Short communicationDelay discounting in opioid use disorder: Differences between heroin and prescription opioid users
Introduction
The prevalence of heroin use and heroin use disorders has risen sharply in recent years, with the rate of past-year heroin use disorders almost doubling between 2002 and 2013 in the U.S. (Jones, 2013, Jones et al., 2015). Following years of increases in prescription opioid misuse, many new heroin users report having initiated opioid use with opioid analgesic medications (Cerda et al., 2015, Jones, 2013, Novak et al., 2016). The initiation of heroin use in this population is associated with a significantly poorer prognosis (Brands et al., 2004, Moore et al., 2007, Potter et al., 2013, Rosenblum et al., 2007, Sigmon, 2006, Weiss et al., 2011). However, little is known about mechanisms that might explain differences between prescription opioid and heroin users, or facilitate the transition from prescription opioids to heroin.
One major difference between prescription opioids and heroin is that prescription opioids can be obtained legally for medical purposes. This may foster the belief that prescription opioids are less risky than heroin (Daniulaityte et al., 2012, Lord et al., 2011). Accordingly, greater impulsivity may be a distinguishing feature of those who use heroin relative to those who use only prescription opioids. Those who are more impulsive perceive risky behaviors to be less harmful (Arria et al., 2008, Doran et al., 2011, Robbins and Bryan, 2004), and may be more likely to engage in such behaviors, even adjusting for perceived risk (Ryb et al., 2006).
The tendency to over-value immediate relative to delayed reward, i.e., delay discounting, is a common feature of substance use and other addictive disorders (Bickel et al., 2014, MacKillop et al., 2011, Reynolds, 2006). Those with higher delay discounting act quickly on current needs, while devaluing future needs. This facet of impulsivity is particularly notable in opioid use disorder; heroin users not only show a dramatically larger preference for immediate rewards relative to healthy comparison samples (Kirby et al., 1999, Madden et al., 1997), but also have higher discounting rates compared to people who abuse alcohol, and rates similar to those who abuse cocaine (Kirby and Petry, 2004). Delay discounting has also been associated with negative treatment outcome in a variety of substance use disorder populations (MacKillop and Kahler, 2009, Stanger et al., 2012, Washio et al., 2011). However, only one published study has examined delay discounting among those who are dependent upon prescription opioids (Yi et al., 2007). To date, no published studies have examined differences in delay discounting between those with opioid use disorder who use prescription opioids vs. heroin.
The objective of the present study was to compare levels of delay discounting in a sample of adults with opioid use disorder, based on the type of opioid abused in the past month. We hypothesized that heroin users would show elevated delay discounting relative to prescription opioid users.
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Participants
A sample of 151 participants seeking treatment for opioid use disorder was recruited from an inpatient detoxification unit as part of a larger study. In this sample, 139 participants completed the delay discounting measure. Eligible participants were 18 years or older, met Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (American Psychiatric Association, 2000) criteria for opioid dependence, and were undergoing a buprenorphine stabilization and taper protocol as part of
Results
Descriptive statistics for sociodemographic and drug use variables are presented in Table 1. Based on self-reported opioid use in the 30 days prior to hospital admission, 60 participants (43.2%) were defined as heroin users, 33 (23.7%) were defined as prescription opioid users, and 46 (33.1%) were defined as combined users. The groups differed significantly with respect to age, education, current cigarette smoking, and diagnosis of a stimulant use disorder (see Table 1). Mean k scores for heroin
Discussion
In a sample of adults hospitalized for opioid use disorder, we found that those who used heroin (whether with or without prescription opioids) exhibited greater delay discounting than those who exclusively used prescription opioids. These differences remained statistically significant after controlling for sociodemographic and drug use variables that differed between groups. Delay discounting is of significant clinical concern in substance-using populations due to its association with the
Conflict of interest
Dr. Weiss has served as a consultant to Indivior, U.S. WorldMeds, and GW Pharmaceuticals. All other authors declare they have no conflicts of interest.
Role of funding source
This work was supported by National Institute on Drug Abuse (NIDA) grants K23 DA035297 (Dr. McHugh) and K24 DA022288 (Dr. Weiss). NIDA had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Contributors
Drs. Weiss, McHugh, and Griffin designed the original study. Dr. McHugh and Ms. Karakula designed this secondary analysis. Ms. Karakula, Dr. McHugh, and Ms. Borges undertook the statistical analysis, and wrote the first draft of the manuscript. Dr. Weiss, Dr. Griffin, Ms. Borges, and Mr. Bailey contributed to the interpretation and presentation of study findings. All authors contributed to and have approved the final manuscript.
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