Table 2 Representative thematic quotes

Care seeking

Oftentimes when I am seeing older patients, the OUD is not at the forefront of their visit. They may come for something else entirely

18

We see them more in the outreach work in the field, rather than our field sites. Or if they come to our field sites, they’re usually using other services, such as HIV testing or other care

3

Complicated patients

The first thing I notice about older adults who are misusing opioids is that they are very, very sick. In addition to addiction and OUD, they frequently have chronic medical issues—cardiac issues, respiratory, neurologic. They are complicated

18

They may need a knee replacement. However, you can’t find a surgeon to operate on them since a surgeon won’t operate on someone with OUD. This creates a cycle where the surgeon will say they won’t operate on someone with too many opioids, but the patient can’t get off of opioids because they are in too much pain. It’s a really difficult cycle to get out of. It’s really hard to ask patients to get off of opioids because they will be in incredible amounts of pain all the time

5

If people have severe OUD that is not controlled, it becomes very difficult to manage any other comorbidity. Addiction introduces a level of chaos into people’s life and that makes it hard to take your medication, attend to your appointments, stick to your diet

18

Overdose risk

A lot of patients with COPD and asthma who are insufflating. That puts them at high risk for overdose and respiratory failure. Physicians are not comfortable prescribing methadone to these patients because they believe that methadone poses a risk for overdose, however, the other alternative is that the patient suffers from respiratory failure

5

I don't see them [older adults] as risk takers because they’ve been able to take it [opioids] for so long and survive. If there’s a risk for overdose, I think it has more to do with the components of the drug and its typically fentanyl. If fentanyl wasn’t in the system, then I think they’d be ok because they tend not to use a lot and be greedy. They’re knowledgeable and cautious based on their experience

3

A lot of the attention in harm reduction is directed towards those who are injecting drugs, but I think overdose prevention efforts target more people who inject and not as many who snort drugs. However, you can definitely snort and die. A lot of people think snorting is a safer way of using

22

I think all of our attention goes to the injectors because they are at higher risk for HIV and hepatitis C even though Hep C can also be transmitted by using straws to snort. I think there’s a lack of program and research focused on that group for that reason

1

A patient who is 85 years old has a lot of confidence that they can safely use since they’ve been doing it for so long

13

Sometimes the older patients and those who only snort often get overlooked. Maybe they’re not injecting, so they’re not getting the same attention since they don’t go to needle exchange programs and receive Narcan treatment

22

I’ll ask if people think it’s safe to do that [using alone] and they’ll say I know my dealer and it’s been the same guy. They have these strategies that they enact that they believe will reduce their risk and, in some cases, may work. In some cases, they’ll test a little bit first and then say, ‘I’ll do more’. Some people will say ‘I tell by the color of it’. More often than not, it’s been I use the same person

3

SUD treatment and older adults

A lot of people think they have to enter a specific treatment program and maybe they are not as familiar with the office-space care

17

They probably don’t understand that treatment for OUD is as accessible as it is now. They tend to be very surprised when they find out they can walk out with a prescription for a week or two of suboxone

17

Older adults are maybe more wary of treatment because they may have had negative experiences with treatment in the past and may have been stigmatized. They’re maybe not familiar with the new breed of providers who are really trying to make an impact in their community

17

Older tropes/patients have had discrimination and negative aspects of disclosing that SUD. They’ve been using for a while but are seeking treatment now because the stigma has been removed

19

Older adults are less likely to travel…accessibility is what draws a lot of people in vs them actually having to engage with the healthcare system and I think that’s a big benefit to our older population. Like the convenience of it. I think programs need to be more convenient and flexible

1

Because of how complicated their chronic medical conditions are, that makes them difficult to access addiction treatment. It may be hard to leave the house and go to a methadone clinic or do buprenorphine in an office-spaced clinic. They may need post-acute care. Accessing addiction treatment while going through post-acute care can be tricky. We are not just treating addiction, we are also treating other comorbidities, congestive heart failure, chronic kidney disease, post stroke care, traumatic injuries

18

The ones we know have been using for quite a while. They’re older and they’ve been able to survive. They tend to figure out other ways to manage their addiction. Very often, drug treatment is part of it, and it is part of their overdose risk, too. If they’re using street drugs and using methadone, there’s an elevated risk of overdose for some folks. As they’re older, their hustling strategies—their ways to raise money for their drug use—is not there. It just gets harder as you are older. They tend to figure out an easier way to use in conjunction with their medically assisted treatment

3

If someone has mild to severe cognitive impairment, they may not remember to take buprenorphine or naloxone on a daily basis or they may not remember when they last used. There are some questions there from what should we do from an ethical perspective and operational perspective

18

Older patients are usually pretty receptive to treatment. 50/50 between those who want to start suboxone vs those who want to start methadone (what older adults are familiar with). Nearly everyone who I have offered help or treatment to after screening over the age of 50 has been pretty appreciative of that

17

The last time I was on a consult service I saw a patient who had a stroke. He was also using opioids and had been using intranasal opioids for a long time. I think our consult service had seen this patient in the past maybe a year ago and had tried to start him on suboxone at that time, but it doesn’t seem like that linkage to care happened. After this stroke, the patient was going to need acute rehab so we were able to restart him on suboxone and connect for him to go on acute rehab on the suboxone. I think this case is similar to most cases since it’s someone who has been using for decades, who was not in for treatment and was open to treatment. It’s someone who we were able to start and link them to care. But I think it’s someone who depending on their degree of recovery from stroke, it may be difficult for them to schedule follow up appointments (securing transportation maybe)

18

Nearly everyone who I have offered help or treatment to after screening over the age of 50 has been pretty appreciative of that

17

Screening

So I think a lot of the older patients have had, you know, discrimination or, you know, negative aspects of disclosing that with people. Like, even in my primary care, you know, with new patients, they don't necessarily disclose that on the first visit. Sometimes it takes much longer, especially with methadone, because you can't really track that and like any kind of external, you know, refill history or things like that. So, if they don't tell you, you really don't know

19

I asked all my patients very early on, and just my like, a review of their past medical history. I go straight to substances, tobacco, alcohol and everything else. And I asked, you know, if not now, has it ever been a problem? So I do my own personal just like questioning, no formal screening questions. What prompts it…falls and cognition would be my two big ones. And just like any self-care concerns, environment at home, their ability to perform, like, if I have any sense of like, their ability to perform ADLs, whether it's just like, how they're dressed at the appointment, their cleanliness? Just want to make sure that I rule out something like that

13

We're trying to build it into our EMR so that… everyone gets at least like a short screener, but we're not there yet. But it is something that is a goal because I do think the providers ask like, oh, do you use substances and stuff? And sometimes that's enough, but sometimes people don't. So they might ask about alcohol and smoking, but they don't necessarily ask about other substances or about, you know, for people who are on chronic opioids, making sure to ask about like any signs that they may be developing that use disorder. So I think that we could do better with like automating that so that people always ask the questions

22

There’s some concern that—In older adults, the screening tools that we have can potentially underestimate and overestimate patients having OUD. Some of the diagnostic questions on DSM regard the drug use impairing someone's ability to work or at school. And probably, the older adults is not working anymore, so those questions are hard to apply. On the flip side, they could be showing signs of opioid misuse like they are confused or sedated in some way. And that can be a result of another medical process and be a false positive for opioid use. You can get false positives and false negatives from the screening tools

18

I think, in particular, for like patients with chronic pain, I think it's important to ask a little bit about like how the medications might be impacting their life and sort of asking about any impact on behavior or like cravings for or do they feel like they're wanting to use more, like take more than they're prescribed? And I think… a lot of this comes out, you know, there's so much stigma around substance use disorder and especially, I think for patients on chronic opioids, for chronic pain, there's like a lot of fear of getting labeled as someone with a use disorder and then being cut off of all their medication and then they have all this pain

18

So I think you have to be really aware of like how we ask the questions and to make sure that patients know that like we ask the questions because we care about them and we want them to do well and not because we're like trying to find, you know what I mean? Like catch somebody who hasn't used disorder and then like ban them from the clinic or something, which unfortunately is kind of what happens sometimes. So I think that there's a way to ask questions without it and making it a collaborative kind of discussion without it being like a—I don't know what's the word I'm looking for—like accusatory kind of questioning

18