Short communicationRacial/ethnic differences in trends in heroin use and heroin-related risk behaviors among nonmedical prescription opioid users
Introduction
Studies using national U.S. data have shown that individuals with previous nonmedical use of prescription opioids (NMUPO) are at greater risk of heroin use (Becker et al., 2008, Jones, 2013, SAMHSA, 2011). Risk increases as past year frequency of NMUPO increases (Jones, 2013). Increased rates of NMUPO across the U.S. have been linked to the increased prescribing of opioid pain relievers, such as OxyContin, since the 1990s (Manchikanti, 2007, Volkow et al., 2011). Rates of NMUPO only recently seemed to have reached a plateau (SAMHSA, 2012), probably due to the recent restrictions placed in the prescription opioids market as well as the introduction of new abuse-deterrent formulations of these drugs (Cicero et al., 2012, Cicero et al., 2014). Links between NMUPO and prescription opioids abuse/dependence, NMUPO onset and transition to heroin and other illegal substances (Becker et al., 2008, Brands et al., 2004, Cleland et al., 2011, Compton and Volkow, 2006, Mars et al., 2013), and NMUPO-related and heroin-related fatal overdoses (Becker et al., 2008, Blanco et al., 2007, Cicero et al., 2005, Unick et al., 2013), have raised particular concerns in recent years. In addition, a particular public health concern is that the transition to heroin and further injecting heroin may increase the risk of bloodborne infections (Miller et al., 2004, Thorpe et al., 2002).
The transition from NMUPO to heroin use may be explained by individual motivations such as desire to get a more potent high, by heroin being easier to use, cheaper (given the low cost of heroin in the U.S. (Ciccarone et al., 2009) and more easily available compared to prescription opioids (Cicero et al., 2012, Cicero et al., 2014). Moreover, the transition from NMUPO to heroin use might be different across race/ethnic groups (Becker et al., 2008, Blanco et al., 2007, Green et al., 2005, Keyes et al., 2013, Mars et al., 2013, Morrison et al., 2000). Minorities have been less likely to receive prescriptions for opioid medications compared to non-Hispanic (NH) Whites (Morrison et al., 2000, Pletcher et al., 2008). NH Whites have been at greater risk of NMUPO onset and prescription opioids-related disorders compared to other ethnic groups (Green et al., 2005, Mars et al., 2013, Morrison et al., 2000). Also, although previous studies have shown that the prevalence of heroin use has been found to be greater among Hispanics and NH Whites compared to other race/ethnic groups (Bernstein et al., 2006a, Kopstein, 1998), recent data indicates that NH Whites are overrepresented among heroin/opioid-related fatal overdose cases (Mack, 2013, Paulozzi, 2012, Paulozzi, 2011, Rudd et al., 2014, Unick et al., 2013). Some evidence also shows that among teenagers, the strong association between early onset of NMUPO and heroin use does not vary by race/ethnic groups (Cerdá et al., under review). It is possible that small sample sizes, with low representation of NH Blacks and Hispanics, or aggregation of different racial/ethnic groups into one category as non-Whites, may limit the availability of information regarding race/ethnic differences in NMUPO and risk of heroin use. Having access to this knowledge could be helpful in the development of strategies targeting specific groups being at greatest risk of adverse outcomes.
Specifically, in this study we: (1) examine the change in the patterns of past-year NMUPO and heroin use between 2002–2005 and 2008–2011 across racial/ethnic groups; (2) examine the association between past year frequency of NMUPO with heroin use, heroin-related risk behaviors and exposure to heroin availability by race/ethnicity. Data came from the National Survey on Drug Use and Health (NSDUH), a large nationally-representative household sample (approximately 67,500 persons are interviewed each year (SAMHSA, 2013), as it has good representation of various races/ethnicities in the US.
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Data
We used NSDUH data from 2002 to 2005 and 2008 to 2011, resulting in a total sample of N = 448,597 participants (obtained from combining data from each of the 8 years used in analyses). The survey uses a multistage area probability sample for each of the 50 states and DC and oversamples younger age groups (aged 12–25) as well as African–Americans and Hispanics. Response rate for household screening and completed interviews ranged between 87–91% and 74–79%, respectively. Interviews were
Heroin use rates (unadjusted)
Table 1 shows the average annual rates of past year heroin use for the two study periods by frequency of past year NMUPO and racial/ethnic group. The rate of heroin use among NH Whites, which was lower than that of NH Blacks and Hispanics in 2002–2004, increased by 75% in 2008–2011, which was the highest rate across racial/ethnic groups in this period (2.57 per 1000). Among Blacks, significant increases in the rate of heroin use were only observed between those using any prescription opioids in
Discussion
There were significant increases in heroin use among those endorsing past year NMUPO of all race/ethnicities between 2002–2005 and 2008–2011. In general, it has been observed that Hispanics and NH Whites report more use of drugs than NH Blacks (Golub and Johnson, 2005, McCabe et al., 2007), with Hispanics being more likely to use heroin than NH Whites or NH Blacks, and NH Blacks being more likely to use cocaine than non-Hispanic Whites and Hispanics (Bernstein et al., 2006b). This study sheds
Role of funding source
The data reported herein come from the National Survey of Drug Use and Health (NSDUH) public use files and made publicly available by the Substance Abuse and Mental Health Services Administration (SAMHSA). Funding source: This study was partially funded by the National Institute of Drug Abuse–National Institutes of Health (NIDA–NIH grant K01DA030449, NIDA–NIH grant R03DA037770, NIDA–NIH grant R01DA037866), the Eunice Kennedy Shriver National Institute of Child and Human Development–National
Contributors
Drs. Martins and Cerda designed the study. Drs. Martins, Santaella, Dr. Marshall and Ms. Maldonado conducted literature searches and provided summaries of previous research studies. Dr. Santaella conducted the statistical analysis under Dr. Martins’ supervision. Drs. Martins and Santaella wrote the first draft of the manuscript and all authors approve the submission of the manuscript to DAD.
Conflict of interest
Dr. Martins was a consultant for Purdue Pharma to conduct secondary data analysis of a diferente dataset unrelated to the topic of this manuscript until December 2014, while working on this manuscript. All other authors have no conflict of interest to declare.
Acknowledgments
None.
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