Deaths of older drug users

Deaths of older drug users Dr. Caryl Beynon Reader in Substance Use Epidemiology Centre for Public Health, Liverpool John Moores University Email: c.m.beynon@ljmu.ac.uk Web: www.cph.org.uk

Drug Treatment Programmes Cheshire and Merseyside

Drug Treatment Programmes Cheshire and Merseyside 98.5% 94.3% 5.6%

Drug Treatment Programmes Cheshire and Merseyside 98.5% 98.1% 94.9% 94.3% 5.6% 5.1% 1.9%

Drug Treatment Programmes Cheshire and Merseyside

Needle and Syringe Programmes Merseyside

Needle and Syringe Programmes Merseyside Source: Inter Agency Drug Misuse Database

Deaths of Older Drug Users Question 1: Has the average age of death of drug treatment clients changed in recent years? Question 2: Do older drug users and younger drug users die from different causes?

National Drug Treatment Monitoring System (NDTMS) North West Monitoring data Anonymous details of people reported as dead Drug treatment agencies Names of people reported as dead Anonymous death details Office of National Statistics (ONS) Centre for Public Health Deaths in Treatment: Methodology Drug treatment agencies (tiers 3 and 4)

Drug related deaths

Age at Death, Drug Treatment Clients (North West of England) Spearman’s rank correlation: P<0.01

Death Age: less than 40 Age: 40 and above Drug related death Non drug related death Drug related death Non drug related death

Death Categorisation by Age

Older drug users are significantly less likely to die from a drug related death (the acute effects of drug use). Then what are older drug users dying from?

Diseases of the Liver • Liver diseases (including alcoholic liver disease). • Hepatitis C. • Neoplasm of the liver (hepatitis as secondary cause). • Not drug related?

Diseases of the Cardiovascular System • Ischemic heart disease. • Cerebrovascular disease. • Stimulants are vasoconstrictors = increased blood pressure = damage to arterial walls = reduction in blood supply. • Nicotine = increased blood pressure…. • Smoking = release of cholesterol into the blood stream = atherosclerosis = increased blood pressure….

Diseases of the Cardiovascular System • Ageing is coupled with: • Blood pressure changes. • Venous value deterioration. • Reduced regenerative processes. • Reduce mobility. • Deep vein thrombosis.

Respiratory Diseases • Acute lower respiratory infections (influenza and pneumonia). • Chronic lower respiratory diseases (chronic obstructive pulmonary disease). • Pneumonia (common in old and young) • Pathogen is inhaled • Pathogen enters via injection site • Reduced immunity of older people. • Chronic lower respiratory diseases (old) • Smoking • Harm reduction?

Deaths from Stroke (England, 2006) Source: British Heart Foundation (2009)

Deaths from Myocardial Infarction (England, 1996-2004) Source: SWEPHO(2006)

Interview Methodology • Semi-structured interviews. • Interview duration: up to one hour. • Data were collected in January/February 2008. • Interviews were taped and transcribed and analysed thematically. • Interviewees were recruited via drug services in Merseyside.

Participant Characteristics • 9 men and 1 woman. • Age range: 54 to 61. • 6 were single, 4 were divorced. • Accommodation included: hostel, own home (council house, flat or housing association bed sit), care home, caravan. • All were, or had been, problematic drug users.

Drug Use Initiation • Late onset drug user. • Adolescence or early adult years. • Recreational use, experimentation, escape, part of the ‘hippie era’, triggered by childhood abuse or parent dying. • Drugs first used: alcohol, cannabis, LSD, amphetamine, morphine hydrochloride, heroin, speedballs (heroin and cocaine), psilocybin-containing mushrooms. • Late onset problematic drug use.

Current Drug Use • Trying to use responsibly and to maintain their health and personal safety. “So I’ve got to be very careful, my body’s not what it was. Occasionally I can get carried away and I’ll be feeling, because I’m feeling young inside, I’ll be feeling young outside, which is just not so. These days I’ve got a handle on that. If I’ve been drinking a lot I won’t smoke. Even if I’m not feeling too good, I’ll leave it until the alcohol’s worn off some to make sure that I’m not going to go asleep and not wake up.” (man aged 61)

Physical Health • Poor physical health. • Chronic and life threatening conditions: circulatory problems (deep vein thrombosis, ulcers, stroke), respiratory problems, pneumonia, diabetes, hepatitis, liver cirrhosis. • Malnutrition, weight loss, obesity, impaired mobility. • History of accidental injury (e.g. falls) and overdose.

Physical Health: Hepatitis C • Half had hepatitis C. • Serious infection. • Long asymptomatic phase. “I’ve never really had any serious illnesses... I forgot the hep C y’know. I’ve had no symptoms. I haven’t been sick or anything y’know but I’ve got the virus”. (man aged 56)

Physical Health: Vein Damage • Problems with venous access. “I can’t get a vein in my arm now” (man aged 56) • Switched to riskier practices. “It’s harder now to inject because your veins. Your veins sort of go y’know... I’ve been injecting in my foot, which is stupid really, y’know. You can catch an infection and you could end up losing your leg”. (man aged 56)

Physical Health: Respiratory Problems • Crack cocaine smokers. “I get out of breath easy. I absolutely panic then”. (man aged 52) “It’s tender inside and when I breathe I can’t breathe hard cos it hurts like hell”. (man aged 58)

Mental Health • Interviewees talked of a life using drugs as being depressing. “It’s a depressing life y’know. It’s not good”. (man aged 56) • A way to forget problems. “That’s all we do anyway. Just take it [heroin] and just mong for the day like and forget about your worries and everything, got problems and you forget all that. Things like that; it’s the reason why people take it like”. (man aged 56)

Mental Health • Drug use escalated, or recommenced, in times of stress. “You reach a point in our life, different points in your life where you’ve got a lot of stress and the easiest thing in the world is to say ‘oh fuck it’. And once you’ve said that, if you’re a drug user, a drug abuser, once you’ve said that, you’re on the rocky road to destruction again”. (man aged 61)

Social Relationships • All participants were single or divorced. • Loss of relationships (family members, spouse or partner, children, friends) common theme. “I’ve just been left to rot on my own”. (man aged 56) • Death of drug-using friends was particularly common. “In fact they’re all dead now, aren’t they, pretty well. I think there’s about two left. And god knows how many all dead.” (man aged 61)

Mental Health and Social Relationships • Strong social networks very important for mental health of older people. • All older people experience loss of friends and family but intensified in drug users. “It’s made me extremely depressed in as much as the few that were left are people I could talk to and at least there’s consolation in company if it’s good company... [now] the only company I could find if I wanted to would be people who are younger and on that totally different scene, and like I say, I have nothing in common with them... Consequently I find myself quite lonely at times”. (man aged 61)

Mental Health and Social Relationships • Exacerbated by paranoia. “You can only enjoy it [drug use] for so long, then paranoia sets in and it does your head in”. (man aged 61) “I don’t like going to pubs. I always get paranoid… Everybody’s looking at me…Drugs. Drugs do it to you”. (man aged 58)

Conclusions • Data suggest that each year, a growing proportion of drug users are reaching the age of 50. • The average age at which drug users die is increasing. • Older drug users face new health challenges (chronic effects of drug use). • Deaths of older drug users are not reflected in official drug related death figures. • Care of older drug users will need to involve primary, secondary and tertiary care and social services as adjuncts to drug treatment.

Deaths of older drug users