Changes In Substance Abuse By The Elderly The Increasing Contribution Of Illicit Drugs

1. Changes In Substance Abuse By The Elderly The Increasing Contribution Of Illicit Drugs David F. Duncan, DrPH, Duncan Associates; Addiction Technology Transfer Center of New England, Brown University Thomas Nicholson, MPH, PhD, John B. White, PhD, John Bonaguro, PhD, Dean College of Health and Human Services Western Kentucky University Introduction Results 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. 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 . 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. 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. Until relatively recently, substance abuse by the elderly apparently was not addressed by either the substance abuse or the gerontological literature. 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 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, New Zealand, and Poland. 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. 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. 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. As can be seen in the figure, 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. Discussion 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 (see table). Most notable is the difference in ethnicity, with a majority of all admissions (64.9%) 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 but such over-representations of minorities are not an uncommon feature of the operations of drug policy in the United States. 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. 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 the table 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. Approach • 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.