Forty-five years ago nearly half a million young people gathered for a three-day music festival that became a definitive symbol for the larger counterculture movement. Woodstock was one of the first benchmarks that later defined the baby boomer generation—a cohort whose experience and identity are forever marked by freethinking experimentation and drug use, from tripping on acid in the Age of Aquarius to smoking reefer (rather than drinking cocktails) after work in middle age.
Today, as the boomers (people born between 1945 and 1964) reach retirement age in ever larger numbers, they face the predictable health problems associated with aging. Many also face drug problems (as well as the more “traditional” problematic use of alcohol).
Yet there remains something of a myth that substance misuse is mainly for the young. The reality is that a growing number of boomers are carrying their drug problems straight through middle age and into their 60s, 70s, and beyond.
Yet there remains something of a myth that substance misuse is mainly a problem for the young. The reality is that a growing number of boomers are carrying their drug problems straight through middle age and into their 60s, 70s, and beyond.
There is also an increasing number of folks who, as a result of the aging process, begin to develop problems with substance use that was previously manageable. Increases in use often occur in conjunction with significant life changes, such as retirement and the death of a loved partners and peers. Rather than aiming to “get high” like sensation-seeking teenagers and young adults, these people typically use drugs and alcohol to alleviate the physical and psychological pain resulting from losses, social isolation, and mental and medical illness.
The vast number of boomers entering retirement over the next two decades poses new and complex challenges to the field of addiction diagnosis and treatment. The vast majority of programs, whether inpatient rehabs, outpatient clinics, or mutual support groups, do not focus on the specific needs of elderly patients. As a result, when accessing treatment, old people are typically marginalized—just as they are by society at large. The aging can feel invisible and alienated—their needs not only unmet but unspoken—in our youth-fixated culture.
With the age distribution of our country changing quickly, we need to adequately prepare our health care workers, especially those who work in addiction, to address these needs of older adults. The task is daunting, in part because we are so far behind the curve.
A LOOMING CRISIS, BY THE NUMBERS
There are currently an estimated 41 million adults ages 65 and older in the U.S. By 2030, this number is projected to increase to 73 million. This dramatic shift in America’s age distribution will place accelerating demands on our entire health care system. A report issued by the Institute of Medicine warns that the sheer volume of older patients threatens to overwhelm the number of health care professionals who possess the skills necessary to provide them with high-quality care.
When it comes to drugs, the percentages remain small, but the overall numbers are still large enough for an increase to have a huge impact. Baby boomers, who came of age when experimenting with drugs was pervasive, are far more likely to use illicit drugs (both illegal and non-medical use of prescription drugs) than previous generations.
According to a report by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), about five percent of all boomers—or about 4.3 million adults over age 50—use illegal drugs. A 2011 SAMHSA study found that the rate of current illicit drug use among people in their 50s increased to 6.3 percent in 2011 from 2.7 percent in 2002.Alcohol tops the list, followed by (in order) marijuana, non-medical prescription drugs, and cocaine.
The non-medical use of prescription drugs is a growing threat. Some studies estimate that up to 10 percent of older people use prescription drugs non-medically—most often anti-anxiety benzodiazepines like Klonopin, sleeping pills like Ambien, and opiate painkillers like Oxycontin.Among those 50 and older, women far outnumber men: 44 percent report non-medical use of prescription drugs, compared to 23.4 percent of men.
The number of 50-and-older people with a substance use disorder is projected to more than double from 2.8 million in 2002 to 5.7 million in 2020. According to a federal report, the trailing edge of the baby boom, ages 50 to 54, is the fastest-growing of older adult groups: They were six percent of all admissions in 2005, up from three percent a decade earlier.
And as with all age groups, problematic use of alcohol and drugs is associated with depression, anxiety, and other mental illnesses. In 2010 the best estimates are that six to eight million older Americans—about 14 percent to 20 percent of that population—had one or more substance use and other mental health disorders.
THE AGE BIAS IN SUBSTANCE USE DIAGNOSES
Effective treatment begins with accurate screening, assessment, and diagnosis, regardless of age. But current research related to screening and brief intervention was conducted with adolescents and young adults in mind, leaving the unique needs of the elderly to fall through the cracks.
“Screening and assessment tools designed for younger adults may use criteria not relevant to older adults, like the negative impact of substance use on work or school,” says Tamara Ward, press officer at SAMSHA. “This calls for the development and use of age-specific tools to properly recognize and diagnose substance misuse problems among older adults.”
Accompanying the myth that old people do not have drug problems is the myth that when they do, it is likely too late for significant life changes.
Screening tools in use today capture the quantity, frequency, and pattern of use, but do not consider duration. This is especially important for older adults—someone with a long-standing drug history may not be using currently, but would still be at greater risk for cancer, cardiovascular disease, and other related problems. Someone with late-onset use may not be at greater risk for these conditions, but would still be in need of treatment to help prevent medication interactions and falls.
“Physicians and nurses get maybe six hours of content on how to screen, conduct brief interventions, and refer to treatment,” says Christine Savage, professor and chair of the Department of Community Public Health at John Hopkins School of Nursing. “The majority of content they get is how to manage withdrawal or overdose.”
These tools also need to fit into an increasingly short visit, says Debra Jay, author of Aging and Addiction and It Takes a Family. “Primary care physicians often feel uncomfortable asking older adults about alcohol and other drug issues, often have little or no training in addiction medicine, and can believe many of the myths about older adults and addiction.”
Accompanying the myth that old people do not have drug problems is the myth that when they do, it is likely too late for significant life changes. Equipping health care professionals with screening and intervention tools is also important because of the stigma associated with mental health problems and substance use disorders among this age group.
“Even if a doctor approaches the issue, the older adult may simply switch doctors or deny a problem exists,” Jay says. “It is usually the adult children who decide to take action and help motivate an older parent to accept treatment, through either informal or formal intervention.”
OLDER PEOPLE'S UNIQUE TREATMENT NEEDS
Addressing the treatment needs of older adults requires different strategies from those used with other populations. That said, there are very few inpatient programs designed specifically for older adults (examples include the Hanley Center in West Palm Beach and Pine Grove in Hattiesburg, Mississippi). Consequently, those with diagnosable substance use disorders are usually treated among the general population aged 18 and over. Depending on the needs and resources of the patient, they may be referred to higher levels of care, but quality of care, length of stay, and other standards vary greatly among treatment programs, resulting in a range of effectiveness.
“As is true for adolescents, this age group has unique needs,” says Debra Jay. “Typically, they progress more slowly through treatment and are facing issues specific to their stage of life: empty nest, change in roles (such as retirement), grief issues, body changes, cognitive deficiencies, limitations related to sight, hearing, and mobility.”
These needs are becoming increasingly apparent with the aging population, leaving health care workers to create solutions. In New York City, Jewish Home Lifecare’s administrator, Gregory Poole-Dayan, for instance, was concerned about the number of patients who had to leave local hospitals but were not ready to return home. Nursing homes have typically shied away from treating addicted patients, but after consulting with local hospitals, he decided that Jewish Home Lifecare would open the first-ever rehab program to help seniors recover from both their medical conditions and their addictions. They started accepting these new residents last month.
SOCIAL SETTING, THE 12 STEPS, AND HARM REDUCTION
One need that is often overlooked is an appropriate social setting. As noted in a 2008 New York Times article, older adults may reject an environment filled with tattooed young adults who have different drug histories and communication styles. “We have different health issues, different emotional issues, different grief issues,” Hanley Center patient Patrick Gallagher says of young adults. “We need more peace and quiet and a different pace.”
“It was a different era,” Ms. Ellison, another patient, says. “We had a lot of guidance growing up. They don’t have that at home. Their parents—and that includes some of us—are out there drugging.”
When the quick-fix mentality of the me generation meets our current health care system, it results in a perfect storm.
Ironically, even when age-specific treatment is accessible, there is a growing divide between two categories of people: the “young-old” (me generation, or baby boomers) and the “old-old” (silent generation). Yet the “young-old” and “old-old” groups do not necessarily have a lot in common, so counselors are bracing for a collision of cultures, as if the “Generation Gap” of the old days were replaying itself. This is mainly because boomers are far more likely to use illicit drugs than previous generations, who tend to associate these substances with socioeconomic class.
During a recent phone conversation, psychologist Jamie Huysman, clinical consultant for Caron Treatment Centers’ Older Adult Services and co-host of Caregiver SOS, highlighted the significance of this social aspect: “I see many aging who are aging isolating way too much. By providing social reinforcement, programs like the 12 Steps have a great way of bringing them back into a community.”
Indeed, when it comes to drinking-related outcomes, older people can benefit from Alcoholics Anonymous. But the findings of a 2004 study suggest that efforts to facilitate their entry into and involvement in 12-step programs may be especially important to older adults. They reported similar amounts of attendance as the younger patients, but they were less likely to have ever considered themselves a member of a 12-step group or to have ever called a member for recovery support. This suggests that older patients may benefit from treatment staff helping to locate a home group comprised of members similar to themselves.
In addition to the lack of elderly specific programs there is a lack of alternatives to abstinence-based treatment. “Baby boomers have a long history of substance misuse,” says a nurse at a geriatric psychiatric unit who requested anonymity. “We are talking about 60 years of less than useful coping mechanisms. More than anything we need to embrace the concept of harm reduction, which is a non-punitive way to provide a tailored program of treatment for this population.”
Because of stigma and denial, older adults are typically referred to treatment only when something dramatic happens, like a DUI or a broken bone resulting from a bad fall. Diagnoses and treatment often come much later than necessary.
In addition, Savage emphasizes that not all people experiencing adverse health consequences associated with substance use will have a diagnosable disorder. “Traditional treatment facilities are set up to treat someone with a diagnosed substance use disorder, using the abstinence model,” she says. “But you first have to think through what it is you are trying to achieve. From my perspective, we have to look at substance use across the continuum and take a harm reduction model to help the older adult move from at-risk use to low-risk use.”
HOW HEALTH CARE FAILS DRUG-USING SENIORS
Ascribing universal attributes to a generation spanning 20 years is difficult. You may believe that the boomers ended the war in Vietnamand changed an old and unequal social order. You may believe they’re self-absorbed consumerists leaving behind massive national debt. Either way, there is no denying that they are a generation marked by strong cultural cleavage and a vocal rejection of traditional values.
When the quick-fix mentality of the me generation meets our current health care system, WellMed Medical Management’s Huysman says, it results in a perfect storm. “Doctors are seeing 30, sometimes 40 patients a day, in a fee-for-service environment. When a patient comes in asking for specific drugs they’ve seen on TV, it takes five minutes to say yes and 45 minutes to say no.”
Ironically, there is a growing divide between two categories of people: the "young-old" (me generation, or baby boomers) and the "old-old" (silent generation).
The primary care world is for the most part separate from the behavioral health world, so medical doctors may be prescribing medications, including addictive psychoactive ones, without their patient’s behavioral health history. Virtually all states are working to combat this issue via prescription monitoring programs, but they vary widely in terms of comprehensiveness, usability, and effectiveness.
The fee-for-service environment is another issue. A persuasive body of evidence indicates that common mental health disorders are most effectively addressed among older adults when care includes outreach and diagnosis, patient education and self-management support, provider accountability for outcomes, and close follow-up and monitoring to prevent relapse. But none of this is likely to be achieved without a substantial change in Medicare payment rules, says the Institute of Medicine. After all, there is a fundamental mismatch between older adults’ need for coordinated care and fee-for-service reimbursement, which precludes payment of trained care managers and psychiatry consultation.
Still, steps are being taken. For example, in 2006, the SAMHSA Center for Substance Abuse Treatment awarded a $14 million grant to the state of Florida, part of which funded the state’s Brief Intervention and Treatment for Elders (BRITE) Project. Jewish Home Lifecare’s nursing home innovation is another. But with more than 70 million boomers, the need for age-specific screening and treatment for substance use disorders is at an all-time high. Yet more than incremental advances are required.
ARE BOOMERS UP TO BATTLING STIGMA?
Stigma always has negative consequences for people who use drugs problematically, and older people are no exception. Stigma prevents them from acknowledging their problem and asking for help. Stigma also prevents their family and their doctors from asking questions that might lead to diagnosis. When coupled with the general bias against aging people—their invisibility, isolation, and the like—stigma even prevents them from making use of treatment and social support in settings that are supposed to be stigma free.
Addressing stigma, however, is a mammoth task. “That’s the first step,” Huysman says. “People need to view addiction like any other chronic disorder. Period.”
Savage agrees. “We have to have what I would call a cultural shift. We had one in terms of tobacco and another in terms of drinking and driving. If we could move into a similar understanding around heavy alcohol consumption, maybe people wouldn’t be so desperate by the time they sought help.”
With their legacy of confronting authority and causing cultural change, the Baby Boomers may be just the people to initiate such a shift.