The Most Commonly Abused Drugs Among Older Adults

Alcohol is, by a wide margin, the substance most commonly misused by adults over 65, followed by prescription opioids, benzodiazepines, and a fast-growing share of cannabis users. What makes substance misuse in this age group distinctive is not just which drugs are involved but how differently an aging body handles them. A dose that was safe at 40 can become dangerous at 70, and the line between appropriate medical use and harmful misuse often blurs in ways it does not for younger people.

Alcohol Remains the Leading Problem

Among older adults entering substance abuse treatment between 2000 and 2012, alcohol was the primary substance in the majority of cases, though its share declined from about 77% to 64% over that period as other substances gained ground.¹ That decline does not mean fewer people are drinking problematically. Alcohol use among adults 65 and older is actually increasing, and the population itself is growing rapidly.²

The risks compound with age in specific, measurable ways. Older drinkers are more sensitive to alcohol’s acute effects on memory, coordination, reaction time, and driving ability. Chronic heavy drinking accelerates age-related problems that would develop anyway: systemic inflammation, sleep disruption, cognitive decline, and increased risk of cancer and liver disease.² One study of older adults found that clinically detected alcohol abuse carried a 56% higher risk of short-term mortality after adjusting for age, sex, and dementia diagnosis. The same study found that dementia of nearly every type (except probable Alzheimer’s disease specifically) was more common among those with definite or questionable alcohol abuse.³

Part of what makes alcohol misuse so prevalent in this group is its social acceptability. A nightly glass of wine or two does not raise the same red flags as a pill bottle, and many older adults have been drinking moderately for decades. The problem is that “moderate” at 45 may not be moderate at 75, because the body’s ability to process alcohol has changed.

Prescription Opioids and the Pain Trap

Chronic pain is common in later life, and opioids remain a standard treatment for it. That puts older adults in a bind: they have legitimate, often severe pain, but the medications prescribed for it carry unique dangers for aging bodies. Physiological changes and altered metabolism in advanced age require special attention when opioids are being used long term.⁴

Opioid use disorder prevalence among Medicare beneficiaries has increased substantially across all demographic subgroups, representing what researchers call an urgent challenge for public health professionals and gerontologists.⁵ Among older cancer survivors with chronic pain conditions, roughly one in eight followed a “persistent use” trajectory of opioid prescriptions, with Black patients and those living in rural areas at notably higher odds of falling into that category.⁶

What makes opioid misuse especially tricky in older adults is that it does not always look like what people picture when they think of addiction. Many older people never sought opioids out recreationally. They were prescribed them after surgery or for arthritis, took them as directed, and gradually became dependent. Clinicians sometimes hesitate to start deprescribing conversations, particularly when a patient has co-occurring mental health concerns or when there is a perceived risk the patient might turn to illicit opioids if their prescription is reduced.⁷

Benzodiazepines and the Paradox of Continued Prescribing

Benzodiazepines, the class of sedatives that includes drugs like diazepam and lorazepam, are among the most paradoxical problem substances for older adults. Multiple major medical organizations, including the American Geriatrics Society, advise against prescribing them to people over 65. Despite those warnings, they continue to be prescribed at high rates to the very group with the highest risk of serious adverse effects.⁸

The concerns are well documented. A substantial proportion of the geriatric population uses these medications chronically despite strong recommendations, based on high-quality evidence, warning of potential cognitive harms.⁹ A retrospective study of veterans found that benzodiazepine exposure was associated with a slightly elevated risk of dementia, though interestingly, the risk did not increase in a dose-dependent fashion: low-exposure and high-exposure veterans had essentially the same small increase in dementia hazard compared with nonusers.¹⁰

Beyond the dementia question, benzodiazepines increase fall risk, cause daytime sedation, and interact badly with other medications older adults commonly take, including opioids. The American Geriatrics Society’s Beers Criteria, a widely used list of medications typically best avoided by older adults, includes benzodiazepines prominently.¹¹ The list is used internationally to help reduce adverse drug reactions, hospital admissions, and mortality in elderly patients.¹² Yet prescriptions keep flowing, often because tapering off benzodiazepines is itself medically complicated and distressing for patients who have been taking them for years.

Cannabis Use Is Climbing Fast

Cannabis may not be the substance most people associate with older adults, but it is the fastest-growing one in this demographic. Past-year cannabis use among adults 65 and older increased from about 2.4% to 4.2% between 2015 and 2018, a 75% relative jump in just a few years.¹³ More recent data paints an even higher picture: a 2025 study found that more than one in ten older adults reported using cannabis in the past 30 days, with smoking and edibles the most common methods. Over half of those current users used cannabis frequently.¹⁴

Legalization appears to play a significant role. Older adults living in states with recreational cannabis laws had roughly two and a half times the odds of past-month use compared with those in states where cannabis remained illegal.¹⁴ Current tobacco use and economic hardship were also associated with higher odds of cannabis use in this age group.

Cannabis use disorder is not rare among older users. Of those with past-month use who had available diagnostic data, about 36% met criteria for cannabis use disorder in the past year, including roughly 23% with mild, 11% with moderate, and about 2.5% with severe presentations. Inhaled cannabis was associated with higher odds of cannabis use disorder compared with edibles alone.¹⁴ Older adults who use cannabis are at increased risk of adverse psychiatric and medical events because of their decreased physical and cognitive reserve, multiple comorbidities, and the many medications they already take.¹⁵

Why an Aging Body Handles Drugs Differently

A recurring theme across all of these substances is that the same dose becomes more potent, or more dangerous, as the body ages. Two main things change. First, the body’s ability to clear drugs slows down: kidney function can decline by as much as 50% in roughly two-thirds of elderly people, and the liver’s capacity to metabolize certain drugs can drop by up to 30%.¹⁶ Second, body composition shifts. Fat-soluble drugs, which include many sedatives and psychiatric medications, distribute into a larger volume of body fat and stick around longer. Water-soluble drugs concentrate in a smaller volume, reaching higher peak levels.¹⁷

On top of these shifts, older adults also tend to become more sensitive to certain drug classes, including anticoagulants, diabetes medications, and psychotropic drugs like sedatives and antidepressants.¹⁷ Emerging research also points to changes in drug transporter function, gut microbiome composition, and protein binding as further factors that can alter how drugs behave in older bodies.¹⁸ The practical consequence: a drug that a younger person metabolizes and excretes within hours might linger in an older person’s system for much longer, accumulating to harmful levels.

Over-the-Counter Medications People Do Not Think to Worry About

When most people hear “drug abuse,” they think of opioids or alcohol. They rarely think of the sleep aid or pain reliever sitting in the medicine cabinet. But over-the-counter medications represent a genuine and overlooked category of misuse in older adults. Elderly people are the largest consumers of both prescription and OTC medicines and are more vulnerable to their adverse effects. Common OTC agents like nonsteroidal anti-inflammatory drugs have recognized side effects that are more common in older users, and all sedating products, including antihistamines marketed as sleep aids, increase the risk of falls.¹⁹

A preliminary study examining OTC misuse found that 60% of older participants had drug-drug interactions with the pain products they selected, and among those who chose sleep medications, 65% were taking products that are considered inappropriate for their age group. Overall, the majority of participants’ OTC selections qualified as some form of misuse when evaluated against clinical criteria.²⁰ Many doctors do not routinely ask patients about OTC use, so these interactions often go undetected.¹⁹

The Polypharmacy Multiplier

What turns any single substance into a greater danger for older adults is the sheer number of medications many of them already take. In one study of older adults with cardiovascular disease, patients were taking an average of nearly 12 medications at home. Ninety-five percent met the threshold for polypharmacy, about 69% were in “hyper-polypharmacy” territory, and roughly 78% had at least one severe potential drug-drug interaction. The most common dangerous interactions involved drugs with additive sedating effects on the central nervous system and drugs that increase the risk of heart rhythm abnormalities.²¹

The probability of harmful drug-drug interactions rises nearly exponentially as the number of medications climbs. Simply following clinical guidelines for each of a patient’s individual diseases can itself produce severe interactions when those diseases are numerous.²² Adding alcohol, cannabis, or even an OTC sleep aid on top of that stack can push an already fragile balance into crisis.

Falls, Emergency Rooms, and the Downstream Consequences

Falls are one of the most immediate and dangerous consequences of substance misuse in older adults. Emergency department visits for alcohol-associated falls among older adults rose about 7.5% per year between 2011 and 2019, representing over 600,000 estimated visits during the decade studied.²³ Opioids carry similar risks. A large study found that during active opioid exposure, the risk of serious fall events was elevated across all age groups but was highest among those 85 and older, who had more than six times the fall risk of younger adults on the same medications. The first 28 days after starting a new opioid prescription was a period of particularly high danger.²⁴

The cognitive consequences extend beyond the immediate injury. A history of alcohol abuse increased the risk of developing Alzheimer’s disease by about 22% and vascular dementia by a similar margin, even after accounting for other psychiatric conditions.²⁵ Having any history of psychiatric and substance use disorders raised the hazard of both types of dementia by about 45-46%.²⁵

Loneliness as a Quiet Driver

Substance use among older adults does not happen in a vacuum. Retirement, the death of a spouse, shrinking social circles, and chronic illness all feed into patterns of misuse. A study of midlife and older adults found that those using at least one substance had a 17% higher risk of reporting they felt lonely “always or usually” compared with nonusers. About 8% of substance users reported feeling lonely always or usually, compared with 4.4% of nonusers.²⁶ Whether loneliness drives the substance use or the substance use deepens the isolation is probably both, but the association is real and underappreciated in clinical settings where the focus tends to be on the drug rather than the life around it.

Prescription Stimulants and Cardiovascular Risk

With growing recognition of attention-deficit/hyperactivity disorder in older adults, stimulant prescriptions in this age group have risen. The cardiovascular concerns are real but nuanced. One study found that the risk of any cardiovascular event was about 40% higher in the 30 days after starting a stimulant, with a threefold increased risk of arrhythmias specifically. These elevated risks, however, did not persist at the one-year mark for most outcomes.²⁷ Pre-existing heart disease is the major red flag: among nearly a million people prescribed stimulants, those with atherosclerotic heart disease had dramatically higher odds of adverse cardiac events. Hypertension, cocaine use, and anxiety disorders were also strong predictors.²⁸

Illicit Drugs Are Not Off the Table

It is tempting to assume illicit drug use is a younger person’s problem, but that assumption is increasingly wrong. The baby boomer generation has higher rates of both lifetime and current cocaine use than older cohorts.²⁹ Between 2000 and 2012, the proportion of older adult treatment admissions for cocaine, heroin, marijuana, and other opiates all increased.¹ The baby boom generation’s unique exposure to drugs during the 1960s and 1970s created attitudes and patterns of use that have persisted into retirement, and projected rates of substance use in older adults are expected to keep climbing for the next two decades.³⁰

Substance use among older adults has been underidentified for decades, partly because clinicians and families do not expect it. Symptoms of misuse, such as confusion, unsteadiness, sleep problems, and mood changes, overlap heavily with normal aging and with common medical conditions, making it easy to miss.³⁰

When Medications Disappear From the Bottle

There is one dimension of drug misuse affecting older adults that receives almost no public attention: medication diversion in care facilities. An analysis of Minnesota investigation reports substantiated as “drug diversion” between 2013 and 2021 in assisted living residences and nursing homes found that over 11,000 tablets were stolen from 368 residents. Nearly all of the stolen medications, about 97.5%, were controlled substances, averaging more than 30 tablets per resident.³¹ This means some older adults in institutional care may be receiving less pain medication or fewer sedatives than their doctors ordered, suffering needlessly because their drugs were diverted by staff.

The Medicare Bill

The financial consequences of substance misuse in this population are staggering. Medicare spending on beneficiaries with opioid use disorder who were not receiving medications for addiction treatment totaled roughly $15.8 billion more than spending on beneficiaries without the disorder. Even compared with those who had opioid use disorder but were receiving treatment, the untreated group cost about $12.1 billion more. Medicare spending specifically attributable to opioid-related comorbidities was estimated at $3 to $4.7 billion, and these totals could be about 1.7 times higher if Medicare Advantage enrollees were included.³² The growing demographic and substance-use shifts among older adults, including rising numbers of women, African Americans, homeless individuals, and those with co-occurring psychiatric problems entering treatment, signal that the demands on health systems are set to intensify.¹

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