Course:SOWK551/2025/Substance Use in an Aging Population
Background
Palliative approaches in end-of-life care are increasingly gaining recognition for their utility in supporting people to access care in ways that reflect individual values and wishes at the end of life. The applicability of palliative approaches at the end of life is important within the health care system, with the proportion of Canadians aged 65 and older projected to account for 25% of the population by 2030 (National Institute on Ageing, 2021). With aging, individuals face changes in their health care needs, and this is increasingly complicated within the health care system supporting individuals who use substances in end-of-life care due to the complex barriers this population faces. People who use substances experience poor health outcomes and complex health challenges compared to those who do not use substances (Homayra et al., 2020). Despite this understanding, people who use substances often face fragmented care delivery and significant barriers to health care at the end of life (Homayra et al., 2020).
In order to better understand the barriers older adults who use substances face within the healthcare system, it is important to understand palliative care and end-of-life approaches, as well as the facilities themselves that work to support individuals at the end of life. Palliative care is an approach that prioritizes patients' quality of life when they are faced with serious, life-threatening illnesses and primarily focuses on symptom management and addressing physical, psychosocial, and spiritual care for the individual and their family (National Institute on Aging, 2021; Stajduhar & Mollison, 2018). Within this scope, end-of-life care is a term that is often used interchangeably with palliative care and utilizes similar approaches, with the specific distinction being care provision when the illness is terminal and death is expected in the near future (National Institute on Aging, 2021; Stajduhar & Mollison, 2018). End-of-life care and palliative care can be provided anywhere the client is living; however, it is well documented that older adults who use substances face barriers in accessing this care despite findings indicating people living with substance use disorders have increased risks of facing poorer health outcomes and life-threatening conditions (Government of British Columbia, 2025; Ebenau et al., 2019; Homayra et al., 2020).
Provision of end-of-life care often occurs within long-term care, hospice, or in patients' homes. Long-term care provides 24-hour professional health care “in a protective and supportive environment for individuals with complex care needs who can no longer be cared for in their own home or assisted living residence” (Government of British Columbia, 2025). Hospice care facilities offer similar 24-hour services; however, they uniquely focus on comfort care and quality of life optimization for individuals with a serious illness who are approaching the end of life (National Institute on Aging, 2021). Notably, people who use substances and face barriers to end-of-life care may be precariously housed, unhoused, or otherwise undetected by health care professionals to provide end-of-life support. Palliative and end-of-life approaches are inherently trauma-informed and focused on harm reduction as this approach is intended to position care around the needs of individuals in ways that are meaningful to them; however, people who use substances are often excluded from this care. People who use substances face unique challenges in receiving palliative care within the health care system due to intersecting experiences of oppression, resistance to accessing care due to previous experiences, and stigma within the health care system, limiting access to services such as hospice or long-term care.
Social Determinants of Health
Social determinants of health uniquely impact individuals' access to care and influence their overall health outcomes. It is important to consider how a person’s age, gender, ethnicity, housing, income, education, and food security, among other factors, interact to determine individuals’ wellbeing and access to appropriate resources (Stajduhar & Mollison, 2018). Differential access based on these variables strongly influences unfair outcomes related to power, oppression, and health inequities experienced by certain individuals (World Health Organization, 2025). Additionally, consideration of the outcomes related to social determinants of health from an intersectional perspective is necessary to understand health outcomes and equitable access to palliative care approaches. Intersectional perspectives seek to understand how outcomes shaped by individuals’ social circumstances and identities create experiences of inclusion and exclusion (Walsh et al., 2025). Consideration of accessibility to end-of-life care for older adults who use substances is critical through these lenses to best understand how social and systemic structures interact to disproportionately lead to poorer health outcomes and health inequity.
Individuals diagnosed with a substance use disorder (SUD) have been closely linked with other structural forms of health inequities, such as experiences of economic disadvantage, limited formal education, and inadequate housing, which hold consequences related to higher rates of disease and poorer health outcomes compared to those who do not face similar health inequities (Higgs, 2022; Stajduhar & Mollison, 2018). Further, navigation of services to access basic needs such as shelter, food, and social insurance income becomes considerably difficult at the end of life (Stajduhar & Mollison, 2018). Fragmented support and lack of connection to community health care practitioners for these older adults to access palliative care at the end of life leave individuals isolated and without strong relationships to support their health care needs. Challenges with accessing care to support their intersecting identities of age and substance use, among other structural disadvantages individuals with a SUD face, make it difficult for them to focus on seeking out palliative end-of-life care support. As a result, individuals who are unhoused or precariously housed have understandably been found to prioritize focusing on immediate survival needs, such as food and shelter (Baines et al., 2025; McNeil, Guirguis-Younger & Dilley, 2012; Song et al., 2007), in lieu of seeking care for their serious illness. Older adults who use substances and are surviving within complex structures of oppression have been found to face increasingly poor physical and mental health outcomes, which impact their overall access to palliative care and facility-based admissions to support their complex care needs (Higgs, 2022).
Harm Reduction Approaches
Many solutions for working with individuals with SUD at the end of life throughout the health care system appear to point towards abstinence as the standard by which care can best be provided. While this may work for some, many older adults who would benefit from palliative approaches at the end of life do not have goals of abstaining from substances, which does not negate the fact that they still require, and are deserving of care.
Harm reduction is an increasingly implemented policy and practice approach that is grounded in person-centered care from a social justice lens (Baines et al., 2025). Harm reduction policies are based on the acceptance that substance use is part of many individuals’ lives; rather than criminalizing substance use, harm reduction practices are based on the understanding that there are many ways to reduce individuals’ risk of harm, respect their human rights, and improve overall health outcomes (Baines et al., 2025; Kerman et al., 2021). Supporting individuals in accessing regulated supply and addressing social conditions of use are harm reduction approaches that work to minimize poor health outcomes and risks associated with unregulated substance use (Baines et al., 2025; National Harm Reduction Coalition, 2020; Jordan, 2023). Additionally, engaging in safer use, managed use, alternative use, or reduced use has centered this approach to support non-judgemental collaboration and prioritize autonomy in decision-making for people who use substances (Baines et al., 2025; National Harm Reduction Coalition, 2020; Jordan, 2023).
Vancouver Coastal Health (VCH) does not provide specific Harm Reduction policies on any of their LTC sites. However, May’s Place Hospice is in the Downtown Eastside and proudly practices a harm-reduction philosophy with dignity and respect (Li, 2024). With an aging population of people who use drugs, there is a clear need for long-term care homes to define and create policies on harm reduction.
Stigma
Older adults with a SUD face many barriers to accessing end-of-life care, reflected by stigma from health care providers and past experiences influencing trust and willingness to engage with health care services at the end of life. Mistrust in the health care system can result in individuals opting not to disclose their substance use, which can contribute to incorrect symptom representations and inadequate pain management (Ebenau et al., 2019), carrying consequences related to poor quality of life and a lack of meaningful palliative approaches for individuals. Health care providers’ perceptions associated with substance use at the end of life have been linked to suboptimal palliative approaches to care focused on comfort and minimizing pain, as health care providers have stated fears of individuals abusing prescribed medications and label individuals as ‘drug seekers’ when requesting medication for pain management (Tayba et al., 2025).
In the long-term care context, older adults with a SUD encounter challenges with even being admitted despite their care needs requiring 24-hour care, and for those who are admitted, they often experience stigma and isolation within the home. Complex health outcomes necessitating long-term care earlier than others who have not faced the same extent of health inequities pose barriers in and of themselves. The role of age is a consideration for admission to long-term care, and research has found that this raises challenges on admission as staff share concerns that people who use substances would not be a good fit in these homes and that “mixing” populations would impact sociability with others in the home (Baines et al., 2025; Yang et al., 2023). Stigma and negative perceptions of older adults who use substances as being time-intensive, unpredictable, or challenging make cases for admission at the end of life more difficult; these perceptions were found to be exacerbated in long-term care homes that are understaffed (Yang et al., 2023). Additionally, older adults who use substances confront challenges in long-term care homes as many require abstinence over harm reduction approaches (Yang et al., 2023). This presents a major barrier for older adults at the end of life when their intention is not to abstain from substances, and their values misalign with those of the long-term care homes providing end-of-life care. As a result, long-term care admissions at the end of life may not be feasible despite a person being eligible due to high barriers requiring abstinence, or the risk of eviction due to reports of challenging behavioural characteristics (Baines et al., 2025).
Application to Practice
Canada’s population is aging, and older adults who use substances will continue to require increased accessibility to strong palliative approaches to care at the end of life. Social workers play a vital role in the provision of health care accessibility for this population, and advocacy for better connection to this necessary care can be pivotal for older adults who use substances at the end of life.
Specialized training and education for social workers are an essential first step in this work to best understand the needs of this population on an individual level and the complex barriers to adequate health care that they experience, which impact their accessibility to end-of-life care. Providing education within health care to decrease stigma associated with substance use will be an important role when working on integrated care teams to ensure person-centered care is maintained and the health care team is utilizing harm reduction approaches to care. Facilities providing palliative and end-of-life care, such as long-term care, hospice, hospitals, and home supports offered from home, must all practice from a trauma-informed and harm reduction lens that is person-centered and cognizant of the dynamic barriers older adults who use substances face in accessing health care.
Developing policies to standardize more appropriate continuity of care would also be fundamental to ensure community, hospital, and bed-based facilities can provide consistent care and support, while also being prepared to best approach care for individuals with various levels of care needs. The benefits of this policy development would be multifaceted and impact individuals across the health care continuum to support end-of-life care. This would provide an opportunity for health care relationships to be initiated much earlier in an individual’s health trajectory once they have been diagnosed with a serious illness, and even before. Social workers can build trust earlier and support navigation of the complicated health system, with a strong role in harm reduction approaches and addressing social determinants of health to improve health outcomes. Social workers advocating for continuity of care is another harm reduction approach that is a necessary practice to ensure older adults receiving palliative care are well supported at every point within the health care system and to prioritize the older adults’ wishes at every step of care.
References
Baines, D., Braedley, S., Daly, T., Hillier, S. and Cabahug, F. (2025) Low-barrier harm reduction and housing for older people in Vancouver’s opiate crisis: meeting people where they are, Critical and Radical Social Work, 13(1): 41–56, DOI: 10.1332/20498608Y2024D000000031
Ebenau, A., Dijkstra, B., ter Huurne, C., Hasselaar, J., Vissers, K., & Groot, M. (2019). Palliative care for people with substance use disorder and multiple problems: A qualitative study on experiences of patients and proxies. BMC Palliative Care, 18(1). https://doi.org/10.1186/s12904-019-0443-4
Government of British Columbia. (2025). End-of-life care. Province of British Columbia. https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/care-options-and-cost/end-of-life-care
Higgs, P. (2022). Ageing (dis)gracefully: People who inject drugs living with hepatitis C and the provision of end-of-life care. In Substance Use, End-of-Life Care and Multiple Deprivation (1st ed., pp. 105–117). essay, Routledge.
Homayra F, Pearce LA, Wang L, Panagiotoglou D, Sambo TF, Smith N, McKendry R, Wilson B, Joe R, Hawkins K, Barrios R, Mitton C, Nosyk B. Cohort profile: The provincial substance use disorder cohort in British Columbia, Canada. Int J Epidemiol. 2021 Jan 23;49(6):1776. doi: 10.1093/ije/dyaa150. PMID: 33097934; PMCID: PMC7825959.
Kerman, N., Polillo, A., Bardwell, G., Gran-Ruaz, S., Savage, C., Felteau, C. and Tsemberis, S. (2021) Harm reduction outcomes and practices in Housing First: a mixed-methods systematic review, Drug and Alcohol Dependence, 228: 109052. Doi: 10.1016/j.drugalcdep.2021.109052
McNeil, R., & Guirguis-Younger, M. (2011). Illicit drug use as a challenge to the delivery of end-of-life care services to homeless persons: Perceptions of Health and Social Services Professionals. Palliative Medicine, 26(4), 350–359. https://doi.org/10.1177/0269216311402713
National Institute on Aging. (2021). What are palliative care and Hospice Care? . https://www.nia.nih.gov/health/hospice-and-palliative-care/what-are-palliative-care-and-hospice-care
Stajduhar & Mollison, 2018 Too Little, Too Late: How we fail vulnerable Canadians as they die and what to do about it. Final Project Report for the Equitable Access to Care Study in Victoria, British Columbia https://www.uvic.ca/research/groups/peol/assets/docs/too-little-too-late.pdf
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Walsh, J. J., Sussman, T., Bosma, H., Carter, R. Z., Cormier, É., & Canham, S. L. (2025). The intersections of palliative care and homelessness in social policy: A content analysis of Canadian policy documents. BMC Palliative Care, 24(1). https://doi.org/10.1186/s12904-025-01866-4
World Health Organization. (2025). Social Determinants of Health. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
Yang, M., Beiting, K. J., & Levine, S. (2023). Barriers to care for nursing home residents with Substance Use Disorders: A qualitative study. Journal of Addiction Medicine, 17(2), 155–162. https://doi.org/10.1097/adm.0000000000001061