The Impact of Later Life Events on Cessation Motivation of Older Adults with Substance Use Disorder in Hong Kong

Abstract

Life-course researchers have found that age-graded life events, such as marriage and employment, may provoke a turning point in the trajectories of substance use and motivate young adults with substance use disorder (SUD) to seek addiction treatment and cease illegal drug use. However, few studies have focused on the impact of the life events experienced by older adults with SUD in their later life on these trajectories. Even less is known about this phenomenon in non-Western contexts. Thus, we conducted interviews with 34 older individuals with SUD in Hong Kong and explored how later life events affected their motivation to cease illegal drug use. Our findings highlight the influence of age on how life events are experienced and the need for age-specific academic studies of substance use trajectories. The results also have implications for policymakers, as the criminalization and stigmatization of drug use may have a negative impact on the trajectories of substance use among older populations.

Keywords

life course perspective life events older people with substance use disorder addiction treatment programs substance use trajectories substance use cessation motivation older people

Introduction

Life-course perspective is a multidisciplinary paradigm that explains the connection between the life experiences of individuals and the historical and social contexts in which these lives unfold (Elder & Johnson, 2003). According to life course perspective scholars in substance use studies, age-graded life events—such as marriage, divorce, employment, or unemployment—that occur throughout the lifespan of individuals with substance use disorder (SUD)¹ can provoke a turning point in their substance use trajectory that increase or reduce motivation to seek addiction treatment and cease illegal drug use (Kelly & Vuolo, 2021; Sohrabi et al., 2018). Scholars have found that positive life events—such as marriage and employment—can provoke a positive turning point in individuals’ lives by encouraging illegal drug cessation (Brookfield et al., 2019). They have hypothesized that these life events allow adolescents and adults to select different, more conventional social roles, to place more emphasis on their quality of life and family relationships, and to avoid potential risks of substance use (Cepeda et al., 2016). However, negative life events—such as unemployment, divorce, and social isolation—tend to result in transitions in the trajectory of substance abuse that reduced treatment motivation, an increased level of dropout from treatment programs, and substance use recurrence after a period of abstinence (Foster et al., 2021).

Two research gaps exist in current studies. First, the global increase in the population of adults older than 65 years has been accompanied by an increase in the number of adults in this age group with SUD (Carew & Comiskey, 2018). However, most scholars have focused on life events experienced by people with SUD in their transition into adulthood and during middle adulthood (e.g., Bax, 2021; Brookfield et al., 2019). Studies of life events experienced by people with SUD in later adulthood (i.e., later life events) are limited (for exceptions, see Cepeda et al., 2016; Foster et al., 2021; Sohrabi et al., 2018). In addition, the differences in how younger and older individuals with SUD experience and perceive life events are unclear. Understanding such differences is important for two reasons. First, people at different ages may experience the same type of life event quite differently (Foster et al., 2021). Second, some life events are less likely to be experienced by individuals until they are older. Gerontologists have found that many of these later life events—such as the aging of the physical body, social isolation, and retirement—negatively impact older persons (Kristensen et al., 2021; Machielse, 2020; Matheson et al., 2019). Research about the impact of these later life events on the motivation of individuals with SUD to cease illegal drug use (hereafter referred to as “cessation motivation”) remains limited, and thus requires additional scholarly attention.

The second research gap is that many existing studies of the relationship between later life events and cessation motivation have been conducted in Western (specifically, in North America and in Europe) contexts. It has been widely acknowledged that macro social context has a vital impact on how life events are experienced, and the impact of life events on the trajectory of substance use in individuals is also affected by these contextual factors (Laub & Sampson, 2020). However, there is a dearth of such research in East Asian contexts, including Hong Kong.

Hong Kong has adopted an approach of so-called “enlightened prohibition” in its drug policy with a “just say no” ethos—the focus is on law enforcement and abstinence-based treatment (Cheung & Cheung, 2018). In this context, while substance addiction is officially defined as a chronic disease, both the possession and consumption of illegally obtained drugs are criminal offenses and can result in imprisonment in Hong Kong (Askew & Bone, 2019; Cheung & Cheung, 2018). Additionally, substance use is socially perceived as an immoral act that brings shame to individuals with SUD and their families (Mak et al., 2015; Tam et al., 2018). Although using drugs is illegal in Hong Kong, both the government and NGOs provide a wide range of addiction treatment services to help individuals with SUD (HKSAR, 2021b). In contrast to the harm reductionist approach that does not require people with SUD to achieve total abstinence, the drug treatment program in Hong Kong is predominantly abstinence-based—aiming at total cessation of illicit drug use and relapse prevention.

Some of the treatment programs are compulsory. For example, compulsory inpatient residential treatment programs were provided to offenders in correctional institutions, similar inpatient residential treatment programs were also provided by NGOs to people under probation (HKSAR, 2021b). Additionally, territory-wide voluntary methadone treatment services are provided in 18 methadone clinics 7 days a week (including public holidays).² In contrast to the abstinence-based treatment models in the US and other contexts that insist on abstinence from all mind- and mood-altering chemicals (methadone included), notions of abstinence in Hong Kong refer to abstaining from illicit drug use (Kong & Laidler, 2020). While people who use methadone were encouraged to reduce their usage gradually, they could also choose to maintain their methadone usage if they found its termination undesirable (HKSAR, 2021c; Legislative Council Secretariat, 1996). Also, to the best of our knowledge, this methadone treatment program is the only MAT program offered by the Hong Kong government and NGOs.

Compared with the situation in the US, none of the informants we met expressed any challenges to access (Mitchell et al., 2021), and the methadone treatment program is implemented differently in Hong Kong. First, Hong Kong is a small city with a well-developed and cheap public transportation system. Traveling to a methadone clinic usually costs less than 10 HKD or 1.25 USD per trip for people younger than 65 years old, and 2 HKD or 0.25 USD for those aged above 65. As such, accessing methadone clinics is not difficult for our informants. Second, similar to MAT programs in other contexts, regular drug tests (once every 2 weeks to once every 3 months depending on the length of time enrolled in the program and the dosage of methadone) are conducted for clients. However, compliance in methadone treatment is not highlighted in Hong Kong as the continuation of drug use would not result in the termination of methadone treatment. In contrast to those that respond to clients who continue using illicit drugs by threatening to discontinue pharmacotherapy, MAT programs in Hong Kong respond to clients by providing further medical consultations and exploring the need to increase the methadone dosage (Legislative Council Secretariat, 1996). This is because, in Hong Kong, while people enrolled in methadone treatment are expected to stop using drugs completely, continuation of drug use is considered a result of insufficient consultation or underdosage of methadone. Therefore, it is believed that more medical consultation sessions or increasing dosage of methadone, instead of terminating the methadone program, could help clients abstain from illicit drugs. As such, in Hong Kong, some harm reductionist elements were incorporated in the abstinence-based treatment program.

Furthermore, voluntary inpatient residential treatment programs and counseling services are also provided by sixteen NGOs. People with SUD could enroll in these residential programs through visiting the NGO directly, or through the referral of social workers (HKSAR, 2021b).

Similar to the situations in North America and Europe, Hong Kong has seen an increase in the percentage of individuals with SUD who are in their older adulthood (Hong Kong Special Administrative Region [HKSAR, 2021a]; Rao, 2021). The percentage of individuals with SUD who are 51 years and older has increased from 15% in 2010 (n = 1972) to 25% in 2020 (n = 1400). According to government records, approximately 90% of them were male, and 10% were female. Today, the most commonly used drugs among both female and male older individuals with SUD are heroin (n = 1256), followed by psychotropic substances including midazolam (n = 235), methamphetamine (ice) (n = 106), cocaine (n = 23), cannabis (n = 18), cough medicine (n = 14), ecstasy (n = 7), ketamine (n = 6), and nimetazepam (n = 6) (HKSAR, 2021a). However, studies of the trajectory of substance use in Hong Kong have also predominantly focused on adolescents and adults who use psychotropic substances (Cheung & Cheung, 2018; Laidler, 2005; Shek & Liang, 2015). To address the research gaps mentioned above, we examined cessation motivation among older individuals with SUD by investigating two issues. First, we explored how later life events affected cessation motivation among older individuals with SUD. Second, we explored the reasons why these later life events had such an impact on these individuals’ cessation motivation. Our findings contribute to the limited but growing body of research on the experiences of older individuals with SUD. Moreover, our findings offer an examination of the impact of later life events on cessation motivation in non-Western contexts.

Methods

In this study, the minimum cutoff age of older individuals with SUD was set at 59 years, based on a constant remaining life expectancy (RLE) of 15 years (Scherbov et al., 2016). Accordingly, the threshold for older adults in Hong Kong is 69.49 years or older. Since heroin is the drug most commonly used by older individuals with SUD in Hong Kong, we set the cutoff age of older individuals with SUD by deducting the expected years of life lost for people who use heroin (10.6) in similar East Asian context (Chang et al., 2015; Legatum Institute, 2020), and hence 59 years was the cutoff age used in this study.

Because of the social stigmatization and criminalization associated with substance use, this segment of the population is somewhat hidden from the point of view of sampling (Cheng, 2019; Sims, 2020). Assisted by a retired frontline drug use rehabilitation practitioner, in this study the first author recruited participants through various communication efforts, including extensive ethnographic fieldwork on sidewalks and parks outside three methadone treatment centers where individuals with SUD congregated. During the fieldwork, we first identified people with SUD who met our inclusion criteria as follows: (1) Age 59 years or older, (2) Self-identified as a person who uses drugs, and (3) Hong Kong resident.

We next recruited participants through further snowball sampling. However, this recruitment method limited the individuals with SUD to whom we had access. First, they were more likely to be individuals with SUD who had received or were receiving methadone treatment. Second, since most of our participants had enrolled in methadone treatment programs, and this type of program is mainly provided to people who use heroin, all participants had used heroin. However, since heroin is the most common type (89%) of illegal drugs used by older individuals with SUD in Hong Kong, and methadone is the most common medication used in treatment programs among people who use heroin, we considered our data reflective of the situation faced by this population. Second, since we recruited people outside the methadone treatment centers, people under compulsory or voluntary residential treatment programs were not included in this study.

Finally, during the years 2019–2021, we recruited a sample of 34 individuals with SUD age 59 years and over in Hong Kong to participate in this study. The total number of interviews was not predetermined. Instead, we ended data collection when we reached data saturation (Glaser & Strauss, 2017).

Data Collection Methods

Audio-recorded semi-structured interviews were conducted by the first author and a research assistant to enable participants to proactively reveal their experiences and perspectives. Semi-structured interviews are considered effective in producing rich in-depth data related to human experiences (Wengraf, 2001). All the interviews were conducted on the street. Each interview lasted 45–90 minutes, and the participants were given 200 HK dollars (approximately 25 US dollars) to compensate for their time. All the older adults with SUD we met on the street were ethnically Chinese and could speak fluent Cantonese. No participants were excluded because of language. The theme of later life events was inductively inferred in one of our previous projects but initially was not addressed is this study. At that time, we had noticed that older individuals with SUD frequently mentioned a number of later life events when they explained why they found drug rehabilitation difficult. In the current project, an interview guideline was specifically prepared to prompt discussion on how later life events affect cessation motivation of older individuals with SUD. The themes in our interviews were as follows: (1) experiences and perceptions of participants’ later life events, (2) motivations and changes (if any) in participants’ cessation motivation in later life, and (3) how different later life events affected participants’ cessation motivation. Interview probes were related to participants’ changes in social roles, physical well-being, employment status, family relationships, social connections, and death events.

For the ethnographic fieldwork, most of the time, the first author carried a small stool and sat on it in the street, listening to or participating in informal chatting among both older and younger people with SUD. At first, they thought it was weird because they could not understand why any person would be interested in their experiences. After showing up with the former rehabilitation practitioners several times and explaining to them our intention (to allow the public to understand more about the experiences of older people with SUD and thereby seeking policies that might improve their current condition), the older people soon got used to the presence of the first author. When a few of the older people even started injecting heroin beside the first author, we believe that we had won their trust. Ethnographic fieldwork of this type allowed the first author to build rapport with older people with SUD. It also gives insights into themes and issues that older people did not or forget to mention in formal interviews (O’Reilly, 2005). These themes and issues also helped the first author shape and modify the questions to be asked in semi-structured interviews.

Data Analysis

All audio recordings were transcribed and thematically coded using ATLAS.ti 8 (ATLAS.ti Scientific Software Development, GmbH, Berlin, Germany, 2019; Braun & Clarke, 2006). First, we read and then reread the transcripts. Next, we generated as many initial codes as possible according to our research aims (Liu & Chui, 2020; Liu & Li, 2021). Examples of these codes included: “weakened body,” “heroin withdrawal pain,” “lack of income,” “poverty,” “death among older individuals with SUD,” “meaningless life,” “broken family,” “social stigma,” “loneliness,” and “hopelessness.” Then, we discussed and regrouped the codes into candidate themes (e.g., health-related life events; finance-related life events; relationship-related life events; feelings evoked by life events; positive and negative cessation motivation) and subthemes. After that, we examined, refined and regrouped the candidates’ themes to reflect the experiences of older individuals with SUD later life events and their cessation motivation (Braun & Clarke, 2006). Finally, we defined and named these themes and subthemes, and selected quotations related to the identified themes from the transcripts. All selected quotes were translated into English by the first author.

Considering the sensitive research topic, we spent substantial time in 2019–2021 in the field to become acquainted with the participants, develop a trust relationship and collect rich narratives from them. To strengthen the validity of the study, we used internal validity triangulation by asking different questions to approach the same topic during each interview. We employed external validity triangulation by comparing data collected from a sample of different older participants with SUD (Liu & Li, 2021; O’Reilly, 2005). Although we were unable to gather feedback from all participants regarding our findings because most older individuals with SUD do not have a fixed telephone number and we lost contact with all but seven of them after the interview, we discussed and confirmed our findings with these seven older individuals with SUD and five frontline workers (not included in this sample of 34) in addiction rehabilitation facilities.

Ethical Considerations

Ethical approval for this study was obtained from the University Research Centre of the Hong Kong Metropolitan University (formerly the Open University of Hong Kong). To ensure that all participants were fully informed and had participated in the study voluntarily, we provided an information sheet about the study, and obtained written informed consent before the interviews. All participants were provided the contact information of the principal investigator, and were informed that they could refuse to answer any of the questions or withdraw from the interviews without negative consequences. To protect participants’ identities, personal information (e.g., names) was not collected, and pseudonyms were used throughout the project and in this paper.

Characteristics of Participants

All 34 participants were former or current users of heroin at the time we met them, and 11 of the participants also used other type of drugs such as methamphetamine and midazolam³ (summarized in Table 1). Among them, thirty were men and four were women. The gender ratio of our sample (8:1) was similar to the gender ratio of all recorded older individuals with SUD in Hong Kong (10:1). Their mean age was 66.1 years (59–78 years). A majority of them had lower socio-economic backgrounds. At the time of the interviews, all participants except four received a social security allowance from the government. Twenty-three participants did not have any income generating activities; three had low-income part-time jobs (i.e., a janitor, a courier, and a maintenance worker); and nine were involved in low-income illegal activities (e.g., street-level drug dealing; serving as a lookout during drug deals; and selling pirated pornographic DVDs). Among the participants, half either lived on the street or in 100 square-foot or smaller rental apartments, with the rest mostly living in 130 square-foot public rental housing units.

Table 1.

Participant Characteristics.

	Variable	N	%
Demography
Age
59–69	28	82
70 or above	6	18
Gender
Female	4	12
Male	30	88
Ethnic/linguistic makeup
Chinese (Cantonese speaking)	34	100
Types of drugs
Heroin	30	88
Methamphetamine	11	32
Midazolam	6	18
Drug use
Currently using	28	82
Abstaining (more than 6 month)	6	18
Treatment
Under methadone treatment	27	79
Under methadone treatment and using drugs	23	68
Under methadone treatment and abstaining from drugs		4	12
Not in any treatment program	7	21
Not in any treatment program and using drugs		5	15
Not in any treatment program and abstaining from drugs	2	5.9
Perceived impact of later life events on cessation motivation
Impact of physical deterioration
Positive	2	5.9
Negative	17	50
Impact of social isolation
Positive	0	0
Negative	11	32
Impact of ongoing exposure to death
Positive	3	8.8
Negative	7	21
Impact of loss of income-generating ability
Positive	3	8
Negative	15	44
Motivated to join methadone treatment		13	38
Reduce both cessation and treatment motivation		2	6

The average age of the onset of drug use was 19.7 years. All except two participants started using drugs before the age of 30 years, and 14 started before 16 years. At the time of the interviews, 28 of 34 participants were using illegal drugs at least three times per month. Only six had stopped using drugs for at least a month. All participants had engaged in addiction treatment programs more than once in their lifetimes. Despite repeated recurrence of substance use, most of the participants (n = 27) were enrolled in addiction treatment (predominantly rehabilitation involving methadone) programs at the time we met them. However, among these 27 participants, 23 used drugs at least three times a month. Among the seven participants who were not enrolled in a treatment program, five were using drugs regularly, and two claimed that they had abstained from substance use, and therefore did not require a treatment program.

Results

Our findings revealed that although most of our participants were enrolled in treatment programs, they were not interested in achieving abstinence. Instead, they participated in the treatment programs to reduce the amount of drugs they needed. We identified four later life events that shaped this cessation motivation among our participants. Three later life events reduced motivation of the older individuals with SUD to seek addiction treatment for the purpose of complete abstinence, and one later life event motivated them to enroll in a treatment program despite not having an interest in abstinence, as follows: Health deterioration made addiction treatment increasingly unbearable and the achievement of a sober life more dangerous; the loss of social connections evoked feelings of loneliness and made the achievement of a sober life meaningless; the ongoing exposure to death created feelings of hopelessness and helplessness and discourage the participants to pursue drug cessation. Despite these feelings of loneliness, hopelessness, and meaninglessness, many still participated in treatment programs. We found this last motivation to be closely related to another later life event—the loss of income-generating ability. This life event motivated most of our participants to reduce the amount of drugs they used, and in some cases, to abstain completely.

Health Deterioration

The first later life event that increasingly discouraged older individuals with SUD to pursue a sober life was deteriorating health. First, all participants told us that aging and the prolonged use of drugs had contributed to negative physical conditions. These conditions included illnesses such as back pain and hepatitis and an overall feeling of physical fragility. Seventeen older individuals with SUD told us they considered heroin a medicine that could suppress these illnesses and that to stop using heroin would destroy their bodies. Pang (63 years, male), for example, expressed his worries:

Now I am more than 60 years old. If I really [stop using drugs], I am afraid that every part of my body will be weakened instead. . . now every part of my body is sustained by heroin. All those illnesses are suppressed by heroin. There will be an outburst of illnesses if I suddenly stop using it. I would be killed [by the illness].

Therefore, the cessation of heroin use was seen by some participants as dangerous because it would lead to a rebound of illnesses. This perspective explains why many participants receiving methadone treatment still periodically used heroin—to maintain their perceived physical well-being and prevent a perceived rebound of illness.

Another negative impact of deteriorating health on cessation motivation is that it discouraged some participants from enrolling in rehabilitation programs involving methadone treatment—the most common treatment for opioid use in Hong Kong. However, four of the participants expressed that they were reluctant to receive this treatment because they still faced the risk of imprisonment—and methadone treatment is not available in prisons in Hong Kong. Older individuals with SUD faced the constant risk of imprisonment, not only because some were involved in minor criminal behaviors such as stealing or petty drug dealing, but also because the use and possession of drugs are illegal in Hong Kong. Over half of the older individuals with SUD expressed that the pain of withdrawal from methadone was much worse than that of heroin alone, and four of them told us that they felt too old and too weak to endure the combination of withdrawal from both heroin and methadone in prison. Sai (63 years, male) told us that he had been imprisoned over 10 times and explained why he gradually gave up methadone as a medicine for addiction treatment:

They don’t give you methadone when you are inside (the prison). . . the withdrawal is a lot worse than just heroin. You won’t be able to sleep for at least few months. The pain is inside your bones, your hands, and your feet. . .I’m too old for that.

The other three older individuals with SUD were also involved in other criminal activities. They felt that their bodies could no longer withstand the pain of withdrawal from heroin or methadone in prison, and this deterred them from attempting methadone for addiction treatment again.

Loss of Social Connections

The second later life event that increasingly demotivated many older individuals with SUD to maintain abstinence was that they had gradually disconnected from their social circles, which evoked feelings of loneliness, and subsequently, they found a drug-free life meaningless. Older individuals with SUD stated that maintaining sobriety required enormous effort and willpower—they were constantly fighting drug cravings; felt cut off from friends who used drugs; and believed they were risking the rebound of illnesses. Furthermore, the loss of social connections with the important people in their lives had made them feel that these efforts were not worthwhile. As Yu (62 years, male) stated:

That’s [my] life. . . How should I put it. . . especially at my age, there is nothing and no one I can devote myself to anymore. I am all alone. It’s not worth the effort.

Older people with SUD, like Yu, also reported that losing connection with their family member discouraged them from achieving abstinence. Being influenced by a mixture of traditional Chinese Confucian doctrines of filial piety and western individualism, although most older people in Hong Kong do not live with their adult child, frequent mutual exchange of material and emotional support is culturally expected (Nauck & Ren, 2019; Peng et al., 2019). Being cut off from family relationship further increase the feelings of stigma and loss among our participants. Lo (66 years, male), a man who slept on the streets and who had used heroin for 50 years, told us how losing connection with his family had made him less willing to seek addiction treatment:

Your family abandoned you. . . What else can I do? I got no son, no daughter, [and] no family members. What else can I do even if I don’t use [heroin]?

To reduce social isolation among older people in general, the Hong Kong government had conducted various policies to encourage younger people to maintain closer ties with their older parents (e.g., by providing allowances to lower-income families that take care of the older parents⁴ and prioritizing subsidized and public rental housing applicants with older family members⁵) (Social Welfare Department, 2022; Transport and Housing Bureau, 2017). However, many older people with SUD were not so much benefited from this kind of policy as they had already lost connection with their family members. Our interview data revealed that there are three reasons why many older individuals with SUD have gradually lost connection with their significant others. First, the likelihood of having fewer relationships increases when one ages (Waycott et al., 2019). For example, the parents of most older individuals with SUD had passed away. Second, some individuals with SUD had lost relationships because of their prolonged drug use and their actions during that period. One commonly mentioned reason for the loss of relationships was related to the participants’ repeated attempts to borrow or steal money from their significant others to finance their drug habits. As Sai (63 years, male) stated:

I’m not like the younger ones. They still have people around them. People have not lost hope in them yet. As you grow older, everyone around you starts to lose hope in you. Old men like me. . . I have borrowed money from everyone [around me]. When they see me, it’s as if they see a ghost. It was much better when I was young. But now? All gone.

The third reason many individuals with SUD became socially disconnected may be attributed to the stigma surrounding drug use. As illustrated by Wah (65 years, male), who had used heroin for 50 years and had disconnected from most of his friends and colleagues who did not use drugs:

If you take these kinds of things (drugs), all your friends stay away from you. They begin to stop talking to you. Even if they have to talk to you, they won’t tell you what they really think. They think that you are not trustworthy.

Older individuals with SUD also claimed that they were perceived as dangerous and hopeless. Moreover, they were often further stigmatized because of their imprisonment. Most of our participants had been sentenced to jail for criminal behavior—among our participants 15 had been imprisoned for possession of drugs. As explained by Kei (64 years, male):

Of course, they see us as bad people, constantly in and out of prison, they see people like us as bad people.

Regardless of the reasons, individuals with SUD who had lost their connections with their family and significant others often stated that they experienced intense loneliness, and this feeling of emptiness demotivated them from seeking drug rehabilitation. As mentioned by Choi (63 years, male):

The major reason [why I don’t seek drug rehabilitation] is the feeling of emptiness. I don’t feel that empty after I use (heroin). . .I have no one around me. Even though some time I have them (other people with SUD) to talk to, I still feel empty after talking to them.

While the Hong Kong government offers community care services like social and recreational activities through daycare and community centers, none of the older people reported that they had used this kind of service. It is especially the case when using substances like heroin is not only stigmatized by also illegal in Hong Kong. For many with SUD, the use of drugs had become their only way to manage their feelings of emptiness and hopelessness.

Ongoing Exposure to Death

The third later life event that increasingly demotivated individuals to seek addiction treatment to achieve a sober life was the ongoing exposure to death among older individuals with SUD. Most of our participants were part of a community of individuals with SUD who gathered around certain methadone treatment centers, parks, and tunnels. They stated that one of the depressing events they often experienced was the death of other older individuals with SUD in the same community. As Wah (65 years, male) explained:

Ten years ago, there were many [individuals with SUD] here (outside the methadone treatment center). Now you see only [a few of] us left. Every month some of the older ones die. They seem fine the day before and then suddenly they pass away the next day. There is no sign. They are just suddenly gone. We often talk about (when we hang out) who are dead and who are still here. We never know who will be the next one to die.

Frequent exposure to the news that fellow older individuals with SUD had died convinced many of participants that not much time remained in their lives. Three of our participants stated that this feeling had had a positive impact—it made them feel that aging implied having limited time left to lead a sober life. As Kei (70 years, male) illustrated:

I really don’t want to keeping using them until I die. I don’t want to bring drugs with me when I die. I don’t want to bring drugs to my coffin.

However, it also demotivated others from seeking addiction treatment because it made them believe that going through the painful withdrawal process from opioids was not worthwhile. As stated by Wah (65 years, male):

I am that old now. Quit? What if I died right after I quit? Some [people with SUD that I knew] died in their fifties, some in their sixties, and some in their seventies. [I] might suddenly die at any moment, right? I mean we are that old already. Quit? For what?

Similarly, Leung (77 years, male) told us:

Every month we have someone who passed away. A few passed away this month, few will pass away next month. All have gone to heaven. . .why should I care (about quitting drugs). Take drugs or not taking drugs, people in my age will die anyway.

From these narratives, we can see that some later life events made the cessation of drug use for the achievement of sobriety difficult, undesirable, and meaningless for older individuals with SUD.

Loss of Income-Generating Ability

Despite the participants’ negative motivations, most of the participants were still enrolled in methadone treatment programs. This phenomenon could be explained by another later life event—the loss of income-generating ability. Aging, drug use, and criminal records made securing a living wage increasingly difficult for our participants. Most of the participants had either unstable, low-paid jobs, or no income-generating activity (i.e., legal or illegal). A majority of them lived on a monthly social security allowance ranging from HKD3000 (approximately USD387) to HKD5000 (approximately USD644). Although the money was sufficient for their other daily expenditures, the participants found it difficult to finance their daily drug use. Seeing no hope to generate this income, a few of our participants made up their mind to abstain from substance use. Sha (69 years, male) had been on methadone for addiction treatment and had been sober for over 1 year. He told us why he finally decided to quit:

I am now weaker and weaker. I have to change. I can’t even afford a decent meal. It is not like before. That’s all [amount of money] I have now. I would rather spend it on food instead.

Whereas Sha had stopped using heroin completely, others had used addiction treatment as a strategy to make the maintenance of their addiction more affordable by reducing the amount of drugs they needed. As Kei (64 years, male) illustrated:

It’s very expensive. I only got like HKD3000 (approximately USD390) from the social security allowance. . . Every time [using heroin] costs HKD300, right? How can I afford it? Now I just use [heroin] once or twice a month. It’s not like when you have a job. No job, no income. All depends on that social allowance, right?

Older individuals with SUD, such as Kei, spent their social security allowance on heroin every month to obtain a minimal amount of the opioid. Then they used methadone to manage withdrawal until they again received their monthly social allowance. Similarly, another older individual with SUD, Ning (59 years, male) told us how he used a residential drug treatment program as a strategy to reduce his tolerance to drugs and to make his addiction more affordable:

So let’s say you now need to spend HKD300 (on drugs) in order to get high, but HKD300 is way too expensive for you. What can you do? Go get yourself in a treatment program. Cool yourself down. When you leave the program after one or two weeks, HKD100 would be enough for you to get very high.

Financial fragility is particularly severe amongst our female participants. While one-fourth of our informants had some low-paid employment (e.g., occasional freelance janitor, keepers of brothels, and pirated pornographic DVD stores), all of our female participants relied almost entirely on monthly social security allowance for sustaining their daily livings, and they did not have any employment in both legal and illegal sectors. Among the female, only Mui (62 years old, female) had unstable additional income during the interview through selling prescribed midazolam that she obtained from public hospitals to other individuals with SUD. Older individuals with SUD used addiction treatment as a strategy to manage the amount of heroin they needed to achieve a euphoric, psychotropic effect (i.e., get high). For many older individuals with SUD, the loss of income-generating ability was seen as an irreversible condition. However, they managed their inability to afford drugs by seeking addiction rehabilitation. Hence, whether or not their goal was abstinence, the loss of income-generating ability had pushed many older individuals with SUD to seek or remain in addiction treatment programs.

Discussion and Conclusion

In our study, we found that life events influenced the trajectory of substance use among our study’s participants and affected their current cessation motivation (Brookfield et al., 2019). Later life events, such as health deterioration, social disconnection and ongoing exposure to death evoked feelings of hopelessness and loneliness in our study’s participants, and made treatment to achieve sobriety both more difficult and meaningless. Despite these obstacles, financial fragility motivated many to enroll in treatment programs for a pragmatic reason—to afford to maintain their addiction.

Furthermore, our findings highlighted potential age differences in the impact of life events on life course trajectories in two ways (Foster et al., 2021). First, the same life event could have a quite different impact on younger and older individuals with SUD. Scholars have demonstrated that increasing concerns for health motivates younger individuals with SUD to achieve sobriety (Mayer et al., 2020). Conversely, we found that these concerns deterred many older individuals with SUD from doing so. This may be because younger individuals with SUD interpreted abstaining from drugs as a way to remedy their health condition, whereas older individuals with SUD perceived—or misunderstood—addiction treatment to represent a potential risk to their physical well-being. Similarly, although distress brought by unemployment is a risk factor for substance use among the younger population of individuals with SUD (Foster et al., 2021), the financial instability brought by the lack of employment among older individuals with SUD impelled them to seek treatment. Second, older individuals with SUD experienced certain life events that typically only happened in later life, and these later life events also affected their cessation motivation. Gerontologists have found that that role loss and continuous exposure to death are associated with anxiety, depression, and stress among older populations (Bolaséll, et al., 2021). Similarly, as reflected in our findings, older individuals with SUD experienced many of their peers passing away at this stage of their life, and they felt that there was not much left for them. Later life events of this kind are potentially associated with feelings of hopelessness and meaninglessness and have thereby undermined their willingness to achieve sobriety. These findings show that experiences of SUD could be unique among an aging population. We argue for the importance of age differences and age sensitivity in the study of the trajectory of substance use. Additionally, we also highlight the importance of taking age differences into consideration when making policies related to illegally obtained substances. Current drug policy and treatment options, in particular those adopted in the Asian and Hong Kong context, had focused either on young people or people with SUD in general (Liu et al., 2020; Chen et al., 2022). Our findings show that support and harm reduction initiatives geared specifically toward older adults would also be vital.

Furthermore, in accordance with previous studies that utilized the life course perspective, we found the life events experience of older individuals with SUD was affected by the macro cultural and policy environment (Brookfield et al., 2019; Laub & Sampson, 2020). Being influenced by the traditional Chinese culture of filial piety, older people in Hong Kong are expected to maintain a close relationship through the mutual exchange of material and emotional support (Nauck & Ren, 2019; Peng et al., 2019). Disconnection with their family members and friends further increased the feelings of stigma and loss among older individuals with SUD. Under the government of Hong Kong’s enlightened prohibition drug policy, substance addiction is officially defined as a chronic relapsing disease, and the provision of rehabilitative support is supposed to be more emphasized than legal sanctions (Cheung & Cheung, 2018). However, our participants’ experience reflected that stigmatization and criminalization of drug use is still common in Hong Kong and imposed negative impact on their cessation motivation. Social isolation and a feeling of loneliness are common among older populations, and the stigmatization and criminalization of drug use has reinforced such a feeling among older individuals with SUD (Machielse, 2020). This finding is in accordance with previous studies that indicate the negative influence of social stigma and social isolation on individuals with SUD’s willingness to seek treatment and maintain abstinence (Askew & Bone, 2019; Foster et al., 2021; Hammarlund et al., 2018). Moreover, in accordance with findings in previous studies (Wallace et al., 2020), the fear of imprisonment and limited access to addiction treatment in prison have also discouraged some older individuals with SUD from seeking treatment. Among our study’s participants, this fear was not that of imprisonment per se but of the unavailability of methadone in prison and the unbearable pain of withdrawal from the medication. In light of this, drug policy that facilitates the destigmatization of substance use and increases the accessibility of medicine in treatment—such as offering methadone treatment programs in prisons—could motivate older individuals with SUD to seek such treatment (Brinkley-Rubinstein et al., 2018; Lo, 2022).

Although the sample size of older female individuals with SUD in this study is small, our findings indicate that the financial fragility they face could be more severe than that faced by the older man. The income-generating ability of both male and female participants was constrained by their health deterioration and drug use. However, some male participants revealed that they were still capable of seeking short-term employment in the illegal market, such as being employed as keepers of brothels and pirated pornographic DVD stores. Our data echoes criminological literature that indicates the gender gap and segmentation in the illegal market (Nguyen et al., 2022; Shen & Winlow, 2014; Zhang, 2022). As income-generation ability is one of the age-graded life events that influence the cessation motivation of individuals with SUD, future research focusing on how the intersection of gender, age, and drug use influences illegal employment and the cessation motivation of individuals with SUD would be recommended.

Besides contextual factors, our findings also highlight the importance of human agency to understand the trajectory of substance use (Elder & Johnson, 2003; Liu & Li, 2021). Our informants did cost-benefit calculation to determine whether and why they attend drug rehabilitation programs. Being constrained by the above-mentioned individual and contextual factors, most of our study’s participants decide to give up achieving abstinence. Contrarily, of most of them who were enrolled in treatment programs, many deviated from the original purpose of these programs and used the programs as a strategic tool to make their addiction more affordable. It shows that our informants were active agents who developed tactics to adapt to their difficult environment to meet their needs (Stephens & Allen, 2022).

Additionally, our findings may seem alarming from a prohibitionist or an abstinence approach because most of our participants were still using illegally obtained drugs. However, viewed from a harm reductionist approach, our findings are more optimistic. Different from the prohibitionist approach, the aim of the harm reductionist drug policy is to reduce the harmful effects of drug use without requiring abstinence (Kapadia et al., 2021). Nearly all of our participants had successfully reduced the amount of drugs they used with the aid of treatment, and scholars have found such reduction to be associated with reduced morbidity and mortality (Socías et al., 2020). It is especially the case when continued drug use is not interpreted as a violation of maintenance regulation but as a client’s need for further consultation and stronger medication. It allows our informants to stay in the treatment program and reduce their drug use even if they cannot achieve total abstinence.

Limitations

Although the findings of this study provide important insights into how later life events affect the cessation motivation of older individuals with SUD, especially in the context of Hong Kong, our study has several limitations. First, this study was based on semi-structured interviews with a relatively small sample of older individuals with SUD. The results may not be generalizable to all older individuals with SUD in Hong Kong or other Asian contexts. Second, we found it very difficult to identify female older individuals with SUD in our ethnographic fieldwork. Therefore, our collected data may not fully reflect gender differences in the experiences of older individuals with SUD. Future research that explores gender-specific experiences of a larger sample of older individuals with SUD is recommended.

Footnotes

Acknowledgements

We appreciate the older individuals with SUD who contributed to this study. We also like to thank Professor Karen Laidler, Professor Jianhua Xu, and Dr. Tiffany Ip for their valuable comments and suggestions on an earlier draft of the paper.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The work described in this paper was fully supported by a grant from the Katie Shu Sui Pui Charitable Trust—Research and Publication Fund (Project Reference No. KS 2020/01). The authors would like to thank the Public and Social Policy Research Centre, established with the substantial support of a grant from the Research Grants Council of the Hong Kong Special Administrative Region, China (Project Reference No: UGC/IDS16/18), for its support. The authors also would like to thank the support from Centre for Criminology of HKU.

ORCID iD

Vincent S. Cheng

Notes

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