Risk Behaviours Among Older Women Who Use Drugs

The prevalence of older people who use drugs is increasing in many countries, with evidence that some women continue or begin illicit substance use in midlife and older age. While research on older people who use drugs is limited, evidence of risk behaviours among older women who use drugs is particularly inadequate. Unsafe drug use and sexual practices that are prolonged and sustained over many years increase the possibilities for poorer health, leading to potentially greater morbidity and early mortality among older drug users. This chapter is a timely contribution to the extant literature and explores our current knowledge of the risk behaviours of older women who use drugs.

In addition, cognitive functioning and quality of life are reportedly poorer among older drug-using adults (Monds et al., 2017). Gender differences are also apparent, with OWWUD exhibiting worse overall health status and more mental health problems than older men who use drugs (Grella & Lovinger, 2012). Furthermore, women who use heroin may be at risk of earlier onset of menopause compared to women in the general population (Schoenbaum et al., 2005).
Ageing populations, drug availability and the introduction of medical treatment and harm reduction interventions are contributing to the growing numbers of OPWUD in many Western countries (Carew & Comiskey, 2018). Those aged 40 years or more comprise on average 19% of all clients entering drug treatment across 9 European countries (range 1.6-28%) with Germany, Spain, France, Italy and the United Kingdom accounting for 81% of all older clients in Europe (EMCDDA, 2010). Nevertheless, these figures are likely to underestimate the true number of OPWUD, and on a global scale the proportion of OPWUD is currently unknown (United Nations Office on Drugs and Crime (UNODC), 2018a). The lack of data available in other regions means that any meaningful comparison across continents and countries is difficult. While we might assume that OWWUD are fewer in number than their older male peers, the empirical evidence required to estimate the prevalence of the global population of OPWUD, and OWWUD in particular, is lacking. Some suggest this is due to researcher indifference (Rosen, Engel, Beaugard, Davis, & Cochran, 2019); others highlight how we know less about women and drugs compared to men (Del Boca, 2016). Our existing knowledge on the gendered nature of health needs highlights the importance of gathering meaningful gendered prevalence rates of OPWUD in order to inform future research and programme planning.

Risk and Edgework
'Risk' as a verb means 'to endanger; to expose to the possibility of injury, death, or loss; to put at risk' (Oxford English Dictionary, n.d.). However, risk is socially constructed and according to Lupton (1999), what we understand to be risky is a historical, social, cultural and political way of seeing. The concept of risk as a discourse is used to 'blame and marginalise' an 'other' who is positioned as a threat ('risk') to self and society (Lupton, 1999, p. 40). 'Risky' individuals are either blamed for their own moral ineptitude or viewed as the victims of external forces. Rarely though blame is placed upon the structural conditions under which many women who use drugs problematically reside. Risk, as a discourse, is a value judgement, and where value judgements exist so too do inequalities. For people who use drugs, inequalities of risk are such that those with economic and social resources are better able to insulate themselves from risk in contrast to those with fewer resources who have less opportunities or means to avoid them. In this late modern era with its emphasis on individualism and individual responsibility, people who transgress the 'normal' boundaries of consumption are labelled 'addicted' or 'out of control ' (Reith, 2005). For women who use drugs and engage in drug risk behaviours, the threat of social and legal sanctions goes beyond those applied to male drug users. For example, proportionately more women are jailed globally for drug offences than men (UNODC, 2018) and in many countries legal sanctions are applied to remove children from mothers who use drugs and to women who use drugs while pregnant (Fentiman, 2017). Given the sanctions that might be applied, how do women respond to notions of risk in everyday life? One answer may lie in the concept of 'edgework'.
'Edgework' refers to voluntary risk taking, something that people do for pleasure (Lyng, 1990). Adapted by Lyng (1990) to explore risk-takers and risk behaviours such as skydiving and rock climbing, the notion of edgework provides a counter-argument to risk as inherently negative. Engaging in risky activities is, for some, an escape from the banality of everyday life and offers fun, belonging, escape and resistance. Edgework conceptualises risk as a form of boundary negotiation wherein the edgeworker explores the edges between life and death, sanity and insanity, safety and danger and consciousness and unconsciousness (Lyng, 2005, p. 5). It offers a clear observable threat to physical or mental well-being and threatens the sense of an ordered existence (Lyng, 1990, p. 857). Criminological edgework, including drug use, represents a form of escape and resistance to the prevailing structures of political and economic power (Lyng, 2005, p. 359). Developing and honing skills and specialist knowledge enables users to negotiate the edge and control the uncontrollable (McGovern & McGovern, 2011). Viewed this way, illicit drug use is a purposeful activity that involves taking risks and creates meaning for the user.
According to Reith (2005), drug users walk the edge between addiction and sobriety and between the urge to indulge in excessive behaviour and the need to exercise self-control, negotiating the boundaries of normal and abnormal consumption. Women who successfully negotiate their identity through their drug use and accrue skills along the way might be described as engaging in resistance and edgework. Rajah (2006) applied the concept of edgework in her study of drug-using women in violent intimate relationships. She found that edgework represented a 'mode of resistance to patriarchal privilege and control' that required intense preparation and the use of skills developed through long-term involvement in the drug scene and interactions with other users (Rajah, 2006, pp. 232-235). Importantly, Rajah (2006) suggested that the 'embodied experience of successful edgework' could lead women to identify the 'contradictions in their social position', which might lead to 'changes in consciousness that counteract their opposition' (p. 240). Here then, the concepts of risk and edgework might be viewed as two sides of the same coin. On one side, risk as a social construct that sets the 'risky' non-conforming individual apart from the rest of society; on the other side, provides meaningful risk-taking opportunities that give life a meaning. Many OWWUD engage in risk behaviours, although to what extent they consciously or subconsciously engage in edgework is unknown due to the lack of research among this cohort. Nonetheless, OWWUD embody that which is 'other', attempting to live up to or defy the cultural and social ideals of femininity and womanhood. Consequently, drug use as edgework can mediate difficult lives and circumstances, and offer OWWUD opportunities for independence and status that might otherwise elude them.

Older Women Who Use Drugs
There is evidence that some women begin drug use at a later age for a variety of reasons including stressful life events such as bereavement or divorce (Johnson & Sterk, 2003). Indeed, some researchers have categorised OPWUD into early-and late-onset users (Boeri, Sterk, & Elifson, 2008). Early-onset users begin their drugusing career in adolescence or early adulthood whereas late-onset users begin in their late 20s and older. Furthermore, while early-onset users have a protective factor of years of experience in terms of controlling their drug use, late-onset users need to learn to negotiate between their drug use, the drug-using environment and mainstream society. In addition, the changing roles that occur across the lifespan (e.g. parents, grandparents, work and retirement) are integrated into the lives of early-onset users while late-onset users either lose these roles as their drug use escalates or are at more liberty to use drugs due to their decreased role in mainstream society (Boeri et al., 2008). Therefore, among OWWUD, late-onset users may have different dependence characteristics and require different treatment approaches than early-onset users. Utilising this early-/late-onset typology in future research is important as there may be different risk factors and risk behaviours among OWWUD depending when they started using drugs.

Risk Behaviours Among OWWUD -What Do We Know?
Older women in Western cultures are culturally devalued (Clarke, 2010). Signs of ageing such as wrinkles and grey hair result in women's loss of status sooner than for men of comparable age. The 'leaks, lumps and lines' that accompany the ageing process become the stigmatising marks that culturally distance older women from the 'ideal' female body we are exposed to through the media (Chrisler, 2011). Similar to other ageing adults in society, competing in a culture that places value on youth is even more challenging for women who use drugs. A qualitative US study of older active drug injectors demonstrated their movement from the centre of action in the drug culture of their youth to the margins in their later years (Anderson & Levy, 2003). Increased violence, power inequity between dealer and buyer, physiological changes, reduced risk taking and increasing selfprotections were all factors in self-imposed marginalisation among this group of older injectors (Anderson & Levy, 2003). Boeri's (2018) recent US research into OPWUD demonstrates clearly the particular difficulties they face. For example, the older women faced greater risks for violence while those who engaged in transactional sex faced a reduction in their selling power (Boeri, 2018, p. 128).
In an earlier study, Boeri (2013) found that OWWUD and lost their mainstream roles increased their risk behaviours through more involvement in illicit activities such as hustling, dealing and sex work. 'Risk behaviours' in these circumstances could be viewed as rational responses to limited social and economic resources and opportunities while simultaneously carrying significant potential for serious personal harm.
A systematic review of the collective data on OPWUD suggests drug use among older people may shift from illicit to non-medical prescription drug use (Shawna, Chapman, & Wu, 2015). This is particularly significant among people aged 65 years and older. Furthermore, gender differences may occur as data suggest women aged 60 years or more use less illicit but more non-medical prescription drugs than men of similar age (Shawna et al., 2015). The current opioid crisis in the United States reminds us that complacency concerning prescribed and nonprescribed opioids may incur a heavy burden in terms of increasing problematic use, reducing physical and mental well-being and increasing overdose deaths. Globally, there is a pattern of increasing overdose deaths and hospitalisations, with cocaine, heroin and prescription opioids most often associated with unintentional overdoses (Martins, Sampson, Cerdá, & Galea, 2015). While difficult to assess gender differences on a global level, in the United States and United Kingdom drug deaths are increasing among OWWUD. Between 1990 and 2010 in the United States, the rates of overdose deaths among women aged 30-64 years increased by 260% and the average age increased from 43.5 years to 46.3 across all drugs (VanHouten, Rudd, Ballesteros, & Mack, 2019). In England and Wales, between 2002-2006and 2012-2016, the average annual number of drug misuse deaths among women increased by 64%, compared to 28% for men, while in Scotland over the same period, female overdose deaths increased by 169% compared to 60% for men (Tweed, Miller, Matheson, & Page, 2018). Potential risk factors that may be contributing to these increases include changes in patterns of drug use (Pierce, Bird, Hickman, & Millar, 2015;Tweed et al., 2018), changes in relationships, missed opportunities in and changes to treatment services and changes in welfare benefits that disproportionately affect women and ageing (Tweed et al., 2018). This picture of increasing drug deaths and overdoses should urgently prompt treatment agencies and policymakers to forestall further increases and work towards reducing this tragedy for individual women, their loved ones and their communities.
In terms of injecting behaviours, some studies suggest OPWUD engage in fewer risky injecting practices and have fewer injection-related problems, such as skin infections and deep vein thrombosis (DVT), compared to their younger counterparts (Broz et al., 2014;Degenhardt et al., 2008;Horyniak et al., 2013). Indeed, Horyniak's team found a five-year increase in age resulted in significant reductions in risk behaviours, although they failed to provide a gendered analysis. In contrast, a small study of incarcerated women in the United States compared older and younger inmates and reported no significant differences in drug use, sexual activity or criminal justice involvement, suggesting that risk behaviours are sustained over the life course of a drug career (Staton, Walker, & Leukefeld, 2003). A longitudinal study in Scotland shows the rate of injecting drugs for people over 35 has increased from 34% in 2008-2009 to 73% in 2017-2018, but this is an ageing cohort of existing injectors rather than a cohort of late injecting initiates (Health Protection Scotland, 2019). Furthermore, while the self-reported injecting rates have remained stable over time, other risk behaviours have increased, including injecting heroin and cocaine together, reusing own needles and syringes, reusing other people's needles and injecting equipment, although these rates still remain relatively low. While this study does not provide a gendered analysis (at least onethird of the overall sample is female) these findings and those of Staton et al. (2003) have important implications for women who initiate drug use at a younger age. Unsafe drug and sexual practices that are prolonged and sustained over many years increase the risks for poorer mental and physical health functioning, which leads to greater morbidity and potential early mortality among OWWUD.
Several US studies have shown that between 10% and 20% of injectors initiate injecting drug use at age 30 years and older and that late injectors are more likely to be female, self-inject for their first injection and be initiated by someone of similar age or younger compared to early injectors (<30 years) (Arreola et al., 2014). Safer injecting practices may be more common among older initiates compared to younger although evidence is scarce. An early study found late-onset injectors (40 years and older) were less likely to engage in needle and syringe sharing, were more likely to use a needle from a sterile wrapper, inject less frequently and be less likely to attend shooting galleries -places or buildings where people go to buy and/or inject drugs (Carneiro, Fuller, Doherty, & Vlahov, 1999). These findings suggest that older injecting initiates may adopt safer injecting practices relatively quickly compared to younger initiates. Nevertheless, our knowledge of the particular risks of older female injectors remains limited. Meanwhile, older injectors may be less likely to inject others, but moral ambivalence and structural vulnerabilities such as poverty and homelessness might lead to 'avoidable risk' taking (Wenger, Lopez, Kral, & Bluthenthal, 2016). For example, providing an injecting service in exchange for drugs, money and/or status could be considered a rational option for those experiencing marginalisation and limited resources.
The transition of older women into the perimenopause and menopausal stage has implications for OWWUD but again, our knowledge of this is meagre. To date, very little has been written on menopausal women who use drugs but where it has been studied this has been primarily in relation to HIV (Schoenbaum et al., 2005;Tuchman, Pennington, Kull, & Daneshyar, 2013). Women with drug-using histories are particularly vulnerable to HIV acquisition due to high-risk drug use and sexual practices. In addition, physiological changes in men and women might influence some older women's non-condom use, such as male impotency, discomfort during sexual intercourse and loss of reproductive capacity (Ludwig-Barron et al., 2014). The risk behaviours of older menopausal women who use drugs are still relatively unknown at this point in time and are a gap in our knowledge that requires attention.
The risk for HIV acquisition is higher among women who inject drugs due to the dual behaviours of unsafe injection practices and unprotected sex. Furthermore, women who engage in drug use and transactional sex are more likely to share needles/syringes and other injection paraphernalia, have unprotected sex with clients as well as intimate partners, have higher rates of STDs and experience sexual and physical violence and incarceration (Azim, Bontell, & Strathdee, 2015). A Russian study of women who inject drugs suggests older age is significantly associated with increased non-condom use and receptive syringe sharing (Girchenko & King, 2017). Factors that inhibit midlife and older women's use of condoms include intimate partner violence, consumption of alcohol and/or drugs, having a HIV diagnosis, lack of awareness of HIV risk factors, lack of skills to negotiate condom use, taking risks for the sake of a relationship, having a perceived low risk of contracting HIV and being reticent to ask potential sex partners about their sexual history (Engstrom, Shibusawa, El-Bassel, & Gilbert, 2011;Ludwig-Barron et al., 2014). Furthermore, women who inject drugs and have at least one psychiatric disorder may also be prone to needle and syringe sharing and having a psychiatric disorder is also likely to impair women's ability to negotiate safer injection and sex practices (Tirado-Muñoz et al., 2018). These findings suggest practitioners should be developing interventions to address low self-esteem and encourage self-efficacy in OWWUD, particularly among those actively engaged in sexual relationships, whether transactional or personal.

Conclusion
The global prevalence of older people using illicit drugs is not known and as such, it is unclear how many older women are using these drugs worldwide. Indeed, even in the West where we have limited information on prevalence rates, our knowledge of older women who use illicit drugs is lacking. It has been suggested that this lack of knowledge is due to research indifference and a tendency to explore drug use and its associated issues through a male lens. However, this gap in our understanding is also due to funding, policy and programme development indifference. Women who use drugs are considered 'risky' and 'at risk' and are more heavily sanctioned against than their male counterparts, suggesting a greater concern for gendered social mores and norms than for women who use drugs and their wider networks. Nevertheless, actions viewed from one perspective as risky, and therefore morally problematic, are from another perspective strategies for risk management, dignity and survival. The concept of 'edgework', therefore, provides an alternative view that offers OWWUD a degree of autonomy and control and explains their drug use and behaviours as a rational response to gendered inequalities and their socially marginalised and culturally devalued position. What we do know about OWWUD is mostly related to the implications of longterm drug use on physical and mental well-being. Our knowledge of risk factors for older women's drug use is limited but somewhat better than our knowledge of their risk behaviours. What little we do know suggests punitive responses, as well as felt and enacted stigmatisation, can contribute to withdrawal from mainstream society that may increase the adverse effects of drug use on health and well-being, including fatal and non-fatal overdoses. Nevertheless, older age may reduce some risk behaviours such as those related to injecting, although evidence is limited and sorely needed.
The contradictions in the studies that are currently available clearly indicate a need for more research in this area. Our knowledge of sexual risk behaviours among OWWUD is more informed than drug-using risk behaviours, with important work on the menopause and HIV in the public domain. Yet even here, research is limited to the United States and when we look at studies that focus on sexual and drug-use risk behaviours the evidence is conflicting inhibiting a clear picture of the needs of OWWUD. Furthermore, what might be the different cultural, social or economic conditions that impel or encourage women to initiate and/ or continue drug use later in life? What can we learn from researchers elsewhere?
What is required is the adoption of the UNODC's call for gender mainstreaming in legislation, policies, programming and research across the world (UNODC, 2018). We need to mainstream gender in studies of OPWUD but more specifically we need to explore the risk behaviours of OPWUD generally and OWWUD particularly. We need to know the drug-using risk behaviours including types of drugs consumed, routes of drug administration, criminal involvement, sexual risk behaviours and how women negotiate and resist risk behaviours. As well as a gendered analysis of older peoples' drug use, we must also explore differences across social and economic classes as well as racial differences and differences across sexualities. It is important that we explore these gaps in our knowledge, as the proportion of OPWUD will continue to increase and with it the avoidable drug deaths among this ageing population. That we know so little about OWWUD is a collective failing of funders, policymakers, programme developers and researchers. Perhaps also, it reflects the marginalisation of older women generally and older women who resist the normative roles of the good wife, mother, grandmother and citizen specifically. For anyone who is serious about the global impact of drug use on women and their communities, this is a gap in our collective knowledge that requires serious attention.