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Correspondence: Address correspondence to Claire Sterk, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta GA 30322. E-mail: csterk{at}emory.edu
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Abstract |
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Key Words: Maturing in • Aging into • Older drug users • HIV/AIDS • Drug trajectories
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Background |
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Limited research is available on late-onset illicit drug use (Neundorfer, Harris, Britton, & Lynch, 2005; Rosen, 2004). Yet the emerging older adult population forms the fastest growing age category of illicit drug users in the United States (Gfroerer et al., 2002). Moreover, substance-abusing older adults are a vulnerable population exposed to increasing health risks such as HIV/AIDS and other blood-borne and sexually transmitted infections (Anderson & Levy, 2003; Burbank, 2006; Emlet, 2006; Johnson & Sterk, 2003; Levy, Ory, & Crystal, 2003). Nokes and Emlet (2006) identified older injection drug users as having increased HIV-risk exposure and less access to HIV-related health services. In 1999, the youngest members of the baby boom cohort turned 35 years old, the age when drug users also are considered older. Baby boomers also are the cohort with the highest prevalence of illicit drug-use (Glantz, 1982), and they have not followed previous patterns of "maturing out" of drug use (Allen & Landis, 1997; Winick, 1962). The diverse cultural norms, values, and social contexts of aging older adults impact their drug use patterns (Stopka, Springer, Khoshnood, Shaw, & Singer, 2004). A life course approach offers a number of advantages for research on individual and cohort variation in aging.
A life course perspective focuses on the interactions between age, cohort, and period effects (Elder, 1994). Life course theory is sensitive to the personal histories of individuals and the timing of their lives in history, as well as the social and cultural systems in which they are embedded (Sampson & Laub, 1993). Changes in the life course are age graded, and behavior changes that are not in sync with age-based social norm expectations can have a negative impact on individuals as they age (Elder, 1994). Drug experimentation is expected to occur in youth, and the onset of illicit drug use after age 20 is assumed to be unlikely (Merline, O'Malley, Schulenberg, Backman, & Johnston, 2004); therefore, life course theory leads us to posit that the lives of older drug-using adults are affected by the age of onset of their drug use.
In this article, we explore heroin use among adults in mid- to late life, focusing on the timing of drug use. We note that the age group represented by the baby boom cohort is considered an "older" drug-using population. The years of birth for baby boomers are 1946 to 1964 (Gfroerer et al., 2002). Employing a life course perspective on the subjective experiences of older heroin-using adults as revealed in their retrospective life history narratives, we focus on differences between early and late onset of heroin use. Based on the literature discussed above, we use age 30 as the dividing point. With this study on older heroin users, we add to understandings of differences between early- and late-onset illicit drug users as well as stimulate research on the aging process of users of heroin and other illicit drugs.
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Methods |
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Eligibility criteria for TRENDS were as follows: (a) being 18 years of age or older; (b) residing in the metropolitan Atlanta area; (c) having used heroin at least once in the previous 30 days and at least six times in the previous 6 months; (d) not currently being in substance abuse treatment, prison, or jail; (e) not being intoxicated at the time of the interview; and (f) being able to conduct the interview in English. The inclusion criterion added for this inquiry was being an older drug user, defined as being 35 years or older in 1999.
Interviews were scheduled with eligible individuals at mutually agreed upon central locations. The approved consent forms were reviewed and signed prior to the collection of any data. All study materials were protected by a Certificate of Confidentiality. Audio-recorded life history interviews were conducted face to face and covered topics such as sociodemographic characteristics, drug use history, drug initiation, use trajectory, and social role involvement. The average length of the interviews was 80 min. The respondents received a $30 incentive for their time commitment to the study.
Data Analysis
The demographic and drug history data were in numerical format, and we summarized them by using descriptive statistics. Transcriptions of the qualitative data provided retrospective life histories of drug use and the effects of use on the lives of the respondents. Research has shown that retrospective life histories collected in cross-sectional designs allow for a life course analysis of change over time (Laub & Sampson, 2003; McElrath, Chitwood, Griffin, & Comerford, 1994; Neundorfer et al., 2005). A modified grounded theory method, driven by the users' perceptions rather than our own preconceived assumptions, guided the qualitative analysis (Becker, 1998; Charmaz, 2001; Strauss & Corbin, 1998). Charmaz (2005) suggested that qualitative researchers bring grounded theory method back to its symbolic interactionist roots, arguing for a "constructivist approach" (p. 509) that discerns and conceptualizes the "subtle empirical relationships" (p. 519). Here, we focused first on the meanings and processes involved in older drug use by comparing early- and late-onset users. This eventually led to conceptualizing early and late onset by the relationship between life course aging processes and onset categories.
Initial open coding involved a team of coders who worked on Project TRENDS at different stages of data collection. Each transcript was read by at least two coders, followed by a team discussion on the emerging codes and themes. The authors conducted the second level of coding for this article, focusing on all initial coding gathered under the themes of early and late onset. A qualitative data management computer program (QSR Nudist) allowed us to sort early- and late-onset quotes more efficiently and retrieve hard copies of coded text by conceptual categories. The conceptual second-level codes identified the subtle relationships between age of onset, timing of lives, and processes related to growing old while using drugs or initiating drug use when older. Although we initially focused on early and late onset, in the final stage of coding we interpreted these differences as a process of maturing in heroin use over the life course as compared to aging into heroin use later in life. We chose the terms maturing in and aging into because they effectively portray the differences between heroin users who become accustomed to using heroin as they mature and those who begin to use when they are already considered older. In this article we combine the a priori terms with our nascent terms to identify those who are early onset/maturing in and those who are late onset/aging into heroin use. We organize the qualitative results by these two categories of users.
Sample Characteristics
The sample for this article consisted of 29 heroin users. Table 1 shows the characteristics of the total sample and a comparison of early-onset/maturing-in and late-onset/aging-into heroin users. Their ages ranged from 35 to 54, with a mean of 43. African Americans represented slightly more than 58% of the sample and women almost 50%. A majority of the respondents were unemployed at the time of the study, and most were living in some housing situation other than owning or renting their own home (e.g., living with relatives or friends). A total of 13% said that they lived on the streets. Almost half of the sample was separated, divorced, or widowed at the time of the interviews. The respondents were almost equally divided between those who had less than a high school diploma (21.4%), a general equivalency diploma or high school diploma (25.0%), some college (28.6%), and a college degree (21.4%). Age of first use of heroin ranged from 10 to 48, and 28 years old was the average age of first use. All were poly-drug users for whom heroin was their primary drug of choice.
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Results |
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The life history narratives revealed two main patterns for the onset of heroin use, typically called early and late onset. Our analysis found that these two categories, which are based on age of onset of heroin use, illustrate the processes of maturing in and aging into heroin use. The maturing-in users typically had started heroin use in their youth and continued using throughout their lives. The aging-into users were those who may have used other drugs at some time in their lives but had never used heroin until they were in their 30s or older. We found that older adults who matured in heroin use differed from those who aged into heroin use in the areas of learning to control their use and navigating both the drug world and mainstream society, and in the timing of their knowledge regarding blood-borne disease transmission.
Early-Onset/Maturing-In Heroin Use
Instead of learning coping skills other than drug use to deal with life stresses, older heroin users in our study who matured in use learned coping skills to deal with their use. Our results showed that for some persistent heroin users, mainstream roles may have acted as motivators to control use throughout their lifetime. For example, one older woman who used throughout her adulthood said her children were her main reason to learn to control her use: "I had my kids and I knew that this is not right, ok. I can't drag my kids through this—that's what really gave me the willpower." Maturing in heroin use also provided the early-onset users with more years of experience navigating both the mainstream and drug-using worlds. For example, one older user explained, "I'm trying to control it, yeah. Back a few years ago, it would have been a problem." However, their lack of knowledge regarding disease transmission related to drug use when they started using in the 1960s and 1970s was a disadvantage for older adults who matured in heroin use. Several early-onset/maturing-in users recounted changing the route of administration over the years as their knowledge of disease transmission through unsafe injection practices increased. Here, we organize the results for early-onset/maturing-in heroin users by the themes of learning to control their use, learning to successfully navigate two worlds, and coping with the lingering health effects of early-onset/maturing-in heroin use.
Learning Control
Old users identified controlling their heroin use as a needed skill for maintaining mainstream roles while using. Maturing-in users revealed learning this through years of experience. Some older users had also experienced a street drug-using lifestyle for a few years but eventually found a way back to mainstream existence. This was illustrated by a 52-year-old father of four who described a controlled heroin user as someone who comes to terms with the life of an addict:
I've gone through stages where I could deal with it or so it seemed, and down and out [when I] just couldn't seem to get it together. I don't know what changed or how it got that way, but I finally sat down with myself and said ... if you're going to be a junkie, you might as well be a junkie ... The people that somehow or another do fairly well—they know who they are as far as being a junkie. They accept their selves and they have, one way or another, gotten themselves in a position where they can maintain themselves.
Although this early-onset/maturing-in user was an upper-middle-class homeowner with a stable work position, not all older users who learned to control their use were as financially secure. For example, one maturing-in heroin user who lived in a part of the city known for its drug market recounted how her years of experience helped her to advise an older drug-using relative: "You can control this. All you gotta do is pay all your bills and shit first ... that's having control over your drug habits. Go pay your bills first."
Learning from past experiences was a theme that had to be disentangled from the commonly held view that willpower and personal strength alone is needed to control addiction. At first, the users seemed to attribute their control to their own willpower, but after exploring this more deeply, they realized that their willpower stemmed from past experiences. A closer examination of their lives revealed that family and work roles were the most important reasons to maintain or regain control of their use. A father with few economic resources explained how he controlled his use to take care of his son:
At one time I felt [my heroin use] was increasing. So what I did was, I went to the hospital and told my doctor that I was hurting. And I told him some things that wasn't true. And he put me back in the hospital. So being in the hospital they gave me some things that helped me kick ... so that brought me all the way back down to one bag ... I don't neglect my son.
Users who matured in heroin use typically used only enough to manage their withdrawal pains. One older adult described learning to control heroin use as "using to feel normal." Once they felt normal they could continue with their lives, whether that be drug dealing or holding a job. For many, being a long-term heroin user meant doing both.
Successfully Navigating Two Worlds
The social context of heroin use included living in two different worlds: One was the mainstream world that involved work, a family, and intimate relationships; the other was the drug world that involved primarily obtaining heroin. The retrospective life histories revealed that for many, navigating these two worlds became easier over time. At the time of the study, most maturing-in users were economically and socially advantaged compared to those who had aged into heroin use later in life. However, some early-onset/maturing-in users had experienced drug use lifestyles such as "panhandling" (begging) on the street before returning to mainstream life. Others learned how to navigate the drug scene to obtain heroin while living otherwise conventional lifestyle. For example, a father who had been using heroin periodically since he was 18 was employed in professional work to support his family, yet he also supplied his habit while hiding it from his children and boss. He maintained his supply of heroin by buying in large quantities and selling to friends, a skill he had learned when working as a drug runner years ago. Although not all of the early-onset/maturing-in users in our sample were middle class, most had lived a conventional lifestyle at different phases in their life courses. Furthermore, most did not start using heroin on the street or stay on the street once they became addicted. Instead, they took advantage of their experience in drug-using environments to better navigate between the drug world and mainstream society once they regained their former social roles.
The stories from the early-onset/maturing-in users illustrate how those with more economic and social resources fared better and were able to choose when and where they would enter into the drug world. For example, one older user from a wealthy family had been using heroin since he was a teenager and had numerous treatment opportunities. He recounted his last treatment experience, which had allowed him time to learn a marketable skill:
I went to a 28 day program ... and then when I was finished there they told me that I needed more treatment time and so they sent me to a halfway house for rich people. I ended up staying in that halfway house for 8 months working, you know, going to support kind of groups. And then I got out and that's when I had the long time clean after that. I got out and went to massage school.
Such was not the case for an older African American woman who was born and raised in drug-dealing neighborhoods. As a woman with legitimate employment, she learned to control her heroin use while navigating a drug-infested world:
When they [street dealers] know it's time for us to get a paycheck or whatever, they're like, "Hey, here, guess what I got some"—matter of fact, little [dealer], he did it yesterday, you know, "Hey, I got somethin right here for you" ... I was like "Man, uh-uh. I already got my shit. I don't need that." You know. But it's like they try to bait you in. And if you a fool and fall for it—you fucked.
Although few of the older users in our sample fit the stereotype of the older street addict, those with a criminal history had more difficulty in mainstream society. One older woman had supported herself and her habit through sex work since she had been a runaway teenager. The street-level work was the cause of her frequent stays in jail. She explained, "I've never been arrested for drugs." She was the only early-onset/maturing-in user in our sample who had never obtained an enduring mainstream role.
Health Effects: The Legacy of Shooting Galleries
The negative health effects of heroin use among some early-onset/maturing-in users stemmed from years of injection use. The deterioration of their livers, kidneys and teeth was mentioned by some of the older users who had been using for years. More often they talked about their collapsed veins and frequent abscesses. For example, an older maturing-in female user described her injection ritual:
Well, anywhere you can get a vein to come up. If I soak my hands in hot water for a while and it will bring up some veins, pretty much in your fingers. My arms—I've got marks and I can get veins up here sometimes but all of these—these are gone.
The early-onset/maturing-in users in our sample started using heroin in the 1960s and 1970s, before widespread knowledge of disease transmission through unsafe injection practices. The social environment of heroin use in the early years of their use involved injection rituals in unsanitary conditions and with a drug of dubious purity. One older user described the heroin obtained during that time period:
It was just disgusting stuff really. It wasn't refined at all ... And you'd have to sit and cook it for half an hour, and you never knew how potent it was gonna be. You were really gambling with it. Bad infections too. [I] got a lotta bad bacterial infections from it.
Most of the early-onset/maturing-in users in our sample had contracted one or more communicable diseases, typically hepatitis B and/or C, by injection in those early days. Some talked about the legendary "shooting galleries" where needles were shared: "They used to have the shooting galleries where there'd be a cup on the table with about 30 syringes in it ... and you would just pick one up and use it." As public health messages regarding AIDS transmission increased, knowledge of how to avoid contracting diseases increased, but often it was too late. Although few reported knowing they were HIV positive, some said they "feared" they were HIV positive but did not want to take the test. For example, one older user seemed resigned to her health status: "I have hepatitis C and I'm afraid I'm HIV positive. I'm pretty sure about it. Yes—because it's always possible. I've used so many syringes."
Late-Onset/Aging-Into Heroin Use
Older adults in our study who aged into heroin use reported great difficulty in controlling or coping with their use. Typically, they began using heroin when they were past the life course phase of raising children or developing a conventional work career, which are motivations for controlling use. Generally, once these users lost control they felt hopeless. In addition, their few years of experience in the drug-using world led them into unknown areas. However, due to the widespread public health initiatives to increase knowledge regarding the transmission of HIV/AIDS and other blood-borne viruses, the late-onset/aging-into older adults reported fewer detrimental health effects from their drug use than those who started earlier in life when this information was not well known. Many of the late-onset/aging-into users said either they never injected drugs or they used safe injection practices. The results for this type of older user are organized here by the themes of loss of control over their use, difficulties navigating two worlds, and the health advantages of more recent harm reduction public health initiatives.
Losing Control
Those who started using heroin at age 30 or older and who lost control of their use had little hope of regaining control. For example, one 54-year-old female user began using heroin late in life while in a relationship with a heroin-using boyfriend. She explained:
When he left I was on my own with no money and a habit ... I had always been a secretary or receptionist. I'd never had a career or anything because my ex-husband and I had lived together 15 years and he was pretty wealthy ... money was never a problem up until I got into drugs. And then, of course, that all changed.
One way to learn control is to experience a few episodes of withdrawal and overcome the fear of withdrawal pains. However, many of the late-onset/aging-into users were afraid of withdrawal, such as this grandmother who started to withdraw with her unsuspecting family in the house:
I'm also afraid because I don't know what would come of it. I don't know how the pain would be physically, mentally, or emotionally. I mean I've never seen anyone detox. I've never done it myself, so it's like what would I expect? Would I live through it? I don't know. I don't wanna scare my daughter or my grandchildren by me holing [sic] up in a room, which I've never done. They've never seen me going through withdrawals.
This grandmother's story illustrates the dilemma of many older aging-into heroin users who have little experience on how to handle withdrawal symptoms and therefore little knowledge of how to control their use when it escalates. In contrast to maturing-in users, those who aged into heroin use later in life had fewer years to learn how to keep their mainstream social roles while using drugs. Some of them did not try maintaining both roles simultaneously. For example, one late-onset/aging-into user was a grandmother who used heroin daily. When asked how she maintained that frequency of use along with her grandmother role, she explained, "If I feel like it's too bad for me to handle, then I'll return my grandchildren home, and then I go and try to do somethin' for myself." As a grandmother, she could always relinquish her grandmother role by returning the children to their mother, so she did not need to control her habit.
Other late-onset/aging-into users implied that learning control was unnecessary for them because they had no other pressing roles at their age. For example, a 49-year-old woman who currently used only four or five times a month explained that she took heroin when she had "just nothing to do—bored." When asked why she had not started any illegal drugs except marijuana until she was 41, she explained she raised her children and was happy, but now her children were grown and gone and she was free to use. Others indicated that they were merely occasional users. Another older adult who called himself a "casual user" explained that he uses only when he is "around friends that use." For these late-onset/aging-into users with no history of previous use, we cannot predict if their casual use will continue or escalate. Yet, as shown by the grandmother's story, with few years of experience and little knowledge of withdrawal patterns or treatment options for heroin, these older late-onset/aging-into users lack vital resources for learning how to control their use when needed.
Difficulties Navigating Two Worlds
Those who aged into heroin use late in life had less time to learn to navigate between the drug-using world and their more familiar mainstream world. Having access to heroin dealers was generally a problem for users who began late in life. Although some users had lived geographically within the drug market previous to their using, they had not interacted with the drug-using components of this area until they began to use. Others from middle-class neighborhoods entered into this world for the first time when they started using heroin and did not have a drug contact where they lived. For example, one older woman from a middle-class neighborhood started using heroin with her ex-boyfriend. She explained her precarious situation after he left: "I didn't really have any connections in the [heroin dealing area of town] ... It was scary—real scary, driving over there in that area."
Other late-onset/aging-into users were already living on the margins of society when they began using heroin. One late-onset/aging-into user described his old neighborhood, which had become a heroin dealing area:
It's not the same people, not here. The young guys are more radical. Anything might happen. They don't know you there—don't know me because I am older than them. I was hanging when they are coming up. Now you got to know somebody to walk around here.
Another older man from a working-class neighborhood began to use heroin late in life and soon lost his foothold in mainstream society. His story illustrates the typical outcome of late-onset/aging-into users with few social resources. After he lost his job due to a drug screen, his wife prohibited him from coming home. At the time of the interview he was living wherever a neighbor would offer a bed. His unfamiliarity with the heroin drug market often left him in desperate situations when he needed drugs. He explained that he was worried about the cut of the heroin he was buying: "I don't want to die. I don't want to OD [overdose]."
The Legacy of Harm Reduction
Most of the late-onset/aging-into heroin users were confident about protecting their health while using. They felt they were well educated in terms of drug-related infectious diseases and harm reduction strategies. Most knew how to protect themselves from contracting communicable diseases because of their exposure to public health initiatives. Those who lived in the heroin market neighborhoods reported obtaining their needles from the local harm reduction organization. Compared to the early-onset/maturing-in users, few late-onset/aging-into users reported having hepatitis or experiences with bacterial infections. Many avoided injection use settings. One older woman who allowed heroin users to frequent her house explained, "When they come here they been done already did their injections. They come here to snort, sit down, and nod out."
We note, however, that these late-onset/aging-into users were still navigating the drug world and learning how to control their use. Despite their knowledge, we found that more intervention in the area of HIV prevention was needed. For example, one late-onset/aging-into older female user who lived in a disadvantaged neighborhood did not want to tell anyone what she had just learned about her health status. After first saying she was not sure if she was HIV positive, she lowered her voice and whispered, "No one knows this but you. Okay? Yeah, I'm HIV. I found out right before I came here."
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Discussion |
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Typically, studies on older heroin users have drawn from street populations (Johnson & Sterk, 2003; Levy & Anderson, 2005) or treatment facilities (Hser et al., 2004; Kwiatkowski & Booth, 2003). Our study sample of older heroin users drew from a wide range of socioeconomic status groups, revealing that older heroin users who began using early in life may have some benefits compared to those who start later. Furthermore, the analysis of this diverse sample reveals that onset categories for older users of illicit drugs might be better explained when conceptualized as categories of early onset/maturing in and late onset/aging into.
A life course perspective focused our analysis on the processes of maturing in or aging into heroin use, thus separating older users not by age of onset alone but also by their life experiences and the timing of their heroin use onset in relation to life course norm expectations. The role adjustments that occur across the life span, such as retirement, grandparenting roles, and other changes that come with aging (Minkler & Roe, 1993), were integrated into the lives of early-onset/maturing-in heroin users as they learned through life experiences. In contrast, the late-onset/aging-into heroin users either lost these roles with little hope of regaining them or were at more liberty to use heroin due to their decreased involvement in mainstream roles as they aged.
This study is limited in that, as an exploratory study with a small sample, the findings are not meant to be generalized to all older users of heroin. We acknowledge that the sample is not representative of older adults who are in institutions, such as prison or mental health facilities, and that it excludes those who are in drug treatment. By incorporating targeted sampling methods, we drew from a wide range of socioeconomic statuses and diverse social networks. Therefore, our sample may be less representative of the more marginalized hard-core users found in studies drawing from treatment and street addict communities (Levy & Anderson, 2005; Stephens, 1991). Larger studies should examine further the differences found here.
We suggest that a model that integrates the concepts of maturing-in and aging-into with early- and late-onset categories is more beneficial for studies on older users of illicit drugs than the age-of-onset model used in alcohol abuse research. Furthermore, baby boomers have different life course experiences than persons of previous drug-using older cohorts (Laub & Sampson, 2003; Mannheim, 1997). Baby boomers are the largest age cohort as well as the largest known drug-using cohort in modern history. A more in-depth understanding of this population is needed to successfully address the predicted epidemic of older drug users.
National surveys, treatment data, and health reports reveal that drug use is increasing among older adults (Gfroerer et al., 2002; Levy et al., 2003). The reality of illicit drug use among older adults does not correspond with the movie version. Most aging heroin users will not die peacefully in their sleep, and families will not passively accept drug use in old age, as depicted in Little Miss Sunshine. The findings of this study are essential for adequately addressing the social and health needs of older adult drug users, specifically those who use heroin. Moreover, our analysis of in-depth interviews with older heroin users contributes to a better understanding of the differences between those who started using heroin early in life and those who started after age 30; distinctions can be used to inform programs aimed at older users. Older adults who are early-onset/maturing-in users have gained experience in controlling their use and navigating drug-using environments; however, they were exposed to injection rituals ubiquitous before widespread awareness of the transmission of blood-born infections and may have greater health issues related to their drug use as they age. In contrast, older adults who started using heroin later in life have benefited from pervasive public education on harm reduction among drug users, but their increased vulnerability to the social difficulties and financial distress associated with drug use needs to be addressed. Exceptions exist in both groups. Among early-onset/maturing-in older users were those who had frequent or long periods of institutionalization, typically in jail or prison, that hindered their ability to bond with mainstream society. Among late-onset/aging-into heroin users were those who were still in the early stages of their use, and only time will reveal if they will be able to continue their occasional use pattern. Together, these results suggest a pressing need for policies that focus less on the incarceration of drug users and more on treatment options at all stages of the drug career, regardless of the user's age. These findings also support research showing that older adults, particularly those from disadvantaged groups, are at increased risk for contracting HIV/AIDS through drug-related practices (Levy et al., 2003; Neundorfer et al., 2005; Theall, Elifson, Sterk, & Klein, 2003). Consistent with previous research on older drug users, the findings call for increased HIV/AIDS intervention and prevention programs targeted at midlife and older adults (Altschuler, Katz, & Tynan, 2004; Anderson & Levy, 2003; Burbank, 2006; Emlet, 2006; Hser et al., 2004; Johnson & Sterk, 2003; Levy et al., 2003; Neundorfer et al., 2005; Orel, Wright, & Wagner, 2004). The life course focus of this study calls attention to the need for programs tailored to either maturing-in or aging-into older heroin users.
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1 Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA.
2 Department of Sociology and Criminal Justice, Kennesaw State University, Kennesaw, GA.
3 Department of Sociology, Georgia State University, Atlanta.
Decision Editor: Nancy M. Schoenberg, PhD
Received for publication September 19, 2007. Accepted for publication March 13, 2008.
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