Research paper
Initiation into prescription opioid misuse amongst young injection drug users

https://doi.org/10.1016/j.drugpo.2011.05.014Get rights and content

Abstract

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.

Introduction

Prescription drug misuse has increased significantly over the past decade in the U.S. (Johnston et al., 2010, SAMHSA, 2009a, SAMHSA, 2010a) and is most prevalent amongst young adults aged 18–25 years old (Boyd et al., 2009, SAMHSA, 2010a). Prescription opioids, such as hydrocodone and oxycodone, are the most frequently misused class of prescription drug amongst young adults (SAMHSA, 2010a). Furthermore, prescription opioids are amongst the most commonly used drugs at initiation into illicit drug use—second only to cannabis (SAMHSA, 2010a). Initiation into prescription opioid misuse is an important public health concern since opioids are increasingly associated with drug dependence (SAMHSA, 2008, Weiss et al., 2010) and fatal overdose (Paulozzi and Xi, 2008, SAMHSA, 2010b).

Young injection drugs users (IDUs) – persons aged 30 and younger who currently inject drugs (e.g., Fuller et al., 2001, Hagan et al., 2010, Page et al., 2009, Roy et al., 2007) – are a particularly high-risk subgroup of adolescents and young adults (Davidson et al., 2002, Miller et al., 2004, Rondinelli et al., 2009, Thorpe et al., 2002). Young IDUs – whose lifetime prevalence of heroin has approached 100% in some studies (Havens et al., 2006, Ochoa et al., 2005) – are at increased risk for initiation and misuse of prescription opioids (SAMHSA, 2009b). Yet, a review of nearly 60 research articles focusing on young IDUs in North America, published since 2000 – the period covering the rapid rise in opioid misuse (SAMHSA, 2009c) – revealed only five manuscripts that reported data on prescription opioid misuse (Evans et al., 2009, Firestone and Fischer, 2008, Hagan et al., 2007, Lankenau et al., 2007a, Lankenau et al., 2007b). These studies provided only minimal descriptive data such as lifetime prevalence (Lankenau et al., 2007a), misuse in the past three months (Hagan et al., 2007, Evans et al., 2009), or anecdotal findings on initiation (Firestone and Fischer, 2008, Lankenau et al., 2007b). Hence, large gaps exist in the research literature concerning fundamental questions about prescription opioid misuse amongst young IDUs.

Two key characteristic of initiation – the drug and the mode of administration – are often studied to understand trajectories into increasingly risky types of drug use, such as transitions to injecting heroin or cocaine (Fuller et al., 2001, Roy et al., 2003, Sherman et al., 2002). Participants in these studies are typically polydrug users who report multiple initiation events during adolescence and young adulthood, e.g., first time smoked crack, first time sniffed heroin, first time injected heroin. Prior research indicates that studying initiation events amongst young IDUs contributes towards a fuller comprehension of emerging drugs (Firestone and Fischer, 2008, Lankenau and Clatts, 2004), user populations (Fuller et al., 2003, Roy et al., 2002), risk behaviours (Lankenau et al., 2010, Roy et al., 2003), social context (Goldsamt et al., 2010, Harocopos et al., 2009) and potential prevention and intervention strategies (Miller et al., 2006, Sherman et al., 2005). Towards this end, an exploratory qualitative study was undertaken to describe patterns of initiation into prescription drug misuse amongst young IDUs in Los Angeles and New York. Using descriptive and qualitative data, this manuscript addresses a number of unanswered questions, such as: at what age do young IDUs initiate misuse of prescription opioids compared to other illicit drugs; where do young IDUs obtain prescription opioids at initiation; why do young IDUs initiate prescription opioid misuse; what are the contextual factors at initiation; and how does this initiation fit into patterns of injection drug use and current drug use, including use of heroin?

Section snippets

Methods

The study design was informed by an ethno-epidemiological methodology (Agar, 1996, Clatts et al., 2002, Pach and Gorman, 2002) that utilises both quantitative data, i.e., frequencies and percentages, to describe broader patterns found within a study sample and qualitative data, i.e., narrative accounts, to provide contextualised details as reported by individual participants. This mixed method approach has been used previously to describe risk behaviours and patterns of substance misuse amongst

Sample characteristics

Overall, the sample was typically male, white, heterosexual, and in their early 20s (Table 1). Many did not complete high school, were expelled from school or held back a grade. Some reported being in foster care or a group home as a minor. Nearly all were homeless at some point, most were currently homeless, and most regarded themselves as “travellers,” that is, moving from city to city in search of work, housing, or adventure. Nearly all had been arrested and served jail time. Most had a

Discussion

This is the first study, to our knowledge, to describe the context for initiation into prescription opioid misuse, subsequent pathways into injecting opioids, and implications for current patterns of opioid and heroin misuse amongst a sample of young IDUs.

Initiation into opioid misuse was characterised by access or exposure to three primary sources of opioids – family members, personal prescription, or friends – whilst friends were the most commonly reported source. However, as young people

Conclusions

Prescription opioid misuse was a key feature of trajectories into injection drug use and/or heroin use amongst this sample of young IDUs. In particular, a new pattern of drug use may be emerging, whereby young people begin experimenting with prescription opioids before initiating heroin. The broader context of initiation into opioid misuse was characterised by substance misuse by family members and varied psychological conditions amongst participants and easy access to opioids via their own

Acknowledgements

This research was supported by a grant provided by the National Institute on Drug Abuse (DA021299). The authors would like to acknowledge the helpful comments provided by three anonymous peer reviewers.

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