Reconceptualizing Early- and Late-Onset: A Life Course Analysis of Older Heroin Users

Abstract

Purpose

Our knowledge regarding older users of illicit drugs is limited despite their increasing numbers. In this paper we apply a life course perspective to gain a further understanding of older adult drug use, specifically contrasting early- and late-onset heroin users.

Design and Methods

Qualitative data were collected from 29 older heroin users. Life course analysis focused on the users’ experiences across the life span.

Results

The findings suggest that those aging-into heroin use (late-onset) are disadvantaged compared to those who are maturing-in (early-onset) except in areas of health.

Implications

We propose that conceptualizing the use of heroin and other illicit drugs among older adults based on their life course trajectory will provide insights for social and health services, including drug treatment.

In 2007, actor Alan Arkin won an academy award for playing a heroin-using grandfather in the movie “Little Miss Sunshine.” It was unclear whether Arkin’s grandfather character began using heroin as a young adult or later in life. He dies peacefully from an overdose. We might ask to what extent popular entertainment is mimicking reality? Older users of illicit drugs, typically referring to those 35 and older (Gilson, Chilcoat, & Stapleton, 1996) are a small but rapidly growing group of users. Traditionally, illicit drug use was assumed to diminish during adulthood. Winick’s (1962) maturing-out thesis posits that most heroin users will mature out of drug use in their thirties as they grow tired of the drug-using lifestyle, resolve the circumstances that triggered their use, or identify different coping mechanisms. Whereas subsequent research supported this thesis (Ball & Snarr, 1969), others found illicit drug use to extend beyond the mid-thirties (Boeri, Sterk, & Elifson, 2006; Levy, 1998; Sterk, 1999). The initiation or continued use of illicit drugs among those in their thirties and older is a phenomenon that is increasing as the baby boom cohort ages (Gfroerer, Penne, Pemberton & Folsom, 2002). Heroin in particular is identified as more commonly used by older adults (Anderson & Levy, 2003; Rosen, 2004). The objective of this study is to examine differences between early-onset older adults who began using heroin before their thirties and who continued using, conceptualized here as maturing-in heroin use, and late-onset older adults who initiated heroin in their thirties or older, conceptualized here as aging-into heroin use.

Background

Initiating the use of a substance late in life is known as late-onset use, a phenomenon that first received attention in alcohol studies (Atkinson, Tolson, & Turner, 1990; Schonfeld & DuPree, 1990). There is some debate regarding the age for defining late-onset (Lynskey, Day, & Hall, 2003). The age for late-onset of alcoholism has been set in the mid-twenties (Dom, Hulstijn, & Sabbe, 2006), thirties (Babor et al., 1992), forties or fifties (Atkinson et al., 1990; Schonfeld & DuPree, 1991) or even at 65 (Benshoff & Roberto, 1987). The trend is to set the initiation age for late-onset at a younger age. When comparing early- and late-onset alcohol abuse, the former appeared to face more cumulative negative effects based on the drain caused by a greater total number of years of use (Atkinson, 1994; Brennan & Moos, 1996).

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 U.S. (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 known as the highest prevalence illicit drug-using cohort (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-using patterns (Stopka, Springer, Koshnood, Shaw, & Singer, 2004). A life course approach offers a number of advantages for research on individual and cohort variation in aging.

Life Course

A life course perspective focuses on the interactions between age, cohort and period effects (Elder, 1994). Life course theory is sensitive to the personal history 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 onset of illicit drug use after age 20 is assumed 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 paper, we explore heroin use among adults in mid-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 our understanding of differences between early- and late-onset illicit drug users as well as stimulate research on the aging process for users of heroin and other illicit drugs.

Methods

Data Collection

The cross-sectional retrospective life-history data presented in this paper are part of project TRENDS, an investigation of emerging drug use patterns in Atlanta, Georgia. Nine women and five men of various racial and ethnic backgrounds conducted the recruiting and interviewing. Targeted sampling guided the recruitment (Watters & Biernacki, 1989) and as the study progressed, theoretical sampling was employed to ensure a diverse sample (Strauss & Corbin, 1998).

Eligibility criteria for TRENDS were: (1) be 18 years of age or older; (2) reside in the metropolitan Atlanta area; (3) have used heroin at least once in the previous 30 days and at least six times in the previous six months; (4) not currently being in substance abuse treatment, prison, or jail; (5) not being intoxicated at the time of interview; and (6) 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, covering topics such as socio-demographic characteristics, drug use history, drug initiation, use trajectory, and social role involvement. The average length of time for the interviews was 80 minutes. 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 summarized 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 shows 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) suggests 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 first focused 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 the Trends project 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 second level of coding for this paper was conducted by the authors, 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 drugs when older. While 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. The terms “maturing-in” versus “aging-into” were chosen since they effectively portray the differences between heroin users who become accustomed to using heroin as they mature and those who begin use when they are already considered older. In this paper 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. The qualitative results are organized by these two categories of users.

Sample Characteristics

The sample for this paper consists of 29 heroin users. Table 1 shows the characteristics of the total sample and a comparison of those who are early-onset/maturing-in and late-onset/aging-into heroin users. Their ages ranged from 35 to 54, with a mean of 43 years old. African Americans represent slightly over 58 percent of the sample and females almost 50 percent. A majority of the respondents were unemployed at the time of the study and most were living in some other housing situation than owning or renting their own home, such as living with relatives or friends. Thirteen percent said they lived on the streets. Almost half of the sample were 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 GED or high school diploma (25.0%), some college (28.6%) and a college degree (21.4%). Age of first use of heroin ranged from age 10 to 48, while 28 years old was the average age of first use. All were poly-drug users for whom heroin was their primary drug of choice.

Table 1.

Sample Characteristics of Early-Onset/Maturing-In and Late-Onset/Aging-Into Older Heroin Users

Variable	Early (%) (N=16)	Late (%) (N=13)	Total (%) (N=29)
Gender
Female	37.5	61.5	48.3
Male	62.5	38.5	51.7
Race/Ethnicity
African American	50.0	69.2	58.6
White	43.8	30.8	37.9
Bi-racial	6.3	0.0	3.4
Employment Status
Full-time	12.5	15.4	13.8
Part-time	18.8	7.7	13.8
Unemployed	68.9	77.7	72.3
Education
Less than HS	12.5	33.4	21.4
HS/GED	6.3	50.0	25.0
Some college	37.6	16.7	28.6
College Degree	37.5	0.0	21.4
Post College	6.3	0.0	3.6
Residential Status
Own or rent	25.0	15.4	20.7
Public Housing	6.3	0.0	3.4
Other Housing	50.1	77.0	62.0
Street	18.8	7.7	13.8
Marital Status
Married	18.8	0.0	10.3
Living w/partner	6.3	23.1	13.8
Steady relationship	6.3	7.7	6.9
Single	25.0	23.1	24.1
Separated/divorce/widowed	43.8	46.2	44.8
Mean Age (SD)	43 (6.0)	43 (5.5)	43 (5.6)
Mean Age (SD) of First Heroin Use	19 (5.2)	40 (5.6)	28 (12.0)

Notes: Mean age is rounded to the nearest year; SD = standard deviation

Results

Compared to early-onset/maturing in users, the late-onset/aging-into heroin users in our sample are more likely to be female, African American, and living with a partner. A greater percentage of early-onset/maturing-in users were married, had post-high school education, and were employed as compared to their late-onset/aging-into peers. There was little difference between the average current age of early-onset/maturing-in and late-onset/aging-into heroin users in this sample, but there was a substantial average age-of-onset difference. These differences are not based on statistical tests. Since the quantitative findings from a small, non-probability sample do not allow generalizations to be proposed, we present this descriptive data to illustrate the diversity of this sample and to set the context for the qualitative results.

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 based on age-of-onset of heroin use illustrate the processes of maturing-in and aging-into heroin use. The maturing-in users typically started heroin use in their youth and continued using throughout their lives. The aging-into users are those who may have used other drugs at some time in their lives but had never used heroin until they were in their thirties 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, navigating both the drug world and mainstream society, and 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 show that for some persistent heroin users, mainstream roles may act 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 in both 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 sixties and seventies 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. The results for early-onset/maturing in heroin users are organized by themes of learning to control their use, learning to successfully navigate two worlds, and the lingering health effects of early-onset/maturing-in heroin use.

Learning control

Controlling their heroin use was identified by older users as a needed skill to maintain mainstream roles while using. Maturing-in users revealed learning this through years of experience. Some older users 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.

While this early-onset/maturing-in user was an upper-middle-class home owner 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 is 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 the use. A father with few economic resources explained he 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. Learning to control heroin use was described by one older adult 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 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 an 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. While not all of the early-onset/maturing-in users in our sample were middle-class, most lived a conventional lifestyle at different phases in their life course. 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 they 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 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 female 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.

While 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 was a runaway teenager. The street-level work was the cause of her frequent stays in jail. As she explained, “I’ve never been arrested for drugs.” She was the only early-onset/maturing-in user in our sample who 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 liver, kidneys and teeth were 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 heroin use in the sixties and seventies, before widespread knowledge of disease transmission through unsafe injection practices. The social environment of heroin use in the early years of their use involved injecting 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 use 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. While few reported knowing they were HIV positive, some said they “feared” they had it 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 they either never injected drugs or they used safe injection practices. The results for this type of older user are organized by themes of losing control over their use, difficulties in navigating two worlds, and the health advantages of more recent harm reduction public health initiatives.

Losing control

Those who started 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 had little experience on how to handle withdrawal symptoms and therefore little knowledge of how to control their use when it escalated. 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 since they had no other pressing roles at their age. For example, a 49-year-old female 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 in 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 in navigating two worlds

Those who aged-into heroin use late in life had less time to learn navigating 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. While some users lived geographically within the drug market previous to their using, they did not interact 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 male 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 losing 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 are 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 is 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.”

Discussion and Implications

In this study we extend the research on onset of use to include heroin-using older adults. In contrast to findings that show early-onset of alcoholism is associated with higher levels of social and family problems compared to late-onset of alcoholism (Atkinson, 1994; Brennan & Moos, 1996; Dom et al. 2006), our findings, while not based on statistical differences, show that early-onset heroin users are more likely to be married, employed, and have post high-school education than are those who are late-onset heroin users. Contrary to expectations, the qualitative data reveals those older users who started heroin as adolescents or young adults were better able to control their heroin use as well as maintain mainstream social roles than were those who started using heroin later in life. Additionally, their years of experience in maintaining mainstream social roles while navigating the drug world was often an advantage over those who came to heroin use later in life. These findings suggest a protective factor of early-onset/maturing-in use linked to years of experience learning how to control their use through trial and error. Our findings support previous literature suggesting that findings on alcoholism cannot be generalized to the use of illicit drugs among older adults (Maher, 2002; Stopka et al., 2004).

Typically, studies on older heroin users draw 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 draws from a wide range of socio-economic status groups, revealing that older heroin users who began use 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 by 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 the life experiences of older users and the timing of heroin use onset in relation to life course norm expectations. The role adjustments that occur across the life span, such as retirement, grand-parenting 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 they were at more liberty to use heroin due to their decreased involvement in mainstream roles as they aged.

However, for many users who started injecting heroin early in life, when needle sharing was more common, the public health warnings regarding the link between drug use and infectious diseases were too late. Our findings show that late-onset/aging-into users benefited from the increased awareness of communicable diseases during the past decade, particularly in regards to HIV/AIDS and hepatitis C. Nevertheless, merely knowing how to contract these diseases may not be sufficient for older users who have few resources and little access to drug-using paraphernalia. This finding supports research showing that older adults, particularly those from disadvantaged groups, are at increased risks for contracting HIV/AIDS through drug-related practices (Levy et al., 2003; Theall, Elifson, Sterk, & Klein, 2003; Neundorfer et al., 2005).

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 in prison or mental health facilities, and excludes those who are in drug treatment. By incorporating targeted sampling methods, we drew from a wide range of socio-economic status 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). The differences found here should be further examined in larger studies.

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 those 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 drug users will not die peacefully in their sleep, and society will not passively accept their continued drug use into old age. The findings of this study are essential to adequately address the increasing 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 thirty. Distinctions emerged that can be used to inform programs aimed at older users. Older adults who are early-onset/maturing-in users gained experienced in controlling their use and navigating drug-using environments; however they were exposed to injection rituals ubiquitous before widespread awareness of 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 benefited from the increased 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, which 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 would be able to continue their occasional use pattern. Together, these results suggest a pressing need for policies that focus less on incarceration of drug users and more on treatment options at the early stages of the drug career, regardless of age. Furthermore, consistent with previous research on older drug users, the findings call for increased HIV/AIDS intervention and prevention programs targeted for 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.