The elderly and the use of illicit drugs: sociological and epidemiological considerations

Ageing and older people who use illicit opioids, cocaine or methamphetamine: a scoping review and literature map

AIMS

To provide an overview of research literature on ageing and older people who use illicit opioids and stimulants by documenting the conceptual frameworks used and content areas that have been investigated.

METHODS

We conducted a scoping review of literature relating to ageing and older people who use illicit stimulants and opioids, defining 'older' as 40 years and above. Primary studies, secondary studies and editorials were included. Searches were conducted in PubMed and Embase in July 2020 and March 2021; the Cochrane library was searched in November 2021. Charted data included methodological details, any conceptual frameworks explicitly applied by authors and the content areas that were the focus of the publication. We developed a hierarchy of content areas and mapped this to provide a visual guide to the research area.

RESULTS

Of the 164 publications included in this review, only 16 explicitly applied a conceptual framework. Seven core content areas were identified, with most publications contributing to multiple content areas: acknowledgement of drug use among older people (n = 64), health status (n = 129), health services (n = 109), drug use practices and patterns (n = 84), social environments (n = 74), the criminal legal system (n = 28) and quality of life (n = 15).

CONCLUSIONS

The literature regarding older people who use illicit drugs remains under-theorized. Conceptual frameworks are rarely applied and few have been purposely adapted to this population. Health status and health services access and use are among the most frequently researched topics in this area.

Patterns of drug use and abuse among aging adults with and without HIV: a latent class analysis of a US Veteran cohort

This study characterized the extent and patterns of self-reported drug use among aging adults with and without HIV, assessed differences in patterns by HIV status, and examined pattern correlates. Data derived from 6351 HIV-infected and uninfected adults enrolled in an eight-site matched cohort, the Veterans Aging Cohort Study (VACS). Using clinical variables from electronic medical records and socio-demographics, drug use consequences, and frequency of drug use from baseline surveys, we performed latent class analyses (LCA) stratified by HIV status and adjusted for clinical and socio-demographic covariates. Participants were, on average, age 50 (range 22-86), primarily male (95%) and African-American (64%). Five distinct patterns emerged: non-users, past primarily marijuana users, past multidrug users, current high consequence multidrug users, and current low consequence primarily marijuana users. HIV status strongly influenced class membership. Non-users were most prevalent among HIV uninfected (36.4%) and current high consequence multidrug users (25.5%) were most prevalent among HIV-infected. While problems of obesity marked those not currently using drugs, current users experienced higher prevalences of medical or mental health disorders. Multimorbidity was highest among past and current multidrug users. HIV-infected participants were more likely than HIV-uninfected participants to be current low consequence primarily marijuana users. In this sample, active drug use and abuse were common. HIV-infected and uninfected Veterans differed on extent and patterns of drug use and on important characteristics within identified classes. Findings have the potential to inform screening and intervention efforts in aging drug users with and without HIV.

Drugs of abuse and the aging brain

Substance abuse among older adults has received little attention in the past, presumably because this population has traditionally accounted for only a small percentage of the drug abuse problem in the United States. The aging of the baby boomer generation (born 1946-1964), however, will soon swell the ranks of older adults and dramatically alter the demography of American society. Several observations suggest that this expansion will likely be accompanied by a precipitous increase in the abuse of drugs, including prescription medications and illicit substances, among older adults. While it is now evident that the brain changes continuously across life, how drugs of abuse interact with these age-related changes remains unclear. The dynamic nature of brain function, however, suggests that substance abuse during older age may augment the risks and require unique considerations for diagnosis and treatment. In addition to describing current and projected prevalence estimates of substance abuse among older adults, the present review discusses how aging affects brain systems involved in drug abuse, and explores the potential impact of drug abuse on the aging brain. Future directions for substance abuse research among older adults will also be considered.

Studying biobehavioral aspects of health disparities among older adult minorities

Current projections suggest that by 2050, the total number of non-Hispanic Whites aged 65 and over will double, the number of Blacks aged 65 and over will more than triple, and the number of Hispanics will increase 11-fold. These significant increases in older minority adults in the United States are in direct contrast to the current limited knowledge about health behaviors like smoking, drinking, and drug use among older Americans. This represents a major area of opportunity for researchers to advance science on the long-term effects of substance abuse and HIV/AIDS. The provision of appropriate public health information for these populations depends, in part, on increased basic and social/behavioral research and particularly on integrative biobehavioral approaches in these understudied older groups. This article provides a brief overview of some of the challenges faced in studying older ethnic minority adults. These include issues such as recruitment, conceptualization, and methodology. Some potential areas for future research are offered.

Effects of morphine on brain-stimulation reward thresholds in young and aged rats

Mesolimbic opioid systems are altered with aging; however, the effects of these changes on the rewarding actions of opioids have not been examined. The present experiment assessed differences in the responsiveness of brain reward pathways in young and aged rats to the effects of morphine using the brain-stimulation reward (BSR) model. Aged (24 months) and young (5 months) male F344/BNF1 rats were stereotaxically implanted with a bipolar stainless steel electrode into the lateral hypothalamic (LH) region of the medial forebrain bundle. Thresholds were determined using the rate-independent psychophysical method. Each animal was tested after the administration of saline or morphine at 0.5, 1, 2.5, 5 and 10 mg/kg doses. A significant difference in the mean baseline threshold between aged (99.8+/-6 microA) and young rats (149.1+/-14 microA) was observed. Although in both groups morphine lowered the BSR threshold, there were no significant differences between the groups except at the 10-mg/kg dose, the difference did approach significance. This study indicates that there are baseline differences in the rewarding threshold in the two groups, that morphine lowers the threshold in young and aged animals and that the hedonic effects produced by morphine, for the most, part remain preserved in aged animals.

Change in the pattern of illegal drug use in an inner city population over 50: an observational study

Though alcohol and prescription drug abuse are well studied in older adults, there is little information regarding illicit drug use in older adults. We investigated illicit drug use in older adults presenting to an inner city emergency department in Los Angeles over a 10-month period. Of 3,417 adults over 50 presenting to the Emergency Department (ED), charts of 107, whose urine toxicology screens were positive for illicit drugs, were reviewed retrospectively. Cocaine was used most frequently (63%), followed by opiates (16%) and marijuana (14%). These rates of drug usage essentially mirror those seen in the general population of the Los Angeles area. Fifty-nine percent of patients using illicit drugs had cardiovascular disease compared with 10% of all older adults upon initial presentation to the ED. The use of illicit drugs by older persons may be an expanding phenomenon conferring serious but unrecognized health risks, and is in need of further study.

HIV risk behaviors among older American drug users

Despite increasing numbers of Americans older than 50 years of age, little is known about the impact of HIV/AIDS on aging drug users. The current study assesses the drug-related and sex-related HIV risk behaviors of older and younger injection drug users and crack smokers. Structured interview responses from 1508 out-of-treatment active drug users older than 50 years of age were compared with those of 1515 out-of-treatment active drug users who were 50 years old or younger. Comparisons were also made within the older cohort to examine differences in risk behaviors between crack smokers and nonsmokers, men and women, and users older than 60 years of age and those in their 50s. Results indicated that although older drug users (older than 50 years of age) were less likely to have had sex in the prior month, those who did were as risky as their younger counterparts with regard to sex-related risk behaviors. They were, however, significantly less risky in their needle sharing practices than those 50 years old or younger. Among the older cohort, those who smoked crack were extremely risky. Men older than 50 years of age were riskier than women older than 50 years of age; however, users older than 60 years of age were no less risky than those in their 50s. Interventions designed for older drug users should focus on sex risk behaviors, especially among those who smoke crack.

Alcohol, drugs and much more in later life

Elderly adults are greater consumers of prescription and 'over the counter' medications than any other age group and polypharmacy, including the co-use of alcohol, is common in this group. Age related physiological changes which influence drug concentrations, metabolism, polypharmacy and interaction of other drugs with alcohol can negatively influence functional capacity, psychomotor ability, and cognition, including attention and memory, placing the older person at greater risk of accident, injury, isolation and ultimately institutionalisation. It is argued that DSM-IV criteria used to define "abuse" or "dependence" are of limited value to the majority of elderly 'problem' alcohol or drug users, with ICD-10 criteria that identify those who are experiencing 'a risk' of or where use "is actually" causing "early" harm, more appropriate. Impediments to psychiatrists and other medical practitioners identifying 'problem' alcohol and other drug use, and appropriate assessment and intervention procedures are briefly discussed. The potential for decreasing the incidence and severity of physical and psycho/social events following a reduction or cessation in problem alcohol or other drug use means that assessment and intervention should be one cornerstone of management practice for this often disenfranchised and vulnerable group.

Age differences in HIV risk behaviors and drug treatment utilization among drug users in Kentucky

The purpose of this study was to (1) profile demographic and other characteristics of two age groups, younger aged 30 to 39 (N = 643), and older aged 40 to 49 (N = 395), (2) examine and identify differences in lifetime drug use patterns and age of drug use initiation, (3) examine HIV risk behaviors: drug use and sexual practices, (4) compare drug user treatment utilization between the two age groups, and (5) examine barriers to drug is treatment utilization by gender. The study sample (N = 1038) was drawn from individuals recruited into the NIDA Cooperative Agreement in Kentucky. The median age in the study sample was 38, the majority were male (72%), and African-American (81%). Results indicate that older subjects initiated drug use at a later age than younger subjects. Compared to the younger age group, significantly more subjects in the older group reported having ever used any of the 10 drugs examined. Injection drug use patterns and lifetime sex exchange practices were more prevalent in the older age group. Older subjects also were more likely to utilize drug user treatment, specifically methadone maintenance treatment. When barriers to drug user treatment were examined, significantly more women than men did not qualify for treatment, and they did not have enough money for treatment. Implications for interventions are discussed.

Predictors and outcomes of outpatient mental health care: a 4-year prospective study of elderly Medicare patients with substance use disorders

BACKGROUND

Many elderly inpatients have substance use disorders; recent treatment guidelines suggest that they should receive regular outpatient mental health care after discharge from hospital.

OBJECTIVE

The prevalence, predictors, and outcomes of outpatient mental health care obtained by elderly Medicare patients with substance use disorders were examined.

RESEARCH DESIGN

A longitudinal prospective follow-up was performed.

SUBJECTS

Data from Medicare Provider Analysis and Review Record and Part B Medicare Annual Data were used to identify elderly inpatients with substance use disorders (n = 4,961) and determine their outpatient mental health care 4 years following hospital discharge.

RESULTS

Only 12% to 17% of surviving elderly substance abuse patients received outpatient mental health care in each of 4 years after discharge. Cumulatively over 4 years, approximately 18% of surviving patients obtained diagnostic/evaluative mental health services, 22% obtained psychotherapy, and 9% received medication management. Of patients who obtained outpatient mental health care, 57% made 10 or fewer outpatient mental health visits over the entire 4 years. Younger, non-black, and female patients were more likely to obtain mental health outpatient care, as were patients with prior substance-related hospitalizations, dual diagnoses, and fewer medical conditions. Prompt outpatient mental health care was predictively associated with higher likelihood of mental health readmissions and, among patients with drug disorders, lower mortality.

CONCLUSION

Very few elderly Medicare substance abuse patients obtain outpatient mental health care, perhaps because of health or economic barriers.