Is non-medical use normal? Normalisation, medicalisation and pharmaceutical consumption

The theory of the normalisation of youth drug use in advanced capitalist societies has had an enduring legacy in contemporary drug scholarship. While the literature on the normalisation of 'illicit' drugs is well developed, less has been written about application of the theory to emerging discourse of pharmaceutical 'abuse', and how this might necessitate different thinking around what can be considered normal consumption. Pharmaceuticals are not directly associated with criminality, and their use does not traditionally attract stigma. In fact, social science scholarship has illustrated how many substances deemed illicit are normalised in the context of an ever-growing set of medical treatments. This paper explores the assumptions about legality, sociality and pleasure which sit behind the drug normalisation thesis, by reflecting on the relevance of drug normalisation in relation to pharmaceuticals, as well as examining scholarship on the medicalisation of society and qualitative research on non-medical use to illustrate the parallel processes of normalisation that apply to pharmaceuticals. The paper argues that questions of normalisation in relation to pharmaceutical use require a deeper engagement with the normative expectations we attach to pleasure, consumption and medicine, and the way this is structured by proximity to medical authority, whiteness and middle-classness.

Prescription opioid characteristics at initiation for non-cancer pain and risk of treated opioid use disorder: A population-based study

BACKGROUND

Long-term prescription opioid use has been associated with adverse health outcomes, including opioid use disorder (OUD). We examined a population of opioid naïve individuals who initiated prescription opioids for non-cancer pain and investigated the associations between opioid prescription characteristics at initiation and time to treated OUD.

METHODS

We conducted a retrospective population-based cohort study in Ontario, Canada among opioid naïve individuals aged 15 years and older dispensed an opioid for non-cancer pain between 2013 and 2016. We used the Narcotic Monitoring System to abstract opioid dispensing data. A multivariable Cox regression model was used to examine the association between average daily dose and time to treated OUD.

RESULTS

We identified 1,607,659 opioid-naïve individuals who initiated a prescription opioid within the study period. The incidence of treated OUD within the study period was 86 cases per 100,000 person-years. Compared to an average daily dose of <20 morphine milligrams equivalent (MME), higher average daily doses at initiation were associated with greater hazard of treated OUD, 20-50 MME (HR 1.11, 95% CI: 1.02, 1.21), >50-90 MME (HR 1.29, 95% CI: 1.16, 1.44), >90-150 MME (HR 1.29, 95% CI: 1.06, 1.56), >150-200 MME (HR 2.49, 95% CI: 1.54, 4.03) and >200 MME (HR 4.15, 95% CI: 2.89, 5.97). Long-acting formulations and days' supply ≥11 days were also associated with greater hazard of treated OUD.

CONCLUSION

Prescription opioid characteristics at initiation are associated with risk of treated OUD, identifying potentially important and modifiable risk factors among people initiating opioids for non-cancer pain.

Peer Influence in Initiation to Heroin Use

Much research on heroin initiation shows that most people use heroin initially with friends or family. However, there is little research examining why those who use heroin would initiate others to its use, and conversely, whether and why one might try to prevent initial heroin use in others. Following recent work on peer influence on crime and delinquency, we test the hypothesis that those with higher levels of self-control are less likely to initiate others to heroin use and are more likely to try to prevent others from using for the first time. The sample included 370 persons entering an opioid withdrawal program. We find that those with low self-control are more likely to initiate others, but there is no relationship between self-control and trying to prevent initiation. We further investigate self-reported motives for initiating others, and find a mix of self-interested and more altruistic motives for initiating others.

On my own terms: Motivations for self-treating opioid-use disorder with non-prescribed buprenorphine

INTRODUCTION

The opioid overdose crisis in the United States has prompted an expansion of treatment services, including pharmacotherapy with buprenorphine. However, many people who use illicit opioids (PWUIO) self-treat their opioid-use disorder (OUD) with non-prescribed buprenorphine (NPB) in lieu of attending formal treatment. The present study aims to qualitatively understand motivations of people who are self-treating their OUD with NPB.

METHODS

Qualitative study designed to supplement and contextualize quantitative findings from natural history study of buprenorphine diversion, self-treatment, and use of substance use disorder treatment services. Interviews were audio-recorded, transcribed, systematically coded and analyzed via Iterative Categorization.

STUDY SETTING

The Dayton, Ohio metropolitan area in the midwestern United States; a site previously characterized as high impact in the national opioid overdose crisis.

PARTICIPANTS

Sixty-five individuals (35 men and 30 women) who met the DSM-5 criteria for OUD (moderate or severe) and had used NPB at least one time in the six months prior to their intake interview.

RESULTS

Participants described four key motivators for self-treating with NPB: perceived demands of formal treatment, the desire to utilize non-prescribed buprenorphine in combination with a geographic relocation, to self-initiate treatment while preparing for formal services, and to bolster a sense of self-determination and agency in their recovery trajectory.

CONCLUSIONS

Use of NPB is a recognized self-treatment modality among PWUIO, with some PWUIO transitioning into sustained recovery episodes or enrollment in formal treatment. Understanding the motivations for opting out of treatment is crucial for improving forms of care for people with OUD.

The Role of Life Events/Contextual Factors and Cannabis Use in Patterns of Other Drug Use Among Young Adult Cannabis Users in Los Angeles: A Qualitative Inquiry

This analysis examined the role of impactful life events/stressful contextual factors and cannabis use in the patterns of illicit drug use. It utilized semi-structured qualitative interviews with 40 young adult medical cannabis patients and 22 non-patient users collected in Los Angeles during 2014-2015. Three patterns of illicit drug use emerged based on participants' narratives: regular/problematic, recreational/occasional, and never users. Among regular/problematic users, a common theme was the lasting impact of traumatic life events or stressful contextual factors on transition to and away from problematic drug use, and using cannabis to cope with negative after effects of drug use. In contrast, most recreational/occasional and never users, who reported impactful life events or stressful contextual factors, used cannabis to cope with those experiences. Family history of addiction and acceptance of cannabis use within a family as protective factors against illicit drug use among some recreational/occasional and never users was an unexpected finding.

Characterization of diverted buprenorphine use among adults entering corrections-based drug treatment in Kentucky

BACKGROUND

Illicit, medically unsupervised use of buprenorphine (i.e., "diverted use") among vulnerable and underserved populations, such as corrections-involved adults, remains underexplored.

METHODS

Survey data (2016-2017) collected as part of a clinical assessment of incarcerated adults entering corrections-based substance use treatment in Kentucky were analyzed. For years examined, 12,915 completed the survey. Removing cases for participants who did not reside in Kentucky for >6 months during the one-year pre-incarceration period (n = 908) resulted in a final sample size of 12,007.

RESULTS

Over a quarter of the sample reported past-year diverted buprenorphine use prior to incarceration and 21.8 % reported use during the 30-days prior to incarceration, using 6.5 months and 14.3 days on average, respectively. A greater proportion of participants who reported diverted buprenorphine use had previously been engaged with some substance use treatment (77.0 %) and reported greater perceived need for treatment (79.4 %) compared to those who did not report use. Use was more likely among participants who were younger, white, male, and who reported rural or Appalachian residence. Diverted buprenorphine users also evidenced extensive polydrug use and presented with greater substance use disorder severity. Non-medical prescription opioid, heroin, and diverted methadone use were associated with increased odds of diverted buprenorphine use while kratom was not. Diverted methadone use was associated with a 252.9 % increased likelihood of diverted buprenorphine use.

CONCLUSIONS

Diverted buprenorphine use among participants in this sample was associated with concerning high-risk behaviors and may indicate barriers to accessing opioid agonist therapies for corrections-involved Kentucky residents, particularly those in rural Appalachia.

Buprenorphine Treatment for Adolescents and Young Adults With Opioid Use Disorders: A Narrative Review

: In the past decade, a new cohort of adolescents and young adults with opioid use disorders (OUD) has emerged. While medications and psychosocial treatments are available, few adolescents and young adults with OUD can access and remain in treatment. Effective, practical, and scalable treatment paradigms for this young population are needed. Buprenorphine is a medication with unique pharmacological and regulatory characteristics that make it a promising component of adolescent and young adult OUD treatment models. Three randomized controlled trials and multiple observational studies have evaluated the use of buprenorphine to treat this population. However, data from these studies have not been consolidated into an up-to-date summary that may be useful to clinicians. The objective of this narrative review is to inform clinical practice by summarizing results of primary and secondary analyses from randomized controlled clinical trials and observational studies that have evaluated the use of buprenorphine to treat adolescents and young adults with OUD. Based on results from these studies, we encourage the conceptualization of OUD among youth as a chronic medical condition requiring a long-term management strategy. This includes treatment with buprenorphine in conjunction with medication-prescribing protocols that do not necessarily require daily clinic attendance for observed medication adherence. However, more study of treatment delivery models, addressing such issues as medication adherence and intensity requirements, is needed to determine practices that optimize outcomes for youth.

Suspected involvement of fentanyl in prior overdoses and engagement in harm reduction practices among young adults who use drugs

Background: From 2011 to 2016, the United States has experienced a 55% increase in overall overdose deaths and a 260% increase in fatal fentanyl-related overdoses. Increasing engagement in harm reduction practices is essential to reducing the rate of fentanyl-related overdoses. This study sought to examine the uptake of harm reduction practices among young adults who reported recent drug use and who were recruited for a study to assess the utility and acceptability of rapid fentanyl test strips. Methods: Between May and October 2017, 93 young adults who reported drug use in the past 30 days were recruited through word of mouth, Internet advertising, and public canvasing. Participants completed an interviewer-administered survey that assessed participants' sociodemographic and behavioral characteristics, suspected fentanyl exposure, and overdose history. We assessed harm reduction practices and other correlates associated with experiencing a suspected fentanyl-related overdose. Results: Of 93 eligible participants, 36% (n = 34) reported ever having experienced an overdose, among whom 53% (n = 18) suspected having experienced a fentanyl-related overdose. Participants who had ever experienced a fentanyl-related overdose were more likely to keep naloxone nearby when using drugs compared with those who had never experienced an overdose and those who had experienced an overdose that they did not suspect was related to fentanyl (P < .001). Additionally, experiencing a suspected fentanyl-related overdose was associated with having previously administered naloxone to someone else experiencing an overdose (P < .001). Conclusion: Those who had experienced a suspected fentanyl-related overdose were more likely to carry and administer naloxone. Future overdose prevention interventions should involve persons who have experienced a suspected fentanyl overdose and/or responded to an overdose in order to develop harm reduction programs that meet the needs of those at risk of an overdose.

Patterns and history of prescription drug use among opioid-related drug overdose cases in British Columbia, Canada, 2015-2016

BACKGROUND

British Columbia is the epicenter of the current fentanyl-related overdose crisis in Canada. Our study characterizes prescribing histories of people who had an opioid-related overdose compared to matched controls.

METHODS

We examined linked administrative data for individuals who overdosed between January 1, 2015 and November 30, 2016. Past prescriptions over five years were assessed for opioids for pain, opioid agonist therapy, benzodiazepines/z-drugs, antidepressants, antipsychotics, gabapentinoids, mood stabilizers and anti-epileptics, muscle relaxants, and other sedating medications. Prescribing history of 9964 cases was compared with that of 49,820 matched controls.

RESULTS

Overdose cases were more likely to be prescribed opioids for pain and to have used prescription opioids on a long-term basis in the previous five years compared to controls. However, at the time of overdose, 92% of men and 86% of women did not have an active opioid for pain prescription, and approximately half had not filled one in the past five years. Those who overdosed tended to have more prescriptions for psychotropic substances than controls. Fewer than 10% of cases had an active prescription for opioid agonist therapy and most were not on treatment in the past.

CONCLUSIONS

Low prevalence of active prescriptions for opioids for pain at the time of overdose suggests that opioid prescribing plays a limited short-term impact in the current fentanyl-related crisis of overdoses. While liberal opioid prescribing practices may have contributed to the development of the current overdose crisis, regulation and enforcement of clinicians' prescribing practices will likely have limited impact in reducing overdoses.

The prescription opioid epidemic: a review of qualitative studies on the progression from initial use to abuse

Most research designed to answer the “why” of the prescription opioid epidemic has relied on structured interviews, which rigidly attempt to capture the complex reasons people use opioids. In contrast this systematic literature review focuses on peer-reviewed studies that have used a qualitative approach to examine the development of an opioid-use disorder from the point of initial exposure. Rather than simply providing a “high,” opioids reportedly relieve psychological/emotional problems or provide an escape from life stressors. As use continues, avoidance of withdrawal sickness becomes an overriding concern, with all other benefits playing minor roles in persistent use. These studies indicate that terms used in structured interviews, such as “nontherapeutic use” or variations thereof, poorly capture the complex range of needs opioids satisfy. Both quantitative/structured studies and more qualitative ones, as well as more focused studies, have an important role in better informing prevention and treatment efforts.

A qualitative study of persons who inject drugs but who have never helped others with first injections: how their views on helping contrast with the views of persons who have helped with first injections, and implications for interventions

BACKGROUND

Transitioning from non-injection to injection drug use dramatically escalates health risks. Evidence suggests that people who inject drugs (PWID) help in a majority of others' first injections, yet these helpers represent only a minority of experienced PWID. Recent research has provided insight into this helping process, as reported by helpers. PWID who have never helped, although the majority of PWID, have not previously been the focus of study. To address this gap, we give primary voice to non-helpers' perspectives on the helping process, while also comparing their views with persons in our sample who have helped with first injections. Finally, we consider how non-helpers' perspectives can inform harm reduction interventions to reduce, or make safer, initiation into injecting drug use.

METHODS

We conducted audio-recorded, qualitative interviews with 23 current opioid injectors on Staten Island, NY, where the opioid epidemic is pronounced. Seventeen had never helped with first injections and 6 had. Interviews were transcribed verbatim, and three coders used a consensus-developed codebook to code all interviews. Framework analysis was used to identify overarching themes.

RESULTS

We identified three key themes in non-helpers' discourse around not helping: altruistic motivations to prevent immediate and delayed harms to individuals injecting for the first time; inhibition due to negative assessments of their own injecting skills; and absolutist ethical convictions against helping. Non-helpers differed from helpers on each theme.

CONCLUSIONS

Because most PWID have never helped with first injections, their perspectives on helping warrant consideration and can inform harm reduction interventions to reduce, or make safer, transitions to injection drug use. Their perspectives can be used to broaden the factors PWID consider around questions of promoting injection and helping with others' first injections, including considerations of the moral issues involved in choosing to help or not to help.

Opioid misuse initiation: Implications for intervention

The nonmedical use of opioids (e.g., prescription painkillers and heroin) has drastically increased over the past two decades. Despite the popular media narrative suggesting initiation often begins with misused personal prescriptions, there has been surprisingly little investigation into how persons initiate their misuse of opioids. Inattention to initiation patterns is an important limitation because understandings of onset directly inform prevention and treatment interventions. The primary goals of this study, therefore, were to: (1) describe the age patterns of opioid misuse initiation, (2) identify the opioid most commonly used at initiation and the source of the initial opioids, and (3) explore the narrative accounts of the circumstances surrounding opioid misuse onset. Surveys (n = 125) and in-depth interviews (n = 30) were conducted with nonmedical opioid users currently residing in southwest Pennsylvania between July 2017 and July 2018. Survey results show that initiation of opioid misuse (both heroin and prescription opioids) tends to occur prior to age 25, peaking between the ages of 18-25, with most (81%) initiating with prescription opioids. Qualitative findings provided additional context regarding the timing of initiation, acquiring opioids at initiation, and motivations for initiating. This study adds to the limited research on opioid misuse initiation and provides insights to drug treatment providers, prescribers, and public health professionals in identifying who is at risk for opioid misuse initiation, and more importantly, when and how to intervene most effectively.

Patient perspectives of transitioning from prescription opioids to heroin and the role of route of administration

Background

As the availability of prescription opioids decreases and the availability of heroin increases, some prescription opioid users are transitioning to heroin. This study seeks to explore factors associated with respondents’ transition from prescription opioid use to heroin.

Methods

In-depth, semi-structured qualitative interviews (n = 20) were conducted with buprenorphine patients in an opioid treatment program. Respondents were predominantly White (n = 13) and male (n = 13), with a range of treatment tenure (4 days to 2 years).

Results

A vast majority of respondents in this study (n = 15) initiated opioid use with either licit (n = 8) or illicit (n = 7) prescription opioids (e.g. hydrocodone, oxycodone, morphine). Of these respondents, all but two transitioned from prescription opioids to heroin (n = 13). For those respondents who transitioned to heroin, most initiated heroin use intranasally (n = 12), after using prescription opioids in the same manner (n = 9), but before using heroin intravenously (n = 9). Respondents attributed this transition between substances to common explanations, such as “it’s cheaper” and “the same thing as pills.” However, respondents also dispel these myths by describing: 1) heroin quality is always uncertain, often resulting in spending more money over time; 2) dramatic increases in tolerance, resulting in spending more money over time and transitioning to intravenous use; 3) more severe withdrawal symptoms, especially when respondents transitioned to intravenous use.

Conclusions

Understanding how route of administration and common myths shape key transition points for opioid users will allow practitioners to develop effective harm reduction and prevention materials that target individuals already using prescription opioids.

Heroin use onset among nonmedical prescription opioid users in the club scene

BACKGROUND

Nonmedical prescription opioid use (NMPOU) is well documented among participants in the club scene, yet prior studies have not examined transition to heroin use. We prospectively examined heroin initiation among a sample of young adults with drug involvement associated with participation in the club scene, to understand factors that influence transition from NMPOU to heroin and to identify opportunities for intervention.

METHODS

Data were drawn from a randomized trial that enrolled 750 Miami-based club and prescription drug users through respondent driven sampling, and tested the efficacy of assessment interventions in reducing risk. Participants reported current substance use at baseline, 3, 6, and 12 month follow-ups. We examined predictors of heroin initiation among participants reporting NMPOU at baseline, with no lifetime history of heroin use (N=323).

RESULTS

The mean age was 25.0 years; 67.5% met DSM-IV criteria for substance dependence. About 1 in 13 participants (7.7%) initiated heroin use at follow-up. In univariable comparisons, frequent LSD use, history of drug overdose, high frequency NMPOU, using oral tampering methods, and endorsing a primary medical source for prescription opioids were associated with greater likelihood of heroin initiation. LSD use, oral tampering, and primary medical source were significant predictors in a Cox regression model.

CONCLUSIONS

Heroin initiation of 7.7% suggests a high level of vulnerability for transition among young adult NMPO users in the club scene. The importance of oral tampering methods in the trajectory of NMPOU may indicate a need to further examine the role of abuse deterrent formulations in prevention efforts.

Pharmaceutical opioid use among oral and intravenous users in Australia: A qualitative comparative study

BACKGROUND

Between 1992 and 2012 dispensing episodes for pharmaceutical opioids (PO) in Australia increased from 500000 to 7500000. In the US, increases in the prescription of PO have been linked to increases in opioid-related morbidity and mortality and transitions to heroin injection. However, Australian data indicate that morbidity and mortality related to PO are relatively low, particularly when compared to heroin and other drugs. This paper explores the characteristics and patterns of non-medical pharmaceutical opioid (NMPO) use among a sample of young people in Sydney, Australia.

METHODS

During 2015, we conducted in-depth qualitative interviews with 34 young people who use PO non-medically by oral (n=22) and intravenous (n=12) routes of administration.

RESULTS

Oral NMPO users were a more affluent group who clustered around the Northern, Inner and Eastern suburbs of Sydney, while the intravenous users came from a range of locations including rural/regional areas of NSW and socioeconomically disadvantaged suburbs of South Western Sydney. Oral users were characterised by intermittent and largely self-limiting NMPO use and reported few health and social consequences. Intravenous users reported heavy and frequent drug, including NMPO, use and a range of adverse health and social consequences including overdose, injecting risk behaviour, hepatitis C virus (HCV) infection and residential instability.

CONCLUSION

Results highlight the significance of social and structural factors in trajectories of opioid use and related harms. Factors such as stable housing and family relationships, disposable income and close social networks observed in young oral NMPO users may help to explain differences in patterns of NMPO use and related outcomes between the two groups.

Nationwide increase in hospitalizations for heroin-related soft tissue infections: Associations with structural market conditions

INTRODUCTION

Little is known about trends in national rates of injection-related skin and soft tissue infections (SSTI) and their relationship to the structural risk environment for heroin users. Use of Mexican-sourced "Black Tar" heroin, predominant in western US states, may have greater risk for SSTI compared with eastern US powder heroin (Colombian-sourced) due to its association with non-intravenous injection or from possible contamination.

METHODS

Using nationally representative hospital admissions data from the Nationwide Inpatient Sample and heroin price and purity data from the Drug Enforcement Administration, we looked at rates of hospital admissions for opiate-related SSTI (O-SSTI) between 1993 and 2010. Regression analyses examined associations between O-SSTI and heroin source, form and price.

RESULTS

Hospitalization rates of O-SSTI doubled from 4 to 9 per 100,000 nationally between 1993 and 2010; the increase concentrated among individuals aged 20-40. Heroin market features were strongly associated with changes in the rate of SSTI. Each $100 increase in yearly heroin price-per-gram-pure was associated with a 3% decrease in the rate of heroin-related SSTI admissions. Mexican-sourced-heroin-dominant cities had twice the rate of O-SSTI compared to Colombian-sourced-heroin-dominant cities.

DISCUSSION

Heroin-related SSTI are increasing and structural factors, including heroin price and source-form, are associated with higher rates of SSTI hospital admissions. Clinical and harm reduction efforts should educate heroin users on local risk factors, e.g., heroin type, promote vein health strategies and provide culturally sensitive treatment services for persons suffering with SSTI.

Predictors of transition to heroin use among initially non-opioid dependent illicit pharmaceutical opioid users: A natural history study

BACKGROUND

Increases in illicit pharmaceutical opioid (PO) use have been associated with risk for transition to heroin use. We identify predictors of transition to heroin use among young, illicit PO users with no history of opioid dependence or heroin use at baseline.

METHODS

Respondent-driven sampling recruited 383 participants; 362 returned for at least one biannual structured interview over 36 months. Cox regression was used to test for associations between lagged predictors and hazard of transition to heroin use. Potential predictors were based on those suggested in the literature. We also computed population attributable risk (PAR) and the rate of heroin transition.

RESULTS

Over 36 months, 27 (7.5%) participants initiated heroin use; all were white, and the rate of heroin initiation was 2.8% per year (95% CI=1.9%-4.1%). Mean length of PO at first reported heroin use was 6.2 years (SD=1.9). Lifetime PO dependence (AHR=2.39, 95% CI=1.07-5.48; PAR=32%, 95% CI=-2% to 64%), early age of PO initiation (AHR=3.08, 95%; CI=1.26-7.47; PAR=30%, 95% CI=2%-59%), using illicit POs to get high but not to self-medicate a health problem (AHR=4.83, 95% CI=2.11-11.0; PAR=38%, 95% CI=12%-65%), and ever using PO non-orally most often (AHR=6.57, 95% CI=2.81-17.2; PAR=63%, 95% CI=31%-86%) were significant predictors.

CONCLUSION

This is one of the first prospective studies to test observations from previous cross-sectional and retrospective research on the relationship between illicit PO use and heroin initiation among young, initially non-opioid dependent PO users. The results provide insights into targets for the design of urgently needed prevention interventions.

Circumstances and contexts of heroin initiation following non-medical opioid analgesic use in New York City

BACKGROUND

As the prevalence of opioid analgesic (OA) misuse and associated harms have increased in the United States, the prevalence of heroin use and rates of unintentional overdose have concurrently risen. Research has begun to identify connections between OA misuse and heroin use, although this relationship remains under explored. The present study explores the context of heroin initiation among persons with histories of OA misuse in New York City.

METHODS

In-depth interviews were conducted with 31 individuals with histories of OA misuse who initiated heroin use within the past five years. Data were collected between August 2013 and January 2015. All participants' OA misuse temporally preceded their heroin use. Interviews were coded and analyzed utilizing thematic qualitative methods.

RESULTS

Participants ranged in age from 18 to 44 years; 25 identified as male and 30 identified as non-Hispanic white and heterosexual. All participants had stable housing at the time of interview and all were high school graduates. Participants described several key points of transition along their trajectories from OA misuse to heroin initiation: dual- to single-entity OAs; oral to intranasal OA administration; and the development of physical opioid dependence. Participants described the breaking down of heroin-related stigma across social networks as new drug use permeated social groups.

CONCLUSION

Several points of transition were identified in participants' trajectories from OA misuse to heroin initiation. In particular the development of physical dependence was a critical factor as existing heroin stigma was rapidly overcome in the face of opioid withdrawal. The relatively short time to heroin initiation documented among new user groups serves as an added challenge to the development of interventions.

Routes Into Opioid Analgesic Misuse

Non-medical use of opioid analgesics (OAs) has increased in the United States over the past decade, yet there has been little in-depth exploration into the circumstances of initiation of OA misuse. This study is based on qualitative data from five focus groups conducted with individuals who misused OAs in New York City. Participants ( n = 19) were aged between 20 and 47 years. The majority were male ( n = 14) and non-Hispanic White ( n = 12). Three initiate groups were identified: recreational initiates, who typically began misusing OAs in their teens through non-medical sources; medical initiates, who initiated OA use through medical treatment; and experienced opioid users, who initiated OA use through both recreational and medical channels but whose entry into misuse followed a history of heroin use. Findings show heterogeneous patterns of initiation, indicating the need for prevention and intervention strategies to be tailored to particular groups.

Dynamic model of nonmedical opioid use trajectories and potential policy interventions

BACKGROUND

Nonmedical use of pharmaceutical opioid analgesics (POA) increased dramatically over the past two decades and remains a major health problem in the United States, contributing to over 16 000 accidental poisoning deaths in 2010.

OBJECTIVES

To create a systems-oriented theory/model to explain the historical behaviors of interest, including the various populations of nonmedical opioid users and accidental overdose mortality within those populations. To use the model to explore policy interventions including tamper-resistant drug formulations and strategies for reducing diversion of opioid medicines.

METHODS

A system dynamics model was constructed to represent the population of people who initiate nonmedical POA usage. The model incorporates use trajectories including development of use disorders, transitions from reliance on informal sharing to paying for drugs, transition from oral administration to tampering to facilitate non-oral routes of administration, and transition to heroin use by some users, as well as movement into and out of the population through quitting and mortality. Empirical support was drawn from national surveys (NSDUH, TEDS, MTF, and ARCOS) and published studies.

RESULTS

The model was able to replicate the patterns seen in the historical data for each user population, and the associated overdose deaths. Policy analysis showed that both tamper-resistant formulations and interventions to reduce informal sharing could significantly reduce nonmedical user populations and overdose deaths in the long term, but the modeled effect sizes require additional empirical support.

CONCLUSION

Creating a theory/model that can explain system behaviors at a systems level scale is feasible and facilitates thorough evaluation of policy interventions.

Evaluating the potential impact of a reformulated version of oxycodone upon tampering, non-adherence and diversion of opioids: the National Opioid Medications Abuse Deterrence (NOMAD) study protocol

AIMS

A new oxycodone formulation (Reformulated OxyContin® was released in Australia, early 2014. It was developed as a tamper-resistant ('abuse-deterrent') formulation of the drug. We summarize methods used in the National Opioid Medication Abuse Deterrence (NOMAD) study, which will examine: (i) whether there is a reduction in extra-medical use (including via tampering) of OxyContin® following the introduction of Reformulated OxyContin®; (ii) potential changes in extra-medical use of non-abuse-deterrent forms of oxycodone, other pharmaceutical opioids and illicit drugs; (iii) whether methods of tampering with Reformulated OxyContin® become widespread over time; (iv) Reformulated OxyContin®'s attractiveness on the illicit market; and (v) sales, prescriptions and harms related to OxyContin® and other drugs.

METHODS

There are three major components. First, analyses of existing routine data sources such as: pharmaceutical sales; prescribing data; data on drug overdose deaths; and survey data on drug use in the general population and among people who inject drugs; secondly, specific data on OxyContin® collected through the Illicit Drug Reporting System; and thirdly, a prospective cohort of n = 606 people who regularly misuse or tamper with pharmaceutical opioids was formed prior to the introduction of Reformulated OxyContin®, followed-up twice post-release to examine potential changes after Reformulated OxyContin®'s introduction.

DISCUSSION

The study's strengths lie in varied data collections; interrupted time-series analysis; and prospective cohort. To our knowledge, this is one of the most comprehensive and transparently conducted studies conducted to date of the potential impact of an opioid medication upon use, tampering and diversion. Results have the potential to inform policymakers, clinicians, consumers and researchers alike.

Sources of pharmaceutical opioids for non-medical use among young adults

The study uses qualitative and quantitative data to describe sources of pain pills for illicit use among young adult (18- to 23-year-old) users. Respondent-driven sampling was used to recruit 383 individuals in the Columbus, Ohio, area. The sample was almost 50% Caucasian and about 55% male. Qualitative interview participants (n = 45) were selected from the larger sample. Qualitative data suggest that pharmaceutical opioid availability was so pervasive that most individuals did not have to venture outside of their immediate social networks to find people who sold or shared pills. Participants emphasized differences between those who are actively involved in obtaining pills and those who play a more passive role. Active involvement was described as going out searching for pills and paying money to obtain them. In contrast, passive role included obtaining pills when somebody offered or shared them free of charge. Multiple logistic regression analysis indicates that a more active role in obtaining pharmaceutical opioids was related to being White, more frequent use of pharmaceutical opioids, extended-release oxycodone use, and using pharmaceutical opioids to get high, as opposed to self-treating a health problem. The study results can help inform drug use epidemiology, interventions, and policy.

Everybody's Doing It: Initiation to Prescription Drug Misuse

In this article, we present findings from a qualitative National Institute on Drug Abuse-funded study of nonmedical prescription drug users in the San Francisco Bay Area. We interviewed young adults between the ages of 18 and 25 years, who used prescription drugs nonmedically at least 12 times in the 6 months prior to the interview. Employing Aker's Social Learning Theory and Zinberg's Drug, Set, and Setting, we explore the factors that contributed to participants' choices to begin using prescription drugs nonmedically. Social Learning Theory provides the framework for understanding how deviant behaviors are learned and imitated, while set and setting emphasizes the psychological and social contexts of initiation and the ways in which the set and setting of the initiating user were influenced by exposure, motivation, access, and setting. Together, social learning, and set and setting allow us to understand the interaction of individual and social factors contributing to nonmedical prescription drug use initiation.

"Every 'never' I ever said came true": transitions from opioid pills to heroin injecting

This qualitative study documents the pathways to injecting heroin by users in Philadelphia and San Francisco before and during a pharmaceutical opioid pill epidemic. Data was collected through in-depth, semi-structured interviews (conducted between 2010 and 2012) that were, conducted against a background of longer-term participant-observation, ethnographic studies of street-based drug users and dealers in Philadelphia (2007-12) and San Francisco (1994-2007, 2012). Philadelphia and San Francisco were selected for their contrasting political economies, immigration patterns and source type of heroin. In Philadelphia the ethnographers found heroin injectors, usually white users, who had started their opiate using careers with prescription opioids rather than transitioning from other drugs. In both Philadelphia and San Francisco, most of the young heroin injectors interviewed began, their drug-use trajectories with opioid pills--usually Percocet (oxycodone and acetaminophen), generic short acting oxycodone or, OxyContin (long-acting oxycodone)--before transitioning to heroin, usually by nasal inhalation (sniffing) or smoking at first, followed by injecting. While most of the Philadelphia users were born in the city or its suburbs and had started using both opioid pills and heroin there, many of the San Francisco users had initiated their pill and sometimes heroin use elsewhere and had migrated to the city from around the country. Nevertheless, patterns of transition of younger injectors were similar in both cities suggesting an evolving national pattern. In contrast, older users in both Philadelphia and San Francisco were more likely to have graduated to heroin injection from non-opiate drugs such as cannabis, methamphetamine and cocaine. Pharmaceutical opioid initiates typically reported switching to heroin for reasons of cost and ease-of-access to supply after becoming physically and emotionally dependent on opioid pills. Many expressed surprise and dismay at their progression to sniffing and subsequently to injecting heroin. Historically and structurally these users found themselves caught at the intersection of two major developments in the opiate supply: (1) an over 500% increase in opiate pill prescription from 1997 to 2005 resulting in easy access to diverted supplies of less stigmatized opiates than heroin and (2) a heroin supply glut, following the US entry of Colombian-sourced, heroin in the early 1990s, that decreased cost and increased purity at the retail level. A nationwide up-cycle of heroin use may be occurring among young inner city, suburban and rural youth fueled by widespread prescription opioid pill use.

Latent class analysis of non-opioid dependent illegal pharmaceutical opioid users in Ohio

BACKGROUND

Increases in non-medical use of pharmaceutical opioids in the U.S. have resulted in increases in opioid dependence and unintentional overdose deaths. We characterize heterogeneity in opioid use patterns among a community-based sample of 18-23 year-olds who use non-medical pharmaceutical opioids, yet are not opioid dependent.

METHODS

Respondent-driven sampling recruited 390 participants. Latent class analysis stratified by racial/ethnic group identified subgroups of non-medical opioid users based on: six-month frequency of use; number of opioid disorder criteria; oral vs. non-oral administration; number of types of opioids used; use of CNS depressants while under using opioids; and reason for opioid use. Multinomial logistic regression estimated the significance of covariates in predicting class membership.

RESULTS

Within whites and non-white groups, three classes emerged that were, generally, hierarchically ordered with respect to negative characteristics associated with non-medical opioid use. Within each group, the class with the least negative characteristics also had the highest proportion of individuals who use opioids only to self-medicate a health problem. Within each group's three classes, a larger proportion who had ≥ 2 opioid abuse and dependence disorder criteria always coincided with a larger proportion who use opioids ≥ 3 days per week, a larger proportion who used CNS depressants while under the influence of opioids, and a smaller proportion who used opioids only to self-medicate.

CONCLUSION

Differences in patterns of opioid use within each racial/ethnic group of young people who are not opioid dependent suggest the need for tailored interventions designed to reduce the risk of transition to opioid dependence.

Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers - United States, 2002-2004 and 2008-2010

BACKGROUND

Heroin use and overdose deaths have increased in recent years. Emerging information suggests this is the result of increases in nonmedical use of opioid pain relievers and nonmedical users transitioning to heroin use. Understanding this relationship is critically important for the development of public health interventions.

METHODS

Combined data from the 2002-2004 National Surveys on Drug Use and Health were compared to the 2008-2010 surveys to examine patterns of heroin use and risk behaviors among past year nonmedical users of opioid pain relievers.

RESULTS

Between 2002-2004 and 2008-2010, past year heroin use increased among people reporting past year nonmedical use (PYNMU) of opioid pain relievers (p<0.01), but not among those reporting no PYNMU. Frequent nonmedical users - people reporting 100-365 days of PYNMU - had the highest rate of past year heroin use and were at increased risk for ever injecting heroin (aOR 4.3, 95% CI 2.5-7.3) and past year heroin abuse or dependence (aOR 7.8, 95% CI 4.7-12.8) compared to infrequent nonmedical users (1-29 days of PYNMU). In 2008-2010, 82.6% of frequent nonmedical users who used heroin in the past year reported nonmedical use of opioid pain relievers prior to heroin initiation compared to 64.1% in 2002-2004.

CONCLUSIONS

Heroin use among nonmedical users of opioid pain relievers increased between 2002-2004 and 2008-2010, with most reporting nonmedical use of opioid pain relievers before initiating heroin. Interventions to prevent nonmedical use of these drugs are needed and should focus on high-risk groups such as frequent nonmedical users of opioids.

Understanding the etiology of prescription opioid abuse: implications for prevention and treatment

Although studies on the initiation of substance abuse abound, the body of literature on prescription opioid abuse (POA) etiology is small. Little is known about why and how the onset of POA occurs, especially among high-risk populations. In this study we aimed to fill this important knowledge gap by exploring the POA initiation experiences of 90 prescription opioid abusers currently in treatment and their narrative accounts of the circumstances surrounding their POA onset. This research was conducted within a storyline framework, which operates on the premise that the path to drug abuse represents a biography or a process rather than a static condition. Audiotapes of in-depth interviews were transcribed, coded, and thematically analyzed. Analyses revealed the presence of four trajectories leading to POA. This study adds to the limited research on POA etiology by not only illuminating the psychosocial factors that contribute to POA onset, but also by situating initiation experiences within broader life processes. The study findings provide crucial insights to policymakers and interventionists in identifying who is at risk for POA, and more important, when and how to intervene most efficaciously.

Patterns of prescription drug misuse among young injection drug users

Misuse of prescription drugs and injection drug use has increased among young adults in the USA. Despite these upward trends, few studies have examined prescription drug misuse among young injection drug users (IDUs). A qualitative study was undertaken to describe current patterns of prescription drug misuse among young IDUs. Young IDUs aged 16-25 years who had misused a prescription drug, e.g., opioids, tranquilizers, or stimulants, at least three times in the past 3 months were recruited in 2008 and 2009 in Los Angeles (n = 25) and New York (n = 25). Informed by an ethno-epidemiological approach, descriptive data from a semi-structured interview guide were analyzed both quantitatively and qualitatively. Most IDUs sampled were both homeless and transient. Heroin, prescription opioids, and prescription tranquilizers were frequently misused in the past 30 days. Qualitative results indicated that young IDUs used prescription opioids and tranquilizers: as substitutes for heroin when it was unavailable; to boost a heroin high; to self-medicate for health conditions, including untreated pain and heroin withdrawal; to curb heroin use; and to reduce risks associated with injecting heroin. Polydrug use involving heroin and prescription drugs resulted in an overdose in multiple cases. Findings point to contrasting availability of heroin in North American cities while indicating broad availability of prescription opioids among street-based drug users. The results highlight a variety of unmet service needs among this sample of young IDUs, such as overdose prevention, drug treatment programs, primary care clinics, and mental health services.

Illicit use of buprenorphine in a community sample of young adult non-medical users of pharmaceutical opioids

BACKGROUND

There is growing evidence about illicit use of buprenorphine in the U.S. The study aims to: (1) identify prevalence and predictors of illicit buprenorphine use in a community sample of 396 young adult (18-23 years old) non-medical users of pharmaceutical opioids and (2) describe knowledge, attitudes and behaviors linked to illicit buprenorphine use as reported by a qualitative sub-sample (n=51).

METHODS

Participants were recruited using respondent-driven sampling. Qualitative interview participants were selected from the larger sample. The sample (n=396) was 54% male and 50% white; 7.8% reported lifetime illicit use of buprenorphine.

RESULTS

Logistic regression analysis results indicate that white ethnicity, intranasal inhalation of pharmaceutical opioids, symptoms of opioid dependence, and a greater number of pharmaceutical opioids used in lifetime were statistically significant predictors of illicit buprenorphine use. Qualitative interviews revealed that buprenorphine was more commonly used by more experienced users who were introduced to it by their "junkie friends." Those who used buprenorphine to self-medicate withdrawal referred to it as a "miracle pill." When used to get high, reported experiences ranged from "the best high ever" to "puking for days." Participants reported using buprenorphine/naloxone orally or by intranasal inhalation. Injection of buprenorphine without naloxone was also reported.

CONCLUSION

Our findings suggest that illicit buprenorphine use is gaining ground primarily among whites and those who are more advanced in their drug use careers. Continued monitoring is needed to better understand evolving patterns and trends of illicit buprenorphine use.

Misuse of prescription and illicit drugs among high-risk young adults in Los Angeles and New York

Background

Prescription drug misuse among young adults is increasingly viewed as a public health concern, yet most research has focused on student populations and excluded high-risk groups. Furthermore, research on populations who report recent prescription drug misuse is limited. This study examined patterns of prescription drug misuse among high-risk young adults in Los Angeles (LA) and New York (NY), which represent different local markets for illicit and prescription drugs.

Design and Methods

Between 2009 and 2011, 596 young adults (16 to 25 years old) who had misused prescription drugs within the past 90 days were interviewed in Los Angeles and New York. Sampling was stratified to enroll three groups of high-risk young adults: injection drug users (IDUs); homeless persons; and polydrug users.

Results

In both sites, lifetime history of receiving a prescription for an opioid, tranquilizer, or stimulant was high and commonly preceded misuse. Moreover, initiation of opioids occurred before heroin and initiation of prescription stimulants happened prior to illicit stimulants. NY participants more frequently misused oxycodone, heroin, and cocaine, and LA participants more frequently misused codeine, marijuana, and methamphetamine. Combining prescription and illicit drugs during drug using events was commonly reported in both sites. Opioids and tranquilizers were used as substitutes for other drugs, e.g., heroin, when these drugs were not available.

Conclusion

Patterns of drug use among high-risk young adults in Los Angeles and New York appear to be linked to differences in local markets in each city for illicit drugs and diverted prescription drugs.

Initiation into prescription opioid misuse amongst young injection drug users

BACKGROUND

Prescription opioids are the most frequently misused class of prescription drugs amongst young adults. Initiation into prescription opioid misuse is an important public health concern since opioids are increasingly associated with drug dependence and fatal overdose. Descriptive data about initiation into prescription opioid misuse amongst young injection drug users (IDUs) are scarce.

METHODS

An exploratory qualitative study was undertaken to describe patterns of initiation into prescription opioid misuse amongst IDUs aged 16-25 years. Those young IDUs who had misused a prescription drug at least three times in the past three months were recruited during 2008 and 2009 in Los Angeles (n=25) and New York (n=25). Informed by an ethno-epidemiological approach, descriptive data from a semi-structured interview guide were analysed both quantitatively and qualitatively.

RESULTS

Initiation into prescription opioid misuse was facilitated by easy access to opioids via participant's own prescription, family, or friends, and occurred earlier than misuse of other illicit drugs, such as heroin. Nearly all transitioned into sniffing opioids, most injected opioids, and many initiated injection drug use with an opioid. Motives for transitions to sniffing and injecting opioids included obtaining a more potent high and/or substituting for heroin; access to multiple sources of opioids was common amongst those who progressed to sniffing and injecting opioids.

CONCLUSION

Prescription opioid misuse was a key feature of trajectories into injection drug use and/or heroin use amongst this sample of young IDUs. A new pattern of drug use may be emerging whereby IDUs initiate prescription opioid misuse before using heroin.

Illicit use of pharmaceutical opioids among young polydrug users in Ohio

This study, conducted in Columbus, Ohio, identified the predictors of current (past 30 day) illicit use of pharmaceutical opioids among young individuals (n=402) with a history of MDMA/ecstasy use who were recruited in 2002-2003 using respondent-driven sampling. To be eligible, participants had to be 18-30 years old, not involved in a drug abuse treatment, and report MDMA/ecstasy use at least once in the past 6 months. About 81% reported lifetime, and more than 31% reported current illicit use of pharmaceutical opioids. Logistic regression analysis revealed that illicit use of pharmaceutical tranquilizers and pharmaceutical stimulants were the strongest predictors of illicit use of pharmaceutical opioids. Risk of pharmaceutical opioid use was also greater among those who had higher levels of depressive symptoms and reported current use of hallucinogens and inhalants. Our findings suggest that the non-medical use of pharmaceutical opioids is a part of polydrug use practices that often incorporate illicit use of other prescription drugs. The observed relationship between depressive symptoms and illicit use of pharmaceutical opioids may have important implications for prevention programming and should be examined in future research.

Reflections on 40 Years of Ethnographic Drug Abuse Research: Implications for the Future

This paper focuses on past, present, and potential future contributions of ethnographic research to describing and understanding “street cultures” of drug use and the implications these have for informing various interventions. The first section provides an overview of ethnography and drug abuse research. This is followed by a historical perspective on the ethnography of street cultures. Next, the significance of ethnographic drug abuse research is highlighted, with a focus on its methodology. Ethnographic contributions to the development, implementation, and evaluation of interventions are discussed, including ethical issues. Subsequently, the interdisciplinary nature of ethnographic drug abuse research is described. Methodological challenges emerged over time as the definition of street cultures and drug trends shifted. These are illustrated with examples, including the use of prescription drugs, new heroin users, and rural drug and methamphetamine use. The final sections focus on career opportunities for ethnographers and opportunities and barriers for the future. We address training needs for interdisciplinary inquiry, the potential role of ethnographers in prevention and treatment research, and the link to studies on the brain and genetics. The future of ethnographic research on drug use will be influenced by the funding structure. We conclude with a summary of reflections on the past and aspirations for the future.

Reflections on the Meaning of Drug Epidemics

Fluctuations in the use of many drugs at one time or another have been characterized as drug epidemics. The depiction of drug use as an epidemic, as in the recent cases of methamphetamine and crack use, is a proven mechanism for communicating that a problem exists, but such depictions are not without risk. When the public characterization of drug use as an epidemic represents more than its epidemiological meaning of “unusually elevated occurrence,” panic is often substituted for reasoned action. Such declarations are likely to truncate objective investigation, generate fear rather than understanding, and stimulate reactive measures that exacerbate drug misuse. This article discusses the epidemiological origin and meaning of epidemic, documents how media headlines have sensationally depicted methamphetamine use, and recommends that alternative strategies for describing an increase in the incidence and prevalence of use may be more successful in directing researchers and policy makers toward effective strategies for reducing misuse.