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Substance Abuse by Older Adults:  Estimates of Future Impact on the Treatment System

Table Of Contents

 Chapter 1. The Impact of Substance Use and Abuse by the Elderly: The Next 20 to 30 Years

Samuel P. Korper,* Ph.D., M.P.H.
Ira E. Raskin, Ph.D.

 

Introduction and Background

Imagine a world where the problems of youthful drug abusers share a common stage with images of senior citizens' health and behavior modified by adverse reactions to multiple prescription drugs, alcohol abuse, and illicit substances. Imagine a world where active efforts to recruit retired workers (some with undiagnosed substance abuse) into a younger, smaller, and more diverse labor force are confounded by historical requirements for a drug-free work environment. Imagine a world where the achievement of balanced resource allocation and intergenerational equity is strained by unanticipated demands for health care resources, including substance use and abuse-related services, for a growing elderly population that was expected to live longer but with a reduced burden of illness (Fries, 1980). Imagine, as Reinhardt (1999) observed in the case of Europe, economic efficiency and long-term capital development sacrificed explicitly for purposes of social equity and increased consumption by a growing elderly population—a phenomenon likely to become more explicit and powerful in the United States as well.

The dynamic arithmetic of aging and the limitations of current substance abuse policy and treatment strategies for the elderly have begun to crystallize these images. However, limited understanding of the extent of licit and illicit substance abuse problems among the elderly makes uncertain the full measure and impact of this reality. Forecasts and figures for the coming years are cautionary and sobering, but their precision is uncertain. Such efforts are made inexact by ever-moving targets, evolutionary treatment approaches accompanied by novel terminology, and redefined target populations. Estimates and forecasts drawn from recent sources (Epstein, 2002; Gfroerer, Penne, Pemberton, & Folsom, in press; Office of National Drug Control Policy, 2001; The Robert Wood Johnson Foundation, 2001) suggest an escalation of the approximately 1.7 million current substance dependent and abusing adults over age 50 to 4.4 million by 2020. But do such estimates matter? Will resources be available to respond? Are caregivers, treatment and service providers, and Federal, State, and local service and funding agencies aware of such projections, and are they preparing for the consequences?

Several chapters in this report address both this uncertainty and the need for more informed discussion about how health policy can creatively balance the competing needs of young and elderly constituencies. This chapter serves as a brief introduction to eight other chapters that explore the data and methods available for estimating the number of elderly substance abusers over the next 30 years.

Approximately 35 million people in the United States are 65 or older, accounting for about 12.4 percent of the total population. As Figure 1 shows, the anticipated impact of the aging of baby boomers—people born between 1946 and 1964—will increase this proportion to 20 percent by 2030, or approximately 70 million people (Federal Interagency Forum on Aging-Related Statistics, 2000).

 

Figure 1 The Growing U.S. Population Aged 65 Years or Older

 D

Source: Federal Interagency Forum on Aging-Related Statistics (2000).

 

As Reinhardt (2000, p. 71) stated, "...the impending retirement of the Baby Boom generation sometime after the year 2010 is viewed with the apprehension normally reserved for an impending hurricane." This expected increase in the elderly population has major ramifications for most facets of American life. The older population will be more ethnically and racially diverse—by 2050, 64 percent of those aged 65 or older will be non-Hispanic whites, down from the present 84 percent. Further, the next several decades will demonstrate sizable increases in the proportion of older men and women without family support and with generally less income (Federal Interagency Forum on Aging-Related Statistics, 2000).

The changes described above are likely to place increased pressure on health care services and on the demand for social services and pensions. As Reinhardt (2000) observed, there is substantial policy and social risk in failing to be responsive to the accelerated growth in the numbers of the elderly and their proportionately greater and more expensive needs for health care services. A more racially diverse and younger worker population will have to support those on Social Security, leading to greater competitive pressure for health resources between the two generations (Waite, 1996). An increased transfer of intergenerational resources will be required to support the health care costs of an older population over the next three decades. This may strain the ability and willingness of a smaller, relatively economically disadvantaged group of taxpayers and workers to share their income with retirees.

A major shift of an experienced labor force into retirement will affect the productivity and income required to support the needs of the elderly. Despite the extension of the age of retirement eligibility, efforts to keep retirees in the workforce may be hampered by various factors. For example, the rise in chronic illness associated with living longer will take its toll on labor force participation and productivity. Another factor is the accumulating evidence of psychoactive substance use by the elderly. The future extent of this use is not certain. However, the experience of the baby boomer generation with drugs and expanded polypharmacy and its associated adverse effects (Center for Substance Abuse Treatment [CSAT], 1998; Williams, Stinson, Parker, Harford, & Noble, 1987) will likely shape this future. Some report that baby boomers have 3 to 4 times the rate of emotional disorders (depression, suicide, anxiety, alcohol and drug abuse) than is found in today's elderly population (Koenig, George, & Schneider, 1994).

Age-related changes in biological sensitivity and physiological reaction of elderly retirees and workers to licit and illicit substances (Atkinson, Ganzini, & Bernstein, 1992) may reduce the potential for rehiring or retaining elderly workers in the labor force. The anticipated growth in the use of substances will affect the readiness and ability of the elderly to continue working in a drug-free environment and will mean major new challenges for the delivery of geriatric health services. Alcohol and substance abuse constitute an estimated 10 percent of all cases treated by geriatric mental health facilities, and alcohol, mental health, and drug abuse problems typically are concomitant and interactive (King, Van Hasselt, Segal, & Hersen,1994). Abuse of alcohol and legal drugs, prescribed and over the counter, is currently a serious health problem among older Americans, affecting up to 17 percent of adults aged 60 or older (approximately 8 million adults) (CSAT, 1998). Prescription drug misuse and abuse are prevalent among older adults, not solely because more drugs are prescribed, but because aging affects vulnerability to drugs. Loss of body mass leads to a decrease in body water and higher concentration of alcohol in the blood of an older person; a decline in a stomach enzyme that breaks down alcohol before it reaches the bloodstream (alcohol dehydrogenase) combines with reduced liver and kidney function to eliminate alcohol more slowly from the blood of an older person (Brody, 2002).

Use of drugs in combination with alcohol carries risk, and multiple drug use increases that risk (CSAT, 1998). Because about 50 percent of the elderly are light or moderate drinkers, interaction between alcohol and other drugs is likely to become an even more significant problem with the aging of the population (Adams, 1997). Substance abuse-related problems may spiral higher as baby boomers age and experience chronic physical disability, shrinking social networks, and lower standards of living (Koenig et al., 1994).

The combination of the negative consequences of polypharmacy described above and the comparatively low rate of illicit drug use (1 to 2 percent) by the elderly represent a relatively small element in the overall picture. However, "we face an aging population that will be accepting of drug use...with considerable impact...on social services" (Rosenberg, 1997, p. 207). Substance abuse among the elderly undoubtedly will enhance the pressure on society's ability to sustain the prevailing balance in the social compact with the elderly and the young. Estimates of treatment needs that consider the long-term health consequences of substance abuse on the baby boomer cohort are required.

 

How Prepared Are Substance Abuse Services to Meet Anticipated Future Requirements?

No one really knows the answer to this question. However, even if the incidence rate of substance abuse among the elderly in 1995 is assumed to drop by half in 2030, there will be increased demand for treatment. The increase in need for marijuana treatment, for example, has been estimated to be 1½ times greater in 2030 if the 1995 incidence rate is assumed constant (Gfroerer & Epstein, 1999). These anticipated increases in treatment stem only partially from demographic changes—substance abuse also interacts with, and complicates, all features of aging, illness, and dysfunction (Atkinson et al., 1992; CSAT, 1998; King et al., 1994). Today's health care system fails to deal with this reality. Some of this deficiency is the result of limited information concerning the most efficacious approaches to preventing, treating, and managing substance abuse among the elderly. Diagnostic and treatment strategies are neither age-specific nor sensitive to what is most clinically effective in accommodating the unique biological and social condition of the elderly. Few studies have explicitly assessed the efficacy of drugs used for treatment of alcohol withdrawal in elderly patients (Kraemer, Conigliaro, & Saitz, 1999). The relative absence of clinical guidelines in treating substance abuse problems among the elderly is largely attributable to a lack of empirical studies targeting these problems and this population, including the diverse ethnic and racial groups that comprise the elderly population.

Substantial work has been done on alcohol abuse, including recent evidence that instruments used to screen for alcohol abuse (MAST-G and CAGE) have adequate validation for older persons (Blow et al., 1992; CSAT, 1998; Jones, Lindsey, Yount, Soltys, & Farani-Enayat, 1993; Joseph, Ganzini, & Atkinson, 1995; Morton, Jones, & Manganaro, 1996). Blow, Walton, Chermack, Mudd, and Brower (2000b) demonstrated that older adults with alcohol problems who received treatment specific to their needs could achieve positive health outcomes. However, this treatment may take longer because alcohol withdrawal may be more severe in elderly than in younger patients (Brower, Mudd, Blow, Young, & Hill, 1994). In general, however, a shortage of trained geriatricians and other relevant professionals limits awareness and understanding of specific clinical patterns and responses in the elderly.

Because many of the definitions, models, and classifications of alcohol consumption levels are static and do not account for age-related physiological and social changes, they do not apply to older adults (e.g., older adults cannot continue to drink the equivalent amount of alcohol consumed safely in earlier years) (CSAT, 1998). It also may be more difficult for health care providers to diagnose alcoholism in older patients because a third of those with problems did not abuse alcohol in their earlier years. Older adults at risk for alcohol abuse may not evidence poor physical health functioning in primary care settings, although they may have significantly poorer mental health functioning than low-risk drinkers (Blow et al., 2000b). These older patients often do not have alcohol-related health problems, difficulties with family relationships associated with problem drinking, or problems with legal and correctional institutions. Older problem drinkers typically begin abusing alcohol and medications following a major life change, such as the death of a spouse, a divorce, or retirement (CSAT, 1998). Difficulty in the clinical detection of substance abuse is further compounded by a wider fluctuation in symptoms over time for elderly alcoholics and a greater level of associated medical, psychiatric, and social dysfunction (in contrast with younger substance abusers) (King et al., 1994). Moreover, many more subtle interactions with prescription medications may not be identified by physicians because they are unaware of the large number of prescriptions the patient possesses or of the compounds actually ingested.

The organization and financing of health care and related services also are factors in the underdiagnosis and undertreatment of elderly substance abusers. Managed care plans are increasingly limiting the provision of services to Medicare patients. Medicare requires a 50 percent copayment from patients for the treatment of substance abuse and mental health problems. Health care practitioners limit the number of Medicare patents in their practices (older adults with complex and consuming psychosocial and medical disorders, including stressed and overburdened families), especially when younger patients can be seen at higher fees than are allowed under Medicare (Koenig et al., 1994). Reduced time for doctor-patient interactions makes it difficult to identify patient problems with substances and drug interactions. The health care system has experienced reduced hospital lengths of stay, increased reliance on primary care physicians, dwindling outpatient resources, and reduced nursing home beds. Older adults with chronic mental illness (and other medical and social covariates of alcohol and drug abuse) subsequently have fewer options as to where they can live and receive care (Koenig et al., 1994). Few Medicare substance abuse patients receive prompt outpatient mental health care after hospital discharge (Brennan, Kagay, Geppert, & Moos, 2001).

Atkinson et al. (1992) reviewed the special risk factors facing the elderly and developed a conceptual framework and synthesis of research in this area. In addition, the reader is referred to the more recent Treatment Improvement Protocol (TIP) Series No. 26 titled Substance Abuse Among Older Adults (CSAT, 1998), which outlines what is known about substance abuse in older adults and establishes a framework for accumulating future, evidence-based data on preventing, screening, assessing, treating, and managing substance abuse in the elderly. The document sets out standards for testing and treating substance abuse in the elderly derived from research-based information and the clinical experience of expert panelists. Of its 65 recommendations, however, only 35 (53.8 percent) are drawn from research- or evidence-based knowledge. Thirty (46.2 percent) of the remaining recommendations are drawn from the experience of the 15 clinicians on the TIP consensus panel. Moreover, approximately 50 percent of the evidence-based data referred to in the TIP recommendations pertains only to alcohol abuse, not to the abuse of other substances (e.g., prescription drugs) or the interactions among various substances and mental health problems.

Current emphasis on the scientific exploration of treatment effectiveness and patient outcomes merits greater investment in substance abuse research and practice standards based on empirical evidence. Although much is known about substance abuse and the elderly, more systematic fact gathering and resource planning are required in preparing for the problems of the 21st century.

 

Initial Federal Response

The legislative authority establishing and authorizing the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (DHHS) provides the legal basis and responsibility to "promote and evaluate substance abuse services for older Americans" (Public Health Service Act, Sec. 501(d)(17)) and to that end requires consultation with other Federal agencies. Earlier analytical work supported by SAMHSA summarized what is known about substance abuse among older adults (CSAT, 1998). In addition, recognizing that available studies of substance abuse among elderly citizens have not been used to estimate future service requirements, SAMHSA's Office of Applied Studies (OAS) has coordinated interagency collaboration and discussion on these issues through the establishment of a Federal work group. The following agencies are involved in this effort:

In a series of interagency meetings, the group identified and reviewed available information, gaps in data, assumptions, important variables, estimation methods, and models. Approaches, key Federal agencies, topics for papers, and outside experts were considered. Future efforts in this collaboration, both in the Federal sector and with non-Federal partners, are expected to encourage novel analysis of existing data, stimulate new research, and accelerate the development of action plans for informing future substance abuse policy.

Subsequent to this interagency activity, OAS/SAMHSA developed this special report. The chapters in this report provide a detailed review of the demographic and clinical perspectives of the elderly and substance abuse, examine various risk factors associated with the use of licit and illicit substances, describe the examination of several data sources that can contribute to an understanding of substance abuse and aging, discuss modeling efforts and the analysis of extant data, array preliminary projections of the number of elderly needing substance abuse services during the 2020-2030 time period, and describe the implications of these projections for needed substance abuse services.

 

Overview of Report

This chapter sets out the overall perspective of substance abuse through the aging process. The model lays the conceptual groundwork for reviewing the potential of various data sources for forecasting substance abuse. It also presents a discussion about the consideration of recovery rates in forecasting.

This chapter contains detailed information on two longitudinal studies of male opiate users and other high-risk drug users identified at emergency rooms, sexually transmitted disease clinics, and jails in California. Preliminary estimates of age-specific recovery, relapse, and mortality rates are provided as the basis for projecting future health care needs of an aging population. Dr. Hser documents that heroin use appears to be persistent with age—the mortality rate rises from about 33 percent for heroin users aged 45 to 49 to 76 percent or higher for users older than 65. Rates of abstinence for 5 years or more increased to about 50 percent beyond ages 45 to 49, but no continuing increase of recovery after age 50 was observed. Age-related drug use progression and recovery appeared to differ depending on the type of drug used. However, the baby boomer generation reported greater levels of illicit drug use. Dr. Hser calls for future studies to include women and to improve sampling of the elderly.

This chapter examines polydrug use among various age groups using the Treatment Episode Data Set (TEDS). Emphasis is placed on baby boomers and current older users of the substance abuse treatment system. The analysis is intended to provide a benchmark to measure future change in polydrug use among the substance-abusing or dependent population treated in publicly supported programs. TEDS data for 1997 indicate that alcohol abuse was the primary problem of those aged 50 or older who were admitted to publicly funded substance abuse treatment. At age 55 or older, an increasing percentage of persons entering treatment for the first time was due to late-onset alcoholism. However, the use of multiple substances was reported by 7 to 20 percent of those aged 55 to 79, increasing among those aged 75 or older to levels comparable with those for persons younger than 40. Abuse of tranquilizers and sedatives increased with age and was consistent with problem prescription drug use among older adults, especially when combined or with alcohol. Referral to treatment by health care providers also increased with age.

This chapter uses data from the 1999 National Household Survey on Drug Abuse (NHSDA) in a series of regression models to estimate the number of adults with substance abuse problems in the year 2020. It is estimated that the number of adults over the age of 50 with substance abuse problems will double to 5 million during the time period from 1999 to 2020. In 2020, approximately 50 percent of persons aged 50 to 70 will be in a high-risk group (use of alcohol and marijuana before age 30) compared with just less than 9 percent in 1999. The authors call for alternative measures of substance abuse in the older population (e.g., persons in recovery or abusing prescription drugs) and for the analysis of different categories of substance abuse.

This chapter offers a conceptual approach to project substance abuse in an older population. The focus in on a life table methodology using data drawn from the National Household Survey on Drug Abuse (NHSDA). Dr. Woodward discusses the limitations of the NHSDA and possible changes to the survey that could facilitate the use of a follow-up life table to track a cohort of substance-abusing baby boomers as they move into old age by 2020 or 2030. A hypothetical example of this type of projection analysis is discussed, as are limitations and strengths of the NHSDA for future study of substance abuse in the older population.

This chapter uses 1992 NLAES data to compute rates of substance abuse by age cohort and gender. Abuse and dependence were shown to be highest among young adults, with the rate of marijuana use higher than any other drug among male and female baby boomers. The analysis indicates that substantial changes in the patterns of substance use/abuse over different age cohorts will have a dramatic effect on future treatment and prevention for senior adults.

This chapter examines changes in drinking among adults aged 18 or older during the years from 1972 to 1992. Data are drawn from the initial NHANES study (1972-74) and the 1982-84, 1987, and 1992 follow-up surveys. Weekly drinking levels were collected from these four waves of data and were calculated based on 5-year and 10-year age categories over the 20-year period. Cross-tabulations were run to indicate differences by gender and age. Alcohol consumption appeared to decrease with increasing age. However, the baby boomer cohort is likely to maintain a higher level of alcohol consumption than previous cohorts. The chapter addresses the need for prevention and treatment strategies targeted at baby boomers.

This chapter examines whether veterans' use of substance abuse services as they became older has changed over time. Cross-sectional data over 11 years of VA utilization are analyzed. Five-year age groups are defined with a base year of 1992. Because baby boomers were born between 1946 and 1964, they were aged 28 to 46 in 1992. Drs. Booth and Blow show that the use of inpatient and outpatient substance abuse treatment by veterans aged 35 to 49 in 1992 did not decline between fiscal years 1988 and 1998. Veterans may not be decreasing their dependence on alcohol and drugs with increasing age. The ramifications for the allocation of VA treatment resources for older veterans are discussed.

This final chapter summarizes the issues raised in this volume, highlights several findings, and amplifies concern about the projected demand for substance abuse services in the next 20 to 30 years. It also recommends steps that may be taken to strengthen the empirical grounding for more informed policy in addressing this demand.

 

References

Adams, W. L. (1997). Interactions between alcohol and other drugs. In A. M. Gurnack (Ed.), Older adults' misuse of alcohol, medicines, and other drugs (pp. 185-205). New York, NY: Springer Publishing Co.

Atkinson, R. M., Ganzini, L., & Bernstein, M. J. (1992). Alcohol and substance-use disorders in the elderly. In J. E. Birren, R. B. Sloane, & G. D. Cohen (Eds.), Handbook of mental health and aging (2nd ed., pp. 515-554). San Diego, CA: Academic Press, Inc.

Blow, F. C., Brower, K. J., Schulenberg, J. E., Demo-Dananberg, L. M., Young, J. P., & Beresford, T. P. (1992). The Michigan Alcoholism Screening Test—Geriatric Version (MAST-G): A new elderly-specific screening instrument. Alcoholism: Clinical and Experimental Research, 16, 372.

Blow, F. C., Walton, M. A., Barry, K. L., Coyne, J. C., Mudd, S. A., & Copeland, L. A. (2000a). The relationship between alcohol problems and health functioning of older adults in primary care settings. Journal of the American Geriatrics Society, 48, 769-774.

Blow, F. C., Walton, M. A., Chermack, S. T., Mudd, S. A., & Brower, K. J. (2000b). Older adult treatment outcome following elder-specific inpatient alcoholism treatment. Journal of Substance Abuse Treatment, 19(1), 67-75.

Brennan, P. L., Kagay, C. R., Geppert, J. J., & Moos, R. H. (2001). Predictors and outcomes of outpatient mental health care: A 4-year prospective study of elderly Medicare patients with substance use disorders. Medical Care, 39(1), 39-49.

Brody, J. R. (2002, April 2). Hidden plague of alcohol abuse by the elderly. New York Times, p. D7.

Brower, K. J., Mudd, S., Blow, F. C., Young, J. P., & Hill, E. M. (1994). Severity and treatment of alcohol withdrawal in elderly versus younger patients. Alcoholism: Clinical and Experimental Research, 18, 196-201.

Center for Substance Abuse Treatment. (1998). Substance abuse among older adults (DHHS Publication No. SMA 98-3179, Treatment Improvement Protocol [TIP] Series 26; available at http://www.health.org/govpubs/BKD250/). Rockville MD: Author.

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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.

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King, C. J., Van Hasselt, V. B., Segal, D. L., & Hersen, M. (1994). Diagnosis and assessment of substance abuse in older adults: Current strategies and issues. Addictive Behaviors, 19, 41-55.

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Kraemer, K. L., Conigliaro, J., & Saitz, R. (1999). Managing alcohol withdrawal in the elderly. Drugs and Aging, 14, 409-425.

Morton, J. L., Jones, T. V., & Manganaro, M. A. (1996). Performance of alcoholism screening questionnaires in elderly veterans. American Journal of Medicine, 101, 153-159.

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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; available at http://www.nida.nih.gov:80/EconomicCosts/Intro.html). Washington, DC: Executive Office of the President.

Reinhardt, U. E. (1999). The political economy of health care for the elderly population. In K. Dychtwald (Ed.), Healthy aging: Challenges and solutions (pp. 203-230). Gaithersburg, MD: Aspen Publishers.

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The Robert Wood Johnson Foundation. (2001). Substance abuse: The nation's number one health problem (prepared by the Schneider Institute for Health Policy, Brandeis University; available at http://www.rwjfliterature.org/chartbook/chartbook.htm). Princeton, NJ: Author.

Rosenberg, H. (1997). Use and abuse of illicit drugs among older people. In A. M. Gurnack (Ed.), Older adults' misuse of alcohol, medicines, and other drugs (pp. 206-254). New York, NY: Springer Publishing Co.

Waite, L. J. (1996). The demographic face of America's elderly. Inquiry, 33, 220-224.

Williams, G. D., Stinson, F. S., Parker, D. A., Harford, T. C., & Noble, J. (1987). Demographic trends, alcohol abuse and alcoholism, 1985-1995 [Epidemiologic Bulletin No. 15]. Alcohol Health & Research World, 11(3), 80-83, 91.

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* To whom correspondence should be sent at the Office of Applied Studies, SAMHSA, Parklawn Building, Room 16-105, 5600 Fishers Lane, Rockville, MD 20857. Telephone: 301-443-2704. E-mail: SKorper@samhsa.gov.

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