Health behaviors of young adult heroin injectors in the Seattle area
Introduction
Heroin use among young people is increasing on a national level (Jones, 2013). Young people ages 18–25 accounted for 27.6% of the treatment admissions for heroin injection in 2009, which is a dramatic increase from 1992 when this age group only accounted for 8.4% of the treatment admissions (US Department of Health and Human Services, 2011). This demographic shift in heroin use is reflected in Washington State. The number of treatment admissions for heroin use increased dramatically from 1999 through 2012 among those aged 18–29, effectively decreasing the median age of treatment admissions for heroin from 40 to 29-years-old. This trend was paralleled by an increase in mortality secondary to overdoses involving heroin in individuals under age 30 (Banta-Green et al., 2013). Nationally, the annual number of drug poisoning deaths involving heroin doubled between 2002 and 2011 (Centers for Disease Control and Prevention, 2014).
Some risk factors for initiation of heroin use may be specific to today's youth. Previous studies have shown that heroin use is often preceded by prescription opioid abuse, especially in younger heroin users (Peavy et al., 2012). In 2012, 6% of tenth graders in Washington State reported using prescription opioids in order “to get high” in the prior month (Washington State Department of Health, 2014). Twenty-three percent of the tenth graders who had recently used prescription-type opioids to get high also reported using heroin at some point, compared to only 3% of the tenth graders who had not recently used prescription-type opioids to get high (Banta-Green, 2013). Both the opioid prescription rate and the misuse of prescription opioids increased in the United States from 2004 to 2011 (Atluri et al., 2014).
Washington State has been on the front lines of strengthening regulations around prescribing opioids (Meier, 2012), with the possible unintended consequence of pushing some prescription opioid abusers to heroin. Having experienced an epidemic of heroin use preceded by prescription opiate abuse and, in turn, early policy action to stem prescription misuse, Washington State is well positioned to identify health behaviors in this young population. Knowledge about these health behaviors can help mitigate these risks in the future, as well as provide information to other regions facing earlier stages of this epidemic.
Injection drug users (IDUs) are at risk for infectious diseases such as human immunodeficiency virus (HIV) and hepatitis C (HCV), primarily via sharing syringes and other injection equipment. Injection drug use is also a risk factor for serious infections such as right-sided endocarditis (Moss and Munt, 2003). Heroin users are at high risk for overdose, with estimates of annual incidence ranging from 15% to 25% (Coffin et al., 2007, Jenkins et al., 2011, Darke et al., 2007). An analysis of opioid injectors at syringe exchange programs in King County showed that recent incarceration and sharing of injection materials were independently associated with nonfatal overdose (Jenkins et al., 2011). Incarceration is an especially strong risk factor for overdose in the time immediately after release from prison (Ochoa et al., 2005, Strang et al., 2013, Farrell and Marsden, 2008).
The purpose of this study is to characterize the younger generation of heroin injectors, including the ways in which they differ from the heroin injectors age 30 and over. This younger generation of heroin injectors may be unique in ways that impact their public health and medical care needs. Given that the size of this population appears to be growing in part due to the cohort effects of recent initiates to heroin starting with prescription opioids and the fact that Washington State may be ahead of the rest of the country in these trends, these analyses may inform outreach programs and medical care for young IDUs in King County, with lessons learned potentially of value for other regions.
Section snippets
Study setting and data collection
Over 5.7 million syringes were exchanged in King County, Washington in 2013. About half of these syringes were exchanged at syringe exchange facilities operated by Public Health–Seattle and King County (PHSKC). The other half of syringes exchanged were exchanged at facilities operated by People's Harm Reduction Alliance (PHRA), a non-governmental organization. In addition to syringe exchange, these programs also provide services such as infectious disease testing, clean injection equipment,
Demographic characteristics
The demographic characteristics of the participants by age <30 vs. ≥30-years-old are presented in Table 1. Younger respondents were significantly more likely to report incarceration in the last year (43.0% vs. 31.3%, p = 0.023) and were less likely to have health insurance than older users (38.4% vs. 51.9%, p = 0.013). Overall, there were more male than female respondents (69.9% vs. 29.3%), but there was no significant difference in the gender composition of the younger and older groups. A somewhat
Overview of findings
This analysis found that King County heroin injectors under age 30 were more likely than older users to have a number of hazardous health behaviors, but they were also taking advantage of harm reduction interventions such as take-home naloxone. Young adults were significantly more likely to report recent incarceration, syringe sharing, using a syringe more than once, recently using buprenorphine, and witnessing an overdose. Younger users were also more likely to possess take-home naloxone,
Contributors
Emily Cedarbaum authored the first draft of the paper and conducted descriptive and bi-variate analyses. Caleb Banta-Green conducted the multivariate analysis and provided overall guidance for the analysis and writing. Both authors contributed to and approve the final manuscript.
Role of funding source
There was no funding for the data analysis conducted at the University of Washington. Original data collection by Public Health–Seattle & King County (PHSKC) was conducted for internal program evaluation purposes; PHSKC
Acknowledgments
The authors thank the following Public Health–Seattle & King County staff: Michael Hanrahan and Hanne Thiede for reviewing this article and Joe Tinsley and the syringe exchange staff and volunteers for survey administration and data collection. Dr. Roger Rosenblatt provided mentoring to Emily Cedarbaum during her work on a previous version of this paper for her thesis.
References (33)
- et al.
Perceived risk, peer influences, and injection partner type predict receptive syringe sharing among young adult injection drug users in five U.S. cities
Drug Alcohol Depend.
(2007) - et al.
Distributive syringe sharing among young adult injection drug users in five U.S. cities
Drug Alcohol Depend.
(2007) 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.
Heroin overdose among young injection drug users in San Francisco
Drug Alcohol Depend.
(2005) - et al.
Trends and geographic patterns in drug-poisoning death rates in the U.S., 1999–2009
Am. J. Prev. Med.
(2013) - et al.
Assessment of the trends in medical use and misuse of opioid analgesics from 2004 to 2011
Pain Phys.
(2014) Info Brief: Heroin Trends Across Washington State
(2013)- et al.
Drug Abuse Trends in the Seattle/King County Area: 2012
(2013) - et al.
Drug Abuse Trends in the Seattle/King County Area: 2013. 2014
(2014) Adolescent abuse of pharmaceutical opioids raises questions about prescribing and prevention
Arch. Pediatr. Adolesc. Med.
(2012)
Mortality after prison release: opioid overdose and other causes of death, risk factors, and time trends from 1999 to 2009
Ann. Intern. Med.
Rates of drug poisoning deaths involving heroin, by selected age and racial/ethnic groups—United States, 2002 and 2011
MMWR
The Changing face of heroin use in the United States
JAMA Psychiatry
Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal
Ann. Intern. Med.
Identifying injection drug users at risk of nonfatal overdose
Acad. Emerg. Med.
Patterns of nonfatal heroin overdose over a 3-year period: findings from the Australian treatment outcome study
J. Urban Health
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