Elsevier

Drug and Alcohol Dependence

Volume 160, 1 March 2016, Pages 127-134
Drug and Alcohol Dependence

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

https://doi.org/10.1016/j.drugalcdep.2015.12.026Get rights and content

Highlights

  • Identify heroin initiation predictors among pharmaceutical opioid (PO) users.

  • Over 36 months, 7.5% (27) of 362 participants initiated heroin use.

  • Predictors: PO dependence; early age PO use; using PO to get high; non-oral PO use.

Abstract

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.

Introduction

Over the past decade, the non-medical use of pharmaceutical opioids emerged as one of the fastest growing forms of drug abuse in the United States with young adults showing rates higher than other age groups (Johnston et al., 2010; Substance Abuse and Mental Health Services Administration (SAMHSA, 2010). Increases in illicit pharmaceutical opioid (PO) use resulted in escalating accidental overdose death rates (Paulozzi et al., 2006) and increasing prevalence of opioid abuse and dependence disorders (McCabe et al., 2008). Prior research with an Appalachian sample of illicit drug users demonstrated that PO use, in particular illicit use of OxyContin (pre-abuse deterrent formulation), was related to a high risk of transition to injection (Young and Havens, 2011).

Growing evidence also suggests that illicit PO use has expanded pathways to heroin initiation and contributed to the heroin epidemic in the United States. Qualitative and cross-sectional quantitative studies conducted in different regions of the country, including Ohio as early as 2002 (Siegal et al., 2003a), Washington (Peavy et al., 2012), California, New York and Pennsylvania (Lankenau et al., 2012, Mars et al., 2014), were among the first to describe a trend of illicit PO users becoming opioid dependent and transitioning to heroin use. Analysis of data from the U.S. National Survey of Drug Use and Health (NSDUH) indicated that between 2002–2004 and 2008–2010, heroin use increased substantially among non-medical users of pharmaceutical opioids but remained unchanged among non-users (Jones, 2013). Martins et al. (2015) also found a significant relationship between illicit PO use and heroin use in the years 2008–2011 NSDUH cohort, compared to the 2002–005 period. Another NSDUH-based study found that the incidence rate of heroin initiation was approximately 19 times greater among prior illicit PO users than among non-users (Muhuri et al., 2013). Data on drug overdose hospitalizations and mortality rates demonstrated significant increases in heroin-related overdoses and reductions in PO-related overdose rates over the past few years (Unick et al., 2013, Dasgupta et al., 2014, Lee et al., 2014, Rudd et al., 2014). Similar trends were identified in Ohio, with overdose death data showing large increases in heroin-related deaths and leveling off of PO-related deaths in 2012 (Massatti et al., 2014). In Ohio, like other areas of the country, these increases appear to be linked to implementation of stricter pharmaceutical opioid prescription policies and guidelines (Massatti et al., 2014) and the introduction of an abuse-deterrent formulation of extended-release oxycodone (ADF OxyContin; Cicero and Ellis, 2015).

Although there is mounting evidence of the “intertwined” epidemics of illicit PO and heroin use, there is a lack of prospective studies designed to identify the factors associated with heroin initiation among illicit PO users. This study reports the findings of a 36-month natural history study of young adult illicit PO users who, at baseline, were not opioid dependent and had no history of heroin use or illicit injection. We examine associations between selected predictors and time to first heroin use using a time-to-event analysis. Potential predictors were selected mostly based on prior retrospective research findings suggesting associations between heroin initiation and: PO dependence (e.g., Jones, 2013, Jones et al., 2015; Lankenau et al., 2012, Mars et al., 2014); frequency of PO use (Jones, 2013, Jones et al., 2015, Muhuri et al., 2013, Cicero and Ellis, 2015); route of administration (ROA; McCabe et al., 2007a, Kirsh et al., 2012, Young et al., 2010); non-medical use of OxyContin (high abuse liability; Hays, 2004, Ternes and O’Brien, 1990, Siegal et al., 2003a, Siegal et al., 2003b, Martins et al., 2009, Cicero and Ellis, 2015, Young and Havens, 2011); and the introduction of ADF OxyContin (Cicero and Ellis, 2015).

Section snippets

Sample recruitment

Between April, 2009 and May, 2010, we recruited 383 eligible participants in the Columbus, Ohio, area using respondent-driven sampling (RDS; Heckathorn, 1997, Heckathorn, 2002). We limited referrals to three eligible participants and compensated referrers $15 for each person presenting at the project office (Wang et al., 2005, Wang et al., 2007). Daniulaityte et al. (2012) provide more details on sample recruitment.

Located in Franklin County, with a population over one million, Columbus is the

Results

About 50% of the sample were White (including Hispanic); among the 180 non-Whites, 92.8% were African American, 2.2% were Asian or Pacific Islander, and 5% biracial. On average, Whites and non-Whites had been using POs non-medically for about four years at baseline, with a mean age of PO initiation of 16.6 years for Whites and 17.3 years for non-Whites (Table 1). For further details regarding the baseline sample, see Carlson et al. (2014) and Daniulaityte et al., 2014).

Discussion

To our knowledge, this is the first prospective study to use a community-based sample to examine the relationship between illicit PO use and heroin initiation among young adults in the U.S. who, at baseline, were not opioid dependent and had no history of heroin use or any illicit drug injection. In addition, it is the first community-based study to provide an estimate of the rate of heroin initiation among young PO users as well as PAR estimates associated with significant predictors.

Over 36

Conflict of interest

Dr. Martins was a consultant for Purdue Pharma between Jan 2013 and December 2015 to assist on secondary data analyses of prescription opioid and alcohol data from the NESARC study, unrelated to the data presented in this manuscript. All other authors declare that there are no conflicts of interest.

Role of funding

This study was supported by The National Institute on Drug Abuse, Grant No. R01DA023577. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse or the National Institutes of Health.

Contributors

R. Carlson, R. Falck, and R. Daniulaityte designed the study and wrote the protocol. R. Carlson wrote the first draft of the methods, results and discussion and made final edits. R. Daniulaityte drafted the Introduction and provided editorial comments on the manuscript. R. Nahhas helped to design the statistical analyses, prepared tables and drafted the statistical methods section. He conducted all statistical analyses and commented on the ms. Silvia Martins helped to design the statistical

Acknowledgments

A previous version of this paper was presented at the College on Problems of Drug Dependence Meetings in San Juan, PR, June 2014. The authors thank project participants, and site coordinators/interviewers Brooke Miller and Pamela Malzahn and interviewer Tim Lane, for their contributions.

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