CHARACTERISTICS OF OLDER ADULTS WHO USE ILLICIT DRUGS IN FINLAND
Shusma Lama Master’s Thesis Public Health School of Medicine Faculty of Health Sciences University of Eastern Finland January 2018
LAMA S. Characteristics of older adults who use illicit drugs in Finland.
Master’s thesis. 51 pages
Instructors: Jussi Kauhanen, MD, PhD, Prof., Sohaib Khan, MBBS, MPH, PhD, Assist. Prof.
January 2018
Key words: illicit drugs, old age, treatment-seeking
CHARACTERISTICS OF OLDER ADULTS WHO USE ILLICIT DRUGS IN FINLAND Substance abuse by older adults is an increasingly common problem worldwide, which includes both legal and illicit drugs. Most of the literature focuses on alcoholism and misuse of prescription medication. Older adults using drugs have unique needs and problems from the drug users of other age groups. This study describes the characteristics of older drug users who visited Helsinki Deaconess Institute (HDI) between 2001 and 2008.
A cross-sectional analysis was done on baseline data of 2526 clients; out of which 2501 were below 49 years and 25 were aged 50 years and above. The data was collected by trained clinicians through interview using structured questionnaire at the first visit of the clients at HDI. Fisher´s Exact test was used to test the differences in categorical variables whereas Mann- Whitney test was used for continuous variables.
There were higher number of older males using drugs than females. Most of the older study participants were not homeless, and their main source of income was unemployment benefits and pension. Polydrug use was common in both young and old drug users. Oral stimulants were most often used as primary drug by older adults, whereas intravenous opiates were the primary drugs in younger adults. Hepatitis C was prevalent in both age groups and there were no significant differences in health problems between these age groups.
The study shows that drug abuse exists as a public health problem in Finland among older adults, although the numbers of those seeking treatment are fairly low. However, further research is needed in this area, using larger sample sizes and more detailed and in-depth analyses.
I am grateful to my respected supervisors, Prof. Jussi Kauhanen Director, MPH, Institute of Public Health and Asst. Prof. Dr. Sohaib Khan for the valuable suggestions and encouragement throughout the study period. I am sincerely indebted to Ifeoma N. Onyeka for her guidance and support in this study.
I wish to express my deepest gratitude to Annika Männikkö, International Coordinator, Institute of Public Health and Clinical Nutrition and all my respected teachers for their kind cooperation and encouragement throughout my study period. I am thankful to Kimmo Ronkainen, computer expert (Atk-asiantuntija) of Institute of Public Health and Clinical Nutrition, University of eastern Finland.
I am enormously grateful to Helsinki Deaconess Institute (HDI) for granting permission to use HUUTI dataset. Without their assistance, this study would not be possible.
I am very thankful to my family and friends, especially Ayushka Shrestha and Sushil Basnet who have supported me and helped in all the possible way to complete this study.
1. INTRODUCTION 9
2. LITERATURE REVIEW 11
2.1. Substance abuse 11
2.2. Substance abuse in older adults 11
2.3. Patterns of illicit drug use in older adults 12
2.3.1. Early onset users 13
2.3.2. Late onset users 13
2.4. Risk factors of substance abuse in older adults 13
2.5. Health consequences of substance abuse 15
2.6. Effects on physiological and psychological health 17
2.7. Barriers to identification and treatment of substance abuse problem in older adults 17
2.7.1. Age-based discrimination 18
2.7.2. Lack of awareness 18
2.7.3. Knowledge of clinicians and health care providers 19
2.7.4. Comorbidity 19
2.7.5. Gender issues 20
2.8. Logical framework of the study 21
3. OBJECTIVES OF THE STUDY 23
3.1. General objectives 23
3.2. Specific objectives 23
4. METHODOLOGY 24
4.1. Study design 24
4.2. Study setting 24
4.2.1. Study area 24
4.2.2. Study participants 24
4.2.3. Inclusion criteria 24
4.3. Data collection 25
4.3.1. Data collection tools 25
4.3.2. Data collection process 26
4.4. Data analysis 26
4.5. Ethical considerations 27
5. RESULTS 28
5.2. Differences in drug using pattern 31
5.2.1. Primary drug 31
5.2.2. Secondary drug 31
5.2.3. Frequency of drug use 32
5.2.4. Number of drugs used 33
5.3. Differences in health problems 34
5.4. Treatment seeking pattern among older participants 36
5.5. Differences in treatment seeking 37
6. DISCUSSION 39
6.1. Discussion of findings 39
6.2. Validity and reliability of study 41
6.3. Strengths and limitations of the study 42
6.4. Implications 42
7. CONCLUSION 44
8. REFERENCES 45
Table 1 Risk factors for substance abuse in the elderly (Atkinson 2002). 15
Table 2 Variables used in the study 25
Table 3 Socio-demographic characteristics of older and younger participants 28
Table 4 Primary drug and its mode of administration 31
Table 5 Secondary drug and its mode of administration 32
Table 6 Frequency of drug use (times/week) 32
Table 7 Number of drugs used 33
Table 8 Differences in medical problems in younger and older adults 34 Table 9 Differences in psychological problems in younger and older adults 35
Table 10 Differences in treatment seeking 37
Figure 1 Logical framework of the study 21 Figure 2 Number of patients (50 years and above) seeking treatment during 2001-2008 36
DSM Diagnostic and Statistical Manual of Mental Disorders EuropASI European Addiction Severity index
HAV Hepatitis A Virus HBV Hepatitis B Virus HCV Hepatitis C Virus
HDI Helsinki Deaconess Institute
HIV/AIDS Human Immunodeficiency Virus / Acquired Immuno-Deficiency Syndrome HUUTI Huumehoitotietokanta
IV Intravenous
MDMA 3,4-methylenedioxy-N-methylamphine SPSS Statistical Package for Social Sciences STIs Sexually Transmitted Infections TDI Treatment Demand Indicator protocol USA United States of America
WHO World Health Organization
1. INTRODUCTION
Europe has been an important market for drugs, including both domestic as well as drugs trafficked from other regions, which accounts for 1.25 million drug law offences. The levels of lifetime use of drugs differ between the countries. Cannabis has the highest rate of lifetime users (78.9 million), followed by cocaine (15.6 million), amphetamines (12.0 million) and 3,4- methylenedioxy-N-methylamphine (MDMA) (12.3 million), among the adults aged 15-64 years (EMCDDA 2015).
Although substance abuse is considered as the problem of youth, the misuse and abuse of illicit drug among older adults, aged 50 and above, have become a growing problem (Simoni-Wastila and Yang 2006). Considerable number of studies and data are available on the epidemiology and treatment of alcohol abuse among older adults (White et al. 2011), however, illicit drug abuse has been a neglected issue in this age group (Roe et al. 2010). It is estimated that in U.S, people aged 50 years and over who need treatment for drug abuse problem will increase from 1.7 million to 4.7 million by 2020 and that in Europe their number will be doubled between 2001 and 2020 (Benyon 2009).
There are several factors that affect substance abuse by older population. Gender, loss of spouse, social isolation, history of substance abuse or mental health disorders and exposure to prescription drugs with potentials for abuse are some of them (Simoni-Wastola and Yang 2006). Older adults have greater sensitivity and intense response to illicit drugs compared to younger adults (Blow et al. 2002). Specific approaches are needed to address their problems with consideration of the unique physical, emotional and psychological effect of ageing.
Since there has been rising concern about the risk of substance abuse among older adults, it may be necessary to characterize and identify problems and needs unique to this particular subgroup. Attention has been more focused on alcohol use among older adults, because it interacts with normal medication (Immonen et al. 2013). Although illicit drug use is an obvious problem among older adults (Wu and Blazer 2011), recent systematic review shows that only few research studies have focused on this area (Rosen et al. 2013).
In Finland, there have been very few studies about older persons who use illicit drugs. The general aim of this study is to describe the characteristics of older drug users who sought
treatment in Helsinki Deaconess Institute (HDI) between 2001 and 2008. The study also explores the differences in sociodemographic characteristics, mental and psychological health, and treatment seeking pattern between younger and older drug users in Helsinki.
2. LITERATURE REVIEW 2.1. Substance abuse
Substance abuse is a serious public health problem around the world. It not only affects physical and mental well-being of the abusers, but also adds increased costs to families and society (Aartsen 2011).
World Health Organization has referred substance abuse as "harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs". Repeated use of psychoactive substances may lead to dependence syndrome which is cluster of behavioral, cognitive and physiological phenomena (WHO 2015).
2.2. Substance abuse in older adults
Substance abuse is a hidden but emerging problem in older adults (Wu and Blazer 2011).
According to WHO (2015), there are at least 15.3 million older people in the world who have drug use disorder.
The number of older adults, aged 50 and above, who have a substance abuse problem is rapidly increasing in United States and Europe (Benyon et al. 2009). In Europe it is estimated that their number will be doubled between 2001 and 2020 (Gossop and Moos 2008). A study by the U.S.
Department of Health and Human Services shows that among adults aged 50 to 59, the rate of illicit drug use has increased from 2.7 percent in 2002 to 6.3 percent in 2011 (SAMSHA 2012).
Many developed countries of world, including those in Europe, and in North America have a pronounced increase in ageing population (Gossop and Moos 2008), owing to improved health and longevity (Wu and Blazer 2014). Due to increase in life expectancy, number of Europeans aged 65 or above has grown three-fold during the 20th century (EMCDDA 2008). It is estimated that more than one third of Europe´s population will be aged 60 or over by 2050 (Gossop and Moos 2008).
Considerable number of studies focused on epidemiology and treatment of alcohol abuse problem are available (White et al. 2011), but the use of illicit drugs by this population is an
understudied area. Because of this, substance abuse in older population is poorly documented (Benyon et al. 2007, Chait 2010).
Among older adults in the United States, marijuana has been the most commonly used illicit drug, followed by prescription drugs used non-medically, and cocaine (NSDUH 2006). The increasing trend in use and misuse of illicit drugs among this population, partially reflects the aging of baby-boom cohort (people born between 1946 and 1964) and the higher rates of substance abuse, especially marijuana, in this generation (Gfreorer et al. 2003).
In a study from northwest England, Benyon (2007) showed that the number of individuals of both gender aged 50-74 years, who sought treatment for drug abuse problem has increased.
Similarly, drug users with syringe exchange programs, aged 50-74, increased from 0.2% in 1992 to 3.8% in 2004.
A study from Australia (Lynskey et al. 2003), shows how the prevalence of substance use typically decreases steadily with increase in age. There is, however, a minority of individuals aged 65 and over who do have these disorders. The reasons for this decreasing prevalence can be related to lack of self-reports because of cognitive decline, problems in distinguishing substance-related problems from health problems and finally, reluctance in admitting the problem. Similarly, increase in mortality among the individuals with lifetime history of substance abuse can also contribute the steady decline. The numbers are low in part also because there are no specific programs or interventions that are aimed to encourage older persons to participate in treatment (Benyon 2007).
Due to lack of standard definitions, under-sampling of older population groups and variations across settings, there is only scarce information about the illicit drug use among older adults (Farkas et al. 2015). Thus, although illicit drug use among older adults is thought to be rare, the numbers are estimated to increase in future (Simoni-Wastalia and Yang 2006; Wang and Andrade 2013).
2.3. Patterns of illicit drug use in older adults
Roe et al. (2010) has described two types of long-term patterns of substance abuse in elderly population, as “early-onset” and “late-onset” users.
2.3.1. Early onset users
This group includes individuals who start the abuse of substance at a young age and continue in the latter stage of life. In other words, they have a long history of substance abuse.
Onset of substance abuse at young age is related to many factors, such as socioeconomic class, race and ethnicity, gender, availability of illicit drugs and life story (Taylor and Grossberg 2012). These factors can also affect the continuing abuse of substances in later stage of life.
2.3.2. Late onset users
This group includes those individuals who initiate substance abusing habit as elders. This is a less common pattern, accounting for less than 10% of substance abuse among elders (Wu and Blazer 2011). Same factors that are associated with onset of substance abuse in young age, are found to be prompting abuse of substance in old age, too. But certain circumstances, such as involvement in criminal behavior, exposure of drug use at home, and a new onset of mental diseases are less likely to be relevant in old age (Taylor and Grossberg 2012).
2.4. Risk factors for substance abuse in older adults
Aging is often related with a range of social, psychological and physical health problems, many of which may be risk factors for illicit drug use (Gossop and Moss 2008). Drug using pattern varies with the diverse cultural norms, values and social contexts of aging (Boeri et al. 2008).
2.4.1. Socioeconomic and psychosocial factors
Socioeconomic status influences the subjective experience of aging. The lower the socioeconomic status, the more rapid is the life events that lead to substance abuse. This combined with factors such as violence, racial discrimination, substance abuse and disparities in health care facility projects increase in shorter life span of African American (Pope et al.
2010). Financial problems due to loss of job or retirement, loss of spouse and friends and social isolation are known causes for depression, which in turn may trigger the use of illegal substance in elderly (EMCDDA 2008; Benshoff et al. 2003).
2.4.2. Family history of drug abuse
Presence of family members with substance abuse problem, media images, and environment have been shown to be crucial factors for initiation of substance abuse amongst African- American baby boomers (Rosen 2004, Pope et al. 2010).
Most elderly illicit drug users have their first exposure to drugs in young age. The problem gets rare after the age of 25-30 years (Arndt et al. 2005), suggesting that those with previous history of drug abuse have higher risk of substance abuse in older age (Shah and Fountain 2008). Being female, African American and living with a partner having drug abuse problem are found to be associated with late onset of illicit drug abuse among elderly (Boeri et al. 2008).
2.4.3. Use of psychoactive drugs
Dependence on psychoactive drugs is also a matter of concern among elderly (Ashton 2005;
Voyer et al. 2009). Risk of non-medical use and dependence on these drugs is increasing due to excessive and inappropriate prescription of psychoactive drugs (Ashton 2005). Factors related with psychoactive drug dependence were being a woman, having cognitive impairment, panic disorders, suicidal ideations and inability to express need of help for emotional problems (Voyer et al. 2009).
2.4.4. Gender
Compared to men, women tend to start drug abuse at a younger age, but this also applies to cessation. Further, women are less likely to be involved in drug related criminal activities and have less access to illicit drugs compared to men. Men have higher predominance in substance abuse than women (Hartel et al. 2006).
2.4.5. Social isolation
Not getting enough support and loneliness increases social isolation in old age. This is experienced by old adults living in family as well as in elderly homes and residential care.
Various factors such as loss of spouse and/or friends, no children, living alone, deteriorating health, limited companionship and other life events, often lead to social isolation (Benyon 2010).
The risk factors associated with substance abuse among elderly population can be summarized in following table.
Table 1 Risk factors for substance abuse in the elderly (Atkinson 2002).
Predisposing factors Family history
Previous substance misuse/dependence Personality traits
Social traits Factors that may
increase substance exposure and consumption level
Gender (men: alcohol, illicit drugs; women: sedative hypnotics, anxiolytics)
Chronic illness associated with pain (opioid analgesics, cannabis), insomnia (hypnotic, drugs), anxiety (anxiolytics) Long-term prescribing (sedative hypnotics, anxiolytics) Care-giver over-use of medication (institutionalized elderly) Life stress, social isolation
Negative effects (depression, demoralization, anger) Boredom and disposable money
Factors that may increase the effects and abuse of potential of substances
Age-associated drug sensitivity (pharmacokinetic and pharmacodynamic factors)
Chronic medical illnesses
Other medications (drug-drug interactions)
2.5. Consequences of substance abuse in health
Aging itself brings many problems related to physical and mental health as well as social well- being of older adults (Immonen et al. 2013). Use of illicit drug combined with the age-related physiological, psychological and social changes produce detrimental effects, which result in higher morbidity and mortality in the aging population (Toress et al. 2011). Although there has been reportedly high number of old adults using illicit drugs, the knowledge and research addressing the health consequences and their well-being is still limited (Boeri et al. 2008, Rosen 2004).
As the demography of illicit drug using older adults have altered since 1970s, there is potential strain on the resources. Health problems of addicted individuals is aggravated by age related illness, social isolation and general physical decline, which require special medical approaches (Rosen 2004).
Older adults using illicit drugs have generally poorer self-rated health and negative health conditions with acute and chronic health problems. Drug abusing older adults, especially who use injectable drug, are particularly at risk of acquiring HIV/AIDS, other blood-borne diseases and sexually transmitted Infections (STIs) (Toress et al. 2011).
Drug use has been associated with earlier onset of diabetes and worsening of other age related diseases such as neurological diseases, respiratory diseases and cancer. Hallucinating or disorienting effect of drugs has increased the risk of fall and accidental injury, which is one of the major reason of disability and mortality in elderly (Benyon 2009, Roe et al. 2010).
Significant relationship has been found between falls and psychoactive drug use among elderly.
Injuries related to fall are a significant cause of hospitalization, nursing home placement, or decreased mobility among older adults, accounting for 40% of accidental injuries in this population (Benshoff et al. 2003).
Older adults have greater sensitivity to psychoactive substances. Interaction of these substances with alcohol or prescription medications can lead to acute and chronic medical and psychiatric preconditions (Blow et al. 2002). There can be negative effects on memory and cognition.
Complications can be seen when these substances are mixed with medications for physical health problems such as hypertension, diabetes, high cholesterol and sleep apnoea (Boddiger 2008).
Liver diseases and STIs, especially syphilis and gonorrhea, together with hepatitis C, was prevalent at significantly higher rates among the older adults (Toress et al. 2011). Use of marijuana, either medicinally or recreationally, poses unique risks in aging population including impairment of short-term memory, increased heart rate, respiratory rate, high blood pressure and increased risk of heart attack (Keurbis et al. 2014).
Malnutrition, weight loss, obesity and loss in mobility are also consequences of illicit drug use with direct effect on health (Roe et al. 2010).
2.6. Effect on physiological and psychological health
Substance abuse is known to cause physiological changes in the body, for example, risks for neurotoxicity and severe medical consequences, resulting from the altered neurotransmission of brain interacting with drug metabolism, pharmacokinetics and age-related changes in brain (Dowling et al. 2008; Simoni-Wastalia and Yang 2006). Psychoactive drugs are often prescribed to older adults. In many cases these drugs tend to be misused, leading to non-medical use or dependency (Wu and Blazer 2013).
Some psychiatric disorders, especially depression, have greater prevalence in older adults using illicit drugs (Chait 2010). If depression is undiagnosed and untreated, it may lead to disability, reduced quality of life, impairment and increased risk of suicide (Conner et al. 2010).
Alcohol and drug use patterns (for example, cannabis use and prescription medicine misuse) are often found to be concurrent with depression in old age (Schonfeld et al. 2010; Satre et al.
2011).
Common impacts of substance abuse on mental health of elderly includes memory loss, paranoia and changed mood conditions such as anger and anxiety (Roe et al. 2010).
2.7. Barriers to identification and treatment of substance abuse problem in older adults There exist distinct challenges in successful identification and screening of substance abuse problem in elderly population. The stereotype belief that drug abuse is problem with people of low income, might neglect to identify the people with substance abuse problem in middle and upper-class population (Benshoff et al. 2003).
Older adults using illicit drugs face societal challenges, which have direct consequences on their treatment seeking behavior. Some common areas of stigma experienced by old adults are drug addiction, use of psychotropic medication, depression, being client of methadone maintenance program, poverty, race and HIV status (Rosen et al. 2011). Absence of social
support and network in the traditional substance abuse treatment interventions is also one of the barriers for older adults to come forward and seek treatment (Smith and Rosen 2009).
2.7.1. Age based discrimination
Elderly people are less likely to be involved in criminal activities in contrast to young drug abusers, thus, are less visible in street drug scene, and may use others such as friends or family members to get drugs. Thus, they are often missed by the studies (Shah and Fountain 2008).
Younger adults with health problems are more likely to also get the underlying substance abuse diagnosed. In the case of older adult with similar comorbidity, a service provider may not look beyond the present problem. Because of the belief that older adults are less likely to have substance abuse problem, these problems are significantly more often ruled out during routine medical care (Curtis et al. 1989).
Family members and professionals may also fail to investigate the problems indicative of substance abuse disorder such as forgetfulness, emotional instability or physical illness, assuming that these are normal part of aging (Benshoff et al. 2003). Also, negative consequences of substance abuse such as absence from job, cannot be applicable to elderly people because of retirement (Shah and Fountain 2008).
2.7.2. Lack of awareness
Lack of awareness or denial of substance abuse among older adults, together with stigma in community, are further significant barriers in identification of substance abuse problem in elderly population (Benshoff et al. 2003). These stigma, shame or denial may be associated with generation, religion, gender culture or combination of many other factors (SAMSHA 2012). Professionals may be reluctant to ask elderly about illicit drug use, due to the fallacious belief that old people do not use drugs (Shah and Fountain 2008).
Older adults are very sensitive about stigma related to psychiatric disorders. Many find it easier to accept medical diagnosis rather than mental or psychiatric disorder. Older adults are less likely than younger ones to perceive their drug abuse as a health care problem, and thus do not frequently seek help from treatment programs (Weiss 1994, Nemes et al. 2004). Since opiates
are also used as prescription drugs, elderly and family members might not think that there is a problem if the medication is used for other reasons than those for which prescription was given.
2.7.3. Knowledge of clinicians and health care providers
Assessment criteria that are devised for younger people do not take account for older adults. In DSM, for instance, one of the criteria for substance abuse is “a failure to fulfill major role obligations at work, school or home”. This is not applicable in a case of older adult who is retired, does not have a job, or has few family responsibilities (Blow et al. 2002).
Many signs of substance abuse such as anxiety, memory loss, disorientation, and headaches correlate with the common signs of ageing. In addition, lack of day to day functioning, and decreased engagement on social activities are also taken simply as to be age-related consequences. Lack of reliable screening instruments and/or treatment methods limit the substance abuse diagnosis in the elderly (Taylor and Grossberg 2012).
There is a high possibility that substance abuse problems in older age group go undiagnosed.
Various other health problems predominant in this age group tend to overshadow the exploration of possible substance abuse. Furthermore, geriatric patients, like any other substance abusers, tend to hide the addiction from the physician (Taylor and Grossberg 2012).
Recently, concerns have been raised regarding training and education of physicians to address the problem of substance disorder in geriatric population (De Jong et al. 2016).
2.7.4. Comorbidity
Medical and psychiatric comorbidities pose a challenge in the identification and treatment of substance abuse in older adults. Neuropsychiatric disorders (for example, dementia, depression), sensory and cognitive impairment, lack of mobility and various other medical complications often tend to take away the attention of the health care professional from the underlying substance abuse problem in older adults, and can even lead to misdiagnosis. Other likely comorbid conditions associated with illicit drug use can be alcohol abuse or dependence (Lofwall et al. 2008), depression (particularly in women) (Blazer and Wu 2009b; Rosen et al.
2008), anxiety disorder (particularly among women) (Preville et al. 2008; Rosen et al. 2008;
Voyer et al. 2009) and chronic medical conditions or diseases (Voyer et al. 2009).
2.7.5. Gender
Not much is known of how gender associates with illicit drug use, and with treatment and recovery among the elderly (Hamilton and Grella, 2009). Benyon (2010) identified female gender, social isolation, depression and substance abuse history as risk factors for the elderly in developing substance abuse related disorder.
Hamilton and Grellla (2009) found that female focus group were more expressive about their experiences and the impact of heroin use on their families. Desire to restore their family relationships, especially with children, is among the major factors to seek treatment.
Female substance abusers have lower participation rate in treatment programs as compared to male counterparts. They also face increased likelihood of having their social support impeded or even experiencing violence from their partners (Greenfield et al. 2007). Such gender differences, seen in younger age groups, can continue into old age. Moreover, older female substance abusers may face more challenges than their younger counterparts in treatment seeking due to decreased mobility and other age-related health problems (Hamilton and Grella 2009).
2.8. Logical framework of the study
Figure 1 Logical framework of the study
Risk factors of substance abuse in older adults
• Socioeconomic status
• Family history
• Previous history of drug abuse
• Use of psychoactive drugs
• Gender
• Social isolation
Barriers to identification
• Age based discrimination
• Lack of awareness
• Knowledge of clinicians
• Comorbidity
• Gender
Increasing trend of drug use in older adults
Effect of drugs on older adults
Effect in physical health
• Impairment of memory
• Injuries due to fall
• HIV
• Hepatitis A, B and C
Effect in psychological health
• Depression
• Psychotic symptoms
• Suicidal thoughts
• Suicidal attemps
Significance of the study
The fact that older people are using illicit drugs is widely considered implausible, because of the common notion that it is a problem of younger people. A study by the U.S. Department of Health and Human Services shows that among older adults aged 50 to 59, the rate of illicit drug abuse has increased from 2.7 per cent in 2002 to 6.3 percent in 2011 (SAMSHA 2012). The effect of substance abuse is generally different in older adults than in younger adults. Aging brings about physiological changes in the body, which in turn decreases the capacity to metabolize substances such as alcohol and drugs. Therefore, older adults have increased sensitivity and decreased tolerance towards these substances. The signs and symptoms of substance abuse are mistakenly believed as being part of normal aging process or other illness.
Substance abuse problem in older adults is often missed by health care providers. Some health care providers do not know that substance abuse may be a problem in older adults, while some may misinterpret it with other medical conditions. In the effort to address the issue, this study aims at making a profile of older adults using illicit drugs in Finland.
3. OBJECTIVES OF THE STUDY 3.1. General objectives
To describe the characteristics of older adults who use illicit drugs in Finland.
3.2. Specific objectives
• To compare sociodemographic characteristics of older (≥50 years) and younger (<50 years) people who use illicit drugs
• To examine differences in drug use patterns between the older and younger age groups
• To identify differences in health problems between these two groups
• To assess changes in treatment seeking by older drug users between 2001 and 2008.
4. METHODOLOGY 4.1. Study design
This is a cross-sectional study based on epidemiological data from "Huumehoitotietokanta"
(HUUTI) consortium research project. It is the first large-scale longitudinal study of illicit drug abusers seeking treatment in Finland.
4.2. Study setting 4.2.1. Study area
The Helsinki Deaconess Institute (HDI) is a large urban drug abuse treatment center, where clients of all groups including family and close contacts can come and get treatment for alcohol and illicit drug abuse problems (Onyeka et al. 2012). The clients from the cities of Helsinki, Espoo, Vantaa and from the communities close to Helsinki are included in this study.
4.2.2. Study participants
HUUTI data includes 4817 study participants, aged 11-65 years, who sought treatment for drug abuse problem at HDI from January 31, 1997 to August 31, 2008. However, to minimize the amount of missing data for some variables of interest in this particular study, the study population was restricted to a subset of clients who attended HDI between 2001 and 2008.
During those years there were 2526 participants, who comprise the sample of this study.
4.2.3. Inclusion criteria
All the 4817 consecutive clients who sought treatment at HDI from 1997 to 2008 were included in the HUUTI study. For the purpose of this study, the participants were divided into two groups - older adults and younger adults. Out of 2526 clients, 25 were aged ≥50 years and 2501 were aged <50 years. The 50 years cut-off age is based on the groups of older adults categorized by United Kingdom Department of Health (DOH) (DOH 2001, pg. 3). This age cut-off has been used by many researches in the UK (Benyon et al. 2007; Benyon et al. 2009) and in the US (Gfroerer et al. 2003; Han et al. 2008).
4.3. Data collection
4.3.1. Data collection tool
Data collection for HUUTI study was done using structured questionnaire. The variables in the questionnaire were adapted from the European Addiction Severity index (EuropASI), the Treatment Demand Indicator Protocol (TDI), and other questions relevant for evaluation of treatment needs and monitoring of clients. EuropASI is an adaptation of the Addiction Severity Index (Fifth version), which is designed to provide basic information on a client prior, during and after substance abuse treatment (EMCDDA 2015). It includes general background information of the client, medical statues, alcohol\drug use, employment status, family and social relationships, legal status and psychiatric/psychological status. TDI, which contains questions about treatment contact, sociodemographic characteristics and drug use, was developed by the Pompidou Group of the Council of Europe (Onyeka et al. 2013).
Table 2 Variables used in the study
Categories Variables
Sociodemographic characteristics Age Sex
Home country Marital status Nationality Homeless Education Working
Health problems Hepatitis A
Hepatitis B Hepatitis C HIV
Psychotic Symptoms Suicidal thoughts Suicide attempts
Preferred drugs Drug 1 (Primary drug)
Drug 2 (secondary drug)
Categories Variables
Drug use pattern Number of drugs
Times/week during last month, drug 1 Times/week during last month, drug 2 Drug free month last year
Treatment seeking pattern Year of first visit to treatment center Guidance for treatment
In treatment elsewhere
4.3.2. Data collection process
At their first visit, clinicians interviewed each client to obtain socio-demographic information and self-reported history of drug use, employment/support, accommodation, medical/psychiatric disorders, family and social history, and legal issues. This was followed by designing treatment plans and assignment to treatment modalities according to the need of patients (Onyeka et al. 2012). Clients were asked about main reason for seeking treatment.
Questions about educational level, employment status and the main source of income at the time of interview were asked, and these data were used to assess social status. Homelessness was defined in terms of “the presence or absence of postal code/address”. To assess information on infectious diseases, the clients were asked whether they had been screened for HIV, Hepatitis A, Hepatitis B and Hepatitis C in the past. Further inquiries about psychosis and suicidal thoughts were made for assessment of their mental health (Onyeka 2013).
4.4. Data analysis
The Statistical Package for Social Sciences (SPSS) version 21 was used for statistical analyses.
The general characteristics of older adults who use drugs including their socio-demographic characteristics, primary and secondary drug, the drug using pattern and medical psychological problems were assessed for comparison with young drug users. Changes in treatment seeking pattern among older drug users between 2001 and 2008 were also analyzed.
The study findings were presented as proportions, means and standard deviations. Fisher´s Exact test was used to test the differences in categorical variables whereas Mann-Whitney test was used for continuous variables. Fisher´s test was chosen instead of Chi-square test (which requires large sample size). The level of significance was set at alpha (α=0.05).
4.5. Ethical consideration
The HUUTI study was approved by the Research Ethics Committee of the Kuopio University Hospital and the Ethics Committee of the Helsinki Deaconess Institute, the Finnish Ministry of Social Affairs and Health and the appropriate municipal authorities at communities where clients resided. The clients´ data were collected as part of routine clinical procedure. Since the clients were not contacted for study itself, informed consent was not required.
5. RESULTS
5.1. Sociodemographic characteristics of older and younger participants
About 98 % of the participants were of Finnish nationality. Majority came from the Helsinki region. There were more males both in the younger (67.1%, n=1678) and older (96.0%, n=24) groups. Majority of participants were not married (83.0%, n=1699) in the younger age group, whereas in the older age group, more participants were separated or divorced (50%, n=9) than non-married (44.4%, n=8).
Table 3 shows the socio-demographic characteristics of the study subjects. In the younger age group majority of participants were unemployed (57.1%, n=1354) whereas in the older age group most of the participants were unemployed (39.1%, n=9) and retired (39.1%, n=9). Salary was the main source of income in younger age group (22.6%, n=442) while pension (33.3%, n=7) and unemployment benefit (28.6%, n=6). Most participants had a definite home address in both groups (young 79.0%, n=1949 and old 91.7%, n=22). In younger age group, most of the participants attended elementary school (62.7%, n=1466). In older age group, 38.9% (n=7) participants attended elementary school; 33.3% (n=6) attended high school or vocational school. Smoking was prevalent in both age groups. 93% (n=2086) of the participants were smoking in younger age group and 95% (n=19) were smoking in older age group.
In both age groups, majority of participants did not have any other drug abuser in household (71.0%, n=1106 in younger age group and 40%, n=4 in older age group) and did not have children younger than 18 years (74.3%, n=1702 and 52.4%, n=11 respectively).
Table 3 Socio-demographic characteristics of older and younger participants
Variables Age category p-value Total
< 50 years n (%)
≥50 years n (%)
Gender (n=2526) 0.002
Male 1678 (67.1) 24(96.0) 1702(67.4)
Female 823(32.9) 1(4.0) 824(32.6)
Total 2501(100) 25(100) 2526(100)
Home municipality (n=2522)
0.525
Helsinki 1742(69.8) 23(92.0) 1765(70.0)
Variables Age category p-value Total
< 50 years n (%)
≥50 years n (%)
Espoo 374(15.0) 1(4.0) 375(14.9)
Vantaa 179(7.2) 0(0.0) 179(7.1)
Järvenpää 18(0.7) 0(0.0) 18(0.7)
Kerava 28(1.1) 1(4.0) 29(1.1)
Kirkkonummi 44(1.8) 0(0.0) 44(1.7)
Lohja 28(1.1) 0(0.0) 28(1.1)
Numijärvi 31(1.2) 0(0.0) 31(1.2)
Porvoo 30(1.2) 0(0.0) 30(1.2)
Hyvinkää 12(0.5) 0(0.0) 12(0.5)
Tuusula 11(0.4) 0(0.0) 11(0.4)
Total 2497(100) 25(100) 2522(100)
Marital status (n=2066) 0.000
Married or Living as a couple
196(9.6) 1(5.6) 197(9.5)
Not married 1699(83.0) 8(44.4) 1707(82.6)
Separated or divorced 152(7.4) 9(50.0) 161(7.8)
Widowed 1(0.0) 0(0.0) 1(0.0)
Total 2048(100) 18(100) 2066(100)
Nationality (n=2521) 0.997
Finnish 2439(97.7) 25(100) 2464(97.7)
Swedish 1(0.0) 0(0.0) 1(0.0)
Russian 24(1.0) 0(0.0) 1(1.0)
Estonian 13(0.5) 0(0.0) 13(0.5)
Vietnamese 4(0.2) 0(0.0) 4(0.2)
Somalian 1(0.0) 0(0.0) 1(0.0)
Other 14(0.6) 0(0.0) 14(0.6)
Total 2496(100) 25(100) 2521(100)
Language (n=2520) 0.988
Finnish 2406(96.4) 25(100) 2431(96.5)
Swedish 27(1.1) 0(0.0) 27(1.1)
Russian 38(1.5) 0(0.0) 38(1.5)
Estonian 5(0.2) 0(0.0) 5(0.2)
Vietnamese 5(0.2) 0(0.0) 5(0.5)
Somalian 3(0.1) 0(0.0) 3(0.1)
Other 11(0.4) 0(0.0) 11(0.4)
Total 2495(100) 25(100) 2520(100)
Homeless (n=2490) 0.129
No 1949(79) 22(91.7) 1971(79.2)
Yes 517(21) 2(8.3) 519(20.8)
Total 2466(100) 24(100) 2490(100)
Variables Age category p-value Total
< 50 years n (%)
≥ 50 years n (%)
Education (n=2355) 0.002
Part of elementary school 292(12.5) 1(5.6) 293(12.4)
Elementary school 1466(62.7) 7(38.9) 1473(62.5)
High school or vocational 474(20.3) 6(33.3) 480(20.4)
University 40(1.7) 2(11.1) 42(1.8)
Other 65(2.8) 2(11.1) 67(2.8)
Total 2337(100) 18(100) 2355(100)
Working (n=2393) 0.000
Employed 322(13.6) 3(13.0) 325(13.25)
Unemployed 1354(57.1) 9(39.1) 1363(57.0)
Student 458(19.3) 0(0.0) 458(19.1)
Housewife/Househusband 20(0.8) 0(0.0) 20((0.8)
Retired 69(2.9) 9(39.1) 78(3.3)
Other 147(6.2) 2(8.7) 149(6.2)
Total 2370(100) 23(100) 2393(100)
Main source of income (n=1981)
0.000
Salary 442(22.6) 4(19.0) 446(22.5)
Pension 70(3.6) 7(33.3) 77(3.9)
Income support 807(41.2) 4(19.0) 811(40.9)
Unemployment benefit 288(14.7) 6(28.6) 294(14.8)
Other 353(18.0) 0(0.0) 353(17.8)
Total 1960(100) 21(100) 1981(100)
Other drug abuser in household (n=1567)
0.009
No 1106(71.0) 4(40.0) 1110(70.8)
Drug abuser 342(22.0) 3(30.0) 345(22.0)
Alcohol abuser 61(3.9) 1(10.0) 62(4.0)
Drug/alcohol abuser 48(3.1) 2(0.1) 50(3.2)
Total 1557(100) 10(100) 1567(100)
Children younger than 18 years (n=2312)
0.000
No 1702(74.3) 11(52.4) 1713(74.1)
In same household 158(6.9) 1(4.8) 159(6.9)
Taken to foster care 109(4.8) 1(4.8) 110(4.8)
Living elsewhere 292(12.7) 4(19.0) 296(12.8)
Other 30(1.3) 4(19.0) 34(1.5)
Total 2291(100) 21(100) 2312(100)
Smoking (n=2264) 0.722
No 158(7.0) 1(5.0) 159(7.0)
Yes 2086(93.0) 19(95.0) 2015(93.0)
Total 2244(100) 20(100) 2264(100)
5.2. Difference in drug using pattern
5.2.1. Primary drug and its mode of administration
Opiate was the primary drug of abuse among younger age group (31.3%, n=783) whereas stimulant was primary drug of abuse in older age group (40%, n=10). Intravenous use of primary drug was most prevalent mode of administration among younger age group (44.4%, n=1042) while in older group oral administration of primary drug was common (50%, n=10).
However, there was no significant difference between the two groups regarding the primary drug and way of using the drug (p=0.30, p=0.156)
Table 4 Primary drug and its mode of administration
Variables (n) Age Category p-value Total
49 years n (%)
≥ 50 years n (%)
Primary drug (n=2526) 0.30
Alcohol 651(26.0) 8(32.0) 659(26.1)
Cannabis 382(15.3) 0(0.0) 382(15.1)
Medication 53(2.1) 2(8.0) 55(2.2)
Opiate 783(31.3) 5(20.0) 788(31.2)
Stimulant 589(23.6) 10(40.0) 599(23.7)
Others 43(1.7) 0(0.0) 43(1.7)
Total 2501(100) 25(100) 2526(100)
Way of using drug (n=2369)
0.156
IV 1042(44.4) 9(45.0) 1051(44.4)
Smoking 376(16.0) 0(0.0) 376(15.9)
Orally 761(32.4) 10(50.0) 771(32.5)
Snorting 170(7.2) 1(5.0) 171(7.2)
Total 2349(100) 20(100) 2369(100)
5.2.2. Secondary drug and its mode of administration
Cannabis was the most used secondary drug among younger age group (35.1%, n=800), whereas alcohol was most common secondary drug among older age group (30%, n=6). p value of 0.06 shows a non-significant association. Secondary drug was commonly used through oral route in both younger (41.4%, n=871) and older age group (60%, n=9). There was no
significant difference between the two groups regarding the secondary drug and way of using the drug (p=0.384).
Table 5 Secondary drug and its mode of administration
Variables Age category p-value Total
49 years n (%)
≥ 50 years n (%) Secondary drug
(n=2301)
0.056
Alcohol 363(15.9) 6(30.0) 369(16.0)
Cannabis 800(35.1) 4(20.0) 804(34.9)
Medication 436(19.1) 2(10.0) 438(19.0)
Opiate 235(10.3) 5(25.0) 240(10.4)
Stimulant 410(18.0) 2(10.0) 412(17.9)
Others 37(1.6) 1(5.0) 38(1.7)
Total 2281(100) 20(100) 2301(100)
Way of using drug 2 (n=2121)
0.380
IV 378(17.9) 3(20.0) 135(5.7)
Smoking 747(35.5) 3(20.0) 750(35.4)
Orally 871(41.4) 9(60) 880(41.5)
Snorting 110(5.2) 0(0.0) 110(5.2)
Total 2106(100) 15(100) 2121(100)
5.2.3. Frequency of drug use
Primary drug was used almost daily (7 times/week or more) by younger age group whereas secondary drug was used once or less than once. In older age group, use of both primary and secondary drugs was nearly on daily basis. There was no significant difference regarding the frequency of drug use between the two groups (p=0.8).
Table 6 Frequency of drug use (times/week)
Variables Age category p-value Total
49 years n (%)
≥ 50 years n (%) Times/week during last
month, drug 1 (n=2389)
0.248
No use 135(5.7) 0(0.0) 135(5.7)
Variables Age category p-value Total
49 years ≥ 50 years
n (%) n (%)
1 time/week or less 507(21.4) 3(14.3) 510(21.3)
2-6 times/week 699(29.5) 10(47.6) 709(29.7)
7 times/week or more 1027(43.4) 8(38.1) 1035(4.3)
Total 2368(100) 21(100) 2389(100)
Times/week during last month, drug 2 (n=2141)
0.286
No use 254(12.0) 1(5.9) 255(11.9)
1 time/week or less 749(35.3) 4(23.5) 753(35.2)
2-6 times/week 643(30.3) 5(29.4) 648(30.3)
7 times/week or more 487(22.5) 7(41.2) 485(22.7)
Total 2124(100) 17(100) 2141(100)
Drug free months during last year (n=2111)
0.803
0-3 1767(84.4) 16(88.9) 1783(84.5)
4-7 185(8.8) 1(5.6) 186(8.8)
8-12 141(6.7) 1(5.6) 142(8.8)
Total 2093(100) 18(100) 2111(100)
5.2.4. Number of drugs used
Table 6 represents the number of drugs used by both younger and older participants. Polydrug use was common in both groups: 91.2 % (n=2281) in younger and 80% (n=200) in older group.
Mono drug use i.e., single drug use, was not common in this study population (p=0.050).
Table 7 Number of drugs used Number of drugs
used (n=2526)
Age Category p-value Total
49 years n (%)
≥ 50 years n (%)
Mono drug 220(8.8) 5(20) 0.050 225(8.9)
Poly drug 2281(91.2) 20(80) 2301(91.1)
Total 2501(100) 25(100) 2526(100)
5.3. Differences in health problems
Medical and psychological problems of the study participants are shown in Table 8. Majority of the participants had suffered from Hepatitis C (45.2%, n=630). However, Hepatitis C was more prevalent (64.3%, n=9) in older age group (p=0.150). HIV was also more prevalent in older age group (p=0.00). A total of 4 out of 25 older participants were HIV positive (Table 8).
Table 8 Differences in medical problems in younger and older adults
Variables n (%) Age category p-value Total
49 years n (%)
≥ 50 years n (%) Hepatitis A
(n=1289)
0.832
No 1205(94.6) 14(93.3) 1219(94.6)
Yes 69(5.4) 1(6.7) 70(5.4)
Total 1274(100) 15(100) 1289(100)
Hepatitis B (n=1325)
0.958
No 1227(93.7) 14(93.3) 1241(93.7)
Yes 83(6.3) 1(6.7) 84(6.3)
Total 1310(100) 15(100) 1325(100)
Hepatitis C (n=1393)
0.150
No 758(55.0) 5(35.7) 763(54.8)
Yes 621(45.0) 9(64.3) 630(45.2)
Total 1379(100) 14(100) 1393(100)
HIV (n=1431)
0.000
No 1371(96.9) 12(75.0) 1383(96.6)
Yes 44(3.1) 4(25.0) 48(3.4)
Total 1415(100) 16(100) 1431(100)
Hepatitis A vaccination
n=1062
0.766
No 656(62.5) 8(66.7) 664(62.5)
Yes 394(37.5) 4(33.3) 398(37.5)
Total 1050(100) 12(100) 1062(100)
Hepatitis B vaccination
n=1943
0.232
No 1128(58.5) 7(43.8) 1135(58.4)
Variables Age category p-value Total
49 years ≥ 50 years
n (%) n (%)
Yes 799(41.5) 9(56.3) 808(41.6)
Total 1927(100) 16(100) 1943(100)
More than half of the study population (58.8%, n=1344) had experienced psychotic symptoms when using drugs. Psychotic symptoms were more common in younger study population (p=0.414). A majority (80%, n=1760) of the participants did not have psychotic symptoms at the time when they were not using drugs. Depressive symptoms were common in both age groups (p=0.383). There were no statistically significant differences in suicidal thoughts and suicidal attempts between groups (p=0.296 and p=0.051, respectively) (Table 9).
Table 9 Differences in psychological problems in younger and older adults
Variables n(%) Age Category p-value Total
49 years n (%)
≥ 50 years n (%) Psychotic
symptoms when using drugs n=2293
No 937(41.2) 12(57.1) 949(41.4)
Yes 1335(58.8) 9(42.9) 1344(58.6)
Total 2272(100) 21(100) 2293(100)
Psychotic
symptoms at other times n=2216
No 1760(80.2) 19(90.5) 1779(80.3)
Yes 435(19.8) 2(9.5) 437(19.7)
Total 2195(100) 21(100) 2 216(100)
Psychotic
symptoms n=2191
0.242
No 1742(80.3) 19(90.5) 1761(80.4)
Yes 428(19.7) 2(9.5) 4301(9.6)
Total 2170(100) 21(100) 2191(100)
Depressive
symptoms n=2216
0.383
No 718(32.7) 8(42.1) 726(32.8)
Variables Age category p-value Total
49 years n (%)
≥ 50 years n (%)
Yes 1479(67.3) 11(57.9) 1490(67.2)
Total 2197(100) 19(100) 2216(100)
Suicidal thoughts n=2203
0.296
No 1444(66.1) 14(77.8) 1458(66.2)
Yes 741(33.9) 4(22.2) 745(33.8)
Total 2185(100) 18(100) 2203(100)
Suicide attempts n=2057
0.051
No 1570(76.9) 9(56.3) 1579(76.8)
Yes 471(23.1) 7(43.8) 478(23.8)
Total 2041(100) 16(100) 2057(100)
5.4. Treatment seeking pattern among older participants
Figure 2 represents the trends of treatment seeking patterns by older participants from 2001 to 2008. The highest number of patients seeking treatment was in 2005 and the treatment seeking pattern was decreasing from 2005.
0
1
5 5
7
2
3
2
0 1 2 3 4 5 6 7 8
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
number of patients
Figure 2 Number of patients (50 years and above) seeking treatment from 2001-2008
5.5. Differences in treatment seeking
Table 8 illustrates the differences in treatment seeking among younger and older aged groups.
More than 90% (n=91.8) of the study population sought treatment because of drug abuse problem, and this reason was common in both groups (p=0.922). More than half of the study participants had been previously treated for drug abuse problem (58.3%, n=811) and there were no differences between age groups (p=0.467). One-fourth of the study population in both groups were also seeking treatment outside the Helsinki Deaconess Institute, but the difference between groups was not statistically significant (p=0.327). More than half of the participants (51.5%, n=1258) initiated treatment-seeking by themselves, with no significant difference in between the two age groups (p=0.830).
Table 10 Differences in treatment seeking
Variables Age category p-value Total
49 years n (%)
≥ 50 years n (%) Main reason for
seeking treatment (n=2422)
0.922
Abuse 2200(91.7) 23(95.8) 2223(91.8)
Physical reasons 2(0.1) 0(0.0) 2(0.1)
Social reasons 90(3.8) 0(0.0) 90(3.7)
Psychiatric reasons 32(1.3) 0(0.0) 32(1.3)
After-treatment 2(0.1) 0(0.0) 2(0.1)
Other reasons 72(3.0) 1(4.2) 73(3.0)
Total 2398(100) 24(100) 2422(100)
Previous treatments anywhere (n=1392)
0.467
No 575(41.8) 6(33.3) 581(41.7)
Yes 799(58.2) 12(66.7) 811(58.3)
Total 1374(100) 18(100) 1392(100)
Treatment elsewhere (n=2404)
0.327
No 1767(74.2) 15(65.2) 1782(74.1)
Yes 614(25.8) 8(34.8) 622(25.9)
Total 2381(100) 23(100) 2404(100)
Guidance for
treatment (n=2442)
0.830
Self-guided 1242(51.3) 16(69.6) 1258(51.5)
Family/friends 487(20.1) 2(8.7) 489(20)
Variables Age category p-value
49 years n (%)
≥ 50 years n (%)
Health center 23(1.0) 0(0.0) 23(0.9)
Hospital 91(3.8) 0(0.0) 91(3.7)
Private health service 8(0.3) 0(0.0) 8(0.3)
School health care 41(1.7) 0(0.0) 41(1.7)
Police 14(0.6) 0(0.0) 14(0.6)
Outpatient at drug abuse services
216(8.9) 4(17.4) 220(9.0)
Inpatient at drug abuse services
17(0.7) 0(0.0) 17(0.7)
Child healthcare 92(3.8) 0(0.0) 92(3.8)
Health counselling service
9(0.4) 0(0.0) 9(0.4)
Other social service 75(3.1) 0(0.0) 75(3.1)
Other health care 37(1.5) 0(0.0) 37(1.5)
Employer 7(0.3) 0(0.0) 7(0.3)
Other 60(2.5) 1(4.3) 61(2.5)
Total 2419(100) 23(100) 2442(100)
6. DISCUSSION
6.1. Findings and methodology
This study examined the characteristics of older adults using illicit drugs who sought treatment in Helsinki Deaconess Institute (HDI) from 2001 to 2008. There were more males than females among both the younger (<50 years of age) and older (≥ 50 years of age) participants. Previous studies and reports in Finland have reported similar predominantly male gender distribution of drug abusers (EMCDDA 2012, Varjonen 2015). Studies outside Finland have also shown that more men with drug abuse disorder seek treatment than female counterparts (Benyon et al.
2001). However, there may be some social or cultural reasoning behind this particular gender distribution. A study by Jesup et al. (2003) demonstrated that due to social stigma and fear, female drug abusers are reluctant to seek treatment.
Most participants in the younger age group were unemployed. In the older age group, the majority were either unemployed or retired. Most of the participants have income support; in older group, pension and unemployment benefit were the main sources of income. In Finland, official retirement age is between 63 to 68 years (Tuominen 2013). Bacharach et al. (2008) conducted a study on drug abuse and retirement trajectories. The sample included 978 retirement eligible employees representing three blue-collar employment sectors:
transportation, manufacturing and construction. They found that 26 percent of sample had at least one problem related to drug abuse. Being fully retired was associated with an increase in drug abuse problem, as compared to those employees deferring their retirement. It was also found that younger employees, who are eligible for retirement but continue to work, have less drug-related problem than their older counterparts (Bacharach et al. 2008).
In this study, multiple drug usage (i.e. two or more drugs) was common in both age groups.
Mixed use of drugs can have cumulative or complementary effect, which is not attainable with individual drug (Boys et al. 2001). Another reason to use additional drug is to reduce the effect of the primary drug, for example, benzodiazepines help users to sleep after taking stimulants (EMCDDA 2009). A study performed by Kedia et al. in 2007 found that about 30% of the study participants reported using two substances, about 15% reported using three drugs and nearly 4% reported using four or more drugs.
In this study, Hepatitis A and Hepatitis B were not common in either age group. However, Hepatitis C was prevalent in both groups. Also, other studies have reported that Hepatitis C is the predominant blood-borne viral infection among intravenous drug users (Loebstein et al.
2009; Nelson et al. 2011). Hepatitis C virus is most often transmitted through contaminated injections (Friedland 2010). Systematic reviews from the United States (Page et al. 2013) and Europe (Wiessing et al. 2014) confirm that Hepatitis C is especially high among young adults who use intravenous route of drug abuse. Our study showed that in the younger ager group the primary drug was administered through intravenous (IV) route. In the older age group, the IV route was used for some drugs, but generally the oral consumption of primary drug was more frequent.
The estimated HIV prevalence was fairly high in the older age group, as one out of six in this group reported being positive to HIV. An earlier study on the HUUTI data examining the factors associated with hospitalization for the blood-borne viral disease found that majority of the clients admitted for HIV were older, homeless and had longer history of drug use (Onyeka et al. 2014). Stimulants were the primary drug of abuse, and mostly administered through IV route. It has been shown that injection drug use is in many populations one of the most significant reasons for new HIV infections (CDC 2012). The study by Broz et al (2014), which compared HIV sero-prevalence and risk behaviours between young (aged 18 years) and older (aged 30 years), found that sharing syringes and unprotected sex remarkably increased the risk of HIV infection.
In this study, there were just 25 participants aged 50 years and above, which is less than one percent of the total treatment seekers from 2001 to 2008 at the HDI. This implies differences in the prevalence of use, but also the fact that younger drug users seek treatment more often than their older counterparts. This result is in accordance with another Finnish study performed by Varjonen (2015).
Although it seems that there are fewer older adults with drug use disorder in Finland, it is important to consider the various barriers that affect identification of drug abuse and lead to underreporting of drug abuse in older population (Rosen et al. 2013). These issues in identification and underreporting of drug abuse in older people are potentially serious, because older people are more often socially isolated, or because physical mobility challenges or
comorbities associated with their age keep them from regularly visiting and seeking health care. (Rosen et al. 2013). These have in part the roots in the ageing phenomenon in general, and have been studied extensively in geriatric research, with findings of an inverse association between ageing and access to health care (Chait et al. 2010). Onyeka et al. (2015) suggested that the distance from the health center is one possible reason for the lower number of older drug users seeking the treatment also in our study.
Another reason behind fewer older people seeking health care in our study can be in the lack of environment and facilities in the treatment center that accommodate the need of elderly drug users. A study performed in United Kingdom has reported that older people do not want to be around with younger drug users, which is also one of the significant reason for not seeking treatment (Ayres et al. 2012). To address this problem, there is a need for such specialized programs to older adults that would increase the accessibility to treatment centers (Schultz et al. 2003).
The highest number of older patients seeking treatment in our study was in 2005, and the trend declined after that. Further studies are needed to find out the factors that are associated with this specific decline.
6.2. Validity and reliability of the study
Validity is defined as “the extent to which a concept is accurately measured in a quantitative study” and reliability is “the extent to which a research instrument consistently has the same results if it is used in the same situation on repeated occasions” (Heale and Twycross 2015).
The HUUTI data was collected using a structured questionnaire. It gathered general information of the client, medical status, alcohol\drug use, employment status, family and social relationships, legal status and psychiatric/psychological wellbeing. The variables were adapted from the European Addiction Severity index (EuropASI), the Treatment Demand Indicator Protocol (TDI) and other questions relevant for evaluation of treatment needs and monitoring of clients. The reliability of self-reported data using TDI has been estimated to be 90% (Kokkevi et al. 1997).
6.3. Strengths and limitations of the study
There have been few international studies focusing on the characteristics of illicit drug use among older people. This study is the first of its kind in Finland, providing the profile of the older illicit drug users in Helsinki over the period between 2001 and 2008. It can provide useful insight in understanding the problems of older drug users in Finland. However, a decade or more has passed since these data were collected. Since societies evolve over time, and sociocultural factors change in their patterns and intensities, so the phenomenon studied in this research work needs to be re-evaluated periodically with the most current data sets available.
Although HUUTI is a fairly large epidemiological study with a considerable sample size, few is participants were 50 years of age or older. Also, only clients who seeked treatment at the HDI could be included in this study. This means our study does not address the problems of non-treatment seeking drug users. And because the study was performed only in the Helsinki metropolitan area, it may be generalized to other cities in Finland, or to other regions outside Finland only with caution.
Some variables in this study had a lot of missing data in the sample, which may have affected some of the results of the study.
6.4. Implications for research, practice and policy
Findings from this research have important implications in treatment services of drug abuse among older adults. The study shows that there are elderly people in Finland who have drug abuse problems, but because of various barriers, they are reluctant to come forward and seek treatment. Thus, there should be elderly-friendly facilities, which encourage those in need to seek treatment.
Further studies with larger sample sizes would be necessary to investigate the barriers faced by older drug users in treatment seeking. A deeper insight to older drug users´ experiences and opinions could be obtained by using qualitative methodologies. Further research combining both qualitative and quantitative methods (a mixed-methods approach) should lead to better understanding of the factors related to the treatment seeking behavior of older adults. It would
in turn provide additional help in policy making and in planning of appropriate services, to address the drug abuse problem in older adults.
7. CONCLUSION
This study aimed to describe the characteristics of older adults using illicit drugs in Finland.
The number of older clients seeking treatment remained low throughout the entire study period.
The profile of an older drug user in study area comes across like this: a male, with a home address, relying on unemployment benefits or pension, using stimulants as primary drug of choice through oral route, and with comorbidities, like Hepatitis C and HIV.
As the number of older drug users may be increasing in the future, more attention should be paid to this less traditional drug using population.
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