-occurring 

medical conditions are at risk for return to 

substance use and lack of follow-up for medical 

conditions after inpatient treatment. This scenario 

demonstrates referral management and ongoing 

recovery support strategies for an older adult 

with a history of polysubstance misuse and cooccurring medical conditions. 

• Polysubstance Misuse: An older adult has a 

history of misuse of heroin and cocaine. 

• Treatment Setting: Inpatient detoxifcation and 

rehabilitation program 

• Provider: Licensed alcohol and drug counselor 

(LADC) on a multidisciplinary treatment team 

• Treatment Strategies: Offer referral and 

recovery management strategies before 

discharge. 

Hal is 74 years old and never married. He started 

using heroin as a soldier in the Vietnam War. 

After discharge from the service, he started using 

cocaine to stay awake during his night shift at the 

post offce. His drug use stayed about the same for 

many years but increased after he retired. He lives 

alone, and his social life includes playing poker with 

friends on Thursdays. During a recent game, Hal 

had numbness in his arm and slurred speech. One 

of his buddies brings him to the ED. Hal is having 

a mild stroke. After he is medically stabilized, Hal 

enters an extended-care inpatient SUD treatment 

program. After 8 weeks of treatment, Hal meets 

with his primary counselor to discuss his continuing 

care plan. 

ADAPTING RESIDENTIAL CARE FOR 

OLDER ADULTS 

Because many older adults have problems 

getting around, upon admission to residential 

and inpatient programs, older adults can beneft 

from being paired with a “senior buddy” to 

help them learn the facility and move from one 

treatment activity to another.948 

The counselor opens the conversation by saying, 

“Hal, you’ve done really well in treatment. You’ve 

participated fully in therapy and educational 

groups here and have a solid plan to keep yourself 

from relapsing and to help you cope with any 

triggers to use once you go home.” Hal responds, 

“Thanks. It’s good to hear that you think I’ve been 

doing well. Frankly, I was kind of anxious when I 

was frst admitted to the program. It really helped 

that you paired me up with Bill to show me the 

ropes.” 

The counselor says, “Let’s talk about your goals for 

ongoing recovery.” Hal says he doesn’t want to go 

back to using but worries that he has no recovery 

support back home. He says, “My poker buddies 

all drink and smoke pot. Even though that wasn’t 

my thing, I think that will be a trigger to use again. 

I liked the NA meetings a lot, but I live in a really 

small town, and there aren’t any NA meetings 

nearby.” 

Hal’s counselor had already contacted the AA 

central service offce closest to Hal and gotten the 

names and contact information of an older AA 

volunteer who would be willing to help Hal get 

to meetings and act as a temporary sponsor. The 

counselor says, “I already talked to Jerry. It turns 

out he is a Vietnam vet, too.” Hal says that talking 

to someone who has “been there” would be a big 

help to him. 

Hal and his counselor talk about other recovery 

management options, like linking with a counselor 

and a continuing care group at an outpatient SUD 

treatment program nearby and getting Hal an 

appointment with a PCP who can provide medical 

care. The counselor tells Hal of a recovery checkup 

program with a peer recovery support specialist 

who will call him regularly to see how he is doing 

and whether he needs linkage to other community 

resources. The counselor will provide a “warm 

handoff” by introducing Hal to the specialist before 

discharge. Hal says, “That sounds great. It will be 

nice to have that connection to the rehab.” Hal 

and his counselor write down his continuing care 

plan and all contact information. His counselor 

says, “Your homework is to call the AA contact 

and schedule a meeting after your discharge on 

Chapter 5 155 
TIP 26

Thursday. Mine is to make referrals to the PCP and 

outpatient addiction counseling program.” Hal is 

satisfed with the recovery plan and motivated to 

follow through and continue his recovery program. 

Summary 

Widespread screening, brief intervention, and 

referral and recovery management are essential 

to the successful treatment of drug use and 

prescription medication misuse, including drug 

use disorders, in older adults. Whatever specifc 

treatment method or strategy you use when 

working with older adults who have drug use 

disorders, make sure it is nonconfrontational and 

age sensitive. Ongoing recovery management 

strategies increase the chance that improvements 

will continue over time and not only help older 

adults reduce negative drug-related health and 

behavioral outcomes, but also improve the quality 

of their lives. 

Chapter 5 Resources 

Provider Resources 

National Council on Aging—Resources (www. 

ncoa.org/audience/professional-resources/?post_ 

type=ncoaresource): This resource provides a 

searchable database of articles, webinars, and 

manuals. 

Treating Substance Use Disorder in Older Adults 

Consumer Resources 

FindTreatment.gov (https://fndtreatment.gov): 

People seeking treatment for SUDs can use this 

federal locator maintained by SAMHSA to fnd 

treatment facilities based on location, availability 

of treatment for co-occurring mental disorders, 

availability of telemedicine care, payment option, 

age, languages spoken, and access to medication 

for OUD. The site also links to information on 

understanding addiction, understanding mental 

illness, and paying for treatment. 

SAMHSA—Behavioral Health Treatment 

Services Locator (https://fndtreatment.samhsa. 

gov/): SAMHSA offers people seeking treatment 

for addiction or mental illness a confdential, 

anonymous information source about treatment 

facilities in the United States and U.S. Territories. 

SAMHSA’s National Helpline (www.samhsa. 

gov/fnd-help/national-helpline): The National 

Helpline is a free, confdential, 24/7, 365-days-ayear treatment referral and information service 

(in English and Spanish) for people facing mental 

disorders and SUDs. The toll-free phone number is 

1-800-662-HELP (4357) or 800-487-4889 (TTY). 

Faces & Voices of Recovery—Guide to Mutual 

Aid Resources (https://facesandvoicesofrecovery. 

org/resources/mutual-aid-resources): Visitors 

can fnd a listing of mutual-help group contact 

information. 

156 Chapter 5 
TIP 26 TREATING SUBSTANCE USE DISORDER 

IN OLDER ADULTS

Chapter 6—Substance Misuse and Cognitive 

Impairment 

KEY MESSAGES 

• Substance misuse can increase the risk of 

having cognitive problems as an older adult. 

• Screening for mental disorders that co-occur 

with substance misuse and can negatively 

affect cognition is very important. Doing such 

screening will help you quickly get clients 

the substance use disorder (SUD) treatment, 

mental health services, and medical evaluation 

they need. 

• Treatment should be offered as needed for the 

full scope of problems facing an older client. 

Treatment should address a client’s substance 

misuse; co-occurring mental conditions, 

including depression or anxiety; and cognitive 

impairment. 

Chapter 6 of this Treatment Improvement 

Protocol (TIP) will most beneft providers. It will 

help them understand how to screen, diagnose, 

and treat older clients who misuse substances 

and have, or are at risk for, cognitive problems. 

Changes in how people think and how their 

brains work are normal parts of getting older 

and vary a lot from person to person. But some 

age-related cognitive changes are abnormal, such 

as Alzheimer’s disease. However, for older adults 

who misuse substances, diffculties with cognition 

and other brain functions can be more serious. 

Older individuals are more sensitive than younger 

and middle-aged adults to the negative effects of 

drugs and alcohol on the brain.949 This puts older 

people who misuse substances at increased risk 

for certain problems with thinking (also called 

cognitive impairment or cognitive disorders), such 

as dementia and delirium. 

Who Can Beneft From Chapter 6 

of This TIP and How? 

Chapter 6 of TIP 26 is for behavioral health 

service, healthcare, and social service providers 

who provide care to older adults who misuse 

substances. Such providers include physicians 

and other healthcare professionals, psychiatrists, 

psychologists, counselors, social workers, drug and 

alcohol counselors, and other behavioral health 

workers, such as peer recovery support specialists. 

Screening, diagnosis, and treatment of older 

clients who misuse substances and have 

cognitive problems may require help from many 

different types of providers. One type of provider 

may screen; another may make the diagnosis; 

yet another may treat the client or work with the 

client’s caregiver. 

If you work with older adults in any setting, you 

are likely seeing more and more older clients who 

misuse substances. Chapter 6 will support you in 

decreasing your clients’ chances of developing 

dementia and other cognitive problems by 

helping them address substance misuse and 

adopt healthier lifestyles.950,951 Chapter 6 will 

help you: 

• Teach older clients about risks of cognitive 

disorders related to substance misuse, such as 

dementia. 

• Understand why you need to screen older 

clients who misuse substances for cognitive 

impairment, as well as conditions that co-occur 

with substance misuse and increase the risk for 

cognitive problems. These include depression, 

anxiety, and posttraumatic stress disorder 

(PTSD). 

157 
TIP 26 Treating Substance Use Disorder in Older Adults 

• Refer older clients with cognitive impairment 

for further cognitive testing and evaluation to 

make sure they receive the correct diagnosis. 

• Offer treatments for SUDs, co-occurring mental 

disorders, and cognitive disorders, including 

education, drug and alcohol counseling, 

mental health services, referral for medication 

treatment, or a combination of these. 

• Work with caregivers of older clients who 

misuse substances, have cognitive disorders, 

or both. Caregivers often need help improving 

their own coping and stress management skills. 

This is important because when caregivers 

suffer, the care they give can suffer too. 

Organization of Chapter 6 of 

This TIP 

Chapter 6 covers education, screening, 

assessment, and treatment of older adults who 

misuse substances and may also have, or be at 

risk for, cognitive impairment. 

The frst section of Chapter 6 discusses how 

common substance misuse is in older adults. 

Many people think substance misuse is “just a 

young person’s problem.” But this is not true. This 

section will help you understand the importance 

of offering substance-related screening and 

treatments. 

The second section addresses whether substance 

misuse causes cognitive problems in older 

people. The fndings from research studies are not 

always clear. But what is clear is why you need to 

look for cognitive problems in older clients who 

misuse substances and how you can do that. 

EXHIBIT 6.1. Key Terms 

In the third section, you will learn more about 

mental disorders that commonly occur in older 

clients who misuse substances and can negatively 

affect their thinking. These include depression, 

anxiety, and PTSD. If untreated, these conditions 

can also make a client’s substance misuse worse. 

Similarly, untreated SUDs can make these cooccurring mental disorders worse. 

The fourth section offers recommendations on 

how to help older clients who misuse substances 

reduce their chances of developing cognitive 

problems through screening, assessment, and 

treatment (or referral to treatment). Screening 

and assessment are discussed in more detail in 

Chapter 3 of this TIP (which includes many of the 

actual screening measures you can use in your 

program). 

The ffth section guides you in helping caregivers 

of older clients who misuse substances and 

have cognitive diffculties. Caregivers face 

many struggles and are often in great need of 

information and resources—not only to help your 

older clients but also to help themselves. 

The fnal section offers resources to support your 

program and resources to share with your clients 

and their family members. More detailed resources 

are in Chapter 9 of this TIP. 

The Appendix presents two screening 

instruments: one for depression and another for 

PTSD. For defnitions of key terms you will fnd in 

Chapter 6 of this TIP, see Exhibit 6.1. 

• Addiction*: The most severe form of SUD, associated with compulsive or uncontrolled use of one or more 

substances. Addiction is a chronic brain disease that has the potential for both recurrence (relapse) and 

recovery. 

• Alcohol misuse: The use of alcohol in any harmful way, including heavy drinking, binge drinking, and 

alcohol use disorder (AUD). 

• At-risk/high-risk drinking: Drinking alcohol in excessive amounts. This defnition encompasses both 

binge drinking and heavy drinking. Additionally, any alcohol consumption is considered risky when 

Continued on next page 

158 Chapter 6 
Chapter 6—Substance Misuse and Cognitive Impairment TIP 26

Continued 

carried out by individuals with certain medical conditions that are worsened by alcohol, those taking 

medicine that can interact harmfully with alcohol, those driving a car or engaged in other activities that 

require alertness, or people recovering from AUD.952,953 Note that for purposes of this TIP, at-risk drinking 

and high-risk drinking are synonymous and either term is acceptable to describe an older adult’s drinking 

patterns. 

• AUD: The ffth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defnes 

this disorder.954 An AUD diagnosis is given to people who use alcohol and meet at least 2 of the 11 DSM-5 

symptoms in a 12-month period. Key aspects of AUD include tolerance, withdrawal, loss of control, and 

continued use despite negative consequences. AUD covers a range of severity and replaces what the 

previous edition of DSM termed alcohol abuse and alcohol dependence. 

• Binge drinking: A drinking pattern that leads to blood alcohol concentration levels of 0.08 grams per 

deciliter or greater. This usually takes place after four or more drinks for women and fve or more drinks 

for men.955,956 However, older adults are more sensitive to the effects of alcohol, and treatment providers 

may need to lower these numbers when screening for alcohol misuse.957 Additionally, other factors such 

as weight, decrease in enzyme activity, and body composition (e.g., amount of muscle tissue present in 

the body) can also affect alcohol absorption rates. 

• Caregivers: Informal caregivers provide unpaid care. They assist others with activities of daily living 

(ADLs), including health and medical tasks. Informal caregivers may be spouses, partners, family 

members, friends, neighbors, or others who have a signifcant personal relationship with the person who 

needs care. Formal caregivers are paid providers who offer care in one’s home or in a facility.958 Most older 

adults do not need caregivers and are as able to address their own needs as younger adults, whether or 

not substance misuse is a factor in their lives. 

• Cognitive disorders: Problems in cognition that are not a normal part of aging. These problems include 

diffculties with memory, attention, using and understanding language, thinking and reacting quickly, 

solving diffcult problems, or a combination of these. Dementia and MCI are examples of cognitive 

disorders. 

• Delirium tremens: A temporary state of confusion that can occur during alcohol withdrawal. If untreated, 

some symptoms, such as unstable heart rate and seizures, can be life threatening. 

• Dementia: A brain disorder in which problems with cognition get worse over time. Problems with 

cognition are serious enough that people need help with activities of everyday living (e.g., bathing, 

getting dressed, and feeding themselves). In DSM-5, dementia is known as major neurocognitive disorder. 

• Drug–drug interaction: The interaction of one substance (e.g., alcohol, medication, an illicit drug) with 

another substance. Drug–drug interactions may change the effectiveness of medications, introduce 

or alter the intensity of side effects, and increase a substance’s toxicity or the concentration of that 

substance in a person’s blood. Potentially serious interactions can also occur with certain foods, 

beverages, and dietary supplements.959 

• Hazardous drinking: Alcohol use that increases the risk of future harm.960 

• Heavy drinking: Consuming fve or more drinks for men and four or more drinks for women in one period 

on each of 5 or more days in the past 30 days.961 

• Illicit substances: Illicit substances include cocaine, heroin, hallucinogens, inhalants, methamphetamine, 

and prescription medications that are taken other than as prescribed (e.g., pain relievers, tranquilizers, 

stimulants, sedatives). 

• MCI: A mild brain disorder that is similar to dementia. With MCI, problems with thinking are present but 

are not severe enough for people to need help with their everyday activities. In DSM-5, MCI is known as 

mild neurocognitive disorder. 

• Moderate drinking: According to the 2015–2020 Dietary Guidelines for Americans, moderate drinking is 

defned as up to two drinks per day for men and up to one drink per day for women.962,963 However, the 

Continued on next page 

Chapter 6 159 
TIP 26 Treating Substance Use Disorder in Older Adults 

Continued 

Centers for Disease Control and Prevention (CDC) notes that these numbers apply to any given day and 

are not meant as an average over several days.964 Additionally, individuals who don’t metabolize alcohol 

well may need to consume even lower quantities. Some people, particularly those with certain alcoholrelated illnesses or engaging in tasks requiring concentration, should not consume alcohol at all. The 

Dietary Guidelines stipulate that those who don’t drink should not begin drinking for any reason.965 

• Mutual-help groups: Groups of people who work together on obtaining and maintaining recovery. Unlike 

peer support (e.g., the use of recovery coaches or peer recovery support specialists), mutual-help groups 

consist entirely of people who volunteer their time and typically have no offcial connection to treatment 

programs. Most are self-supporting. Although 12-Step groups such as Alcoholics Anonymous and 

Narcotics Anonymous are the most widespread and well researched type of mutual-help groups, other 

groups may be available in some areas. They range from groups affliated with a religion or church (e.g., 

Celebrate Recovery, Millati Islami) to purely secular groups (e.g., SMART [Self-Management and Recovery 

Training] Recovery, Women for Sobriety). 

• Peer support: The use of peer recovery support specialists (e.g., someone in recovery who has lived 

experience in addiction plus skills learned in formal training) to provide nonclinical (i.e., not requiring 

training in diagnosis or treatment) recovery support services to individuals in recovery from addiction and 

to their families. 

• Psychoactive substances: Substances that can alter mental processes (e.g., cognition or affect; in other 

words, the way one thinks or feels). Also called psychotropic drugs, such substances will not necessarily 

produce dependence, but they have the potential for misuse or abuse.966 

• Recovery*: A process of change through which individuals improve their health and wellness, live a selfdirected life, and strive to reach their full potential. Even individuals with severe and chronic SUDs can, 

with help, overcome them and regain health and social function. This is called remission. When those 

positive changes and values become part of a voluntarily adopted lifestyle, that is called being in recovery. 

Although abstinence from all substance misuse is a cardinal feature of a recovery lifestyle, it is not the 

only healthy, prosocial feature. 

• Relapse*: A return to substance use after a signifcant period of abstinence. 

• Remission: A medical term meaning a disappearance of signs and symptoms of the disease or disorder. 

DSM-5 defnes remission as present in people who previously met SUD criteria but no longer meet any 

SUD criteria (with the possible exception of craving).967 Remission is an essential element of recovery. 

• Substance misuse*: The use of any substance in a manner, situation, amount, or frequency that can 

cause harm to users or to those around them. For some substances or individuals, any use would 

constitute misuse (e.g., underage drinking, injection drug use). 

• Substance use disorder*: A medical illness caused by repeated misuse of a substance or substances. 

According to DSM-5,968 SUDs are characterized by clinically signifcant impairments in health and social 

function and impaired control over substance use. They are diagnosed through assessing cognitive, 

behavioral, and psychological symptoms. SUDs range from mild to severe and from temporary to chronic. 

They typically develop gradually over time with repeated misuse, leading to changes in brain circuits 

governing incentive salience (the ability of substance-associated cues to trigger substance seeking), 

reward, stress, and executive functions like decision making and self-control. Multiple factors infuence 

whether and how rapidly a person will develop an SUD. These factors include the substance itself; the 

genetic vulnerability of the user; and the amount, frequency, and duration of the misuse. Note: A severe 

SUD is commonly called an addiction. A mild SUD is generally equivalent to what previous editions of 

DSM called substance abuse; a moderate or severe SUD is generally equivalent to what was formerly 

called substance dependence. 

* The defnitions of all terms marked with an asterisk correspond closely to those given in Facing Addiction in 

America: The Surgeon General’s Report on Alcohol, Drugs, and Health. This resource provides a great deal of useful 

information about substance misuse and its impact on U.S. public health. The report is available online (https://addiction. 

surgeongeneral.gov/sites/default/fles/surgeon-generals-report.pdf). 

160 Chapter 6 
Chapter 6—Substance Misuse and Cognitive Impairment TIP 26

Substance Misuse in Older Adults 

Substance misuse in older people is increasing,969 

yet it is often overlooked and underaddressed 

by providers.970,971 Older clients may not feel 

comfortable telling you about their substance misuse 

or asking for help. This is problematic, as older 

people are more likely than younger or middle-aged 

people to experience negative effects from alcohol, 

drugs, and prescription medications.972,973 

Healthcare, behavioral health service, and 

social service providers can have diffculty 

noticing substance misuse in older clients. This 

is partly because most older adults who misuse 

substances do not meet all DSM-5 criteria for an 

SUD. For example, tolerance is a key diagnostic 

criterion of an SUD. But because of the aging 

process, older adults have a lower tolerance for 

alcohol and other substances than younger people. 

Thus, although tolerance in an older person is still a 

sign of substance dependence, it looks different in 

older adults than in younger individuals. 

Chapter 1 of this TIP provides information and statistics 

about overall substance misuse, misuse of specifc 

substances, and effects of substance misuse among 

older adults. The following sections in this chapter of 

the TIP provide a brief summary of this information. 

Alcohol Misuse 

Older adults use alcohol more than any other 

substance.974,975 In 2019, 52.8 percent of people 

ages 60 to 64 years and 43.9 percent of people 65 

and older were estimated to have used alcohol in 

the past month,976 and 3.4 percent of adults 50 

and older had AUD.977 

Alcohol misuse differs between older men and 

older women. For example, women tend to feel 

the negative effects of alcohol after having fewer 

drinks than is the case for men.978 They may be 

more vulnerable to the effects of alcohol misuse—a 

concerning fact, given that drinking rates (including 

for binge drinking) are increasing more rapidly 

among older women than older men.979 

Misuse of Other Substances 

Although most older adults do not use illicit 

substances, some do. For example, according 

to data from 2019,980 SUDs involving illegal drugs 

occurred in approximately 390,000 adults ages 50 to 

54; 271,000 adults ages 55 to 59; 282,000 adults ages 

60 to 64; and 227,000 adults ages 65 and older. 

Prescription medications are some of the 

most commonly misused substances among 

older adults in the United States. Prescription 

medication misuse involves taking a medication 

other than as prescribed, whether accidentally or 

on purpose. Some older adults use prescription 

medications to “get high,” but many misuse 

prescription medications by mistake to address 

sleep problems, chronic pain, or anxiety. Pain 

relievers are the most commonly misused 

prescription medication among older adults.981 

Exhibit 6.2 describes classes of prescription 

medication. 

EXHIBIT 6.2. Understanding 

Classes of Medications 

Most of your older clients will be taking at least 

one prescription medication. Many clients take 

more than one. Be sure you are familiar with the 

different types of medication classes. This will help 

you better understand the potential cognitive 

effects and drug–drug interactions related to the 

medications your clients are taking. Common 

medication classes include:982 

• Sedative-hypnotics, which are often prescribed 

for sleep problems or anxiety. They include 

barbiturates (e.g., amobarbital, secobarbital) and 

benzodiazepines (e.g., lorazepam, alprazolam). 

Sometimes the term “tranquilizer” is used 

to describe antianxiety medications such as 

benzodiazepines. 

• Opioid analgesics, which are prescribed to treat 

pain. Opioid analgesics work by attaching on 

opioid receptors in the brain. Examples include 

oxycodone and hydrocodone/acetaminophen. 

• Nonopioid analgesics, which people take to 

control pain. But these pain medications do not 

act on opioid receptors in the brain. Examples 

include aspirin and acetaminophen. 

• Stimulants, which help people feel alert or full 

of energy. Examples include amphetamine/ 

dextroamphetamine and methylphenidate. 

Chapter 6 161 
TIP 26 Treating Substance Use Disorder in Older Adults 

Between 11 and 18 percent of older adults, 

depending on age range, report using tobacco 

in the past month.983 These numbers are troubling 

because, in adults ages 65 and older, smoking is 

associated with more than double the chances of 

binge drinking and triple the chances of illicit drug 

use or prescription medication misuse.984 

The true population rate for benzodiazepine 

misuse by older adults is unknown. The 

American Geriatrics Society notes that although 

at times prescribing benzodiazepines to older 

adults may be appropriate, these medications 

may be potentially inappropriate for some older 

individuals. These medications increase the risk of 

falls and fractures, car accidents, problems with 

cognition, substance misuse and dependence, and 

death.985,986 

It is unclear how many older adults use cannabis 

with a prescription, how many use it recreationally 

in areas where doing so is legal, and how many 

misuse it (whether through using recreationally in 

areas where it is illegal or by misusing prescription 

cannabis). Cannabis may seem harmless, but in 

some older adults it may be linked to memory 

and thinking problems, AUD and nicotine use 

disorder, and co-occurring mental disorders 

like depression, anxiety, bipolar disorder, and 

PTSD.987,988 

Efects of Substance Misuse 

Older adults are more likely than younger and 

middle-aged adults to feel the negative physical 

effects of medications, illicit drugs, and alcohol. 

In older people:989 

• It takes longer for organs (e.g., liver, kidneys) to 

remove the alcohol and drugs from the body. 

• With less lean body mass and total body water, 

older people can become intoxicated on even 

small amounts of a substance. 

• The central nervous system is more sensitive to 

the effects of drugs and alcohol. 

• Harmful drug–medication interactions are 

more likely. (See, for example, “Resource Alert: 

Preventing Dangerous Alcohol–Medication 

Interactions.”) Older adults often take more 

than one medication. Harmful drug–medication 

interactions are associated with negative events 

such as:990,991,992 

- Injury (e.g., falls). 

- Breathing problems. 

- Sleeping problems. 

- Cognitive changes. 

- Seizures. 

- Internal bleeding. 

- Dangerous changes in blood pressure. 

- High or low blood sugar levels. 

- Overdose, which can be fatal. 

- Suicide and self-harm. 

• Alcohol misuse can increase an older person’s 

risk of injury, including those from:993,994,995,996 

- Falls. 

- Traumatic brain injury. 

- Car accidents. 

- Experiencing violence or abuse frsthand. 

- Suicide and nonsuicidal self-injury. 

• Binge drinking on 5 or more days in the past 

month can increase the risk of certain physical 

conditions and mental disorders or make them 

worse. Such conditions include:997,998,999,1000 

- Depression. 

- Cancer. 

- Diabetes. 

- High blood pressure. 

- Heart failure. 

- Sleep diffculties. 

162 Chapter 6 
Chapter 6—Substance Misuse and Cognitive Impairment TIP 26

RESOURCE ALERT: PREVENTING DANGEROUS ALCOHOL–MEDICATION 

INTERACTIONS 

Older adults are at high risk for dangerous alcohol–medication interactions. Learn more about commonly 

used prescription and over-the-counter medications and how they interact with alcohol in the National 

Institute on Alcohol Abuse and Alcoholism's (NIAAA) publication Harmful Interactions (www.niaaa.nih.gov/ 

publications/brochures-and-fact-sheets/harmful-interactions-mixing-alcohol-with-medicines). 

Additionally, the Substance Abuse and Mental Health Services Administration (SAMHSA) publication Get 

Connected: Linking Older Adults with Resources on Medication, Alcohol, and Mental Health discusses the 

dangers of older adults misusing alcohol and prescription and over-the-counter drugs. It describes the 

signs of misuse and steps that older adults can take to prevent problems (https://store.samhsa.gov/product/ 

SMA03-3824). 

Links Between Substance Misuse 

and Cognitive Disorders 

You will note that this section addresses the 

cognitive effects of alcohol misuse in far greater 

depth than it does the cognitive effects of other 

substance misuse. This is because most research 

on substance misuse and cognitive disorders 

focuses on alcohol. Research on the relationship 

between cognitive disorders and other substances, 

such as cocaine and cannabis, is still new, 

somewhat mixed, and inconclusive. This section 

does address benzodiazepines and tobacco, but in 

less detail. 

The brain undergoes certain changes with age, like the shrinkage of white and gray matter tissue and 

decreased blood fow.1001,1002 Because of these alterations, people sometimes experience changes in thinking 

as they age. Examples of normal age-related changes in thinking include:1003 

• Having trouble recalling information without cues or reminders, such as not remembering what was on a 

shopping list when the list is not in front of the individual. 

• Being unable to remember where a piece of information was heard or learned. Was it in the newspaper? 

Did someone mention it? Was it on television? 

• Forgetting to perform activities, such as not remembering to turn off the kitchen light before going to 

bed. 

• Having problems remembering the names of common objects. 

Remember that aging differs across individuals, and whether someone experiences age-related changes in 

cognition depends on many factors. 

Alcohol and Cognition 

The link between alcohol use and problems with 

cognition in later life is complex. The effects of 

alcohol on a person’s health are infuenced by 

many factors, including how much and how often 

a person drinks, as well as by genetic and familyrelated factors. Social, cultural, and environmental 

factors can also affect a person’s misuse of alcohol. 

These include such factors as:1004 

• Exposure to alcohol consumption through 

television, movies, magazines, and social 

media. 

• Experience of hardships related to 

immigration and cultural adjustment to life in 

the United States. 

• Cultural norms related to drinking. 

• Community environment, including level of 

violence, neighborhood housing conditions, 

and number of liquor stores in the community. 

Chapter 6 163 
TIP 26

• Involvement with family, friends, or peers who 

misuse alcohol, raising the potential for misuse 

as a “learned behavior” adopted through 

attempts to imitate the drinking patterns of 

others. 

Alcohol misuse is harmful to overall health1005 

and can increase the risk of dementia.1006 It can 

also negatively affect certain areas of cognition, 

like memory.1007,1008 Drinking too much alcohol 

can damage the brain (as well as the liver, heart, 

and other organs).1009,1010 Older adults may be 

more likely than younger adults to experience 

harm to the brain and body caused by heavy 

drinking:1011,1012 

• Heavy alcohol use can damage older adults’ 

ability to:1013,1014 

- Learn new information. 

- Recall information. 

- Speak and understand language. 

- Solve problems. 

- Think and react quickly. 

• Heavy alcohol use can lead to negative physical 

changes in the brain. For instance, too much 

alcohol can cause brain cells and tissues to 

shrink or no longer work as they should.1015 

• Even lower levels of alcohol use can sometimes 

harm the brain of middle-aged and older 

adults,1016 including areas of the brain that 

control memory.1017 

What amount of alcohol harms a person’s 

thinking? There is no one right answer. The 

amount that is harmful can differ from person to 

person. Alcohol can affect a person’s cognition, 

no matter how little they drink. Clients need 

not have a problem with alcohol for it to have 

signifcant effects on their thinking. Do not make 

the mistake of thinking only people with AUD are 

at risk for cognitive problems like dementia and 

MCI. 

Dementia and MCI 

Does alcohol misuse cause or increase the risk 

of dementia or MCI? The answer is unclear, 

especially for Alzheimer’s disease.1018 Part of the 

Treating Substance Use Disorder in Older Adults 

problem is that different studies defne terms such 

as “alcohol consumption,” “light to moderate 

drinking,” and “heavy or excessive drinking” 

differently. 

Some studies have found a negative link 

between alcohol and cognitive disorders. For 

instance, research has found that: 

• Heavy drinking can increase the risk of 

Alzheimer’s disease.1019 

• Heavy drinking, especially binge drinking, can 

increase risk of cognitive problems in later 

life.1020,1021 

• Light-to-moderate drinking can increase the risk 

of MCI turning into dementia.1022 

• Heavy drinking as a young adult can increase the 

risk of certain types of dementia later in life.1023 

• Middle-aged adults who drink often (i.e., several 

times per month) may be more than twice as 

likely to have MCI in older adulthood as people 

who do not drink often (i.e., less than once per 

month). This risk appears to be even higher 

in people who have genes that increase their 

chances of developing Alzheimer’s dementia 

(e.g., the APOE e4 gene).1024 

What happens when people who already have 

dementia, MCI, or other problems with cognition 

drink alcohol? It depends on how much they drink 

and other individual factors. For instance, which if 

any medications are they taking? Are they at risk 

for dementia because of their genetic background? 

Consider the following: 

• Heavy alcohol use can be toxic to the brain. 

People with dementia or MCI are already 

struggling with their thinking. Adding alcohol 

to the situation can potentially worsen their 

cognitive problems. 

• Alcohol use can worsen dementia symptoms 

(e.g., lack of interest in people or activities).1025 

• Clients with cognitive problems may forget how 

much they drank, raising risk for drinking too 

much. 

What should you as a provider tell your older 

clients about alcohol misuse and their risk 

of cognitive problems? First, remember that 

defnitions, methods, and research questions differ 

164 Chapter 6 
Chapter 6—Substance Misuse and Cognitive Impairment TIP 26

among studies. This makes it diffcult to know 

the true relationship between alcohol and risk of 

dementia or MCI. However, that does not mean 

that you should take this risk lightly. 

Here are some important points you can make 

when discussing with older clients their risk 

of developing cognitive problems because of 

alcohol misuse: 

• Heavy alcohol use damages the brain, heart, 

liver, and other organs.1026,1027 

• Older people are more likely than younger 

people to feel alcohol’s negative effects.1028,1029 

So even light or moderate drinking can be more 

harmful to the brain. 

• Drinking habits and biological factors differ 

from person to person. For instance, people 

who drink wine may be at less risk from lightto-moderate drinking than people drinking 

other alcoholic beverages. People who do not 

have genes that elevate their risk for dementia 

(such as the e4 allele of the APOE gene) may 

be at less risk from light-to-moderate drinking 

than others who are at high genetic risk for 

dementia.1030 

HOW MUCH ALCOHOL IS “HEALTHY”? 

How “safe” or “healthy” is alcohol truly? A 2018 systematic analysis tried to answer this question by 

estimating the risk of alcohol consumption levels to health among people in 195 countries.1031 The study 

authors found that alcohol contributed greatly to disability and deaths, owing to its connection to 

conditions such as: 

• Tuberculosis. • Diabetes. 

• Cancer. • Accidental injuries. 

• Cardiovascular disease. • Self-harm. 

• Stroke. • Interpersonal violence. 

The study authors state that, based on their fndings, any amount of alcohol use, even minimal, can lead to 

loss of health. Although they found some benefcial effects of alcohol consumption for heart disease and 

diabetes among women, these benefts were outweighed by the health risks, especially those of cancer, 

infectious diseases, and injuries. 

“The widely held view of the health benefts of alcohol needs revising,” the authors write. “Our results 

show that the safest level of drinking is none” (p. 1026). 

The TIP consensus panel recommends that you 

counsel older clients on the possible dangers of 

alcohol misuse, especially heavy alcohol use and 

possible alcohol–medication interactions. If you 

screen a client for alcohol misuse, you should 

also screen him or her for cognitive impairment. 

Delirium Tremens 

People who drink heavily are at risk for a lifethreatening condition called delirium tremens 

(or alcohol withdrawal delirium). Delirium tremens 

is different from delirium. Delirium is a cognitive 

disturbance in which people become confused 

and disoriented. Delirium can occur in older 

people who have recently undergone surgery 

or are taking multiple prescription medications, 

or who are experiencing common but serious 

medical conditions such as infections or 

dehydration.1032,1033,1034 

Delirium tremens is a serious and potentially 

deadly consequence of alcohol withdrawal. In 

fact, it is the most serious adverse effect of alcohol 

withdrawal. Symptoms of delirium tremens could 

be mistaken for signs of dementia. Dangerous 

symptoms can include:1035,1036 

• Hallucinations. 

• Confusion (or disorientation). 

Chapter 6 165 
TIP 26 Treating Substance Use Disorder in Older Adults 

• Rapid heart rate or high blood pressure. 

• Sweating. 

• Nausea or vomiting. 

• Seizures and tremors. 

Behavioral health service and healthcare 

providers should stay alert for symptoms of 

delirium tremens when treating older clients 

with alcohol withdrawal. About 3 to 5 percent 

of people hospitalized for alcohol withdrawal 

have delirium tremens.1037 Without treatment, 

delirium tremens can be deadly because of serious 

complications like heart arrhythmias.1038 Thus, it 

often requires treatment in intensive care. 

Alcohol-Related Dementia 

Long-term heavy drinking can directly cause 

alcohol-related dementia (ARD).1039 ARD occurs 

in up to a quarter of older people with AUD and 

is more likely to be diagnosed in men.1040 Little 

scientifc evidence exists on the amount, length, 

and severity of alcohol use that leads to ARD.1041 

Some researchers believe that ARD develops 

because of a lack of vitamin B1 (thiamine)1042 and 

the direct neurotoxic effects of ethanol.1043 To 

confrm a diagnosis of ARD, refer the client to a 

neuropsychologist or neuropsychiatrist for indepth 

cognitive testing. 

WERNICKE–KORSAKOFF SYNDROME 

Wernicke–Korsakoff syndrome (WKS) includes both Wernicke’s encephalopathy and Korsakoff syndrome— 

two brain disorders linked to lack of vitamin B1 (thiamine). Heavy alcohol use is often the cause of WKS, but 

physical conditions, such as cancer, can also cause it.1044 

WKS is sometimes called alcohol-induced persisting amnestic disorder. Three main symptoms occur in 

WKS: problems with eye movement, confusion, and an inability to control muscle movements (also called 

ataxia), such as when walking. WKS is rare, occurring in about 1 percent of the general population. WKS is 

much more common in people with AUD, but prevalence rates vary widely.1045 

In some ways, WKS is similar to ARD. Both appear to be caused in part by a lack of vitamin B1. Both 

conditions can improve after clients stop using alcohol, start taking vitamin B1, or both. People with WKS 

can have such behavioral symptoms as loss of interest in all activities (called apathy) and restlessness, mood 

symptoms (e.g., depression, anxiety), and psychotic symptoms (e.g., hallucinations, delusions).1046 To confrm 

a diagnosis of WKS, you will need to refer the client to a neuropsychologist or neuropsychiatrist for cognitive 

testing. 

Benzodiazepines and Cognition 

Compared with older people who have never 

used benzodiazepines, older adults who have 

used them1047 (ever, recently, previously, or for 

long periods of time) appear to have a higher 

risk of dementia. Older people with long-term use 

(i.e., greater than 3 months) of benzodiazepines 

may be 1.5 to 2 times more likely to develop 

dementia as people who have not used them long 

term.1048 The risk of dementia with benzodiazepine 

use appears to grow as the dose of benzodiazepine 

increases.1049 

Offer older clients who have taken 

benzodiazepines for a long time or have 

taken a high dose of these medications 

cognitive screening to assess problems in their 

thinking. (See Chapter 3 for cognitive screening 

measures.) Assessment of memory and cognitive 

functioning should be part of the annual exam 

of all older adults. High-dose or long-term use 

of benzodiazepines is an appropriate reason to 

perform cognitive screening, whether or not the 

older client asks for it, because older clients, 

especially those with cognitive impairment, may 

not realize that they need this screening. 

166 Chapter 6 
Chapter 6—Substance Misuse and Cognitive Impairment TIP 26

The American Geriatrics Society cautions that 

benzodiazepines are potentially inappropriate in 

most older clients, but also notes that their use may 

be appropriate in certain limited circumstances, 

such as for seizure disorders.1050 (See text box on the 

American Geriatrics Society 2019 Beers Criteria® for 

Potentially Inappropriate Medication Use in Older 

Adults.) Consider whether older clients who take 

benzodiazepines need referral for a medication 

switch. Cognition may improve following the 

switch to alternative medications or with a gradual 

reduction in dosage of these medications. 

In addition to understanding the problems 

related to benzodiazepines, determine whether 

there have been any changes or additions to 

the client’s medications. 

Medications contraindicated or causing adverse 

reactions and complications may temporarily 

impair cognition or exacerbate existing MCI. 

The American Geriatrics Society Beers Criteria® list medications that are potentially inappropriate for older 

adults because the risks often outweigh the benefts. At the time of this publication, the 2019 Beers Criteria® 

are the most recent.1051 Clients taking medications in the brief list that follows (which is drawn from the full 

Beers Criteria®) should be referred to a healthcare provider to discuss possibly switching medications: 

• Certain antidepressants (e.g., amitriptyline, nortriptyline) 

• First-generation (older) and second-generation (atypical) antipsychotics 

• Barbiturates (e.g., phenobarbital, secobarbital) 

• Short-, intermediate-, and long-acting benzodiazepines (e.g., alprazolam, clonazepam) 

• Certain pain medications (e.g., ibuprofen, naproxen) 

The 2019 Beers Criteria® also newly recommend avoiding concurrent use of benzodiazepines and 

prescription opioids, while stating that concerns about interactions should be weighed against the need to 

treat chronic pain. 

Note that the Beers Criteria® list medications that are potentially but not defnitely inappropriate. For more 

on how to properly apply the recommendations, see this editorial in the Journal of the American Geriatrics 

Society: https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.15766. 

Tobacco and Cognition 

A recent study found that people who currently 

smoke cigarettes were much more likely to have 

dementia (any type) than people who had never 

smoked.1052 Interestingly, people who formerly 

smoked had the same risk of dementia as people 

who never smoked. This means that stopping 

tobacco use could be powerful in reversing 

the risk of dementia. Research fndings from 

four large studies appear to confrm the harmful 

relationship between smoking and increased risk 

of dementia.1053,1054,1055,1056 However, more research 

is needed to explore this relationship. That said, 

tobacco use is known to cause many serious 

negative health problems. You should counsel all 

clients who use tobacco to quit. 

RESOURCE ALERT: GOING SMOKE 

FREE 

For free support in helping your clients quit 

tobacco, call 1-800-QUIT-NOW (1-800-784-8669) 

and visit https://smokefree.gov. 

For tips on quitting tobacco use from former 

smokers, direct your clients to this CDC webpage: 

www.cdc.gov/tobacco/campaign/tips/index.html. 

Chapter 6 167 
TIP 26

Substance Misuse and 

Co-Occurring Mental Disorders 

That Afect Cognition 

Some older adults who have mental disorders 

also misuse substances.1057 For instance, in 

older adults, alcohol misuse often co-occurs with 

depression.1058,1059 In older people, depression is 

associated with problems with reported memory, 

attention, problem-solving, and the ability to 

think and react quickly.1060 According to data from 

the National Survey on Drug Use and Health, an 

estimated 1.7 million older adults (ages 50 and 

above) in the United States had a co-occurring 

mental disorder and SUD in 2019.1061 

Treatment rates for older people with cooccurring conditions are low. Estimates from 2019 

showed that just 9.6 percent of people 50 and older 

with any mental illness and a past-year SUD received 

substance misuse services at an SUD treatment 

facility as well as mental health services.1062 One 

reason for the undertreatment of co-occurring 

disorders (CODs) in older adults is that CODs tend 

to be overlooked and underdiagnosed.1063 

Older adults with CODs tend to use more 

behavioral health services than do older adults 

without CODs. Even so, they are at risk for 

negative health and psychosocial outcomes, 

including:1064,1065 

• Thoughts of suicide and of death in general. 

• Some medical issues (e.g., liver disease). 

• Severe symptoms of depression. 

• Being divorced, separated, or widowed. 

Substance misuse often makes the symptoms 

of a co-occurring mental disorder worse and 

harder to treat. For example, substance misuse 

can worsen cognitive symptoms of co-occurring 

mental disorders. Just like substance misuse, mental 

disorders can lead to diffculties with cognition. 

Cognitive symptoms can make it harder for older 

adults to recognize their substance misuse,1066 which 

could reduce likelihood of seeking SUD treatment. 

Substance misuse, co-occurring mental disorders, 

and cognitive disorders are all related to one 

another. And they all have similar symptoms. If 

an older client has any one of these conditions, 

Treating Substance Use Disorder in Older Adults 

screen for all three. (Screening measures for these 

conditions appear in Chapter 3 of this TIP.) Major 

depressive disorder (MDD) and generalized anxiety 

disorder (GAD) often co-occur with substance 

misuse in older adults and negatively affect the 

brain. PTSD is less common in older people than 

MDD and GAD, but it does occur, especially in 

older military veterans. Be alert for these disorders 

in older clients who misuse substances and have 

cognitive diffculties. 

MDD and Depressive Symptoms 

MDD and depressive symptoms are both risk 

factors for and outcomes of substance misuse 

in older adults. In fact, MDD is one of the most 

commonly co-occurring mental disorders of 

older clients who misuse substances.1067 A recent 

meta-analysis found that one in four people with 

dementia had clinically signifcant depressive 

symptoms.1068 In a large sample of older adults 

with alcohol misuse, 29.7 percent reported having 

symptoms of depression.1069 In this same study, 

rates of depression were especially high among 

older adults with two or more chronic health 

conditions (such as heart disease or diabetes). In 

these adults, alcohol misuse was fve times more 

common in those with depression than in those 

without depression. 

Whether MDD is a risk factor for dementia 

is unclear. It is also unknown whether having 

depression and substance misuse causes more 

cognitive problems than just having depression 

or substance misuse, but not both.1070 Some 

research suggests that a relationship does exist 

between depression and cognitive disorders.1071 

For example: 

• Adults with depression that starts earlier in life 

are at double the risk for dementia than adults 

who do not have depression.1072 

• People with late-life depression are at a higher 

risk of certain types of dementia.1073 

Depression is not a normal part of aging. Do not 

ignore even mild symptoms of depression in 

older clients. 

168 Chapter 6 
Chapter 6—Substance Misuse and Cognitive Impairment TIP 26

• In one study, 70 percent of women ages 85 

and older with depressive symptoms were 

diagnosed with MCI within 5 years, and 65 

percent had dementia.1074 

• Dementia risk seems higher in people with more 

frequent and severe depressive episodes.1075 

Anxiety Disorders 

About 10 to 15 percent of older adults meet 

criteria for an anxiety disorder.1076,1077 Among the 

most common anxiety disorders in older people 

are GAD and specifc phobias.1078 In Wave 2 of 

the National Epidemiologic Survey on Alcohol 

and Related Conditions (NESARC), prevalence of 

any past-year anxiety disorder among adults ages 

55 and older was 11.4 percent, that of GAD was 

2.8 percent, and that of specifc phobias was 5.8 

percent.1079 

Older adults with anxiety may be at an increased 

risk of substance misuse.1080 Older adults living in 

the community, as well as those in SUD treatment, 

have higher rates of comorbid mental disorders, 

including anxiety, than older adults without 

substance misuse.1081 In an analysis of data from 

Waves 1 and 2 of NESARC,1082 older adults with a 

past-year SUD had a signifcantly greater chance 

of also having persistent anxiety compared with 

older adults without an SUD. The risk of substance 

misuse in older people with anxiety may be even 

higher for older women.1083 

Anxiety symptoms in older adults can increase 

the risk of cognitive problems, especially with 

memory and learning.1084 Anxiety disorders are 

also linked to other conditions that can affect 

cognition, including depression1085 and substance 

misuse.1086 

In a 2018 meta-analysis, the overall prevalence 

of clinically signifcant anxiety among people 

with dementia was 14 percent.1087 Compared with 

depression, less is known about anxiety as a risk 

factor for dementia. Even so, the evidence shows: 

• Among individuals newly diagnosed with 

dementia, about 31 percent previously had 

an anxiety diagnosis, compared with only 14 

percent of older adults without dementia.1088 

• An anxiety disorder almost triples the risk of 

dementia.1089 

• People who have anxiety and depression 

are about 2.85 times more likely to have 

dementia.1090 

• Anxiety appears to be a major predictor of 

cognitive problems in general and of dementia 

specifcally.1091 This may be especially true for 

many older adults (ages 80 and older). 

• When older adults with anxiety have cognitive 

problems, these problems are often with 

memory, attention, and problem-solving 

abilities.1092 

PTSD and Trauma 

Older people are at risk for PTSD and substance 

misuse, although the rate of PTSD in older 

people is low. For instance, in Wave 2 of NESARC, 

3.5 percent of adults ages 55 and older were 

reported to have past-year PTSD.1093 In another 

study that also looked at Wave 2 data from the 

same survey, about 22 percent of adults ages 60 

and older who met some but not all criteria for 

PTSD had an SUD, and 27 percent of older adults 

who met full criteria for PTSD had an SUD.1094 

Older adults who met at least some criteria for 

PTSD had 1.6 times greater chances of having an 

SUD than older adults who met no PTSD criteria. 

It is unclear how common PTSD is in people with 

dementia. A meta-analysis examining rates of 

mental disorders among people with dementia 

noted a lack of research on PTSD specifcally.1095 

Based on very limited studies, the authors 

estimated the overall prevalence of PTSD in 

dementia to be 4.4 percent. 

Older adults who are military veterans also may 

be at risk for co-occurring PTSD and substance 

misuse. In a systematic literature review of studies 

about older veterans with PTSD, the prevalence of 

co-occurring SUDs ranged from about 1 percent to 

11 percent.1096 

Take the time to learn whether older clients who 

misuse substances also have a history of trauma 

or abuse. (Please refer to “Screening for PTSD, 

Trauma Symptoms, and Abuse” in Chapter 3 of 

this TIP for additional information.) Also determine 

whether PTSD is present. A trauma-informed 

approach to the screening, assessment, and care 

of older clients who misuse substances can help 

Chapter 6 169 
TIP 26

put clients at ease. It will create a setting in which 

clients are more likely to open up and share with 

you the details of their trauma. You can take a 

trauma-informed approach by:1097,1098 

• Making sure clients feel safe in your program— 

both physically and mentally. 

• Using a gentle and warm attitude. 

• Staying open and nonjudgmental. This builds 

trust among providers, staff members, clients, 

and family members. 

• Working with your clients in a cooperative, 

shared way to make treatment decisions 

together. This helps empower clients and 

reminds them that they have a voice in the care 

process. 

• Letting clients know that it is normal and 

healthy to express emotions, whether positive 

or negative. This is especially useful with older 

clients because older adults may be more likely 

to shy away from discussing negative feelings 

or traumas. They may be more likely to talk 

about physical symptoms rather than emotional 

ones or to dismiss traumas as “normal” parts of 

life.1099 

• Being responsive to racial, ethnic, and gender 

disparities that may affect your clients’ health. 

Realize that clients may have specifc needs in 

these areas that can be addressed in the healing 

process. 

• Offering peer support and referral to mutualhelp programs. Working with someone who 

understands the lived experience of trauma and 

PTSD can be powerful for clients. 

• Remembering to screen and assess clients 

for mental disorders and other conditions 

that co-occur with PTSD or trauma, such as 

depression and substance misuse. 

How Providers Can Help 

To help older adults with cognitive or co-occurring 

mental disorders related to substance misuse: 

• Educate older clients and their caregivers 

about the defnitions and facts on co-occurring 

mental disorders and cognitive problems related 

to substance misuse. This includes making 

sure clients and caregivers understand that the 

“safest” level of alcohol use is none at all. No 

Treating Substance Use Disorder in Older Adults 

amount of alcohol will be safe for older clients 

who take certain medications, have certain 

health conditions, or engage in certain activities 

(see Chapter 4). 

• Screen older clients who misuse substances for 

co-occurring mental health conditions such as 

depression, anxiety, and PTSD. 

• Screen older clients who misuse substances 

(especially alcohol) for co-occurring cognitive 

impairment. Older clients who take high 

doses of benzodiazepines or have been taking 

benzodiazepines long term also should be 

screened for cognitive problems. 

• Interview clients, caregivers, and practitioners 

(with clients’ permission) to determine whether 

changes in medications are leading to, or 

worsening, cognitive impairment. 

• Offer clients drug and alcohol counseling, 

mental health services, or both, as 

appropriate. If your program does not offer 

these services, refer clients to a local program 

that does—and, if possible, to one that is 

experienced in working with older clients who 

misuse substances. 

• For clients who screen positive for cognitive 

problems, give referrals for full cognitive 

assessments, which should include indepth 

cognitive testing. Only behavioral health service 

providers with specifc training and experience 

can give these tests (a neuropsychologist or 

neuropsychiatrist). 

• Offer resources and mental health services 

(or referrals for services) as needed to older 

clients who misuse substances, have cognitive 

disorders, or both; make such offers to their 

caregivers as well, if needed. 

The U.S. Preventive Services Task Force 

recommends that healthcare providers screen 

for unhealthy alcohol use in adults ages 18 

years or older and provide those who show risky 

or hazardous drinking with “brief behavioral 

counseling interventions” to reduce unhealthy 

alcohol use (www.uspreventiveservicestaskforce. 

org/Page/Document/UpdateSummaryDraft/ 

unhealthy-alcohol-use-in-adolescents-andadults-screening-and-behavioral-counselinginterventions). 

170 Chapter 6 
Chapter 6—Substance Misuse and Cognitive Impairment TIP 26

Screening for CODs and Cognitive 

Disorders 

Older clients in need of treatment or already 

in treatment for SUDs should be screened for 

disorders that co-occur with SUDs, such as 

depression, anxiety, and PTSD, as well as cognitive 

disorders. 

Screening Instruments 

This section discusses several screening measures 

for depression, anxiety, PTSD, trauma/abuse, 

and cognitive problems. Some age-appropriate 

measures appear in the Chapter 6 Appendix and 

the Chapter 3 Appendix. 

Consider your scope of practice before 

delivering these instruments. You may need 

training before you can give certain ones to clients. 

This is especially true for cognitive measures. 

Make sure you understand how to administer 

each instrument properly, how to interpret the 

score, and what follow-up is needed based on the 

score. If no one in your program can help you get 

the training you need, refer the client to another 

behavioral health service or healthcare provider 

who can perform the screening. 

Screening instrument for cognitive disorders 

For a client who may have cognitive impairment, 

use the Mini-Cog©. See Chapter 3 for a description 

of and link to this instrument. 

Screening instruments for depression 

Screen older clients who misuse substances, 

have cognitive disorders, or both for depression. 

Depression commonly co-occurs in older people 

who misuse substances.1100,1101 This TIP discusses 

two well-researched depression screeners 

approved for use in older clients: 

• The Geriatric Depression Scale–Short Form (15 

item). 

• The nine-item Patient Health Questionnaire. 

Screening instruments for anxiety 

Older adults with anxiety are at increased risk for 

substance misuse, especially alcohol misuse and 

tobacco use.1102 You can screen for anxiety using the: 

• Geriatric Anxiety Scale. 

• Penn State Worry Questionnaire. 

These measures have been approved for use with 

older adults.1103,1104 

Screening instruments for PTSD, trauma, and 

abuse 

PTSD or a history of trauma or abuse can increase 

the odds that an older person will misuse 

substances.1105 In addition to asking older clients 

about their current and past history of trauma 

and abuse, use brief screening measures to 

further explore this area. For instance, you can 

use the: 

• PTSD Checklist for DSM-5. 

• Primary Care PTSD Screen for DSM-5. 

To screen for possible abuse, give the Elder 

Abuse Suspicion Index©. 

Interventions for Substance Misuse and 

Co-Occurring Mental/Cognitive Disorders 

Healthcare and behavioral health service providers 

have several options for helping older clients who 

misuse substances and have depression, anxiety, 

PTSD, or cognitive problems: 

• Educate clients about substance misuse, its 

effects on older people, and what “safe” or 

“nonrisky” use means. For some older clients, 

education alone helps them end their substance 

misuse. 

• Provide drug and alcohol counseling to help 

clients reduce or stop their use of substances. 

If your program cannot offer specialized 

addiction services, make a referral to another 

local program that can. (Learn more about AUD 

treatment and drug use disorder treatment 

for older adults in Chapters 4 and 5 of this TIP, 

respectively.) 

• Brief counseling approaches, such as 

motivational interviewing, can help older adults 

reduce substance use.1106 Brief approaches 

can be adapted to clients’ level of cognitive 

impairment.1107 

Chapter 6 171 
TIP 26

• Find out whether your client has an interest 

in other nonmedication treatments, such as 

therapy that involves art, music, or animals. 

Some research suggests that these “alternative” 

therapies can help people with dementia reduce 

their anxiety, restlessness, and apathy.1108,1109,1110 

• Help your clients live healthier lives. A healthy 

lifestyle may help slow the rate at which 

cognitive problems get worse over time. For 

instance, you can:1111,1112 

- Encourage clients to stay physically active 

through light exercise (e.g., walking, yoga, 

stretching programs). 

- Remind clients that mental activity is just as 

important as physical activity. Offer them ways 

to stay mentally active through reading, using 

computers/the Internet, or doing crossword 

puzzles and other “brain games.” 

- Offer behavioral techniques to help clients 

who are not getting enough quality sleep 

each night (like teaching good sleep hygiene 

and providing advice on reducing nighttime 

stimuli).1113 

- Encourage clients to spend time socializing 

with family, friends, and close others as well 

as develop social networks (for clients who 

do not already have or use them). 

- Teach clients the importance of a healthy 

diet that meets their nutritional needs. A 

healthy diet can improve other physical 

problems affecting cognition (e.g., high 

blood pressure, obesity). 

- Support clients’ efforts to reduce or stop 

substance use; give information and 

interventions related to tobacco cessation. 

- Find out whether clients have hobbies or 

interests that remain enjoyable. If not, help 

them identify pleasant activities to try to 

improve their quality of life and lift their 

spirits. 

• Make referrals to healthcare providers who 

can work with clients and their caregivers 

to decide whether medication treatment is 

needed. Medication treatment may be useful for 

certain types of SUDs, such as AUD, tobacco use 

disorder, and opioid use disorder. (See Chapters 

4 and 5 for more information.) Medications may 

also be useful for cognitive problems. They 

Treating Substance Use Disorder in Older Adults 

cannot cure dementia, but they may be able to 

help reduce some of its symptoms.1114 

• Be supportive and positive for your clients. 

One way to do this is by referring them 

to peer recovery or mutual-help groups, 

such as Seniors in Sobriety. (See “Chapter 6 

Resources.”) These groups can increase clients’ 

chances of achieving long-term abstinence, plus 

help keep clients socially active. Keep on hand 

a list of local peer recovery support programs to 

present to clients. 

• Supply informational materials in your program’s 

waiting room and meeting rooms (e.g., 

bulletin board or display case fyers, brochures, 

handouts) and offer these resources to your 

clients. 

Addressing Caregiver Concerns 

Many people provide unpaid care to older adults 

with whom they have a personal relationship. 

These caregivers, typically signifcant others like 

family members, friends, and neighbors, provide 

a wide range of services and supports to older 

adults, including:1115,1116 

• Help with ADLs, such as bathing, dressing, 

eating, toileting, and transferring (in and out of 

a wheelchair, for instance). 

• Help with instrumental ADLs, such as 

transportation, housework, food preparation, 

shopping, using communication devices, and 

managing fnances. 

• Emotional and spiritual support. 

• Financial help. 

• Shared housing. 

• Help with communication and advocacy with 

service providers. 

• Help with navigating service systems. 

• Help with decision making related to healthcare 

and fnancial matters. 

• Monitoring of health problems. 

• Medication administration and monitoring. 

• Medical/nursing tasks, like injections, tube 

feeding, and care of catheters, colostomies, and 

wounds. 

172 Chapter 6 
Chapter 6—Substance Misuse and Cognitive Impairment TIP 26

Caregivers may carry out these activities 

intermittently, part time, or full time, including from 

a distance. 

The physical, mental, emotional, and fnancial 

challenges of these caregiving responsibilities 

can result in “caregiver burden.”1117 Caregiving 

for older adults who misuse substances, have 

cognitive disorders, or both can be very stressful. 

This stress can make it hard for caregivers to 

function well at work, maintain social relationships, 

and take care of themselves.1118 

Behavioral health service, healthcare, and social 

service providers need to be alert for caregiver 

stress. Stress can negatively affect the quality 

of attention the caregiver gives to your client. 

For instance, caregiver stress has been linked to 

a higher risk of elder abuse.1119 Also, caregiver 

stress is associated with higher mortality.1120 

And caregivers may themselves be at risk for 

developing chronic health conditions such as high 

blood pressure, heart disease, and back pain.1121 

Caregiver stress may even lead to caregiver 

substance misuse. Caregivers who feel high levels 

of stress may need behavioral health services to 

build better coping skills, access resources, address 

their concerns, and improve their mood. 

Caregivers may not tell you outright that they 

are feeling stressed or frustrated. Make a point to 

ask caregivers directly about any diffculties 

they are having, including mental and physical 

symptoms. Here are some examples of questions 

you can ask to help caregivers open up: 

• “I know caring for your wife must be very 

diffcult. How are you holding up?” 

• “What do you do for fun or to ‘let off steam’?” 

• “Who do you turn to when you need support?” 

• “Have you spoken with other caregivers 

who care for someone with dementia? 

Many caregivers fnd it very helpful to talk to 

someone who really ‘gets it.’ May I give you 

some information about local caregiver support 

groups?” 

• “Are you familiar with Al-Anon? Many adult 

children of people with alcohol addiction fnd 

their meetings useful. Would you like me to 

give you their contact information?” 

Helping Caregivers of Clients Who 

Misuse Substances 

Caregivers may not always see the alcohol or 

drug use as a problem. They may feel guilty 

asking the person to stop using. Comments like the 

following are not unusual: 

• “My George has had a beer after work every 

night for 40 years. I’m not telling him to stop 

now.” 

• “It’s none of my business if she has a couple of 

glasses of wine. At her age, what’s the harm, 

really?” 

• “I feel bad asking my brother to stop smoking. 

His cigars are his one last pleasure in life.” 

Many caregivers may think that substance use 

is harmless. But for aging adults, that is not 

necessarily true. You can help caregivers by: 

• Sharing facts about alcohol or drug use in 

older adults and the importance of avoiding 

illicit drugs, prescription medication misuse, and 

harmful drug–drug interactions. 

• Teaching them new coping skills and offering 

interventions. This could include: 

- Helping caregivers share their feelings of 

stress or concern with your older clients. 

Talking to older adults about their substance 

misuse can be hard. You can help caregivers 

learn how to express their thoughts and 

feelings in a way that is healthy and helpful. 

- Teaching caregivers better ways to handle 

your older clients’ upsetting behaviors. 

Some older adults who misuse substances 

can “act out,” become angry, or behave in 

ways that are stressful to caregivers. Teach 

caregivers how to better manage these 

intense emotions and behaviors. 

- Offering caregivers mental health services 

or referral to treatment. 

• Helping them fnd peer recovery support 

groups (e.g., caregiver support groups). 

• Encouraging them to join support groups. 

Refer them to local mutual-help groups 

for family members of people who misuse 

substances, like Al-Anon and Adult Children of 

Alcoholics. 

Chapter 6 173 
TIP 26

Helping Caregivers of Clients With 

Dementia 

Caring for individuals with dementia can have 

negative psychosocial and physical effects. 

For example, such caregiving can negatively 

affect sleep, blood pressure, mood, and social 

functioning.1122 

A caregiver may use alcohol or benzodiazepines 

to try to control an older adult’s behavior. For 

instance, a caregiver may give alcohol to help the 

older adult sleep or to calm down the older adult 

when he or she is upset and angry. This is not 

recommended, is unsafe, and can worsen these 

behaviors. Tell caregivers not to use alcohol or 

benzodiazepines in this way. 

Supports for people caring for older adults with 

dementia can include:1123,1124,1125 

• Education-based programs to help caregivers: 

- Learn about the disease. 

- See the importance of taking care of 

themselves and reducing their own stress. 

- Better handle the older adults’ negative 

behaviors (e.g., acting “out of control”). 

• Psychosocial services that provide: 

- Stress management techniques. 

- Relaxation skills. 

- Positive thinking strategies. 

- Tips on proper self-care (e.g., healthy eating, 

sound sleeping). 

- Chances for caregivers to share frustration, 

fear, sadness, and other negative feelings. 

- Problem-solving and other coping 

techniques. 

• Participation in caregiver support groups— 

especially ones that focus on caregiving 

for someone with dementia. These groups 

let caregivers share common experiences 

and learn from one another; for instance, 

the Alzheimer’s Association offers caregiver 

support groups (www.alz.org/events/ 

event_search?etid=2&cid=0). 

Treating Substance Use Disorder in Older Adults 

Helping Caregivers of Clients With Both 

Substance Misuse and Dementia 

Anecdotal reports give some indication of the 

needs and problems faced by people caring for 

older adults with both substance misuse and 

dementia. These caregivers likely face signifcant 

stressors. Greater levels of caregiver burden 

are present in caregivers of older adults with 

alcohol misuse who also have certain behavioral 

symptoms common in dementia—disinhibition 

(or “out of control” behavior) and irritability— 

compared with caregivers of older adults with 

those same behavioral symptoms but no alcohol 

misuse.1126 

Research about the burden of caring for people 

with multiple, complex, chronic conditions is also 

telling. For instance, having more than one chronic 

illness is linked to:1127 

• Being highly dependent on a caregiver. 

• A higher risk of death. 

• More time spent in the hospital. 

• Poor quality of life. 

• Greater healthcare costs. 

A caregiver of an older adult with co-occurring 

substance use and mental disorders may have 

unique challenges and special needs beyond 

those of caregivers of people with mental disorders 

only, including:1128 

• Feeling unable to leave the older adult alone. 

• Being more likely to fear the older adult will hurt 

himself or herself or others. 

• Feeling less close to the older adult. 

• Having more problems getting the older adult 

to take medications. 

• Having more problems fnding treatment. 

• Feeling a higher level of emotional stress related 

to caregiving. 

• Feeling that caregiving threatens his or her 

health. 

• Feeling lonely as a caregiver. 

• Having trouble talking with others about the 

older adult’s mental health needs. 

• Wanting help from a care coordinator or care 

manager. 

• Wanting legal assistance. 

174 Chapter 6 
Chapter 6—Substance Misuse and Cognitive Impairment TIP 26

Because of these concerns, caregivers for clients 

such as these may be especially in need of your 

help and resources. Be sure to reach out to them! 

Summary 

Substance misuse in older adults can increase 

the chances of having cognitive problems. It also 

can increase the chances of having co-occurring 

mental disorders with symptoms similar to 

cognitive disorders or mental disorders that cause 

changes in cognition and could be mistaken for 

a cognitive disorder. These co-occurring mental 

disorders include depression, anxiety, and PTSD. 

Behavioral health service and healthcare providers 

need to be aware of these other conditions and 

use screening instruments wisely to ensure that all 

older adult clients receive the right diagnosis and 

timely treatment. Treatments can address clients’ 

and caregivers’ mood, cognition, and functioning. 

Positive changes through treatment are possible 

for older adults who are dealing with substance 

misuse, mental disorders, and cognitive decline. 

Chapter 6 Resources 

Behavioral Health Service Provider 

Resources 

Alcohol Misuse 

SAMHSA—A Guide to Preventing Older Adult 

Alcohol and Psychoactive Medication Misuse/ 

Abuse: Screening and Brief Interventions (www. 

ncoa.org/wp-content/uploads/SBIRT-Older-AdultManual-Final.pdf): This manual is designed to 

help providers implement an early prevention 

intervention program for older adults who are 

at risk for misusing alcohol or psychoactive 

medication. 

SAMHSA—Get Connected: Linking Older 

Adults With Resources on Medication, Alcohol, 

and Mental Health (https://store.samhsa.gov/ 

product/Get-Connected-Linking-Older-Adults-withResources-on-Medication-Alcohol-and-MentalHealth-2019-Edition/SMA03-3824): This toolkit will 

help providers learn—and educate clients—about 

alcohol and prescription medication misuse and 

mental health issues among older adults. 

Dementia 

Alzheimer’s Association—Dementia Care Practice 

Recommendations (www.alz.org/professionals/ 

professional-providers/dementia_care_practice_ 

recommendations): These recommendations 

provide guidance to healthcare and social service 

providers who work with individuals living with 

dementia in residential and community-based care 

settings. 

Association for Frontotemporal Degeneration— 

For Health Professionals (www.theaftd.org/ 

for-health-professionals/): This webpage 

provides resources on diagnosing and treating 

frontotemporal degeneration, as well as links to 

webinars and clinical presentations. 

National Alzheimer’s and Dementia Resource 

Center (https://nadrc.acl.gov): Visitors to this 

website can access reports, toolkits, assessment 

tools, and webinars and other training materials. 

National Institute on Aging (NIA)—Alzheimer’s 

and Dementia Resources for Professionals 

(www.nia.nih.gov/health/alzheimers-dementiaresources-for-professionals): This webpage offers 

clinical practice tools, training materials, and other 

resources for healthcare and behavioral health 

service providers. 

Registered Nurses’ Association of Ontario— 

Delirium, Dementia, and Depression in Older 

Adults: Assessment and Care (https://rnao. 

ca/sites/rnao-ca/fles/Delirium_dementia_and_ 

depression_in_older_adults_LTC_case_study_and_ 

discussion_guide.pdf): This publication contains a 

case study and a discussion guide to help providers 

learn the differences between depression, delirium, 

and dementia in older adults. 

Client and Caregiver Resources 

General Resources 

Administration on Aging—Eldercare Locator 

(https://eldercare.acl.gov/Public/Index.aspx): This 

locator connects users to local services for older 

adults and their families. 

ElderLawAnswers (www.elderlawanswers.com): 

This website maintains resources on fnancial and 

legal services related to caring for an older adult 

with healthcare and other needs. 

Chapter 6 175 
TIP 26

Family Caregiver Alliance (www.caregiver.org): This 

organization offers an information line for caregivers 

of adults with chronic medical illnesses living at 

home, online caregiver support groups, and an 

online Family Care Navigator that provides a stateby-state list of services and assistance for caregivers. 

mmLearn.org—Caregiver Training Videos (https:// 

training.mmlearn.org/caregiver-training-videos): 

mmLearn has a library of free videos for healthcare, 

pastoral, and family member caregivers of older 

adults. Videos are available on specifc topics, 

including caring for adults with dementia (https:// 

training.mmlearn.org/caregiver-training-videos/ 

topic/dementia). 

National Alliance for Caregiving (www.caregiving. 

org): This organization conducts research and 

policy analysis, develops national best-practice 

programs, coordinates state and local caregiving 

coalitions, and provides a website offering 

educational resources for family caregivers. 

Alcohol Misuse 

Adult Children of Alcoholics (https://adultchildren. 

org): Adult children of people with AUD can use 

this website to fnd a listing of in-person and 

electronic meetings. 

Al-Anon (https://al-anon.org): Al-Anon is a national 

mutual-help organization for people concerned about 

or affected by someone with alcohol misuse. The 

website offers information about the organization and 

how to fnd a local or electronic meeting. 

NIA—Facts About Aging and Alcohol (www.nia. 

nih.gov/health/facts-about-aging-and-alcohol): NIA 

offers information about how alcohol can affect 

older adults’ health and safety. 

NIA—Older Adults and Alcohol (https://order.nia. 

nih.gov/sites/default/fles/2018-01/older-adultsand-alcohol.pdf): Older adults can use this guide to 

learn about alcohol’s harmful effects and ways to 

get help for alcohol misuse. 

NIAAA—Harmful Interactions (www.niaaa.nih.gov/ 

publications/brochures-and-fact-sheets/harmfulinteractions-mixing-alcohol-with-medicines): Older 

adults and their caregivers can use this consumer 

guide to learn about harmful medication– 

medication and medication–alcohol interactions. 

Treating Substance Use Disorder in Older Adults 

Seniors in Sobriety (www.seniorsinsobriety.com): 

This mutual-help organization for older adults 

with alcohol misuse has information about local 

meetings on its website. 

Tobacco Use 

CDC—Tips From Former Smokers (www.cdc.gov/ 

tobacco/campaign/tips/index.html): Through this 

campaign, CDC offers videos of tips and stories 

from former smokers, plus other resources to help 

with tobacco cessation. 

National Cancer Institute—Clear Horizons: A 

Quit-Smoking Guide for People 50 and Older 

(https://smokefree.gov/sites/default/fles/pdf/clearhorizons-accessible.pdf): People ages 50 and older 

interested in tobacco cessation will fnd helpful 

information and strategies in this guide. 

NIA—Quitting Smoking for Older Adults (www.nia. 

nih.gov/health/quitting-smoking-older-adults): This 

webpage provides information about nicotine and 

nicotine delivery devices (e.g., e-cigarettes, hookahs) 

and about strategies for stopping tobacco use. 

Dementia 

Alzheimer’s Association—Resources (www.alz.org/ 

help-support/resources): This webpage has links to 

a collection of consumer resources on Alzheimer’s 

disease and dementia, including online tools, 

locators for community services and Alzheimer’s 

Association chapters, and a virtual library. 

Alzheimer’s Association—Support Groups (www. 

alz.org/care/alzheimers-dementia-support-groups. 

asp): Local and online support groups offered by the 

Alzheimer’s Association for caregivers and individuals 

with Alzheimer’s can be found through this webpage. 

NIA—Alzheimer’s Disease & Related Dementias 

(www.nia.nih.gov/health/alzheimers): This webpage 

provides information about Alzheimer’s causes, 

symptoms, and treatments, and about living with the 

illness or providing caregiving to someone who does. 

NIA—Vascular Dementia and Vascular Cognitive 

Impairment: A Resource List (www.nia.nih.gov/ 

health/vascular-dementia-and-vascular-cognitiveimpairment-resource-list): This webpage links 

to free resources about vascular dementia, 

CADASIL (a rare form of vascular dementia), and 

Binswanger’s Disease. 

176 Chapter 6 
TIP 26

 

 

Chapter 6—Substance Misuse and Cognitive Impairment 

Chapter 6 Appendix 

Geriatric Depression Scale (GDS)–Short Form 

Client Version 

Client’s Name: Date: 

Instructions: Circle the best answer for how you felt over the past week. 

1. Are you basically satisfed with your life? Yes No 

2. Have you dropped many of your activities and interests? Yes No 

3. Do you feel that your life is empty? Yes No 

4. Do you often get bored? Yes No 

5. Are you in good spirits most of the time? Yes No 

6. Are you afraid that something bad is going to happen to you? Yes No 

7. Do you feel happy most of the time? Yes No 

8. Do you often feel helpless? Yes No 

9. Do you prefer staying at home, rather than to going out and doing new things? Yes No 

10. Do you feel you have more problems with memory than most people? Yes No 

11. Do you think it is wonderful to be alive now? Yes No 

12. Do you feel pretty worthless the way you are now? Yes No 

13. Do you feel full of energy? Yes No 

14. Do you feel that your situation is hopeless? Yes No 

15. Do you think that most people are better off than you are? Yes No 

Scoring Version 

Client’s Name: Date: 

Scoring: Count boldface responses for a total score. A score of 0–5 is normal. A score of 6 or above suggests 

depression. 

Instructions: Circle the best answer for how you felt over the past week. 

1. Are you basically satisfed with your life? Yes No 

2. Have you dropped many of your activities and interests? Yes No 

3. Do you feel that your life is empty? Yes No 

4. Do you often get bored? Yes No 

5. Are you in good spirits most of the time? Yes No 

6. Are you afraid that something bad is going to happen to you? Yes No 

7. Do you feel happy most of the time? Yes No 

8. Do you often feel helpless? Yes No 

Continued on next page 

Chapter 6 177 
TIP 26 Treating Substance Use Disorder in Older Adults 

Continued 

9. Do you prefer staying at home, rather than going out and doing new things? Yes No 

10. Do you feel you have more problems with memory than most people? Yes No 

11. Do you think it is wonderful to be alive now? Yes No 

12. Do you feel pretty worthless the way you are now? Yes No 

13. Do you feel full of energy? Yes No 

14. Do you feel that your situation is hopeless? Yes No 

15. Do you think that most people are better off than you are? Yes No 

The Client Version and Scoring Version of the GDS–Short Form were both adapted from material in the public domain.1129 

Clients with a GDS score of 6 or higher need further assessment and may need treatment for MDD.1130 Clients with a GDS 

score below 6 should be screened again in 1 month if symptoms of depression are still present.1131 If a client’s depressive 

symptoms are no longer present in 1 month, give the depression screener again in 6 months.1132 

178 Chapter 6 
Chapter 6—Substance Misuse and Cognitive Impairment TIP 26

PTSD Checklist for DSM-5 (PCL-5) 

Instructions: Below is a list of problems that people sometimes have in response to a very stressful 

experience. Please read each problem carefully and then circle one of the numbers to the right to indicate 

how much you have been bothered by that problem in the past month. 

In the past month, how much were you bothered 

by: 

Not at 

all 

A little 

bit Moderately 

Quite 

a bit Extremely 

1. Repeated, disturbing, and unwanted memories 

of the stressful experience? 0 1 2 3 4 

2. Repeated, disturbing dreams of the stressful 

experience? 0 1 2 3 4 

3. Suddenly feeling or acting as if the stressful 

experience were actually happening again (as if 

you were actually back there reliving it)? 

0 1 2 3 4 

4. Feeling very upset when something reminded 

you of the stressful experience? 0 1 2 3 4 

5. Having strong physical reactions when 

something reminded you of the stressful 

experience (for example, heart pounding, 

trouble breathing, sweating)? 

0 1 2 3 4 

6. Avoiding memories, thoughts, or feelings 

related to the stressful experience? 0 1 2 3 4 

7. Avoiding external reminders of the stressful 

experience (for example, people, places, 

conversations, activities, objects, or situations)? 

0 1 2 3 4 

8. Trouble remembering important parts of the 

stressful experience? 0 1 2 3 4 

9. Having strong negative beliefs about yourself, 

other people, or the world (for example, having 

thoughts such as: I am bad, there is something 

seriously wrong with me, no one can be trusted, 

the world is completely dangerous)? 

0 1 2 3 4 

10. Blaming yourself or someone else for the 

stressful experience or what happened after it? 0 1 2 3 4 

11. Having strong negative feelings such as fear, 

horror, anger, guilt, or shame? 0 1 2 3 4 

12. Loss of interest in activities that you used to 

enjoy? 0 1 2 3 4 

13. Feeling distant or cut off from other people? 0 1 2 3 4 

Continued on next page 

Chapter 6 179 
TIP 26 Treating Substance Use Disorder in Older Adults 

Continued 

In the past month, how much were you bothered 

by: 

Not at 

all 

A little 

bit Moderately 

Quite 

a bit Extremely 

14. Trouble experiencing positive feelings (for 

example, being unable to feel happiness or 

have loving feelings for people close to you)? 

0 1 2 3 4 

15. Irritable behavior, angry outbursts, or acting 

aggressively? 0 1 2 3 4 

16. Taking too many risks or doing things that 

could cause you harm? 0 1 2 3 4 

17. Being “superalert” or watchful or on guard? 0 1 2 3 4 

18. Feeling jumpy or easily startled? 0 1 2 3 4 

19. Having diffculty concentrating? 0 1 2 3 4 

20. Trouble falling or staying asleep? 0 1 2 3 4 

Reprinted from material in the public domain.1133 A digital, fllable form is available online (www.ptsd.va.gov/professional/ 

assessment/documents/PCL5_Standard_form.PDF). 

180 Chapter 6 
TIP 26 TREATING SUBSTANCE USE DISORDER 

IN OLDER ADULTS

Chapter 7—Social Support and Other 

Wellness Strategies for Older Adults 

KEY MESSAGES 

• Strong social networks support older adults 

in achieving and maintaining recovery from 

substance misuse. Providers can help older 

adults develop and maintain a social network 

that promotes recovery and wellness. 

• Older adults have to increase their health 

literacy to maintain recovery and prevent 

relapse. 

• Providers need to engage older adults in illness 

management and relapse prevention activities 

specifc to substance misuse with a focus on 

health and wellness. 

• Providers can help older adults feel more 

empowered by understanding the normal 

developmental challenges of aging and agespecifc strategies for promoting resilience and 

setting goals. 

Chapter 7 of this Treatment Improvement 

Protocol (TIP) will most beneft healthcare, 

behavioral health service, and social service 

providers who work with older adults (physicians, 

nurse practitioners, physician assistants, nurses, 

social workers, psychologists, psychiatrists, mental 

health counselors, alcohol and drug counselors, 

and peer recovery support specialists). It explains 

how older adults who misuse substances can 

beneft from wellness strategies that support 

relapse prevention, ongoing recovery, and better 

overall health. The keys to wellness for this group 

are having strong social networks and participating 

in health and wellness activities that support 

recovery. 

The high prevalence of isolation in older adults 

who misuse substances can negatively affect 

cognitive functioning and reduce well-being. Older 

adults who lack family ties or social networks may 

fnd maintaining recovery from substance misuse 

diffcult. Healthcare, behavioral health service, and 

social service providers can help older adults who 

misuse substances reduce isolation and improve 

recovery outcomes by promoting broader social 

networks. 

Maintaining recovery from substance use can 

be harder for older adults who have trouble 

understanding and using health information. It 

may also be more diffcult for those with limited 

self-management skills (e.g., diffculty engaging 

in regular exercise, healthy eating, or medication 

adherence). Medical conditions common in later 

life can also reduce functioning. Providers can 

engage older clients in skill-building and wellness 

activities that will support resilience and overall 

health while also reducing the likelihood of a return 

to substance misuse. 

Organization of Chapter 7 of 

This TIP 

Chapter 7 addresses promoting social support 

and other health and wellness strategies relevant 

to older adults in recovery from substance 

misuse. 

The frst section of Chapter 7 describes the 

importance of social support in promoting and 

maintaining health, wellness, and recovery 

among older adults who misuse substances. 

Types of positive social support, the impact 

of social isolation on health and wellness, and 

strategies for promoting and maintaining social 

support are examined. 

181 
TIP 26 Treating Substance Use Disorder in Older Adults 

The second section addresses how to promote 

other wellness strategies for older adults. This 

section specifcally focuses on assessing and 

promoting health and wellness for older adults in 

recovery. It addresses health and wellness activities 

relevant to older adults, strategies for promoting 

health and wellness, illness self-management and 

relapse prevention approaches, and strategies for 

EXHIBIT 7.1. Key Terms 

promoting resilience and empowerment among 

older adults, including goal setting. 

The fnal section identifes targeted resources to 

support your practice, some of which appear in full 

in the Chapter 7 Appendix; additional resources 

appear in Chapter 9 of this TIP. Exhibit 7.1 provides 

defnitions for key terms that appear in Chapter 7. 

• Addiction*: The most severe form of substance use disorder (SUD), associated with compulsive or 

uncontrolled use of one or more substances. Addiction is a chronic brain disease that has the potential for 

both recurrence (relapse) and recovery. 

• Age-specifc: Treatment approaches and practices specifcally developed for older adults (e.g., an older 

adult specialty group in a mixed-age SUD treatment program). 

• Alcohol misuse: The use of alcohol in any harmful way, including heavy drinking, binge drinking, and 

alcohol use disorder (AUD). 

• Caregivers: Informal caregivers provide unpaid care. They assist others with activities of daily living 

(ADLs), including health and medical tasks. Informal caregivers may be spouses, partners, family 

members, friends, neighbors, or others who have a signifcant personal relationship with the person who 

needs care. Formal caregivers are paid providers who offer care in one’s home or in a facility.1134 Most older 

adults do not need caregivers and are as able to address their own needs as younger adults, whether or 

not substance misuse is a factor in their lives. 

• Health literacy: The ability to understand and use health information to make informed choices about 

health, wellness, and recovery. 

• Illicit substances: Illicit substances include cocaine, heroin, hallucinogens, inhalants, methamphetamine, 

and prescription medications that are taken other than as prescribed (e.g., pain relievers, tranquilizers, 

stimulants, sedatives). 

• Mutual-help groups: Groups of people who work together on obtaining and maintaining recovery. Unlike 

peer support (e.g., the use of recovery coaches or peer recovery support specialists), mutual-help groups 

consist entirely of people who volunteer their time and typically have no offcial connection to treatment 

programs. Most are self-supporting. Although 12-Step groups such as Alcoholics Anonymous (AA) and 

Narcotics Anonymous (NA) are the most widespread and well researched type of mutual-help groups, 

other groups may be available in some areas. They range from groups affliated with a religion or church 

(e.g., Celebrate Recovery, Millati Islami) to purely secular groups (e.g., SMART [Self-Management and 

Recovery Training] Recovery, Women for Sobriety). 

• Peer recovery support specialist: Someone in recovery who has lived experience in addiction plus skills 

learned in formal training. Peer recovery support specialists may be paid professionals or volunteers. They 

are distinguished from members of mutual-help groups because they maintain contact with treatment 

staff. They offer experiential knowledge that treatment staff often lack. 

• Peer support: The use of peer recovery support specialists (e.g., someone in recovery who has lived 

experience in addiction plus skills learned in formal training) to provide nonclinical (i.e., not requiring 

training in diagnosis or treatment) recovery support services to individuals in recovery from addiction and 

to their families. 

Continued on next page 

182 Chapter 7 
Chapter 7—Social Support and Other Wellness Strategies for Older Adults TIP 26

Continued 

• Recovery*: A process of change through which individuals improve their health and wellness, live a selfdirected life, and strive to reach their full potential. Even individuals with severe and chronic SUDs can, 

with help, overcome them and regain health and social function. This is called remission. When those 

positive changes and values become part of a voluntarily adopted lifestyle, that is called being in recovery. 

Although abstinence from all substance misuse is a cardinal feature of a recovery lifestyle, it is not the 

only healthy, prosocial feature. 

• Relapse*: A return to substance use after a signifcant period of abstinence. 

• Remission: A medical term meaning a disappearance of signs and symptoms of the disease or disorder. 

The ffth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defnes remission 

as present in people who previously met SUD criteria but no longer meet any SUD criteria (with the 

possible exception of craving).1135 Remission is an essential element of recovery. 

• Resilience: The ability to rebound from adversity, skillfully address age-specifc developmental tasks, and 

respond creatively to stress and grow from those experiences. 

• Substance misuse*: The use of any substance in a manner, situation, amount, or frequency that can 

cause harm to users or to those around them. For some substances or individuals, any use would 

constitute misuse (e.g., underage drinking, injection drug use). 

• Substance use disorder*: A medical illness caused by repeated misuse of a substance or substances. 

According to DSM-5,1136 SUDs are characterized by clinically signifcant impairments in health and social 

function and impaired control over substance use. They are diagnosed through assessing cognitive, 

behavioral, and psychological symptoms. SUDs range from mild to severe and from temporary to chronic. 

They typically develop gradually over time with repeated misuse, leading to changes in brain circuits 

governing incentive salience (the ability of substance-associated cues to trigger substance seeking), 

reward, stress, and executive functions like decision making and self-control. Multiple factors infuence 

whether and how rapidly a person will develop an SUD. These factors include the substance itself; the 

genetic vulnerability of the user; and the amount, frequency, and duration of the misuse. Note: A severe 

SUD is commonly called an addiction. A mild SUD is generally equivalent to what previous editions of 

DSM called substance abuse; a moderate or severe SUD is generally equivalent to what was formerly 

called substance dependence. 

* The defnitions of all terms marked with an asterisk correspond closely to those given in Facing Addiction in 

America: The Surgeon General’s Report on Alcohol, Drugs, and Health. This resource provides a great deal of useful 

information about substance misuse and its impact on U.S. public health. The report is available online (https://addiction. 

surgeongeneral.gov/sites/default/fles/surgeon-generals-report.pdf). 

Social Support: The Key to Health, 

Wellness, and Recovery 

People with signifcant social support tend to have 

healthier lifestyles, engage in fewer behaviors that 

risk health (e.g., substance misuse), and be more 

active. Older adults in long-term recovery from 

substance misuse have better outcomes when their 

social supports promote abstinence.1137,1138 

Three major components of positive support for 

older adults are: 

• Family and friends. Family members often 

provide most of an older adult’s basic social 

support. Strong friendships and neighborhood 

supports can also be important to older adults. 

Friends often provide emotional support, 

and neighbors can offer immediate help in an 

emergency. 

Chapter 7 183 
TIP 26

• Mutual-help groups. Mutual-help groups 

such as AA and NA can support abstinence 

and foster new social connections, a sense of 

belonging, and healthy lifestyles. 

• Religious or spiritual supports. Participation in 

religious or spiritual fellowships can decrease 

social isolation and is associated with health and 

wellness.1139 

In the 2015 World Values Survey, more than 75 

percent of adults in the United States over age 60 

responded that they considered themselves to be 

religious and sometimes or often contemplated 

the meaning of life (an indicator of a spiritual 

focus).1140 

Many religions discourage drug use and alcohol 

use or misuse.1141,1142 Involvement in religious 

and spiritual organizations can give older adults 

a sense of meaning, optimism, and self-esteem, 

lessening the impact of stressful life events like the 

death of a signifcant other.1143 A sense of meaning 

and optimism can help maintain recovery from 

substance misuse. 

The quality and diversity of older adults’ social 

networks matter more than size in promoting 

health, well-being, and recovery and in lowering 

risk of substance misuse.

1144,1145 For example, 

tense relationships with family members can 

increase stress, which can negatively affect 

older adults’ health and avoidance of relapse. 

In addition, too much support from children, 

although well-meaning, may increase older adults’ 

dependence and reduce their sense of self-effcacy 

and well-being. Conversely, work colleagues, social 

contacts at senior centers, and behavioral health 

service and healthcare providers can be additional 

sources of emotional support. Mutual-help groups 

such as AA and NA can provide older adults with 

a stable source of friendships and enhance the 

diversity of their social networks. 

The consensus panel recommends that you 

assess the number of social connections older 

adults have and also gauge the quality and 

diversity of those connections and how they 

promote wellness and recovery. (See the 

Treating Substance Use Disorder in Older Adults 

Chapter 7 Appendix for the Social Network Map 

for assessing and discussing social networks with 

older adults.) 

Social Isolation 

Social isolation, linked to loneliness, is common in 

older adults. Their social networks narrow because 

of retirement, decreased physical functioning, 

and deaths of spouses, intimate partners, and 

friends.1146 A spouse or intimate partner is essential 

for many older adults’ well-being. The death of 

a spouse puts older adults at high risk for social 

isolation, and may decrease life expectancy for 

men.1147 Loneliness is linked with substance misuse 

in some older women.1148 

ADDRESSING GRIEF 

Older adults may experience multiple losses 

in a short time. Grief is a highly individualized 

experience; coping strategies need to be fexible 

and adaptive as you help clients explore feelings 

of grief. 

Grief has no set timeframe. People do not “get 

over” the death of a loved one. Daily life continues 

as people integrate the experience of loss into 

their lived experience. As integration happens, 

the disorientation and disruption initially 

experienced after a death subsides, and older 

adults can open up to new possibilities.1149 

You can provide a safe and supportive 

environment for clients to explore their feelings, 

help them remember their loved one, offer 

information about the grief process, identify 

struggles with coping, encourage them to tap 

into their own strengths and wisdom, and help 

them integrate the loss.1150 If clients experience 

prolonged or complicated grief that interferes 

substantially with daily functioning—or if they 

have persistent suicidal ideation—consider 

referral to psychiatric evaluation or to a trained 

grief counselor. 

Other factors that can add to social isolation for 

older adults include family members living far away, 

lack of transportation, cognitive decline, living 

alone or in unsafe neighborhoods,1151 poverty, 

physical disability,1152 and disruption of existing 

social networks via relocation to long-term care 

facilities. 

184 Chapter 7 
Chapter 7—Social Support and Other Wellness Strategies for Older Adults TIP 26

Social isolation in older adults has been linked 

to: 

• Increased likelihood of engaging in risky 

behaviors such as alcohol misuse and 

smoking.1153 

• Increased risk of depression.1154 

• Cognitive decline and risk for developing 

dementia.1155 

• Poor overall health, cardiovascular disease, 

high blood pressure, sleep disturbances, and 

sedentary lifestyles.1156,1157 

• Impairment in executive functioning, which 

makes it hard to engage in health-promoting 

physical activities1158 or follow a relapse 

prevention plan. 

• Increased risk for falls, rehospitalization, and 

death from all causes, including suicide among 

men.1159 

SOCIAL ISOLATION AMONG 

OLDER ADULTS IN METHADONE 

MAINTENANCE TREATMENT 

Older adults with opioid use disorder (OUD) 

who are in methadone maintenance treatment 

(MMT) may experience even more social isolation 

than older adults with other types of SUDs. Older 

adults who have used opioids for many years may 

have severed ties with family and friends and lost 

friends who overdosed. People who are in MMT 

also tend to be secretive about their history of 

opioid use and their status in treatment because 

of negative attitudes of friends, family, and 

society. Recent evidence suggests that people 

with a history of OUD tend to self-isolate because 

of:1160 

• Past experiences of being taken advantage of. 

• Fear of future loss. 

• Desire to avoid depression/grief at death of 

friends/family. 

• Past experiences of domestic violence. 

You may need to address these concerns before 

you can work collaboratively with clients to build 

a nonusing social network that supports MMT as 

a pathway of recovery for older adults. 

The consensus panel recommends that you 

screen older adults for social isolation and 

help them learn about the link between social 

isolation and substance misuse as part of your 

efforts to educate clients on health literacy. (See 

the Chapter 7 Appendix for a discussion of the 

Lubben Social Network Scale, a social isolation 

screening tool for older adults.) 

Promoting Social Support for Older 

Adults 

A lifespan perspective suggests that social 

networks change over a person’s lifetime. One of 

the unique aspects of older adults’ social networks 

is that those networks naturally shrink as people 

age and their close family members and friends 

die. This shrinkage may also occur because older 

adults become increasingly aware of the limits of 

time left in life and choose to focus on the most 

rewarding relationships. Doing so may help them 

emphasize emotional support while deemphasizing 

less satisfying relationships.1161 A high degree of 

emotional closeness is associated with high levels 

of quality of life and well-being for older adults.1162 

Strategies for improving social support for older 

adults in recovery from substance misuse should 

focus on expanding network size, increasing 

network diversity, and deepening the emotional 

closeness of network connections. Interventions 

to decrease social isolation and improve well-being 

should be adaptable to older adults’ needs and 

interests, include their input about what works for 

them, and actively versus passively engage them 

(e.g., playing cards with friends versus watching TV 

together).1163 

The consensus panel recommends the following 

interventions to promote social support for older 

adults who misuse substances. 

Engage family members and other caregivers 

in recovery support. Perhaps the most important 

social support for older adults is frequent contact 

with family members (or other caregivers) who 

support their recovery. Help foster positive social 

contact between family members and older adults 

who misuse substances by: 

Chapter 7 185 
TIP 26

• Involving family members and other caregivers 

in older adults’ treatment (with express consent 

from clients). 

• Educating clients, caregivers, and families about 

the importance of emotional and instrumental 

support for older adults’ recovery. (An example 

of instrumental support is providing rides to 

appointments.) 

• Educating caregivers about skillful ways to 

provide support. 

• Educating family members about the 

importance of visiting the older adult when he 

or she is not misusing substances, rather than 

visiting only during substance-related crises 

(e.g., binge episodes). 

• Recommending that family members and other 

caregivers participate in family support groups 

for caregivers and mutual-help groups for family 

members such as Al-Anon. 

When family members are not nearby 

geographically or older adults are homebound, 

explore the possibility of clients’ connecting with 

family members regularly via phone or video 

calling services. Studies show that frequent contact 

between older adults and family members via 

online communication applications decreases 

loneliness and increases social contact for the older 

adults.1164 

See Chapter 4 of this TIP for more information 

about family and caregiver involvement. 

Enlist neighborhood supports. Social cohesion in 

neighborhoods is another factor that promotes the 

health and well-being of older adults. For example, 

when neighbors provide instrumental support for 

older men and emotional support for older women, 

the older adults attain better physical health and 

mental well-being.1165 You can help older adults 

build up this support by: 

• Asking which neighbors they are close to. 

• Helping them identify which neighbors have 

provided which kinds of support to them in the 

past. 

• Asking them which neighbors they think would 

be supportive of their recovery efforts. 

Treating Substance Use Disorder in Older Adults 

Many communities have befriending programs 

that send “friendly visitors”—who are trained 

volunteers—to the homes of older adults who 

have no close ties to neighbors or nearby 

relatives, or who are homebound. Visitors 

spend an hour or two a week with older adults to 

provide companionship, friendship, and linkage 

to health and wellness resources. They can often 

identify signs of substance misuse in the older 

adults they visit and help link these older adults 

to treatment resources. Contact your local Area 

Agency on Aging (AAA; see Resource Alert) to 

fnd out whether it or another organization in your 

community has a friendly visitor program. 

RESOURCE ALERT: AREA 

AGENCIES ON AGING 

AAAs’ mission is to help older adults age with 

independence and dignity at home and in the 

community through a coordinated system of 

services and supports (https://eldercare.acl. 

gov/Public/About/Aging_Network/AAA.aspx). 

Established by the Older Americans Act (OAA) 

in 1973, AAAs now number 622 nationwide. The 

OAA was amended in 1978 to include services 

to American Indians, Alaska Natives, and Native 

Hawaiians. 

Each AAA provides core services that address 

nutrition, disease prevention, health promotion, 

caregiver services, and older adult rights. 

Many AAAs also provide Medicare counseling, 

transportation, fall prevention and gentle 

exercise classes, adult daycare programs, social/ 

recreational classes and groups, and other 

services geared to local community needs. AAAs 

are also a great place for older adults to volunteer. 

Many states have Aging and Disability Resource 

Centers, often associated with AAAs, which 

can also provide specifc community resources 

for services and supports to older adults and 

individuals with disabilities. 

Go to https://eldercare.acl.gov and put in your ZIP 

Code to fnd the AAA in your community. 

186 Chapter 7 
Chapter 7—Social Support and Other Wellness Strategies for Older Adults TIP 26

In rare cases, friends and family members 

may commit elder abuse.1166 If you think such 

mistreatment is occurring, screen your older client 

for elder abuse (see Chapter 3 of this TIP). 

Link clients to social and behavioral health 

support groups. In addition to linking your older 

clients to mutual-help groups such as AA, NA, 

or SMART Recovery, which can provide social as 

well as recovery support, refer them to social and 

behavioral health support groups in the community. 

These can range from smoking cessation groups to 

walking clubs to depression support groups. Create 

a list of organizations that offer support groups 

for older adults and actively link your client to one 

or more groups that are appropriate, accessible, 

and acceptable to him or her. (See Chapter 4 of 

this TIP for more information on active linkage to 

community resources and referral management.) 

Agencies and organizations with support groups 

that may be helpful to older adults include: 

• Recovery support organizations. 

• Senior centers. 

• Adult day health services. 

• Community and private hospitals. 

• Healthcare, behavioral health service, and social 

service programs for older adults. 

• Veterans programs. 

• Coalitions and advocacy groups for older adults. 

• Assisted living facilities. 

• Faith-based organizations. 

• Community centers. 

Link clients to peer recovery support specialists. 

An important strategy for increasing social support 

for older adults in recovery is to link them to 

peer recovery support services.1167,1168,1169 Peer 

recovery support specialists work in a variety of 

settings, including addiction treatment programs, 

faith-based institutions, and recovery community 

organizations (RCOs).1170 (For information on 

RCOs, see www.recoveryanswers.org/resource/ 

recovery-community-centers.) 

Peer recovery support specialists offer four 

types of social support: emotional, instrumental, 

informational, and affliational (i.e., facilitating 

contact with others to strengthen social 

networks).1171 

Linking older adults to peer recovery support 

specialists can: 

• Increase and diversify older adults’ social 

networks. 

• Introduce older adults to the culture of recovery. 

• Facilitate engagement and active participation 

in community-based mutual-help groups. 

• Prevent relapse by helping older adults stay 

connected to mutual-help groups. 

Peer recovery support specialists who work with 

older adults should have age-specifc training 

and a commitment to working with this age 

group. These specialists are often older adults who 

can share their own experiences with recovery at 

this stage of life. 

See Chapter 2 of this TIP for more information 

on key strategies for providing support to older 

adults. 

Educate clients about social media and online 

social networking support. Online technologies— 

including social media applications and social 

networking websites—may be an important way 

for older adults to expand their support networks. 

Videoconferencing and use of social networking, 

educational and informational websites, and online 

discussion forums can reduce social isolation 

and improve social support, self-effcacy, and 

empowerment among older adults.1172 In addition, 

information exchange about specifc issues—such 

as substance misuse, recovery resources, chronic 

illness management, and health and wellness 

resources—in online social networks and discussion 

forums can boost well-being for older adults.1173 

Many addiction-focused mutual-help groups offer 

online meetings through chat rooms, web-based 

forums, and telephone or videoconferencing 

applications. 

Many baby boomers already use smartphones and 

online technologies. About 42 percent of adults 

ages 65 and older own smartphones, up from 18 

percent in 2013; 67 percent use the Internet.1174 

However, barriers to social media and mobile 

technology use include:1175,1176,1177 

Chapter 7 187 
TIP 26 Treating Substance Use Disorder in Older Adults 

• The cost of owning a computer, tablet, or cell 

phone and data or Internet access fees. 

• Lack of broadband infrastructure in rural and 

tribal areas. 

• Concerns about privacy and what happens to 

personal information once it is posted on the 

web. 

• Decline in cognitive and physical functioning, 

which hinders use. For instance, older adults 

may have physical or cognitive barriers in 

reading webpages that do not have universal 

accessibility, or diffculties using features of 

the device, like buttons on a cell phone or 

touchscreens. 

Help older clients who are curious about or 

interested in trying online technologies for social 

support: 

• Access basic information about using 

online technologies safely (e.g., protecting 

personal information, avoiding scams; for 

more information, see the Substance Abuse 

and Mental Health Services Administration’s 

[SAMHSA] TIP 60, Using Technology-Based 

Therapeutic Tools in Behavioral Health Services). 

• Problem-solve ways to overcome access 

barriers (Chapter 4 offers problem-solving 

strategies). 

• Learn about local and online resources that 

are appropriate and acceptable to them. For 

example, senior centers, libraries, community 

colleges, community centers, AARP, Senior.net 

learning centers, and adult learning programs 

are potential sources of free or low-cost 

educational programs to help older adults 

learn how to use a computer and social media 

websites and applications. 

• Ask for support from family members or techsavvy friends who can help set up a computer, 

tablet, or cell phone; teach them how to safely 

use social media and other apps; and provide 

ongoing support in their use of technologies. 

Specifc websites offering assistance with social 

media are listed in the folllowing Resource Alert. 

RESOURCE ALERT: CONNECTING 

OLDER ADULTS WITH SOCIAL 

MEDIA SUPPORTS 

The Staying Connected: Technology Options 

for Older Adults brochure from Eldercare 

Locator (https://eldercare.acl.gov/Public/ 

Resources/Brochures/docs/N4A_Tech_Brochure_ 

P06_high.pdf) introduces older adults to types of 

social media and their benefts. It includes basic 

information on how to set up a Facebook account 

and how to use free video calling services like 

Skype. 

Lifeline Support (www.lifelinesupport.org) 

provides information about a Federal 

Communications Commission program that 

offers eligible individuals fnancial assistance for 

Internet or cell phone services. 

Some older adults living in retirement 

communities or long-term care facilities have a 

built-in social network that facilitates drinking.1178 

Older adults in such settings may perceive drinking 

as a pleasurable or necessary aspect of socializing 

with their fellow residents. If you have older clients 

who misuse alcohol to ft in to their residential 

setting, help them learn to feel comfortable saying 

“no” to too much—or any—alcohol in social 

situations. If you have older clients who enjoy the 

social aspects of drinking in these settings but 

engage in alcohol misuse, educate them about the 

importance of reducing their alcohol intake.1179 

Promoting Wellness Strategies for 

Older Adults 

This section reviews the eight dimensions of 

wellness and how to explore wellness from a clientcentered perspective. It then examines strategies 

for promoting wellness, illness self-management 

and relapse prevention approaches, and strategies 

for promoting resilience and empowerment 

relevant to older adults in recovery from substance 

misuse. 

188 Chapter 7 
Chapter 7—Social Support and Other Wellness Strategies for Older Adults TIP 26

What Is Wellness for Older Adults in 

Recovery? 

Wellness is not simply abstinence from alcohol 

or drugs or the absence of illness or stress; 

it is being in good physical, emotional, and 

mental health.1180 To better promote wellness 

and recovery in older adults, effective strategies 

should include a focus on illness self-management 

and relapse prevention and an emphasis on health 

potential.1181 

SAMHSA has identifed eight dimensions of 

wellness1182 (Exhibit 7.2) that further a person’s 

health, well-being, and recovery from substance 

misuse and mental disorders: 

• Emotional—Coping effectively with life and 

creating satisfying relationships 

• Environmental—Occupying pleasant, 

stimulating environments that support 

well-being 

• Financial—Being satisfed with current and 

future fnancial situations 

• Intellectual—Recognizing creative abilities and 

fnding ways to expand knowledge and skills 

• Occupational—Personal satisfaction and 

enrichment from one’s work 

• Physical—Recognizing the need for physical 

activity, healthy foods, and sleep 

• Social—Developing a sense of connection, 

belonging, and a well-developed support 

system 

• Spiritual—Expanding a sense of purpose and 

meaning in life 

The consensus panel recommends that you 

explore all of these dimensions of wellness as a 

way to help older adults sustain their recovery 

from substance misuse. 

Talk with clients about their own wellness goals in 

each of the eight dimensions. (See “Collaborative 

Goal Setting” in this chapter for more information.) 

This will help you understand what wellness means 

to each client and open the conversation about 

ways to develop health and wellness in recovery. 

(See the Chapter 7 Appendix for the Health 

Enhancement Lifestyle tool to assess older adults’ 

health and wellness.) 

For older adults in retirement, occupational 

wellness may be more about satisfaction 

and enrichment from nonpaid work such as 

volunteering in the community or a satisfying 

hobby like gardening or painting. 

EXHIBIT 7.2. SAMHSA Wellness 

Wheel 

Reprinted from material in the public domain. 

1183 

Promoting Health and Wellness in 

Recovery 

You can promote health and wellness among 

older adults in recovery from substance misuse by 

exploring obstacles to recovery, understanding 

their perspectives on health and wellness, and 

supporting their interest in and readiness to 

engage in activities that maximize health and 

wellness. The consensus panel recommends the 

strategies discussed below, which apply to diverse 

clinical and service settings, for promoting wellness 

among older adults in recovery. 

Chapter 7 189 
TIP 26

 

General Wellness Promotion Strategies 

Reduce fear, shame, guilt, and defensiveness 

related to substance misuse. Older adults may 

feel shame and guilt about acknowledging that 

they misuse substances. The frst step in helping 

them achieve better health and wellness is to 

address their misconceptions about substance 

misuse and any fears they may have about 

treatment and the recovery process. One 

helpful strategy is to discuss substance misuse 

in a nonjudgmental way as a health issue like 

any other chronic illness (e.g., diabetes). Also 

express understanding and compassion to help 

older adults manage their fears and uncertainties 

Treating Substance Use Disorder in Older Adults 

about recovery from substance misuse and ways 

to engage in wellness activities to improve their 

health and well-being.1184 

Identify wellness activities. Use the table in 

Exhibit 7.3 with clients to identify wellness 

activities that they fnd accessible, acceptable, and 

appropriate. Introduce the table by describing 

the eight dimensions of wellness and give some 

examples of activities in each domain. Then 

brainstorm with clients to identify specifc activities 

in each domain that ft their preferences and 

wellness goals. With express consent from clients, 

ask supportive family members for suggestions on 

activities. 

EXHIBIT 7.3. Identifying Wellness Activities 

DOMAINS EXAMPLES CLIENT IDEAS 

Emotional Join a recovery or other support group; engage 

in storytelling with family or friends; keep a life 

history journal. 

Environmental Make home modifcations to age in place; 

create a quiet space at home; plant a fower 

box; seek “senior-friendly” safe housing. 

Financial Organize fnancial documents; seek fnancial 

planning assistance. 

Intellectual Join a book club; take an adult education or 

senior college class; learn a new skill; mentor a 

youth; teach a course or workshop. 

Occupational Volunteer (e.g., become an AA or NA sponsor); 

get involved in advocacy initiatives; participate 

actively in a new or old hobby. 

Physical Exercise by walking, dancing, swimming, 

or doing yoga or tai chi; eat healthy foods; 

develop a healthy sleep routine. 

Social Go on group outings, such as to museums 

or historical sites; join a bridge club; take a 

cooking class. 

Spiritual Join a faith-based or spiritual fellowship; 

meditate or pray; read inspirational material. 

190 Chapter 7 
Chapter 7—Social Support and Other Wellness Strategies for Older Adults TIP 26

Strategies To Increase Motivation 

Increase motivation to change health risk 

behaviors and participate in wellness activities 

through motivational interviewing (MI). MI is a 

nonconfrontational, respectful approach that can 

effectively help older adults resolve ambivalence 

about change and increase motivation to change 

a target behavior.1185 MI strategies can help older 

adults reduce alcohol consumption and tobacco 

use, improve general health, increase physical 

activity and exercise, improve diet, reduce 

cardiovascular risk factors, lose weight, and prevent 

disease.1186,1187 

MI strategies can help older adults change health 

risk behaviors like intentional or unintentional 

misuse of prescription medications, and resolve 

ambivalence about participating in wellness 

activities. Use the following MI strategies to help 

older clients identify and plan for achieving target 

behaviors that reduce health risk, improve wellness, 

and sustain recovery from substance misuse: 

• Identify a specifc target behavior that the 

client is willing to explore (e.g., attending an 

educational session about the health risks of 

medication misuse for older adults or calling 

the local senior center to fnd out about a tai chi 

class). The more specifc the target behavior, the 

more likely you and the older adult will be able 

to work together toward achieving the client’s 

change goal. 

• Apply MI communication skills (e.g., OARS— 

open questions, affrmations, refective listening, 

and summarization) to shape the conversation 

with clients to help them resolve ambivalence 

about change. (See the Chapter 7 Appendix for 

an example of using OARS.) 

• Emphasize change talk through refective 

listening. 

• Help the client create a change plan for each 

target behavior by writing down the change 

goal and a timeframe for achieving that goal. 

(The “Collaborative Goal Setting” section has 

more information.) 

• Follow up with the client to see whether the 

change plan is working or needs adjustment. 

For more on MI, see SAMHSA’s update of TIP 35, 

Enhancing Motivation for Change in Substance 

Use Disorder Treatment (https://store.samhsa. 

gov/product/TIP-35-Enhancing-Motivation-forChange-in-Substance-Use-Disorder-Treatment/ 

PEP19-02-01-003). 

Educational Strategies To Address Nutrition, 

Exercise, and Fall Prevention 

Provide education on nutrition, exercise, and 

fall prevention. Access to health information, 

a key component of health literacy, enables 

people to better manage their health and sustain 

recovery. Three key elements of preventive care 

for older adults in recovery from substance misuse 

are nutrition, exercise, and fall prevention. You 

don’t need to be an expert in nutrition or ftness 

to provide older adults with accurate information 

about health. Just knowing a few things about 

these elements of wellness for older adults can 

help you get the conversation started. 

Advise older clients to check with their healthcare 

provider before starting or dramatically changing 

their exercise routine or diet. 

Begin by educating yourself. Explore the 

resources listed in the Resource Alert below 

for information on nutrition, exercise, and fall 

prevention for older adults. Then take a clientcentered approach to client education and 

information exchange using these strategies: 

• Ask older clients what they know about 

nutrition, exercise, and fall prevention for 

people their age. 

• Provide small chunks of information that are 

personally relevant to older clients; use visual 

aids. 

• Ask clients what they think of this information 

and how it affects their level of interest in 

or readiness to engage in health promotion 

activities. 

Chapter 7 191 
TIP 26 Treating Substance Use Disorder in Older Adults 

• Develop an individualized change plan. If the 

information has an impact and clients are ready 

to act, brainstorm activities that they think are 

fun, easy, accessible, and personally relevant. 

• Follow up at the next visit. Ask clients what 

worked and did not work, and help them adjust 

the change plan while making progress toward 

change goals. 

Client education is a process of information 

exchange over time, not a single event. Information 

exchange can help you build a closer relationship 

with clients through a deeper understanding of 

their own experiences with making health behavior 

changes. 

RESOURCE ALERT: OLDER ADULT 

NUTRITION, EXERCISE, AND FALL 

PREVENTION 

The National Institute on Aging’s (NIA) Health 

Topics A-Z webpage (www.nia.nih.gov/health/ 

topics) offers easy-to-read information specifc to 

older adults on a range of health topics, including 

healthy eating, exercise, and fall prevention. 

Engaging American Indian/Alaska Native 

Elders in Fall Prevention Programs (www.ncoa. 

org/resources/engaging-american-indianalaskanative-elders-falls-prevention-programs), a 

National Council on Aging tip sheet, offers 

culturally responsive, practical strategies for 

American Indian and Alaska Native elders on fall 

prevention. 

Strategies for Complementary Therapies, 

Spirituality, and Ancillary Services 

Encourage the informed use of complementary 

therapies and activities. Complementary 

and integrative medicine techniques can be 

categorized into three groups—natural products 

(e.g., vitamins, herbal products), mind–body 

practices (e.g., meditation, yoga), and other health 

approaches (e.g., homeopathy, naturopathy). (See 

“Resource Alert: Complementary and Integrative 

Health for Older Adults.”) Many complementary 

therapies and activities are appropriate for helping 

older adults maintain good health and well-being 

in ongoing recovery. For example, owning or 

interacting with a pet (e.g., in animal-assisted 

therapy) can increase physical activity, improve 

cardiovascular functioning, enhance socialization, 

lower blood pressure, and decrease loneliness 

in some older adults.1188 Tai chi, a low-impact 

exercise and meditative movement, may prevent 

falls by improving balance, strength, mobility, and 

fexibility.1189,1190 It may also help older adults sleep 

better.1191 

Practicing mindfulness has many mental, 

emotional, spiritual, and health benefts that 

can enhance older adults’ sense of well-being. 

Mindfulness has been widely adapted and studied 

in the United States as a strategy for stress 

reduction and healthy coping. Mindfulness helps 

people develop open, nonjudgmental attention 

to present-moment experience. Older adults can 

use mindfulness skills to cope with stresses like 

physical pain and fnancial worries. Mindfulness 

may also increase older adults’ social support, 

well-being, and ability to regulate emotional states 

like depression, anger, and anxiety.1192 

You can incorporate mindfulness practices in 

work with older adults or refer your clients to 

local programs that teach mindfulness. For more 

on mindfulness and mindfulness-based programs, 

see the website of the Center for Mindfulness 

in Medicine, Health Care, and Society at www. 

umassmed.edu/cfm. 

Other complementary therapies and wellness 

activities appropriate for older adults in recovery 

include: 

• Gentle or senior-friendly yoga. 

• Dance and movement therapy. 

• Low-impact ftness programs. 

• Swimming and water therapy. 

• Meditation. 

The consensus panel recommends that you 

explore the benefts and potential downsides 

of complementary therapies with your older 

clients and work collaboratively with them to 

fnd the right ft based on cost, level of physical 

and cognitive functioning needed to participate 

successfully, age-specifc adaptations, and ease 

of access. 

192 Chapter 7 
Chapter 7—Social Support and Other Wellness Strategies for Older Adults TIP 26

Explore the spiritual dimension of wellness and 

recovery. As mentioned previously, participation 

in religious or spiritual fellowship can expand 

the social dimension of wellness for older adults. 

For example, one recent study found that more 

frequent attendance at church among adults 

ages 50 and older is associated with a sense of 

belonging and greater spiritual support, which 

are in turn associated with a greater likelihood of 

positive self-report of health.1193 Engagement in 

religious activities (e.g., praying, attending religious 

services) and spiritual practices (e.g., mindfulness, 

meditation), including the spiritual aspects of 

AA, are linked with better alcohol use outcomes, 

improved recovery from AUD, increased coping 

skills and ability to manage stress, decreased anxiety 

and depression, and improved cognition.1194,1195 

To explore the spiritual dimensions of wellness 

and recovery with older clients, you can: 

• Acknowledge that spirituality or religious 

engagement may be important to your clients’ 

well-being. 

• Be open to exploring clients’ spiritual or 

religious beliefs and practices and their 

potential impact on clients’ health, wellness, and 

recovery. Do not insert your own beliefs into the 

conversation. 

• Explore how your clients’ understanding of 

spirituality relates to their overall well-being, 

experience of recovery, sense of meaning and 

purpose, health, and coping with loss, stress, or 

adversity. 

• Encourage active participation in personally 

relevant religious or spiritual activities such as 

attending religious services, attending AA or 

NA 12-Step meetings, praying, engaging in 

mindfulness or meditation, or “giving back” by 

becoming an AA or NA sponsor or volunteering 

in the community. 

Actively link or refer older adults to ancillary 

services, such as: 

• Health care provided by physicians with 

experience and training in geriatric medicine. 

• Specialized pharmacy services. 

• Health education programs. 

• Disease prevention or wellness counseling 

services. 

• Complementary therapies. 

• Fitness programs for older adults. 

Active linkage includes contacting the service or 

program you are referring your client to, getting a 

release from your client, giving written instructions 

to your client about how to access the service 

(e.g., name of provider, appointment time), and 

following up with the ancillary service provider via 

phone, letter, or email. (Chapter 4 of this TIP has 

more information about active linkage and referral 

management.) 

RESOURCE ALERT: 

COMPLEMENTARY AND 

INTEGRATIVE HEALTH FOR 

OLDER ADULTS 

These resources offer providers and consumers 

research-based information on some 

complementary and integrative medicine 

treatments for older adults: 

• The American Society on Aging’s blog post 

about mindfulness and older adults is easy 

to read and could serve as a useful one-page 

handout to clients (www.asaging.org/blog/behere-now-and-age-mindfully). 

• The American Geriatrics Society website 

GeriatricsCareOnline.org offers a useful 

summary of complementary and integrative 

medicine approaches. The site also includes 

a table of natural products and their 

interactions with prescribed medications as 

well as a summary of the evidence base for 

complementary and integrative medicine 

approaches as they relate to different 

health conditions common in aging (https:// 

geriatricscareonline.org/FullText/B030/B030_ 

VOL001_PART001_SEC002_CH012). 

Recognize and explore strengths. Older adults 

have a great deal of knowledge from their own 

experience, practical wisdom, and a wide range 

of skills and abilities. A strengths-based approach 

assumes that people do not simply survive 

diffcult life circumstances, including substance 

misuse and the aging process itself, but can 

thrive in recovery and achieve enhanced health 

and wellness. Exploring older adults’ strengths 

Chapter 7 193 
TIP 26

involves validating their interests, acknowledging 

and appreciating their successes, and inviting them 

to refect on future possibilities.1196 

Clinical Scenario: A Strengths-Based 

Intervention 

Older adults in recovery from substance misuse 

who are widows or widowers may feel guilty about 

surviving and lose interest in life. The following 

scenario focuses on exploring an older adult’s 

strengths to rekindle a sense of possibility about 

the future. 

• AUD Recovery and Loss: An older adult in 

recovery from AUD drops out of AA after 

becoming a widower. 

• Treatment Setting: Outpatient addiction 

treatment program 

• Provider: Licensed alcohol and drug counselor 

• Treatment Strategy: Strengths-based approach 

Harry is 79 years old. He has been in recovery from 

AUD for 3 years. He initially attended AA meetings, 

became actively involved in the program, and 

attended recovery-oriented social gatherings 

with his wife, Ginny. When Ginny died suddenly, 

Harry stopped going to AA and isolated himself 

from family and friends. His daughter became 

worried about him and convinced him to go see a 

counselor. 

At the initial interview, the provider acknowledges 

Harry for maintaining his abstinence through a very 

diffcult time. This acknowledgement helps Harry 

feel more comfortable talking about how he has 

lost interest in going to meetings or spending time 

with family and friends. He says, “I just can’t let 

myself have fun or feel joy anymore. It’s like I would 

be betraying Ginny. I’m the alcoholic and she is the 

one who died too young. It should have been me.” 

The provider offers Harry an affrmation and an 

open question that directs the conversation toward 

exploring Harry’s strengths and an alternative story 

about his pulling back from life, “I appreciate your 

efforts to honor Ginny’s memory. It seems like you 

really respect and appreciate how other people 

have touched you and contributed so much to your 

life. Not everyone has that quality. How did you 

come by that ability?” 

Treating Substance Use Disorder in Older Adults 

Harry begins to tell a story about how he learned 

about respecting others early in his life and how 

important being respectful is to him. This opens 

the door for the counselor to explore Harry’s other 

strengths and abilities. “What other abilities or 

talents would you say have contributed to your 

life?” 

As the provider helps Harry identify his strengths, 

Harry starts to believe in himself again and gives 

himself permission to feel good. His story about 

honoring Ginny changes. He sees another way he 

can honor his wife: by getting back to living his 

own life. He decides to call his former AA sponsor 

about returning to his home group. 

Promoting Self-Management and Relapse 

Prevention 

Perhaps the most critical tasks for older adults 

who misuse substances are to achieve stability 

and maintain ongoing recovery. Sustaining 

recovery is challenging without a sense of health 

and well-being, especially for older adults with 

co-occurring mental disorders or multiple chronic 

illnesses. Relapse prevention planning is the 

key to helping older adults identify potential 

relapse triggers and build coping skills. Engaging 

older adults in chronic illness self-management 

programs, relapse prevention planning, continuing 

care, and ongoing recovery support can help them 

maintain long-term recovery. 

Chronic Illness Self-Management 

Chronic illnesses can increase isolation and 

interfere with substance misuse recovery efforts. 

Mental disorders like depression and anxiety are 

common in older adults. So are chronic health 

conditions: 80 percent of older adults have at least 

one chronic health condition, such as diabetes, 

arthritis, hypertension, cardiovascular disease, 

pulmonary disease, and chronic pain.1197 Illness 

self-management programs are an important 

part of integrated and client-centered care. They 

improve health outcomes, help people maintain 

higher levels of health functioning, and enrich 

quality of life by helping people develop skills to 

manage their symptoms and change attitudes and 

behaviors.1198 

194 Chapter 7 
Chapter 7—Social Support and Other Wellness Strategies for Older Adults TIP 26

One such program, the Stanford Chronic Disease 

Self-Management Program (CDSMP),1199 is an 

evidence-based approach that has demonstrated 

effectiveness with older adults. CDSMP has 

helped people improve wellness across several 

dimensions, such as through improvements in 

exercise, cognitive symptom management, and 

self-reported general health; decreases in health 

distress, fatigue, and disability; and reduced 

hospitalizations.1200 To help older clients develop 

and sustain chronic illness self-management plans, 

CDSMP: 

• Explores with clients how having a chronic 

condition affects them and how, if not properly 

managed, the condition may interfere with 

recovery from substance misuse. 

• Addresses depression and anxiety, often 

associated with substance misuse and chronic 

illnesses. 

• Acknowledges the challenges and successes of 

daily self-management of symptoms. 

• Addresses ways to build structure into daily 

routines to support clients’ ability to manage 

symptoms while emphasizing recovery and 

wellness activities (e.g., take medication as 

scheduled, have lunch with a friend, attend AA 

meetings or other support groups). 

• Provides information on and links clients to local 

or online CDSMP services. 

• Supports clients in their efforts to sustain 

self-management of symptoms while actively 

participating in recovery and wellness activities. 

To fnd organizations that offer a licensed CDSMP, 

go to www.eblcprograms.org/evidence-based/ 

map-of-programs. Also check with the AAA or the 

Aging and Disability Resource Center (if available) 

for your community. 

The Self-Management Resource Center (www. 

selfmanagementresource.com) offers a variety 

of illness self-management programs, including 

an online program, originally developed by and 

housed at the Stanford Patient Education Research 

Center. The Self-Management Resource Center 

also provides information about training and 

licensing for organizations that would like to offer a 

CDSMP. 

Clinical Scenario: Promoting Chronic 

Illness Self-Management 

Older adults in recovery from substance misuse 

who have chronic medical conditions may feel 

ashamed of having an illness that limits their 

functioning and ability to engage in recovery 

activities. The following scenario focuses on an 

older adult’s negative self-judgments about having 

a chronic medical condition. 

• AUD Recovery and Chronic Medical Condition: 

An older adult in long-term recovery from AUD 

has a chronic medical condition. 

• Treatment Setting: Hospital-based outpatient 

behavioral health program 

• Provider: Licensed psychologist 

• Treatment Strategies: Foster self-acceptance 

and promote chronic illness self-management 

activities. 

Ruth is 69 years old, is in long-term AUD recovery, 

and has attended AA for many years. She lives with 

her daughter and two grandchildren. Her daughter 

is divorced and works full time. Ruth watches 

her grandchildren after school. She became the 

General Service Representative of her home AA 

group and sponsored many members over the 

years. She smoked cigarettes for 20 years. Ruth 

frequently tells people that “smoking is a bad habit 

I picked up at meetings.” She recently stopped 

after she was diagnosed with chronic obstructive 

pulmonary disease (COPD). Ruth’s pulmonologist 

referred her to counseling at the hospital’s 

outpatient program given her score of 12 on the 

Patient Health Questionnaire, indicating moderate 

depression. (Chapter 3 of this TIP offers screening 

and assessment tools.) She also was not following 

instructions for managing her COPD. 

In counseling, Ruth discloses that she feels 

ashamed that she has COPD. She stopped going 

to AA meetings because she feels like a failure for 

having a chronic medical condition that she says 

she should have avoided. She also fnds it more 

and more diffcult to leave the house. Her energy 

is low, and she coughs all the time. She also states 

that she has recently felt like drinking after seeing 

alcohol commercials on TV. 

Chapter 7 195 
TIP 26

The provider helps Ruth identify specifc selfjudgments about COPD. Ruth says, “I hate being 

sick all the time. I don’t want another chronic 

illness. It’s my fault for not taking care of myself. 

I really failed this time.” The provider helps her 

reevaluate her perspective about what it means 

to have a chronic illness and how to manage it, 

using her experience in recovery as an analogy. 

The provider says, “You told me that when you frst 

got into recovery, you felt a lot of shame. But you 

started to feel more accepting when other people 

talked about alcoholism as a disease that has no 

cure but can be managed a day at a time.” Ruth 

tells the provider that she benefted from having a 

support group to help her learn about her disease, 

how to accept it, and ways to manage it. 

The provider asks Ruth how she quit smoking after 

20 years and avoided drinking. She says that she 

got a nicotine patch and went to a quit smoking 

group at the hospital. The provider says, “So it 

seems like you used some of the same tools you 

used to get sober to stop smoking and stay sober 

too.” Ruth says, “I guess I’m not such a failure. If I 

can stay sober for this long and quit smoking after 

20 years, I can learn to manage the COPD.” 

The provider then explores possible community 

COPD support resources, including a pulmonary 

rehabilitation program at the hospital that teaches 

people about COPD, how to manage their 

symptoms, and how to save their energy for other 

activities. Ruth agrees to sign up for the program. 

She says, “If I can get this thing under control and 

I have more energy, I’m sure I can get back to my 

home group. I really miss everyone.” 

Ruth and her provider agree to keep meeting 

while Ruth is in the pulmonary rehabilitation 

program to monitor her progress and explore 

any obstacles to returning to AA and staying 

focused on managing her COPD. 

Continuing Care and Relapse Prevention 

Continuing care in addiction treatment has 

traditionally consisted of short-term (e.g., 12-week) 

outpatient group counseling and passive referral 

to mutual-help groups. Current thinking about 

continuing care emphasizes interventions that 

are long term and fexible enough to adjust 

to the needs of clients as they move through 

different stages of recovery. 

Treating Substance Use Disorder in Older Adults 

Staying longer in addiction treatment and having 

a social support system after treatment that 

reinforces abstinence from alcohol and illicit drugs 

are two of the most important factors associated 

with long-term recovery for older adults.1201 

Continuing care for older adults should emphasize: 

• Retention in ongoing treatment and recovery 

support, including mutual-help group meetings. 

• Relapse prevention planning. 

• Use of in-home or telephone counseling 

as appropriate to strengthen retention and 

engagement. 

• Active involvement (with the older adults’ 

permission) of spouses and other family 

members, or other signifcant others who 

support the older adults’ recovery. 

• Active linkage to and follow-up with 

community-based resources, such as housing 

and employment services (when needed); 

senior centers; and ftness, health, and wellness 

services for older adults. 

Also, some individuals fnd treatment facility alumni 

programs helpful in supporting their recovery 

from SUDs. Alumni programs typically offer 

graduates of the same treatment facility ongoing 

support through organized activities, continued 

contact with treatment staff, and further addiction 

education. 

SOCIAL NETWORK COUNSELING 

Network Support is a counseling intervention 

that consists of 12 counseling sessions (some 

including a spouse or signifcant other) that 

emphasize AA as a mutual-help group where 

people can make new friends and engage in 

nondrinking social and recreational activities. This 

approach can change the social network of the 

participants to include more nondrinking friends, 

which in turn can increase self-effcacy and 

coping, leading to improvements in long-term 

drinking outcomes.1202 A key to ongoing recovery 

for older adults is a social network that supports 

recovery. When talking with older adults about 

the benefts of AA, emphasize the social aspects 

of mutual-help group attendance, an important 

factor in sustaining long-term recovery. 

196 Chapter 7 
Chapter 7—Social Support and Other Wellness Strategies for Older Adults TIP 26

Relapse prevention planning is an important 

part of treatment and continuing care. You can 

facilitate this process by understanding older 

adult-specifc relapse risk factors and strategies 

for reducing the risk of a return to substance 

misuse. 

Some factors that increase the risk of relapse for 

older adults who misuse substances1203 include: 

• Loneliness and isolation. 

• Boredom. 

• Chronic pain. 

• Untreated mental disorders or symptoms of 

anxiety and depression. 

• Complicated grief. 

• Sleep problems. 

• Lack of social support for recovery. 

• Chronic medical problems. 

• Unsafe or unsuitable living environment. 

• Prolonged stress. 

• Diffculty managing instrumental ADLs including 

fnances. 

• Misunderstanding of relapse or lack of a relapse 

prevention plan. 

Support your older clients in maintaining 

ongoing recovery and reducing the risk of 

relapse by:1204,1205,1206 

• Helping them develop meaningful leisure, social, 

or vocational activities. 

• Working with them and their physicians on 

alternative pain management strategies. 

• Addressing grief issues throughout treatment 

and referring for additional supportive services 

when needed. (See the grief resource in the 

Chapter 4 Appendix of this TIP.) 

• Providing information about good sleep habits 

(e.g., give up a daytime nap if it interferes with 

sleep at night) and low-risk nonpharmacological 

ways to cope with sleep problems. 

• Ensuring that co-occurring mental and physical 

disorders get addressed and treated. 

• Ensuring that they are keeping medical 

appointments, taking medications as prescribed, 

and communicating changes in health status to 

their healthcare providers. 

• Teaching them stress management and coping 

skills throughout treatment. 

• Helping them develop or broaden social 

networks that support recovery. 

• Developing relapse prevention plans tailored to 

their individual needs. 

• Exploring the potential for a return to substance 

use, normalizing relapse without implying that it 

is inevitable, and reframing relapse as a learning 

opportunity. 

• Reviewing their past success in managing 

triggers; discussing themes and triggers for past 

relapses. 

• Developing plans for reengaging in treatment if 

they return to substance use before it becomes 

a full relapse to previous levels of use. 

• Working with them to evaluate coping strategies 

and, if needed, retrain on existing strategies or 

develop new ones. 

• If appropriate to your role and setting, 

sustaining long-term supportive contact with 

them, with the emphasis on helping them 

maintain stability in recovery and better health 

and wellness. 

Promoting Resilience and Empowerment 

in Recovery 

Interventions that promote resilience can support 

relapse prevention efforts.1207 Thinking of older 

adults as infexible or “set in their ways” is 

ageist and fails to acknowledge the skills, 

abilities, and wisdom they have acquired from 

years of experience. Instead, promote resilience 

and empower your older clients in recovery from 

substance misuse by: 

• Learning about their unique life-course events 

and challenges. 

• Tapping into their wisdom. 

• Supporting them in refecting on successful 

resolutions to past challenges they have faced. 

• Helping them build coping skills to meet the 

challenges of recovery from substance misuse. 

Chapter 7 197 
TIP 26

Tasks and Challenges of Aging 

Developmental theory suggests that a person 

has unique, age-specifc tasks to master over the 

life course. The tasks of older adulthood can be 

challenging, yet rewarding, and include: 

• Adjusting to decreasing physical health, 

strength, and cognitive functioning. 

• Adjusting to retirement and reduced income. 

• Trying new activities (e.g., creative hobbies 

limited earlier by career, job, or family 

responsibilities). 

• Establishing safe housing and satisfactory living 

arrangements. 

• Entering new social roles, including affliating 

with one’s age group, caring for relatives 

(particularly relevant for women), and 

grandparenting. 

• Adjusting to and accepting the death of a 

spouse, other family members, or friends. 

• Finding meaning in life while facing the prospect 

of death.1208 

One way to think about the challenges of aging 

is to understand that with age comes a broad 

spectrum of losses and transitions that may 

be traumatic for the older adult. Work from a 

perspective of trauma-informed care, which 

assumes that older clients’ presenting issues, 

behaviors, and emotional reactions may be 

adaptive responses to trauma or loss and not 

symptoms of pathology. 

The consensus panel recommends that you 

approach every older adult in SUD treatment or 

recovery from a trauma-informed and personcentered perspective that recognizes that the 

experiences of trauma, loss, and grief are highly 

individualized. 

See SAMHSA’s TIP 57, Trauma-Informed Care 

in Behavioral Health Services, for an indepth 

examination of a trauma-informed approach to 

the treatment and prevention of addiction and 

mental illness (https://store.samhsa.gov/product/ 

TIP-57-Trauma-Informed-Care-in-BehavioralHealth-Services/SMA14-4816). See also www. 

samhsa.gov/trauma-violence. 

Treating Substance Use Disorder in Older Adults 

Despite age-related losses and limitations 

on physical and cognitive functioning, older 

adults can experience mental growth and 

maturation.1209 Most older adults maintain 

a positive outlook, improve their emotional 

regulation over time, and express a high degree 

of life satisfaction. Many older adults rise to the 

challenge, rediscover themselves, and grow from 

traumatic or stressful experiences. You can support 

your older clients in recovery in addressing the 

tasks and challenges of aging by: 

• Recognizing that loss and transition are a normal 

part of aging and helping your older clients 

identify the losses and transitions specifc to 

them. 

• Recognizing that your older clients who have 

experienced the death of a spouse or intimate 

partner are at higher risk for starting or 

returning to alcohol misuse or drug use. 

• Connecting your older clients with recovery 

supports when the urge to drink or use drugs 

arises. 

• Recognizing that multiple losses may trigger 

trauma reactions in older adults with a history of 

depression, anxiety, or other mental disorders, 

including posttraumatic stress disorder, 

and treating co-occurring mental disorders 

concurrently. 

• Helping your older clients identify day-to-day 

coping strategies, including maintaining a 

regular schedule, which helps people structure 

activities and maintain participation in social 

activities.1210 

• Helping your older clients accept supports and 

services needed to maximize functioning and 

independence. 

• Aiding them in balancing distraction from 

negative emotions with acceptance and learning 

to tolerate intense emotions associated with 

trauma. 

• Helping clients identify personally relevant 

strategies for coping with and making meaning 

of loss and managing normal feelings of grief. 

• Exploring with them whether reconnecting to 

a faith community could provide meaning and 

purpose. 

198 Chapter 7 
Chapter 7—Social Support and Other Wellness Strategies for Older Adults TIP 26

• Linking clients in institutional settings (e.g., 

hospitals, assisted living) to mutual-help groups 

that provide meetings in such settings, if 

available. 

• Helping clients build bridges to new sources of 

meaning and purpose.1211 

• Exploring with clients the role adjustments 

they may face related to retirement; death of 

a spouse, other family members, friends, or a 

sponsor; a move to another geographic area; or 

taking on a parenting role for grandchildren. 

• Helping clients build and strengthen their 

support networks. 

• Encouraging them to explore creative ways to 

make amends, bring closure to a chapter in 

their life, celebrate past accomplishments and 

new developments in their life, or remember 

a signifcant other (e.g., creating personally 

meaningful rituals and ceremonies, writing 

therapeutic letters, creating memory books). 

Strategies for Strengthening Resilience 

To help your older clients foster resilience, 

encourage them to recognize that they can 

develop cognitive, emotional, and behavioral 

coping skills that strengthen their ability to 

prevent relapse, manage stress, and rebound from 

adversity. Bolstering resilience in older adults helps 

promote healthy aging, improves responses to 

developmental tasks and challenges, and heightens 

quality of life.1212 The ability to cope with stressful 

situations is a key factor in preventing relapse from 

SUDs (see Resource Alert). 

RESOURCE ALERT: STRATEGIES 

FOR BUILDING RESILIENCE1213 

An American Psychological Association webpage 

(www.apa.org/topics/resilience) describes 

strategies people can use in supporting recovery 

from SUDs. 

Collaborative Goal Setting 

Collaborative goal setting draws on clients’ 

strengths and focuses on developing attainable 

goals. This can promote a positive attitude 

toward changing substance misuse behaviors1214 

and create a sense of self-effcacy and hope for 

older adults in ongoing recovery. Goals should be 

personally relevant to your older clients, challenging 

but realistic, achievable, and specifc.1215 

As a provider, you can facilitate goal setting with 

your older clients by: 

• Helping them identify emotionally meaningful 

goals that support recovery and improve health 

and wellness (e.g., spending more time with 

family and friends, maintaining independence or 

recovery support, aging in place). 

• Targeting short-term, easily attainable goals 

that build toward larger goals. For example, to 

stop alcohol use, help clients identify activities 

to do instead of drinking (like going out to 

dinner with a nondrinking friend rather than 

staying home at night drinking). 

• Collaborating with your clients to develop 

a SMART plan (Exhibit 7.4) for achieving the 

identifed substance misuse or wellness goal; 

the plan should specify a timeframe and any 

supports clients need to meet the goal. 

• Monitoring progress toward meeting goals 

for reducing or stopping substance misuse or 

engaging in wellness activities. 

• Helping clients modify goals as needed. 

Questions you can ask your older clients include: 

- Was your initial goal too easy or too hard? 

- Would accomplishing smaller tasks, like 

reducing your alcohol intake, make it easier 

to accomplish your ultimate goal of stopping 

completely? 

- What obstacles prevented you from achieving 

or maintaining abstinence? 

- What obstacles prevented you from starting 

the wellness activity (e.g., taking a walk every 

day)? 

- What are some of your strategies for 

overcoming these obstacles? 

- Is your goal still important to you, or is it time 

to move to a different goal? 

Chapter 7 199 
TIP 26 Treating Substance Use Disorder in Older Adults 

EXHIBIT 7.4. Writing a SMART Goal 

Specifc: State the goal clearly. Ask the client to be specifc. For example, if the goal is “I just want to be 

healthy,” ask “How will you know when you are ‘healthy’?” or “What things will you be able to do when you 

are healthy that you can’t do now?” 

Measurable: Identify and quantify the observable markers of progress, such as pain levels or the number 

of days and amount of time the client walked each week. Invite the client to keep a log of these markers so 

you can discuss the client’s progress. 

Attainable: Break the goal into smaller, actionable steps. Identify expected barriers and make a plan 

to address them. For example, if the goal is to get 8 hours of sleep each night, break the goal into smaller 

tasks, like turn all the lights in the bedroom off at 10 p.m. at least fve nights a week. Then ask, “What might 

keep you from turning the lights off at 10 p.m.?” 

Relevant: Make sure the goal refects what’s personally relevant to the individual. Use MI to set the 

agenda and determine goals on which to focus. Link goals, such as blood pressure control, to the goal of 

staying healthy. 

Time-bound: Defne when the goal is to be attained. Help the client be specifc about the timeframe. 

Make it realistic and attainable, based on the client’s subjective evaluation. Agree when to check progress. 

Content reproduced with the permission of the National Committee for Quality Assurance (NCQA). NCQA disclaims all 

liability for the use and interpretation of the content.1216 

Help older clients learn which health and wellness 

activities will help them prevent return to substance 

misuse, broaden social networks, build resilience, 

and give meaning and purpose to ongoing 

recovery. 

Chapter 7 Resources 

Provider Resources 

A Clinician’s Guide to CBT With Older People 

(www.uea.ac.uk/documents/246046/11919343/ 

CBT_BOOKLET_FINAL_FEB2016%287%29. 

pdf/280459ae-a1b8-4c31-a1b3-173c524330c9): 

This workbook explores age-sensitive strategies for 

adapting cognitive–behavioral therapy for older 

adults. 

Centers for Disease Control and Prevention 

(CDC)—Alzheimer’s Disease and Healthy Aging 

(www.cdc.gov/aging/index.html): CDC offers 

educational materials and resources to help 

healthcare providers engage in activities of its 

Healthy Aging Program. 

Centers for Medicare and Medicaid Services— 

Annual Wellness Visit (www.cms.gov/Outreachand-Education/Medicare-Learning-Network-MLN/ 

MLNProducts/downloads/AWV_chart_ICN905706. 

pdf): Healthcare providers can use this booklet 

to learn about the elements of the Health Risk 

Assessment and the Annual Wellness Visit. 

National Council on Aging—Center for Healthy 

Aging (www.ncoa.org/center-for-healthy-aging): 

The Center for Healthy Aging provides educational 

resources for providers on health and wellness, 

disease management, nutrition, exercise, and fall 

prevention for older adults. 

NIA—Health Topics A-Z (www.nia.nih.gov/health/ 

topics): NIA provides an alphabetical listing of 

educational resources and information that may be 

useful for providers when educating older adults 

on health and wellness topics. 

200 Chapter 7 
Chapter 7—Social Support and Other Wellness Strategies for Older Adults TIP 26

Consumer Resources 

Administration on Aging—Eldercare Locator 

(https://eldercare.acl.gov/Public/Index.aspx): The 

locator connects older adults and their families to 

local services. 

Eldercare Locator—Expand Your Circles: Prevent 

Isolation and Loneliness As You Age (https:// 

eldercare.acl.gov/Public/Resources/Brochures/ 

docs/Expanding-Circles.pdf): This easy-to-read 

brochure offers tips to older adults about 

expanding their social networks. 

National Council on Aging—Resources (www. 

ncoa.org/audience/older-adults-caregiversresources/?post_type=ncoaresource): This 

webpage contains a searchable database of 

articles, webinars, and other resources. 

NIA—Alcohol Use or Abuse (www.nia.nih.gov/ 

health/topics/alcohol-use-or-abuse): This webpage 

has links to information for older adults and family 

members about alcohol misuse. 

NIA—Older Adults and Alcohol: You Can Get 

Help (https://order.nia.nih.gov/sites/default/ 

fles/2018-01/older-adults-and-alcohol.pdf): This 

easy-to-read consumer brochure lays out the issues 

and answers common questions that older adults 

have about drinking. 

Silver Sneakers—Health and Fitness for Older 

Adults (www.silversneakers.com): Silver Sneakers 

connects eligible older adults on some Medicare 

plans to free memberships at ftness programs 

across the nation. This website also offers general 

information about wellness and ftness for older 

adults. 

Chapter 7 201 
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Chapter 7—Social Support and Other Wellness Strategies for Older Adults TIP 26

to map social networks of older adults and adults

with SUDs.1218 The Social Network Map is a clientcentered tool that collects information on the 

composition of older adults’ networks, the extent

to which network members provide different types 

of support, and the nature of relationships within 

the networks.1219 The version depicted below is

adapted for use with older adults in recovery. 

Chapter 7 Appendix 

Assessing Social Support 

The Social Network Map is a handy visual tool 

to help you and your clients identify members 

of their social network and the types of support 

they provide.1217 It was developed as a clinical 

tool for assessing and broadening social support 

resources for families and has been used in studies 

SOCIAL NETWORK MAP FOR OLDER ADULTS IN RECOVERY 

Adapted from Tracy & Whittaker (1990).1220 

Chapter 7 203 
TIP 26

The following strategies1221 will help you and your 

older clients develop a social network map: 

• Create a pie chart with the seven domains. 

Health, behavioral health service, social service, 

and peer recovery support providers may be 

part of the support network clients identify. 

• Ask older clients to identify members of their 

social networks by frst name or initials only. 

• Ask clients to describe how available (e.g., 

rarely, sometimes, often) each member of the 

network is to give emotional, instrumental, or 

informational support. Give examples and be 

specifc: 

- “Who is available to give you emotional 

support like comforting you if you are upset 

or listening if you are stressed?” “How 

often does this person give you that kind of 

support?” 

- “Who is available to help you out in a 

concrete way like giving you a ride or helping 

with a chore?” “How often does this person 

give you that kind of support?” 

- “Who would give you information on how to 

do something new or help you make a big 

decision?” “How often does this person give 

you that kind of support?” 

• Note the type and frequency of support each 

person listed in each domain can offer. 

• Ask clients to describe how close they are to 

each member of their network, how long they 

have known them, and how frequently they see 

them. 

• Ask clients to review the map and identify types 

of support that may be lacking and strategies 

for adding new network members to beef up 

their social support. 

Assessing Isolation 

Assess older adults’ level of social isolation and 

explore all possible sources of social support they 

have. The Lubben Social Network Scale (LSNS) 

is designed for use with older adults. It measures 

social isolation and focuses on the nature of older 

adults’ relationships with family and friends.1222 

Older clients can easily complete the six-item 

Treating Substance Use Disorder in Older Adults 

short version (LSNS-6), a self-report questionnaire. 

The LSNS-6 is available via www.bc.edu/content/ 

bc-web/schools/ssw/sites/lubben/description.html. 

For the LSNS-6, the total score (0–30) is an equally 

weighted sum of the scale’s six items. A score 

below 12 indicates social isolation and need for 

further assessment.1223 Low scores are associated 

with increased mortality, hospitalization for all 

causes, physical health problems, depression 

and other mental disorders, and low adherence 

to health-promoting activities.1224 The Modifed 

LSNS-R, with a “family of choice” subscale, was 

developed for use with lesbian older adults.1225 

A screening tool like the LSNS-6 will give you an 

overall sense of the number of people in an older 

adult’s life who provide support and the level of 

social isolation or social support the older adult is 

experiencing. The next step is to explore the kinds 

of social support older adults have or would like to 

have. This exploration will help you and your client 

generate strategies for increasing the diversity of 

social supports that promote health, wellness, and 

recovery. 

Three types of social support enhance the health of 

older adults: 

• Emotional support (e.g., feeling heard and 

understood, having help with refecting on one’s 

values, providing a sense that someone cares) 

• Instrumental support (e.g., helping with 

fnances, transportation, medication adherence) 

• Informational support (e.g., providing 

information about community resources or the 

benefts of wellness and recovery activities, 

problem-solving, giving advice when asked)1226 

Begin your conversation by describing the beneft 

of social support to people’s health and well-being 

and give examples of the three types of support 

mentioned above. Then indicate that you would 

like to ask a few questions to see what kind of 

support your client already has. 

Screening Instruments and Other Tools 

The Health Enhancement Lifestyle Profle (HELP) 

is a validated assessment tool of older adults’ 

habits and routines in health-promoting behaviors 

204 Chapter 7 
Chapter 7—Social Support and Other Wellness Strategies for Older Adults TIP 26

in fve of the eight dimensions of wellness. It is 

administered as either a self-report questionnaire 

or a structured interview.1227 The HELP screening 

tool is a short version of the comprehensive 

assessment. It is a 15-item questionnaire that asks 

for “yes” or “no” responses. It is quick and easy 

to understand when administered to older adults 

as a self-report review of health-related lifestyle 

and wellness factors. (See page 32 of www.csudh. 

edu/Assets/csudh-sites/ot/docs/3%20Health%20 

Enhancement%20Lifestyle%20Profle%20(HELP)-

Guide%20for%20Clinicians-2016.pdf for the 

screening tool.) The questions focus on exercise, 

nutrition, social support, recreational activities, and 

spirituality. 

If further exploration is needed, focus the 

conversation with the client on items marked 

“no.” For example, if the client marks “no” on 

the item about exercise, you might start with a 

nonjudgmental observation like “I noticed that 

you normally don’t exercise more than twice 

a week. Exercise can mean different things to 

different people. Tell me more about what you do 

for exercise.” This will open a conversation about 

physical activity and the client’s understanding 

of what exercise is. Build on what the client is 

already doing before providing information about 

recommended guidelines or jumping in with advice 

about how to improve in that area. 

The OARS approach is a person-centered 

communication approach used in motivational 

interviewing.1228 You can use OARS throughout 

conversations with clients to help them feel 

relaxed, understood, and open to thinking about 

changing their pattern of substance misuse 

or engaging in wellness activities. Here are 

some examples of how to apply OARS to your 

discussions with older clients. 

CLINICAL SKILLS: USING OARS IN CLIENT COMMUNICATIONS ON SUBSTANCE 

MISUSE 

“O”—Open-ended questions: These questions help you learn more about the client’s thoughts, feelings, 

and experiences. They are questions that cannot be answered with a simple “yes” or “no.” Some examples 

are: 

• “What do you think are some reasons for you to stop drinking?” 

• “In what ways is not drinking important to you?” 

• “How do you think your relationship with your daughter would be different if you were not using 

marijuana?” 

“A”—Affrmations: These statements show support for the older adult’s efforts to make diffcult changes. 

Affrmations help the client build self-effcacy (a person’s belief in his or her ability to do something, such as 

change a behavior). Examples of affrmations include: 

• “Your willingness to discuss the risks of taking more pain medication than prescribed by your doctor 

fts right in with your health goals. I appreciate your willingness to talk about something that might be 

uncomfortable for you.” 

• “You are working hard to cut back on your drinking. When you set your mind to something you are 

determined to meet your goal.” 

“R”—Refective listening: Refective listening involves listening for the feelings or meaning of the client’s 

statements and refecting that meaning back to the client using his or her own words or paraphrasing. This 

shows that you are paying attention and trying to understand the client’s perspective. Refective listening 

also helps the client become more self-aware. You can use refective listening by: 

• Simply repeating key words or phrases back to the client. 

• Rephrasing what the client said using your own words. 

Continued on next page 

Chapter 7 205 
TIP 26 Treating Substance Use Disorder in Older Adults 

Continued 

• Refecting the underlying meaning or feeling of the client’s statement. Here is an example: 

- Client: “I started drinking more after my wife died. It just made the pain go away for a while. But then I 

fell and broke my hip one night after I had a few.” 

- Provider: “Drinking helped you manage sadness temporarily, but then it started hurting your health.” 

“S”—Summarization: Summarizing is a form of refective listening that ensures that you understand what 

the client has told you. It also helps you move the conversation to the next stage of the MI process. You can 

summarize by saying things like: 

• “Let’s review what we have talked about so far.” 

• “We covered a lot of topics this afternoon. Here’s what it sounds like you’re telling me.” 

• “You talked about your misuse of pain medications and how you have mixed feelings about that. You said 

that you are kind of scared to give them up completely, and the most important reason you can think of 

to taper off them is so you can have a better relationship with your grandson. Tell me a bit more about 

how important it is to have a better relationship with him and how getting off the medication will help 

you achieve that goal.” 

206 Chapter 7 
TIP 26 TREATING SUBSTANCE USE DISORDER 

IN OLDER ADULTS

Chapter 8—Drinking as an Older Adult: 

What Do I Need To Know? 

KEY MESSAGES 

• As you age, alcohol can affect you more 

because: 

- Your body does not process alcohol as well as 

it used to. 

- You’re more likely to be taking medications 

that interact negatively with alcohol. 

- You’re more likely to have health conditions 

that will get worse if you drink alcohol. 

• If you drink too much, reducing or cutting back 

on your alcohol consumption can improve your 

health and well-being. 

• Family members, caregivers, friends, and other 

people in your life can help you quit or cut back 

on drinking. 

• If you need treatment for a drinking problem, a 

range of effective options are available to you. 

• Have hope! Many older adults are able to 

change their drinking habits to improve health 

and well-being. 

Chapter 8 of this Treatment Improvement 

Protocol (TIP) benefts older adults, caregivers, 

and family members. It discusses the effects of 

alcohol and recommended guidelines for drinking 

in older adults. It will help older adults fgure out 

whether they might have a drinking problem and 

how they can reduce or stop using alcohol. It will 

help families and friends recognize when an older 

adult in their lives is misusing alcohol and what they 

can do to support healthy changes in the older 

adult’s drinking habits while also taking care of their 

own needs. 

Older adults use alcohol more than any other 

substance.1229 Drinking carries more risks for older 

adults, and they are at risk even when they drink 

less than younger adults. Physical changes that 

come with age increase sensitivity to alcohol. 

Other common changes in later life—like the 

death of a spouse or close friend, retirement, 

or a move to a different neighborhood or living 

situation—can lead to unhealthy drinking. But 

don’t be discouraged! Older adults in treatment 

can do as well as or even better than younger 

adults do.1230,1231,1232 That said, many older adults 

cut back on or quit drinking without specialized 

treatment.1233,1234,1235 

Organization of Chapter 8 of 

This TIP 

Chapter 8 is for older adults who drink (including 

those who have questions about how much they 

should drink), their families, and their caregivers. 

It provides information about how alcohol can 

affect older adults’ changing bodies, health, and 

life circumstances. 

The frst section of Chapter 8 discusses drinking 

guidelines specifc to older adults. It also lists 

reasons why some older adults misuse alcohol and 

lists some effects and warning signs of misuse. 

The second section describes alcohol’s health 

effects and the ways alcohol and medication 

interact. 

The third section gives tips and cautions for 

addressing your drinking on your own. 

The fourth section describes treatment options. 

The ffth section educates older adults’ families 

and caregivers about alcohol misuse. 

The fnal section lists some helpful resources. A 

more detailed resource guide is in Chapter 9 of this 

TIP. Exhibit 8.1 defnes some key terms you’ll see as 

you read further. 

207 
TIP 26 Treating Substance Use Disorder in Older Adults 

EXHIBIT 8.1. Key Terms 

• Addiction*: The most severe form of substance use disorder (SUD), associated with compulsive or 

uncontrolled use of one or more substances. Addiction is a chronic brain disease that has the potential for 

both recurrence (relapse) and recovery. 

• Alcohol misuse: The use of alcohol in any harmful way, including heavy drinking, binge drinking, and 

alcohol use disorder (AUD). 

• At-risk/high-risk drinking: Drinking alcohol in excessive amounts. This defnition encompasses both 

binge drinking and heavy drinking. Additionally, any alcohol consumption is considered risky when 

carried out by individuals with certain medical conditions that are worsened by alcohol, those taking 

medicine that can interact harmfully with alcohol, those driving a car or engaged in other activities that 

require alertness, or people recovering from AUD.1236,1237 Note that for purposes of this TIP, at-risk drinking 

and high-risk drinking are synonymous and either term is acceptable to describe an older adult’s drinking 

patterns. 

• AUD: A diagnosis that applies to people who have lost control of their drinking, continue to use alcohol 

despite negative consequences, and experience symptoms such as craving and withdrawal. 

• Binge drinking: A drinking pattern that leads to blood alcohol concentration levels of 0.08 grams per 

deciliter or greater. This usually takes place after four or more drinks for women and fve or more drinks 

for men.1238,1239 However, older adults are more sensitive to the effects of alcohol, and treatment providers 

may need to lower these numbers when screening for alcohol misuse.1240 Additionally, other factors such 

as weight, decrease in enzyme activity, and body composition (e.g., amount of muscle tissue present in 

the body) can also affect alcohol absorption rates. 

• Caregivers: Informal caregivers provide unpaid care. They assist others with activities of daily living, 

including health and medical tasks. Informal caregivers may be spouses, partners, family members, 

friends, neighbors, or others who have a signifcant personal relationship with the person who needs 

care. Formal caregivers are paid providers who offer care in one’s home or in a facility.1241 Most older adults 

do not need caregivers and are as able to address their own needs as younger adults, whether or not 

substance misuse is a factor in their lives. 

• Heavy drinking: Consuming fve or more drinks for men and four or more drinks for women in one period 

on each of 5 or more days in the past 30 days.1242 

• Moderate drinking: According to the 2015–2020 Dietary Guidelines for Americans, moderate drinking is 

defned as up to two drinks per day for men and up to one drink per day for women.1243,1244 However, the 

Centers for Disease Control and Prevention (CDC) notes that these numbers apply to any given day and 

are not meant as an average over several days.1245 Additionally, individuals who don’t metabolize alcohol 

well may need to consume even lower quantities. Some people, particularly those with certain alcoholrelated illnesses or engaging in tasks requiring concentration, should not consume alcohol at all. The 

Dietary Guidelines stipulate that those who don’t drink should not begin drinking for any reason.1246 

• Peer support: The use of peer recovery support specialists (for example, someone in recovery who has 

lived experience in addiction plus skills learned in formal training) to provide nonclinical (in other words, 

not requiring training in diagnosis or treatment) recovery support services to individuals in recovery from 

addiction and to their families. 

• Screening: A process for evaluating the possible presence of a specifc problem. The outcome is normally 

a simple yes or no. 

• Substance misuse*: The use of any substance in a manner, situation, amount, or frequency that can 

cause harm to users or to those around them. For some substances or individuals, any use would 

constitute misuse (for example, underage drinking, injection drug use). 

• Substance use disorder*: A medical illness caused by repeated misuse of a substance or substances. 

According to the ffth edition of the Diagnostic and Statistical Manual of Mental Disorders,1247 

Continued on next page 

208 Chapter 8 
Chapter 8—Drinking as an Older Adult: What Do I Need To Know? TIP 26

Continued 

SUDs are characterized by clinically signifcant impairments in health and social function and 

impaired control over substance use. They are diagnosed through assessing cognitive, behavioral, and 

psychological symptoms. SUDs range from mild to severe and from temporary to chronic. They typically 

develop gradually over time with repeated misuse, leading to changes in brain circuits governing 

incentive salience (the ability of substance-associated cues to trigger substance seeking), reward, stress, 

and executive functions like decision making and self-control. Multiple factors infuence whether and how 

rapidly a person will develop an SUD. These factors include the substance itself; the genetic vulnerability 

of the user; and the amount, frequency, and duration of the misuse. Note: A severe SUD is commonly 

called an addiction. 

* The defnitions of all terms marked with an asterisk correspond closely to those given in Facing Addiction in 

America: The Surgeon General’s Report on Alcohol, Drugs, and Health. This resource provides a great deal of useful 

information about substance misuse and its impact on U.S. public health. The report is available online (https://addiction. 

surgeongeneral.gov/sites/default/fles/surgeon-generals-report.pdf). 

Drinking Guidelines and Alcohol 

Misuse in Older Adults 

What Is Moderate Drinking? 

The Dietary Guidelines defne moderate drinking 

as up to one drink a day for women and up to 

two drinks a day for men. Importantly, these 

numbers apply to any given day and are not meant 

to be interpreted as averages over numerous 

days.1248,1249,1250 

To make sure that your drinking is not high 

risk, avoid binge drinking. Binge drinking means 

drinking more than three drinks (if you’re a woman) 

or four drinks (if you’re a man) per day. However, 

given the body’s decreased ability to absorb 

alcohol with age, you may need to limit yourself to 

fewer drinks to avoid binge drinking.1251 

Don’t drink when you will be driving a car or 

boat or doing other activities that require you to 

be coordinated and alert. 

Heavy or binge drinking at any age harms the 

brain.1252 These patterns of drinking slow down 

communication among brain cells. Over time, 

heavy or binge drinking also shrinks the brain and 

changes it in other ways that negatively affect how 

it works. These changes can affect behavior; cause 

dementia; and worsen memory, coordination, and 

the ability to plan and learn.1253,1254 

For some older adults, any amount of alcohol is 

risky.1255 Don’t drink if you:1256,1257 

• Have a chronic medical condition that alcohol 

can worsen, like diabetes or heart disease.1258,1259 

• Are recovering from AUD.1260 

• Take medications to help you worry less or 

sleep. People often take a type of prescription 

medication called benzodiazepines to treat 

anxiety or sleeplessness.1261 

• Take opioid pain relievers, which healthcare 

providers may prescribe for severe or chronic 

pain.1262 

• Take other prescription or over-the-counter 

(OTC) medications that interact negatively with 

alcohol—that is, they may cause serious harmful 

effects if you take them and also drink alcohol. 

For more information about how various 

medications interact with alcohol, see the “What 

Medications Interact With Alcohol?” section. 

Why Do Experts Suggest Lower Limits for 

Older Adults? 

The two main reasons for lower drinking limits are: 

• You’re more likely than younger adults to 

experience harmful alcohol–medication 

interactions. 

• As you age, your body responds differently to 

alcohol. 

Chapter 8 209 
TIP 26 Treating Substance Use Disorder in Older Adults 

You may have already noticed that you feel the age-related changes affect how your body handles 

effects of alcohol sooner than you used to, even alcohol.1263,1264,1265 Exhibit 8.2 shows some of these 

if you don’t take any medications. That’s because age-related changes. 

EXHIBIT 8.2. How Aging Affects the Body’s Response to 

Alcohol1266,1267,1268,1269,1270,1271 

DOES ALCOHOL USE OR MISUSE AFFECT OLDER WOMEN DIFFERENTLY THAN IT 

AFFECTS OLDER MEN? 

If an older man and woman of about the same size and age drink the same amount of alcohol in the same 

amount of time, the woman will get drunk sooner. That’s because the woman probably:1272,1273,1274 

• Has less body water to dilute the alcohol. 

• Has less lean muscle mass to absorb the alcohol. 

• Has less of the enzyme that breaks down alcohol. 

This means that older women who misuse alcohol over time are likely to have more alcohol-related 

health problems than older men who do so. These problems will likely appear sooner and be more severe.1275 

Compared with older men, older women are also more likely to:1276,1277,1278 

• Live alone longer, increasing their risk of drinking to cope with loneliness. 

• Be less fnancially secure, increasing their risk of drinking to cope with fnancial worries. 

• Take benzodiazepines, which have particularly harmful interactions with alcohol. (See the text box 

“Benzodiazepine Alert: Cautions for Older Adults Who Drink.”) 

Nevertheless, research suggests that older women respond to alcohol treatment better than older men 

do.1279 

210 Chapter 8 
Chapter 8—Drinking as an Older Adult: What Do I Need To Know? TIP 26

What Counts as One Drink? 

To help you stay within the recommended limits, 

you need to know what counts as one drink.1280 It 

may be less than you think. In the United States, a 

standard drink contains 14 grams of pure alcohol, 

or about 0.6 fuid ounces. Exhibit 8.3 shows

standard drink amounts by beverage type. 

EXHIBIT 8.3. What Is a Standard Drink? 

Image adapted from material in the public domain.1281 

Alcohol content can vary by type of drink. Read 

container labels to see how much alcohol is in a 

serving. 

What if you have a cocktail or mixed drink that 

combines a few different kinds of alcohol? You 

can fgure out about how many standard drinks 

you’re really consuming by using the Cocktail 

Content Calculator (www.rethinkingdrinking.niaaa. 

nih.gov/Tools/Calculators/Cocktail-Calculator. 

aspx) on the National Institute on Alcohol Abuse 

and Alcoholism’s (NIAAA) Rethinking Drinking 

website. The calculator gives the alcohol content 

and standard drink equivalent for several common 

mixed drinks. 

To keep track of your drinking, it helps to know the 

number of standard drinks in a bottle of wine or 

other type of alcohol container. NIAAA’s Drink Size 

Calculator tells you how many standard servings 

are in many common kinds of beverage containers. 

It shows this information by type and strength of 

beverage (www.rethinkingdrinking.niaaa.nih.gov/ 

Tools/Calculators/Drink-Size-Calculator.aspx). 

Chapter 8 211 
TIP 26

ACTIVITY: HOW MUCH ARE YOU 

REALLY DRINKING? 

For this activity, you’ll need: 

• Two glasses you typically use for drinking 

alcohol (the glasses must be identical). 

• A measuring cup (make sure it’s for liquids, not 

dry ingredients). 

• The “What Is a Standard Drink?” diagram. 

Using water instead of alcohol, fll one glass with 

what you think of as a single serving. Find in 

Exhibit 8.3 the standard drink amount for your 

type of drink. Fill the measuring cup with that 

amount of water, then pour it into the second 

glass. Compare the amounts in the two glasses. 

What Can Cause Older Adults To Misuse 

Alcohol? 

Alcohol misuse can begin or resume at any age. 

People who misuse alcohol may not always 

realize they are doing so. Stressful life changes 

that may lead to alcohol misuse in older adults 

include:1282,1283,1284,1285,1286,1287 

• The death of a spouse, partner, child, or close 

friend. 

• Increasing isolation. 

• Increasing disability or a chronic illness. 

• Forced or unplanned retirement.1288 

• A change of residence. 

• Increased fnancial strain.1289 

• Boredom; lack of meaningful activity. 

• Physical separation from adult children. 

Spending time with people who drink is linked 

with alcohol misuse. For example, older adults 

may begin drinking too much after moving to a 

retirement community where drinking is a big part 

of socializing.1290 

If your drinking patterns worsen in response to 

a change in your life, take action. The sections 

“How Can I Quit or Cut Back on My Own?” and 

“How Do I Talk to My Healthcare Provider About 

Alcohol Use?” can help you. 

Treating Substance Use Disorder in Older Adults 

Some older adults use alcohol to cope with 

physical or emotional problems.1291 This is 

called self-medicating. Drinking to self-medicate 

can lead to alcohol misuse1292 and can actually 

worsen the problem instead of helping. For 

example, drinking to cope with depression can 

make symptoms of depression worse.1293 Similarly, 

drinking to cope with sleep problems can worsen 

sleep by reducing time spent in deep sleep and by 

causing snoring and other problems that interfere 

with sleep.1294,1295 

Also, what was low-risk drinking when you were a 

younger adult can become alcohol misuse as you 

age, simply because your body does not handle 

alcohol as well as it used to. Refer back to Exhibit 

8.2. 

Healthcare providers sometimes mistake AUD for 

other conditions that are common in older adults. 

Some providers wrongly believe that older adults 

are not likely to develop AUD. These are good 

reasons for you to educate yourself about alcohol 

misuse in older adults. 

How Can I Tell Whether I’m Misusing 

Alcohol? 

Ask yourself whether any of these possible signs 

and symptoms of alcohol misuse apply to you: 

• Cognitive symptoms: 

- Feeling confused after drinking1296 

- Having memory problems1297 

• Physical and mental symptoms: 

- Having problems with balance1298 

- Falling after drinking1299 

- Feeling clumsy1300 

- Experiencing incontinence1301 

- Slurring words1302 

- Continuing to drink even if you take 

medication that interacts negatively with 

alcohol 

- Continuing to drink even if you have a 

medical condition made worse by alcohol 

212 Chapter 8 
Chapter 8—Drinking as an Older Adult: What Do I Need To Know? TIP 26

• Social symptoms: 

- Having relatives or friends who are concerned 

about your drinking1303 

- Losing friends because of your drinking1304 

• Behavioral symptoms: 

- Bathing or showering infrequently1305 

- Taking less care of your appearance1306 

- Taking less care of your living space1307 

- Spending too much money on alcohol1308 

- Skipping meals because of drinking1309 

- Putting oneself in risky situations (like driving, 

having unsafe sex) while drinking1310 

If you have experienced or are experiencing 

any of these warning signs, consider speaking 

with your healthcare provider or an addiction 

specialist about your drinking. Also see “What 

Should I Expect During My Medical Appointment?” 

and “What Are My Options for Specialized AUD 

Treatment?” 

Contact your healthcare provider if you: 

• Drink despite taking one or more medications 

that have severe interactions with alcohol. 

• Have had symptoms of alcohol withdrawal. See 

the text box titled “Warning Signs of Alcohol 

Withdrawal” for more information. 

Alcohol’s Efects on Older Adult 

Health 

Can Drinking Cause or Worsen Health 

Conditions? 

Alcohol misuse causes or increases your risk of 

developing more than 200 health conditions.1311 

Drinking also worsens many health conditions 

common among older adults, including 

diabetes, high blood pressure, osteoporosis, 

pain, sleep problems, stroke, and urinary 

incontinence.1312,1313,1314,1315,1316 

Alcohol misuse can also make it harder for you to 

manage any chronic medical conditions you already 

have. For example, you may skip meals, forget to 

exercise, or mix up medications. 

Alcohol misuse may put you and others at risk of 

injuries and other harms, like HIV. Harms linked 

with alcohol misuse by older adults commonly 

result from falls, motor vehicle crashes, and suicide 

attempts.1317,1318,1319 Alcohol misuse can also lead to 

risky sexual behavior (such as having unprotected 

sex with a new partner), which can spread HIV or 

other sexually transmitted diseases.1320,1321,1322,1323 

What About News Reports That Say Light 

or Moderate Drinking Is Healthy? 

Don’t base decisions about drinking on news 

reports of alcohol’s benefts. News stories don’t 

always clarify whether a study found that alcohol 

causes or is simply associated with a health 

beneft. If a study shows that alcohol is only 

associated with a health beneft, other factors 

like genetics or income level may have also 

played a role.1324 The report may ignore a study’s 

limitations.1325 For example, the results of a study 

with only younger participants may not apply to 

older adults. 

You and your healthcare provider should weigh 

the possible benefts of light or moderate 

drinking with the known negative effects of 

alcohol use, especially if you: 

• Take medication that interacts badly with 

alcohol. 

• Have a history of alcohol misuse. 

• Have, or are at risk for, a medical condition 

worsened by alcohol. 

Exhibit 8.4 presents just some of the health 

conditions linked to alcohol misuse. 

Chapter 8 213 
TIP 26 Treating Substance Use Disorder in Older Adults 

EXHIBIT 8.4. Some Health Risks of Alcohol 

Misuse1326,1327,1328,1329,1330,1331,1332,1333,1334,1335 

What Medications Interact With Alcohol? 

Many older adults who drink regularly take 

prescription medications that interact harmfully 

with alcohol.1336,1337 Drinking makes some 

medications less effective and can make others 

more potent. The results can be unpleasant, 

dangerous, and even deadly.1338 

Alcohol and medication can make a dangerous 

mix, even if you do not consume them at the 

same time.1339 

If you drink, ask your healthcare provider 

whether alcohol can interact harmfully with any 

of your medications. Negative interactions may 

occur even if you don’t see signs or symptoms like 

vomiting or dizziness right away. Serious effects of 

alcohol–medication interactions, like liver damage, 

can develop “silently” over time.1340 

Dietary supplements (e.g., vitamins, herbal 

products) and OTC medications (like aspirin) 

can interact harmfully with alcohol. Talk to 

your healthcare provider if you take any of these 

products and drink.1341 

214 Chapter 8 
Chapter 8—Drinking as an Older Adult: What Do I Need To Know? TIP 26

ACTIVITY: CHECK YOUR MEDICATIONS FOR ALCOHOL INTERACTIONS 

Check labels on prescription bottles for warnings about drinking while taking the medication. 

If the medication came with a printed “Patient Package Insert” or “Medication Guide,” check for 

additional warnings on alcohol use. If you have questions about your medication and alcohol use, 

talk to your pharmacist or healthcare provider. 

Check the “Drug Facts” labeling for your OTC medications: Look under “Warnings” for any 

mentions of alcohol. 

Information that comes with prescription and OTC medications usually does not include 

warnings specifcally for older adults. If you’re unsure whether you can drink while taking a 

medication, be safe and don’t drink.1342 

Exhibit 8.5 lists 12 medications that interact 

badly with alcohol. Many older adults take these 

and similar medications. This list is provided 

for illustration only. Other medications for the 

same condition may have different interactions, 

and many conditions are not included. For more 

comprehensive lists, see the entries under “Alcohol 

and Medication Interactions” in the “Resources” 

section at the end of this Chapter. 

EXHIBIT 8.5. Common Prescription Medication–Alcohol Interactions1343,1344 

CONDITION 

MEDICATION 

EXAMPLE POSSIBLE INTERACTIONS WITH ALCOHOL 

Anxiety Clonazepam Increased dizziness, drowsiness, and memory problems; decreased 

coordination; increased risk of fatal overdose1345 

Arthritis Naproxen Ulcers, stomach bleeding, liver damage 

Blood clots Warfarin Internal bleeding with occasional or heavy drinking; increased risk of 

blood clots, strokes, or heart attacks with heavy drinking 

Cough 

Depression 

Dextromethorphan 

Sertraline 

Drowsiness, dizziness, diffculty concentrating,1346 higher overdose risk 

Increased depression, drowsiness, dizziness 

Diabetes Metformin Very low blood sugar (symptoms: dizziness, drowsiness, confusion), 

lactic acidosis (symptoms: muscle pain, slow heartrate, dizziness) 

Heartburn Ranitidine Rapid heartbeat; increased alcohol levels1347 

High blood 

pressure 

Lisinopril Dizziness, drowsiness, fainting, weakness from low blood pressure,1348 

heart problems such as changes in the heart’s normal rhythm 

High 

cholesterol 

Simvastatin Liver damage 

Insomnia Zolpidem Drowsiness, dizziness, sleepiness, slowed or diffcult breathing, loss of 

coordination, unusual behavior, memory problems 

Pain Ibuprofen Stomach bleeding and ulcers 

Pain (severe) Oxycodone Drowsiness, dizziness, slowed or diffcult breathing, loss of 

coordination, unusual behavior, memory problems, increased risk for 

fatal overdose 

Chapter 8 215 
TIP 26

BENZODIAZEPINE ALERT: CAUTIONS 

FOR OLDER ADULTS WHO DRINK 

Prescription benzodiazepines mainly treat anxiety 

or insomnia.1349 Common benzodiazepines 

include: 

• Alprazolam (Xanax, Xanax XR). 

• Diazepam (e.g., Valium, Diastat). 

• Clonazepam (Klonopin). 

• Lorazepam (Ativan). 

Drinking while taking benzodiazepines puts 

you at great risk. Alcohol and benzodiazepines 

slow down critical bodily functions like breathing 

and heartbeat. Combining them can cause 

blackouts and even death.1350,1351 

If you drink alcohol at all and take 

benzodiazepines, tell your healthcare provider. 

Also ask whether you should try a different 

approach to treating the condition for which 

you take the benzodiazepines. If you and your 

healthcare provider decide you should keep 

taking the medication, even at a reduced dosage, 

that’s a good reason for you to quit drinking. 

Don’t change benzodiazepine use on your own. 

You need medical advice when stopping or 

reducing benzodiazepine use. Your healthcare 

provider should give you a schedule to slowly 

reduce (taper) your dosage. Tapering helps avoid 

benzodiazepine withdrawal. Tapering also makes 

it less likely that the symptoms the medication 

treated will return.1352 Many older adults end or 

reduce benzodiazepine use through tapering 

alone, but you may also need counseling, such 

as cognitive–behavioral therapy (CBT), to achieve 

this goal.1353 

Here are some more tips on avoiding negative 

interactions between alcohol and your medications: 

• Ask your healthcare provider or pharmacist 

whether a newly prescribed medication interacts 

harmfully with alcohol, even if you don’t drink 

often. 

Treating Substance Use Disorder in Older Adults 

• Never take prescription medication offered to 

you by a family member or a friend, especially 

if you drink. The medication was prescribed with 

someone else’s medical situation in mind, not 

yours. Taking it could harm you. In some cases, 

sharing prescription medications is illegal. 

• Check the ingredients of cough and cold 

medications and laxatives, which may contain 

alcohol. 

OPIOID ALERT: CAUTIONS FOR 

OLDER ADULTS WHO DRINK 

Prescription opioid medications mainly treat 

severe or ongoing pain. Common opioid 

medications include: 

• Codeine. 

• Meperidine (Demerol). 

• Hydrocodone combined with acetaminophen 

(e.g., Vicodin, Lorcet). 

• Oxycodone (e.g., OxyContin). 

• Oxycodone combined with acetaminophen 

(e.g., Percocet). 

If you take opioid pain relievers and also drink 

alcohol, you put yourself at especially high 

risk for overdose, confusion, unusual behavior, 

and serious injury.1354,1355 Let your healthcare 

provider know immediately if you take 

opioid pain relievers and you drink, even just 

occasionally. 

You and the healthcare provider who prescribed 

the opioids should discuss whether to treat 

your pain in a different way. Keep in mind that 

many alternative pain medications also interact 

harmfully with alcohol.1356 

If only prescription opioids control your pain, 

you need to quit drinking while taking them. 

Talk with your provider about how to stop 

drinking safely. 

216 Chapter 8 
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Chapter 8—Drinking as an Older Adult: What Do I Need To Know? 

Tips and Cautions for Addressing 

Drinking on Your Own 

Is Alcohol Withdrawal a Concern? 

If you drink more than is recommended for older 

adults—especially if you drink heavily or have 

been drinking regularly for a long time—don’t 

sharply cut back on your drinking or suddenly 

quit on your own. Get medical advice frst. Your 

body may be dependent on alcohol, so you could 

experience withdrawal if you go without drinking 

for longer than usual.1357 Severe alcohol withdrawal 

can be deadly if not treated right away in a 

hospital.1358,1359 

WARNING SIGNS OF ALCOHOL 

WITHDRAWAL 

Symptoms may occur up to 7 days after your 

last drink. They may vary in severity1360 and 

include:1361,1362,1363,1364 

• Agitation. • Increased pulse rate. 

• Anxiety. • Insomnia. 

• Diarrhea. • Nausea. 

• Headache. • Sweating. 

• Raised blood • Tremor. 

pressure. 

Delirium tremens (also known as DTs) is the 

most severe form of alcohol withdrawal.1365 It can 

be fatal and must be treated in a hospital. It 

can develop 2 to 10 days after the last drink.1366 

Possible symptoms include rapid heart rate, 

intense tremor, extreme agitation, confusion, 

fever, drenching sweats, and coma.1367 

How Can I Quit or Cut Back on My Own? 

Consider Why You Want To Change Your 

Drinking Habits 

Think about how drinking conficts with your top 

values—values you want your life to refect, like 

independence, generosity, health, and honesty. Try 

these value-identifying exercises available online: 

• www.smartrecovery.org/smart-recovery-toolbox/ 

values-and-goals-clarifcation 

• https://harvard.az1.qualtrics.com/jfe/form/ 

SV_e35whN7tkXtvlHv (interactive) 

• www.therapistaid.com/worksheets/valuesclarifcation.pdf 

Feel free to add any of your own top values that 

you don’t see listed in these exercises. Here are 

just a few possibilities: alertness, dependability, 

and empathy. The activity below will help you 

understand the relationship between drinking and 

your top values. 

ACTIVITY: DOES YOUR DRINKING 

CONFLICT WITH YOUR TOP VALUES? 

Think about your top values in life—the principles, 

qualities, and beliefs most important to you 

that you want your life to refect. Does drinking 

confict with any of your top values? If so: 

Which values does drinking confict with? 

How does drinking confict with these values? 

How does this confict keep you from living out 

your top values in your daily life? Be as specifc 

as possible. 

Chapter 8 217 
TIP 26

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___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

Treating Substance Use Disorder in Older Adults 

Make a Plan for Change answers to the “Does Your Drinking Confict With 

Your Top Values?” activity. Consider frst reading Writing a plan for change (Exhibit 8.6) will help the “How Can I Get Support From Family and you set and keep goals for cutting back or quitting Friends?” section. drinking. Before making a plan, look at your 

EXHIBIT 8.6. Writing a Change Plan 

Goal (pick one): 

____ I want to drink no more than ____ drink(s) per day and no more than ____ drink(s) per week. 

(See “What Is Moderate Drinking?” before flling out.) 

____ I want to stop drinking. 

I will begin following my plan on this date: ________________________. 

My most important reasons for changing my drinking are:_________________________________________________ 

The situations where I may be most tempted to drink are:_________________________________________________ 

Some things I will do and say to handle these situations are:_______________________________________________ 

The people who can help me stick to my goal, and the ways they can help, are:____________________________ 

Adapted from material in the public domain.1368 

Pace Yourself When You Drink 

Your main goal is to cut back and slow down 

your alcohol consumption when you drink. 

Try:1369,1370,1371 

• Putting your drink down between sips. 

• Holding something in your hand besides your 

drink between sips. 

• Following an alcoholic drink with a nonalcoholic 

one. 

• Eating something while you drink—but avoid 

foods that make you thirsty. 

Track Your Drinking 

Using a drinking tracker card (Exhibit 8.7), write 

down how many drinks you have each day. This 

will help you keep better track of your drinking as 

you work to cut back or quit.1372 

218 Chapter 8 
TIP 26

GOAL: No more than ____ drinks on any day and ____ per week.

Week 

starting Su M T W Th F Sa Total

____/____

____/____

____/____

____/____

Chapter 8—Drinking as an Older Adult: What Do I Need To Know? 

EXHIBIT 8.7. Four-Week Drinking Tracker Card 

Reprinted from material in the public domain.1373 

Find Alternatives to Drinking 

You may drink out of habit, boredom, or loneliness, 

or when you’re with friends who drink. Try to fnd 

other activities that appeal to you and ft your 

abilities and budget. Here are some ideas: 

• Participate in recreation programs at your local 

community recreation center or senior center. 

(Be sure to consult with your healthcare provider 

before increasing your physical activity.) 

• Put your experience and gifts to use by 

volunteering at a nonproft organization or a 

school. 

• Join a book discussion group hosted by a local 

library or bookstore. 

Think about what your interests are and how you 

can make them a bigger part of your life. 

Have a Plan for Dealing With Challenging 

Situations 

Some occasions, like holiday parties or 

anniversaries of losses, may tempt you to drink or 

to drink too much. So may being around people or 

places that remind you of drinking. You can fght 

temptation better if you have a plan for handling 

such situations.1374 For example, you could plan to 

spend the evening of a diffcult anniversary with an 

understanding friend. A written plan (Exhibit 8.6) 

can help you remember what steps to take to avoid 

temptation. 

Join a Mutual-Help Group 

Another action you can take is to join a mutualhelp group. Members of these groups support 

each other in their recovery from the misuse of 

alcohol and other substances. Mutual-help groups 

meet regularly, are free, and usually take place in 

community spaces, such as houses of worship and 

schools. 

Some groups follow the 12-Step approach, 

which has abstinence as its goal.1375 Alcoholics 

Anonymous (AA) was the frst 12-Step group. To 

fnd a meeting, go to www.aa.org/pages/en_US/ 

fnd-aa-resources or look in your local newspaper 

or community newsletter. Some communities have 

meetings designated as senior friendly.1376 If you 

have diffculty getting around, you can check out 

AA’s online and telephone meetings (https://aaintergroup.org/directory.php). 

Chapter 8 219 
TIP 26 Treating Substance Use Disorder in Older Adults 

For older adults-only meetings, look into Seniors 

In Sobriety (SIS), which is part of AA. The SIS 

website (www.seniorsinsobriety.com) provides a list 

of meetings. 

Alternatives to traditional 12-Step organizations 

include: 

• SMART (Self-Management and Recovery 

Training) Recovery (www.smartrecovery.org). 

• Women for Sobriety (https://womenforsobriety. 

org). 

• Secular Organizations for Sobriety (www. 

sossobriety.org). 

• Moderation Management (www.moderation.org). 

You can fnd faith-based mutual-help organizations 

at www.recoverymonth.gov/resource-category/ 

faith-based. 

Consider dropping by a mutual-help group 

meeting to see whether it’s a good ft for you. Call 

the local offce or contact person frst to make sure 

that the meeting is open to the public. If you want 

to attend a meeting but feel a little uncomfortable 

with the idea, think about going with a friend. 

MOBILE APPS 

If you have a smartphone or tablet, you have 

access to many free mobile apps that can 

help you overcome alcohol misuse, including 

addiction. Common features of these apps 

include:1377,1378 

• Counters showing how long you’ve been 

alcohol free (some go down to the minute or 

second). 

• Calculators showing how much money and 

time you’ve saved by not drinking. 

• Support-meeting locators. 

• Community forums for sharing information and 

support anonymously. 

• Daily inspirational messages. 

• Progress notifcations. 

• Virtual rewards, like “coins” or “trophies,” for 

milestones achieved. 

Examples of such apps are I Am Sober (https:// 

iamsoberapp.com) and Nomo - Sobriety Clocks 

(https://saynomo.com).1379 

When It’s Time To Get Help 

How Do I Talk to My Healthcare Provider 

About Alcohol Use? 

• If you have questions about your alcohol use 

or think you need help addressing it, you may 

need to raise the subject with your healthcare 

provider yourself. That’s because some 

healthcare providers: 

- Feel uncomfortable asking an older adult 

about his or her alcohol use.1380 

- May mistake an older adult’s alcohol misuse 

for another health condition.1381 

- Believe there’s no point in encouraging an 

older adult to stop or reduce drinking.1382 

Here are some ideas for starting the 

conversation: 

• “I’m on several medications, so is it a problem 

that I have a couple of drinks in the evening?” 

• “It takes me awhile to fall asleep, so I have 

a nightcap. Is that okay, given my medical 

conditions?” 

• “My wife says I drink too much at parties. I’d like 

to know what you think.” 

Whether you raise the subject of alcohol use or 

your healthcare provider does, be honest about 

how much and how often you drink. Your health 

and even your life may depend on it. 

What Should I Expect During My Medical 

Appointment? 

Screening 

If you bring up alcohol concerns with your 

healthcare provider, he or she will likely 

ask you to answer a screening instrument 

or questionnaire. The most common alcohol 

screening instruments have just 1 to 10 questions. 

Your healthcare provider may ask you the questions 

directly, or you may answer them on paper or on a 

computer or tablet. Examples of alcohol screening 

questions are “Have you ever felt you should cut 

down on your drinking?” and “Do you usually take 

a drink to calm your nerves?”1383,1384 

220 Chapter 8 
Chapter 8—Drinking as an Older Adult: What Do I Need To Know? TIP 26

Screening helps your healthcare provider decide 

whether to look further into your alcohol use. It 

will also help you and your healthcare provider 

decide whether you may need specialized 

treatment to address alcohol misuse. 

Assessment 

If screening suggests that you misuse alcohol, 

your healthcare provider will probably do an 

“assessment” or refer you to a specialist who 

can do it. Whoever does the assessment will ask 

you more questions about how much and how 

often you drink. The assessment will help your 

healthcare provider understand any negative 

effects of your drinking, your drinking history, 

and any previous treatment you may have had 

for misuse of alcohol or other substances. Other 

assessment questions may focus on your living 

situation and degree of support from family and 

friends.1385 You will likely have a physical exam, and 

you may also have lab tests to check for alcohol 

use and any resulting damage to your liver or other 

organs. 

What Typically Happens Next? 

During this or a follow-up visit, your healthcare 

provider should give you more information and 

feedback about your drinking. The feedback will 

help you understand the results of the assessment 

and lab tests. Any other information you receive 

may help explain the risks and health effects of 

your alcohol use. Your healthcare provider may 

diagnose you with AUD if you meet certain criteria. 

CAN MEDICATION TREAT AUD? 

The Food and Drug Administration has approved three medications for treating AUD.1386 All three 

require a prescription. If you receive a prescription for any of them, you’ll need to take the medication for 

at least 3 months1387 and probably longer.1388 Although these medications don’t work for everyone, they do 

appear to be as safe and effective for older adults as they are for younger adults.1389 

Not all healthcare providers prescribe these medications. You may need to see an addiction specialist or 

psychiatrist if you want to explore this approach to treatment. Most people who take medication for AUD do 

better if they receive counseling too, especially early in treatment.1390 

Some people incorrectly regard taking medication for AUD as substituting one addiction for another. You 

may even encounter this attitude in certain addiction treatment programs.1391 However, none of these 

medications is addictive. Using them is like taking medication for any other chronic illness, like 

diabetes or asthma.1392 

You may also receive a referral to an addiction 

specialist or an addiction treatment facility, 

depending on your level of alcohol use and 

health status.1393 You should seek someone who 

specializes in addiction treatment with older adults 

who have been using alcohol for a long time or 

who have health conditions that could complicate 

treatment for alcohol misuse. Your healthcare 

provider may also refer you to a mutual-help 

group like AA.1394 

What Are My Options for Specialized 

AUD Treatment? 

If you receive specialized treatment for AUD, you 

may move from one setting to another as the 

treatment proceeds. Whatever the setting, you will 

usually get counseling and education about alcohol 

misuse. Personal preference, availability, and 

eligibility requirements can affect your decision on 

where to get treatment. Cost can also affect your 

decision. Check with your health insurer to see how 

much coverage it provides for the treatment option 

you seek. 

The following list describes the main specialized 

treatment options: 

• Regular outpatient treatment typically consists 

of individual therapy, group therapy, or both, 

provided by a trained therapist. Additional 

services, such as family therapy and connection 

Chapter 8 221 
TIP 26 Treating Substance Use Disorder in Older Adults 

RESOURCE ALERT: TREATMENT 

LOCATOR FOR VETERANS 

If you are a veteran or are covered by health 

benefts for veterans, the Department of Veterans 

Affairs (VA) can help you fnd VA services close to 

you. Use the VA SUD Program Locator at www. 

va.gov/directory/guide/SUD.asp for your search. 

to mutual-help groups, may be included.1395 

Some outpatient treatment is provided by 

healthcare providers or addiction specialists. In 

addition to doing assessments and diagnosing 

AUD, these specialists may provide counseling 

and prescribe medications for AUD. Outpatient 

programs differ a lot in how long they last and 

how intensive they are. 

• Medically supervised withdrawal is a process 

during which healthcare providers monitor 

you as your body clears itself of alcohol. This 

process is sometimes called detoxifcation, or 

“detox.” In medically supervised withdrawal, 

medical staff monitor and treat withdrawal 

symptoms and manage other health conditions 

as needed.1396 Medically supervised withdrawal 

in an inpatient setting, such as a hospital, is 

normally recommended for older adults.1397 If 

you undergo medically supervised withdrawal, 

you may receive referrals from the medical staff 

to addiction counselors or other behavioral 

health service providers for continuing 

treatment of AUD. If no referral is offered, 

you can ask for one or explore other options 

for continuing treatment or recovery support, 

such as attending AA meetings or using a 

treatment locator like FindTreatment.gov or the 

Substance Abuse and Mental Health Services 

Administration’s (SAMHSA) National Helpline 

(1-800-662-HELP). 

• Intensive outpatient programs typically 

provide services at least 3 days a week, for 

at least 2 or 3 hours each day (or evening).1398 

These services can include group and individual 

counseling, family therapy, medical and mental 

health evaluations, medication, and education 

about addiction and coping skills.1399,1400 These 

programs may take place at hospitals, mental 

health clinics, or offce-based private practices. 

• Partial hospitalization programs typically run 

4 to 6 hours a day, 3 to 7 days a week. They 

are also called day treatment programs. As with 

intensive outpatient programs, you do not stay 

overnight for treatment. These programs often 

treat addiction and mental disorders at the same 

time.1401 

• Specialized residential treatment facilities 

usually offer group and individual therapy, 

recreational activities, and mutual-help 

group meetings. Consider this type of facility 

if you would have diffculty getting to and 

from outpatient treatment or if you need 

more counseling, medical services, or ongoing 

guidance than an outpatient program would 

offer. 

WHAT ARE RESIDENTIAL TREATMENT 

FACILITIES? 

These facilities range from small group homes 

or recovery houses with few staff and services 

to specialized facilities with intensive, highly 

structured programs that keep physicians and 

nurses on staff. People staying in group homes or 

recovery houses may get outpatient treatment 

at another facility. A residential facility may be a 

good option for you if you think you’d do better 

in treatment while away from your home or 

neighborhood.1402 

How Do I Pick a Treatment Program? 

NIAAA’s Alcohol Treatment Navigator recommends 

10 general questions to ask when looking for a 

quality alcohol treatment program. The Navigator 

is available online (https://alcoholtreatment. 

niaaa.nih.gov/how-to-fnd-alcohol-treatment/10-

questions-for-alcohol-treatment-programs). 

222 Chapter 8 
Chapter 8—Drinking as an Older Adult: What Do I Need To Know? TIP 26

Think about the issues you most want help with in 

treatment. Ask the programs you’re considering 

whether they address these issues. You may also 

want to ask:1403 

• Does the program focus just on older adults or 

have a special track or groups for older adults? 

• Does the program cover topics like grief, loss, 

and isolation? 

• Can an older adult who uses a wheelchair/ 

walker/cane easily enter and move around the 

facility? 

• What modifcations will the program make for 

older adults with vision/hearing problems? 

• Do I need my own transportation to get there? 

If you can’t fnd a program just for older adults 

even though that’s what you want, consider one 

that mixes age groups. Research shows that older 

adults can also do well in these programs.1404,1405 

If possible, take tours of the facilities that you are 

considering. 

RESOURCE ALERT: SAMHSA’S FREE NATIONAL HELPLINE 

SAMHSA’s free National Helpline at 1-800-662-HELP (4357) can refer you to SUD treatment facilities that 

accept Medicare or Medicaid. If you are uninsured, check this SAMHSA directory for the agency in your state 

to contact about possible help with paying for addiction services: www.samhsa.gov/sites/default/fles/ssadirectory-01212020.pdf. 

COMMON TYPES OF THERAPY 

As part of inpatient or outpatient treatment, you’ll likely participate in one or more forms of therapy to 

help you address the feelings and behaviors that led to your alcohol misuse. Some of the most common 

therapies are briefy described below. Often, two or more of these therapies are used together.1406,1407 

Acceptance and commitment therapy encourages people to live a satisfying life by accepting losses that 

are fnal, reconnecting with their values, and working toward goals that refect those values.1408 

Example: Through therapy, a man who began drinking heavily alone after his wife’s death recognizes 

that drinking conficts with the value he places on being an involved grandfather. He could enter alcohol 

treatment with the goal of becoming abstinent so that he can spend more time with his granddaughter. 

Behavioral couples therapy (BCT) seeks to encourage abstinence in someone who misuses substances by 

improving his or her relationship with a spouse or partner through better communication, shared activities, 

and positive reinforcement. The spouse or partner also participates in the therapy. 

Example: Through BCT, a husband agrees to discuss his wife’s drinking only during a set time each day, and 

both he and she agree to end the discussion with words of appreciation for each other.1409 

CBT involves working with a therapist to identify and change unhelpful thought processes that trigger 

alcohol misuse and to develop healthier behaviors to replace drinking.1410,1411 

Example: A man worries that he won’t ft in with his golf group if he stops drinking with them after games. 

After talking about his beliefs and thoughts with his therapist, he could experiment with having only 

nonalcoholic drinks after games and realize that he’s not bothered by his golf partners’ reactions. 

Continued on next page 

Chapter 8 223 
TIP 26 Treating Substance Use Disorder in Older Adults 

Continued 

Coping skills therapy focuses on dealing with diffcult thoughts (including cravings), emotions, and 

situations in ways that don’t involve alcohol. Goals include learning how to manage anger and stress, 

become more assertive, and avoid people and places that encourage drinking.1412 

Example: A woman who drinks after phone calls with her argumentative brother might role-play with a 

therapist how to change the subject during an argument or limit the length of calls. 

Family therapy ideally involves the entire family of a person in treatment for AUD and seeks to improve 

how family members relate to each other. The goals are to support both the recovery of the individual in 

treatment and the family’s well-being.1413 

Example: Through family therapy, a widow who had avoided interacting with her two adult children 

because of her secret alcohol misuse could work on repairing her relationships with them. They in turn 

could become more understanding by learning how she drank to cope with their father’s death. 

Mindfulness-based relapse prevention (MBRP) is a group therapy approach that combines teaching 

mindful meditation practices and traditional relapse prevention techniques, such as how to refuse drinks. 

Mindfulness helps you accept awareness of impulses to drink and develop the ability not to act on them.1414 

Example: Through MBRP, a woman who used to unwind from her job by drinking heavily at home after 

work could instead use breathing techniques and guided meditations on audiotapes to calm her mind. 

Motivational interviewing is an approach for overcoming unhealthy habits in which the therapist helps the 

client explore and strengthen the desire for change, and then develop and act on a plan for change.1415 

Example: A man who takes heart medication and socializes mainly at his independent living facility’s daily 

happy hour could, through motivational interviewing, decide that he doesn’t want to risk a medication– 

alcohol interaction. He could do his socializing instead after the facility’s nightly movie showing. 

Relapse prevention therapy helps people recognize and plan to respond constructively to high-risk 

situations for, or warning signs of, a return to alcohol use. 

Example: A woman at risk of drinking when alone at night could work with a therapist to fnd activities to 

do instead of drinking, such as coloring or scrapbooking. 

How Can I Get Support From Family and 

Friends? 

Don’t be embarrassed or shy about involving 

supportive family members and friends in your 

effort to quit or cut back on drinking. They will 

probably want to help, especially if they have 

already told you they are concerned about your 

drinking. Consider asking them to:1416,1417,1418 

• Avoid drinking in front of you. 

• Offer you just nonalcoholic beverages. 

• Join you in alcohol-free activities. 

• Go along when you discuss your drinking with a 

healthcare professional, to help you take notes 

and to provide support. 

• Accompany or drive you to mutual-help group 

meetings. 

• Be available to talk to you if you get an urge to 

drink. 

Another way that family members can help 

is by participating in family therapy or BCT 

with you, if you are in treatment and your 

provider recommends such therapy. For more 

information, refer family members to SAMHSA’s 

Family Therapy Can Help booklet, which is 

available at no cost (https://store.samhsa.gov/ 

product/Family-Therapy-Can-Help-For-Peoplein-Recovery-From-Mental-Illness-or-Addiction/ 

SMA15-4784).1419 

Also consider asking any family members that you 

live with to keep little or no alcohol at home.1420 

224 Chapter 8 
Chapter 8—Drinking as an Older Adult: What Do I Need To Know? TIP 26

WHAT IF MY FAMILY AND FRIENDS 

ARE NOT SUPPORTIVE? 

What if you are uncomfortable asking those 

around you to actively support your abstinence, 

or you do ask but don’t get a positive response? 

First, don’t isolate yourself.1421 Instead, consider 

joining a mutual-help group and/or working 

with a recovery coach or peer recovery support 

specialist. This individual, who often has personal 

experience with addiction, acts as a mentor and 

a motivator. He or she can also help you fnd 

alcohol treatment. Some are volunteers and 

some are paid by you or a third party.1422 

How Can I Encourage Myself? 

First, give yourself credit for realizing that you 

may need to do something about your drinking. 

Remember that many different treatment options 

are available for alcohol misuse. These options 

have enabled many older adults like you to stop or 

reduce their alcohol consumption.1423 Congratulate 

yourself on any action you take to limit how much 

you drink. In addition, remind yourself that, no 

matter what your age, overcoming alcohol misuse 

can help you feel better and live longer. 

Information for Family and 

Caregivers 

What Can I Do as a Caregiver or Family 

Member? 

Know the Warning Signs of Alcohol Misuse 

If you think a family member may be misusing 

alcohol, review the list of warning signs in the 

“How Can I Tell Whether I’m Misusing Alcohol?” 

section. Other signs to look for include:1424,1425 

• Hiding alcohol supplies. 

• Denying or justifying drinking. 

• Refusing to discuss drinking. 

• Becoming annoyed when asked about 

drinking.1426 

• Becoming aggressive or abusive. 

• Displaying excessive mood swings. 

• Having new problems with decision making.1427 

• Appearing sleepy during the day. 

• Falling behind on bills. 

• Having unexplained burns or bruises.1428 

• Having frequent car accidents. 

• Talking about or attempting suicide. 

Suicide attempts and talk of suicide require 

immediate attention. Call 911 if your family 

member attempts or threatens suicide. Call your 

family member’s healthcare professional or the 

National Suicide Prevention Lifeline (1-800-273-

8255) if you worry that he or she is thinking about 

suicide. Note that by July 2022, you will also be 

able to reach this hotline by dialing 988. 

CHALLENGES TO RECOGNIZING 

ALCOHOL MISUSE 

Alcohol misuse among older adults often goes 

unrecognized. These three examples illustrate 

the problem: 

• A healthcare provider who cares for an older 

woman assumes that the broken capillaries on 

her face are the result of old age rather than 

her heavy drinking. 

• An older man who drinks as much as he did 

in middle age does not realize that what was 

moderate drinking then is alcohol misuse 

now—especially given that he’s developed 

diabetes. 

• A daughter does not know that her widowed 

father misuses alcohol because he drinks only 

when home alone. 

Know About Your Family Member’s 

Medications 

Know what prescription and OTC medications 

your relative takes. The same advice applies to 

dietary supplements, including vitamins and herbal 

products. Review the “Check Your Medications 

for Alcohol Interactions” text box for tips on 

fnding out whether these products have harmful 

interactions with alcohol. 

Chapter 8 225 
TIP 26 Treating Substance Use Disorder in Older Adults 

You may need written or verbal permission from 

your family member to discuss possible alcohol 

interactions with his or her healthcare provider 

or pharmacist.1429 Even without such permission, 

you can still inform these healthcare providers of 

any concerns you have about interactions. 

Know How To Connect Your Family Member 

With Help 

See “What Are My Options for Specialized AUD 

Treatment?” for information on fnding treatment 

facilities and providers in your area. Look at the 

section “Join a Mutual-Help Group” for tips on 

fnding mutual-help group meetings, if this type 

of support would be appropriate for your family 

member. 

Know When and How To Talk About 

Getting Help 

Talking constructively with a family member 

about a drinking problem takes patience. But 

the payoff may be a greater willingness on his or 

her part to address the problem. Where you can, 

connect the conversation to your concerns about 

your family member’s health. Here are some other 

tips:1430,1431,1432 

• Don’t bring up the topic when your family 

member is intoxicated. 

• Use “I” messages that express your feelings and 

concern, not “You” messages that criticize or 

blame the older adult. For example, you can say, 

“I worry that you’ll have another bad fall if you 

don’t cut back on your drinking” instead of “You 

drink so much that you get falling-down drunk!” 

• Don’t use guilt, threats, or bribes to try to get 

your family member to stop drinking. 

• Avoid using offensive terms like “an alcoholic” 

or “an addict” or “a drunk.” 

• Make positive comments about your family 

member’s strengths and personality. 

• Adjust what you say and how much you say 

at one time to match his or her ability to 

understand. 

• Remind the person how drinking interferes 

with his or her values, relationships, or favorite 

activities. 

• Offer to drive or arrange transportation for 

treatment or a mutual-help group. 

Participate in Therapy 

Participating in therapy with your family member 

can support his or her treatment. Your relationship 

with your family member could also beneft 

because of your participation. See “Family 

Therapy” and “Behavioral Couples Therapy” in 

the “Common Types of Therapy” section for brief 

descriptions of these approaches. You can read 

more about family therapy in SAMHSA’s Family 

Therapy Can Help booklet at https://store.samhsa. 

gov/product/Family-Therapy-Can-Help-For-Peoplein-Recovery-From-Mental-Illness-or-Addiction/ 

SMA15-4784. 

Don’t Enable Drinking 

Sometimes it may seem easier just to pretend 

that a family member’s drinking is not a problem. 

But doing so can be unhealthy for both of you. 

Also, if your family member has dementia, don’t 

use alcohol to help him or her sleep or calm down. 

Doing so is unsafe and can worsen symptoms. 

Help Your Family Member Avoid Alcohol 

Withdrawal 

If your family member requires emergency 

hospitalization for any reason, tell the hospital 

staff immediately if he or she misuses alcohol. 

Otherwise, he or she may experience alcohol 

withdrawal, which the medical team could miss or 

mistake for another condition. The medical team 

involved in a planned hospitalization for your family 

member also needs to know in advance if he or she 

misuses alcohol.1433 See the “Is Alcohol Withdrawal 

a Concern?” section for more information. 

Take Care of Yourself 

Sometimes you have to put yourself frst to 

continue to care for your family member. Accept 

offers of help and make time to socialize with 

others. Try to get enough sleep and exercise. Look 

after yourself by keeping medical appointments 

and not using alcohol or other substances to cope 

with stress or other diffcult emotions. 

226 Chapter 8 
Chapter 8—Drinking as an Older Adult: What Do I Need To Know? TIP 26

WHAT IF I’M OVERWHELMED? 

If you are concerned about caregiving’s effects 

on your health or behavior, consider taking 

the Caregiver Self-Assessment Questionnaire 

(CSAQ), originally developed and tested by the 

American Medical Association. This questionnaire 

is available online (www.healthinaging.org/ 

tools-and-tips/caregiver-self-assessmentquestionnaire) without cost in interactive and 

downloadable versions. 

The CSAQ is meant as a guide only. Discuss any 

concerns you have about your results with your 

healthcare provider.1434 Also consider talking with 

a therapist, especially one with experience with 

addiction issues.1435 

Join a Mutual-Help Group 

Al-Anon is a mutual-help group for people 

concerned about or affected by someone with 

alcohol misuse. If you cannot attend an in-person 

meeting, look into meetings that take place online 

or by phone. To learn more, call 1-888-425-2666 

(toll-free) or go to the Al-Anon website (https:// 

al-anon.org). 

If your family member is in addiction treatment, 

fnd out whether the facility or individual provider 

runs support groups or programs for family 

members and friends.1436 Other options are listed in 

the Resource Alert at the end of this section. 

What If My Family Member Won’t Discuss 

Drinking? 

Your family member may refuse to discuss his 

or her drinking habits no matter what you say. 

Options for next steps include talking to and 

involving:1437 

• Your family member’s healthcare provider. 

• An adult family member. 

• A close family friend. 

• A clergyperson. 

• Your family member’s case manager or social 

worker, if applicable. 

It may be easier for your family member to hear 

about his or her alcohol misuse from someone 

other than you. Getting another viewpoint may 

also help your family member see how serious the 

problem is. 

Also consider taking a facility tour, if possible, 

so that you can better discuss the treatment 

experience. 

RESOURCE ALERT: RESOURCES 

FOR CAREGIVERS 

AARP offers online forums and information 

resources on caregiving at www.aarp.org/ 

caregiving. 

The Alzheimer’s Association’s locator for its 

caregiver support groups is available through 

www.alz.org/help-support/community/supportgroups. 

The Eldercare Locator, available at https:// 

eldercare.acl.gov/Public/index.aspx or 1-800-677-

1116, provides links to state and local agencies on 

aging and community-based organizations that 

serve older adults and their caregivers. You can 

search the site by ZIP Code, city/state, or topic. 

The Family Caregiver Alliance has an 

information line for caregivers of adults with 

chronic medical illnesses living at home (1-800-

445-8106), an online Family Care Navigator that 

provides a state-by-state list of services and 

assistance for caregivers, and a free website/app 

called FCA CareJourney that provides information 

tailored to individual caregivers’ specifc needs. To 

learn more, visit www.caregiver.org. 

Through the VA, family caregivers for veterans 

have free access to a support line, telephone 

education groups on caregiving and self-care, a 

6-week online workshop on caregiving, and peer 

recovery support mentoring. To learn more, call 

the support line at 1-855-260-3274 or visit www. 

caregiver.va.gov/Care_Caregivers.asp. 

Chapter 8 227 
TIP 26

Chapter 8 Resources 

General 

National Institute on Aging (NIA)—Alcohol Use 

or Abuse (www.nia.nih.gov/health/topics/alcoholuse-or-abuse): This webpage provides tips on 

talking to a doctor about alcohol and reasons and 

resources for addressing alcohol use. 

NIA—Older Adults and Alcohol: You Can Get 

Help (https://order.nia.nih.gov/sites/default/ 

fles/2018-01/older-adults-and-alcohol.pdf): This 

easy-to-read brochure lays out the issues and 

answers common questions that older adults have 

about drinking. 

NIAAA—Rethinking Drinking (www. 

rethinkingdrinking.niaaa.nih.gov): This NIAAA 

website provides information about what a 

standard drink is; gives tips on how to refuse 

drinks and reduce or quit drinking; and offers 

interactive tools to help address alcohol misuse, 

such as an alcohol spending calculator. Note that 

the information provided is not specifc to older 

adults. 

VA—VetChange (https://mobile.va.gov/app/ 

vetchange): VetChange is an app that, according 

to the VA, can be used by anyone interested in 

developing healthier drinking behaviors. Among 

the app's features are tools for cutting down or 

quitting drinking and tools for managing stress 

symptoms. The app is not meant to replace 

professional treatment. 

Alcohol–Medication Interactions 

NIAAA—Harmful Interactions (www.niaaa.nih.gov/ 

publications/brochures-and-fact-sheets/harmfulinteractions-mixing-alcohol-with-medicines): 

This consumer guide provides information about 

the dangers of harmful medication–medication 

interactions and medication–alcohol interactions. 

Treating Substance Use Disorder in Older Adults 

Information on Finding and Accessing 

Treatment 

FindTreatment.gov (https://fndtreatment.gov): 

People seeking treatment for SUDs can use this 

federal locator maintained by SAMHSA to fnd 

treatment facilities based on location, availability 

of treatment for co-occurring mental disorders, 

availability of telemedicine care, payment option, 

age, languages spoken, and access to medication 

for OUD. The site also links to information on 

understanding addiction, understanding mental 

illness, and paying for treatment. 

SAMHSA—Behavioral Health Treatment Services 

Locator (https://fndtreatment.samhsa.gov/): This 

locator is another tool for fnding facilities that offer 

treatment for substance use or mental disorders. 

The site includes a video tutorial on ways to flter 

search results by different criteria. 

SAMHSA—Finding Quality Treatment for 

Substance Use Disorders (https://store.samhsa. 

gov/product/PEP18-TREATMENT-LOC): People 

seeking alcohol treatment can use this factsheet to 

learn about the necessary steps to complete before 

accessing a treatment center and the fve signs of a 

quality treatment center. 

MedicareInteractive.org—Treatment for 

Alcoholism and Substance Use Disorder (www. 

medicareinteractive.org/get-answers/medicarecovered-services/mental-health-services/ 

treatment-for-alcoholism-and-substance-abuse): 

This webpage discusses Medicare coverage of 

treatment for SUDs. 

NIAAA—Alcohol Treatment Navigator (https:// 

alcoholtreatment.niaaa.nih.gov): This website helps 

people understand what alcohol use disorder is 

and how to locate high-quality treatment for it. 

228 Chapter 8 
TIP 26 TREATING SUBSTANCE USE DISORDER 

IN OLDER ADULTS

Chapter 9—Resources for Treating Substance 

Use Disorder in Older Adults 

Chapter 9 of this Treatment Improvement 

Protocol (TIP) provides an annotated collection 

of resources, organized by audience and topic, 

addressing substance misuse, recovery, and related 

health and wellness issues among older adults. It is 

for addiction treatment and mental health service 

providers, supervisors, and administrators; allied 

healthcare providers; and older adults and their 

families, friends, and caregivers. The resources 

support and expand on the materials contained in 

each chapter of the TIP. 

Adults who have substance use disorders (SUDs) 

may develop more physical and psychosocial needs 

as they age. Providers working with adults with 

SUDs have an increasing need to know where to 

fnd the necessary information to coordinate and 

support these clients’ care across major life areas 

as these clients age. This resource compendium is 

designed to complement the strategies discussed 

in other chapters of this TIP. Because SUD is a 

chronic condition, this compendium contains a 

selection of validated tools to choose from to help 

overcome the many challenges with identifying 

SUD in older clients, intervene, and see older 

adults through recovery and maintenance. 

The selected client-, family-, and caregiver-oriented 

resources are designed to help readers become 

better informed about SUDs and other conditions, 

make decisions about addiction treatment, improve 

recovery and health, and fnd support during their 

recovery or caregiving journey. 

Many resources will be of interest across audiences, 

so readers are encouraged to look at entries 

throughout Chapter 9. 

Provider Note: Use any tools not specifcally 

identifed as modifed or validated with older 

adults with caution and only within the scope of 

your training and practice. 

Organization of Chapter 9 of 

This TIP 

Chapter 9 offers comprehensive resources on 

substance misuse in older adults. It is divided 

into sections on general resources and resources 

for supervisors and administrators, for providers, 

and for clients and families, with a fnal section on 

provider tools. 

General Resources 

Facts, Figures, and General Information 

Centers for Disease Control and Prevention 

(CDC)—Alzheimer’s Disease and Healthy Aging 

Data Portal 

www.cdc.gov/aging/agingdata/index.html 

Resource summary: This website provides 

consumers with self-reported data on health 

indicators in adults over 50. It contains a database 

of overall health indicators (e.g., ratings of 

suffcient sleep) and chronic conditions reported 

by participants in CDC’s Behavioral Risk Factor 

Surveillance System. It also tracks other reported 

dimensions of health collected by this CDC 

survey, including cognitive decline, screenings and 

vaccinations, nutrition, activity level, mental health, 

and caregiving efforts. This information can be 

used by healthcare policy stakeholders to gauge 

the level of health risk behaviors, health conditions, 

and use of preventive services among the aging 

population. 

229 
TIP 26 Treating Substance Use Disorder in Older Adults 

The website also provides links to relevant online 

content and related publications. Instructions are 

included for using the portal to create custom 

reports, but the site also allows for creating reports 

using standard templates that show data by state 

or U.S. region based on age level, year, and health 

dimension. 

Referral, Treatment, and Support Group 

Locators 

Association of Recovery Community 

Organizations (ARCO) 

https://facesandvoicesofrecovery.org/arco/ 

Resource summary: ARCO’s mission is to grow and 

sustain the recovery movement, both nationally 

and internationally, in three main ways. First, 

ARCO vets nonproft recovery organizations 

for acceptance as ARCO affliates and provides 

training and technical assistance to further their 

reach in local communities. Second, ARCO 

engages in advocacy efforts aimed at the general 

public and policymakers that involve education 

against stigma and for acceptance of the recovery 

community. Third, the organization helps people 

realize long-term recovery by supporting clients’ 

transitions from treatment to recovery services. 

Department of Veterans Affairs (VA)—SUD 

Program Treatment Locator 

www.va.gov/directory/guide/SUD.asp 

Resource summary: The VA treatment locator can 

be searched by state for VA Medical Centers that 

offer specialized SUD treatment. 

Eldercare Locator 

https://eldercare.acl.gov 

Resource summary: Sponsored by the 

Administration on Aging (AoA), this website 

provides information on support services for older 

adults and caregivers and valuable information 

on elder rights, housing, health conditions and 

wellness, insurance benefts, transportation, and 

long-term care planning. Users can search for 

information and referrals for assistance through 

federal, state, and local resources, as well as 

health insurance counseling agencies. The site is 

user friendly and offers many options for fnding 

assistance at the community level. Consumers also 

may request help by phone, online chat, or email. 

Consumer publications and outreach materials can 

be ordered for free, but there may be shipping and 

handling costs. 

Faces & Voices of Recovery—Guide to Mutual 

Aid Resources 

https://facesandvoicesofrecovery.org/resources/ 

mutual-aid-resources 

Resource summary: Faces & Voices of Recovery 

offers information on mutual-help organizations 

based on the following categories: 12-Step, 

alcohol, co-occurring health conditions, faithbased, family-/friend-focused, gender-specifc, 

medication-assisted, secular, and youth. 

FindTreatment.gov 

https://fndtreatment.gov 

Resource summary: People seeking treatment for 

SUDs can use this federal locator maintained by 

the Substance Abuse and Mental Health Services 

Administration (SAMHSA) to fnd treatment 

facilities based on location, availability of treatment 

for co-occurring mental disorders, availability of 

telemedicine care, payment option, age, languages 

spoken, and access to medication for OUD. The 

site also links to information on understanding 

addiction, understanding mental illness, and paying 

for treatment. 

NIAAA (National Institute on Alcohol Abuse and 

Alcoholism) Alcohol Treatment Navigator 

https://alcoholtreatment.niaaa.nih.gov 

Resource summary: This site offers comprehensive 

information on alcohol use disorder (AUD) 

and AUD treatment. It describes the need for 

professional assessment and individualized 

treatment plans and explains the recovery process, 

including the possibility of relapse and ways to 

overcome it. Access is available for clients, family, 

friends, and clinicians to information sources, 

mutual-support groups, and resources for older 

adults who are using alcohol. 

230 Chapter 9 
TIP 26

 

 

Chapter 9—Resources for Treating Substance Use Disorder in Older Adults 

Readers can learn about the different types of 

treatment available, how to fnd treatment, costs 

of treatment, insurance coverage, and options for 

support throughout recovery. The site provides 

a toolkit that can be downloaded and used by 

clients, therapists, and treatment providers to 

“navigate” the process of fnding the right kind of 

help at different stages of recovery and treatment. 

It includes worksheets that can be individualized to 

track progress and lists of important questions for 

clients to ask of providers and treatment programs. 

Substance Abuse and Mental Health Services 

Administration (SAMHSA)—Behavioral Health 

Treatment Services Locator 

https://fndtreatment.samhsa.gov 

Resource summary: This online resource provides 

users with a confdential, easy-to-use tool for 

fnding local behavioral health service facilities 

that offer treatment for substance use and mental 

disorders. The site includes tutorials for using the 

interactive tool to search for both inpatient and 

outpatient programs in a given area. 

SAMHSA—National Directory of Drug and 

Alcohol Abuse Treatment Facilities, 2020 

https://www.samhsa.gov/data/sites/default/fles/ 

reports/rpt23267/National_Directory_SA_facilities. 

pdf 

Resource summary: This document contains a 

comprehensive list of state-certifed substance 

use and mental disorder treatment facilities 

that responded to the 2019 National Survey of 

Substance Abuse Treatment Services (N-SSATS). 

The directory provides a list of state behavioral 

health agencies and individual treatment facilities 

broken out by city and state. 

Each facility is coded for primary focus, type of 

care, treatment setting, treatment approaches, 

payment and funding assistance options, language 

services, ancillary services, age groups and 

genders served, and targeted programs for special 

populations such as active and retired military; 

court-ordered clients; trauma victims; and lesbian, 

gay, bisexual, or transgender (LGBT) individuals. 

This directory supplements FindTreatment.gov, 

which is updated more frequently. The directory, 

however, contains more detailed information about 

each facility. 

SAMHSA’s National Helpline 

www.samhsa.gov/fnd-help/national-helpline 

Resource summary: SAMHSA’s National Helpline 

provides free treatment referral and relevant 

information for individuals who need help dealing 

with substance misuse or mental illness. The phone 

lines (1-800-662-HELP [4357]; 1-800-487-4889 

[TTY]) are staffed 24 hours a day by information 

specialists who can respond in English or Spanish. 

All calls to the helpline are free and confdential. 

The helpline website features free publications 

on substance use and mental disorder awareness, 

plus family treatment approaches, interventions, 

and self-help for achieving recovery from these 

disorders. 

Government Agencies and Departments 

Administration for Community Living (ACL) 

www.acl.gov 

Resource summary: ACL, part of the Department 

of Health and Human Services (HHS), provides 

funding and support services to community-based 

organizations that promote independent living 

and full community participation among older 

adults and people with disabilities. The website 

offers information and educational resources about 

behavioral health and aging issues, chronic disease 

management, and healthy aging geared toward 

people with disabilities, older adults, and their 

family and friends. 

Chapter 9 231 
TIP 26

 

Treating Substance Use Disorder in Older Adults 

National Institute on Aging (NIA) 

www.nia.nih.gov 

Resource summary: NIA is part of the National 

Institutes of Health (NIH). Its primary focus is to 

support a broad scientifc effort to understand the 

nature of aging and the health and wellness of 

older adults. The website has consumer-oriented 

information on a wide variety of topics, including 

caregiving, cognitive health, and doctor–patient 

communication. 

The site also contains training for researchers, 

clinicians, and students; grants and funding 

opportunities; clinical practice tools; publications; 

and health information for the Spanish-speaking 

community. 

Additional Government Resources 

CDC—Alzheimer’s Disease and Healthy Aging 

www.cdc.gov/aging/index.html 

Resource summary: This CDC page provides 

easy access to health information on a number of 

topics for older adults and resources in advance 

care planning. It also features updates on the 

HHS Healthy Brain Initiative; educational materials 

on aging, depression, and Alzheimer’s disease; 

training and prevention resources; emergency 

planning tips; data and reports; and other 

publications. 

Centers for Medicare & Medicaid Services 

(CMS)—Program of All-Inclusive Care for the 

Elderly (PACE) 

www.cms.gov/Medicare-Medicaid-Coordination/ 

Medicare-and-Medicaid-Coordination/MedicareMedicaid-Coordination-Offce/PACE/PACE 

Resource summary: PACE is a joint Medicare/ 

Medicaid program that provides prepaid, 

capitated, comprehensive healthcare services 

to enhance the quality of life and independence 

of older people in their communities. It is an 

innovative model that integrates preventive, acute 

care, and long-term services for a defned subset 

of frail elderly to manage their often complex 

medical, functional, and social needs. It promotes 

the use of fexible, coordinated services and 

systems that expand the scope of Medicare- and 

Medicaid-covered services. The webpage links 

to information for clients, family, caregivers, and 

healthcare providers on program eligibility and 

services, as well as the full PACE manual. 

Department of Justice—Older Adults, Families, 

and Caregivers 

www.justice.gov/elderjustice/victims-familiescaregivers 

Resource summary: People concerned about the 

safety of an older adult can use this page to learn 

about fnding help or reporting abuse. The page 

also contains important information on the warning 

signs, impact, and extent of physical, sexual, 

and mental abuse and fnancial exploitation of 

older adults. Consumers can learn how to protect 

themselves and their family members or friends by 

reading real stories of abuse and how people took 

action to stop it. 

Health Resources and Services Administration 

Health Workforce—Geriatrics 

https://bhw.hrsa.gov/grants/geriatrics 

Resource summary: HRSA developed this 

webpage specifcally for the geriatrics workforce. 

Users can fnd training materials and information 

on grant funding, strategic partnerships, and 

technical assistance as well as the Geriatrics 

Workforce Enhancement Program and the 

Geriatrics Academic Career Award Program, both 

aimed at improving health care for older adults by 

integrating geriatrics with health care at individual 

and institutional levels. 

HHS—Aging 

www.hhs.gov/aging/index.html 

Resource summary: The HHS Aging webpage 

provides or links to information on healthy 

aging, age discrimination, elder justice, caregiver 

resources and long-term care, retirement planning 

and security, Social Security benefts, Medicare 

enrollment, and Medicaid coverage. 

232 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

HIV.gov—Older Adults 

www.hiv.gov/topics/olderadults 

Resource summary: Readers can access useful 

resources on HIV and aging; HIV testing sites and 

care services; and blog posts and articles about HIV 

that focus on veterans, complications facing older 

adults with HIV, and technology that helps older 

adults with HIV and AIDS manage these conditions. 

The page also contains success stories as well as 

information on food safety and nutrition, physical 

activity, and employment. 

National Center on Elder Abuse 

https://ncea.acl.gov 

Resource summary: This site offers free resources 

for professionals and the public on how to prevent, 

recognize, report, and stop elder abuse. 

National Highway Traffc Safety Administration 

(NHTSA)—Older Drivers 

www.nhtsa.gov/road-safety/older-drivers#topicmedical-conditions 

Resource summary: NHTSA offers tips to older 

drivers and their caregivers on driving safety. The 

webpage provides indepth information on how to 

recognize a decline in driver function. Materials are 

available on topics that include speaking to older 

adults about alternative transportation methods, 

modifying driving habits, and adapting vehicles 

to accommodate special medical issues for safer 

driving. This webpage can be viewed in English 

and Spanish. 

National Institute of Mental Health (NIMH)— 

Older Adults and Mental Health 

www.nimh.nih.gov/health/topics/older-adults-andmental-health/index.shtml 

Resource summary: This webpage contains or links 

to information on mental health topics important 

to older adults, including depression and anxiety 

disorders. The page connects readers to statistics, 

brochures and factsheets, sites for help with 

mental illness, information about clinical trials, and 

hotlines. Resources are available in English and 

Spanish. 

National Library of Medicine MedlinePlus— 

Healthy Aging 

https://medlineplus.gov/healthyaging.html 

Resource summary: The Healthy Aging webpage 

links to federal and nonfederal information on how 

to stay healthy and active during older adulthood. 

It also links to relevant statistics and research. 

Information on this page can be displayed in 

English or Spanish. 

Nutrition.gov—Older Individuals 

www.nutrition.gov/topics/audience/olderindividuals 

Resource summary: This page, sponsored by the 

Department of Agriculture, serves as a gateway 

to reliable information on nutrition and health for 

older adults. Content is provided by registered 

dietitians at the Food and Nutrition Information 

Center and other federal experts. Consumers 

can learn about other federal resources, such 

as ChooseMyPlate (formerly MyPlate), the NIA 

health information page, the Food and Drug 

Administration (FDA) guide for understanding food 

labels, and several university webpages explaining 

osteoporosis and nutrition. They can also fnd 

interactive tools for weight management, research 

and education resources, and help with food 

assistance programs. 

VA—Geriatrics and Extended Care 

www.va.gov/GERIATRICS/index.asp 

Resource summary: This page provides 

information on geriatric and extended-care 

issues; home- and community-based services; 

residential settings and nursing homes; payment 

methods for long-term care; and well-being tips 

for older veterans, their caregivers, and healthcare 

providers. The page also helps users fnd health 

programs for veterans, including smoking and 

substance use cessation. Consumers can also 

search topics from A to Z or link to the VA public 

health page, which provides information on military 

exposures and related health conditions, health 

and wellness, research, and statistics. 

Chapter 9 233 
TIP 26 Treating Substance Use Disorder in Older Adults 

Groups and Organizations 

AARP 

www.aarp.org 

Resource summary: AARP is a nonproft 

organization that works to address the needs and 

interests of older adults in the United States. The 

AARP website provides information and resources 

in English and Spanish on substance misuse, 

health, and wellness for older adults, among other 

topics. The AARP Foundation (www.aarp.org/aarpfoundation/fnd-help/?intcmp=FOU-R2-C2-SRVCS) 

offers an online local assistance directory that helps 

older adults with limited resources search for free 

or reduced-cost services in their area, including 

healthcare and food programs. 

Faces & Voices of Recovery 

https://facesandvoicesofrecovery.org 

Resource summary: Faces & Voices of Recovery 

is a recovery advocacy organization promoting 

science-based addiction treatment and recoveryfocused policies that emphasize health and wellbeing and reduce discrimination against people 

with addiction. The website contains a library 

of resources related to recovery advocacy and 

education, reports, toolkits, and recovery stories, 

as well as links to recovery research, recovery data, 

capacity building, training, and ideas for getting 

involved in your community. 

National Association of Area Agencies on Aging 

www.n4a.org 

Resource summary: This website provides or links 

to information for consumers and professionals on 

a variety of older adult–related topics, including 

health care, housing, transportation, Medicare 

savings programs, low-income subsidies, health 

assistance, health insurance, and home- and 

community-based services. Consumers can access 

information on aging services, advocacy, initiatives, 

and resources. 

National Association of Social Workers—Aging 

www.socialworkers.org/practice/aging 

Resource summary: This webpage offers guidance 

on practice standards and professional growth 

for social workers who work with older adults. It 

provides members with access to professional 

development opportunities, practice and advocacy 

tools, and other resources to enhance social 

workers’ capacity to support older adults and 

family caregivers. 

National Council on Aging (NCOA) 

www.ncoa.org 

Resource summary: NCOA promotes the health 

and economic security of older adults. Its website 

maintains a collection of resources on healthy 

aging for providers, older adults, advocates, and 

caregivers. Topics covered include fall prevention, 

chronic disease management, and aging mastery. 

Cultural Diversity 

American Psychological Association (APA)— 

Multicultural Competency in Geropsychology 

www.apa.org/pi/aging/programs/pipeline/ 

multicultural-competency.pdf 

Resource summary: This report, developed 

by the APA Committee on Aging, provides 

recommendations for increasing multicultural 

competencies among psychologists who work with 

older adults. The report provides guidelines for 

improving and maintaining cultural competence 

in psychological practice and recognizes training 

modules designed to help providers and 

organizations develop multicultural standards in 

geropsychology. It also contains information on key 

issues facing the multicultural aging population. 

APA—Lesbian, Gay, Bisexual and Transgender 

Aging 

www.apa.org/pi/lgbt/resources/aging 

Resource summary: This webpage provides 

information and links to publications, organizations, 

and media coverage with a focus on LGBT aging 

issues. 

National Asian Pacifc Center on Aging (NAPCA) 

www.napca.org 

Resource summary: NAPCA is dedicated to 

diversity and advocacy efforts to promote the 

capacity of employers and mainstream service 

providers to support Asian Americans and Pacifc 

234 Chapter 9 
TIP 26

 

Chapter 9—Resources for Treating Substance Use Disorder in Older Adults 

Islanders. Website topics for consumers include 

self-management of chronic diseases, preventing 

Medicare fraud, healthy eating, brain health, 

and Medicare Part D enrollment assistance. The 

website also contains information on dementia, 

elder abuse prevention, family caregiving, healthy 

aging, and mature workers. 

National Caucus and Center on Black Aging, Inc. 

(NCBA) 

https://ncba-aging.org 

Resource summary: NCBA is a national 

organization focusing on issues affecting minority 

adults ages 50 and older. Consumers can access 

on its website information on health and wellness 

services, employment services, housing services, 

and other topics. 

National Hispanic Council on Aging (NHCOA) 

www.nhcoa.org 

Resource summary: NHCOA is a national 

organization concerned with improving the health, 

economic security, and housing of Hispanic older 

adults, their families, and their caregivers. The 

organization’s health-related work includes local 

health education and promotion and cultural 

competency training for healthcare providers. 

National Indian Council on Aging (NICOA) 

https://nicoa.org/ 

Resource summary: NICOA is concerned 

with improving the health, social services, and 

economic well-being of American Indian and 

Alaska Native elders. It is involved with advocacy 

issues, networking with aging organizations 

and community service providers, and technical 

assistance for Native American communities. The 

website offers information on policy issues, health 

and wellness for elders, and caregiver support. 

National Resource Center on Native American 

Aging (NRCNAA) 

www.nrcnaa.org 

Resource summary: Funded by ACL, NRCNAA 

provides education, training, and technical 

assistance to help develop community-based 

solutions to improve the delivery of support 

services to the Native American aging population. 

Its aim is to improve their health and social 

conditions through free projects and services 

and to empower them to live their best over the 

lifespan. The site contains educational tools for 

service providers, caregivers, and community 

members. Consumers can access factsheets, 

reports, presentations, and articles on policy 

activities as well as service locators for aging 

Native Americans, long-term planning information, 

programs for balancing health and well-being, and 

the Native Aging Visions newsletter. 

SAGE (Advocacy & Services for LGBT Elders) 

www.sageusa.org/ 

Resource summary: The SAGE website provides 

advocacy, training, programming, and resource 

development to improve aging for LGBT people 

nationwide. Older adults and their caregivers can 

sign up for the SAGE newsletter to get action 

alerts, event invites, and the latest news on LGBT 

aging issues. Through its sister sites, the National 

Resource Center on LGBT Aging and SAGECare, 

SAGE provides cultural competency training and 

education for aging services providers. 

Understanding Issues Facing LGBT Older Adults 

www.lgbtmap.org/fle/understanding-issues-facinglgbt-older-adults.pdf 

Resource summary: This report from the 

Movement Advancement Project and SAGE helps 

providers and others better understand the social 

isolation and health challenges that affect many 

LGBT older adults. 

Chapter 9 235 
TIP 26 Treating Substance Use Disorder in Older Adults 

SAMHSA Publications 

All publications listed in this section are available 

at no cost from SAMHSA’s publications ordering 

webpage (https://store.samhsa.gov) or from1-877-

SAMHSA-7 (1-877-726-4727). 

Family Therapy Can Help: For People in Recovery 

From Mental Illness or Addiction 

https://store.samhsa.gov/product/Family-TherapyCan-Help-For-People-in-Recovery-From-MentalIllness-or-Addiction/SMA15-4784 

Resource summary: This brochure explores the 

role of family therapy in recovery from mental 

illness, SUDs, or both. It explains how family 

therapy sessions are run and who conducts them. 

It also provides information on how effective family 

therapy sessions are in supporting recovery. 

Get Connected: Linking Older Adults With 

Resources on Medication, Alcohol, and 

Mental Health 

https://store.samhsa.gov/product/ 

Get-Connected-Linking-Older-Adultswith-Resources-on-Medication-Alcohol-andMental-Health-2019-Edition/SMA03-3824 

Resource summary: Developed in collaboration 

with NCOA, this resource includes a program 

coordinator’s guide and program support 

materials. The latter are education curriculums for 

program staff, factsheets and handouts, and forms 

and resources. This resource is designed for health 

and aging services providers. The main goal of 

this resource is to improve the lives of older adults 

who may be misusing alcohol or medications and 

who may need the help of mental health services. 

Content was designed to increase awareness and 

educate providers about the signifcant effects of 

alcohol and medication misuse and mental illness 

in the older adult population and the steps to take 

for mitigating problems. The program support 

materials will help guide providers to adopt 

effective practices for screening and referral to 

community-based resources and support services 

in the areas of substance misuse and mental health. 

Medication for the Treatment of Alcohol Use 

Disorder: A Brief Guide 

https://store.samhsa.gov/product/Medication-forthe-Treatment-of-Alcohol-Use-Disorder-A-BriefGuide/SMA15-4907 

Resource summary: This document provides 

guidance on the use of FDA-approved medications 

for treating AUD in clinical practice. It includes a 

section on assessing and treating older adults. The 

document discusses developing a treatment plan 

and selecting a medication, initiating treatment 

with medication, and monitoring patient progress. 

Treatment of Depression in Older Adults 

https://store.samhsa.gov/product/TreatmentDepression-Older-Adults-Evidence-BasedPractices-EBP-Kit/SMA11-4631 

Resource summary: The authors of this guide note 

that depression is widely underrecognized and 

undertreated in older adults and offer important 

tips for working with older adults in terms of 

communication, privacy, and assessment. This 

booklet describes how practitioners—such as 

psychiatrists, psychologists, physicians, nurses, 

social workers, and aging services providers—can 

provide effective care for older adults who 

have depression. It discusses evidence-based 

approaches for screening and diagnosis, treatment, 

and outcomes evaluation. 

TIP 27: Comprehensive Case Management for 

Substance Abuse Treatment 

https://store.samhsa.gov/product/TIP-27-

Comprehensive-Case-Management-for-SubstanceAbuse-Treatment/SMA15-4215 

Resource summary: TIP 27 describes case 

management as an interdisciplinary approach to 

addiction treatment that includes coordination of 

health, substance use, mental health, and social 

services. This TIP provides guidance and resources 

to help keep clients engaged in treatment 

and moving toward recovery, which requires 

periodically assessing clients and facilitating service 

delivery across different levels of care, particularly 

for clients with other disorders and conditions who 

require multiple services over extended periods of 

time and who face diffculty in gaining access to 

those services. 

236 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

TIP 34: Brief Interventions and Brief Therapies 

for Substance Abuse 

https://store.samhsa.gov/product/TIP-34-BriefInterventions-and-Brief-Therapies-for-SubstanceAbuse/SMA12-3952 

Resource summary: TIP 34 documents the 

components of and criteria for the use of brief 

cognitive–behavioral therapy (CBT), brief strategic 

and interactional therapies, brief humanistic and 

existential therapies, brief psychodynamic therapy, 

short-term family therapy, and time-limited group 

therapy. Each of these therapies can be used to 

treat select subpopulations of people with SUDs 

and those at risk of developing them. These 

therapies are intended for clients who may not 

have the time or money to dedicate to traditional 

therapy or for clients who are functioning in 

society but who misuse substances. These therapy 

approaches can be used in a variety of settings 

and can be useful for reaching a greater number 

of people than more traditional approaches 

(e.g., for clients who are on waiting lists for 

specialized programs). The publication discusses 

the effectiveness of each approach. It also provides 

historical background, outcomes research, rationale 

for use, and case scenarios for implementation of 

brief interventions and therapies for a range of 

problems related to substance misuse. 

TIP 35: Enhancing Motivation for Change 

in Substance Use Disorder Treatment 

https://store.samhsa.gov/product/TIP-35-

Enhancing-Motivation-for-Change-in-SubstanceUse-Disorder-Treatment/PEP19-02-01-003 

Resource summary: This updated TIP describes 

the elements of motivational interventions, the fve 

principles of motivational interviewing, catalysts 

for changing behavior, and the stages of change 

that a client will go through while working toward 

recovery from substance use. Readers will learn 

how to integrate motivational approaches into 

treatment programs, and how to measure client 

motivation. The TIP provides guidance on how to 

develop a therapeutic relationship that respects 

and builds on the client’s autonomy, how to tailor 

treatment to a client’s stage of readiness for 

change, and how to address client resistance or 

ambivalence by asking open-ended questions 

and using other motivational strategies. The 

information in this TIP will help equip clinicians with 

the necessary skills for enhancing client motivation 

at different stages of the change process. Content 

includes a description of proven motivational 

techniques, research results, case studies, and 

multiple screening and assessment tools to assist 

providers in guiding their clients toward positive 

treatment outcomes. 

TIP 54: Managing Chronic Pain in Adults With or 

in Recovery From Substance Use Disorders 

https://store.samhsa.gov/product/TIP-54-

Managing-Chronic-Pain-in-Adults-With-orin-Recovery-From-Substance-Use-Disorders/ 

SMA13-4671 

Resource summary: TIP 54 discusses the 

physiological, social, and mental impact of chronic 

noncancer pain; the cycle of chronic pain and 

addiction; the importance of ongoing assessment; 

and the complexity of managing pain in clients 

with active addiction. This manual is intended 

for primary care providers, addiction specialists, 

psychiatrists, pharmacists, and nurses who treat 

or are likely to treat adult patients with or in 

recovery from SUDs who present with chronic 

noncancer pain. It offers guidance on chronic 

pain management, treating patients in recovery, 

managing addiction risks in patients treated with 

opioids, using patient education and treatment 

agreements and tools for assessing dimension 

and level of pain, and talking with patients about 

complementary and alternative treatments. 

TIP 57: Trauma-Informed Care in Behavioral 

Health Services 

https://store.samhsa.gov/product/TIP-57-TraumaInformed-Care-in-Behavioral-Health-Services/ 

SMA14-4816 

Resource summary: The audience for this guide 

includes healthcare and behavioral health service 

providers, prevention specialists, program 

administrators, community service providers, 

criminal justice system support workers, and 

researchers. The TIP covers trauma awareness, the 

impact of trauma, trauma-informed screening and 

assessment, implementation of trauma-informed 

care, and development of a trauma-informed 

workforce. 

Chapter 9 237 
TIP 26

TIP 59: Improving Cultural Competence 

https://store.samhsa.gov/product/TIP-59-

Improving-Cultural-Competence/SMA15-4849 

Resource summary: TIP 59 provides an 

introduction to cultural competence in behavioral 

health services targeted to treatment counselors, 

clinical and programmatic staff, and program 

administrators. The guide identifes core 

competencies necessary for culturally responsive 

evaluation and treatment planning and discusses 

the need for cultural competence of support 

service organizations and behavioral health 

services for different racial and ethnic groups. The 

appendixes include cultural resources and clinical 

tools for screening, assessment, and treatment. 

TIP 63: Medications for Opioid Use Disorder 

https://store.samhsa.gov/product/TIP-63-

Medications-for-Opioid-Use-Disorder-FullDocument/PEP20-02-01-006 

Resource summary: TIP 63 provides an introduction 

to the three FDA-approved medications for 

opioid use disorder (OUD) treatment and explains 

their use in addressing OUD in medical settings. 

These medications—methadone, naltrexone, and 

buprenorphine—have proven effective in rigorous 

scientifc studies for treating OUD, particularly when 

administered alongside individualized psychosocial 

supports and other recovery services. The TIP 

includes practical guidelines and clinical tools for 

OUD screening, assessment, diagnosis, treatment 

planning, and referral to recovery support services. 

It also contains resources for fnding medical and 

behavioral health service providers who specialize in 

treating OUD. 

Resources for Supervisors and 

Administrators 

Facing Addiction in America: The Surgeon 

General’s Report on Alcohol, Drugs, and Health 

https://addiction.surgeongeneral.gov/sites/default/ 

fles/surgeon-generals-report.pdf 

Resource summary: This report describes the 

current state of SUD treatment in the United States 

and offers key recommendations for expansion and 

further integration of SUD treatment services into 

medical and behavioral health services so that more 

people can achieve recovery and reduce the related 

Treating Substance Use Disorder in Older Adults 

negative impacts of substance misuse. The report 

mentions older adult alcohol prevention programs 

and health considerations for older adults with OUD. 

Grantmakers In Aging—Heartache, Pain, and 

Hope: Rural Communities, Older People, and the 

Opioid Crisis 

www.giaging.org/documents/170823_GIA_Rural_ 

Opioid_Paper_FINAL_for_web.pdf 

Resource summary: This publication is aimed at 

funders and policymakers who want to help solve 

the opioid crisis in rural America. It describes 

some promising programs that have been 

implemented at the community level as well as 

policy recommendations for opioid use treatment 

and prevention strategies for helping older adults 

in rural communities. This document also looks at 

strategies for mitigating risks and outlines several 

programs that have been funded at the local level, 

some which have become statewide initiatives. 

Institute of Medicine (IOM)—Coordinating Care 

for Better Mental, Substance-Use, and General 

Health 

www.ncbi.nlm.nih.gov/books/NBK19833 

Resource summary: This resource is a chapter from 

Improving the Quality of Health Care for Mental 

and Substance-Use Conditions. It provides an 

overview of the provider challenges in coordinating 

care across services and suggests strategies for 

enhancing care management and coordination that 

are applicable to older clients. 

For access to the full PDF at no cost, users can 

create a free account and log in. 

IOM—The Mental Health and Substance Use 

Workforce for Older Adults: In Whose Hands? 

www.nap.edu/catalog/13400/the-mental-healthand-substance-use-workforce-for-older-adults 

Resource summary: This report assesses the 

behavioral healthcare needs of older adults and 

makes policy and research recommendations 

for meeting those needs through a well-trained 

behavioral health geriatric workforce. Topics 

include mental illness, SUDs, models of care, and 

specialized programs. 

The IOM Committee on the Mental Health 

Workforce for Geriatric Populations assessed the 

mental health and SUD needs of adults ages 65 

238 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

and older. It learned that older adults face a wide 

range of negative effects related to issues such as 

emotional distress, functional disability, decreased 

quality of life, and increased mortality. The 

committee used these data to develop workforce 

recommendations to address these negative 

effects. Topics include education, training, modes 

of practice, as well as the fnancing of public and 

private programs for older adults in need. 

For access to the full PDF at no cost, users can 

create a free account and log in. 

(Note that IOM is now the National Academy of 

Medicine.) 

Offce of Minority Health—National Standards 

for Culturally and Linguistically Appropriate 

Services (CLAS) in Health and Health Care 

https://thinkculturalhealth.hhs.gov/clas 

Resource summary: This document describes 

principles and standards of culturally appropriate 

treatment services that are applicable to diverse 

older adults in various health settings, including 

healthcare and behavioral health programs. The 

resource is intended for a broad audience that 

includes hospitals, clinics, community health 

centers, emergency services, public health 

stakeholders, and policymakers. 

The blueprint for implementing the standards 

includes a rationale section for enhancing national 

CLAS standards to ensure the delivery of effective, 

equitable, and respectful healthcare services and 

steps for achieving enhanced standards. Other 

topics include the recruitment, education, and 

retention of both leadership and a workforce 

that supports enhanced standards, as well as 

quality assessment, communication/language 

competence, and community partnerships. See 

https://thinkculturalhealth.hhs.gov/clas/blueprint. 

NCOA—Promoting Older Adult Health: Aging 

Network Partnerships to Address Medication, 

Alcohol, and Mental Health Problems 

www.ncoa.org/resources/promoting-older-adulthealth-aging-network-partnerships-to-addressmedication-alcohol-and-mental-health-problems 

Resource summary: This publication offers 

organizations information on linking providers of 

aging services with addiction and mental disorder 

treatment. It is dedicated to improving the lives of 

older adults facing addiction and mental illness by 

frst identifying them and then connecting them to 

appropriate intervention services. 

Contents deal with outreach, education, and 

prevention; screening, referral, and treatment; and 

service improvement by means of partnerships 

and team development. The appendixes list 

national partner organizations, federal and national 

agencies that provide resources on substance 

misuse and mental illness among older adults, and 

mental health and aging coalitions. 

Resources for Providers 

General Information 

SAMHSA—Addiction Technology Transfer Center 

(ATTC) Network 

https://attcnetwork.org 

Resource summary: The ATTC Network is a 

multidisciplinary resource for professionals in the 

addiction treatment and recovery services feld. 

The network’s 10 U.S-based centers, 2 national 

focus area centers, and network coordinating offce 

provide access to news, tools and other resources, 

and free and low-cost training programs in the 

addiction feld. For example, the Mid-America 

ATTC in 2019 released BHMEDS-R3, the latest 

version of its app on medications prescribed for 

SUDs and mental disorders. The app is meant to 

be a quick reference for nonprescribing behavioral 

health service professionals and for consumers. See 

https://attcnetwork.org/centers/mid-america-attc/ 

product/bhmeds-r3-app. 

APA Guidelines for Psychological Practice with 

Older Adults 

www.apa.org/pubs/journals/features/older-adults. 

pdf 

Resource summary: This APA resource updates 

the 2003 Guidelines for Psychological Practice 

with Older Adults. It provides information to 

psychologists on evaluating their own readiness for 

working with older adults. It also offers information 

on clinical issues, assessment, intervention, 

consultation, professional issues, and continuing 

education and training related to working with the 

older adult population. 

Chapter 9 239 
TIP 26

Council on Social Work Education— 

Gero-Ed Center 

www.cswe.org/Centers-Initiatives/CSWE-Gero-EdCenter.aspx 

Resource summary: This resource, aimed at 

social work faculty, students, practitioners, 

and program managers, offers free resources, 

educational materials, and curriculums to enhance 

the competencies of social work providers caring 

for older adults. Webinar topics include patientcentered medical homes, social work in integrated 

settings, and how to become a certifed application 

counselor to facilitate patient enrollment in the 

healthcare marketplace. 

Users can access educational resources, such as 

the Specialized Practice Curricular Guide for Gero 

Social Work Practice, information on workforce 

development projects, and specialized curriculums 

on age-friendly community initiatives, caregiver 

well-being, elder justice, rural aging, and LGBT 

older adults. 

NAADAC, The Association for Addiction 

Professionals—Institute Webinar Series 

www.naadac.org/webinars 

Resource summary: NAADAC provides free 

training and low-cost continuing education credits 

for addiction professionals. Webinars may be viewed 

live or on demand. Topics include SUD treatment, 

supervision, workforce development, veterans, 

families, trauma, and peer recovery support. 

NCOA—Resources 

www.ncoa.org/audience/professionalresources/?post_type=ncoaresource 

Resource summary: This webpage serves as a 

searchable database of more than 2,000 resources, 

including articles, webinars, and manuals, for 

providers who work with aging adults. Topics 

include fall prevention strategies and the role of 

self-management in chronic diseases. 

Alcohol Misuse and Drug Use 

SAMHSA—A Guide to Preventing Older Adult 

Alcohol and Psychoactive Medication Misuse/ 

Abuse: Screening and Brief Interventions 

www.ncoa.org/wp-content/uploads/SBIRT-OlderAdult-Manual-Final.pdf 

Treating Substance Use Disorder in Older Adults 

Resource summary: This document is an evidencebased practice manual for guiding behavioral 

health service providers and administrators in 

designing, implementing, and delivering screening 

and brief intervention programs to prevent 

substance misuse in older adults. It also includes a 

collection of resources. 

American Society of Addiction Medicine (ASAM) 

www.asam.org/asam-home-page 

Resource summary: The website offers information 

and education and training resources for medical 

providers in the feld of addiction medicine. The site 

also offers articles on advocacy issues and addiction 

news, among other resources. The information 

presented on the website is free, but training and 

education courses may require payment. 

Drug Interactions Checker 

www.drugs.com/drug_interactions.html 

Resource summary: This site features an 

interactive tool for consumers and clinicians that 

checks for drug interactions with other drugs, 

including over-the-counter (OTC) medications 

medications; foods; alcohol and other beverages; 

herbal products, and some medical conditions. 

Readers can search for information on drugs and 

have access to a searchable pill identifer, FDA 

alerts, news, and other resources for preventing 

unexpected consequences from medication use. 

National Institute on Drug Abuse (NIDA)— 

NIDAMED: Clinical Resources 

www.drugabuse.gov/nidamed-medical-healthprofessionals 

Resource summary: The NIDAMED website 

lists resources for healthcare professionals to 

learn about the effects of substance misuse on 

clients’ health and describes how to identify 

drug use early and prevent it from turning into 

misuse or addiction. Resources are tailored to 

emergency physicians, dentists, pharmacists, family 

physicians, nurse practitioners, physician assistants, 

pediatricians, osteopathic physicians, and addiction 

medicine specialists. 

Visitors to the site can access news; education and 

continuing medical education activities; information 

for patients, teens, and parents; and a clinician 

resource and quick reference guide for drug screening. 

240 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

NIAAA—Professional Education Materials 

www.niaaa.nih.gov/publications/clinical-guidesand-manuals 

Resource summary: This site is geared toward 

clinicians, physicians, social workers, and other 

providers who work with people who misuse 

alcohol. It offers access to screening, treatment 

planning, and general information. The site also 

provides links to related resources on such topics 

as medications for treating AUD, the impact of 

alcohol use on families, and epidemiologic data on 

alcohol use. 

NIDA—Screening for Drug Use in General 

Medical Settings: Resource Guide 

www.drugabuse.gov/sites/default/fles/resource_ 

guide.pdf 

Resource summary: This NIDA three-step resource 

guide describes how providers can use the NIDA 

Quick Screen and NIDA-modifed Alcohol, Smoking 

and Substance Involvement Screening Test (ASSIST) 

tools to determine clients’ risk of substance 

misuse. The NIDA Quick Screen can assess clients’ 

past-year drug use and alcohol misuse, and the 

ASSIST measures lifetime drug use and prescription 

medication misuse. The resource guide instructs 

providers on how to score these measures and how 

to follow up with clients based on their results. 

VA—Brief Addiction Monitor 

www.mentalhealth.va.gov/communityproviders/ 

docs/bam_continuous_3-10-14.pdf 

Resource summary: This questionnaire collects 

information from patients in recovery on drug and 

alcohol use, emotional and physical well-being, 

income needs, and risk activities. This screening 

tool may be downloaded at no cost. 

VA/Department of Defense (DoD) Clinical 

Practice Guideline: Management of Opioid 

Therapy for Chronic Pain 

www.healthquality.va.gov/guidelines/Pain/cot 

Resource summary: This publication, cosponsored 

by DoD and the VA, provides practitioners with 

the most current recommendations on prescribing 

opioid therapy for chronic pain throughout the 

DoD and VA healthcare systems. The webpage 

with the link to this publication also contains 

patient–provider tools for identifying risks 

associated with opioid use, managing side effects, 

and tapering and discontinuing opioids. 

VA—Opioid Safety Initiative 

www.va.gov/PAINMANAGEMENT/Opioid_Safety_ 

Initiative_OSI.asp 

Resource summary: The VA Opioid Safety Initiative 

page features a toolkit for clinical practice. It 

includes an updated patient education guide, an 

acute pain provider guide, a quick pain reference 

guide, as well as medication guidelines, forms, and 

a treatment manual. Clinical teams caring for older 

veterans with chronic pain may fnd this information 

useful. 

The page also provides information on opioid 

therapy risks, resources on opioids for veterans 

and providers, and access to the National Library 

of Medicine Opiate Addiction Portal and Opioid 

Safety Initiative materials. 

World Health Organization (WHO)—The ASSIST 

Screening Test Version 3.0 and Feedback Card 

www.who.int/substance_abuse/activities/assist_ 

test/en/ 

Resource summary: This validated interview tool 

is used to screen clients for all types of substance 

misuse. A computer version and a shorter version 

(ASSIST-Lite) are available. The full version of 

WHO’s ASSIST screener, scoring system, and client 

feedback guidance can be downloaded and is 

available in multiple languages. 

Dementia and Other Cognitive Disorders 

Alzheimer’s Association—2018 Dementia Care 

Practice Recommendations 

www.alz.org/professionals/professional-providers/ 

dementia_care_practice_recommendations 

Resource summary: These recommendations 

provide guidance to healthcare and social service 

providers who work with individuals living with 

dementia and their families in residential and 

community-based care settings. They aim to inform 

and infuence dementia care standards, training, 

practice, and policy. 

The document contains review articles on the 

fundamentals of person-centered care for 

individuals with dementia, person-centered 

assessment and care planning, evidence-based 

nonpharmacological practices to address 

Chapter 9 241 
TIP 26

behavioral and psychological symptoms of 

dementia, and evidence-based interventions 

for transitions in care for individuals living with 

dementia. The guide also discusses supportive and 

therapeutic environments for people living with 

dementia, practice principles for quality dementia 

care, progressive support activities of daily living 

for people living with dementia, ongoing medical 

management of dementia, and information on 

meeting the informational, educational, and 

psychosocial support needs of people living with 

dementia and their caregivers. 

Association for Frontotemporal Degeneration— 

For Health Professionals 

www.theaftd.org/for-health-professionals 

Resource summary: This webpage provides 

educational resources for healthcare professionals 

about frontotemporal degeneration (FTD), 

including clinical presentations of the various 

subtypes of FTD, approaches for diagnosing FTD, 

and methods for treating symptoms of FTD. It also 

links to support resources for those living with FTD 

and their families, and to research and clinical trials. 

NIA—Alzheimer’s and Dementia Resources for 

Professionals 

https://www.nia.nih.gov/health/alzheimersdementia-resources-for-professionals 

Resource summary: This NIA webpage offers free 

clinical practice tools for diagnosis, treatment, and 

management; training materials and professional 

curriculums; articles on patient care; and other 

resources on cognitive impairment for medical and 

behavioral health service providers who see older 

adults. 

The site also contains a section for caregivers and 

patients as well as links to e-alerts, news, funding 

announcements, and options for ordering free 

publications. 

Cognitive Screeners 

Alzheimer’s Association—Cognitive Assessment 

Toolkit 

www.alz.org/getmedia/9687d51e-641a-43a1-a96bb29eb00e72bb/cognitive-assessment-toolkit 

Resource summary: Developed by the Alzheimer’s 

Association, this toolkit is a collection of validated 

Treating Substance Use Disorder in Older Adults 

measures, including the Mini-Cog©, the Memory 

Impairment Screen, and the General Practitioner 

Assessment of Cognition, the short form of the 

Informant Questionnaire on Cognitive Decline in 

the Elderly, and the Eight-Item Informant Interview 

to Differentiate Aging and Dementia. The toolkit 

also contains a journal article on the association’s 

recommendations for assessing cognitive 

impairment during the Medicare Annual Wellness 

Visit using structured assessment tools. 

Mini-Cog© 

https://mini-cog.com/ 

Resource summary: This website provides 

guidance on how to administer this freeto-clinicians tool for screening for cognitive 

impairment in older adults. It contains details on 

how permissions (if required) may be obtained for 

use and provides downloadable PDFs for clinical 

use. The Mini-Cog© is available in English, Chinese, 

Arabic, Spanish, Portuguese, and Malay. 

Counseling Approaches 

A Clinician’s Guide to CBT With Older People 

www.uea.ac.uk/documents/246046/11919343/ 

CBT_BOOKLET_FINAL_FEB2016%287%29. 

pdf/280459ae-a1b8-4c31-a1b3-173c524330c9 

Resource summary: This workbook explores 

age-sensitive strategies for adapting CBT for older 

adults. It includes an overview of fundamentals 

required for increasing treatment access for older 

people, the problems of depression and anxiety 

in later life, age-appropriate augmentations to 

CBT, working with complex comorbidity issues, 

and the challenges of ageism in general and in 

the treatment feld itself. The workbook contains 

practical exercises and case studies illustrating 

how to use CBT to help older people reduce their 

symptoms of concern. 

Dialectical Behavior Therapy (DBT) Research 

and Training 

http://depts.washington.edu/uwbrtc/research/ 

treatment-development-clinic/ 

Resource summary: This webpage, for the 

Behavioral Research & Therapy Clinics (BRTC) 

at the University of Washington, explains that 

DBT incorporates mindfulness practices to help 

242 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

people manage overwhelming emotions. It is 

a skill-building approach that shows promise in 

treating older adults who experience emotional 

dysregulation and have poor interpersonal skills. 

The page provides links to research and training 

areas, BRTC research, the treatment development 

clinic, publications, and a subscription area for 

receiving related news. 

Dulwich Centre—A Gateway to Narrative 

Therapy and Community Work 

https://dulwichcentre.com.au 

Resource summary: This site provides information 

and educational resources on narrative therapy, 

a link to collective projects, and access to the 

subscriber page of the International Journal of 

Narrative Therapy and Community Work. 

Motivational Interviewing Network of Trainers 

(MINT) 

https://motivationalinterviewing.org 

Resource summary: The MINT website provides 

users with information about the network, how 

to join, and a library of MI publications. The site 

includes references, articles, videos, and links to 

training opportunities in the theory and practice 

of MI. Users can search the site for trainings and 

events, information about MI, MI in the news, news 

about MINT, MI research, and other resources. 

NIAAA—Twelve Step Facilitation (TSF) Therapy 

Manual 

https://pubs.niaaa.nih.gov/publications/ 

projectmatch/match01.pdf 

Resource summary: The TSF manual provides 

step-by-step instruction on using TSF for treating 

alcohol misuse. Its practical rules are applicable 

across a variety of outpatient treatment settings 

and it is fexible enough to allow for individual 

treatment interventions that are consistent with the 

12 Steps of Alcoholics Anonymous. 

Anxiety and Depression 

SAMHSA—Older Americans Behavioral Health: 

Issue Brief 6, Depression and Anxiety: Screening 

and Intervention 

https://acl.gov/sites/default/fles/programs/2016-

11/Issue%20Brief%206%20Depression%20and%20 

Anxiety.pdf 

Resource summary: This document, published 

by SAMHSA and AoA, provides an overview 

of depression and anxiety in older adults, 

links to screening and assessment tools, and 

recommendations for treatment by healthcare and 

social service organizations. It provides links to 

several depression and anxiety measures, including 

the Geriatric Depression Scale (GDS) and the 

nine-item Patient Health Questionnaire (PHQ-9). 

The authors discuss several evidence-based 

treatment programs, such as PEARLS (Program to 

Encourage Active, Rewarding Lives for Seniors) 

and the Healthy IDEAS (Identifying Depression 

& Empowering Activities for Seniors) model of 

community-based depression care management. 

The document also includes recommendations for 

aging services providers, behavioral health service 

providers, and healthcare providers on treatment 

options and fnancing. 

SAMHSA—Treatment of Depression in Older 

Adults, Evidence-Based Practices Kit 

https://store.samhsa.gov/product/TreatmentDepression-Older-Adults-Evidence-BasedPractices-EBP-Kit/SMA11-4631 

Resource summary: SAMHSA offers this toolkit, 

which provides indepth information for family, 

caregivers, providers, and administrators 

on treatment of depression in older adults. 

Information includes evidence-based guidelines 

for screening, treating, and assessing depression in 

older adults, along with planning, implementation, 

and maintenance ideas. This free kit is available as 

downloadable PDFs. 

Anxiety and Depression Association of America 

(ADAA) 

https://adaa.org 

Resource summary: ADAA promotes awareness 

of anxiety disorders and depression and supports 

scientifc innovation in treatment. The website 

contains information and links to education, 

treatment, resources, and support for the public 

and for treatment providers. Consumers can fnd 

therapists and support groups, blog posts, the 

ADAA newsletter, news, and tips for managing 

symptoms. The site also provides access to a free 

online support group. 

Chapter 9 243 
TIP 26 Treating Substance Use Disorder in Older Adults 

Posttraumatic Stress Disorder (PTSD) and 

Trauma 

SAMHSA’s Concept of Trauma and Guidance for 

a Trauma-Informed Approach 

https://store.samhsa.gov/product/SMA14-4884 

Resource summary: The purpose of this 

publication is to provide a working concept of 

trauma and key principles of a trauma-informed 

treatment approach that can be used not only 

by the behavioral health service sector, but by an 

array of service systems. The paper also provides 

suggested guidance for implementing a traumainformed approach. 

National Center for PTSD—For Providers 

www.ptsd.va.gov/professional/index.asp 

Resource summary: This VA webpage offers 

training materials, information, and tools to 

help with assessing and treating trauma-related 

disorders. It contains links to continuing education 

on PTSD assessment approaches and measures, 

essential treatments and treatment approaches for 

specifc populations (including older adults), and a 

consultation program for VA and non-VA providers 

serving veterans. 

Short Post-Traumatic Stress Disorder Rating 

Interview (SPRINT) Self-Report Screen 

www.ptsd.va.gov/professional/assessment/screens/ 

sprint.asp 

Resource summary: SPRINT is a valid, reliable 

measure for asking about different PTSD 

symptoms. Visit the webpage to learn how to get 

copies of SPRINT. 

SPAN Self-Report Screen 

www.ptsd.va.gov/professional/assessment/screens/ 

span.asp 

Resource summary: SPAN is named for the trauma 

symptoms it measures (Startle, Physically upset by 

reminders, Anger, and Numbness). Respondents 

rate four items on a fve-point scale. Visit the 

webpage for information on how to get copies of 

SPAN. 

Trauma Screening Questionnaire (TSQ) 

www.ptsd.va.gov/professional/assessment/screens/ 

tsq.asp 

Resource summary: The TSQ is a brief 10-item 

self-report screening measure designed for use 

with survivors of all types of traumatic stress. For 

sample items and information on how to get copies 

of the TSQ, see the webpage provided. 

Tobacco Use 

CDC—Smoking & Tobacco Use 

www.cdc.gov/tobacco 

Resource summary: This webpage provides 

free resources and information for clients and 

clinicians for reducing cigarette smoking, tobacco 

dependence, and related consequences of tobacco 

use. The site also offers tools and resources; 

data and statistics; multimedia options; state and 

community resources; stories and tips from former 

smokers; and information on global tobacco 

control activities, tobacco-related disparities, and 

special populations. 

HHS—Million Hearts® Initiative: Tobacco Use 

https://millionhearts.hhs.gov/tools-protocols/tools/ 

tobacco-use.html 

Resource summary: Providers can use the tools 

on this webpage to improve the tobacco use 

interventions they undertake as part of clinical care. 

National Cancer Institute (NCI)—Smokefree.gov 

https://smokefree.gov 

Resource summary: Smokefree.gov explains the 

journey from wanting to quit to taking action and 

offers free support to help clients quit tobacco. 

The site provides tips for how to cope with stress 

without smoking, steps for preparing to quit, and 

ideas for managing cravings. It discusses withdrawal 

symptoms, triggers, and the health benefts of 

quitting and offers a variety of ways for smokers 

to reach their goals, including the use of nicotine 

replacement therapy, smoke-free apps, social media 

support, and smoke-free texting programs. The site 

offers links to other Smokefree.gov pages specifc 

to the needs of women, veterans, teens, Spanish 

speakers, and people over 60. 

244 Chapter 9 
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Health and Wellness 

SAMHSA—Treating Sleep Problems of People in 

Recovery From Substance Use Disorders: In Brief 

https://store.samhsa.gov/product/ 

Treating-Sleep-Problems-of-People-inRecovery-From-Substance-Use-Disorders/ 

sma14-4859 

Resource summary: This publication offers tips 

for healthcare providers on how to help clients in 

recovery from SUDs who have sleep problems. It 

discusses the potential impact of poor sleep on 

recovery and offers recommendations on screening 

and treatment. 

American Geriatrics Society—Complementary 

and Integrative Medicine 

(https://geriatricscareonline.org/FullText/B030/ 

B030_VOL001_PART001_SEC002_CH012) 

Resource summary: This webpage offers a useful 

summary of complementary and integrative 

medicine approaches. The page also includes a 

table listing natural products and their interactions 

with prescribed medications, as well as a summary 

of the evidence base for complementary and 

integrative medicine approaches as they relate to 

different health conditions common in aging. 

CDC—Timed Up & Go (TUG) Test 

www.cdc.gov/steadi/pdf/TUG_Test-print.pdf 

Resource summary: The TUG test is part of the 

Stopping Elderly Accidents, Deaths, and Injuries 

(STEADI) Program from CDC. The test assesses 

a client’s ability to stand from a sitting position, 

walk a short distance (10 feet), turn around, and 

walk back to where he or she was sitting. Several 

parameters are measured during the exercise, such 

as gait, arm swinging, shuffing, posture, stride, and 

time to completion of the task. Results are used to 

gauge the person’s risk for falling or to indicate a 

possible need for further clinical evaluation. 

CMS—Annual Wellness Visit 

www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/downloads/ 

AWV_chart_ICN905706.pdf 

Resource summary: This document is targeted to 

Medicare fee-for-service providers to help them 

provide covered services to their patients during 

annual wellness visits. It can be printed out in hard 

copy but also contains links to resources such as 

the CMS Initial Preventive Physical Examination 

sheet, CDC’s health risk assessment framework, 

Medicare’s coverage of SUD treatment services, 

and Medicare’s claims processing manual, which 

contains coding for rural health clinics and federally 

qualifed health centers. 

NCOA—Center for Healthy Aging 

www.ncoa.org/center-for-healthy-aging 

Resource summary: The Center for Healthy Aging 

collaborates with national, state, and community 

partners to improve the lives of aging adults. It 

supports expansion and sustainability efforts aimed 

at health promotion and disease prevention among 

this population. It provides educational resources 

on health and wellness, disease management, 

nutrition, exercise, and fall prevention for older 

adults. 

The center houses the National Chronic Disease 

Self-Management Education Resource Center and 

the National Falls Prevention Resource Center, 

both funded by ACL. These resources are for 

clinicians and consumers. 

NCOA—Engaging American Indian/Alaska Native 

Elders in Falls Prevention Programs 

www.ncoa.org/resources/engaging-americanindianalaska-native-elders-falls-preventionprograms 

Resource summary: This NCOA webpage has a 

link to a tip sheet with culturally sensitive, practical 

strategies for engaging American Indian and 

Alaska Native elders in fall prevention efforts. 

Users can download a tip sheet that discusses 

the issue of falls among the elderly and related 

impacts, risk factors, the needs of aging tribal 

members, intervention approaches that leverage 

existing resources, and ways to ensure a culturally 

competent workforce. 

NIA—Health Information 

www.nia.nih.gov/health 

Resource summary: This page of the NIA site 

offers easy-to-read information on a broad range 

of health topics specifc to older adults, including 

healthy eating, exercise, and fall prevention. Users 

can search for such topics as Alzheimer’s disease, 

caregiving, cognitive health, physical activity, 

healthy eating, doctor–patient communication, 

menopause, hyperthermia, shingles, heart health, 

Chapter 9 245 
TIP 26

depression, Lewy-body dementia, and advance care 

planning. They can also order print publications, 

fnd opportunities to participate in clinical trials, and 

contact NIA for more specifc information. 

Self-Management Resource Center 

www.selfmanagementresource.com 

Resource summary: The center makes available a 

variety of small-group self-management programs 

for chronic illness. The programs are available 

online or through licensed local organizations. 

In addition to the core program for groups with 

multiple chronic illnesses, several conditionfocused programs are offered, including ones for 

diabetes, chronic pain, and HIV. These programs 

were originally developed by and housed at the 

Stanford Patient Education Research Center. 

The site provides information about provider 

training as well as licensing for organizations 

that would like to offer one or more of the selfmanagement programs. The site also provides 

access to implementation tools, trainer certifcation 

guidelines, administrative manuals in English and 

Spanish, and facilitator videos, and it links to a 

locator for fnding local programs. 

Resources for Clients and Families 

General 

NCOA 

www.ncoa.org 

Resource summary: NCOA promotes the health 

and economic security of older adults. Its website 

maintains a collection of resources on healthy 

aging for providers, older adults, advocates, and 

caregivers, including news on related topics of 

interest; innovations in the feld; and information on 

economic security, healthy living, and public policy 

affecting older adults. The site also provides links to 

interactive tools for determining benefts, getting 

fnancial tips, and fnding the best Medicare plan. 

NCOA—Resources 

www.ncoa.org/audience/older-adults-caregiversresources/?post_type=ncoaresource 

Resource summary: This webpage contains a 

searchable database of articles and webinars on 

topics ranging from behavioral health issues to fall 

prevention. 

Treating Substance Use Disorder in Older Adults 

Alcohol Misuse and Drug Use 

SAMHSA—Finding Quality Treatment for 

Substance Use Disorders 

https://store.samhsa.gov/product/FindingQuality-Treatment-for-Substance-Use-Disorders/ 

PEP18-TREATMENT-LOC 

Resource summary: This one-page downloadable 

factsheet provides useful guidelines for fnding 

a quality SUD treatment provider. It identifes 

steps for accessing care and the fve signs of 

quality treatment: program and staff accreditation, 

availability of FDA-approved medications, use of 

evidence-based practices, promotion of family 

involvement, and provision of ongoing support 

(e.g., ongoing counseling, help with meeting basic 

needs like sober housing). 

A.A. for the Older Alcoholic—Never Too Late 

www.aa.org/assets/en_US/p-22_AAfortheOlderAA. 

pdf 

Resource summary: This booklet presents stories 

from men and women who became involved 

with AA as older adults. It recreates the narrative 

approach of AA speakers at meetings in a largeprint format. The stories briefy describe the 

individuals and the transformation to sobriety that 

they achieved through attending AA meetings. 

How Do You Talk to Older Adults Who May Be 

Addicted? 

www.hazeldenbettyford.org/articles/how-to-talk-toan-older-person-who-has-a-problem-with-alcoholor-medications 

Resource summary: This easy-to-read online 

article can be used by family members and others 

concerned about an older adult’s use of alcohol 

or drugs. It offers information about how to 

identify signs that an older adult may be misusing 

alcohol or drugs, how to talk with the older person 

nonconfrontationally, and how to get help. The 

article presents practical approaches and specifc 

language for talking with older adults in the case of 

risky alcohol or medication use. 

Interactive Alcohol Misuse Screener 

www.alcoholscreening.org 

Resource summary: AlcoholScreening.org is a free 

service of the Center on Addiction. The screening 

tool is designed to help people determine whether 

their alcohol use is harmful to their health or if it 

246 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

increases their risk for future harm. Depending on 

the results of the screener, the site offers guidance 

on lowering a person’s risks of harm from drinking 

and urges those with hazardous drinking patterns to 

take positive action. Note that the site’s discussion of 

drinking in moderation is not specifc to older adults. 

MedicareInteractive.org—Treatment for 

Alcoholism and Substance Use Disorder 

www.medicareinteractive.org/get-answers/ 

medicare-covered-services/mental-health-services/ 

treatment-for-alcoholism-and-substance-abuse 

Resource summary: This webpage discusses 

Medicare coverage of treatment for SUDs. 

NIAAA Alcohol Treatment Navigator 

https://alcoholtreatment.niaaa.nih.gov 

Resource summary: This website helps consumers 

understand AUD and take steps for fnding the 

best treatment options based on individual needs 

and preferences. It explains the different types of 

treatment available, associated costs, and ways to 

identify quality treatment. 

The site offers a downloadable toolkit to help users 

organize and simplify their search process. 

NIAAA—Rethinking Drinking: Alcohol & Your 

Health 

www.rethinkingdrinking.niaaa.nih.gov 

Resource summary: This interactive website 

from NIAAA provides consumers with accurate 

information about what a standard drink is and 

how to calculate their level of alcohol consumption 

based on the types and quantity of alcoholic 

beverages they consume. See the Drink Size 

Calculator (www.rethinkingdrinking.niaaa.nih. 

gov/Tools/Calculators/Drink-Size-Calculator. 

aspx) and the Cocktail Content Calculator (www. 

rethinkingdrinking.niaaa.nih.gov/Tools/Calculators/ 

Cocktail-Calculator.aspx). Note that guidelines 

at this website are for all adults; they are not 

specifc to older adults. Users can download 

publications in English- or Spanish-language 

versions. 

NIA—Alcohol Use or Abuse 

www.nia.nih.gov/health/topics/alcohol-use-orabuse 

Resource summary: This webpage provides 

readers with tips on discussing sensitive topics 

with their healthcare providers, including alcohol 

use. It also provides information on how to help 

someone who misuses alcohol, recognize when 

drinking has become a problem, and understand 

the relationship between alcohol and drug 

use. Consumers can fnd facts about aging and 

alcohol, such as how alcohol may affect older 

people differently than younger people, and how 

heavy drinking can cause health problems, make 

some health problems worse, and affect safety in 

general. 

NIA—Older Adults and Alcohol: You Can 

Get Help 

https://order.nia.nih.gov/sites/default/fles/2018-

01/older-adults-and-alcohol.pdf 

Resource summary: This publication is for 

older adults and their family members, friends, 

and caregivers. It provides free, easy-to-read 

information and answers to common questions 

about how alcohol affects the body as people 

age and how to get help if drinking is negatively 

affecting health. The document explains how the 

aging body becomes more sensitive to the effects 

of alcohol and how heavy drinking can make 

some health problems worse. It also discusses the 

harmful effects of drinking alcohol while taking 

medicines, as well as the benefts of social supports 

for cutting down or quitting drinking. 

Alcohol and Medication Interactions 

Drugs.com—Drug Interactions Checker 

www.drugs.com/drug_interactions.html 

Resource summary: Consumers can access 

information that explains what drug–drug 

interactions are, how they occur, how to check for 

them, and what other factors can cause interactions 

with certain medications. Consumers can also check 

medication–alcohol interactions and download the 

website’s mobile app for information on the go. The 

app is compatible with Android and iOS devices. 

FDA—My Medicine Record 

www.fda.gov/downloads/AboutFDA/ 

ReportsManualsForms/Forms/UCM095018.pdf 

Resource summary: My Medicine Record is a form 

that clients can use to keep track of all of their 

medications and record any adverse reactions that 

occur. It includes sections for recording emergency 

contact information, primary care physician, 

Chapter 9 247 
TIP 26

and pharmacy. The form also provides a list of 

questions to ask providers about medications and 

dietary supplements. Clients can enter information 

electronically or print the form and write on it. 

NIAAA—Harmful Interactions: Mixing Alcohol 

With Medicines 

https://pubs.niaaa.nih.gov/publications/Medicine/ 

Harmful_Interactions.pdf 

Resource summary: This 10-page pamphlet 

discusses commonly used prescription and OTC 

medications and how they interact with alcohol. 

After giving a brief explanation of the dangers 

involved, such as reduced effectiveness of the 

medication or toxicity, the document displays a 

multipage table that contains a list of commonly 

used medications, by brand names and generic 

names, and identifes the reactions that might 

occur when drinking alcohol and taking a given 

medication. 

Tobacco Use 

NIA—Quitting Smoking for Older Adults 

www.nia.nih.gov/health/quitting-smokingolder-adults 

Resource summary: This webpage provides free 

information to help older adults quit smoking. 

It contains a list of federal resources and their 

associated quit lines and discusses the dangers 

of traditional cigarettes, cigars, pipes, hookahs, 

chewing tobacco, snuff, and secondhand smoke, 

and the benefts of quitting at any age. Some of 

the dangers are increased risks for lung disease, 

heart disease, cancer, respiratory disease, 

osteoporosis, eye disease, and diabetes. 

NCI—Clear Horizons: A Quit-Smoking Guide for 

People 50 and Older 

https://smokefree.gov/sites/default/fles/pdf/clearhorizons-accessible.pdf 

Resource summary: Clear Horizons serves as 

both a self-help guide for older smokers who 

want to quit and an addiction counseling protocol 

for clinicians who work with this population. The 

document contains information on the health 

benefts of quitting smoking, step-by-step 

guidance for preparing to quit, and tips for 

remaining smoke free. 

Treating Substance Use Disorder in Older Adults 

Content addresses the issues of individual triggers, 

craving, withdrawal, and “slips.” The guide says 

that slipping back into the smoking habit is 

common but emphasizes that this does not indicate 

failure. The guide recommends getting back on 

track after a slip by following the 4 D’s: Distract 

yourself, Deep breathing, Drink water, and Do 

something else. Information about quit-smoking 

medication, consumer resources, and a sample quit 

journal can also be found in the guide. 

Mutual-Help Groups 

Al-Anon 

https://al-anon.org/ 

Resource summary: Al-Anon family group 

meetings allow friends and family members of 

people who misuse substances to share their 

experiences and learn how to apply the principles 

of the Al-Anon program to their individual 

situations. Sponsorship gives members the chance 

to receive personal support from more experienced 

individuals in the program. Many Al-Anon 

members beneft by hearing about situations and 

relationships that are similar to their own. 

Al-Anon literature is available in more than 40 

languages. The Al-Anon/Alateen Service Manual is 

available in Spanish and French, and the Al-Anon 

website is available in English, Spanish, and French. 

Alcoholics Anonymous (AA) 

https://aa.org/ 

Resource summary: The AA website offers 

information about alcohol misuse and links to local 

resources that provide lists of AA group meetings 

for people who misuse alcohol and want to stop. 

AA sponsors provide members with more personal 

support from experienced individuals. 

Information is provided for clinicians, AA 

members, and the general public. Local resources 

can be obtained by entering in your ZIP Code. 

The site showcases a number of public service 

announcements (available in English, Spanish, and 

French), as well as AA literature, e-books, selfsupport resources, the press page, General Service 

Board, General Service Offce newsletters, regional 

forums information, and international AA activities. 

248 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

Narcotics Anonymous (NA) 

www.na.org 

Resource summary: NA is a global communitybased organization with a multilingual, multicultural 

membership that supports addiction recovery via a 

12-Step program, including regular group meeting 

attendance. It is an ongoing support network for 

maintaining a drug-free lifestyle. 

The website features information for the public, 

literature and other products, a link to events, 

resources and updates for NA members, and an 

interactive database to search for local helplines 

and meetings. 

Secular Organizations for Sobriety (SOS) 

www.sossobriety.org 

Resource summary: SOS is a network of support 

groups focused on helping people achieve sobriety 

from SUDs or compulsive eating using meeting 

support in a secular setting. Consumers who 

want to fnd a meeting must send a message and 

provide their name, phone number, and email 

address. 

Seniors In Sobriety (SIS) 

www.seniorsinsobriety.com 

Resource summary: SIS is an offshoot of AA 

and has been actively reaching out to older 

adults with AUD since 1990. Its outreach efforts 

include encouraging local meetings to designate 

themselves as senior friendly and starting SIS 

meetings. 

This website provides information about SIS’s 

history, focus, and annual conference. It also has 

a list of meetings where older adults who misuse 

alcohol can meet for fellowship, help with cutting 

down or quitting alcohol consumption, and 

education on the unique problems alcohol misuse 

causes their age group. 

SMART (Self-Management and Recovery 

Training) Recovery 

www.smartrecovery.org 

Resource summary: The SMART Recovery website 

provides information about its program, training 

opportunities, and a searchable database of local 

and online meetings in the United States and 

abroad. The SMART Recovery program supports 

people who are trying to break free from addictive 

activities of all kinds. It provides education and 

tools to help clients change their behaviors and 

thinking. The site’s SMART Recovery Toolbox 

includes quick reference worksheets, homework 

exercises, and literature resources that focus on 

confdence building, coping with anxiety, decision 

making, and relapse prevention. 

Women for Sobriety (WFS) 

https://womenforsobriety.org 

Resource summary: WFS is a recovery program 

based on women’s unique emotional needs that 

focuses on helping women with SUDs enter 

into and maintain recovery. The WFS New Life 

Program is based on 13 Acceptance Statements 

that encourage emotional and spiritual growth. 

WFS has certifed moderators and chat leaders 

facilitating mutual-help groups online and in 

person, as well as phone volunteers available for 

one-on-one support. 

Consumers have access to information on the 

program, an interactive meeting fnder, online and 

phone support, the annual conference, a signup 

page for the email list, and articles. 

Caregiver Resources 

Alzheimer's Association—Support Groups 

www.alz.org/care/alzheimers-dementia-supportgroups.asp 

Resource summary: This webpage describes group 

meetings that provide a safe place for caregivers, 

family, and friends of people with dementia to 

meet and develop a mutual support system. The 

page provides a 24/7 helpline and a searchable 

database of caregiver support groups. 

Caregiver Self Assessment Questionnaire 

www.healthinaging.org/tools-and-tips/ 

caregiver-self-assessment-questionnaire 

Resource summary: Originally developed and 

tested by the American Medical Association, this 

questionnaire is hosted on the HealthinAging.org 

website and is available in multiple languages. The 

questionnaire is available as an interactive online 

assessment tool or can be downloaded as a PDF. 

Questions are related to physical, emotional, and 

mental conditions. 

Chapter 9 249 
TIP 26

 

Treating Substance Use Disorder in Older Adults 

ElderLaw Answers 

www.elderlawanswers.com 

Resource summary: ElderLaw Answers provides 

free tools and indepth information for consumers 

and elder law attorneys. The website maintains 

resources on fnancial and legal services related 

to caring for an older adult with healthcare and 

other needs. Consumers can search for information 

on estate planning, Medicaid, probate matters, 

long-term care insurance, nursing homes and other 

support care options, senior living, retirement 

planning, and veterans’ benefts, as well as answers 

to common questions and statistics on related 

issues. 

Family Caregiver Alliance (FCA) 

www.caregiver.org 

Resource summary: FCA works to address the 

needs of caregivers for family members. The site 

has information on complex caregiver challenges 

and provides education resources on chronic 

illnesses, a research registry, and advocacy tools. 

It also offers an information line for caregivers of 

adults with chronic medical illnesses living at home, 

online caregiver support groups, and an online 

Family Care Navigator that provides a state-bystate list of services and assistance for caregivers. 

mmLearn.org 

https://training.mmlearn.org/video-library 

Resource summary: mmLearn.org maintains a 

library of free videos for caregivers who seek 

practical ways to meet the physical, emotional, 

and spiritual needs of the older adults in their 

care. Videos are available on specifc topics, 

including substance misuse, Alzheimer’s disease, 

assistive devices, wound care, depression, and 

fall prevention. This resource also offers free 

continuing education for practitioners. 

National Caregivers Library 

www.caregiverslibrary.org 

Resource summary: This website contains an 

extensive online library for caregivers that includes 

useful articles, forms, checklists, and links to topicspecifc external resources. It offers free resources 

specifc to caregiving activities and support, 

self-care for the caregiver, employer support, 

nutrition, safety, disaster preparedness, elder 

abuse, and caregiving ministries. 

Topics discussed include disabilities, diseases, 

emotional issues, end-of-life issues, government 

resources, legal and money matters, and 

transportation. Users can fnd details on advanced 

directives, consumer protection, senior care 

options, and new research. 

VA—Caregiver Support 

www.caregiver.va.gov/Care_Caregivers.asp 

Resource summary: The VA offers a number of free 

services to support family caregivers of veterans, 

including the online workshop Building Better 

Caregivers, which gives caregivers information and 

tools to help them learn more effective caregiving 

strategies, as well as ways to manage their own 

stress and emotions. The webpage also offers 

links to many other caregiver resources, such as 

the VA’s Caregiver Support Line—an information 

and referral center staffed by licensed healthcare 

professionals; the Caregiver Support Website; 

the VA’s Peer Support Mentoring Program; a 

telephone-based coaching program for caregivers; 

a suicide prevention toolkit for caregivers; and 

a secure video-based tool that allows veterans 

and their caregivers to meet with VA healthcare 

providers through a computer or mobile phone 

application. In addition, caregivers can obtain 

help from the local VA Medical Center’s Caregiver 

Support Coordinator, a licensed professional 

who can provide valuable information and match 

caregivers with services for which they are eligible. 

The website provides or links to tips and tools on 

managing medicines, talking with providers, caring 

for oneself, staying organized, and other topics. It 

also has links to a hospital locator, health programs 

for veterans, long-term and community-based care, 

A–Z health topics, the National Center for PTSD, 

and the National Resource Directory. 

Health and Wellness 

ACL—Expand Your Circles: Prevent Isolation and 

Loneliness As You Age 

https://eldercare.acl.gov/Public/Resources/ 

Brochures/docs/Expanding-Circles.pdf 

Resource summary: This easy-to-read brochure 

offers tips for older adults on how to expand 

their social networks and remain socially engaged 

with others. It provides statistics related to social 

250 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

isolation among older adults; lists negative health 

effects associated with isolation and loneliness; and 

links to resources for connecting with other people. 

NIA—A Good Night’s Sleep 

www.nia.nih.gov/health/good-nights-sleep 

Resource summary: This NIA webpage focuses on 

the importance of a good night’s sleep. It discusses 

sleep apnea, movement disorders in sleep, and the 

effects of Alzheimer’s disease on sleep patterns, 

and tips for falling asleep safely. It also provides 

access to outside resources and articles on related 

topics, such as fatigue in older adults, sleep 

problems and menopause, and ways to manage 

sleep problems for older adults with Alzheimer’s 

disease. 

NIMH—Older Adults and Depression 

www.nimh.nih.gov/health/publications/ 

older-adults-and-depression/19-mh-8080-

olderadultsanddepression_153371.pdf 

Resource summary: This NIMH brochure discusses 

depression among older adults. The publication 

describes the most common types of depression, 

depression signs and risk factors, treatment 

options, and steps to take in addition to treatment. 

It also offers tips on how to help someone with 

depression and tells the reader what to do if he or 

she is having suicidal thoughts. 

Silver Sneakers—Health Fitness for Older Adults 

www.silversneakers.com 

Resource summary: Silver Sneakers is a fexible 

health and ftness program for adults ages 65 

and older. It is covered under some Medicare 

Advantage Plans. Classes are held in a variety of 

settings, such as gyms and community centers. 

Consumers can search the website for locations 

across the United States. 

Silver Sneakers ftness programs offer beginnerand experienced-level classes. Consumers can 

browse the different classes offered on the 

website, including cardio ftness lessons, lowimpact water activities, and balance training. If 

unable to attend classes in person, Silver Sneakers 

members can access online exercise videos on the 

website or use an online app to tailor their exercise 

program and track healthy living goals. 

The website also has links to articles and 

information about healthy living for seniors, 

including tips on preparing meals, beating the 

winter blues, volunteering, and maintaining 

interests. 

Technology and Social Media 

Lifeline Support 

www.lifelinesupport.org 

Resource summary: This federal program lowers 

the monthly cost of phone and Internet service for 

eligible customers who use a participating phone 

or Internet provider. The website explains eligibility 

requirements and the application process, and 

includes a locator for participating companies. 

Staying Connected: Technology Options for 

Older Adults 

https://eldercare.acl.gov/Public/Resources/ 

Brochures/docs/N4A_Tech_Brochure_P06_high.pdf 

Resource summary: This brochure introduces older 

adults to types of social media options and their 

benefts. It contains information on text messaging, 

Internet, email, Facebook, Skype, YouTube, instant 

messaging, Twitter, blogging, cell phones, and 

other technologies used to receive information and 

communicate with family and friends. The brochure 

briefy explains how and when to use social media, 

and gives privacy and etiquette tips. 

Dementia and Other Cognitive Disorders 

Alzheimer’s Association—Resources 

www.alz.org/help-support/resources 

Resource summary: This webpage has caregiver 

training resources in English and Spanish; a virtual 

library of publications, databases, and social media 

tools; information for children and teens; tips for 

handling holidays and resolving family conficts 

surrounding the disease; and other resources. 

Users can link to their local Alzheimer’s Association 

chapter, community resources, and message 

boards. 

Chapter 9 251 
TIP 26

Association for Frontotemporal Degeneration 

(AFTD)—Newly Diagnosed 

www.theaftd.org/living-with-ftd/newly-diagnosed 

Resource summary: This webpage has information 

on and links to AFTD’s Helpline, a detailed guide 

for people diagnosed with FTD, online and local 

support groups, printable FTD awareness cards, 

FTD FAQs, and caregiver resources. 

Treating Substance Use Disorder in Older Adults 

NIA—Dementia 

www.nia.nih.gov/health/topics/dementia 

Resource summary: This webpage provides health 

information about dementia—the different types 

of dementia, assessment and diagnosis, mixed 

dementia, end-of-life care for people with the 

disease, biomarker research, and support services. 

The page also contains links to other information 

on the NIA site, such as research and funding, 

news and events, and a free app for understanding 

medical scans. 

252 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

Provider Tools 

General 

Alcohol Use Quantity and Frequency Guidelines 

Federal guidelines defne the following levels of alcohol consumption; however, these numbers are 

applied to all adults, and older adults may need to adhere to lower amounts:1438,1439,1440,1441 

Moderate drinking: 

• Men: No more than two standard drinks per day. 

• Women: No more than one standard drink per day. 

• Both: The numbers apply to any given day and are not meant as averages over multiple days. 

Binge drinking: 

• Men: More than four standard drinks in a single day. 

• Women: More than three standard drinks in a single day. 

Older adults should not drink any alcohol if they: 

• Are taking certain prescription medications, especially psychoactive prescription medications (e.g., 

opioid analgesics and benzodiazepines). 

• Have medical conditions that can be made worse by alcohol (e.g., diabetes, heart disease). 

• Are planning to drive a car or engage in other activities requiring alertness and skill. 

• Are recovering from AUD. 

Provider Note: Guidelines are based on the standard drink equivalency provided. When you are taking a drinking 

history and assessing risk level, explore your client’s understanding of the meaning of “a drink” and the kind of 

alcoholic beverage they drink. For example, a typical mixed drink might be the equivalent of 1 to 3 standard drinks.1442 

Provide nonjudgmental feedback to clarify quantity and frequency estimates and to determine whether your client is 

consuming more than the recommended amount. 

Adapted from material in the public domain.1443,1444 

Chapter 9 253 
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Treating Substance Use Disorder in Older Adults 

Alcohol Misuse and Drug Use 

Alcohol and Drug Screening and Assessment Tools 

Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G) 

Resource summary: The SMAST-G is a screening tool for identifying alcohol misuse in older adults. It can 

be used in a variety of clinical settings, including general healthcare practices. 

Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G) 

Yes (1) No (0) 

1. When talking with others, do you ever underestimate how much you drink? 

2. After a few drinks, have you sometimes not eaten or been able to skip a meal because 

you didn’t feel hungry? 

3. Does having a few drinks help decrease your shakiness or tremors? 

4. Does alcohol sometimes make it hard for you to remember parts of the day or night? 

5. Do you usually take a drink to relax or calm your nerves? 

6. Do you drink to take your mind off your problems? 

7. Have you ever increased your drinking after experiencing a loss in your life? 

8. Has a doctor or nurse ever said they were worried or concerned about your drinking? 

9. Have you ever made rules to manage your drinking? 

10. When you feel lonely, does having a drink help? 

TOTAL SMAST-G-SCORE (0-10) _________ 

SCORING: 2 OR MORE “YES” RESPONSES IS INDICATIVE OF AN ALCOHOL PROBLEM. 

Ask the extra question below but do not calculate it in the fnal score. 

Extra question: Do you drink alcohol and take mood or mind-altering drugs, including prescription 

tranquilizers, prescription sleeping pills, prescription pain pills, or any illicit drugs? 

© The Regents of the University of Michigan, 1991. Source: University of Michigan Alcohol Research Center.1445 

Adapted with permission. 

254 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5): AUD Criteria and Older 

Adults Who Drink 

Resource summary: This tool summarizes physical, cognitive, and social aspects of aging to consider when 

using DSM-5 diagnostic criteria to assess and diagnose AUD in older adults. 

DSM-5 Criteria and Older Adults Who Drink 

DSM-5 CRITERIA FOR AUD1446 CLINICAL CONSIDERATIONS1447,1448,1449 

Criterion A1 Older adults may need less alcohol to feel physical effects. Cognitive 

impairment can make it hard for older adults to keep track of their drinking. 

Criterion A2 No special considerations for older adults. 

Criterion A3 Effects of alcohol can result from drinking even small amounts, so relatively 

less time may be spent getting and drinking alcohol and recovering from 

using it. 

Criterion A4 No special considerations for older adults. 

Criterion A5 Older adults may have different role responsibilities because of life-stage 

changes, such as retirement. Role responsibilities more common in older 

adulthood include caregiving for a spouse or another family member, such as 

a grandchild. 

Criterion A6 Older adults may not realize that social or interpersonal problems they are 

experiencing are connected to their alcohol use. 

Criterion A7 Older adults may take part in fewer activities generally, making it more 

diffcult to discover when drinking is causing them to withdraw from activities. 

Criterion A8 Older adults may not understand that their alcohol use is hazardous, 

especially when they are drinking the same as or less than before. In addition, 

older adults may not realize the physical dangers of drinking in certain 

situations (e.g., before using a step stool). 

Criterion A9 Older adults experiencing physical or psychological problems may not realize 

that drinking could be a factor. 

Criterion A10 Changes in tolerance occur because of increased sensitivity to alcohol 

with age. Previously manageable quantities of alcohol may cause greater 

impairment. 

Criterion A11 Withdrawal symptoms in older adults can last longer, be less obvious, or be 

mistaken for age-related illness. 

Comorbidity Alcohol Risk Evaluation Tool (CARET) 

Resource summary: The CARET screens for at-risk drinking in older adults by pairing quantity and 

frequency of drinking with specifc drinking behaviors, use of medications, and co-occurring conditions 

in the past 12 months. For more information about the items in the CARET and how to score them, 

please see Barnes et al., 2010.1450 

Chapter 9 255 
TIP 26 Treating Substance Use Disorder in Older Adults 

Alcohol Use Disorders Identifcation Test (AUDIT) 

www.drugabuse.gov/sites/default/fles/audit.pdf 

Resource summary: This validated screening tool was designed by WHO to assess alcohol misuse. The 

modifed version is useful for screening older adults, using a lower cutoff score than used for general adult 

populations. The adapted provider interview and client self-report versions are included here. 

Alcohol Use Disorders Identifcation Test (AUDIT): Interview Version 

Read questions as written. Record answers carefully. Begin the AUDIT by saying “Now I am going to ask you some 

questions about your use of alcoholic beverages during this past year.” Explain what is meant by “alcoholic beverages” 

by using local examples of beer, wine, vodka, etc. Code answers in terms of “standard drinks.” Place the correct answer 

number in the box at the right. 

1. How often do you have a drink containing 

alcohol? 

(0) Never [Skip to Qs 9-10] 

(1) Monthly or less 

(2) 2 to 4 times a month 

(3) 2 to 3 times a week 

(4) 4 or more times a week 

6. How often during the last year have you needed a frst drink in the morning to get yourself 

going after a heavy drinking session? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

2. How many drinks containing alcohol do you 

have on a typical day when you are drinking? 

(0) 1 or 2 

(1) 3 or 4 

(2) 5 or 6 

(3) 7, 8, or 9 

(4) 10 or more 

7. How often during the last year have you had 

a feeling of guilt or remorse after drinking? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

3. How often do you have six or more drinks on 

one occasion? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

Skip to Questions 9 and 10 if Total Score 

for Questions 2 and 3 = 0 

8. How often during the last year have you been 

unable to remember what happened the 

night before because you had been drinking? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

4. How often during the last year have you 

found that you were not able to stop 

drinking once you had started? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

9. Have you or someone else been injured as a 

result of your drinking? 

(0) No 

(2) Yes, but not in the last year 

(4) Yes, during the last year 

5. How often during the last year have you 

failed to do what was normally expected 

from you because of drinking? 

(0) Never 

(1) Less than monthly 

(2) Monthly 

(3) Weekly 

(4) Daily or almost daily 

10. Has a relative or friend or a doctor or 

another health worker been concerned 

about your drinking or suggested you 

cut down? 

(0) No 

(2) Yes, but not in the last year 

(4) Yes, during the last year 

Record total of specifc items here 

Scoring: The cutoff score indicating hazardous and harmful alcohol use for the AUDIT is generally 8; however, for older 

adults a score of 5 indicates a need for clarifying questions and further assessment.1451 

Adapted from Barbor et al. (2001).1452 

256 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

Alcohol Use Disorders Identifcation Test (AUDIT): Self-Report Version 

CLIENT: Alcohol use can affect your health and interfere with some medications and treatments, so it’s 

important that we ask some questions about your alcohol use. Your answers will remain confdential; please 

be honest. 

Place an X in one box that best describes your answer to each question. 

Questions 0 1 2 3 4 

1. How often do you have a drink 

containing alcohol? 

Never Monthly 

or less 

2-4 times 

a month 

2-3 times 

a week 

4 or more 

times a week 

2. How many drinks containing 

alcohol do you have on a typical 

day when you are drinking? 

1 or 2 3 or 4 5 or 6 7 to 9 10 or more 

3. How often do you have six or more 

drinks on one occasion? 

Never Less 

than 

monthly 

Monthly Weekly Daily or 

almost 

daily 

4. How often during the last year have 

you found that you were not able to 

stop drinking once you had started? 

Never Less 

than 

monthly 

Monthly Weekly Daily or 

almost 

daily 

5. How often during the last year 

have you failed to do what was 

normally expected of you because 

of drinking? 

Never Less 

than 

monthly 

Monthly Weekly Daily or 

almost 

daily 

6. How often during the last year 

have you needed a frst drink in the 

morning to get yourself going after 

a heavy drinking session? 

Never Less 

than 

monthly 

Monthly Weekly Daily or 

almost 

daily 

7. How often during the last year have 

you had a feeling of guilt or remorse 

after drinking? 

Never Less 

than 

monthly 

Monthly Weekly Daily or 

almost 

daily 

8. How often during the last year 

have you been unable to remember what happened the night 

before because of your drinking? 

Never Less 

than 

monthly 

Monthly Weekly Daily or 

almost 

daily 

9. Have you or someone else been 

injured because of your drinking? 

No Yes, but 

not in the 

last year 

Yes, 

during the 

last year 

10. Has a relative, friend, doctor, or 

other health care worker been 

concerned about your drinking 

or suggested you cut down? 

No Yes, but 

not in the 

last year 

Yes, 

during the 

last year 

Total 

Adapted from Barbor et al. (2001).1453 

Provider Note: The self-report version should be given to older clients to fll out. Ask them to 

return it to you, and then discuss the results with them. A cutoff score of 5 means you need to 

assess further.1454 

Chapter 9 257 
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Treating Substance Use Disorder in Older Adults 

Alcohol Use Disorders Identifcation Test-C (AUDIT-C) 

Resource summary: The AUDIT-C is a much shorter version of the AUDIT that can help you identify alcohol 

misuse in your clients. It contains only three questions, which add up to a total score of 0–12. A higher 

score usually means the client is engaging in more hazardous alcohol use. The AUDIT-C is scored 

as follows: 

• For Questions 1 and 3, assign 0 points to response a, 1 point to response b, 2 points to response c, 

3 points to response d, and 4 points to response e. 

• For Question 2, assign 0 points to responses a and b, 1 point to response c, 2 points to response d, 

3 points to response e, and 4 points to response f. 

A total score of 3 or higher for women and 4 or higher for men means problematic alcohol use. In such 

cases, you should assess further (or refer for formal assessment) to learn more about the client’s drinking 

habits and determine whether AUD is present. Learn more about the AUDIT-C, including how to score 

and interpret results, at www.queri.research.va.gov/tools/alcohol-misuse/alcohol-faqs.cfm#top. 

Alcohol Use Disorders Identifcation Test-C (AUDIT-C) 

Patient Name: ____________________________________________________________ Date:______________________ 

1. How often do you have a drink containing alcohol?

□ a. Never 

□ b. Monthly or less 

□ c. 2-4 times a month 

□ d. 2-3 times a week 

□ e. 4 or more times a week 

2. How many drinks containing alcohol did you have on a typical day when you were drinking in 

the past year?

□ a. 0 drinks 

□ b. 1 or 2 

□ c. 3 or 4 

□ d. 5 or 6 

□ e. 7 to 9 

□ f. 10 or more 

3. How often do you have six or more drinks on one occasion?

□ a. Never 

□ b. Less than monthly 

□ c. Monthly 

□ d. Weekly 

□ e. Daily or almost daily 

Adapted from material in the public domain.1455,1456 

258 Chapter 9 
TIP 26

 

Chapter 9—Resources for Treating Substance Use Disorder in Older Adults 

Senior Alcohol Misuse Indicator (SAMI) 

Resource summary: SAMI is a tool for assessing older adults who may have at-risk alcohol use. A score of 

1 or higher suggests at-risk drinking. 

Senior Alcohol Misuse Indicator (SAMI) 

1a. Have you recently (in the last few months) experienced problems with any of the following

 (if yes, please check box): 

Changes in sleep? Changes in appetite or weight? Dizziness? 

Drowsiness? Diffculty remembering things? Poor balance? 

Falls? 

1b. Have you recently (in the last few months) experienced problems with any of the following 

(if yes, please check box): 

Feelings of sadness? Lack of interest in daily activities? Feelings of 

worthlessness? Loneliness? Feelings of anxiety? 

2. Do you enjoy wine/beer/spirits? Which do you prefer? 

3. As your life has changed, how has your use of [selected] wine/beer/spirits changed? 

4. Do you fnd you enjoy [selected] wine/beer/spirits as much as you used to? Yes No 

(For clinical use. Not included in scoring.) 

5. You mentioned that you have diffculties with_______________ (from answers to questions 1a and b). 

I am wondering if you think that [selected] wine/beer/spirits might be connected? Yes No 

SCORING KEY 

Single responses (a score of 1 for each Multiple responses (a score of 1 for each 

response): combination of responses): 

Question 2: Question 2 & 3:

Yes, I do enjoy alcohol I enjoy all three of wine/beer/spirits OR 

There has been no change in alcohol consumption I enjoy a combination of any two 

from wine/beer/spirits => If both responses provided, check box => 

Question 3: Question 1, 2 & 3:

Yes, I have experienced 5 or more symptoms I have increased alcohol consumption 

from when I was younger Yes, I do enjoy alcohol 

Indicates any current alcohol consumption Question 5: (regardless of any change in pattern) Yes, there may be a connection between 

my alcohol use and health => If all three responses provided, check box => 

SUBTOTAL 2 = ____________ /2 SUBTOTAL 1 = ____________ /3 

TOTAL SCORE = SUBTOTAL 1 + SUBTOTAL 2 = ________________ 

Developed by B. Purcell. © Centre for Addiction and Mental Health, 2003. The Senior Alcohol Misuse Indicator is licensed 1457 for reuse under the terms of Creative Commons Attribution-NonCommercial-NoDerivs CC BY-NC-ND.

Chapter 9 259 
TIP 26 Treating Substance Use Disorder in Older Adults 

Cannabis Use Disorder Identifcation Test-Revised (CUDIT-R)1458 

https://adai.uw.edu/instruments/pdf/Cannabis%20Use%20Disorders%20Identifcation 

%20Test%20Revised%2059.pdf 

Resource summary: This test measures problem cannabis use in the past 6 months. A score of 8 or more 

indicates hazardous use; a score of 12 or more indicates the need to assess for cannabis use disorder. 

Cannabis Use Disorder Identifcation Test-Revised (CUDIT-R) 

Reprinted from material in the public domain.1459 

260 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

CAGE Adapted to Include Drugs (CAGE-AID) 

Resource summary: The CAGE (Cut down, Annoyed, Guilty, Eye opener) Questionnaire has been widely 

used to screen for risk of alcohol misuse. This similar version, the CAGE-AID,1460 asks about alcohol misuse 

and drug use. A “yes” response to any of the questions can mean that substance misuse is present. 

However, the CAGE-AID does not ask about certain important aspects of substance use, including past 

substance use, frequency of use, and effects of using the substance. It is available at www.hiv.uw.edu/ 

page/substance-use/cage-aid. 

Treatment Planning 

Alcohol Health-Related Risk and Treatment Response Pyramid1461,1462,1463 

Resource summary: The Alcohol Health-Related Risk and Treatment Response Pyramid illustrates how to 

apply clinical interventions to corresponding levels of health-related risk associated with drinking. It can be 

used to assess older adults’ risks. 

Alcohol Health-Related Risk and Treatment Response Pyramid 

Chapter 9 261 
TIP 26

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

Treating Substance Use Disorder in Older Adults 

Alcohol Use Agreement and Drinking Diary Cards 

Resource summary: Providers can use these sample forms to develop an alcohol consumption 

agreement with clients and help them track their daily drinking. 

Alcohol Use Agreement and Drinking Diary Cards 

The purpose of this step is to decide on a drinking limit for yourself for a particular period of time. 

Negotiate with your healthcare provider so you can both agree on a reasonable goal. A reasonable 

goal for some people is abstinence—not drinking any alcohol. 

As you develop this agreement, answer the following questions: 

• How many standard drinks? 

• How frequently? 

• For what period of time? 

Agreement 

Date ______________ 

Client signature __________________________________ 

Clinician signature ________________________________ 

Drinking Diary Card 

One way to keep track of how much you drink is the use of drinking diary cards. One card is used for each 

week. Every day record the number of drinks you had. At the end of the week 

add up the total number of drinks you had during the week. 

Card A Card B 

Keep Track of What You Drink Over Keep Track of What You Drink Over 

The Next 7 Days The Next 7 Days 

Starting Date ________________________________ 

Beer Wine Liquor Number 

Sunday 

Monday 

Tuesday 

Wednesday 

Thursday 

Friday 

Saturday 

WEEK’S TOTAL: 

Starting Date ________________________________ 

Beer Wine Liquor Number 

Sunday 

Monday 

Tuesday 

Wednesday 

Thursday 

Friday 

Saturday 

WEEK’S TOTAL: 

Adapted from material in the public domain.1464 

262 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

Behavioral Health and Cognitive Impairment Screening and Assessment Tools 

Generalized Anxiety Disorder (GAD-7) Screening Tool 

Resource summary: This well-established diagnostic tool diagnoses anxiety and measures its severity. 

It is a self-report scale that asks individuals to rate symptoms over the past 2 weeks. The GAD-7 has 

been validated with older adults with a cutoff score of 5 for older adults indicating a need for further 

assessment.1465 For more on the GAD-7 and its questions, see the article “A Brief Measure for Assessing 

Generalized Anxiety Disorder: The GAD-7” by Spitzer and colleagues at https://jamanetwork.com/ 

journals/jamainternalmedicine/fullarticle/410326.

1466 

Geriatric Anxiety Scale (GAS) 

www.uccs.edu/agingandmentalhealthlab/scale 

Resource summary: The Geriatric Anxiety Scale is a 30-item measure developed for and validated in older 

adult populations.1467 It is a self-report measure that assesses somatic, affective, and cognitive symptoms of 

anxiety over the past 7 days. A shorter 10-item version is also available; it is also valid and reliable for older 

adults.1468 

Geriatric Anxiety Scale (GAS) 

Below is a list of common symptoms of anxiety or stress. Please read each item in the list carefully. 

Indicate how often you have experienced each symptom during the PAST WEEK, INCLUDING TODAY, 

by checking under the corresponding answer. 

Not at all 

(0) 

Sometimes 

(1) 

Most of 

the time 

(2) 

All of 

the time 

(3) 

1. My heart raced or beat strongly. 

2. My breath was short. 

3. I had an upset stomach. 

4. I felt like things were not real or like I was 

outside of myself. 

5. I felt like I was losing control. 

6. I was afraid of being judged by others. 

7. I was afraid of being humiliated or 

embarrassed. 

8. I had diffculty falling asleep. 

9. I had diffculty staying asleep. 

10. I was irritable. 

11. I had outbursts of anger. 

12. I had diffculty concentrating. 

13. I was easily startled or upset. 

14. I was less interested in doing something I 

typically enjoy. 

15. I felt detached or isolated from others. 

Continued on next page 

Chapter 9 263 
TIP 26 Treating Substance Use Disorder in Older Adults 

Continued 

Not at all 

(0) 

Sometimes 

(1) 

Most of 

the time 

(2) 

All of 

the time 

(3) 

16. I felt like I was in a daze. 

17. I had a hard time sitting still. 

18. I worried too much. 

19. I could not control my worry. 

20. I felt restless, keyed up, or on edge. 

21. I felt tired. 

22. My muscles were tense. 

23. I had back pain, neck pain, or muscle cramps. 

24. I felt like I had no control over my life. 

25. I felt like something terrible was going to 

happen to me. 

26. I was concerned about my fnances. 

27. I was concerned about my health. 

28. I was concerned about my children. 

29. I was afraid of dying. 

30. I was afraid of becoming a burden to my 

family or children. 

GAS Scoring Instructions 

Items 1 through 25 are scorable items. Each item ranges from 0 to 3. Each item loads on only one scale. 

Items 26 through 30 are used to help clinicians identify areas of concern for the respondent. 

They are not used to calculate the total score of the GAS or any subscale. 

Total Score = sum of items 1 through 25. 

Somatic subscale (9 items) = sum of items 1, 2, 3, 8, 9, 17, 21, 22, 23 

Cognitive subscale (8 items) = sum of items 4, 5, 12, 16, 18, 19, 24, 25 

Affective subscale (8 items) = sum of items 6, 7, 10, 11, 13, 14, 15, 20 

© Daniel L. Segal, Ph.D., 2014. Reprinted with permission.1469 

264 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

Penn State Worry Questionnaire (PSWQ) 

Resource summary: The PSWQ is a 16-item self-report questionnaire that measures worrying (e.g., how 

much a person worries, the effects of worrying on a person). 

Penn State Worry Questionnaire (PSWQ) 

Instructions: Rate each of the following statements on a scale of 1 (“not at all typical of me”) to 5 (“very 

typical of me”). Please do not leave any items blank. 

Not at Very 

all typical typical 

of me of me 

1. If I do not have enough time to do everything, 

I do not worry about it. 1 2 3 4 5 

2. My worries overwhelm me. 1 2 3 4 5 

3. I do not tend to worry about things. 1 2 3 4 5 

4. Many situations make me worry. 1 2 3 4 5 

5. I know I should not worry about things, but 

I just cannot help it. 1 2 3 4 5 

6. When I am under pressure I worry a lot. 1 2 3 4 5 

7. I am always worrying about something. 1 2 3 4 5 

8. I fnd it easy to dismiss worrisome thoughts. 1 2 3 4 5 

9. As soon as I fnish one task, I start to worry 

about everything else I have to do. 1 2 3 4 5 

10. I never worry about anything. 1 2 3 4 5 

11. When there is nothing more I can do about a 

concern, I do not worry about it anymore. 1 2 3 4 5 

12. I have been a worrier all my life. 1 2 3 4 5 

13. I notice that I have been worrying about things. 1 2 3 4 5 

14. Once I start worrying, I cannot stop. 1 2 3 4 5 

15. I worry all the time. 1 2 3 4 5 

16. I worry about projects until they are all done. 1 2 3 4 5 

Developed by Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. Reproduced under the terms of the Creative 

Commons Attribution-NonCommercial 3.0 license (https://creativecommons.org/licenses/by-nc/3.0).1470 

Scoring: Each of the 16 items is rated on a 5-point scale. Items 1, 3, 8, 10, and 11 are reverse scored as follows: 

• Very typical of me = 1 (circled 5 on the sheet) 

• Circled 4 on the sheet = 2 

• Circled 3 on the sheet = 3 

• Circled 2 on the sheet = 4 

• Not at all typical of me = 5 (circled 1 on the sheet) 

The remaining items are scored regularly. The item scores are added to produce a total score ranging from 16 to 80, with 

higher scores refecting more worry. A score of 50 or higher by an older person could mean signifcant worries are 

present, but research on cutoff scores in older people is too limited to know for certain.1471 Do not assume that an older 

client who scores below 50 does not have anxiety. 

Chapter 9 265 
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Treating Substance Use Disorder in Older Adults 

Geriatric Depression Scale (GDS)–Short Form 

https://web.stanford.edu/~yesavage/GDS.html 

Resource summary: The GDS–Short Form is one of the most popular depression screeners for older 

adults. The version of the GDS that should be given to clients is shown frst below, followed by the scoring 

version. Clients with a GDS score of 6 or greater need further assessment and may need treatment for 

major depressive disorder (MDD).1472 Clients with a GDS score below 6 should be screened again in 1 

month if symptoms of depression are still present.1473 If a client’s depressive symptoms are no longer 

present in 1 month, give the depression screener again in 6 months.1474 

Geriatric Depression Scale (GDS)–Short Form 

Client Version 

Client’s Name: Date: 

Instructions: Circle the best answer for how you felt over the past week. 

1. Are you basically satisfed with your life? Yes No 

2. Have you dropped many of your activities and interests? Yes No 

3. Do you feel that your life is empty? Yes No 

4. Do you often get bored? Yes No 

5. Are you in good spirits most of the time? Yes No 

6. Are you afraid that something bad is going to happen to you? Yes No 

7. Do you feel happy most of the time? Yes No 

8. Do you often feel helpless? Yes No 

9. Do you prefer staying at home, rather than going out and doing new things? Yes No 

10. Do you feel you have more problems with memory than most people? Yes No 

11. Do you think it is wonderful to be alive now? Yes No 

12. Do you feel pretty worthless the way you are now? Yes No 

13. Do you feel full of energy? Yes No 

14. Do you feel that your situation is hopeless? Yes No 

15. Do you think that most people are better off than you are? Yes No 

Scoring Version 

Client’s Name: Date: 

Scoring: Count boldface responses for a total score. A score of 0–5 is normal. A score of 6 or above suggests 

depression. 

Instructions: Circle the best answer for how you felt over the past week. 

1. Are you basically satisfed with your life? Yes No 

2. Have you dropped many of your activities and interests? Yes No 

3. Do you feel that your life is empty? Yes No 

Continued on next page 

266 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

Continued 

4. Do you often get bored? Yes No 

5. Are you in good spirits most of the time? Yes No 

6. Are you afraid that something bad is going to happen to you? Yes No 

7. Do you feel happy most of the time? Yes No 

8. Do you often feel helpless? Yes No 

9. Do you prefer to stay at home, rather than going out and doing new things? Yes No 

10. Do you feel you have more problems with memory than most people? Yes No 

11. Do you think it is wonderful to be alive now? Yes No 

12. Do you feel pretty worthless the way you are now? Yes No 

13. Do you feel full of energy? Yes No 

14. Do you feel that your situation is hopeless? Yes No 

15. Do you think that most people are better off than you are? Yes No 

The Client Version and Scoring Version of the GDS–Short Form were both adapted from material in the public 

domain.1475 

Chapter 9 267 
TIP 26

Patient Health Questionnaire (PHQ-9) 

https://cde.drugabuse.gov/instrument/ 

f226b1a0-897c-de2a-e040-bb89ad4338b9 

Resource summary: The PHQ-9 is a nine-item 

screener for depression in adults of any age. It is 

tested and approved for use with older clients.1476 

The screener is also useful for monitoring 

depression severity and treatment response in 

clients who have already screened positive for 

or been diagnosed with depression. A two-item 

version of the PHQ-9 is available (the PHQ-2) 

that includes only the frst two questions from 

the PHQ-9. However, compared with the PHQ-9, 

the PHQ-2 has a higher likelihood of giving older 

adults a false positive (that is, incorrectly rating 

a person as depressed when they are not).1477 To 

get more reliable results, you should give the full 

PHQ-9. If you give the PHQ-2, be sure to give the 

full PHQ-9 to older adults who have a total score of 

3 or higher.1478 

Treating Substance Use Disorder in Older Adults 

Scoring: The total score for the PHQ-9 is derived 

by frst summing each column (e.g., each item 

chosen in column “More than half the days” = 2), 

then summing the column totals. Total scores range 

from 0 to 27 and indicate the following levels of 

depression severity: 

0–4: None-minimal 

5–9: Mild depression 

10–14: Moderate depression 

15–19: Moderately severe depression 

20–27: Severe depression 

In addition to the total score, review responses 

to Question #9 (suicidality) and the unnumbered 

question below it (the effect of symptoms on 

the client’s daily functioning) when determining 

whether to initiate or refer for further 

assessment and treatment.1479,1480,1481 

268 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

PTSD Checklist for DSM-5 (PCL-5) 

www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp 

Resource summary: The PTSD Checklist for DSM-5 has been approved for use with older adults.1482 The 

VA gives instructions on how to use the tool. A score of 50 often means PTSD is present.1483 However, in 

older clients a score of 50 may be too high and might not catch all older people with possible PTSD.1484 

Because of this, a cutoff score of 34 is better for adults ages 50 to 64, and a cutoff score of 24 is better for 

adults ages 65 to 81.1485 

PTSD Checklist for DSM-5 (PCL-5) 

Instructions: Below is a list of problems that people sometimes have in response to a very stressful 

experience. Please read each problem carefully and then circle one of the numbers to the right to indicate 

how much you have been bothered by that problem in the past month. 

In the past month, how much were you Not A little Moderately Quite Extremely 

bothered by: at all bit a bit 

1. Repeated, disturbing, and unwanted 

memories of the stressful experience? 

0 1 2 3 4 

2. Repeated, disturbing dreams of the 

stressful experience? 

0 1 2 3 4 

3. Suddenly feeling or acting as if the 

stressful experience were actually 

happening again (as if you were actually 

back there reliving it)? 

0 1 2 3 4 

4. Feeling very upset when something 

reminded you of the stressful 

experience? 

0 1 2 3 4 

5. Having strong physical reactions 

when something reminded you of the 

stressful experience (for example, heart 

pounding, trouble breathing, sweating)? 

0 1 2 3 4 

6. Avoiding memories, thoughts, or 

feelings related to the stressful 

experience? 

0 1 2 3 4 

7. Avoiding external reminders of the 

stressful experience (for example, 

people, places, conversations, activities, 

objects, or situations)? 

0 1 2 3 4 

8. Trouble remembering important parts 

of the stressful experience? 

0 1 2 3 4 

9. Having strong negative beliefs about 

yourself, other people, or the world (for 

example, having thoughts such as: I am 

bad, there is something seriously wrong 

with me, no one can be trusted, the 

world is completely dangerous)? 

0 1 2 3 4 

Continued on next page 

Chapter 9 269 
TIP 26 Treating Substance Use Disorder in Older Adults 

Continued 

In the past month, how much were Not A little Moderately Quite Extremely 

you bothered by: at all bit a bit 

10. Blaming yourself or someone else 

for the stressful experience or what 

happened after it? 

0 1 2 3 4 

11. Having strong negative feelings 

such as fear, horror, anger, 

guilt, or shame? 

0 1 2 3 4 

12. Loss of interest in activities that 

you used to enjoy? 

0 1 2 3 4 

13. Feeling distant or cut off from 

other people? 

0 1 2 3 4 

14. Trouble experiencing positive 

feelings (for example, being 

unable to feel happiness or have 

loving feelings for people close to 

you)? 

0 1 2 3 4 

15. Irritable behavior, angry outbursts, 

or acting aggressively? 

0 1 2 3 4 

16. Taking too many risks or doing 

things that could cause 

you harm? 

0 1 2 3 4 

17. Being “superalert” or watchful or 

on guard? 

0 1 2 3 4 

18. Feeling jumpy or easily startled? 0 1 2 3 4 

19. Having diffculty concentrating? 0 1 2 3 4 

20. Trouble falling or staying asleep? 0 1 2 3 4 

Reprinted from material in the public domain.1486 A digital, fllable form is available online (www.ptsd.va.gov/professional/ 

assessment/documents/PCL5_Standard_form.PDF). 

270 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

Primary Care PTSD Screen for DSM-5 (PC-PTSD-5)1487 

www.ptsd.va.gov/professional/assessment/documents/pc-ptsd5-screen.pdf 

Resource summary: The PC-PTSD-5 is used to screen clients for PTSD. A score of 3 or more “yes” 

responses is considered cause for more indepth screening. 

Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) 

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For 

example: 

• a serious accident or fre 

• a physical or sexual assault or abuse 

• an earthquake or food 

• a war 

• seeing someone be killed or seriously injured 

• having a loved one die through homicide or suicide. 

Have you ever experienced this kind of event? 

YES NO 

If no, screen total = 0. Please stop here. 

If yes, please answer the questions below. 

In the past month, have you... 

1. had nightmares about the event(s) or thought about the event(s) when you did not want to? 

YES NO 

2. tried hard not to think about the event(s) or went out of your way to avoid situaitons that reminded you 

of the event(s)? 

YES NO 

3. been constantly on guard, watchful, or easily startled? 

YES NO 

4. felt numb or detached from people, activities, or your surroundings? 

YES NO 

5. felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may 

have caused? 

YES NO 

Reprinted from material in the public domain.1488 This tool and additional information on it can be found online (www. 

ptsd.va.gov/professional/assessment/documents/pc-ptsd5-screen.pdf). 

Chapter 9 271 
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Treating Substance Use Disorder in Older Adults 

Health and Wellness 

Health and Wellness Screening and Assessment Tools 

Elder Abuse Suspicion Index© (EASI©)

1489 

www.mcgill.ca/familymed/research/projects/elder 

Resource summary: The EASI© is a short questionnaire about abuse of older people. You should ask 

Questions 1 through 5 directly to the client. Questions apply to the last 12 months. You can answer 

Question 6 yourself. A “yes” response on one or more questions (other than on Question 1) is considered 

a positive screen. This tool is available and validated in English and French. 

Elder Abuse Suspicion Index© (EASI©) 

EASI© Questions 

Q.1-Q.5 asked of patient; Q.6 answered by doctor 

(Within the last 12 months) 

1) Have you relied on people for any of the following: 

bathing, dressing, shopping, banking, or meals? YES NO Did not 

answer 

2) Has anyone prevented you from getting food, clothes, 

medication, glasses, hearing aids or medical care, or 

from being with people you wanted to be with? 

YES NO Did not 

answer 

3) Have you been upset because someone talked to you in 

a way that made you feel shamed or threatened? YES NO Did not 

answer 

4) Has anyone tried to force you to sign papers or to use 

your money against your will? YES NO Did not 

answer 

5) Has anyone made you afraid, touched you in ways that 

you did not want, or hurt you physically? YES NO Did not 

answer 

6) Doctor: Elder abuse may be associated with findings 

such as: poor eye contact, withdrawn nature, 

malnourishment, hygiene issues, cuts, bruises, 

inappropriate clothing, or medication compliance 

issues. Did you notice any of these today or in the last 

12 months?

YES NO Not sure 

Reprinted with permission. Yaffe MJ, Wolfson C, Weiss D, Lithwick M. Development and validation of a tool to assist 

physicians’ identifcation of elder abuse: The Elder Abuse Suspicion Index (EASI©). Journal of Elder Abuse and Neglect, 2008; 

20 (3): 276-300. This tool is available online (www.mcgill.ca/familymed/research/projects/elder). 

Mark J. Yaffe, MD, McGill University, Montreal, Canada, mark.yaffe@mcgill.ca 

Maxine Lithwick, MSW, CSSS Cavendish, Montreal, Canada, maxine.lithwick.cvd@ssss.gouv.qc.ca 

Christina Wolfson, PhD, McGill University, Montreal, Canada, christina.wolfson@mcgill.ca 

272 Chapter 9 
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Chapter 9—Resources for Treating Substance Use Disorder in Older Adults 

Revised Iowa Pain Thermometer (IPT-R) 

Resource summary: The IPT-R is easy for older patients to understand and to use. It is approved for use in 

older adults, including those from diverse racial and ethnic populations.1490 The IPT-R can also be used with 

older adults with cognitive impairment.1491 

Revised Iowa Pain Thermometer (IPT-R) 

Revised Iowa Pain Thermometer (IPT-R, 2011) printed with permission. © Keela Herr, The University of Iowa.1492 

Revised Faces Pain Scale 

Resource summary: The revised Faces Pain Scale is easy for older adults to understand and to use. It is 

approved for use in older adults, including those from diverse racial and ethnic populations.1493 

In the following instructions, say “hurt” or “pain,” whichever seems right for a particular client. “These 

faces show how much something can hurt. This face [point to face on far left] shows no pain. The faces 

show more and more pain [point to each from left to right] up to this one [point to face on far right]—it 

shows very much pain. Point to the face that shows how much you hurt [right now].” 

Score the chosen face 0, 2, 4, 6, 8, or 10, counting left to right. Therefore, “0” = “no pain” and “10” = 

“very much pain.” Do not use words like “happy” or “sad.” This scale is intended to measure how a client 

feels inside, not how his or her face looks. 

Revised Faces Pain Scale 

Faces Pain Scale – Revised, ©2001, International Association for the Study of Pain [ www.iasp-pain.org/FPSR ] 

Chapter 9 273 
TIP 26 Treating Substance Use Disorder in Older Adults 

Katz Index of Independence in Activities of Daily Living (Katz ADL)1494,1495 

Resource summary: The Katz ADL is one of the most commonly used instruments for measuring a client’s 

functional status in relation to ADLs. It assesses performance in six areas: bathing, dressing, toileting, 

transferring, continence, and feeding. A person’s ability or inability to perform ADLs and instrumental 

ADLs (IADLs) is used to gauge the need for care. 

Katz Index of Independence in Activities of Daily Living (Katz ADL) 

Activities Independence (1 Point) 

No supervision, direction, or 

personal assistance 

Dependence (0 Points) 

With supervision, direction, 

personal assistance, or total 

care 

BATHING 

Points: __________ 

(1 POINT) Bathes self completely or 

needs help in bathing only a single 

part of the body, such as the back, 

genital area, or disabled extremity. 

(0 POINTS) Needs help with 

bathing more than one part of the 

body, getting in or out of the tub, 

or shower. Requires total bathing. 

DRESSING 

Points: __________ 

(1 POINT) Can get clothes from closet 

and drawers and put on clothes 

and outer garments complete with 

fasteners. May have help tying shoes. 

(0 POINTS) Needs help with 

dressing self or needs to be 

completely dressed. 

TOILETING 

Points: __________ 

(1 POINT) Goes to the toilet, gets on 

and off, arranges clothes, and cleans 

genital area without help. 

(0 POINTS) Needs help transferring 

to the toilet or cleaning self or uses 

bedpan or commode. 

TRANSFERRING 

Points: __________ 

(1 POINT) Moves in and out of bed or 

chair unassisted. Mechanical transfer 

aids are acceptable. 

(0 POINTS) Needs help in moving 

from bed to chair or requires a 

complete transfer. 

CONTINENCE 

Points: __________ 

(1 POINT) Exercises complete selfcontrol over urination and defecation. (0 POINTS) Is partially or totally 

incontinent of bowel or bladder. 

FEEDING 

Points: __________ 

(1 POINT) Gets food from plate into 

mouth without help. Preparation of 

food may be done by another person. 

(0 POINTS) Needs partial or total 

help with feeding or requires 

parenteral feeding. 

Total Points: ________ 

A score of 6 indicates full function; 4, moderate impairment; and 2 or less, severe functional impairment. 

Adapted from Katz, S., Down, T. D., Cash, H. R., & Grotz, R. C. Progress in the development of the index of ADL. Gerontologist 

1970, 10(1):20‒30. By permission of The Gerontological Society of America.1496 

274 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

Barthel Index 

Resource summary: The Barthel Index is a brief, widely used screener for ADLs.1497,1498,1499 It measures a 

person’s abilities to perform the following: feeding, bathing, grooming, dressing, toileting, bladder and 

bowel control, transfers, mobility, and using the stairs. 

Functional Activities Questionnaire 

Resource summary: This tool is used for older adults with normal cognition; mild cognitive impairment; 

or mild, moderate, or advanced dementia. It is used to measure IADLs.1500 The questionnaire should 

be completed by a person who knows the client well (usually a caregiver or adult family member), 

has observed his or her behavior, and can assess the client’s ability to complete IADLs and how much 

assistance they need, if any. 

Lubben Social Network Scale (LSNS) 

www.bc.edu/content/bc-web/schools/ssw/sites/lubben/description.html 

Resource summary: The LSNS is designed for use with older adults. It is intended to gauge the level of 

a person’s social support from family and friends and to determine whether that person’s score indicates 

social isolation, which can contribute to increased mental and physical problems in older adults. Older 

clients can easily complete the six-item short version (LSNS-6), a self-report questionnaire available at the 

same website. 

Social Network Map 

www.researchgate.net/publication/232542443_The_Social_Network_Map_Assessing_Social_Support_in_ 

Clinical_Practice 

Resource summary: The Social Network Map is a client-centered tool that collects information on the 

composition of the older adult’s social network, the extent to which network members provide different 

types of support, and the nature of relationships in the network.1501 The version below is adapted for older 

adults in recovery. 

Social Network Map for Older Adults in Recovery 

Adapted from Tracy & Whittaker (1990).1502 

Chapter 9 275 
TIP 26 Treating Substance Use Disorder in Older Adults 

The following strategies1503 will help you and your older clients develop a social network map: 

• Create a pie chart with the seven domains. Health, behavioral health service, social service, and peer 

recovery support providers may be part of the support network clients identify. 

• Ask older clients to identify members of their social networks by frst name or initials only. 

• Ask clients to describe how available (e.g., rarely, sometimes, often) each member of the network is to 

give emotional, instrumental, or informational support. Give examples and be specifc: 

- “Who is available to give you emotional support like comforting you if you are upset or listening if 

you are stressed?” “How often does this person give you that kind of support?” 

- “Who is available to help you out in a concrete way like giving you a ride or helping with a chore?” 

“How often does this person give you that kind of support?” 

- “Who would give you information on how to do something new or help you make a big decision?” 

“How often does this person give you that kind of support?” 

• Note the type and frequency of support each person listed in each domain can offer. 

• Ask clients to describe how close they are to each member of their network, how long they have known 

them, and how frequently they see them. 

• Ask clients to review the map and identify types of support that may be lacking and strategies for 

adding new network members to beef up their social support. 

Wellness Planning Tools 

Collaborative Goal Setting Using SMART 

www.samhsa.gov/sites/default/fles/nc-smart-goals-fact-sheet.pdf 

Resource summary: SMART goals are Specifc, Measurable, Attainable, Relevant, and Time-bound. Use 

the following tips for writing SMART goals related to alcohol and drug use and to health and wellness. 

Writing a SMART Goal 

Specifc: State the goal clearly. Ask the client to be specifc. For example, if the goal is “I just want to be 

healthy,” ask “How will you know when you are ‘healthy’”? or “What things will you be able to do when you 

are healthy that you can’t do now?” 

Measurable: Identify and quantify the observable markers of progress, such as pain levels or the 

number of days and amount of time the client walked each week. Invite the client to keep a log of these 

markers so you can discuss the client’s progress. 

Attainable: Break the goal into smaller, actionable steps. Identify expected barriers and make a plan 

to address them. For example, if the goal is to get 8 hours of sleep each night, break the goal into smaller 

tasks, like turn all the lights in the bedroom off at 10 p.m. at least fve nights a week. Then ask, “What might 

keep you from turning the lights off at 10 p.m.?” 

Relevant: Make sure the goal refects what’s personally relevant to the individual. Use MI to set the 

agenda and determine goals on which to focus. Link goals, such as blood pressure control, to the goal of 

staying healthy. 

Time-bound: Defne when the goal is to be attained. Help the client be specifc about the timeframe. 

Make it realistic and attainable, based on the client’s subjective evaluation. Agree when to check progress. 

Content reproduced with the permission of the National Committee for Quality Assurance (NCQA). NCQA disclaims all 

liability for the use and interpretation of the content.1504 

276 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

Haight’s Life Review and Experiencing Form 

Resource summary: Haight’s Life Review provides questions to guide you in conducting a structured life 

review with older clients. 

Haight’s Life Review and Experiencing Form 

Childhood: 

1. What is the very frst thing you can remember in your life? Go as far back as you can. 

2. What other things can you remember about when you were very young? 

3. What was life like for you as a child? 

4. What were your parents like? What were their weaknesses, strengths? 

5. Did you have any brothers or sisters? Tell me what each was like. 

6. Did someone close to you die when you were growing up? 

7. Did someone important to you go away? 

8. Do you ever remember being very sick? 

9. Do you remember having an accident? 

10. Do you remember being in a very dangerous situation? 

11. Was there anything that was important to you that was lost or destroyed? 

12. Was church a large part of your life? 

13. Did you enjoy being a boy/girl? 

Adolescence: 

1. When you think about yourself and your life as a teenager, what is the frst thing you can remember 

about that time? 

2. What other things stand out in your memory about being a teenager? 

3. Who were the important people for you? Tell me about them. Parents, brothers, sisters, friends, 

teachers, those you were especially close to, those you admired, those you wanted to be like. 

4. Did you attend church and youth groups? 

5. Did you go to school? What was the meaning for you? 

6. Did you work during these years? 

7. Tell me of any hardships you experienced at this time. 

8. Do you remember feeling that there wasn’t enough food or necessities of life as a child or adolescent? 

9. Do you remember feeling left alone, abandoned, not having enough love or care as a child or 

adolescent? 

10. What were the pleasant things about your adolescence? 

11. What was the most unpleasant thing about your adolescence? 

12. All things considered, would you say you were happy or unhappy as a teenager? 

13. Do you remember your frst attraction to another person? 

14. How did you feel about sexual activities and your own sexual identity? 

Family and home: 

1. How did your parents get along? 

2. How did other people in your home get along? 

3. What was the atmosphere in your home? 

4. Were you punished as a child? For what? Who did the punishing? Who was the “boss”? 

5. When you wanted something from your parents, how did you go about getting it? 

6. What kind of person did your parents like the most? The least? 

7. Who were you closest to in your family? 

8. Who in your family were you most like? In what way? 

Continued on next page 

Chapter 9 277 
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Treating Substance Use Disorder in Older Adults 

Continued 

Adulthood: 

1. What place did religion play in your life? 

2. Now I’d like to talk to you about your life as an adult, starting when you were in your twenties up to 

today. Tell me of the most important events that happened in your adulthood. 

3. What was life like for you in your twenties and thirties? 

4. What kind of person were you? What did you enjoy? 

5. Tell me about your work. Did you enjoy your work? Did you earn an adequate living? Did you work hard 

during those years? Were you appreciated? 

6. Did you form signifcant relationships with other people? 

7. Did you marry? 

(yes) What kind of person was your spouse? 

(no) Why not? 

8. Do you think marriages get better or worse over time? Were you married more than once? 

9. On the whole, would you say you had a happy or unhappy marriage? 

10. Was sexual intimacy important to you? 

11. What were some of the main diffculties you encountered during your adult years? 

a) Did someone close to you die? Go away? 

b) Were you ever sick? Have an accident? 

c) Did you move often? Change jobs? 

d) Did you ever feel alone? Abandoned? 

e) Did you ever feel need? 

Summary: 

1. On the whole, what kind of life do you think you’ve had? 

2. If everything were to be the same would you like to live your life over again? 

3. If you were going to live your life over again, what would you change? Leave unchanged? 

4. We’ve been talking about your life for quite some time now. Let’s discuss your overall feelings and ideas 

about your life. What would you say the main satisfactions in your life have been? Try for three. Why 

were they satisfying? 

5. Everyone has had disappointments. What have been the main disappointments in your life? 

6. What was the hardest thing you had to face in your life? Please describe it. 

7. What was the happiest period of your life? What about it made it the happiest period? Why is your life 

less happy now? 

8. What was the unhappiest period of your life? Why is your life more happy now? 

9. What was the proudest moment in your life? 

10. If you could stay the same age all your life, what age would you choose? Why? 

11. How do you think you’ve made out in life? Better or worse than what you hoped for? 

12. Let’s talk a little about you as you are now. What are the best things about the age you are now? 

13. What are the worst things about being the age you are now? 

14. What are the most important things to you in your life today? 

15. What do you hope will happen to you as you grow older? 

16. What do you fear will happen to you as you grow older? 

17. Have you enjoyed participating in this review of your life? 

Adapted with permission from Barbara K. Haight and Health Professions Press, Inc. Permission conveyed through 

Copyright Clearance Center, Inc.1505 

278 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

Handouts for Clients and Families 

The Large-Print Grief Handout, which can be shared with clients, is an example of a brief information tool 

modifed to refect age-sensitive practices (https://staging.helpguide.org/articles/grief/coping-with-griefand-loss.htm). 

Large-Print Grief Handout 

What Is Grief? 

Grief is a natural response to loss. It’s the emotional suffering you 

feel when something or someone you love is taken away. Whatever 

your loss, it’s personal to you. 

Coping With Grief 

Although loss is a part of life that cannot be avoided, there are 

ways to help cope with the pain, come to terms with your grief, 

and eventually, fnd a way to move on with your life. This doesn’t 

mean you will forget your loved one, but you can fnd a way to hold 

that individual in your heart and your memories while continuing to 

live your life. This includes: 

•	 Acknowledging your pain. 

•	 Accepting that grief can bring up many different and 

unexpected feelings. 

•	 Understanding that your grieving process will be unique to 

you. 

•	 Seeking out face-to-face support from people who care about 

you. 

•	 Supporting yourself emotionally by taking care of yourself 

physically. 

•	 Learning the difference between grief and depression. 

Continued on next page 

Chapter 9 279 
TIP 26

____________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________ 

Treating Substance Use Disorder in Older Adults 

Continued 

The Grieving Process 

Grieving is highly individual; there’s no right or wrong way 

to grieve. The grieving process takes time. Healing happens 

gradually; it can’t be forced or hurried—and there is no “normal” 

timetable for grieving. Some people start to feel better in weeks 

or months. For others, the grieving process is measured in years. 

Whatever grief is like for you, it’s important to be patient with 

yourself and allow the process to naturally unfold. 

Reprinted with permission.1506 

The next set of handouts will help you and your clients understand how drinking may confict with their 

values, keep track of their drinking, manage their alcohol consumption, and make a change plan around 

alcohol use. 

Does Your Drinking Confict With Your Top Values? 

If you are considering quitting or cutting back on your alcohol intake, it may help to think about whether your 

drinking conficts with your top values. You may frst need to identify what those values are. Think of your top 

values as the principles, qualities, and beliefs that are most important to you and that you most want your 

life to refect. Examples of values include independence, generosity, and honesty. The Internet has many free 

exercises on identifying top values. These exercises differ in what values are listed and how you prioritize them, 

so you may want to look at more than one exercise. Some values exercises can be found at: 

• www.smartrecovery.org/smart-recovery-toolbox/values-and-goals-clarifcation 

• https://harvard.az1.qualtrics.com/jfe/form/SV_e35whN7tkXtvlHv 

• www.therapistaid.com/worksheets/values-clarifcation.pdf 

Below are several questions to ask yourself about the relationship between your drinking and your top 

values. Does drinking confict with any of your top values? If so: 

Which values does drinking confict with? __________________________________________________________________ 

How does drinking confict with these values? ______________________________________________________________ 

How does this confict keep you from living out your top values in daily life? Be as specifc as possible. _______ 

280 Chapter 9 
Chapter 9—Resources for Treating Substance Use Disorder in Older Adults TIP 26

Drinking Logs: Many people fnd using drinking cards or logs helpful in reducing or quitting alcohol 

consumption. The idea is to write down when and how much you drink. Here is an example of a drink 

monitoring tool. 

Four-Week Drinking Tracker Card 

GOAL: No more than ____ drinks on any day and ____ per week.

Week 

starting Su M T W Th F Sa Total

____/____

____/____

____/____

____/____

Reprinted from material in the public domain.1507 

Chapter 9 281 
TIP 26 Treating Substance Use Disorder in Older Adults 

Alcohol Consumption Plan Management: Clients can write plans to remind themselves of the steps they 

will take to manage their alcohol consumption. If clients have a hard time coming up with ideas, suggest 

that they get ideas from a supportive family member or friend, healthcare professional, clergyperson, or 

case manager or social worker if they have one. 

Four A’s for Managing Alcohol Consumption 

AVOID. What are the highly tempting situations in which you might drink more than your plan? Avoid 

these situations if possible over the next month. 

1. _________________________________________________________________________________________________________ 

2. ________________________________________________________________________________________________________ 

ALTER. For situations you can’t avoid, how can you alter them to make them easier? 

1. _________________________________________________________________________________________________________ 

2. ________________________________________________________________________________________________________ 

ALTERNATIVES. What can you do with your mouth and hands when you want to drink and it is a day you 

are not drinking or have already reached your limit? 

1. _________________________________________________________________________________________________________ 

2. ________________________________________________________________________________________________________ 

ACTION. When you get the urge to drink and it does not ft with your drinking plan, what can you do to be 

active or busy until the urge passes? 

1. _________________________________________________________________________________________________________ 

2. ________________________________________________________________________________________________________ 

Are there situations in which it will be a challenge to stay within your drinking limits? If so, list them and 

what you will do to effectively manage those situations. 

1. _________________________________________________________________________________________________________ 

Plan ______________________________________________________________________________________________________ 

2. _________________________________________________________________________________________________________ 

Plan ______________________________________________________________________________________________________

 Reprinted with permission from the American Psychological Association.1508 

282 Chapter 9 
TIP 26

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

Chapter 9—Resources for Treating Substance Use Disorder in Older Adults 

Change Plans: Making a written “change plan” will help clients identify and stick with drinking goals. 

Writing a Change Plan 

Goal (pick one): 

____ I want to drink no more than ____ drink(s) per day and no more than ____ drink(s) per week. 

(See “What Is Moderate Drinking?” in Chapter 8 before flling out.) 

____ I want to stop drinking. 

I will begin following my plan on this date: ________________________. 

My most important reasons for changing my drinking are:_________________________________________________ 

The situations where I may be most tempted to drink are:_________________________________________________ 

Some things I will do and say to handle these situations are:_______________________________________________ 

The people who can help me stick to my goal, and the ways they can help, are:____________________________ 

Adapted from material in the public domain.1509 

Chapter 9 283 
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IN OLDER ADULTS

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347 Searby, A., Maude, P., & McGrath, I. (2015). Dual 

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352 Bartels, S. J., Blow, F. C., Van Citters, A. D., & 

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354 Ettner, S. L., Xu, H., Duru, O. K., Ang, A., Tseng, C. 

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356 Barnes, A. J., Moore, A. A., Xu, H., Ang, A., Tallen, 

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357 Searby, A., Maude, P., & McGrath, I. (2015). Dual 

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358 Center for Behavioral Health Statistics and Quality. 

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359 Searby, A., Maude, P., & McGrath, I. (2015). Dual 

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360 Wu, L. T., & Blazer, D. G. (2014). Substance use disorders 

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369 Richardson, T. M., He, H., Podgorski, C., Tu, X., & 

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372 Richardson, T. M., He, H., Podgorski, C., Tu, X., & 

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373 Bower, E. S., Wetherell, J. L., Mon, T., & Lenze, E. 

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376 Reynolds, K., Pietrzak, R. H., El-Gabalawy, R., Mackenzie, 

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377 Koychev, I., & Ebmeier, K. P. (2016). Anxiety in older 

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400 Choi, N. G., DiNitto, D. M., Marti, C. N., & Choi, B. Y. 

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401 Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, 

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402 Reynolds, K., Pietrzak, R. H., Mackenzie, C. S., Chou, K. 

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415 Shrira, A. (2016). A youthful age identity mitigates 

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603 Arndt, S., & Schultz, S. K. (2015). Epidemiology and 

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P. Sacco, & F. Zanjani (Eds.), Alcohol and aging: Clinical 

and public health perspectives (pp. 181–199). New York, 

NY: Springer. 

668 Blow, F. C., & Barry, K. L. (2000). Older patients 

with at-risk and problem drinking patterns: New 

developments in brief interventions. Journal of Geriatric 

Psychiatry and Neurology, 13(3), 115–123. 

669 Moore, A. A., Blow, F. C., Hoffng, M., Welgreen, S., 

Davis, J. W., Lin, J. C., ... Barry, K. L. (2011). Primary 

care-based intervention to reduce at-risk drinking in 

older adults: A randomized controlled trial. Addiction, 

106(1), 111–120. 

670 Moore, A. A., Blow, F. C., Hoffng, M., Welgreen, S., 

Davis, J. W., Lin, J. C., ... Barry, K. L. (2011). Primary 

care-based intervention to reduce at-risk drinking in 

older adults: A randomized controlled trial. Addiction, 

106(1), 111–120. 

671 Miller, W. R., Forcehimes, A., & Zweben, A. (2011). 

Treating addiction: A guide for professionals. New York, 

NY: Guilford Press. 

672 Schutte, K., Lemke, S., Moos, R. H., & Brennan, P. L. 

(2015). Age-sensitive psychosocial treatment for older 

adults with substance abuse. In I. Crome, L.-T. Wu, R. T. 

Rao, & P. Crome (Eds.), Substance use and older people 

(pp. 314–339). West Sussex, UK: Wiley-Blackwell. 

673 Satre, D. D., & Leibowitz, A. (2015). Brief alcohol and 

drug interventions and motivational interviewing for 

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depression, anxiety, trauma, and substance abuse (pp. 

163–180). Washington, DC: American Psychological 

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674 Serdarevic, M. (2016). Literature review: Motivational 

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jpcpy.2016.06.00409 

675 Satre, D. D., & Leibowitz, A. (2015). Brief alcohol and 

drug interventions and motivational interviewing for 

older adults. In P. A. Areán (Ed.), Treatment of late-life 

depression, anxiety, trauma, and substance abuse (pp. 

163–180). Washington, DC: American Psychological 

Association. 

676 Cummings, S. M., Cooper, R. L., & Cassie, K. M. (2009). 

Motivational interviewing to affect behavioral change 

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677 Lundahl, B., Moleni, T., Burke, B., Butters, R., Tollefson, 

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678 Kuerbis, A., Treloar Padovano, H., Shao, S., Houser, 

J., Muench, F., & Morgenstern, J. (2018). Comparing 

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240–246. 

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679 Miller, W. R., & Rollnick, S. (2013). Motivational 

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680 Miller, W. R., Forcehimes, A., & Zweben, A. (2011). 

Treating addiction: A guide for professionals. New York, 

NY: Guilford Press. 

681 Schutte, K., Lemke, S., Moos, R. H., & Brennan, P. L. 

(2015). Age-sensitive psychosocial treatment for older 

adults with substance abuse. In I. Crome, L.-T. Wu, R. T. 

Rao, & P. Crome (Eds.), Substance use and older people 

(pp. 314–339). West Sussex: UK: Wiley-Blackwell. 

682 Miller, W. R., Forcehimes, A., & Zweben, A. (2011). 

Treating addiction: A guide for professionals. New York, 

NY: Guilford Press. 

683 Blow, F. C., & Barry, K. L. (2000). Older patients 

with at-risk and problem drinking patterns: New 

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684 National Institute on Alcohol Abuse and Alcoholism. 

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685 Miller, W. R., & Rollnick, S. (2013). Motivational 

interviewing: Helping people change (3rd ed.). New 

York, NY: Guilford Press. 

686 Magill, M., Stout, R. L., & Apodaca, T. R. (2013). 

Therapist focus on ambivalence and commitment: 

A longitudinal analysis of motivational interviewing 

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687 Magill, M., Kiluk, B. D., McCrady, B. S., Tonigan, J. S., & 

Longabaugh, R. (2015). Active ingredients of treatment 

and client mechanisms of change in behavioral 

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688 Magill, M., Gaume, J., Apodaca, T. R., Walthers, 

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(2014). The technical hypothesis of motivational 

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689 Schutte, K., Lemke, S., Moos, R. H., & Brennan, P. L. 

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adults with substance abuse. In I. Crome, L.-T. Wu, R. T. 

Rao, & P. Crome (Eds.), Substance use and older people 

(pp. 314–339). West Sussex, UK: Wiley-Blackwell. 

690 Schutte, K., Lemke, S., Moos, R. H., & Brennan, P. L. 

(2015). Age-sensitive psychosocial treatment for older 

adults with substance abuse. In I. Crome, L.-T. Wu, R. T. 

Rao, & P. Crome (Eds.), Substance use and older people 

(pp. 314–339). West Sussex, UK: Wiley-Blackwell. 

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691 Schutte, K., Lemke, S., Moos, R. H., & Brennan, P. L. 

(2015). Age-sensitive psychosocial treatment for older 

adults with substance abuse. In I. Crome, L.-T. Wu, R. T. 

Rao, & P. Crome (Eds.), Substance use and older people 

(pp. 314–339). West Sussex, UK: Wiley-Blackwell. 

692 Schutte, K., Lemke, S., Moos, R. H., & Brennan, P. L. 

(2015). Age-sensitive psychosocial treatment for older 

adults with substance abuse. In I. Crome, L.-T. Wu, R. T. 

Rao, & P. Crome (Eds.), Substance use and older people 

(pp. 314–339). West Sussex, UK: Wiley-Blackwell. 

693 Schutte, K., Lemke, S., Moos, R. H., & Brennan, P. L. 

(2015). Age-sensitive psychosocial treatment for older 

adults with substance abuse. In I. Crome, L.-T. Wu, R. T. 

Rao, & P. Crome (Eds.), Substance use and older people 

(pp. 314–339). West Sussex, UK: Wiley-Blackwell. 

694 Substance Abuse and Mental Health Services 

Administration & National Institute on Alcohol Abuse 

and Alcoholism. (2015). Medication for the treatment of 

alcohol use disorder: A brief guide. HHS Publication No. 

(SMA) 15-4907. Retrieved from https://store.samhsa. 

gov/product/Medication-for-the-Treatment-of-AlcoholUse-Disorder-A-Brief-Guide/SMA15-4907 

695 Substance Abuse and Mental Health Services 

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adults with resources on medication, alcohol, and 

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696 Schutte, K., Lemke, S., Moos, R. H., & Brennan, P. L. 

(2015). Age-sensitive psychosocial treatment for older 

adults with substance abuse. In I. Crome, L.-T. Wu, R. T. 

Rao, & P. Crome (Eds.), Substance use and older people 

(pp. 314–339). West Sussex, UK: Wiley-Blackwell. 

697 Schutte, K., Lemke, S., Moos, R. H., & Brennan, P. L. 

(2015). Age-sensitive psychosocial treatment for older 

adults with substance abuse. In I. Crome, L.-T. Wu, R. T. 

Rao, & P. Crome (Eds.), Substance use and older people 

(pp. 314–339). West Sussex, UK: Wiley-Blackwell. 

698 Kuerbis, A., & Sacco, P. (2013). A review of existing 

treatments for substance abuse among the elderly 

and recommendations for future directions. Substance 

Abuse, 7, 13–37. 

699 Satre, D. D., Knight, B. G., & David, S. (2006). 

Cognitive-behavioral interventions with older adults: 

Integrating clinical and gerontological research. 

Professional Psychology: Research and Practice, 37(5), 

489–498. 

700 Schutte, K., Lemke, S., Moos, R. H., & Brennan, P. L. 

(2015). Age-sensitive psychosocial treatment for older 

adults with substance abuse. In I. Crome, L.-T. Wu, R. T. 

Rao, & P. Crome (Eds.), Substance use and older people 

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314 Appendix 
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702 Oslin, D. W., & Zanjani, F. (2016). Treatment of unhealthy 

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703 Schutte, K., Lemke, S., Moos, R. H., & Brennan, P. L. 

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704 Kuerbis, A., Sacco, P., Blazer, D. G., & Moore, A. A. 

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705 Kuerbis, A., Sacco, P., Blazer, D. G., & Moore, A. A. 

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707 Satre, D. D., Knight, B. G., & David, S. (2006). 

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716 Donovan, D. M., Ingalsbe, M. H., Benbow, J., & Daley, 

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717 Donovan, D. M., Ingalsbe, M. H., Benbow, J., & Daley, 

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719 Kelly, J. F., Stout, R. L., Magill, M., Tonigan, J. S., 

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721 Schutte, K., Lemke, S., Moos, R. H., & Brennan, P. L. 

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722 Kuerbis, A., Sacco, P., Blazer, D. G., & Moore, A. A. 

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723 Substance Abuse and Mental Health Services 

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725 Lal, R., & Pattanayak, R. D. (2017). Alcohol use among 

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726 Ramchandani, V. A., Slattum, P. W., Patkar, A. A., Li-Tzy, 

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727 Kuerbis, A., Sacco, P., Blazer, D. G., & Moore, A. A. 

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728 Witkiewitz, K., Saville, K., & Hamreus, K. (2012). 

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729 Hassell, C., Wilkins, K., & Trevisan, L. A. (2017). 

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730 Substance Abuse and Mental Health Services 

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731 Kuerbis, A., Sacco, P., Blazer, D. G., & Moore, A. A. 

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732 Sinclair, J., Chambers, S., Shiles, C., & Baldwin, D. 

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733 Hassell C., Wilkins, K., & Trevisan, L. A. (2017). 

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734 Kuerbis, A., Sacco, P., Blazer, D. G., & Moore, A. A. 

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735 Substance Abuse and Mental Health Services 

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738 Kuerbis, A., Sacco, P., Blazer, D. G., & Moore, A. A. 

(2014). Substance abuse among older adults. Clinics in 

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739 Hassell, C., Wilkins, K., & Trevisan, L. A. (2017). 

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740 Le Roux, C., Tang, Y., & Drexler, K. (2016). Alcohol and 

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741 Lal, R., & Pattanayak, R. D. (2017). Alcohol use among 

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742 Lal, R., & Pattanayak, R. D. (2017). Alcohol use among 

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743 Friedmann, P. D. (2013). Alcohol use in adults. 

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744 Bommersbach, T. J., Lapid, M. I., Rummans, T. A., & 

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745 Bommersbach, T. J., Lapid, M. I., Rummans, T. A., & 

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746 Bommersbach, T. J., Lapid, M. I., Rummans, T. A., & 

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747 Kuerbis, A., Sacco, P., Blazer, D. G., & Moore, A. A. 

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316 Appendix 
TIP 26

 

 

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NY: Springer. 

749 Taheri, A., Dahri, K., Chan, P., Shaw, M., Aulakh, A., & 

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withdrawal syndrome in older adults. Journal of the 

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750 Bommersbach, T. J., Lapid, M. I., Rummans, T. A., & 

Morse, R. M. (2015). Geriatric alcohol use disorder: 

A review for primary care physicians. Mayo Clinic 

Proceedings, 90(5), 659–666. 

751 Bommersbach, T. J., Lapid, M. I., Rummans, T. A., & 

Morse, R. M. (2015). Geriatric alcohol use disorder: 

A review for primary care physicians. Mayo Clinic 

Proceedings, 90(5), 659–666. 

752 Schutte, K., Lemke, S., Moos, R. H., & Brennan, P. L. 

(2015). Age-sensitive psychosocial treatment for older 

adults with substance abuse. In I. Crome, L.-T. Wu, R. T. 

Rao, & P. Crome (Eds.), Substance use and older people 

(pp. 314–339). West Sussex, UK: Wiley-Blackwell. 

753 Schutte, K., Lemke, S., Moos, R. H., & Brennan, P. L. 

(2015). Age-sensitive psychosocial treatment for older 

adults with substance abuse. In I. Crome, L.-T. Wu, R. T. 

Rao, & P. Crome (Eds.), Substance use and older people 

(pp. 314–339). West Sussex, UK: Wiley-Blackwell. 

754 Kuerbis, A., & Sacco, P. (2013). A review of existing 

treatments for substance abuse among the elderly 

and recommendations for future directions. Substance 

Abuse, 7, 13–37. 

755 Kuerbis, A., & Sacco, P. (2013). A review of existing 

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756 Substance Abuse and Mental Health Services 

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760 Kuerbis, A., Sacco, P., Blazer, D. G., & Moore, A. A. 

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761 Kuerbis, A., Sacco, P., Blazer, D. G., & Moore, A. A. 

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762 McCrady, B. S. (2006). Family and other close 

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764 National Academies of Sciences, Engineering. and 

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765 National Academies of Sciences, Engineering. and 

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766 National Academies of Sciences, Engineering. and 

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767 National Academies of Sciences, Engineering. and 

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768 Satre, D. D., Chi, F. W., Mertens, J. R., & Weisner, C. M. 

(2012). Effects of age and life transitions on alcohol and 

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Studies on Alcohol and Drugs, 73(3), 459–468. 

769 Satre, D. D., Chi, F. W., Mertens, J. R., & Weisner, C. M. 

(2012). Effects of age and life transitions on alcohol and 

drug treatment outcome over nine years. Journal of 

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770 Satre, D. D., Chi, F. W., Mertens, J. R., & Weisner, C. M. 

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771 Donovan, D. M., Ingalsbe, M. H., Benbow, J., & Daley, 

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772 Timko, C. (2008). Outcomes of AA for special 

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Research on Alcoholics Anonymous and spirituality 

in addiction recovery (pp. 373–392). New York, NY: 

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1259 Bommersbach, T. J., Lapid, M. I., Rummans, T. A., & 

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1269 Choi, N. G., DiNitto, D. M., Marti, C. N., & Choi, B. Y. 

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’

SAMHSA Publication No. PEP20-02-01-011 

Published 2020 

Substance Abuse and Mental Health Services Administration 

SAMHSAs mission is to reduce the impact of substance abuse 

and mental illness on America’s communities. 

1-877-SAMHSA-7 (1-877-726-4727) I 1-800-486-4889 (TDD) 

www.samhsa.gov