To the Editor: Cocaine use in young people has been well documented and is recognized as a precipitating cause of chest pain and myocardial infarction (MI). Less is known regarding the extent of cocaine abuse in an older population, and thus its role is poorly documented. This population is at higher risk of having underlying atherosclerotic disease, which may worsen the effect of cocaine particularly on the cardiovascular system. Furthermore, physicians are least likely to suspect or question illicit drug use in the older population. Given the propensity of drug abuse in the baby boomer generation, it is expected that, as they age, the incidence of drug abuse will also increase.1 It is estimated that, by 2030, 70.5 million people, or 20% of the U.S. population, will be aged 65 and older and Medicare eligible.2
Recently, a 75-year-old man was admitted with an acute ST elevation MI secondary to smoking crack cocaine.
Given the novelty of this case, the number of cocaine-positive urine drug screens done in an academic suburban community hospital in patients aged 65 and older was investigated. From January 1, 2004, to April 29, 2009, 10,868 drug screens were done in the hospital. Of those, 800 were done in patients aged 65 and older. Of 10,868 drug screens done, 2,472 (22.7%) tested positive for cocaine, including 18 (2.3%) in those aged 65 and older.
Previously, it was believed that older people “aged out” of using illicit drugs.1,3 Current data do not fully support these beliefs. It is not clear whether illicit drug abuse in older people represents a pattern of continued use, a return to use after a period of abstinence, new onset of use, or a combination of all these patterns.4 Despite limited geriatric data, based on the National Household Survey on Drug Abuse (NHSDA), it has been estimated that the need for treatment for illicit drug abuse for persons aged 50 and older would quintuple between 1995 and 2020.5
In adults aged 50 to 59, the rate of current illicit drug use went from 1.9% in 2002 to 4.1% in 2007.5 This may be a reflection of the baby boomer generation moving into the older age bracket. In this cohort, lifetime rates of illicit drug use are higher than those of older cohorts.
In a recent study, researchers found, through a chart review of 117 veterans aged 50 and older treated for crack cocaine, that 14.5% began their cocaine abuse after the age of 50.6 Patients with drug-related disorders tend to have higher mortality rates than do patients with alcohol-related disorders.7 In an inner-city hospital study of patients aged 60 and older, 2% were positive for cocaine. This was a much higher prevalence than the NHSDA survey of 0.6% in patients aged 65 and older.7
Understanding the patterns of illegal drug use in older individuals is important from several standpoints. Cocaine users are more likely also to smoke tobacco and drink alcohol than those who do not use cocaine; the combination of cocaine, tobacco, and alcohol can further and synergistically exacerbate underlying medical conditions. Causes of illegal drug use in older adults has been attributed to stressful late-life events, loss of productive social roles, loneliness, drinking habits acquired in early life, and the absence of supportive social relationships.8 Because cocaine has been clearly implicated in cardiovascular disease, older patients should also be queried about such usage.
Different geographic areas, ethnicities, and socioeconomic groups all require further study. It is apparent from reviewing the literature that cocaine abuse in older adults is underscreened. Proper counseling and treatment for substance dependence will not be provided if the problem is not identified. Many physicians do not focus on drug use history in a geriatric population. This is a dangerous trend that may stem from prejudices that this population “ages out” of abusing illicit substances.1,2 There is a high prevalence of psychiatric disorders, particularly depression, in older adults and a known link with drug abuse.8–10 The overall trend is for a rise in the prevalence of cocaine use, and thus an expected similar rise in the older population is likely. It is also likely that this problem is much less recognized in older adults because of its relative infrequency. Moreover, the statistics seem to underestimate the number of patients affected. Until there is greater appreciation of this problem and the underreporting bias is eliminated, it is likely that the abuse of cocaine by older adults will continue to be an “invisible epidemic.”