Opinion

Today’s baby boomers have used alcohol and other drugs at higher rates than previous generations. Many will continue to do so in older age and this is associated with greater risk of harm. The growth of this population will dramatically increase the absolute number of older individuals with substance use problems. Internationally, is it is estimated that the number of older people with alcohol and other drug problems, or requiring treatment for a substance use disorder, will more than double between 2000 and 2020. (2)

Older people with substance misuse problems are not a homogenous group and will require a range of services. These trends will have major implications for alcohol and other drug prevention, early intervention and treatment programs in the future.

Older people can be particularly vulnerable to experiencing alcohol- and other drug-related harm as they have a reduced capacity to metabolise, distribute and eliminate drugs. Those who do not reduce their intake as they become older are at risk of incurring harm even though their intake may not have changed. In addition, interactions between alcohol, illicits, other drugs and medicines, particularly opioids and sedative hypnotics, can increase the risk of falls and other injuries.

Greater life expectancy, increased disposable income and life changes (such as new patterns of socialising, retirement, bereavement or social isolation) may also contribute to increased risk. Other factors contributing to increased risk include:

• Increased opioid and sedative/hypnotic use among older Australians
• Major advances in preventive and curative health care and drug treatment which have increased longevity and duration of exposure to potentially harmful drug use.

As increasing numbers of older people seek treatment for their AOD problems, many will have complex physical and mental health comorbidities. Common mental health comorbidities include:

• Depression
• Anxiety
• Confusional states
• Sleep problems
• Post-traumatic stress disorder
• Drug-induced psychosis
• Self-harm
• Dementia (3)

Common physical comorbidities include:

• Injuries related to falls and trauma
• Cardiovascular problems
• Liver diseases (eg fatty liver, fibrosis, infective, non-infective hepatitis and cirrhosis)
• Blood borne diseases
• Irritable bowel syndrome and incontinence
• Dietary deficiencies, diabetes, malnutrition and pancreatitis
• Overweight and obesity
• Seizures and neuropathy
• Cancers (particularly mouth, oesophagus, throat, liver and breast) (3-5)

Older injecting drug users, in particular, may face challenges related to poor physical and mental health, housing and financial issues. These challenges can be further compounded by discrimination, the cost of pharmacotherapy, involvement in criminality to purchase illicit drugs, social isolation and family problems. (6)

These trends will have substantial implications for the provision of AOD prevention and treatment services in Australia. In particular, services will need to:  

• Be relevant, flexible, holistic and responsive to the individual needs of older people
• Offer age-specific, supportive, non-confrontational programs that build or rebuild clients’ self-esteem and focus on coping with depression, loneliness and loss
• Operate at an appropriate pace using evidence-based approaches
• Have staff members who are interested and experienced in working with older adults
• Create linkages with medical services, aged services and other settings for referral into and out of treatment, as well as case management to meet client’s comorbidity needs
• Provide equity of access (ie ensure that services for older people are given the same priority as other groups and are physically accessible to older people) (4,7,8) 

There is also an ongoing need for comprehensive workforce development approaches, to ensure that practitioners fully understand the unique needs of older people with AOD problems, possess the requisite skills to address these needs, and are supported to do so. (7)

References

1. Australian Bureau of Statistics. Population by age and sex, australian states and territories Canberra: Australian Bureau of Statistics; 2011.
2. Gossop M. Substance use among older adults: a neglected problem. Lisbon, Portugal: European Monitoring Centre for Drugs and Drug Addiction; 2008.
3. Royal College of Psychiatrists. Our invisible addicts: First report of the older persons' substance misuse working group of the Royal College of Psychiatrists. London: Royal College of Psychatrists; 2011.
4. Substance Abuse and Mental Health Services Administration. Substance abuse among older adults: Treatment Improvement Protocol (TIP) Series, No. 26. Rockville, MD: Substance Abuse and Mental Health Services Administration; 1998.
5. Hunter B, Lubman D. Substance misuse: Management in the older population. Australian Family Physician 2010;39(10).
6. Kelsall J, Parkes P, Watson M, Madden A, Byrne J. Double Jeopardy: Older injecting opioid users in Australia. Canberra: Australian Injecting and Illicit Drug Users League; 2011.
7. DrugScope. It's about time: Tackling substance misuse in older people. London: DrugScope; 2014.
8. Schonfeld L, Dupree L. Treatment approaches for older problem drinkers. Substance Use & Misuse. 1995;30(13-14):1819-42.