Introduction
There are several reasons why the topic of older substance misusers is of growing importance. Polypharmacy due to prescribed medication and self-medication with over-the-counter drugs, thus increasing the risk of adverse drug interactions as well as higher illicit substance use among those born between 1946 and 1964 (baby boomers), compared with previous generations, is likely to continue. In addition, there is under-diagnosis or mis-diagnosis of substance misuse since the older population present with several (sometimes atypical) co-morbidities. Finally, there is stigma and prejudice against older people and drug addicts having the right to treatment.
According to the British Crime Survey 2008/2009, 0.1% of adults aged 16–59 years reported using heroin, methadone (and opiates overall) in the last year.Reference Hoare9 The statistics from the National Drug Treatment Monitoring Service (NDTMS) show that the number of people in structured treatment in England doubled between 1998/1999 and 2005/2006.12 During 2004/2005, 8% were older people (45 years old or over) and most were dependent on opiates. While the number of people coming into treatment has fallen across all age groups, it has increased in the over-40-year-olds.20
At present, very little is known about the psychosocial profile of older heroin-dependent patients in terms of characteristics. Heroin use, particularly injecting drug use, is also associated with considerably higher mortality rates (12–22 times greater) than the general population, with overdose being the most likely cause of death.Reference Frischer, Goldberg, Rahman and Berney7, Reference Oppenheimer, Tobutt, Taylor and Andrew21, Reference Oppenheimer, Tobutt, Taylor and Andrew24.
Methods
Retrospective examination of case records of older (age 45 and over) patients attending a specialist adult addiction treatment service in Stoke on Trent were illuminating. The case notes were selected by identifying the twenty oldest patients receiving out-patient pharmacological treatment, i.e. methadone or buprenorphine for opiate dependence, using a computerized database.
Findings
The psychosocial characteristics of the typical older heroin-dependent patient in the UK are summarized in Box 1.
Box 1. Characteristics of older heroin-dependent patients
For the first time, the psychosocial characteristics of the older heroin-dependent patient in the UK are established. The profile is of a white Caucasian male. He left school with a very basic education and was involved in criminal activity from a young age. As a teenager, he used nicotine, alcohol, cannabis and amphetamines. Having formed a relationship in his early twenties, he had one or two children, whilst being employed in an unskilled job or an apprenticeship. By his late twenties he had been exposed to heroin, initially smoking it, but within a year beginning to use intravenously in addition to other illicit substances. Several hundred pounds per week was required to fund his habit: his criminal activity increased dramatically or all his earnings would be used. By his late thirties he would be single, his partner having divorced him or left him. By his forties he would be living in a hostel, council house, or with his parents. At this point his physical condition would have started to deteriorate and he would have memory loss and depression. While continuing to smoke nicotine and cannabis, he would have limited access to veins for intravenous heroin, so would smoke increasingly, and would either be misusing alcohol or would be abstaining completely. With decreased physical activity, his criminal activity would be on the decline, so it would be increasingly difficult to fund his heroin habit. He would enter treatment for heroin dependence again, having tried several times in the past. Once referred for treatment he would be prescribed methadone as a preferred choice and would remain in treatment for several years, but would still use one or two bags of heroin once a week. He would then start to use benzodiazepines and codeine or dihydrocodeine for the pain from a chronic musculoskeletal problem caused by injury.
Demographic data
There were 20 patients aged 45 or over receiving treatment for heroin dependence, which constitutes 4% of the total number of patients receiving prescriptions. The mean age of the cohort was 48.3 years (range 45–55 years). The ethnicity was 95% white British. Only one patient was female, while one male was born abroad and 16 were born in Stoke on Trent. Eighty-five per cent were single: 50% were divorced or separated after the age of 35. Eighty per cent had at least one child.
Education and employment
Educational attainment among the cohort was poor: 65% had left secondary school without passing a single O-level, and only one patient had gone to university (but left without graduating). The rest of the cohort had achieved between four and nine O-levels, and one patient had an engineering diploma. Ninety per cent were unemployed, while 10% were employed as skilled workers. One in ten had never worked and 20% had been employed for less than 3 years during their lives.
Social circumstances
Current accommodation varied: 50% were renting a room or living in council property; 28% were living in their parent's home; 17% were living in a hostel; for 5% accommodation was unknown or not recorded.
Substance misuse history
The typical age first exposed to heroin was 29.8 years (range 16–46 years; SD = 8.8) and the average length of heroin use was 18.5 years (range 6–38 years; SD = 8.7). Only three had never injected heroin, and 53% of patients had started injecting within 1 year of exposure to heroin, at an average of 30.6 years (SD = 9.2). In at least 20% of cases a major life event occurred prior to using heroin (e.g. subarachnoid haemorrhage, the loss of a newborn child, divorce). Seventy-five per cent of the cohort self-reported past, and 55% current, use of cannabis. Fifty per cent reported using crack cocaine in the past: 35% produced urine samples that were positive for cocaine/crack. Amphetamines had been used by 60% in the past, but none reported current use or tested positive whilst in treatment. None reported ever using ecstasy. Hallucinogens had been used by 20% in the past, but none reported recent use. Urine samples were positive for benzodiazepines in 35% of patients while, during treatment, 10% of patients were prescribed benzodiazepines by a medical practitioner. General practitioners prescribed opiate analgesics in 10% of cases whilst the patient was still on methadone or buprenorphine. Ten per cent of patients bought street dihydrocodeine. In the 15 case notes where it was documented, all of the patients had a current and past history of nicotine use, varying from 4 to 30 cigarettes daily. Although current alcohol consumption was not documented in 20%, 25% were known to be misusing alcohol (drinking more than 21 units/week), but 56% abstained from alcohol completely. Alcohol had been misused in the past by almost half (47%).
Criminal activity
Only 10% had not been involved in or convicted of criminal activity. At least 40% were involved with the police in their teenage years; one patient was first involved at the age of eight. Sixty per cent had received custodial sentences and 25% had had more than five custodial sentences, involving burglary, fraud, shoplifting and drug dealing. The only female patient in the cohort had been convicted of soliciting and drug dealing.
Psychiatric history
During the course of their lifetime, 40% of patients had a diagnosis of depression, 20% had a diagnosis of anxiety disorders, and 10% had a diagnosis of personality disorder. Only 16% of patients had a family history of mental illness; in all cases it was of depression. General practitioners prescribed a range of medications: antidepressants (10%), zopiclone (15%), antipsychotic medication (5%), and methylphenidate (5%). Family history (usually a sibling) of opiate abuse was present in 22% of patients. Parental history of alcohol abuse was present in 17% of cases. In 60% of cases there was no family history of substance abuse. A history of self-harm (in all cases an overdose) had been documented in 42% of patients. In 63% of those that had self-harmed, the act had been documented as the intention to commit suicide with overdose. Memory loss problems were reported by 25% of patients, though the mini-mental state examination was documented in only one case.
Treatment outcome
Mean dose of methadone was 51 ml (range 25–94 ml) and treatment duration in half the cohort was longer than 3 years. Urine screening for illicit drugs was carried out on 18 patients, as two were only just starting treatment. Of these, 39% produced consistently positive urine samples for opiates over the treatment period, which varied between 9 months and 3 years. Thirty-nine per cent of patients had a varying pattern in the percentage of opiate-positive urine samples during the treatment episode. Four patients (22%) showed a gradual decline in illicit use, eventually testing negative for opiates. Of the patients who had been using intravenous heroin at the start of treatment, 87% stopped whilst in treatment. The patients that continued to use heroin (50% of the group) did so mainly by smoking it. In all cases the reported quantity of heroin consumed per week decreased. This was mirrored by a reduction in cost from £300 to £20 per week. On the whole, patients were retained in treatment, which led to some improvement.
Comment
To our knowledge, this is the first time that the psychosocial characteristics of the older heroin addict in treatment have been described. Their needs do not appear to be comprehensively met by the current service constellation in that there is little co-ordinated psychosocial intervention or support for social or physical health difficulties. This is despite the finding that older people do respond to treatment if it is accessible and available.Reference Moy, Crome, Frisher and Crome14
The study had limitations in that the cohort comprised only 20 patients. The Department of Health defines the older patient as anyone over 40 years old.5 Had our threshold been over age 40, the cohort would have been 50 patients, including 11 females. Lack of standardization of assessment and record keeping was a further difficulty in monitoring care accurately.
Seventeen (85%) of the patients had injected heroin. This is double the rate of heroin users nationally who present for treatment reporting injecting drugs.5 This group were polydrug users who started using substances in their teenage years. Although the number of illicit substances used had decreased in older age, they continued regular use of cannabis and heroin. Cocaine and crack were used by 35% of the group occasionally, but only one patient (5%) was a regular user. Benzodiazepines were increasingly misused as the cohort aged. Individuals who had stopped using heroin were likely to substitute with benzodiazepines. This substantiates increased risk of benzodiazepine misuse in methadone maintenance treatment.Reference Barnas, Rossmann, Roessler, Reimer and Fleischaker1, Reference Simoni-Wastila and Yang22 Nine out of ten general practitioners and specialist addiction prescribers thought that benzodiazepines were being misused in Stoke on Trent, Telford and Shropshire.25 Alcohol was generally misused by half the group in their younger years and, at an older age, a quarter were still misusing alcohol. The major concern is the potentially lethal combination of methadone, benzodiazepines and alcohol.
A large proportion of the group (25%) complained of memory problems, which were not assessed or investigated further in the majority of cases. Recent observations have shown heroin users to have evidence of Alzheimer's-like histopathology, i.e. accumulation of β-amyloid precursor protein.Reference Buttner, Rohrmoser, Mall, Penning and Weis3 It is, therefore, important that these patients are fully assessed and investigated for memory problems. Heroin use had assumed a primacy in the lives of these individuals at the expense of relationships, jobs, housing and health, and they were increasingly susceptible to depression. The prevalence of depression was 40%, which is much higher than the national average point prevalence for major depression (2.1%) and anxiety and depression (9.8%) in the 16–65 age group.15 Self-harm was high in this cohort, presumably due to the high prevalence of intravenous use. That 63% of those who had overdosed had the intention of committing suicide is not surprising, given the prevalence of depression. A process of continuous self-harm risk assessment is, therefore, mandatory.
Further longitudinal research is needed to describe more fully the local, regional and national picture with regard to pattern of use and social background.Reference Firoz and Carlson6–Reference Gossop, Marsden and Stewart8, Reference Oppenheimer, Tobutt, Taylor and Andrew21 At present, none of the health policies and guidelines focuses on the specific care of older substance misusers.5, 16–19 This study has shown that older heroin-dependent patients have already developed a complex range of health and social issues, which will only increase in number and severity if not prevented or adequately managed in the early stages. The burden on health and social services will inevitably increase as this cohort survives into old age.Reference Hser, Gelberg, Hoffman, Grella, McCarthy and Anglin10, Reference Hser, Hoffman and Grella11 However, since there are grounds to be optimistic about treatment outcome, treatment, aligned with education, research and policy initiatives are key to change.Reference Bartram, Crome, McGrath, Corrado, Allen and Crome2, 13, Reference Moy, Crome, Frisher and Crome14, 23
Conflicts of interest
The authors have no conflicts of interest to declare.
Acknowledgements
This project was undertaken as a special study option during undergraduate medical studies. We would like to thank Corrina Knight for expert secretarial assistance. The Edward Myers Centre provided the research base for this project and their support is acknowledged.
