Drug Abuse in the 21st Century: What Problems Lie Ahead for the Baby Boomers?

United States

Introduction

Substance Abuse in the Elderly—An Overview

Timothy P. Condon, Ph.D.

The baby boomer generation is America’s largest thus far, and in 30 years will comprise 20 percent of the nation’s population (~70 million people). While substance abuse typically declines with age, for a variety of social, cultural, and economic reasons, baby boomers appear to be using and abusing alcohol, illicit drugs, and prescription drugs at higher rates than previous cohorts. However, little is known about how the aging brain may respond to drugs of abuse, how early drug use affects the aging process, or how drugs of abuse may interact with medical conditions associated with aging. For example, markers of dopamine function decrease both as a function of age as well as in response to drugs of abuse. The implications of these findings for substance abuse in the aging brain are unknown. Neurotoxic indicators also show greater drug-induced effects with age, suggesting interactions between drug abuse and aging in the brain. However, more research is needed to elucidate these interactions. Changes in drug disposition and metabolism with age, as well as the preponderance of co-morbid physical and mental health conditions, may also pose greater complications for substance abuse in this population. Finally, in order to address this problem, unique considerations must be taken into account in devising effective prevention, detection, and treatment strategies for older adults. As this is an emerging field of research, NIDA welcomes recommendations for the development of a research agenda aimed at more fully delineating the extent of the problem, the potential medical, psychological, and social consequences, as well as effective means for ameliorating the potentially devastating consequences of substance abuse in older adults.

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Prevalence

Substance Use Among Older Adults: Current Prevalence and Future Expectations

Joseph C. Gfroerer

Although substance abuse has historically been concentrated primarily among youths and young adults, there is increasing concern about the problem in older adults. With the aging of the baby boomer cohort, the older adult population will soon comprise a large proportion of persons who have used marijuana and other illicit drugs in their lifetimes. Combined with the fact that the baby boomer cohort is larger than prior cohorts, we should expect to see substantial increases in the number of older adults with substance use problems in the next two decades. Joseph Gfroerer used the most recent data from the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health (NSDUH) and Treatment Episode Data Set to present current patterns and prevalence and recent trends in alcohol and illicit drug use and treatment among persons age 50 and older in the United States. He also presented the estimated prevalence of substance use problems among older adults in 2020, based on a statistical model that merges NSDUH data with U.S. Census population projections.

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Long-Term Trajectory of Substance Abuse and Psychiatric Comorbidity: Vietnam Era Study

Rumi Kato Price, Ph.D.

The study sample for this presentation was a cohort of 1,227 non-officer Army men who returned from their Vietnam duty in September 1971, including drug-positive (D+) veterans (a probability sample of those who tested positive after urinalysis in 1971, n=512); drug-negative (D–) veterans (a probability sample of all returnees, n=431); and nonveteran controls (a sample from Selective Service registration lists who were individually matched to those in the second sample, n=284). The presentation addressed four questions: (1) What is the trajectory of drug use and abuse among male baby boomers at risk of continuous drug use and psychiatric problems? (2) What are the predictors for continuation of, or remission from, drug abuse? (3) How have drug use and abuse affected other areas of baby boomers’ lives over 30 years? (4) What are the emerging patterns of drug use and abuse when baby boomer drug users reach middle age? The presentation concluded with assessments of the ways in which youthful drug use and abuse were harmful for baby boomers up to their mid-lives, resiliency factors for continuous drug use, potential intervention and prevention areas to promote remission from drug abuse or to minimize harm of continuous drug use, and readiness of the current health care system for baby boomers with a history of youthful drug abuse. Although the study cohort is unique, the results can be generalized to male baby boomers with war experience, who currently constitute over 20 percent of the U.S. male population aged 40 to 60. 

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Continuity in Substance Use Problems Among Baby Boomers in the National Comorbidity Survey Replication

Ronald C. Kessler, Ph.D.

Dr. Ronald Kessler’s presentation covered continuity in substance use problems among baby boomers, using data from the National Comorbidity Survey (NCS), the NCS Replication Survey (NCSR), and the NCS Panel Survey (NCS2). The NCS, a nationally representative survey of substance use and mental disorders, was carried out from 1990 to 1992 to assess the prevalence and correlates of DSM-III-R disorders. The NCS2 is a re-interview survey of the original NCS respondents a decade after the baseline survey. NCSR is a replication of the NCS in a new sample of respondents; comparison of NCS and NCSR data is used to study aggregate trends in substance use disorders. Using these data, Dr. Kessler examined intercohort differences among baby boomers, such as baseline predictors of lifetime alcohol, nicotine, and illicit drug use disorders and speed of recovery (publication pending).

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Use of Medications, Alcohol, and Smoking in Elderly Japanese-American Men in Hawaii: A Report From the Honolulu-Asia Aging Study (HAAS)

Lon R. White, M.D.

The Honolulu-Asia Aging Study is an ongoing population-based investigation with a conceptual focus on neurodegenerative diseases and stroke. It utilizes the cohort and accrued data of the Honolulu Heart Program, which began in 1965 with the interview and examination of 8,006 Japanese-American men who were born between 1900 and 1919 and living on Oahu. Information on smoking and alcohol intake has been collected at eight examination cycles between that time and today. Information on use of all medications as well as use of traditional medical treatment (including herbals) has been collected at three exam cycles since 1991. While alcohol intake declined as the men became older, it did remain a significant health problem in a small number of the participants. Data were presented on the prevalence and correlates of mid- and late-life alcohol intake, and on the use of specific medications, multiple medications, over-the-counter medications, and herbals.

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Prescription Drugs and Drug Interactions

Prescription Drug Abuse and Misuse in the Elderly

Thomas L. Patterson, Ph.D.

Approximately 12 percent of U.S. health expenditures are dedicated to prescription drugs. This amount is steadily increasing, reported Dr. Thomas Patterson, and the greatest expenditures are among the elderly. Approximately 30 percent of prescriptions are consumed by those over age 65. The elderly spend as much as $15 billion each year on prescriptions, which is four times the spending level of younger individuals. The greater use of prescription medications by the elderly is largely due to increased medical conditions with age. However, prescription drug misuse also occurs in this population. There are a number of types of misuse, including overdose, underdose, use of prescriptions for reasons other than prescribed, and drug combinations that may poorly interact. Reasons for misuse of medications include difficulties in reading and following prescriptions, cognitive deficits, cost of meds, and complexity of drug treatment. The largest proportion of medications taken by the elderly target cardiovascular, central nervous system, and musculoskeletal problems. The most frequently abused drugs by the elderly are opiates. Prevalence estimates of abuse by the elderly may be conservative due to problems with definitions and diagnoses of drug abuse among this age group. Age-associated changes in pharmacokinetics and the impact of psychosocial factors may have unique impacts on the onset and exacerbation of drug problems as they relate to the prevalence of drug problems among aging Americans. Dr. Patterson suggested goals and strategies for the field, such as improving diagnostic criteria, focusing research on compliance, standardizing prescription labeling, developing treatment programs tailored to elderly, considering dual diagnosis (e.g., posttraumatic stress disorder and drug use), explicating age-related changes in drug abuse, examining ethnic and cultural differences, and examining the impact of Internet/foreign purchase of medications.

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Prescription Drug Nonmedical Use and Abuse in Older Women

Linda Simoni-Wastila, Ph.D.

The use, nonmedical use, and abuse of prescription drugs with addiction potential is a current and growing problem among today’s older adults. Although the true extent of prescription drug abuse and dependence in older adults remains unknown, in 1999, nearly 7.2 million older adults were medically exposed to prescription drugs with addictive potential. Further, it is widely acknowledged that nonmedical prescription drug use and abuse will be compounded in the near future as the baby boomer population, known for both its historical and current acceptance of licit and illicit drug taking, begins entering older adulthood. Indeed, of all individuals in treatment for substance abuse disorder, it is estimated that nearly half belongs to this aging cohort. Although little research has been conducted on factors associated with nonmedical prescription drug use and abuse in older adults, the female gender has emerged as one of its most significant immutable predictors. This finding stands in sharp contrast to the tremendous body of literature that finds the male gender a robust factor for use of other substances, including alcohol and illicit drugs. This presentation aimed to document the prevalence of prescription drug nonmedical use and abuse in older men and women, and examine the risk and protective factors common to both genders, as well as those that may be specific to gender. The discussion concluded with some observations concerning the growing problem of nonmedical prescription drug use and abuse, and the ramifications for prevention and treatment efforts aimed at elderly and near-elderly men and women.

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Drug Interactions in Older Adults

Joseph T. Hanlon, Pharm.D.

Dr. Joseph T. Hanlon presented drug-drug interactions involving both pharmacokinetic and pharmacodynamic mechanisms. Specifically, he focused on those drug interactions involving narrow therapeutic-range drugs and those that are clinically significant. Herb-drug interactions and others involving food and drink (including grapefruit juice) also were briefly discussed. In addition, Dr. Hanlon presented data from his new research focusing on drug-disease interactions in older adults. The presentation concluded with a discussion on the epidemiology of drug interactions in older adults and strategies to prevent or manage drug interactions.

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Comorbidities and Consequences

Addictive and Co-Occurring Disorders in Late Life

David W. Oslin, M.D.

The impact of late-life addictive disorders is a growing public health concern. Epidemiological studies have demonstrated that the abuse of addictive substances is common among older adults. Moreover, substance abuse in early adulthood can have lasting effects, including an increase in the likelihood of developing late-life mental health problems. Thus, in measuring the impact of addictions on older adults, one must consider the lifetime use and abuse of these substances. Dr. David Oslin’s presentation focused on the intersection between use and abuse of addictive substances and the presence and course of other mental health disorders. He emphasized mainly those substances that are most commonly abused by older adults (alcohol, cigarettes, and benzodiazepines), but discussed other abused drugs as well.

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Cognitive and Brain Aging in the Baltimore Longitudinal Study of Aging

Susan M. Resnick, Ph.D.

The Baltimore Longitudinal Study of Aging (BLSA), conducted by the National Institute on Aging (NIA), is America’s longest running scientific study of human aging. Adult men and women have been enrolled and followed since 1958 and 1978, respectively. An investigation of age-related changes in memory and other cognitive functions in BLSA participants was initiated in the early 1960s. It focused on longitudinal age changes, especially cognitive tasks (e.g., visual memory, problem solving skills, and reaction time). The cognitive testing program was expanded in 1986 to include prospective diagnoses of dementia and cognitive impairment. In 1993, a separate test battery was introduced to tap a broad range of cognitive functions as predictors of cognitive decline. Since 1994, we also have assessed longitudinal changes in brain structure and function to identify early biomarkers of the development of cognitive impairment and dementia. We have performed annual MRI and PET scans to measure age changes in brain structure and regional cerebral blood flow, respectively, in approximately 150 BLSA participants aged 55 years and older. Results of these studies show that there are longitudinal declines in brain volume, degenerative changes in white matter tissue characteristics, and longitudinal changes in patterns of functional brain activation during cognitive challenge even in the nondemented elderly. Thus, effects of drug abuse on cognition and brain structure and function in the elderly will be superimposed upon a changing brain.

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Long-Term Consequences of Heroin and Cocaine Addiction

Yih-Ing Hser, Ph.D.

Dr. Yih-Ing Hser discussed findings from two long-term followup studies. The 33-Year Followup Study of Narcotics Addicts followed a sample of 581 male narcotics addicts admitted to the California Civil Addict Program (CAP) from 1962 through 1964. The CAP was a compulsory drug treatment program for opiate-dependent criminal offenders committed under court order. The program consisted of an inpatient period followed by supervised community aftercare. The sample was interviewed in 1974/75, 1985/86, and 1996/97. In 1998, medical examinations were performed among a subset of these subjects. Results empirically demonstrated poor health conditions and high morbidity among surviving narcotics addicts. The Cocaine Followup Study is a 12-year followup study of 321 cocaine-dependent men originally admitted in 1988/89 to their first treatment for cocaine dependence at the West Los Angeles Veterans Affairs Medical Center. Respondents were interviewed at intake and in 1990/91 and 1991/92, and the latest followup was in 2002/03. Results showed that cocaine abstinence was associated with less criminality, morbidity, psychological distress, and higher employment.

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Prevention, Diagnosis and Treatment

Substance Abuse Prevention, Screening and Identification, and Assessment for Older Adults

Frederic C. Blow, Ph.D.

There is a growing proportion of individuals in the United States who are near or in retirement, and a larger cohort of baby boomers who will reach late life in the coming decades. These cohorts may drink alcohol and abuse prescription and illicit drugs at higher levels than previously reported. They also may experience greater alcohol- and drug-related consequences related to the use of these substances. Although there is a paucity of research on effective prevention, screening, and assessment approaches for this rapidly growing and vulnerable population, research on these important issues is beginning to be conducted and reported in the scientific literature. Dr. Frederic Blow highlighted existing knowledge in substance abuse prevention and early identification, identified important gaps in our knowledge in these areas, and elucidated critical topics for future research.

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Substance Abuse Treatment in the Elderly

Lawrence Schonfeld, Ph.D.

This presentation focused on treatment of older adults for alcohol abuse, prescription and over-the-counter medication misuse, and illicit substance use. Research studies describing treatment modalities used in the United States and Canada were presented by Dr. Lawrence Schonfeld. While alcohol remains the most frequently abused substance, there are indications that illicit drug use in later years may increase as baby boomers age. Dr. Schonfeld discussed studies on mixed-age and elder-specific treatment approaches, as well as recommended treatment focus areas, such as teaching skills necessary to cope with depression and loneliness, enhancing social support and activities, and preventing relapse in older adults. Medication misuse, an often unintentional occurrence, was discussed in terms of patients’ knowledge and providers’ education. Florida BRITE, a pilot project funded by the State of Florida’s Substance Abuse Program Office, also was highlighted. BRITE involves the implementation and evaluation of screening, brief intervention, and brief treatment approaches for older adults residing in three counties. This recently initiated project offers several sessions of brief intervention to those who screen positive, or if more intensive treatment is required, cognitive-behavioral/self-management approaches. 

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Drug and Alcohol Treatment Outcomes in Older Adults

Derek D. Satre, Ph.D.

The adverse consequences of drug and alcohol problems in older adults are substantial. However, treatment research in this population has been very limited. Studies including women and privately insured individuals have been especially lacking. To help address these research gaps, this presentation summarizes the results of recent studies conducted by the Drug and Alcohol Research Team at the Kaiser Permanente Division of Research in an outpatient Kaiser Chemical Dependency Recovery Program. Three treatment outcome studies analyzed individual, treatment, and extra-treatment factors that may influence outcomes. These studies investigated baseline clinical characteristics, as well as 6-month and 5-year outcomes of older adults (aged 55 and over) compared with middle-aged adults (aged 40 to 54) and younger adults (aged 18 to 39), including gender differences and social networks. Kaiser automated health plan records were used to identify medical conditions of patients in treatment and age group differences in health service utilization and cost. The findings will contribute to understanding the service needs of older adults in treatment, factors associated with positive treatment outcomes, and the effects of drug and alcohol treatment on other aspects of health care.

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