Changing Patterns of Substance Abuse by the Elderly:

The Increasing Contribution of Illicit Drugs

 

David F. Duncan, DrPH1,2

Thomas Nicholson, MPH, PhD3

John B. White, PhD3

John Bonaguro, PhD2,3

 

 

 

 

 

 

 

 

 

1Duncan & Associates, Bowling Green, Kentucky 42101, USA.

2Office of the Dean, College of Health and Human Services, Western Kentucky University, Bowling Green, Kentucky 42101, USA.

3Department of Public Health, Western Kentucky University, Bowling Green, Kentucky 42101, USA.

Presented at the Oxford Round Table on Public Policy, Lincoln College, Oxford University, Oxford, United Kingdom, April, 2009.


 

Between now and 2030 the number of adults aged 65 and older in the United States will almost double, from around 37 million to more than 70 million, an increase from 12 percent of the U.S. population to almost 20 percent. (U.S. Census Bureau, 2008; Institute of Medicine, 2008).  While this is partly due to increasing longevity and partly to a declining birth rate, it is principally due to the maturing of the postwar "baby boom" of persons born in the U.S. between 1946 and 1964 (Siegel, 1996).  In 2011 the first baby boomers will turn 65, and by 2030 the entire baby boom generation will be 65 or older.

This demographic change has great importance for America's health care system because older persons make considerably greater use of health care services than do younger Americans and have health care needs that are often more complex.  The Institute of Medicine (IOM) (2008) has warned that the American health care system is already struggling with the challenge of delivering high-quality services to older adults and that most of America’s health care professionals lack adequate education and training with respect to the health care needs of older adults.  Looking ahead, they note that "the next generation of older adults will be like no other before it" (Institute of Medicine, 2008, p. 15).  America’s aging baby boomers will have greater racial and ethnic diversity,  higher levels of education, lower levels of poverty, fewer children, higher divorce rates, and more openness regarding their sexual orientation than any previous cohort of American elders (He, 2005; U.S. Census Bureau, 2008; Institute of Medicine, 2008).  Unmentioned in the IOM report is any difference in substance abuse prevalence between baby boomers and previous generations.  The National Academies Keck Futures Initiative similarly ignores drug abuse as an issue in the elderly, implying that it is an issue only in young people (National Academies Keck Futures Initiative, 2008, p. 69).  Until relatively recently, substance abuse by the elderly apparently was not addressed by either the substance abuse or the gerontological literature (Center for Substance Abuse Treatment, 1998). 

It was long held that, with only a few isolated exceptions, substance abuse simply did not exist among the elderly.  Alcoholism was described as a self-limiting condition with an early life onset, which ended in either abstinence or death before old age was reached (Duncan, 1994) and the elderly were seen as non-users of other recreational drugs.  When this view was challenged by researchers in the last quarter of the Twentieth Century, a new consensus emerged asserting that alcohol abuse and misuse was the substance abuse problem of concern among older adults, affecting some 2.5 million of them.  This growing recognition that the aged may suffer from alcohol abuse and alcoholism has not been limited to the United States – finding a place in the medical literature in such other nations as Germany (Lieb, Rosien, Bonnet & Scherbaum, 2008), New Zealand (Berks & McCormick, 2008), and Poland (Suwala & Gerstenkorn, 2007).

Abuse of legal medications by the elderly has generally come to be seen as a real but smaller problem (Atkinson & Kofoed, 1982; Schonfeld & Dupree, 1995).  Recently, however, the U.S. Center for Substance Abuse Treatment (CSAT) identified abuse of alcohol and prescription drugs among adults 60 and older as one of the fastest growing health problems facing the nation -- one that “remains underestimated, underidentified, underdiagnosed, and undertreated” (Center for Substance Abuse Treatment, 1998). 

A recent review by Simoni-Wastila and Yang (2006) of the literature published in English between January, 1990 and May, 2006 found that while there was a growing literature on the epidemiology and treatment of alcoholism in older adults, there was very little that addressed the abuse of other drugs by the elderly.  While they urged greater attention to problems of misuse and abuse of prescription drugs by the elderly also seemed to regard abuse of illegal drugs by the elderly to be too rare to be a matter of any serious concern (Simoni-Wastila & Yang, 2006).  This view would seem to be supported by a recent examination of substance abuse treatment admissions in the year 2001 of persons aged 55 and older (Arndt, Gunter & Acion, 2005).  Their report indicates that all such admissions were alcohol-related, consistent with the general consensus view that this was the sole substance abuse problem among the elderly.

We have suggested that this assessment of the situation may no longer be valid and that increasing attention needs to be paid to the possible abuse of illicit drugs by elder Americans as “baby boomers” (i.e., those born between 1946 and 1964 in the USA) reach retirement age (White & Duncan, 2008).  In this previous analysis of data from an annual national survey of drug use we found support our view that the baby boomer’s were showing higher levels of drug use later in life.  While the proportion reporting use of alcohol remained relatively stable, the proportion that had ever used each of six categories of illicit drugs studied increased.  Current (past month) use was greater for marijuana (1.6 % v. 0.3%), cocaine (0.3% v 0.1%), and inhalants (0.1% v 0%).  While these percentages may look small it should be remembered that this amounts to an estimated increase of 1,268,262 in the number of elder Americans who are currently using marijuana, 140,422 cocaine users, and 56,547 inhalant users.  Furthermore, the same amount of drug taken at the age of 25 may have markedly different effects when consumed at the age of 75. 

Of course, not all of these older users of illicit drugs have an addiction or abuse problem.  Generally speaking, only about 10% to 20% of the users of a drug (other than tobacco) ever develop an abuse problem (Anthony & Helzer, 1991; Duncan, White & Nicholson, 2003; Nicholson, Duncan & White, 2002).  This still suggests that there has been a substantial increase in the numbers of elder Americans who abuse illicit drugs.  We can no longer assume that substance abuse among the elderly refers only to problems with alcohol, prescription drugs, and over-the-counter medications.

Given the historically high levels of drug use among the “baby boom” generation we would expect a growing impact on admissions of older patients to substance abuse treatment programs.  In order to test this hypothesis, we examined treatment admissions data for persons 55 and older in the Treatment Episode Data Set (TEDS) over the fifteen year period from 1992 through 2006.

TEDS is an administrative data system providing descriptive information about the national flow of admissions to specialty providers of substance abuse treatment.  TEDS is part of the Drug and Alcohol Services Information System (DASIS), a cooperative program between the Substance Abuse and Mental Health Services Administration (SAMHSA) and the substance abuse agencies of the 50 States, the District of Columbia, and Puerto Rico.  The TEDS system was designed to provide data on the number and characteristics of admissions to programs that receive State alcohol and/or drug agency funds for the provision of treatment services.  Approximately 1.6 million records are submitted to TEDS each year, which is estimated to represent about two-thirds of all such treatment admissions in the U.S.

We examined admissions of persons 55 and older (n = 918,955) rather than 65+ because the TEDS system does not include any age category older than 55.  This may be seen as reflecting the general lack of interest in older adults as a treatment population at the time when the TEDS was created.  Descriptive data of the sample are presented in Table 1.  Of this sample 80.4% were male, a majority (64.9%) were white, the largest proportion were divorced or widowed (44.8%), and a quarter of them were veterans (25.4%).  Most had completed high school (64.0%) and were not in the labor force (60.3%).  A surprisingly high percentage of them were homeless (15.6%). 


Over the time period 1992 to 2006, the proportion of individuals admitted for alcohol abuse declined from 81.7% to 51.6%, respectively.  The proportion of individuals admitted for “other drug use” accounted for 32.5% of admissions in 2006 compared to 1992 when it accounted for only 10.3% of total admissions age 55 and older.

Text Box: Figure 1. Admissions aged 55 and older by primary problem.

As can be seen from Figure 1, total numbers of admissions of persons aged 55 and older have grown over the fifteen year period.  Total admissions with a primary drug problem with alcohol have remained relatively stable over this time.  Admissions for problems with a primary drug other than alcohol have shown a steady and substantial increase.

The admissions for a primary problem with a drug other than alcohol bore some noteworthy distinctions from all admissions of persons aged 55 and older, as can be seen in Table 1.  Most notable is the difference in ethnicity, with a majority of all admissions (64.9%)

Table 1. Characteristics of patients 55 and older admitted to substance abuse treatment

 (USA 1992-2006).

 

 

All Drug Admits

Other Drug Admits

Variable

Level

N

%

n

%

Gender

Male

734,774

80.4

152,267

77.5

 

Female

179,388

19.6

44,222

22.5

 

 

 

 

 

 

Ethnicity

Alaskan Native

3,912

0.4

733

0.4

 

American Indian

21,767

2.4

1,613

0.8

 

Asian or Pacific Islander

5,868

0.6

2,746

1.4

 

Black

206,241

22.8

81,512

41.8

 

White

587,152

64.9

77,347

39.7

 

Other single race

79,027

8.7

30,864

15.8

 

Two or more races

507

0.1

184

0.1

 

 

 

 

 

 

Marital

Never married

116,189

17.4

30,614

25.5

Status

Now married

198,105

29.7

27,007

22.5

 

Separated

54,696

8.2

12,929

10.8

 

Divorced/widowed

299,029

44.8

49,468

41.2

 

 

 

 

 

 

Education

< 8 years

142,747

16.1

26,577

13.7

 

9-11

177,079

19.9

48,000

24.8

 

12

331,626

37.3

74,653

38.6

 

13-15

140,887

15.9

31,650

16.3

 

16+ years

95,791

10.8

12,762

6.6

 

 

 

 

 

 

Veteran

Yes

133,377

25.4

15,843

15.9

 

No

391,392

74.6

83,666

84.1

 

 

 

 

 

 

Living

Homeless

110,097

15.6

17,269

13.1

 

Dependent

72,503

10.3

19,585

14.8

 

Independent

522,728

74.1

95,299

72.1

 

 

 

 

 

 

Income

Wages/salary

124,041

25.0

17,043

18.7

 

Public assistance

46,128

9.3

12,718

14.0

 

Retirement/pension/disability

118,922

24.0

17,763

19.5

 

Other

125,345

25.3

26,874

29.5

 

None

81,506

16.4

16,610

18.3

 

 

 

 

 

 

Employment

Full-time

150,705

17.4

22,618

11.9

 

Part-time

44,925

5.2

8,635

4.5

 

Unemployed

148,916

17.2

40,262

21.1

 

Not in labor force

523,735

60.3

118,882

62.4

being White while only a minority (39.7%) of those admitted for problems with “other drugs” were White.  The proportion of African-Americans was 22.8% in the total sample but 41.8% among those whose problem was with drugs other than alcohol.  This is striking given that a majority of drug users in America are White (Substance Abuse and Mental Health Services Administration, 2008) but such over-representations of minorities are not an uncommon feature of the operations of drug policy in the U.S. (Ramchand, Pacula & Iguchi, 2006).  In making policy analyses based on clinical data one should always be aware of the possibility of the “clinician’s fallacy” in generalizing from patient populations to the true prevalence or distribution of a disorder in a community (Duncan, 1997).

The two groups also differed in terms of veteran status, with 25.4% of total admissions being veterans compared to 15.9% of “other drug” admissions.  Differences in living arrangements may also be meaningful, with 15.6% of total admissions being homeless and 10.3% in a dependent living situation, while 13.1% of “other drug” admits are homeless and 14.8% are in a dependent living arrangement.  Given the large sample size, all differences reported in Table 1 are likely to meet a test of significance, leaving the real life importance of these observed differences open to subjective interpretation.

We found support for the hypothesis that the aging of the “baby boom” generation will be reflected in increased treatment admissions of older persons with abuse and addiction problems involving the currently illicit drugs.  Treatment programs and referrers need to be aware of this shift and prepare for it. Educational and training programs for health care providers should reflect the need to screen for illicit drug abuse as well as alcohol and prescription drug abuse in the elderly.  To the extent that these older illicit drug users and abusers are at risk of entry into the criminal justice system they may present serious new challenges for an already overburdened system not prepared to deal with the greater health care needs of the aged.


 

References

 

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