Drug use among older people is a neglected topic. Not all older drug users are a social problem; they have varying needs and live in different situations within and between countries. Most policies focus on the young but numbers of older problem drug users are rising. There are high levels of unmet need and co-morbidity. Mainstream services will have to adapt to the changed profile of this population. A variety of proposals have been suggested by researchers and practitioners. There is a need to expand harm reduction services, provide services in the community and involve primary care physicians, encourage services to be more sensitive to the needs of this group, recruit and train staff appropriately, initiate innovations, link generic and specialist practitioners and coordinate health services with social care and housing provision. Key dilemmas are how to organise and finance services and whether these should be specialist or mainstream.