Rao and Roche  note the number of people aged over 50 using substances problematically is increasing across a range of settings globally [2, 3]. We wish to extend their editorial by pointing out that the proportion of older people who inject drugs (PWID) also appears to be increasing, at least in the developed world . Many PWID commenced their injecting careers in the drug epidemics of the 1980s and 1990s and continue to use substances (including injecting) through to today. Research on the health needs of older PWID, particularly those who continue to use opioids in North America, [5-7] and the United Kingdom [8-10] shows how little we understand of the life trajectories of ageing and drug use. This cohort has already established lifestyle and health trajectories which will carry them into their old age over the next two decades, the management of which has emerged as an increasingly important public health problem [11-14].
For example, some symptoms such as changes in blood pressure, changes in moods or memory impairment may only manifest in older age and the lives of older PWID are likely to be characterised by considerable levels of morbidity  not experienced by other older people without a drug injecting history. A range of barriers to accessing health care for PWID have been identified for PWID, including stigma and discrimination [16, 17], health workers’ lack of confidentiality , service models that are unacceptable or inaccessible [19, 20], cultural differences in approaches to managing health problems  economic disadvantage and competing priorities . Recent research has also highlighted that PWID often do not seek health care or delay accessing it .
Australian surveillance data suggest there is a large, ageing cohort of (predominantly) opioid injectors in Australia . Similarly, national opiate substitution treatment (OST) data show that, of the over 48,500 people receiving OST, 22 per cent were aged over 50 . It is also largely unknown what impact continuing to inject has on the life course of older people.
Issues of stigma mean that relatively few older adults with injecting histories seek on-going primary health care, this is despite many having regular contact with pharmacies and alcohol and other drug specialists . Primary care and other health-care services may provide a valuable opportunity to screen for any potential health problems associated with either opioid use or ageing the burden of which may be due to issues directly related to on-going injecting drug use.
There is a need to understand and design services for this population the key features of which are likely to be low-threshold and client centred. There is still much to understand in relation to the impact of OST on people who have been using it for decades especially in relation to cardiovascular disease, especially given the high rates of smoking in this population. As PWID get older their presentations to primary care for a broad range of chronic health problems will likely increase the sooner we can address these the less likely they are to end up in tertiary health settings.
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Competing interests: PH has received funding from Gilead Sciences and AbbVie for work unrelated to this letter. PD is supported by an ARC Future Fellowship and has received funding from Gilead Sciences and Reckitt Benckiser for work unrelated to this letter.