The publication of Our Invisible Addicts in 2011 represented an important landmark in recognising the extent of substance-related health problems amongst older people and that the special service needs to deal with the complexity of such problems, which often involve co-morbid mental and physical health problems, polypharmacy and psychosocial adversity.

Since then, our knowledge concerning the clinical and public mental health aspects of substance misuse in older people has continued to advance but substance misuse amongst older people continues to grow as the population of “baby boomers” ages, increasing both the number of older people and the percentage of the older population with experience of substance misuse. 

Given the further experience and knowledge we now have and the growing need, it is now timely to readdress the issue and to review and revise the original report and build on its recommendations. With this revision, we seek to build on the progress made over the past six years and to emphasise anew that including older people with substance problems in national policies is imperative and that there is a need for organisational reform to tackle this burgeoning issue.

The complex constellation of risks that older people with addictions face and create can result in presentation to a variety of services such as older people’s mental health, addictions, primary care, acute hospital settings, social care, housing, criminal justice and the voluntary sector. In many cases the staff in these settings have little specialist knowledge of how to deal with such complexity. As a result, in this revision we consider and advocate the further development of a clinical workforce with the appropriate knowledge, skills and attitudes to provide identification, assessment, treatment, and assist in recovery and referral for substance misuse in an older population. In particular, we see a need to reverse the loss of multi-professional specialist training in addictions that has taken place in recent years. We also explain how the problem can be best addressed though an approach that is multi-professional, involving psychiatry, nursing, pharmacy, occupational therapy, psychology, social work and the voluntary sector (including peer support).

This report also addresses the important public mental health aspect. The public is poorly informed about the relationship between drinking and health risks in older people. There is also a need to improve knowledge and awareness around the increasing use of illicit and prescription drugs, as well as the harm caused by novel psychoactive substances, substances acquired using the internet, and other addictions accompanying substance misuse such as gambling.

Improving health and social outcomes for older people with substance-related disorders requires a rigorous approach and this report collates the most up-to-date information relevant to practising psychiatrists, their teams and other colleagues.  There is a need for best practice to be implemented and extended to all relevant settings including the criminal justice system and end of life care. As we do so, we should continue to research the effectiveness of the different approaches taken, using both qualitative and quantitative measures to evaluate this. This report, which has been developed with representation from a patient, the Royal College of Psychiatrists, the Royal College of General Practitioners and the British Geriatrics Society, provides the latest milestone on the journey towards developing the best possible response to this important problem.

This report replaces CR165. Our Invisible Addicts (from 2011).

Contents

• Foreword
• Acknowledgements
• Working group
• Executive summary
• Key commendations
• Introduction
• Notes and thoughts from a patient
• Public health and substance misuse in older people
• Assessment of substance misuse
• Treatment
• Service delivery and development
• Education and training
• Ethical and legal considerations for older people with substance misuse
• Research and development
• Conclusion
• References
• Appendix
• Abbreviations
• Glossary
• Models of service