Elsevier

Drug and Alcohol Dependence

Volume 158, 1 January 2016, Pages 132-138
Drug and Alcohol Dependence

Full length article
Nonmedical opioid use and heroin use in a nationally representative sample of us high school seniors

https://doi.org/10.1016/j.drugalcdep.2015.11.005Get rights and content

Highlights

  • 12.4% of high school seniors reported lifetime nonmedical opioid use.

  • As frequency of opioid use increased, so too did the odds for reporting heroin use.

  • Over three-quarters (77.3%) of heroin users reporting lifetime nonmedical opioid use.

  • Females were consistently at low odds for reporting use of opioids and heroin.

  • Racial minority students were less likely to report opioid or heroin use.

Abstract

Background

Nonmedical use of opioids has become increasingly problematic in recent years with increases in overdoses, treatment admissions, and deaths. Use also appears to be contributing to heroin initiation, which has increased in recent years. Further research is needed to examine which adolescents are at highest risk for nonmedical use of opioids and heroin and to explore potential links between nonmedical opioid use and heroin use.

Methods

Data were analyzed from a nationally representative sample of American high school seniors in the Monitoring the Future study (2009–2013, Weighted N = 67,822). We examined associations between frequency and recency of nonmedical use of opioids and heroin. Sociodemographic correlates of use of each drug were also examined.

Results

12.4% of students reported lifetime nonmedical opioid use and 1.2% reported lifetime heroin use. As frequency of lifetime nonmedical opioid use increased, so too did the odds for reporting heroin use, with over three-quarters (77.3%) of heroin users reporting lifetime nonmedical opioid use. Recent (30-day) nonmedical opioid use was a robust risk factor for heroin use and almost a quarter (23.2%) of students who reported using opioids ≥40 times reported lifetime heroin use. Black and Hispanic students were less likely to report nonmedical opioid or heroin use than white students, but they were more likely to report heroin use in absence of nonmedical opioid use.

Discussion

Recent and frequent nonmedical opioid use are risk factors for heroin use among adolescents. Prevention needs to be targeted to those at highest risk.

Introduction

Nonmedical use of prescription opioids (i.e., narcotics, analgesics, pain killers) has become increasingly problematic in the US over the last decade. Although results from national surveys suggest prevalence of use has begun to decrease in recent years (Miech et al., 2015, Substance Abuse and Mental Health Services Administration (SAMHSA), 2014a), overdoses, emergency department (ED) visits, treatment admissions, and deaths related to use have increased (Centers for Disease Control and Prevention (CDC), 2012; Chen et al., 2014, Substance Abuse and Mental Health Services Administration (SAMHSA), 2013, Substance Abuse and Mental Health Services Administration (SAMHSA), 2014b). However, a new concern is that a subset of opioid users may be transitioning to heroin, which is often more likely to lead to deleterious outcomes. Research is needed to help identify adolescents at risk for nonmedical opioid and/or heroin use, and to delineate which opioid users are at highest risk for heroin use.

While medical use of opioids tends to be efficacious when used as prescribed to treat pain, nonmedical use – often through overprescribing or diversion from doctors (Wang et al., 2014, Shei et al., 2015) – has become a major public health issue. From 2004 to 2011, ED visits involving prescription opioids increased by 183% (SAMHSA, 2013) and opioid-related admissions to substance abuse treatment centers increased from 2% in 2002 to 10% in 2012 (SAMHSA, 2014b). Results from National Vital Statistics demonstrate that the rate of opioid overdose deaths nearly quadrupled from 1999 to 2011, growing from 1.4 per 100,000 to 5.4 per 100,000 (Chen et al., 2014), and according to the CDC (2012), almost three out of every four prescription medication overdoses were associated with opioids. While the rate of increase in overdoses has slowed somewhat since 2006 (Chen et al., 2014), there is now concern that these decelerating rates of opioid-related deaths may be related to recent increases in heroin use, as individuals dependent on prescription opioids may be transitioning to heroin, which tends to be less expensive and more freely available (Cicero et al., 2014, Kanouse and Compton, 2015, Mateu-Gelabert et al., 2015). Heroin is among the most dangerous illicit drugs (Nutt et al., 2007, Gable, 2004) and use is associated with high rates of dependence, overdose, death, transmission of pathogens such as HIV and HCV, and social marginalization (Demaret et al., 2013, Hser et al., 2015, Hosztafi, 2011, Brown, 2015, Zhou et al., 2015). Heroin overdose deaths have increased since 2002, rising from 0.7 deaths per 100,000 to 2.7 deaths per 100,000 in 2013 (Jones et al., 2015). This rise was particularly dramatic from 2011 to 2013, when rates almost doubled.

Heroin user demographics appear to be shifting in the US. While rates of heroin initiation were similar between whites and non-whites decades ago (Cicero et al., 2014), now whites are at a higher risk for nonmedical prescription opioid use, as well as heroin use (Cicero et al., 2014, Fischer et al., 2008, Peavy et al., 2012, Pollini et al., 2011). While women previously used at substantially lower rates than men (Cicero et al., 2014), their use of opioids and transition to heroin is increasing, with prescription opioids appearing to serve as a stepping stone (Cotto et al., 2010). Furthermore, use of heroin is increasing (Cicero et al., 2015), particularly among individuals living in non-urban areas, whereas it used to be a predominantly urban phenomenon (Cicero et al., 2014). A recent analysis of the National Surveys on Drug Use and Health (NSDUH), a nationally representative sample of non-institutionalized individuals in the US, compared data from 2002–2004 to 2008–2010, and found that past-year heroin use increased among many sociodemographic groups, including whites, those with higher income and those with health insurance (Jones et al., 2015). Whites, young adults (age 18–25), and those with opioid abuse/dependence were also found to be at high risk for heroin use/dependence. Alarmingly, this recent study found that between 2002 and 2013 there was a 138% increase in heroin use among nonmedical opioid users. Other studies have also found that many heroin users have moved onto heroin after nonmedical opioid use (Lankenau et al., 2012Peavy et al., 2012, Mateu-Gelabert et al., 2015). Nonmedical opioid users have been found to transition to heroin as they considered heroin more “practical” as it is reportedly less expensive and easier to acquire (Cicero et al., 2014, Mars et al., 2014), especially as availability is reduced due to abuse-deterrent formulations and prescription monitoring programs (Cassidy et al., 2014, Worley, 2012).

Nonmedical opioid use is associated with poor health outcomes such as opioid dependency, sexual violence, overdose, and death (Jamison and Mao, 2015, Frank et al., 2015, Jessell et al., 2015); however, moving onto heroin from prescription opioids appears to be a dangerous (and understudied) emerging pattern among younger populations. While studies focusing on national data have begun to examine associations between nonmedical opioid use and heroin use and dependence, more information is needed regarding frequency and recency of nonmedical opioid use as it relates to heroin use—in both a bivariable and multivariable manner. Assessing the risk factors associated with nonmedical opioid use, and how its use may increase risk for heroin use is critical to developing appropriate prevention, intervention, and harm reduction programming geared toward adolescents at highest risk. An examination of a nationally representative sample of adolescents allows us to determine which subgroups of high school students are at highest risk for nonmedical opioid use and heroin use. This study examines the correlates of nonmedical use of opioids and heroin and examines how frequency and recency of opioid use relates to heroin use in a nationally representative sample of high school seniors.

Section snippets

Procedure

Monitoring the Future (MTF) is a nationally representative cross-sectional study of US high school students. Approximately 15,000 high school seniors (12th graders) are surveyed every year from approximately 130 public and private schools throughout 48 states. MTF uses a multi-stage random sampling procedure: geographic areas are selected, then schools within areas are selected, and then classes within schools are selected. Since the main outcome (heroin use) is rare, in order to have adequate

Results

Sample characteristics are presented in Table 1. Nonmedical opioid and heroin use are presented in Table 2. About 12% of the sample reported using opioids at least once and using it 1–2 times was most common among users. About one out of 100 students reported lifetime use of heroin.

Table 3 presents associations between level of lifetime opioid use and heroin use. We found that 7.5% of nonmedical opioid users reported ever using heroin, and the higher the frequency of opioid use, the higher the

Discussion

For a substantial number of individuals, especially young, white males, nonmedical opioid use is an important correlate of use of a more dangerous substance—heroin (Mateu-Gelabert et al., 2015, Peavy et al., 2012, Brands et al., 2005, Lankenau et al., 2012, Mars et al., 2014, Jones, 2013). Considering this alarming trend, it is essential to determine the risk factors for nonmedical use of opioids and heroin use. Although longitudinal data would most adequately allow us to delineate correlates

Conclusions

Increases in heroin use in the last decade may be related to opioid use and transition from opioid to heroin use, particularly among young, white, non-urban males. We found a dose-response indicating that greater frequency and more recent use of nonmedical opioids result in substantially greater odds of heroin use. Future interventions should be aimed at decreasing nonmedical opioid use among adolescents and young adults before initiation of heroin use, with special attention given to

Role of funding source

This project was funded by the National Institutes of Health (NIH) (K01 DA-038800, PI: Palamar). The Inter-university Consortium for Political and Social Research and Monitoring the Future (MTF) principal investigators had no role in analysis, interpretation of results, or in the decision to submit the manuscript for publication.

Contributors

All authors are responsible for this reported research. J. Palamar conceptualized and designed the study, and conducted the statistical analyses. J. Shearston and E.

Acknowledgments

The authors would like to thank the principal investigators of Monitoring the Future (Miech, Johnston, Bachman, O’Malley, and Schulenberg) at The University of Michigan, Institute for Social Research, Survey Research Center, and the Inter-university Consortium for Political and Social Research for providing access to these data (http://www.icpsr.umich.edu/icpsrweb/landing.jsp). Monitoring the Future data were collected through a research grant (R01 DA-01411) from the National Institute on Drug

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