Full length articlePredictors of transition to heroin use among initially non-opioid dependent illicit pharmaceutical opioid users: A natural history study
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.
References (71)
- et al.
Drug use practices among mdma/ecstasy users in Ohio: a latent class analysis
Drug Alcohol Depend.
(2005) - et al.
Latent class analysis of non-opioid dependent illegal pharmaceutical opioid users in Ohio
Drug Alcohol Depend.
(2014) - et al.
Respondent-driven sampling to recruit young adult non-medical users of pharmaceutical opioids: problems and solutions
Drug Alcohol Depend.
(2012) Self-report among injecting drug users: a review
Drug Alcohol Depend.
(1998)- et al.
Observed transition from opioid analgesic deaths toward heroin
Drug Alcohol Depend.
(2014) - et al.
Non-medical drug use among adults in small towns in rural Ohio
J. Subst. Abuse Treat.
(2005) - et al.
Selection of a substance use disorder diagnostic instrument by the national drug abuse treatment clinical trials network
J. Subst. Abuse Treat.
(2004) - et al.
The use of the DSM-III R checklist for initial diagnostic assessments
Compr. Psychiatry
(1993) Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers—United States, 2002–2004 and 2008–2010
Drug Alcohol Depend.
(2013)- et al.
Initiation into prescription opioid misuse amongst young injection drug users
Int. J. Drug Policy
(2012)
Trends in licit and illicit drug-related deaths in Florida from 2001 to 2012
Forensic Sci. Int.
Every ‘never’ I ever said came true: transitions from opioid pills to heroin injecting
Int. J. Drug Policy
Racial/ethnic differences in trends in heroin use and heroin-related risk behaviors among nonmedical prescription opioid users
Drug Alcohol Depend.
Correlates of extramedical use of OxyContin versus other analgesic opioids among the US general population
Drug Alcohol Depend.
Motives, diversion and routes of administration associated with nonmedical use of prescription opioids
Addict. Behav.
Trends in prescription drug abuse and dependence, co-occurrence with other substance use disorders, and treatment utilization: results from two national surveys
Addict. Behav.
Subtypes of nonmedical prescription drug misuse
Drug Alcohol Depend.
Motives for medical misuse of prescription opioids among adolescents
J. Pain
Why does the rapid delivery of drugs to the brain promote addiction?
Trends Pharmacol. Sci.
Respondent-driven sampling to recruit MDMA users: a methodological assessment
Drug Alcohol Depend.
Respondent-driven sampling in the recruitment of illicit stimulant drug users in a rural setting: findings and technical issues
Addict. Behav.
Assessing consistency of responses to questions on cocaine use
Addiction
Emerging adulthood: a theory of development from the late teens through the twenties
Am. Psychol.
Transitions in drug use during late adolescence and young adulthood
National Survey on Drug Use and Health
Nonmedical prescription opioid use in childhood and early adolescence predicts transition to heroin use in young adulthood: a national study
J. Pediatr.
The changing face of heroin use in the United States a retrospective analysis of the past 50 years
JAMA Psychiatry
Abuse-deterrent formulations and the prescription opioid abuse epidemic in the United States: lessons learned from OxyContin
JAMA Psychiatry
Regression models and life-tables
J. R. Stat. Soc. Ser. B Methodol.
Initiation to pharmaceutical opioids and patterns of misuse: preliminary qualitative findings obtained by the Ohio substance abuse monitoring network
J. Drug Issues
Sources of pharmaceutical opioids for non-medical use among young adults
J. Psychoact. Drugs
Respondent-driven sampling: an assessment of current methodology
Sociol. Methodol.
Assessing respondent-driven sampling
Proc. Natl. Acad. Sci. U. S. A.
Cocaine: patterns of use, route of administration, and severity of dependence
Br. J. Psychiatr.
A profile of oxycontin addiction
J. Addict. Dis.
Cited by (160)
Predicting first use of heroin from prescription opioid use subtypes: Insights from the Monitoring the Future longitudinal panel
2024, Drug and Alcohol DependenceCharacterizing prescription opioid, heroin, and fentanyl initiation trajectories: A qualitative study
2024, Social Science and MedicineCost-effectiveness of office-based buprenorphine treatment for opioid use disorder
2023, Drug and Alcohol Dependence