“I Know Far More Dead People Than I Do Live Ones”: Social Isolation Among Older Adults Who Use Stimulants

BACKGROUND: Social isolation is associated with poor physical health and premature mortality. Midlife and older adults who use stimulants (cocaine or methamphetamine) may be especially vulnerable to social isolation. METHODS: We conducted in-depth semi-structured interviews with 35 participants who used cocaine or methamphetamine for at least 5 years and 10 of the past 30 days in San Francisco, CA. Interviews included validated scales and open-ended questions on sociodemographic characteristics, substance use history, social support, and social capital. We present proportions of categorical measures and medians of continuous variables. Social support and capital scores were compared using Wilcoxon rank sum tests. Qualitative data were transcribed verbatim and coded until consensus. Inductive thematic analysis identified emergent themes of social isolation. RESULTS: Median age was 55 years (interquartile range: 47-62), 58% were black or African American, and 34% were unhoused/marginally housed. All participants smoked cocaine or methamphetamine. Social support and capital were limited. Participants described profound loss of loved ones that deepened their isolation, while stigma around substance use further eroded remaining relationships. With limited support, many participants used stimulants to cope with grief and loneliness. A strong preference for solitary substance use emerged, as both a means of control and a response to mistrust, but this practice reinforced cycles of isolation and substance use. CONCLUSIONS: Older people who use stimulants represent a population with distinct needs, and interventions that increase their social engagement may help address social isolation, substance use, and related health outcomes.