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While teen drug use continues to decline, it is the baby boomers who are suffering the greatest losses from substance abuse, and whose plight is largely overlooked by policy makers.
by Richard A. Sherer
America appears to be winning its war on substance abuse. However, some critics are concerned that we may be losing-or not even recognizing-a broader front in the war. Drug abusers today are more likely to be in their mid-30s to mid-50s or 60s. The consequences include increased drugrelated deaths and increased crime rates and arrests in the adult population.
In December, the Office of National Drug Control Policy reported a sharp drop in methamphetamine and steroid use among young people since 2001. They also found that the number of teenagers using illicit drugs had decreased by 700,000 during a 4-year period. The office summed it up by noting that, Overall, teen drug use continues to decline.
While these findings are unquestionably positive for the younger generation, it is the baby boomers who are suffering the greatest losses from substance abuse, and whose plight is largely overlooked by policy makers.
There is a generational bias going on, declared Mike Males, PhD, a lecturer in sociology at the University of California's Santa Cruz campus. Of 3700 drug deaths in California during 2003, only 51 were [in people] under the age of 20. Consistent with this trend in drug-related deaths, the Drug Addiction Help Line, a referral service, reported that the average age of a person likely to die of a drug overdose was 43 years in 2005, up from 32 years in 1985 and 22 years in 1970.
According to Males, The authorities have refused to deal with this issue. I think there are several reasons for this: For one, the war on drugs historically has gone after out-groups-minorities, immigrants, youth. We are unable, for political reasons, to deal with drug abuse problems among mainstream populations. Feared drugs were tied to feared populations, as an article in Scientific American said a few years ago.
The statistics are forcing that attitude to change. In 2003, DAWN, the Drug Abuse Warning Network of the Substance Abuse and Mental Health Services Administration (SAMHSA), reported that decedents aged 35 to 54 years accounted for more than half of the drug misuse deaths in 30 metropolitan areas, and three fourths of such deaths in Detroit; Milwaukee; and Washington, DC. Persons this age accounted for fewer than half of drugrelated deaths in only 2 metropolitan areas, both of which were in Utah. The fatality rate for this group exceeded 400 deaths per 1 million population in Albuquerque, Baltimore, and Salt Lake City, and 300 per 1 million in an additional 5 metropolitan areas, as well as the states of New Mexico and Utah.
In Washington, DC, the greatest number of drug deaths-76-occurred in 2004 among persons aged 35 to 54, according to Erin Artigiani, deputy director for policy at the Center for Substance Abuse at the University of Maryland, College Park. The next-highest was the over-55 group, with 16 deaths. The 21- to 34-year age group had only 12 deaths, and only 1 person under 21 died. Artigiani added, That's nothing unusual. We don't usually see many people under 21. Mostly, it's the older users-those with the longest history of drug use, and who are using harder drugs.
DAWN's interim estimate of emergency department (ED) visits nationwide for the third and fourth quarters of 2003 reaffirms the point: 35- to 44- year-olds led all other age groups in ED visits for every category of illicit drug use. Combined with the 45- to 54- year age group, they accounted for 53% of visits for cocaine use, 48% of heroin cases, 31% of marijuana cases, and 32% of cases involving stimulants.
I'm surprised the numbers have escaped attention this long. How did it get to the level it did with no notice? It's really a remarkable information breakdown, Males said. These numbers are not generally picked up in the popular press, added Artigiani. People usually look for the heart-wrenching stories, the young person who lost his or her chance at life. Emergency room doctors and counselors are well aware of the older sector of drug users.
A variety of substances involved
Keep in mind that the large majority of drug-related deaths involve more than one substance, said Leah Young, a spokesperson for SAMHSA. Look at the mortality report for 2003. The vast majority of reported deaths had more than 1 substance in the body. It's hard to know if they were synergetic, or if just one substance was responsible for the death. With older individuals, you also may have prescription drugs involved. Many people take more than 1 of them, and continue using alcohol and smoking marijuana. You have to ask, 'What killed them?'
Males pointed out that the body becomes less tolerant as the drug becomes more concentrated. But you also have a new population that's taking up hard drugs in later years. Kids are using milder drugs, like marijuana. Ecstasy use has now subsided. These are much more forgiving than harder drugs like heroin, cocaine, methamphetamine, or whiskey. You're also seeing stronger drugs, like OxyContin, which is practically the same as buffered heroin, turning up quite a bit among people who do not have histories of serious drug abuse. This should have been studied for 20 years. It's inexcusable that we don't know more about it at this point.
Artigiani notes that many of the deaths in Washington, DC, involved cocaine. We also saw a lot of analgesics. In other parts of the country, you might see a lot more deaths from methamphetamine, for instance. We did see a couple of deaths in DC from oxycodone, the active ingredient in OxyContin. There was 1 from hydrocodone, some related to codeine, a couple related to antipsychotics and antidepressants.
The rise in middle-aged drug use parallels an increase in depression among the baby boom generation. One 2005 study found that the highest risk of major depressive disorder was among adults aged 45 to 60 and that more than 57% of patients with major depressive disorder suffered from comorbid alcohol or drug use. The average depressed patient is about 40 years old, noted Kenneth B. Wells, MD, MPH, professor of health services at the University of California, Los Angeles School of Public Health.
The widespread abuse of drugs by adults in their 40s and 50s has far-reaching consequences for both health care and law enforcement efforts. We're in the midst of a middle-aged crime scourge that also cannot be discussed. We're seeing huge eruptions in crime and arrests of middle-agers nationally and in California, said Males, pointing to statistics showing an increase in convictions among adult Californians, from 84,323 in 1975 to 225,217 in 2004. We have to find ways to deal with this drug problem, he said. Locking them up doesn't solve it. There's a 70% recidivism rate.
It's important to address multiple things in any drug strategy, Artigiani emphasized. We have to be active in prevention; the best thing is to stop people from starting at all. We also need to be able to deal with people who are using drugs now, in terms of treatment resources, housing, child care-a whole range of services. In addition, we need to keep law enforcement involved, so they know what the current trends are and deal with the people who are using the drugs.
The nature of the problem is changing, said Joseph C. Gfroerer, director of the division of population surveys for SAMHSA. Our treatment programs and policies need to take that into account. We have to consider the need for specialized programs or the expansion of current programs. We're looking at the kinds of issues that are different, taking into account other health problems as well as family issues that require special treatments and interventions.
Gfroerer said that it is wrong to focus too heavily on the baby boom generation alone. The cohorts right after the baby boomers have continuing high rates of drug use. The problem is not going to end with the baby boomers, because the next generation also has high rates of use.
Gfroerer and colleagues recently completed a study of the treatment needs of middle-aged persons projected for the year 2020, based on such predictive factors as the early use of marijuana. According to their findings, the overall number of illicit drug users is projected to increase from 1.6 million in 1999 to 2001, to 3.5 million in 2020. (This estimate is based on increases in population and drug use from 2.2% to 3.1%, a 41% increase.) Distribution by race/ethnicity will not change radically, but the proportion of persons in their 50s will decline from 74% to 51%, while representation of persons in their 60s-men and women currently in their 40s-is expected to increase from 14% to 37%.
The consequences of the shift in use to older adults will present some challenges to health care providers. As Gfroerer's group noted in an article published online November 8, 2005, in Annals of Epidemiology: Key to understanding the impactof potential increases in drug usein older adults will be research onthe effects of illicit drugs on theaging brain in terms of both chronicand acute effects. Although thistopic has received little attention,Bartzokis et al showed that cocaineaddicts have increases in thenumber of white-matter lesionswith age. In addition, pharmacokineticsand pharmacodynamicsshift in older individuals, who typicallymetabolize drugs moreslowly than younger persons. Inaddition, the brain may be moresensitive to drug effects as individualsage. Thus, drug intoxicationand residual effects may differin older persons, affecting thecognitive and motor functioningnecessary for such complex behaviorsas driving and possibly simplertasks of daily living. Chronic andacute drug effects in aging andelderly persons may exaggerate thenormal slowing of reaction timesand other physical functions,increasing the risk for falls, accidents,and other safety hazards.Finally, illicit drugs and pharmaceuticalsused without a physician'sdirections may interact withprescribed medications, causingunanticipated and potentiallyharmful consequences or diminishingthe effectiveness of neededmedications.
Males sees the urgent need for action to cope with this shift in priorities. First, we've got to admit that there is a problem, he said. The current approach to the war on drugs does not stem this problem. It is clear that prison doesn't work. In talking to treatment personnel, it's very different to treat an aging drug abuser. It's not as expensive as imprisoning him, but it's difficult. We'll need to make a radical reinvestment from prisons to innovative therapies designed to deal with aging users. It will take a wholesale attitude change. This generation of drug abusers, after causing tremendous damage, is going to die off. We have to ask ourselves, Have we set the stage for the next generation of users?