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By Samuel P. Korper, Ph.D., M.P.H. & Ira E. Raskin, Ph.D.
Paper was published by US Department of Health & Human Services: Substance Abuse and Mental Health Administration Services and was originally posted at www.oas.samhsa.gov/aging/chap10.htm
Information contained in the chapters of this report documents the reasons for concern about the projected demand for substance abuse services over the next 20 to 30 years. Analysis of empirical evidence demonstrates the relatively higher illicit substance abuse and dependence among those born between 1946 to 1964 (baby boomers) and projects that this problematic pattern of use will moderate less in this group than has been the case in previous generations’ cohorts. As noted in Chapter 1, there may be a doubling in the number of citizens with substance abuse problems in the next 20 years. However, such estimates are likely to fluctuate as more knowledge accrues. To make more reliable forecasts of the demand for substance abuse treatment services, more updated and expanded information on the life course of substance abuse problems is needed on those who abuse substances and are in recovery, those who continue to abuse substances throughout their lives and may or may not be in treatment, and those who begin abusing substances later in life. In addition, patterns of relapse and remission must be better understood. The chapters highlight uses of available data and provide examples of analyses and methodological issues required to refine forecasts of the demand for substance abuse services emerging over the next several decades.
A brief summary of evidence provided by the analyses in this report includes the following:
Demographic projections suggest that the proportion of the population aged 65 years or older in the United States will rise from the current 12 percent to 20 percent by 2030. Moreover, the population will become more ethnically and racially diverse, live longer, and face higher health care service and prescription drug costs than ever before. This shift suggests that the labor force will be proportionally smaller and will increasingly support the rising health care costs of the older, nonworking population. The impact of substance abuse on these costs is unknown. To estimate this future impact, methods are needed that account for drug abuse/misuse incidence, prevalence, empirical evidence and recognition of the potential for recovery, and death throughout the life cycle (Korper and Raskin, Chapter 1; Ray, Chapter 2).
Few longitudinal studies provide direct measures of age-specific recovery, relapse, and mortality of substance abusers. In addition, they do not provide the characteristics of late onset abusers. A review of California follow-up data on heroin addicts indicates that rates of permanent recovery (5 years or more abstinence) increased from 36 percent in the 45 to 49 age category to about 50 percent for those older than 49, but no continuing increase of recovery after age 50. Overall mortality rates rose from about 33 percent for those in the younger age category to 76 percent or higher among those older than 65. Analysis of another California dataset of high-risk substance abusers indicated that baby boomers in emergency rooms and sexually transmitted disease clinics generally reported greater levels of illicit drug use but comparable levels of use of prescription medications. The relationship between age and the progression of drug use or the recovery process appears to differ depending on the type of drug used. Future studies need to include women and to improve sampling of the elderly (Chapter 3, Hser).
Analysis of data from the Treatment Episode Data Set (TEDS), a component of the Substance Abuse and Mental Health Services Administration (SAMHSA) Drug and Alcohol Services Information System (DASIS) that collects information on clients admitted for substance abuse treatment, indicates that abuse of tranquilizers and sedatives, although relatively low, increases with age. This is consistent with reports in the clinical literature of problem prescription drug use among older adults. Beginning at age 55, an increasing proportion of persons entering treatment were doing so for the first time, largely for abuse of alcohol alone. The few aged 75 who entered the publicly funded treatment system had more severe and complex problems than those just a few years younger (i.e., they were more likely to be polydrug users and to have been in treatment previously). Future TEDS research could include analysis of patterns among birth cohorts and analysis of age and historical period of drug use initiation cohorts (Chapter 4, Henderson).
Estimates suggest that there will be a doubling of the number of problem substance users aged 50 or older during the next two decades—from 2.5 million in 1999 to 5.0 million in 2020. (More recent work by these authors suggests that due to the combined increase in the number of older adults and the increase in the rate of treatment need in this population, that the aging baby boom cohort will place increasing demands on the substance abuse treatment system in the next two decades and will require a shift in focus to address the special needs of an older population of substance abusers (Gfroerer, Penne, Pemberton, & Folsom, in press). There is also a need to develop improved tools for measuring substance use and abuse among older adults (Chapter 5, Gfroerer et al.).
The National Household Survey on Drug Abuse (NHSDA) should be supplemented with selected questions in order to use a life table approach for projecting substance abuse problems among older adults. It also may be necessary to develop new data systems tailored to substance abuse among the aging baby boom population (Chapter 6, Woodward).
There have been and will likely continue to be substantial changes in the patterns of substance use and abuse over different age cohorts, particularly among those born after World War II, that will have a dramatic impact on the content, focus, and delivery of specialized substance abuse prevention and treatment interventions needed for adults in late life. The development of innovative and effective screening and treatment methods for substance misuse among older adults is an important focus of future research (Chapter 7, Blow et al.).
Analysis of data from the National Health and Nutrition Examination Survey I (NHANES-I) indicate that mean alcohol consumption appears to remain higher over time for the midlife group (including the baby boom generation) than for other age groups. This suggests that the baby boom generation, as it continues to age, could maintain a higher level of alcohol consumption than in previous older cohorts (Chapter 8, Blow et al.).
Military veteran substance abusers from the baby boom generation utilize the largest proportion of substance abuse services from the Department of Veterans Affairs (VA). There is little evidence of declining need for treatment or “aging out” among this group of substance-using veterans. Future research should attempt to follow longitudinally a birth cohort in order to identify incidence of comorbid conditions and changing patterns of health care use and to conduct mortality studies (Chapter 9, Booth and Blow).
This report has examined a series of representative data resources to provide a clearer understanding of the expected change in the magnitude and complexity of adult substance abuse in the coming decades. Complementing the well-documented accelerated aging of the U.S. population will be a new and expanded constellation of factors, including longer life span, changing demographic profile, greater per capita use of multiple prescription drugs for longer-term chronic disability, pronounced economic pressure to support a relatively larger group of retired elderly, pressure to retain older persons in the workforce, and an enhanced propensity of those entering their senior years to abuse both licit and illicit substances. The individual and collective impact of these factors on substance abuse and the ramifications for treatment resources and health policy choices will require novel solutions based upon understanding derived from novel analytical approaches.
Several of the analyses included in this report have estimated selected dimensions of the approaching problem of elderly drug abusers. These analyses emphasize the need to develop and include improved measures and undertake the collection of longitudinal (life course) data (e.g., changes in sampling the elderly and women, improving the representativeness of the datasets, and encompassing more sensitivity to the real potential of polydrug use in the elderly). Changes in the collection of information, however, will not significantly enhance the treatment system’s readiness for a substantially modified arithmetic of aging and substance abuse over the next 20 to 30 years.
A review of the history of public health in the United States provides several important lessons concerning necessary caution in interpreting and projecting trends and impacts. This report’s projected expansion in substance abuse among the elderly may be overstated. For example, the analyses in this report use 1992 as a base year. Fluctuations in substance abuse patterns since then may confound analysis and interpretation. Further, it is conceivable that future generations may benefit from advances in substance abuse treatment that evolve from gene therapy or new medications—the proverbial “magic bullet”—that have influenced the course and/or infectivity of many diseases (University of Texas, 2000). Research also has demonstrated that the elderly who continue to work have better perceived health and life satisfaction than those who do not participate in the labor force (Soumerai & Avorn, 1983). Improved general health and a reduction in polypharmacy and associated multiple drug interactions would mitigate against substance abuse among the elderly. But can we count on such fortuitous events?
In terms of today’s knowledge and incentives, the health care system in the United States does not yet appear to have recognized or to be effectively dealing with the increased and increasing use and abuse of licit and illicit psychoactive substances by older populations (Office of National Drug Control Policy, 2001; The Robert Wood Johnson Foundation, 2001). Few incentives or widely shared information technologies are in place to counter the trend in polypharmacy and adverse prescription drug interactions. Few validated instruments to screen and assess substance abuse problems in older people exist. Many clinicians lack the sensitivity needed to understand differences in patient attitudes toward use of substances that may stem from different ethnic perspectives, or misdiagnose the confusion often present in the elderly. Given a significant expansion of this group of elderly abusers in the coming decades, more informed and active policy will require new approaches and investment in the following:
data and analysis, with increased emphasis on documenting substance abuse in the elderly, in addition to the historical emphasis on alcohol abuse and mental health problems;
expanded literature review, encompassing studies not considered in this report, some of which may not be specific to substance abuse but can offer new conceptual and methodological insights;
prevention, treatment, and management strategies specifically tailored for the elderly from different ethnic, gender, and racial groups, including immigrant populations, and so on;
monitoring of demographic shifts in heterogeneous elderly populations; and
long-term projections of the demand for expanded clinical and public health services for substance abusers.
More information in and of itself, however, does not ensure the evolution of effective policies or immediate action to solve the future problem of drug abuse and the elderly. Policy action and related resource allocation in the near term are typically related to the current, politically felt presence of a problem and not to what might occur decades from now. Faced with the reality of competing budgetary demands, it will be difficult for health and budget planners to shift resources today to deal with the identified, far off impact of substance abuse by the elderly on the health care system. The need for timely action, however, is important in dealing with this particular health problem. First, absent a palliative or effective “magic bullet,” the expected large increase in the problem of substance abuse and the elderly is likely to be understated rather than overstated. Forecasts are affected by incomplete knowledge, such as few longitudinal and generalizable studies of the problem, which could help to trace the complex and interactive nature of clinical and social factors that increase the use and abuse of substances by older populations. Further, the current data do not make adjustments that reflect the clinical propensity to underdiagnose substance abuse in the elderly and the presence of multiple diagnoses, where substance abuse may trigger, mask, or be undetected in the presence of other comorbidities (e.g., mental health problems or other chronic conditions). Clinicians can be trained to do a better job in diagnosing substance abuse problems, in general, and, specifically, in older populations. Much lead time, however, is required to train an adequate number of physicians in the detection and treatment of substance abuse by the elderly patient (Fishbein, 1999).
Second, as policymakers have come to recognize, inaction becomes a de facto policy decision. Doing nothing about a problem perceived as relatively remote incurs costs in terms of missed opportunities for early intervention. In the case of substance abuse in the aging population, the cost of not addressing the multifaceted health implications of a larger, older population in a timely manner is likely to be high. A policy decision not to take preemptive action will be costly given the projected population changes, substance abuse patterns of the baby boom generation, and other clinical and systemic changes associated with a major increase in the elderly population. In the case of substance abuse and general health care of an older population, not investing current resources to investigate and prepare for the increased health care needs of the future elderly population will lead to a relatively uninformed and frenzied search for solutions, and a much higher bill for addressing the problem in a reactive rather than proactive mode.
References
Fishbein, J. (1999, January 25). Filling the geriatric gap: Is the health system prepared for an aging population? (National Health Policy Forum Brief No. 729; retrieved from http://www.nhpf.org/pubs/pubs.htm). Washington, DC: George Washington University.
Gfroerer, J., Penne, M., Pemberton, M., & Folsom, R. (in press). Substance abuse treatment among older adults in 2020: The impact of the aging baby-boom cohort. Drug and Alcohol Dependence.
Office of National Drug Control Policy (Harwood, H., Fountain, D., & Livermore, G.). (2001). The economic costs of drug abuse in the United States, 1992-1998 (NCJ-190636 and NIH Publication No. 98-4327; http://www.nida.nih.gov:80/EconomicCosts/Intro.html). Washington, DC: Executive Office of the President.
Soumerai, S. B., & Avorn, J. (1983). Perceived health, life satisfaction, and activity in urban elderly: A controlled study of the impact of part-time work. Journal of Gerontology, 38, 356-362.
University of Texas. (2000, May 15). New combination drug treatment shows promise for treating alcoholics with neurochemical abnormalities (5-15-00 news release). San Antonio, TX: University of Texas Health Science Center. [Published May 16, 2000, in Alcoholism: Clinical and Experimental Research, Johnson, B.A.]