Samuel P. Korper,* Ph.D., M.P.H.
Ira E. Raskin, Ph.D.
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:
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 medicationsthe 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:
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.
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; available as a PDF at 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; available at http://www.uthscsa.edu/opa/releases/nrel15may00.html). San Antonio, TX: University of Texas Health Science Center. [Published May 16, 2000, in Alcoholism: Clinical and Experimental Research, Johnson, B.A.]
* 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.
This page was last updated on June 16, 2008.
This page was last updated on June 16, 2008.