Last week (14 June 2019), the government’s independent Advisory Council on the Misuse of Drugs (ACMD) published a new report on Our Ageing Cohort of Drug users.
The past decade has seen a shift in the age profile of those seeking treatment for drug use. An ageing cohort, who have survived lengthy histories of heavy drug use, now account for an increasing portion of the treatment group in the UK and Europe.
The report explores the specific issues for older people with a drug problem focusing on those who have had a drug problem for an extended period of time. It describes the health and social care needs of this population, and identifies effective services responses and best practice.
Specialist drug treatment data have charted a looming challenge with increases in the number of older drug users receiving treatment.i The ageing cohort we focus on is characterised by problematic opiate/opioid use. Available data show a substantial, consistent, year-on-year increase in the number of treated opiate users who are over the age of 40: this number almost tripled, from around 26,000 in 2005/06 to around 75,000 in 2017/18.
The graphic below shows that the number of individuals in treatment for primary opiate problems under the age of 30 has declined substantially over the past decade (from around 55,000 to around 13,000 (compiled by a working group from PHE, NDTMS data).
As this cohort ages, some will recover, achieve sustained abstinence and exit specialist treatment services. Some people will die as a direct or indirect consequence of their drug use or other age-related conditions. Over time, it might be expected that the older opiate-misusing treatment population will reduce in size, but those still in treatment will have increasingly complex physical, psychological and social needs.
It seems likely that this older population will have poor prospects of achieving permanent abstinence, although some may do so and this may continue to be the ultimate aim of treatment. Their need for stabilising substance misuse treatment will persist, as will the need to address increasing and premature age-related ill health. Therefore, unless there are dramatic and unexpected changes in this population, addressing the complex and varied needs of older opioid/opiate users will become the mainstream of treatment activity rather than a treatment specialism.
Challenges for treatment services
The ACMD notes that community-based specialist drug services have experienced significant disinvestment and also experienced a loss of skilled staff . This is highly likely to impact on the capacity of the treatment system to undertake the type of complex interventions needed by an ageing cohort of opioid/opiate users. Concerns have been raised about the declining involvement of professionals in delivering community drug treatment services, especially addiction specialist doctors, psychologists, nurses, and social workers. There is growing recognition among the workforce and stakeholders of increasingly complex needs in the service user population. The workforce that is needed should be ‘competent in identifying and responding to a wide range of health and social care needs and be able to support people to access treatment for co-existing physical and mental health issues’.
The ACMD highlights that as this cohort ages further, it will require a set of costly and multi-disciplinary interventions beyond specialist drug treatment. Such measures do not appear to be in place at the levels required to meet the current and upcoming needs of this population. Less successful outcomes in treatment populations is a particular concern for healthcare services.
Drug services thus need a workforce skilled in the complexity of need among older drug users, covering not just substance use, but common comorbidities. Non-drug services, that are generic and other specialist health and social care services, need skills to detect drug use in the older population and awareness that some of their service users may be long-term substance users.
Treatment outcomes may be improved further if treatment is delivered by a substance misuse service specifically for ageing people (as indicated by examples, such as programmes operated within services like those at the Bristol Drugs Project). However, few of these services exist in the UK and most that do exist are only commissioned to deliver alcohol treatment. Several best practise examples of services for the ageing cohort and innovatory services exist (listed in Appendices to the report). The ACMD provides a helpful list of the critical success factors of these services:
- Person-focused interventions:
- intensive case management;
- helping clients to build their confidence;
- encouraging physical activity;
- helping clients to develop and maintain a social network; and,
- providing a stable independent home combined with personalised support.