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SMAD. Revista eletrônica saúde mental álcool e drogas

versão On-line ISSN 1806-6976

SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. (Ed. port.) vol.17 no.4 Ribeirão Preto out./dez. 2021 



The consumption of psychoactive substances among older adults: a complex perspective*



Vania Dias CruzI; Silvana Sidney Costa SantosI; Michele Mandagará de OliveiraII; Cristiane Lima de MoraesI; Paola Camargo de OliveiraII

IUniversidade Federal do Rio Grande, Escola de Enfermagem, Rio Grande, RS, Brazil
IIUniversidade Federal de Pelotas, Faculdade de Enfermagem, Pelotas, RS, Brazil

Corresponding author




OBJECTIVE:to describe the pattern of consumption of psychoactive substances among older adults from the perspective of complexity.
METHOD: a qualitative survey of the multiple-case study type, carried out with eleven older adults at their homes and/or at a health service; data was collected through documents, unsystematic observation and semi-structured interview; they were analyzed in a general, analytical and theoretical way by comparing the cases; its theoretical axis was complexity, being approved by the research ethics committee.
RESULTS: regarding the pattern of consumption of psychoactive substances, two themes were found: encounter with the substance, which identified older adults using legal and illegal substances, and forms of consumption; consequences and motivations of drug use and/or abandonment. Consequences are material/economic losses and crime, and motivations for socialization and escape from stress/anxiety. The older adults who stopped or reduced their consumption adhered to the harm reduction strategy.
CONCLUSION: the consumption of psychoactive substances by older adults was evidenced, with space for the success of health/nursing interventions, with the creation of actions/programs with a specific approach to harm reduction.

Descriptors: Aged; Drug Users; Health of the Older Adults; Nursing.




The definition of psychoactive substances (PAS) has three axes: the substance itself, which concerns the pharmacological action, including dosage/route that is used; the set corresponds to the individual's state/expectation at the time of use; and setting, regarding the influence of the physical/social environment/context at the place of use(1). Thus, as the person who uses PAS we understand the individual who consumes it, regardless of legality, without therapeutic/medical intention.

The type of PAS consumed, regularity and frequency used tend to influence the consumption pattern. People go through an initial stage where they try different substances and, over time, tend to define the drug of choice, establishing continuity of consumption(1). Thus, the consumption of PAS can be classified as controlled, where the user tends to define the ideal amount of the drug to be consumed, without interfering in daily activities, proposing behavior patterns and maintaining social activities; and abusive, characterized by daily and intense consumption, where the individual cannot maintain control(1).

The use of PAS is often interpreted as a problem that affects only the young population. Research studies dealing with the use of PAS among older adults, mostly, address the use of medications and consumption of alcoholic beverages(2-3). Regarding the use of illegal substances, studies are scarce and punctual considering the age group above 50 years old(4-5), justifying that people using PAS tend to have high rates of medical morbidities when compared to young individuals.

The fact that there is an increase in the number of older adults who use PAS can be explained by the "baby boomer" generation, born in the 40s and 50s until the beginning of the 60s, strongly influenced by the hippie movement that had in their context the use of these substances. Although always present in humanity, recreational/ritualistic use has gained greater prominence since the hippie era, in which the population of the time is aged today(5).

Among older adults, the consumption of PAS is often poorly identified, but it is a significant public health problem because, in addition to causing negative impacts on the health and well-being of the individuals, it also influences the socioeconomic aspects of the community, generating high sustainability costs for taxpayers and government agencies, in addition to health and quality of life aspects(4-7).

In addition, it is perceived that there is an increased risk for the consumption of PAS among older adults, since the aging process can cause them to reflect on limitations and possible survival in the world, leading them to question about death and the finitude of life. In this sense, problems of biopsychosocial origin and experiencing feelings of sadness/loneliness can be responsible for the susceptibility to the use of PAS(8).

Thus, when reflecting on older adults who consume PAS, there is a need to avoid judgments and understand that this process is circular, allowing deconstruction, uncertainty and reconstruction of their attitudes(9).

According to the complexity theory, it is unlikely that we know a person or context, from a single perspective, considering that the causes and consequences of a given phenomenon do not present themselves in a linear way(9). That is, it is unlikely that we understand the consumption of PAS by older adults without considering the different biopsychosocial and cultural facets that influence use. It is relevant to understand the context/environment in which the older adult lives or moves, focusing on the characteristics of their daily lives and social support networks, in addition to the pharmacological properties of the substance consumed.

The complexity discussed by Morin, used as the foundation of this research, implies an interaction between human beings and the context in which they are inserted, originating from events and incident retro-actions that constitute the world of phenomena. Complexity is an integrative perspective. Observing society, it is possible to perceive the existence of interactions between individuals, where different cultures are present, in which simplification is insufficient in view of the empirical difficulties and insurmountable contradictions(9).

The idea that reality is complex and presents itself on multiple levels confers particular meanings to the use of PAS by older adults, defined from the logic of different times, cultures and consumer groups. Conferring a single meaning to a diversity of forms and patterns of consumption would contribute to present a deformed and partial view.

Thus, the use of PAS among older adults can be a complex/multi-factorial situation, since the consumption rates of this population associated with the aging process are underestimated and can present specificities regarding their effects and forms of treatment/care in health(4,6). Thus, it becomes necessary to know the experiences and interfaces of the consumption of PAS, of this age group, which is marked by invisibility. In this context, this study aimed to describe the pattern of consumption of PAS among older adults, from the perspective of complexity.



Qualitative research of the multiple-case study type, which considered five essential components for its development: study question, study proposals, units of analysis, connection of the data to the proposal and the criteria for data interpretation(10).

For the methodology of the case study to reveal its essence, it is suggested that the research question uses the terms of "how" or "why"(10). Thus, the question is: How is the pattern of consumption of PAS presented among older adults, from the perspective of complexity?

The study proposal is restricted to what will be analyzed in the work, leading to search for related evidence(10), that is, the experimentation and continuation of the consumption of PAS among older adults has a strong relationship with the environment, social relationships and lifestyle.

In a multiple-case study, the development of 4 to a maximum of 12 cases is suggested(10). The study was carried out in a municipality of Rio Grande do Sul, Brazil, with 11 older adults consuming PAS. The inclusion criteria were the following: being 60 years of age or older and consuming PAS; and the exclusion criteria were as follows: having cognitive limitations that prevented answering questions and not being registered with the health service/Harm Reduction.

The identification of the older adults who use PAS occurred through searches in the records of the Harm Reduction service, and indications from the Harm Reduction Agents of those who maintained a link/contact with the service, facilitating their location.

Data was collected in the participant's natural environment (home), at the Basic Health Unit (BHU) or Psychosocial Care Center for Alcohol and Drugs (Centro de Atenção Psicossocial de Álcool e Drogas, CAPS-AD), depending on the availability of health professionals to accompany the researcher. Contact with the participants was made at the time of the interview, with no refusals.

The following was used to collect the data: field diary to record unsystematic observations, describing in detail the "occurrences in the field", the subjects, the locations, special events and behaviors; documents from the medical records of the older adults, and semi-structured individual interviews(10). Collection was performed from December 2015 to February 2016.

The script of the semi-structured interview was constructed by the authors, taking into account questions that contemplated the study proposals. Among the specific issues, the following were addressed: consumption of PAS (age at use start, who offered, quantity, frequency, form, associations, location, value and source from the resources spent), what the motivations, expectations, difficulties and losses experienced are, and strategies employed to stop use and/or reduce the resulting harms.

The interviews were conducted in a single meeting and lasted a mean of 30 minutes; each participant was identified by the word "case" followed by the number corresponding to the order in which it was carried out (for example: case 1), having been recorded and later transcribed in full, preserving the reliability of each statement. In addition, the technique of unsystematic observation was used in order to identify behaviors, gestures and expressions that could complement the data learned in the interview, recording them in a field diary, with the objective of reducing the possibilities of information loss(10).

The connection of the data to proposals and the criteria for the interpretation of the findings foreshadow the stages of data analysis, whose unit was the older adult who consumes PAS. Thus, from the interaction of the three collection methods, data were incorporated, which were analyzed based on three strategies: general analytics, which defined priorities; descriptive analytics, which constituted the description of the cases and their consequences; and theoretical analytics, which established the structure based on the literature review and theoretical framework, providing reflections and interpretations about the consumption of PAS by older adults(10).

Thus, two themes/categories emerged: Encounter with the substance: drug of choice, forms of consumption and reasons for continued use; Consequences of substance use and motivations for drug abandonment.

The study respected the formal requirements of national/international research standards involving human beings, as well as Resolution No. 466/2012 of the National Health Council (Conselho Nacional de Saúde, CNS), being approved by the Research Ethics Committee (Comitê de Ética em Pesquisa, CEP), under opinion number 40/2015.



The older adults studied were two women and nine men who used alcohol, marijuana, tobacco and/or cocaine; aged between 60 and 79 years old; eight white-skinned, one brown-skinned and two black-skinned; four living alone and seven with family members; five married or in a stable relationship, two divorced, two widowers and two single; all with children; five retirees, one pensioner and five self-employed; nine with a monthly income of up to one minimum wage and two of two wages; nine living in their own home and two in a ceded residence, all of masonry.

Encounter with the substance: drug of choice, forms of consumption and reasons for continued use

The experimentation with the consumption of PAS among older adults occurred early, in childhood/adolescence, due to the influence of family/friends/curiosity/lifestyle. The substances used were diverse, especially alcohol, tobacco, marijuana and cocaine.

I started working at 15 in a beverage factory, bottling and drinking... (Case 1); I started drinking at 14 and smoking at 25, because I thought it was beautiful to go out on the street smoking, I started with glamor (Case 3). The first time I used marijuana my friends offered me, I was about 17 years old... (Case 10); I tried cocaine when I was 14 and injectable I used it from 18 to 26 years old, out of curiosity... (Case 11).

The meanings constructed before the substance and how its representations in society occur enable and give meaning to the beginning of drug use, arousing the curiosity of the users: Drugs are the moment, the moment now is the stone, there was cocaine, marijuana, 'loló', these addictions I've tried everything, but I don't take it seriously... (Case 8).

Among the older adults who consume legal substances, the place of use is the residence itself and the companies are family members/friends: I smoke cigarettes at home, a rolled-up package lasts for two days... (Case 2); I smoke on the street/patio, mostly alone or with my grandchildren. (Case 4).

The financial structure presented itself as a factor that directly interferes in the consumption pattern among the older adults: To buy the drug, I worked as a painter, a doorman and also at the city hall... (Case 7); I was once a drug dealer. I made money every day, all the time, here in the workshop and also by welding. (Case 8); I trafficked and always worked as a painter and as a plater. Before, everything I had would go, I would leave with 3thousand and returned with zero... (Case 9); I always worked, worked on my own. But crack, if I had 1,000.00 in my pocket, everything would go. (Case 11).

Today, more reflective and with less purchasing power, they rethink consumption and use PAS, mainly illicit, with greater control or only when they obtain them from another user: I've used everything, I've used cocaine all my life, now I use it only once in a while, when a friend brings it. Marijuana depends on the day, the mood, what you expect and who you are relating to. I have been using after work... (Case 8); Marijuana and cocaine I use when somebody gives them to me, I don't have money to buy all the time. I know and helped the whole city when I was dealing, now they remember me. I drink beer and wine every day, 12 or 15cans a day... (Case 7); I use booze every day at home. (Case 9); Cocaine I don't always use, I don't even buy, in fact, the place I go to the guys help... (Case 11).

There are several reasons that older adults report to continue consuming PAS: Anxiety is my main reason, I drink because I want to escape from problems... (Case 1); It's the head itself, seeing others smoking, it's the addiction... (Case 2); I use marijuana because I'm upset, stressed, and also after work to relax.... (Case 8); I use to go out, talk, go for a walk, exchange an idea, that's what motivates me. (Case 9).

Consequences of substance use and motivations for drug abandonment

Older adults who use only tobacco have not identified any type of social harm in their lives. People who used alcohol in their youth blame it for not being retired and for their low economic condition.

Because of the booze I lost many jobs, I missed the service, this issue that I'm underpaid today was my biggest loss... (Case 2); I put everything out, went to the night and spent it all at parties and drinking. Today I say, if I'm not retired, it's my fault... (Case 3).

Among users of multiple illicit substances, some issues related to crime have emerged: I lost what I could lose, when it reaches the limit, you stop. Anyone who says they steal because of the drug is shameless. I put out car/motorcycle/gun. I used to be a drug dealer. In court, I had problems because I bought stolen material, then I was in prison for three years... (Case 8); I've already fought in the street. With justice, I went to jail several times for drug trafficking, but I never stole anything from anyone... (Case 9); I lost everything, I'm just recovering. I lived on the street, I had nowhere to live and my family didn't want me. With justice, I had problems twice for trafficking and fighting... (Case 11).

The older adults have tried various substances throughout their lives and several have stopped using those they considered "heavy", opting for the most pleasant/rewarding ones.

Alcohol transformed me a lot, so I stopped going to bars, I bought my cigarettes elsewhere, I couldn't ask for a drink or accept if someone else offered me.... (Case 2); Alcohol one day I got sick and never drank again. Now I can be at a party, a bar and in places people are drinking that I no longer drink. (Case 3); 40years ago I used marijuana, but I stopped. Cachaça more than 30 years ago I also stopped. When I want, I master the addiction. I just realized that I had to stop and stopped. (Case 5); Abstinence and will, they only exist in the head of the weak, I'm here to tell you that I have no addiction and have used everything. I stopped smoking and drinking because of my stomach ulcer... Today I use marijuana to relax. (Case 8).

Older adults with individual/subjective attitudes were identified, which were modified from experience with the substance. Older adults who learned to recognize the effects of each PAS and, today, use it in order to enjoy its positive effects, such as relaxation and socialization.



Faced with the consumption of PAS by older adults, more than a simplifying epistemology, it is necessary to assume diversity, instability and complexity, considering the context and culture of the individuals involved, in addition to situating each phenomenon in its space-time, expanding the horizons of thought(9). Thus, the complexity theory allows us to visualize each system from the fabric of events, actions, interactions, retro-actions, determinations and chance, understanding the phenomena in depth(9).

The systematic consumption of a set of substances capable of altering the behavior, conscience and mood of human beings is proven to be ancient and presents itself in different ways depending on the season and the event in which it is used(11). For example, in the present research, the consumption of PAS occurred early in life, after a recreational or experimentation consumption instance, influenced by the hippie era of the time or by the positive meanings of empowerment, which faced people who use certain substances.

A number of research studies show that the use of PAS initiated in youth is more common than when initiated in maturity(4,6,8). The consumption of alcohol and tobacco has become a common act among young people, due to the fact that they are legal drugs, easily accessible, merchandise with a lot of publicity and low cost, with the possibility of becoming more vulnerable to future dependence, experimentation and continued use of other drugs(12-13). In most cases, there is an escalation between the consumption of legal substances until the first contact with the illegal ones(1,11).

There are several motivations for experimenting and continuing to use PAS. An analysis of 617 self-reports by people of different nationalities identified that the experimentation with new substances occurred because they believed that a certain drug is safer and more convenient; to satisfy curiosity and interest in the effects; for facilitating a new and exciting adventure; promote self-exploration and growth; assist as coping agents; improve skills and performance; promote social bonding and belonging and/or act as a means of recreation and pleasure(14).

Consciousness is extremely fragile; the human spirit knows how to reject what is unpleasant and select what satisfies it. Memory and selective forgetting are also operators of illusion(9). Thus, for some, the beginning and maintenance of consumption may have occurred due to the difficulty of dealing with the feelings and emotions felt, in which the PAS provided pleasure and forgetfulness of anguish, but it becomes illusory to the subject, because reality and problems come up after a few hours.

The problem of the consumption of PAS and the classification of a controlled or abusive pattern is linked to social, political and moral ties, with a close relationship between economic availability and quantity of substance consumption(5,15). Restricted financial availability is a limiting factor for the use of illicit substances in this research, which is why older adults only use the drug when they obtain it from friends/acquaintances. In their youth, the older adults used more substances due to their greater purchasing power and the ease of obtaining money, not worrying about spending.

Complexity arises from new reflections, based on distinction, conjunction and implication(9). The elements that surround the "world of drugs" can be the reason and the consequence of the pattern of use, they can be the causer or the caused, thus making it unlikely to understand the phenomenon of the use of PAS from the parts without knowing the whole, or to know the whole without identifying the parts. The interfaces of substance use among older adults circulate between the axes of social, family and environmental life(6), influencing the consumption pattern and making the system complex, open and integrated.

The return of favors among users is explicit in the speech of the older adults; those who trafficked and shared the drug during their youth, today are gratified by the children/grandchildren/acquaintances of former clients, who give them some cocaine lines.

A study carried out in the scenes of use of crack highlights the relationships of solidarity, protection and company that exist among the users, in which the material and non-material exchange between individuals is responsible for supporting the group. In this case, from the donation of the crack stone by the group leader, more stones tended to return to him, completing the cycle of giving, receiving and giving back, fueled by the relationship of alliance and solidarity(15).

Regarding the forms of consumption of PAS, the licit ones are used daily, in the residence itself, their use is accepted by family members and, sometimes, shared among the members. Such behavior in the face of alcohol consumption, as well as that of tobacco, leads to the erroneous idea that they are less harmful substances than illicit drugs and end up having their consumption facilitated, and may bring with it several clinical, psychological, family and social complications(8,13).

The use of illicit PAS is marked by a more isolated/hidden behavior, such as at friends' homes, in order to avoid the risk of aggression/violence by certain groups of abusive users. Certain social groups are more vulnerable when using PAS, demonstrating that the consequences of use are not only related to the pharmacological effects of the drug on the human body, but to the entire context of the user's life and the social characteristics of the groups(16).

The criminality attributed to the consumption of the illicit substance is mainly related to drug trafficking. Crack/cocaine dependent individuals are more likely to be involved in illegal activities, putting their physical integrity at risk(17-19). However, in the present research, the subjects associate the involvement in illegal practices to individual characteristics and not to the substance used.

The facets that surround the lives of the older adults who consume PAS can be understood as a system permeated by fluctuations and turbulences that lead to uncertain, non-linear events that seek a circular and multidimensional understanding(9). Different interpretations about the phenomena must always be complementary and not excluding, needing an expanded look and actions that lead to the non-fragmentation of this multidimensional system(9). However, society tends to exclude and not contextualize the phenomena, judging the subjects from a single characteristic: good older adult or bad older adult, as if conflicts and paradoxes did not exist in our relationships. The contradiction is severely punished and rationality imposes, in this case, the non-consumption of PAS.

After years of consumption, some older adults chose the type of substance for continued use and decided to abandon those that they considered most harmful to their health and life. Strategies were used by the older adults to abandon the substances, among them: distancing from the places where they used to buy the substances, not trying drugs that serve as triggers for abusive use, "not taking the first sip, to take the second" and, simply, awareness and the desire to stop.

The practices of regulating consumption, by reducing the use or even abstinence, seem to result from a certain accumulated experience about the drug and the harms/benefits associated with consumption. The individual's exposure to environmental factors previously associated with the use of the drug produces a strongly conditioned response, which incites the person to the substance. Thus, the interruption/reduction of use is influenced by several factors, including: drug cravings, the subject's emotional state, treatment and some environmental stimuli(11,20).

When experiencing the reality of compulsion, which leads to the exhaustive consumption of the drug, the person faces an ambiguous path: on the one hand, pleasure and, on the other, losses and harms, which can affect their social and health relationships. Uncertainty is one of the guiding principles of humanity and based on complexity, it is proposed to understand the contradiction and the unpredictable from the integration of contradictory elements. To think in a complex way is to face confusion, uncertainty and contradiction, while living with the solidarity of the existing phenomena(9).

When associated with the aging process, the results and consequences of the consumption of PAS among the older adults can have an impact on health(3,21). It is important to recognize the diversity of experiences and paths followed, distinguishing between early and late onset and different consumption patterns, so that the best health treatment/monitoring is advised(6,18).

The literature indicates that the use of a late-onset substance presents greater possibility of withdrawal from consumption than early onset(6,18). However, early-onset users have advantages compared to late-onset users, such as: greater control of consumption, understanding of the effects of the substance on health, transmission of diseases, and greater capacity for socialization(6).

According to the theory of complexity, the notion of recursion refers to the movement to go through the same path again, often with an inexhaustible back and forth movement of actions and implementations(9). Among people who consume PAS, this process of repetition is common due to the alternation between moments of abstinence with a pattern of intense consumption of the drug.

Thus, it is indispensable that health professionals/nurses have knowledge and skills on how to identify and care for older adults who consume PAS, seeking a relational dynamic of dialog, understanding the notion of recursion, thus proposing dignified, supportive and quality care(12).



This study achieved the proposed objective by describing the pattern of consumption of PAS among the older adults, from the perspective of complexity based on the identification of people who use legal and illegal substances, describing companions and the consumption space that provides them with security, pointing to material losses in youth, continuity in the consumption of PAS to promote socialization, as well as the abandonment of those that they considered harmful to health/life and were used to minimize stress/anxiety.

The use of the case study methodology was considered adequate, since the consumption of PAS by older adults is a contemporary phenomenon, with little control by the researchers over the facts and with a reduced number of published scientific research studies, thus being used due to its possibility of deepening.

The description of a pattern of consumption of PAS by the older adults, considering the innumerable experiences throughout their lives, presented a strong relationship with the environment, social relationships and lifestyle, making the use of the complexity theory opportune and adequate to subsidize/analyze the data collected, as it made it possible to perceive the entanglement of a social problem under several aspects, which could better clarify the understanding of the world of life, which is not compartmentalized or watertight, but spiral and complex.

It presents contributions to Nursing and implications for future research studies because, as evidence of the consumption of PAS by the older adults is established, there is room for the success of health/nursing interventions, from the design of actions/programs to be developed and improved by means of harm reduction.





Corresponding author:
Vania Dias Cruz

Received: Sep 21st 2020
Accepted: Dec 21st 2020



Author's contribution
Study concept and design: Vania Dias Cruz, Silvana Sidney Costa Santos, Michele Mandagará de Oliveira, Cristiane Lima de Moraes, Paola Camargo de Oliveira.
Obtaining data: Vania Dias Cruz.
Data analysis and interpretation: Vania Dias Cruz, Silvana Sidney Costa Santos, Michele Mandagará de Oliveira, Cristiane Lima de Moraes, Paola Camargo de Oliveira.
Drafting the manuscript: Vania Dias Cruz, Silvana Sidney Costa Santos, Michele Mandagará de Oliveira, Cristiane Lima de Moraes, Paola Camargo de Oliveira.
Critical review of the manuscript as to its relevant intellectual content: Vania Dias Cruz, Silvana Sidney Costa Santos, Michele Mandagará de Oliveira, Cristiane Lima de Moraes, Paola Camargo de Oliveira.
All authors approved the final version of the text.
Conflict of interest: the authors have declared that there is no conflict of interest.
*Paper extracted from doctoral dissertation "O cuidado de enfermagem direcionado à pessoa idosa que consome substâncias psicoativas: uma abordagem complexa", presented to Departamento de Enfermagem, Universidade Federal do Rio Grande, Rio Grande, RS, Brazil.

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Corresponding author:
Vania Dias Cruz

Received: Sep 21st 2020
Accepted: Dec 21st 2020



Author's contribution
Study concept and design: Vania Dias Cruz, Silvana Sidney Costa Santos, Michele Mandagará de Oliveira, Cristiane Lima de Moraes, Paola Camargo de Oliveira.
Obtaining data: Vania Dias Cruz.
Data analysis and interpretation: Vania Dias Cruz, Silvana Sidney Costa Santos, Michele Mandagará de Oliveira, Cristiane Lima de Moraes, Paola Camargo de Oliveira.
Drafting the manuscript: Vania Dias Cruz, Silvana Sidney Costa Santos, Michele Mandagará de Oliveira, Cristiane Lima de Moraes, Paola Camargo de Oliveira.
Critical review of the manuscript as to its relevant intellectual content: Vania Dias Cruz, Silvana Sidney Costa Santos, Michele Mandagará de Oliveira, Cristiane Lima de Moraes, Paola Camargo de Oliveira.
All authors approved the final version of the text.
Conflict of interest: the authors have declared that there is no conflict of interest.
*Paper extracted from doctoral dissertation "O cuidado de enfermagem direcionado à pessoa idosa que consome substâncias psicoativas: uma abordagem complexa", presented to Departamento de Enfermagem, Universidade Federal do Rio Grande, Rio Grande, RS, Brazil.

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