Rao and Roche [1] 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 [4]. 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 [15] 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 [18], service models that are unacceptable or inaccessible [19, 20], cultural differences in approaches to managing health problems [21] economic disadvantage and competing priorities [22]. Recent research has also highlighted that PWID often do not seek health care or delay accessing it [23].
Australian surveillance data suggest there is a large, ageing cohort of (predominantly) opioid injectors in Australia [24]. Similarly, national opiate substitution treatment (OST) data show that, of the over 48,500 people receiving OST, 22 per cent were aged over 50 [25]. 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 [26]. 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.
References
1. Rao, R. and A. Roche, Substance misuse in older people. BMJ, 2017. 358.
2. Han, B.H., et al., Demographic trends among older cannabis users in the United States, 2006–13. Addiction, 2017. 112(3): p. 516-525.
3. Lintzeris, N., et al., Substance use, health status and service utilisation of older clients attending specialist drug and alcohol services. Drug and Alcohol Review, 2016. 35(2): p. 223-231.
4. Madden, A. and P. Parkes, Coming of Age - Issues for older opiod injectors. Drug and Alcohol Review, 2010. 29(Supp 1): p. 47.
5. Rosenburg, H., The Elderly and the Use of Illicit Drugs: Sociological and Epidemiological Considerations. Substance Use & Misuse, 1995. 30(13-14): p. 1925-1951.
6. Tuchman, E., Methadone and Menopause: Midlife Women in Drug Treatment Journal of Social Work Practice in the Addictions, 2003. 3(2): p. 43-55.
7. Anderson, T.L. and J.A. Levy, Marginality among older injectors in today's illicit drug culture: assessing the impact of ageing. Addiction, 2003. 98(6): p. 761-770.
8. Beynon, C., G. Stimson, and E. Lawson, Illegal drug use in the age of ageing. Br J Gen Pract, 2010. 60(576): p. 481-2.
9. Beynon, C.M., et al., Self reported health status, and health service contact, of illicit drug users aged 50 and over: a qualitative interview study in Merseyside, United Kingdom. BMC Geriatr, 2009. 9: p. 45.
10. Beynon, C.M., Drug use and ageing: older people do take drugs Age and Ageing, 2009. 38(1): p. 8-10.
11. Degenhardt, L., M. Lynskey, and W. Hall, Cohort trends in the age of initiation of drug use in Australia. Australian and New Zealand Journal of Public Health, 2000. 24(4): p. 421 - 426.
12. Dietze, P. and J. Fitzgerald, Interpreting changes in heroin supply in Melbourne: droughts, gluts or cycles? Drug Alcohol Rev, 2002. 21(3): p. 295-303.
13. European Monitoring Centre for Drugs and Drug Addiction, Treatment and care for older drug users. 2010, EMCDDA: Spain.
14. Boeri, M.W., C.E. Sterk, and K.W. Elifson, Baby Boomer Drug Users: Career Phases, Social Control, and Social Learning Theory*. Sociological Inquiry, 2006. 76(2): p. 264-291.
15. Beynon, C.M., J.I.M. McVeigh, and B. Roe, Problematic drug use, ageing and older people: trends in the age of drug users in northwest England. Ageing & Society, 2007. 27(6): p. 799-810.
16. Radcliffe, P. and A. Stevens, Are drug treatment services only for 'thieving junkie scumbags'? Drug users and the management of stigmatised identities. Social Science & Medicine, 2008. 67(7): p. 1065-1073.
17. Stoove, M.A., S.M. Gifford, and G.J. Dore, The impact of injecting drug use status on hepatitis C related referral and treatment. Drug Alcohol Depend, 2005. 77(1): p. 81-6.
18. Ho, H. and L. Maher, Co Vay Co Tra: Vulnerability to blood-borne viral infection among ethnic Vietnamese IDUs. Drug Alcohol Rev, 2008. 27(4): p. 420-428.
19. Coupland, H., et al., Promoting equitable access to hepatitis C treatment for Indo-Chinese injecting drug users. Health Promot J Austr, 2009. 20(3): p. 234-40.
20. Winter, R., et al., Integrating enhanced Hepatitis C testing and counselling in research. International Journal of Drug Policy, 2008. 19(1): p. 66-70.
21. Higgs, P., et al., Heroin-gel capsule cocktails and groin injecting practices among ethnic Vietnamese in Melbourne, Australia. Int J Drug Policy, 2009. 20(4): p. 340-346.
22. McCoy, C.B., et al., Drug use and barriers to use of health care services. Subst Use Misuse, 2001. 36(6-7): p. 789-806.
23. Morgan, K., J. Lee, and B. Sebar, Community health workers: A bridge to healthcare for people who inject drugs. International Journal of Drug Policy, 2015. 26(4): p. 380-387.
24. Stafford, J., Breen, C., Australian Drug Trends 2016. Findings from the Illicit Drug Reporting System (IDRS), in Australian Drug Trend Series. No. 163. . 2017, National Drug and Alcohol Research Centre, UNSW Australia: Sydney.
25. Australian Institute of Health and Welfare, National opioid pharmacotherapy statistics. 2015, AIHW: Canberra
26. Higgs, P., J. Kelsall, and P. Dietze, Understanding the health needs of older opiate users. Drug Alcohol Rev, 2011. 30(Supp 1): p. 39-40.
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.
Rapid Response:
Older drug injectors require attention too
Rao and Roche [1] 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 [4]. 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 [15] 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 [18], service models that are unacceptable or inaccessible [19, 20], cultural differences in approaches to managing health problems [21] economic disadvantage and competing priorities [22]. Recent research has also highlighted that PWID often do not seek health care or delay accessing it [23].
Australian surveillance data suggest there is a large, ageing cohort of (predominantly) opioid injectors in Australia [24]. Similarly, national opiate substitution treatment (OST) data show that, of the over 48,500 people receiving OST, 22 per cent were aged over 50 [25]. 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 [26]. 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.
References
1. Rao, R. and A. Roche, Substance misuse in older people. BMJ, 2017. 358.
2. Han, B.H., et al., Demographic trends among older cannabis users in the United States, 2006–13. Addiction, 2017. 112(3): p. 516-525.
3. Lintzeris, N., et al., Substance use, health status and service utilisation of older clients attending specialist drug and alcohol services. Drug and Alcohol Review, 2016. 35(2): p. 223-231.
4. Madden, A. and P. Parkes, Coming of Age - Issues for older opiod injectors. Drug and Alcohol Review, 2010. 29(Supp 1): p. 47.
5. Rosenburg, H., The Elderly and the Use of Illicit Drugs: Sociological and Epidemiological Considerations. Substance Use & Misuse, 1995. 30(13-14): p. 1925-1951.
6. Tuchman, E., Methadone and Menopause: Midlife Women in Drug Treatment Journal of Social Work Practice in the Addictions, 2003. 3(2): p. 43-55.
7. Anderson, T.L. and J.A. Levy, Marginality among older injectors in today's illicit drug culture: assessing the impact of ageing. Addiction, 2003. 98(6): p. 761-770.
8. Beynon, C., G. Stimson, and E. Lawson, Illegal drug use in the age of ageing. Br J Gen Pract, 2010. 60(576): p. 481-2.
9. Beynon, C.M., et al., Self reported health status, and health service contact, of illicit drug users aged 50 and over: a qualitative interview study in Merseyside, United Kingdom. BMC Geriatr, 2009. 9: p. 45.
10. Beynon, C.M., Drug use and ageing: older people do take drugs Age and Ageing, 2009. 38(1): p. 8-10.
11. Degenhardt, L., M. Lynskey, and W. Hall, Cohort trends in the age of initiation of drug use in Australia. Australian and New Zealand Journal of Public Health, 2000. 24(4): p. 421 - 426.
12. Dietze, P. and J. Fitzgerald, Interpreting changes in heroin supply in Melbourne: droughts, gluts or cycles? Drug Alcohol Rev, 2002. 21(3): p. 295-303.
13. European Monitoring Centre for Drugs and Drug Addiction, Treatment and care for older drug users. 2010, EMCDDA: Spain.
14. Boeri, M.W., C.E. Sterk, and K.W. Elifson, Baby Boomer Drug Users: Career Phases, Social Control, and Social Learning Theory*. Sociological Inquiry, 2006. 76(2): p. 264-291.
15. Beynon, C.M., J.I.M. McVeigh, and B. Roe, Problematic drug use, ageing and older people: trends in the age of drug users in northwest England. Ageing & Society, 2007. 27(6): p. 799-810.
16. Radcliffe, P. and A. Stevens, Are drug treatment services only for 'thieving junkie scumbags'? Drug users and the management of stigmatised identities. Social Science & Medicine, 2008. 67(7): p. 1065-1073.
17. Stoove, M.A., S.M. Gifford, and G.J. Dore, The impact of injecting drug use status on hepatitis C related referral and treatment. Drug Alcohol Depend, 2005. 77(1): p. 81-6.
18. Ho, H. and L. Maher, Co Vay Co Tra: Vulnerability to blood-borne viral infection among ethnic Vietnamese IDUs. Drug Alcohol Rev, 2008. 27(4): p. 420-428.
19. Coupland, H., et al., Promoting equitable access to hepatitis C treatment for Indo-Chinese injecting drug users. Health Promot J Austr, 2009. 20(3): p. 234-40.
20. Winter, R., et al., Integrating enhanced Hepatitis C testing and counselling in research. International Journal of Drug Policy, 2008. 19(1): p. 66-70.
21. Higgs, P., et al., Heroin-gel capsule cocktails and groin injecting practices among ethnic Vietnamese in Melbourne, Australia. Int J Drug Policy, 2009. 20(4): p. 340-346.
22. McCoy, C.B., et al., Drug use and barriers to use of health care services. Subst Use Misuse, 2001. 36(6-7): p. 789-806.
23. Morgan, K., J. Lee, and B. Sebar, Community health workers: A bridge to healthcare for people who inject drugs. International Journal of Drug Policy, 2015. 26(4): p. 380-387.
24. Stafford, J., Breen, C., Australian Drug Trends 2016. Findings from the Illicit Drug Reporting System (IDRS), in Australian Drug Trend Series. No. 163. . 2017, National Drug and Alcohol Research Centre, UNSW Australia: Sydney.
25. Australian Institute of Health and Welfare, National opioid pharmacotherapy statistics. 2015, AIHW: Canberra
26. Higgs, P., J. Kelsall, and P. Dietze, Understanding the health needs of older opiate users. Drug Alcohol Rev, 2011. 30(Supp 1): p. 39-40.
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.