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The Baby Boomer Effect: Changing Patterns of Substance Abuse AmongAdults Ages 55 and OlderDavid F. Duncana; Thomas Nicholsonb; John B. Whitec; Dana Burr Bradleyd; John Bonaguroe

a President, Duncan & Associates, Bowling Green, Kentucky, USA b Professor, Department of PublicHealth, Western Kentucky University, Bowling Green, Kentucky, USA c Associate Professor,Department of Public Health, Western Kentucky University, Bowling Green, Kentucky, USA d

Director, Center for Gerontology, College of Health and Human Services, Western KentuckyUniversity, Bowling Green, Kentucky, USA e Dean, College of Health and Human Services, WesternKentucky University, Bowling Green, Kentucky, USA

Online publication date: 29 June 2010

To cite this Article Duncan, David F. , Nicholson, Thomas , White, John B. , Bradley, Dana Burr and Bonaguro, John(2010)'The Baby Boomer Effect: Changing Patterns of Substance Abuse Among Adults Ages 55 and Older', Journal of Aging &Social Policy, 22: 3, 237 — 248To link to this Article: DOI: 10.1080/08959420.2010.485511URL: http://dx.doi.org/10.1080/08959420.2010.485511

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Journal of Aging & Social Policy, 22:237–248, 2010Copyright © Taylor & Francis Group, LLCISSN: 0895-9420 print/1545-0821 onlineDOI: 10.1080/08959420.2010.485511

The Baby Boomer Effect: ChangingPatterns of Substance Abuse Among Adults

Ages 55 and Older

DAVID F. DUNCAN, DrPHPresident, Duncan & Associates, Bowling Green, Kentucky, USA

THOMAS NICHOLSON, MPH, PhDProfessor, Department of Public Health, Western Kentucky University, Bowling Green,

Kentucky, USA

JOHN B. WHITE, PhDAssociate Professor, Department of Public Health, Western Kentucky University, Bowling

Green, Kentucky, USA

DANA BURR BRADLEY, PhDDirector, Center for Gerontology, College of Health and Human Services, Western Kentucky

University, Bowling Green, Kentucky, USA

JOHN BONAGURO, PhDDean, College of Health and Human Services, Western Kentucky University, Bowling Green,

Kentucky, USA

Between now and 2030, the number of adults aged 65 and olderin the United States will almost double, from around 37 million tomore than 70 million, an increase from 12% of the U.S. populationto almost 20%. It was long held that, with only a few isolated excep-tions, substance abuse simply did not exist among this population.In light of the impact of the baby boom generation, this assumptionmay no longer be valid. The authors examined admissions of per-sons 55 years and older (n = 918,955) from the Treatment EpisodeData Set (1998–2006). Total admissions with a primary drug prob-lem with alcohol have remained relatively stable over this time.

Received October 9, 2009; revised November 16, 2009; accepted December 16, 2009.This paper was presented at the Oxford Round Table, Oxford University, Oxford, United

Kingdom, April 2009.

Address correspondence to David F. Duncan, Duncan & Associates, 81 Bowling GreenEstates, 2039 Russellville Road, Bowling Green, KY, USA. E-mail: dfduncan@insightbb.com

237

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238 D. F. Duncan et al.

Admissions for problems with a primary drug other than alcoholhave shown a steady and substantial increase. Clearly, data fromthe Treatment Episode Data Set indicate a coming wave of olderaddicts whose primary problem is not alcohol. The authors suspectthat this wave is led primarily by the continuing emergence of thebaby boomer generation.

KEYWORDS addiction, aging, baby boomers, illicit drug,substance abuse, treatment

INTRODUCTION

Between now and 2030, the number of adults aged 65 and older in theUnited States will almost double, from around 37 million to more than70 million, an increase from 12% of the U.S. population to almost 20% (U.S.Census Bureau, 2008; Institute of Medicine [IOM], 2008). While this is partlydue to increasing longevity and partly to a declining birth rate, the increase isprincipally due to the maturing of the postwar “baby boom” of persons bornin the United States between 1946 and 1964 (Siegel, 1996). In 2011, the firstbaby boomers will turn 65, and by 2030 the entire baby boom generationwill be 65 or older.

This demographic change has great importance for America’s healthcare system because older persons make considerably greater use of healthcare services than do younger Americans and have health care needs that areoften more complex. The IOM (2008) has warned that the American healthcare system is already struggling with the challenge of delivering high-qualityservices to older adults and that most of America’s health care professionalslack adequate education and training with respect to the health care needsof older adults. Looking ahead, they note that, “The next generation of olderadults will be like no other before it” (IOM, 2008, p. 15). America’s agingbaby boomers will have greater racial and ethnic diversity, higher levels ofeducation, lower levels of poverty, fewer children, higher divorce rates, andmore openness regarding their sexual orientation than any previous cohortof American older adults (He & Sengupta, 2005; U.S. Census Bureau, 2008;IOM, 2008).

Unmentioned in the IOM report is any difference in substance abuseprevalence between baby boomers and previous generations. The NationalAcademies Keck Futures Initiative similarly ignores drug abuse as an issue inthe older adult, implying that it is an issue only in young people (NationalAcademies Keck Futures Initiative, 2008, p. 69). Until relatively recently,substance abuse by the older adult apparently was not addressed by eitherthe substance abuse or the gerontological literature (Center for SubstanceAbuse Treatment [CSAT], 1998).

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Changing Patterns of Substance Abuse 239

Historically, with only a few isolated exceptions, substance abuse wasnot documented among older adults. Alcoholism was described as a self-limiting condition with an early-life onset that ended in either abstinence ordeath before old age was reached (Duncan, 1994). Older adults were seenas nonusers of other recreational drugs. When this view was challenged byresearchers in the last quarter of the 20th century, a new consensus emerged,asserting that alcohol abuse and misuse was the substance abuse problemof concern among older adults, affecting some 2.5 million of them (CSAT,1998).

Abuse of legal medications by the older adult has generally come to beseen as a real but smaller problem (Atkinson & Kofoed, 1982; Schonfeld &Dupree, 1995). However, the U.S. CSAT identified abuse of alcohol andprescription drugs among adults 60 and older as one of the fastest grow-ing health problems facing the nation—one that “remains underestimated,underidentified, underdiagnosed, and undertreated” (CSAT, 1998).

A recent review by Simoni-Wastila and Yang (2006) of the literaturepublished in English between January 1990 and May 2006 found that, whilethere was a growing literature on the epidemiology and treatment of alco-holism in older adults, there was very little that addressed the abuse ofother drugs by this population. While the authors urged greater attentionto problems of misuse and abuse of prescription drugs by the older adult,they also suggested that illicit drug use is relatively rare among older adults(Simoni-Wastila & Yang, 2006). This view would seem to be supported bya recent examination of substance abuse treatment admissions in the year2001 of persons aged 55 years and older (Arndt, Gunter, & Acion, 2005).Their report indicates that most admissions were alcohol-related, consistentwith the general consensus view that alcohol is the sole substance abuseproblem among the older adults.

We have suggested that this assessment of the situation may no longerbe valid and that increasing attention needs to be paid to the possibleabuse of illicit drugs by older Americans as “baby boomers” (i.e., those bornbetween 1946 and 1964 in the United States) reach retirement age (White &Duncan, 2008). In this previous analysis, we conducted a secondary analy-sis of archived data from the National Household Survey on Drug Abuseand its successor survey, the National Survey on Drug Use and Health(NSDUH). Sponsored by the Substance Abuse and Mental Health ServicesAdministration (SAMHSA), both surveys were designed to provide yearlynational data on the uses of alcohol, tobacco, and illicit and prescriptiondrugs in the United States. It was found that adults older than 50 reportedhigher levels of drug use in 2006 than in 1985. While the proportion report-ing use of alcohol remained relatively stable, the proportion that had everused each of six categories of illicit drugs studied increased. Current (past-month) use was greater for marijuana (1.6 % versus 0.3%), cocaine (0.3%versus 0.1%), and inhalants (0.1% versus 0%). While these percentages may

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240 D. F. Duncan et al.

look small, they amount to an estimated increase of 1,268,262 in the num-ber of Americans 50 and older who are currently using marijuana, 140,422cocaine users, and 56,547 inhalant users. Furthermore, the same amountof drug taken at the age of 25 may have markedly different effects whenconsumed at the age of 75.

This suggests that baby boomers are using illicit drugs at a higher ratethan their predecessors. Thus, as boomers enter the latter half of their lives, asubstantial number of admissions will come from this group. Of course, notall of these older users of illicit drugs have an addiction or abuse problem.Over a lifetime, about 10% to 20% of all users of a drug (other than tobacco)ever develop an abuse problem (Anthony & Helzer, 1991; Duncan, White, &Nicholson, 2003; Nicholson, Duncan, & White, 2002).

These studies suggest that there may be a changing pattern of drugabuse in the older adult population. To examine this possibility, we studiedtreatment admissions data for persons 55 years and older in the TreatmentEpisode Data Set (TEDS) over the 15-year period from 1992 through 2006.

METHODS

TEDS is an administrative data system providing descriptive informationabout the national flow of admissions to specialty providers of substanceabuse treatment. TEDS is part of the Drug and Alcohol Services InformationSystem, a cooperative program between SAMHSA and the substance abusetreatment agencies of the 50 states, the District of Columbia, and PuertoRico. The TEDS system was designed to provide data on the number andcharacteristics of admissions to programs that receive state alcohol and/ordrug agency funds for the provision of treatment services. The scope offacilities included in TEDS is affected by differences in state licensure, cer-tification, accreditation, and disbursement of public funds. Most states areable to report all admissions to all eligible facilities, although some reportonly admissions financed by public funds (SAMHSA, 2009). Approximately1.6 million records are submitted to TEDS each year, which is estimated torepresent about two-thirds of all such treatment admissions in the UnitedStates.

We examined admissions of persons 55 years and older (n = 918,955)rather than 65 and older because the TEDS system does not include anyage category older than 55. This may be seen as reflecting the general lackof interest in older adults as a treatment population at the time when theTEDS was created. This is a weakness in the data set in that we are unable todifferentiate between the aging adult, the old, the old old, and the oldest old.

TEDS data are fundamentally about admissions. The same person couldbe admitted 10 times in 1 year. Thus, any trends could be confounded byrelapse instead of reflecting demographic change in the general population.

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Changing Patterns of Substance Abuse 241

RESULTS

Table 1 presents both the total admissions data and admissions for patientswhose primary drug of abuse was not alcohol. Thus, the non-alcohol admis-sions would include both licit (primarily prescription) and illicit drug abuse(i.e., cocaine, heroine, marijuana, etc). Of this sample, 80.4% were male,64.9% were White, 44.8% were divorced or widowed, and a quarter wereveterans (25.4%). Most had completed high school (64.0%) and were notin the labor force (60.3%). A surprisingly high percentage of them werehomeless (15.6%).

TABLE 1 Characteristics of Patients 55 Years and Older Admitted to Substance AbuseTreatment (USA, 1992–2006)

All drug admitsNon-alcohol

admits

Variable Level N % n %

Sex Male 734,774 80.4 152,267 77.5Female 179,388 19.6 44,222 22.5

Ethnicity Alaskan Native 3,912 0.4 733 0.4American Indian 21,767 2.4 1,613 0.8Asian or Pacific Islander 5,868 0.6 2,746 1.4Black 206,241 22.8 81,512 41.8White 587,152 64.9 77,347 39.7Other single race 79,027 8.7 30,864 15.8Two or more races 507 0.1 184 0.1

Marital Never married 116,189 17.4 30,614 25.5status Now married 198,105 29.7 27,007 22.5

Separated 54,696 8.2 12,929 10.8Divorced/widowed 299,029 44.8 49,468 41.2

Education <8 years 142,747 16.1 26,577 13.79–11 177,079 19.9 48,000 24.812 331,626 37.3 74,653 38.613–15 140,887 15.9 31,650 16.316+ years 95,791 10.8 12,762 6.6

Veteran Yes 133,377 25.4 15,843 15.9No 391,392 74.6 83,666 84.1

Living Homeless 110,097 15.6 17,269 13.1Dependent 72,503 10.3 19,585 14.8Independent 522,728 74.1 95,299 72.1

Primary Wages/salary 124,041 25.0 17,043 18.7income Public assistance 46,128 9.3 12,718 14.0source Retirement/pension/disability 118,922 24.0 17,763 19.5

Other 125,345 25.3 26,874 29.5None 81,506 16.4 16,610 18.3

Employment Full-time 150,705 17.4 22,618 11.9Part-time 44,925 5.2 8,635 4.5Unemployed 148,916 17.2 40, 262 21.1Not in labor force 523, 735 60.3 118, 882 62.4

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242 D. F. Duncan et al.

Over the time period from 1992 to 2006, the proportion of admissionsfor alcohol abuse declined from 81.7% to 51.6%. The proportion of individu-als admitted for “other drug use” accounted for 32.5% of admissions in 2006compared to 1992, when it accounted for only 10.3% of total admissions forthose aged 55 and older.

As shown in Figure 1, total numbers of admissions of persons 55 yearsand older grew over the 15-year period. Total admissions with a primarydrug problem with alcohol remained relatively stable over this time.Admissions for problems with a primary drug other than alcohol showeda steady and substantial increase.

The admissions for a primary problem with a drug other than alcoholbore some noteworthy distinctions from all admissions of persons 55 yearsand older, as can be seen in Table 1. Most notable is the difference inethnicity, with a majority of all admissions (64.9%) being White while onlya minority (39.7%) of those admitted for problems with drugs other thanalcohol were White. The proportion of African Americans was 22.8% in thetotal sample, but 41.8% among those whose problem was with drugs otherthan alcohol. This is striking given that a majority of drug users in Americaare White (SAMHSA, 2008), but such overrepresentations of minorities arenot uncommon features of the operations of drug policy in the United States(Ramchand, Pacula, & Iguchi, 2006). In making policy analyses based onclinical data, one should always be aware of the possibility of the “clinician’sfallacy” in generalizing from patient populations to the true prevalence ordistribution of a disorder in a community (Duncan, 1997).

The two groups also differed in terms of veteran status, with 25.4% oftotal admissions being veterans compared to 15.9% of non-alcohol admis-sions. Differences in living arrangements may also be meaningful, with

FIGURE 1 Admissions of persons aged 55 and older by primary problem.

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Changing Patterns of Substance Abuse 243

15.6% of total admissions being homeless and 10.3% in a dependent livingsituation, while 13.1% of non-alcohol admissions are homeless and 14.8%are in a dependent living arrangement. Given the large sample size, all dif-ferences reported in Table 1 are likely to meet a test of significance, leavingthe real-life importance of these observed differences open to subjectiveinterpretation.

The “non-alcohol admits” category presented in Table 1 includes bothillicit drugs and prescription drugs. To look more clearly at the issue of illicitdrug abuse, we examined admissions of persons using any of six commonlyused illicit drugs (see Table 2). In most of the drug categories shown, thereis a clearly increasing pattern of illicit drug use reported at admission. Thesedata represent only a portion of the total illicit use among this population.For example, it is unknown how many people reporting opiates were usingillicit opiates or using prescribed opiates.

We found support for the expectation that the aging of the “baby boom”generation will be reflected in increased treatment admissions of older per-sons with abuse and addiction problems involving the currently illicit drugs.Treatment programs and referrers need to be aware of this shift and preparefor it. Educational and training programs for health care providers shouldreflect the need to screen for illicit drug abuse as well as alcohol and pre-scription drug abuse in the older adult. To the extent that these older illicitdrug users and abusers are at risk of entry into the criminal justice sys-tem, they may present serious new challenges for an already overburdenedsystem not prepared to deal with the greater health care needs of the aged.

DISCUSSION

As mentioned previously, the IOM (2008) report suggests that the U.S. healthcare system is largely unprepared for the incoming wave of baby boomersand their diverse health needs. This problem is even worse in the area ofsubstance abuse treatment. A recent report from the Robert Wood JohnsonFoundation states that, “The economic stability of the drug and alcohol treat-ment system is uncertain. Demands to use evidence-based practices, changesin the financing of care, and struggles finding and retaining qualified staffchallenge the current system of care” (McCarty, McConnell, & Schmidt, 2009,p. 4). Our data suggest that a system already stressed to the breaking point isabout to be hit by a wave of older adults who may not fit current substanceabuse treatment protocols.

We do know something about alcohol treatment among the older adultthat may give us some idea about what to expect with this population. Olderalcoholics in treatment programs are more compliant and have outcomes asgood as, or better than, those of younger alcoholics (Dufour & Fuller, 1995;Janik & Dunham, 1983; Oslin, Streim, Parmelee, Boyce, & Katz, 1997). But,

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TAB

LE2

Adm

issi

on

ofA

dults

55Yea

rsan

dO

lder

by

Illic

itD

rug

Use

Mar

ijuan

aCoca

ine

Her

oin

Phen

cycl

idin

eH

allu

cinoge

ns

Met

ham

phet

amin

e

Yea

rN

n%

n%

n%

n%

n%

n%

1992

102,

705

1,62

71.

583,

158

3.07

3,61

13.

5229

0.03

260.

0313

80.

1319

9310

6,43

01,

855

1.74

3,77

13.

544,

340

4.08

250.

0253

0.05

153

0.14

1994

107,

213

2,19

62.

054,

642

4.33

5,18

44.

8427

0.03

430.

0419

10.

1819

9510

6,14

52,

335

2.20

4,85

94.

585,

352

5.04

230.

0268

0.06

291

0.27

1996

107,

830

2,73

32.

535,

031

4.67

5,34

34.

9612

0.01

540.

0534

20.

3219

9710

7,66

72,

805

2.61

5,23

74.

865,

766

5.36

200.

0288

0.08

284

0.26

1998

117,

720

3,13

62.

666,

163

5.24

6,27

05.

3322

0.02

350.

0342

20.

3619

9912

6,53

23,

619

2.86

6,86

85.

437,

062

5.58

220.

0252

0.04

564

0.45

2000

135,

272

3,71

82.

757,

648

5.65

8,02

65.

9317

0.01

610.

0558

00.

4320

0114

0,50

93,

961

2.82

8,18

45.

828,

324

5.92

250.

0262

0.04

640

0.46

2002

159,

355

4,92

53.

0910

,202

6.40

9,98

56.

2738

0.02

600.

041,

063

0.67

2003

164,

990

5,51

13.

3411

,235

6.81

10,5

506.

3946

0.03

690.

041,

253

0.76

2004

168,

204

6,00

83.

5712

,369

7.35

11,0

396.

5648

0.03

850.

051,

285

0.76

2005

186,

420

7,29

13.

9115

,041

8.07

12,5

206.

7252

0.03

890.

051,

635

0.88

2006

202,

270

8,72

34.

3117

,718

8.76

15,3

157.

5741

0.02

104

0.05

2,16

31.

07

244

Downloaded By: [Duncan, David F.] At: 02:12 10 July 2010

Changing Patterns of Substance Abuse 245

the only research published using a random assignment to test treatment inaging individuals dealt with alcoholics 45 years of age and older (Kashner,Rodell, Ogden, Guggenheim, & Karson, 1992). These authors found thataging adults should be in treatment with other aging adults rather than mixedages. Similar studies need to be conducted among drug abusers in the agingpopulation and appropriate evidence-based treatment protocols developed.

A policy issue raised by McCarty, McConnell, and Schmidt (2009) con-cerns the interface between substance abuse treatment and primary care.Are primary care physicians trained to evaluate older adults with substanceabuse problems? And are they doing so? If substance abuse disorders areperceived as rare issues in older patients, then they are likely to remainlargely undiagnosed problems among older adults. One policy responsewould be to provide physicians with training on the recognition of sub-stance abuse disorders in primary care, as is done, for example, in ProjectMainstream (Brown et al., 2006). Most physicians receive limited training inthe science of addiction that results in missed opportunities for care (Fiellin,Butler, D’Onofrio, & O’Connor, 2002).

However, a focus on the physician/patient encounter may miss theactual provision of care. After all, much of health care is provided by non-physician personnel. Nurses, certified nursing assistants, psychiatric aides,etc. should be provided training in appropriate protocols on screening andtreatment. There is a need to increase efforts not only for primary care physi-cians but also for other allied health professionals such as occupational andphysical therapists from whom older adults often receive treatment due tothe increase in acute and chronic diseases associated with aging (Bonaguro,Nalette, & Seibert, 2002). Of course, in the absence of clear policy leadership,these have yet to be developed for older adults.

Current payment mechanisms are oriented toward inpatient care of sub-stance abuse. Given the research support for Screening, Brief Intervention,and Referral to Treatment strategies (Babor et al., 2007) policies should bedeveloped that provide more funding for this approach. For example, spe-cific groups of interest might include (1) persons in recovery, (2) personsabusing prescription drugs, (3) persons abusing primarily illicit drugs, and(4) persons with a DSM-IV-TR diagnosis of substance dependence or abuse.Policies regarding payment, place of treatment (inpatient versus outpatient),and screening need to be revaluated by entities responsible for the contin-uum of care. Unfortunately, little current research is available to guide policyrecommendations on these issues as they relate to the older Americans.

There are important epidemiological questions about this group as well.We don’t know about the long-term health consequences of illicit drug abuseamong aging adults. From these data we do not even know when use ofillicit drugs was initiated. We do know that the effect of drugs can be muchgreater as a person ages. For example, a dose of a drug taken at the ageof 23 may have a mild euphoric effect while the same amount taken at age

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246 D. F. Duncan et al.

55 may induce a more potent effect. This suggests the need for longitudinalnatural history studies of drug abuse among aging adults.

The extant literature is filled with authors differentiating between agingadults and younger populations. However, no one can tell us which of thesedocumented differences affect treatment outcomes. Further research shouldattempt better to describe the diverse characteristics that may affect bothdrug use and treatment outcomes.

A serious limitation of this study concerns the age variable providedfor analysis in the TEDS system. Currently, all adults aged 55 and older arelumped into a single category. For instance, there is no reason to suspect,a priori, that adults aged 50 to 54 and adults aged 55 and older consumethe same drugs, at the same rates, with the same consequences. We cannotassume homogeneity of use and effectiveness of treatments. It might beinformative to compare the drug admission patterns over time, perhaps using5-year increments, to trace the rates of illicit drug admissions among differentcohorts of adults. However, this study cannot be performed with the currentpublic use files.

This weakness is not exclusive to the TEDS data set. Many other nationaldata files available for secondary analysis, such as the NSDUH, routinely treatolder adults as one large, homogenous group. This makes almost as muchsense as combining all persons of color into one group (i.e., Latinos, AfricanAmericans, and Asians). Essentially, we must get out of the habit of lumpingdiverse groups into one.

Overall, these results start to document changing demographic trendsamong admissions for substance abuse treatment in the United States. Wesuspect that these trends are led primarily by the continuing emergence ofthe baby boomer generation. Fundamentally, however, the present data donot answer the question of what to do with a baby boomer who enterstreatment. Future research will be needed to address that issue, but thequestion has now been raised.

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