Substance Use Disorder in Long-Term Care: What Leaders Should Know

Substance Use Disorder (SUD) is often underrecognized in long-term care. In skilled nursing facilities, assisted living communities, and other senior care settings, substance use concerns may appear alongside depression, anxiety, grief, trauma, chronic pain, cognitive changes, medication complexity, or major life transitions.

For long-term care leaders, the goal is not to label or shame residents. The goal is to recognize concerns earlier, respond with compassion, support staff, coordinate care, and connect residents with the right level of behavioral health and SUD support.

Why SUD can be overlooked in older adults:

Substance use concerns among older adults do not always look as people expect. Warning signs may be mistaken for aging, dementia, medication side effects, grief, pain, or personality changes.

Common reasons SUD can be missed include:

• Symptoms overlap with other health conditions

• Residents may feel shame or fear losing independence

• Staff may not be trained to recognize substance use concerns

• Families may minimize or avoid the issue

• Medication complexity can make the picture harder to understand

• Alcohol or prescription medication misuse may not be obvious at first

SAMHSA’s guidance on treating SUD in older adults emphasizes that providers need stronger awareness of older adults’ unique needs when identifying and responding to substance use concerns.

Common substance use concerns in long-term care

Substance use concerns in senior care settings may include:

• Alcohol use or alcohol misuse

• Prescription medication misuse

• Opioid use or opioid use disorder

• Cannabis use

• Sedative or sleep medication concerns

• Substance use connected to chronic pain

• Co-occurring depression, anxiety, trauma, or grief

Warning signs staff may notice first

Staff are often the first to notice when something changes. Possible signs may include:

• Increased confusion or mood changes

• Falls or balance concerns

• Sleep disruption

• Isolation or withdrawal

• Missed medications or medication-seeking behavior

• Increased conflict with staff, family, or other residents

• Changes in appearance or hygiene

• Secrecy around alcohol, medications, or substances

• Repeated requests for certain medications

• New or worsening anxiety, depression, or irritability

Why SUD support belongs inside behavioral health programming

Substance Use Disorder support and treatment deserves a space in behavioral health because mental health and substance use concerns often overlap. Senior care residents who may be experiencing grief, chronic pain, trauma, isolation, or loss of independence greatly benefit from this whole-person approach.

A stronger behavioral health program helps long-term care communities:

• Recognize concerns earlier

• Reduce stigma

• Train staff to respond appropriately

• Coordinate care with providers and families

• Support residents with co-occurring mental health and SUD needs

• Create clearer escalation and referral pathways

• Protect resident dignity while supporting safety

AHRQ describes behavioral health as an overarching term that includes mental health, substance use conditions, life stressors, crises, stress-related physical symptoms, and health behaviors.

The role of staff education

It isn't necessary for Long-term care staff to become SUD clinicians, but they do need practical tools. Training greatly empowers caregivers, nurses, and leaders to understand what to watch for, how to document concerns, how to avoid shame-based responses, and when to involve clinical or behavioral health professionals.

Staff education can cover:

• Signs of substance use concerns in older adults

• Co-occurring mental health needs

• De-escalation and compassionate communication

• Documentation and escalation pathways

• Family communication

• Resident rights, dignity, and privacy

• Crisis prevention and referral options

What leaders should build into their SUD response plan

Long-term care leaders should consider:

• Screening and early identification processes

• Referral pathways for assessment and treatment

• Staff training and refreshers

• Medication review coordination

• Family communication protocols

• Crisis response planning

• Relapse prevention support

• Partnerships with behavioral health and SUD providers

• Clear documentation expectations

• Leadership review of recurring patterns or risks

CMS has also released a guide for substance use screening in nursing facilities that highlight early identification and opportunities for residents to share their substance use history: link here

A compassionate approach supports residents and staff

Substance Use Disorder support in long-term care is not about judgment. It's about considering the whole person, understanding what may be driving a behavior change, and helping care teams respond with clarity.

When behavioral health and SUD support are part of the care model, residents feel more supported, staff feel more prepared, families feel more informed, and leaders have a clearer path forward.

Need support building a behavioral health and SUD care model for your community?

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