Prescription painkiller misuse and the perceived risk of harm from using heroin

Naloxone expansion is not associated with increases in adolescent heroin use and injection drug use: Evidence from 44 US states

BACKGROUND

Naloxone distribution is central to ongoing efforts to address the opioid overdose crisis. Some critics contend that naloxone expansion may inadvertently promote high-risk substance use behaviors among adolescents, but this question has not been directly investigated.

METHODS

We examined relationships between naloxone access laws and pharmacy naloxone distribution with lifetime heroin and injection drug use (IDU), 2007-2019. Models generating adjusted odds ratios (aOR) and 95% confidence intervals (CI) included year and state fixed effects, controlled for demographics and sources of variation in opioid environments (e.g., fentanyl penetration), as well as additional policies expected to impact substance use (e.g., prescription drug monitoring). Exploratory and sensitivity analyses further examined naloxone law provisions (e.g., third-party prescribing) and applied e-value testing to assess vulnerability to unmeasured confounding.

RESULTS

Adoption of any naloxone law was not associated with changes in adolescent lifetime heroin or IDU. For pharmacy dispensing, we observed a small decrease in heroin use (aOR: 0.95 [CI: 0.92, 0.99]) and a small increase in IDU (aOR: 1.07 [CI: 1.02, 1.11]). Exploratory analyses of law provisions suggested that third-party prescribing (aOR: 0.80, [CI: 0.66, 0.96]) and non-patient-specific dispensing models (aOR: 0.78, [CI: 0.61, 0.99]) were associated with decreased heroin use but not decreased IDU. Small e-values associated with the pharmacy dispensing and provision estimates indicate that unmeasured confounding may explain observed findings.

CONCLUSION

Naloxone access laws and pharmacy naloxone distribution were more consistently associated with decreases rather than increases in lifetime heroin and IDU among adolescents. Our findings therefore do not support concerns that naloxone access promotes high-risk adolescent substance use behaviors. As of 2019, all US states have adopted legislation to improve naloxone access and facilitate use. However, further removal of adolescent naloxone access barriers is an important priority given that the opioid epidemic continues to affect people of all ages.

Finding the Hidden Risk Profiles of the United States Opioid Epidemic: Using a Person-Centered Approach on a National Dataset of Noninstitutionalized Adults Reporting Opioid Misuse

Opioid misuse can lead to use disorder and other adverse outcomes. Identifying sociodemographic risk profiles and understanding misuse patterns in combination with health indicators can inform prevention science and clinical practice. A latent class analysis of opioid misuse was conducted on noninstitutionalized United States civilians aged 18 and older that reported opioid dependence or abuse in the 2017 National Survey of Drug Use and Health (n = 476; weighted n = 2,018,922). Opioid misuse was based on heroin and/or prescription pain reliever use, and associated determinants of health and mental health indicators. Five misuse profiles were identified: (1) single heroin or prescription misuse with high-income; (2) female prescription pain reliever misuse with psychological distress and suicidality; (3) younger polyopioid misuse with the highest proportion of Hispanics and heroin use; (4) older polyopioid misuse with the highest proportion of non-Hispanic blacks and disability; and (5) older non-Hispanic white male exclusive dual heroin and/or prescription misuse (27%, 20%, 38%, 10%, and 5% of sample, respectively). The identified risk profiles can inform public health practice to develop interventions for acute and immediate response by providing etiological evidence and to inform prevention and intervention efforts along the continuum from opioid initiation to use disorder.

Perceived Risk of Heroin in Relation to Other Drug Use in a Representative US Sample

Low perception of risk is a risk factor for heroin use. Research is needed to determine whether this risk factor for heroin use is affected by the use of other drugs. Data were analyzed from participants in the 2015/2016 National Surveys on Drug Use and Health who denied lifetime heroin use (N= 110,102). We examined how recency of use of various drugs and number of drugs used relate to perceptions that using heroin is not a great risk. Results from multivariable models suggest that no lifetime drug use, and recent prescription opioid misuse and methamphetamine use, in particular, were associated with higher odds of perceiving that heroin use is not of great risk. Recent marijuana use was associated with lower odds of reporting that heroin use is not of great risk. Use of more drugs in one's lifetime, past year, and/or past month tended to be associated with lower odds of reporting heroin use as not a great risk. Prevention experts should consider that recent prescription opioid misuse in particular is a risk factor for the lower perception of risk, while individuals reporting no lifetime drug use may also require better education regarding harms associated with heroin use.