January/February 2012 Issue

The Changing Face of Older Adult Substance Abuse
By Christina Reardon, MSW, LSW
Social Work Today
Vol. 12 No. 1 P. 8

A surprising number of baby boomers are abusing drugs and alcohol into their older adult years. Asking about substance use is a necessary part of elder mental health assessment.

Take a minute to do a quick visualization exercise. Close your eyes and imagine someone who is addicted to cocaine, strung out on heroin, or high on pot.

What do you see? Who do you see? Do you see a gray-haired grandmother? Do you see a wrinkled man who is getting ready for retirement?

Probably not. But you should, because this is the changing face of elder substance abuse in America.

There are approximately 78 million baby boomers nationwide, and estimates are that a boomer turns 50 every seven seconds. And many of these boomers are taking the abuse of cocaine, heroin, marijuana, and other illicit drugs into their “golden years.” Although alcohol remains the top substance of choice among older adults, the aging baby boom cohort has resulted in illicit drugs accounting for a growing proportion of users and admissions to treatment facilities.

“We have those stereotypical images of someone who abuses illicit substances as someone who’s homeless and living under a bridge, not someone’s grandmother or uncle,” says Neil Capretto, DO, medical director at Gateway Rehabilitation Center in Moon Township, PA. “We have to get past those stereotypes.”

With this shift in drug use trends comes increasing concern among social workers and other behavioral health professionals about how illicit drug use will affect elders’ physical and mental health and how these effects will impact the already-strained healthcare, mental health, and social services systems.

Recognizing Trends
Researchers have long recognized the importance of collecting data about substance abuse among older adults, but much of their work has focused on alcohol abuse. However, the body of research about illicit drug use among older adults has grown in recent years.

The federal Substance Abuse and Mental Health Services Administration (SAMHSA) disseminates national data through its Treatment Episode Data Set (TEDS), which tracks characteristics and substance abuse problems of treatment admissions, and its National Survey on Drug Use and Health. Among the SAMHSA’s findings (2010, 2011) are the following:

• An estimated 4.8 million adults aged 50 and older have used an illicit drug in the past year. That is 5.2% of all adults in this age group. Marijuana was the most commonly used substance, followed by the nonmedical use of prescription drugs. The prevalence of illicit drug use was higher among adults aged 50 to 59 than those aged 60 and older.

• Among treatment facilities that receive some public funding, the proportion of treatment admissions for people aged 50 and older nearly doubled between 1992 and 2008 (6.6% of all admissions for people aged 12 and older vs. 12.2%).

• Alcohol remained the most common primary substance of abuse among older adult admitted for treatment, but the proportion of admissions reporting alcohol as the primary substance of abuse dropped from 84.6% in 1992 to 59.9% in 2008.

• In comparison, the proportion of older adult admissions reporting heroin as the primary substance of abuse more than doubled, from 7.2% in 1992 to 16% in 2008, and the proportion reporting cocaine as the primary substance of abuse quadrupled from 2.8% to 11.4%. The proportion of older adult admissions reporting prescription pain relievers, marijuana, or amphetamines as primary substances of abuse also increased but remained small compared with admissions related to alcohol, heroin, and cocaine.

In a recent study published in the American Journal of Geriatric Psychiatry (Arndt, Clayton, & Schultz, 2011), researchers analyzed TEDS data, focusing on first-time substance abuse treatment admissions among adults aged 55 and older. The researchers found that admissions in which users identified heroin or cocaine as a problem substance increased substantially between 1998 and 2008. Admissions related to marijuana increased as well but not as dramatically.

Researcher Stephan Arndt, PhD, says the study’s results were surprising and challenge the picture of older adult substance abusers as 1960s hippies who can’t give up their pot. “I thought I’d see more marijuana,” says Arndt, director of the Iowa Consortium for Substance Abuse Research and Evaluation. “What I did not expect to see were the big jumps in heroin and cocaine. Those were not ‘60s drugs.”

So why are aging baby boomers more likely than their older counterparts to use illicit drugs? Experts interviewed by Social Work Today cited three primary reasons. One is cultural: Baby boomers grew up in an era when illicit drugs were widely available, and their use had a certain allure. Another reason is economic: Boomers are increasing their use of illicit drugs because the recession and its aftermath have heightened their anxiety about job security and retirement savings. A third reason is emotional: Aging boomers may turn to illicit drugs to cope with grief and loss issues such as the death of a spouse or the end of a career.

The majority of boomers who use illicit drugs had some experience with the substances during their youth, and many of these boomers have been using consistently since their 20s or 30s. An increasing number of older baby boomers who were able to function for many years despite their substance abuse may be entering treatment because their bodies are aging, and they can no longer tolerate the effects drugs are having on them physically and mentally, says Patrick Arbore, EdD, founder and director of the Center for Elderly Suicide Prevention and Grief Related Services at the San Francisco-based Institute on Aging. They also may be growing tired of what they must do to obtain their drug of choice, Arndt says.

“I think there’s a tremendous denial that life is impermanent and we’re not going to be here forever,” Arbore says. “So we [as baby boomers] continue to live like we’re in our 40s when we’re definitely not.”

Some treatment providers have recognized the differences between baby boomers and their older counterparts and have tailored services for each group. One is Hanley Center, a residential treatment facility in West Palm Beach, FL. Hanley’s Freedom Program for Boomers is designed for clients born between 1946 and 1964. Hanley also offers the Independence Program for Older Adults.

Hanley has offered programming focused on older adults for more than a decade. But it became apparent in recent years that many baby boomers felt they did not fit in a program with 70- and 80-year-olds, says Juan Harris, MBA, MS, CAP, CAPP, SAP, ICADC, who directs both the Freedom Program for Boomers and the Independence Program for Older Adults. “People who are 55 or 57, they don’t identify with wheelchairs and walkers,” Harris says. “They want a program that’s more vibrant.”

Hanley’s boomer program provides that vibrancy by giving clients ample opportunities for activities and physical exercise. Group sessions focus on boomers’ concerns, including sex and intimacy, “sandwich” generation responsibilities, and issues at work.

Harris says he’s noticed clear differences between baby boom and pre-baby boom clients, both in terms of why they seek treatment and how they approach treatment. For example, illicit drugs are involved in about 30% to 40% of cases in Hanley’s boomer program compared with about 5% of cases in its Independence Program for Older Adults. And those clients born during the Great Depression or World War II are more likely to readily accept therapists’ recommendations about the course of treatment, while boomers are more likely to ask questions and demand explanations for treatment decisions.

Arbore believes illicit drug use among aging baby boomers will lead to increased—and costly—utilization of healthcare and mental health services as boomers begin to experience the effects of long-term drug use. Among these effects are mood, memory, pain, and sleep disorders as well as cardiovascular and respiratory problems (Crome, Sidhu, & Crome, 2009).

The Challenge of Identifying Users
Despite the serious and damaging effects illicit drugs can have on older adults, recognizing such drug use often is not easy. In fact, it can be more difficult than recognizing use among younger users. Blow, Oslin, & Barry (2002) note that many signs of substance abuse among older adults, such as anxiety, memory loss, disorientation, headaches, and incontinence, mirror symptoms of physical and mental health conditions that affect elders.

In addition, it may be more difficult to see evidence that older adults’ day-to-day functioning has been affected by substance abuse, especially if they become less engaged in society when they retire or when their children move out of the family home, Capretto says. “If you’re younger and raising small children, you can’t just go away for a day or two and keep things together,” he says. “As people age, they become more invisible.”

A related challenge is that many assessment instruments used to diagnose substance abuse are designed for younger people and do not take the experience of older adults into account. For example, one of the DSM’s criteria for substance abuse is “a failure to fulfill major role obligations at work, school or home.” Such a criterion may not apply to someone who is retired and has few, if any, work or familial obligations (Blow et al., 2002).

Even if older adults are suspected of using illicit substances, convincing users that they have a problem and need treatment can be an uphill battle. Such users may believe they deserve to use drugs because of the years they put in at work and in raising a family, says Karen Khaleghi, PhD, cofounder and director of education at Creative Care Inc., a rehabilitation center in Malibu, CA. “With the older group, what we see is the thought that ‘I’ve earned it. I’ve put in my time. I’ve struggled, and this is my time to relax,’” Khaleghi says.

Social Workers’ Response — Asking the Questions
Social workers can play a key role in responding to illicit drug use among older adults, Arbore says. But they must first be willing to accept that some older adults do use illicit substances and be willing ask about it. “We need to get back to basics regarding training, retraining, and staff development,” he says. “I don’t think service providers are used to asking someone age 65 if they’re still using illicit drugs. We need to make sure they are trained to ask.”

Social workers have a unique perspective on elder substance abuse because they are in the field working with individuals, says Kimberly Williams, LMSW, director of the Geriatric Mental Health Alliance of New York. That puts social workers in a powerful position to educate older adults and their caregivers as well as advocate for specialized services in community- and home-based settings. Social workers also can help other professionals recognize that older adults who abuse substances are a diverse group who require diverse services. “We need to improve access and educational outreach,” says Williams, who is also director of the Center for Policy, Advocacy & Education at the Mental Health Association of New York City. “There need to be services where people are and where they go.”

Social workers cannot address elder substance abuse alone, says Jamie Huysman, PsyD, LCSW, CAP, CFT, a Miami-based social worker who writes and speaks extensively on aging and addictions. Social workers must be willing to work cooperatively with other providers who serve older adults, especially medical professionals.

“There’s a lack of coordination of care. We’ve always separated physical and mental health, which makes it harder to treat older adults,” Huysman says. “[Social workers] really need to bring those two worlds together.”

— Christina Reardon, MSW, LSW, is a freelance writer based in Harrisburg, PA, and a contributing editor at Social Work Today.

References
Arndt, S., Clayton, R., & Schultz, S. K. (2011). Trends in substance abuse treatment 1998-2008: Increasing older adult first-time admissions for illicit drugs. American Journal of Geriatric Psychiatry, 19(8), 704-711.

Blow, F. C., Oslin, D. W., & Barry, K. L. (2002). Use and abuse of alcohol, illicit drugs and psychoactive medication among older people. Generations, 25(1), 50-54.

Crome, I., Sidhu, H., & Crome, P. (2009). No longer only a young man’s disease: illicit drugs and older people. The Journal of Nutrition, Health & Aging, 13, 141-143.

Substance Abuse and Mental Health Services Administration. (2010). The TEDS report: changing substance abuse patterns among older admissions: 1992 and 2008. Retrieved from http://oas.samhsa.gov/2k10/229/229OlderAdms2k10Web.pdf.

Substance Abuse and Mental Health Services Administration. (2011). The NSUDUH report: illicit drug use among older adults. Retrieved from http://oas.samhsa.gov/2k11/013/WEB_SR_013_HTML.pdf.