Research paper
High risk and little knowledge: Overdose experiences and knowledge among young adult nonmedical prescription opioid users

https://doi.org/10.1016/j.drugpo.2014.07.013Get rights and content

Highlights

  • Despite significant overdose experiences, nonmedical prescription opioid users were uninformed about overdose prevention.

  • Despite significant overdose experiences, nonmedical prescription opioid users were uninformed about the use of naloxone.

  • Nonmedical prescription opioid users in our study tended to see themselves as distinct from traditional heroin users.

  • Nonmedical prescription opioid users were often outside of the networks reached by overdose prevention services.

  • There is a pressing need to develop outreach strategies to better reach young adult nonmedical prescription opioid users.

Abstract

Background

Opioid-involved overdoses in the United States have dramatically increased in the last 15 years, largely due to a rise in prescription opioid (PO) use. Yet few studies have examined the overdose knowledge and experience of nonmedical PO users.

Methods

In depth, semi-structured, audio-recorded interviews were conducted with 46 New York City young adults (ages 18–32) who reported using POs nonmedically within the past 30 days. Verbatim interview transcripts were coded for key themes in an analytic process informed by grounded theory.

Results

Despite significant experience with overdose (including overdose deaths), either personally or within opioid-using networks, participants were relatively uninformed about overdose awareness, avoidance and response strategies, in particular the use of naloxone. Overdose experiences typically occurred when multiple pharmaceuticals were used (often in combination with alcohol) or after participants had transitioned to heroin injection. Participants tended to see themselves as distinct from traditional heroin users, and were often outside of the networks reached by traditional opioid safety/overdose prevention services. Consequently, they were unlikely to utilize harm reduction services, such as syringe exchange programs (SEPs), that address drug users’ health and safety.

Conclusions

These findings suggest that many young adult nonmedical PO users are at high risk of both fatal and non-fatal overdose. There is a pressing need to develop innovative outreach strategies and overdose prevention programs to better reach and serve young PO users and their network contacts. Prevention efforts addressing risk for accidental overdose, including opioid safety/overdose reversal education and naloxone distribution, should be tailored for and targeted to this vulnerable group.

Introduction

Opioid-involved overdoses have become an increasing concern as their incidence has risen markedly in the past 20 years (Calcaterra et al., 2013, Jones et al., 2014, Paulozzi, 2012). During the most recent decade, drug overdose deaths in the United States increased from approximately 4000 in 1999 to 14,800 in 2008 (Warner et al., 2011). Overdose rates have especially increased among young adults (ages 18–24) who experienced a greater increase in rates of death from opioid analgesics than any other age group from 1999 to 2006 (Blending Initiative, 2009). In New York City, the location of this study, unintentional opioid-involved overdose deaths increased by 267% between 2000 and 2011 (59 deaths vs. 220 deaths) (New York City Department of Health and Mental Hygiene, 2013). Much of the rise has been attributed to a dramatic increase in overdose among nonmedical prescription opioid (PO) users (Green et al., 2011, Katz et al., 2013, Silva et al., 2013) or recently initiated heroin users who transitioned to heroin from POs (Lankenau et al., 2012a, Lankenau et al., 2012b, Nielsen et al., 2011). Nonmedical prescription opioid use is particularly high among students and young adults in the United States as well as internationally (Brands et al., 2010, Ghandour et al., 2012, National Institute on Drug Abuse, 2013).

Previous research has found that many nonmedical PO users are unaware of potential overdose risks, particularly in regard to polysubstance use (Lankenau et al., 2012a), and that while PO users are concerned about overdose, most believe the risk only applies to others who “use too much” or are “not careful ‘enough”’ (Daniulaityte, Falck, & Carlson, 2012). Yet overdose was not the focus of these studies, and, to our knowledge, there are no studies examining nonmedical PO users’ overdose knowledge and experience (apart from studies evaluating the effectiveness of naloxone distribution programs; see, for example, Strang et al., 2008, Williams et al., 2013).

Organized responses to the rising rate of overdose in the U.S. began to form in the mid 1990s with community-based programs that provided opioid overdose prevention services to persons who use drugs, as well as their family members and friends (CDC, 2012). Since 1996, increasing numbers of programs have offered naloxone, a specific opioid receptor antagonist used to reverse an opioid overdose or the effects of opioid analgesia (CDC, 2012, Galea et al., 2006). However, the United States Food and Drug Administration (FDA) regulations that designate naloxone as a prescription medication have made access difficult, and until recently, Syringe Exchange Programs (SEPs) and harm reduction organizations were among the few places where drug users and their families and friends were able to acquire naloxone and training in its proper use (NASADAD, 2013). The rise in opioid-involved overdoses has led to increased efforts by government and community organizations to make overdose prevention and response education (including naloxone) available outside of the SEP/harm reduction model (Albert et al., 2011, Doe-Simkins et al., 2009, NASADAD, 2013). Over the last decade, 17 U.S. States have passed laws intended to expand the availability of naloxone (NASADAD, 2013) to community organizations and family or friends of opioid users.

In 2006, New York State established the Opioid Overdose Prevention program which enables non-medical persons to administer naloxone in case of an opioid-involved overdose (New York City Department of Health and Mental Hygiene, 2014, New York Society of Addiction Medicine, 2011). Additionally, New York City recently began a pilot program supplying police officers in Staten Island (an area with particularly high rates of opioid-involved overdose) with naloxone and requisite training, leading to the first police officer-reversed overdose in January 2014 (New York City Department of Health and Mental Hygiene, 2014). Although such programs reflect increasing awareness of the role of POs in overdose and the importance of community-based responses, they are still relatively new and only available in select localities.

This exploratory study aims to elucidate the high overdose rates among young adults by providing a description of the overdose-related knowledge and experiences of young adult nonmedical PO users. Using a qualitative approach based on in-depth interviews with 46 young adults (ages 18–32) in New York City who reported nonmedical PO use within the past month, we sought to better understand how PO use relates to the likelihood and experience of overdose. Additionally, we aim to describe this group's knowledge of and experience with existing opioid safety/overdose prevention services and practices and how this impacts their experience with overdose.

Section snippets

Participant recruitment

This qualitative study is based on interviews with 46 New York City young adults (ages 18–32) who had engaged in nonmedical PO use in the 30 days preceding the interview. Participants were recruited via a combination of purposive and chain-referral sampling. The goal of the sampling strategy was to include a broad array of participants from a variety of racial, ethnic, gender, and socioeconomic status (SES) groups, and different geographic areas of New York City, as well as those with a range

Participant characteristics

Our study involved 46 participants. Within that group there were: 32 Whites; 9 Latinos; 3 African Americans; and 2 Asians. Twenty-seven participants were male, 18 female, and 1 transgender. Participants’ mean age was 25.3 years (SD = 3.9 years; range = 18–32 years), with 24 participants between the ages of 18–25 and 22 participants age 26 years or older. Participants’ level of education was as follows: 14 attended some high school; 9 received a high school diploma or GED; 14 attended some college;

Discussion

Although the rise in opioid-involved overdose deaths since 2000 has been widely reported in recent years (Centers for Disease Control, 2011, Green et al., 2011, Katz et al., 2013), there have been relatively few qualitative studies describing the social contexts and factors leading to overdose among young nonmedical PO users. Other studies have described the varying pathways to injection heroin use in light of recent increases in PO use (Mars, Bourgois, Karandinos, Montero, & Ciccarone, 2013),

Acknowledgements

This study is supported by Grant No. R01DA035146 from the National Institute on Drug Abuse. David Frank was supported as a predoctoral fellow in the Behavioral Sciences Training in Drug Abuse Research program sponsored by Public Health Solutions and National Development and Research Institutes with funding from the National Institute on Drug Abuse (5T32 DA07233). Points of view, opinions, and conclusions in this paper do not necessarily represent the official position of the U.S. Government,

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