Volume 2, Issue 1
Article Type: Short Commentary

Clinical presentation of opioid use disorder in older adults: Implications for gerontological nursing practice

Janice Collins McNeil, PhD, APRN, PHN, CNS, FNP, BC^*

North Carolina Central University, School of Nursing, 1801 Fayetteville St, Durham, NC 27701, USA.

Received: Feb 05, 2026
Accepted: Mar 03, 2026
Published Online: Mar 10, 2026
Journal: Annals of Gerontology and Geriatrics
Copyright: McNeil JC et al. © All rights are reserved

Citation: McNeil JC. Clinical presentation of opioid use disorder in older adults: Implications for gerontological nursing practice. Ann Gerontol Geriatr. 2026; 2(1): 1031.

Introduction

Opioid Use Disorder (OUD) in older adults is frequently under-recognized in clinical practice, partly due to its presentation that differs from that of conventional substance use disorder frameworks and its overlap with prevalent geriatric syndromes. Instead of manifesting overt intoxication or explicit drug-seeking behaviors, older adults with OUD often exhibit functional decline, cognitive changes, falls, and medication-related adverse events commonly attributed to aging, multimorbidity, or polypharmacy [10,12]. This diagnostic ambiguity positions gerontological nurses as crucial players in identifying OUD through longitudinal assessment and age-informed clinical judgment.

Functional impairment is a common occurrence among older adults receiving long-term opioid therapy. These individuals might experience increased gait instability, a heightened risk of falls, and reduced ability to perform daily life activities, even without dose escalation [17]. Cognitive alterations (e.g., confusion, impaired attention, and fluctuating alertness) are prevalent and frequently misattributed to the progression of dementia or acute delirium unrelated to opioid exposure [8]. These clinical manifestations underscore the essential role of nursing competencies in conducting comprehensive geriatric assessments, fundamental to gerontological nursing practice.

In older adults diagnosed with OUD, pain trajectories frequently exhibit paradoxical characteristics. The development of tolerance and opioid-induced hyperalgesia could induce intensified pain despite continued opioid consumption, leading patients to rely on opioids to maintain baseline functioning rather than achieve analgesia [2]. Nurses may observe behavioral indicators, such as distress, when doses are delayed, strict adherence to medication schedules, or frequent early refill requests, signals of a loss of control that could be overlooked when opioids are prescribed and consumed as directed [10].

Withdrawal symptoms in older adults are often misdiagnosed. Symptoms such as anxiety, insomnia, diaphoresis, gastrointestinal distress, tachycardia, or hypertension are frequently attributed to infections, cardiovascular conditions, or generalized anxiety rather than opioid withdrawal [12]. Age-related alterations in pharmacokinetics and pharmacodynamics further exacerbate susceptibility to adverse effects, even at therapeutic dosages [15]. These complexities underscore the necessity for gerontological nurses to incorporate substance use assessments into the routine evaluation of both acute and chronic symptoms.

Polypharmacy markedly increases the risk of overdose in older adults. The simultaneous use of opioids with benzodiazepines, sedative-hypnotics, gabapentin, or alcohol is prevalent and strongly linked to respiratory depression, falls, and mortality [3,9]. Repeated visits to emergency departments for falls, syncope, or unexplained injuries might thus serve as sentinel events indicating opioid-related harm rather than isolated incidents, an understanding that relies on nursing care continuity across different healthcare settings.

Psychosocial factors further complicate the recognition of substance use disorders. Conditions such as depression, bereavement, social isolation, and substance use-associated stigmatization in later life could potentially hinder disclosure and delay the pursuit of assistance [7]. In addition, older adults are less frequently screened for substance use disorders, perpetuating the misconception that OUD is rare within this demographic group. From a gerontological nursing perspective, this situation highlights a broader deficiency in age-inclusive addiction frameworks.

OUD in older adults is amenable to treatment. Medications for Opioid Use Disorder (MOUD), with a particular emphasis on buprenorphine, could be administered safely and effectively in this population when initiated with caution and monitored closely (Substance Abuse and Mental Health Services Administration [SAMHSA], 2021, 2024). Gerontological nurses are integral to conducting age-sensitive assessments, monitoring for adverse effects, coordinating care transitions, educating patients and caregivers, and facilitating referrals to evidence-based treatments. Failure to identify OUD in older adults constitutes a missed opportunity to prevent overdoses, reduce hospitalizations, and maintain functional independence.

Implications for advanced practice nursing roles and clinicians

Advanced Practice Registered Nurses (APRNs) and clinicians in gerontology, mental health, and primary care settings are crucial for improving access to evidence-based care for OUD among older adults. APRNs frequently serve as the primary point of contact for aging patients with complex multimorbidity, uniquely positioning them to integrate OUD assessment and management into routine care. The age-informed prescription of Medications for Opiate Use Disorder (MOUD) requires careful initiation, dose titration, and vigilant monitoring for adverse effects, particularly in the context of chronic pain, cardiovascular disease, and cognitive impairment.

Beyond direct clinical management, APRNs assume a vital leadership role in coordinating interdisciplinary care, aligning OUD treatment with chronic disease management, and facilitating transitions across care settings. Clinical nurse specialists and nurse practitioners could lead the development of geriatric specific protocols, mentor nursing staff in non-stigmatizing care approaches, and integrate screening and brief interventions into wellness and follow-up visits. These roles position APRNs as central contributors to the provision of safe, effective, and person-centered OUD care for older adults.

Implications for medicare-aligned care models

Medicare-aligned care models offer significant opportunities to enhance nursing responses to OUD in older adults. Services such as the Annual Wellness Visit, Chronic Care Management, Transitional Care Management, home health, and skilled nursing care provide structured opportunities for nurse-led assessment, medication review, and care coordination. Incorporating OUD screening and medication safety monitoring into these interactions could facilitate early risk identification and ensure continuity of care following hospitalization or care transitions. As Medicare increasingly prioritizes quality, safety, and prevention, nurse-led interventions targeting opioid-related harm align with broader objectives of reducing preventable hospitalizations, falls, and adverse drug events among the elderly. Care models that allocate nursing time for assessment, education, and coordination, especially in home-based and community settings, are crucial for addressing the complex interplay of aging, chronic illness, and opioid use. Strengthening nursing integration within Medicare-aligned frameworks might improve outcomes while maintaining functional independence in aging populations. An increased emphasis on age-informed assessment and nurse-led intervention across gerontological practice, advanced nursing roles, and Medicare-aligned care models is vital to mitigate preventable opioid-related harm in later life.

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