Non-medical use of prescription opioids is associated with heroin initiation among US veterans: a prospective cohort study
Geetanjoli Banerjee
Department of Epidemiology, Brown School of Public Health, Providence, RI, USA
Search for more papers by this authorE. Jennifer Edelman
Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA
Search for more papers by this authorDeclan T. Barry
Yale University School of Medicine, New Haven, CT, USA
APT Foundation Pain Treatment Services, New Haven, CT, USA
Search for more papers by this authorWilliam C. Becker
Pain Research, Informatics, Multi-morbidities and Education (PRIME) Center, VA, Connecticut Healthcare System, West Haven, CT, USA
Search for more papers by this authorMagdalena Cerdá
Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA
Search for more papers by this authorStephen Crystal
Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ, USA
Search for more papers by this authorJulie R. Gaither
Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA
Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT, USA
Search for more papers by this authorAdam J. Gordon
Center for Health Equity Research and Promotion (CHERP) & Mental Illness Research Education and Clinical Center (MIRECC), VA Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, PA, USA
Search for more papers by this authorKirsha S. Gordon
VA Connecticut Healthcare System, West Haven, CT, USA
Search for more papers by this authorRobert D. Kerns
Pain Research, Informatics, Multi-morbidities and Education (PRIME) Center, VA, Connecticut Healthcare System, West Haven, CT, USA
Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT, USA
Search for more papers by this authorSilvia S. Martins
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
Search for more papers by this authorDavid A. Fiellin
Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA
Search for more papers by this authorCorresponding Author
Brandon D. L. Marshall
Department of Epidemiology, Brown School of Public Health, Providence, RI, USA
Correspondence to: Brandon Marshall, Department of Epidemiology, Brown University, 121 South Main Street, Providence, RI 02912, USA. E-mail: [email protected]
Search for more papers by this authorGeetanjoli Banerjee
Department of Epidemiology, Brown School of Public Health, Providence, RI, USA
Search for more papers by this authorE. Jennifer Edelman
Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA
Search for more papers by this authorDeclan T. Barry
Yale University School of Medicine, New Haven, CT, USA
APT Foundation Pain Treatment Services, New Haven, CT, USA
Search for more papers by this authorWilliam C. Becker
Pain Research, Informatics, Multi-morbidities and Education (PRIME) Center, VA, Connecticut Healthcare System, West Haven, CT, USA
Search for more papers by this authorMagdalena Cerdá
Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA
Search for more papers by this authorStephen Crystal
Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ, USA
Search for more papers by this authorJulie R. Gaither
Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA
Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT, USA
Search for more papers by this authorAdam J. Gordon
Center for Health Equity Research and Promotion (CHERP) & Mental Illness Research Education and Clinical Center (MIRECC), VA Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, PA, USA
Search for more papers by this authorKirsha S. Gordon
VA Connecticut Healthcare System, West Haven, CT, USA
Search for more papers by this authorRobert D. Kerns
Pain Research, Informatics, Multi-morbidities and Education (PRIME) Center, VA, Connecticut Healthcare System, West Haven, CT, USA
Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT, USA
Search for more papers by this authorSilvia S. Martins
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
Search for more papers by this authorDavid A. Fiellin
Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA
Search for more papers by this authorCorresponding Author
Brandon D. L. Marshall
Department of Epidemiology, Brown School of Public Health, Providence, RI, USA
Correspondence to: Brandon Marshall, Department of Epidemiology, Brown University, 121 South Main Street, Providence, RI 02912, USA. E-mail: [email protected]
Search for more papers by this authorAbstract
Aims
To estimate the influence of non-medical use of prescription opioids (NMUPO) on heroin initiation among US veterans receiving medical care.
Design
Using a multivariable Cox regression model, we analyzed data from a prospective, multi-site, observational study of HIV-infected and an age/race/site-matched control group of HIV-uninfected veterans in care in the United States. Approximately annual behavioral assessments were conducted and contained self-reported measures of NMUPO and heroin use.
Setting
Veterans Health Administration (VHA) infectious disease and primary care clinics in Atlanta, Baltimore, New York, Houston, Los Angeles, Pittsburgh and Washington, DC.
Participants
A total of 3396 HIV-infected and uninfected patients enrolled into the Veterans Aging Cohort Study who reported no life-time NMUPO or heroin use, had no opioid use disorder diagnoses at baseline and who were followed between 2002 and 2012.
Measurements
The primary outcome measure was self-reported incident heroin use and the primary exposure of interest was new-onset NMUPO. Our final model was adjusted for socio-demographics, pain interference, prior diagnoses of post-traumatic stress disorder and/or depression and self-reported other substance use.
Findings
Using a multivariable Cox regression model, we found that non-medical use of prescription opioids NMUPO was associated positively and independently with heroin initiation [adjusted hazard ratio (AHR) = 5.43, 95% confidence interval (CI) = 4.01, 7.35].
Conclusions
New-onset non-medical use of prescription opioids (NMUPO) is a strong risk factor for heroin initiation among HIV-infected and uninfected veterans in the United States who reported no previous history of NMUPO or illicit opioid use.
Supporting Information
Table S1 Baseline characteristics of eligible and excluded Veterans Aging Cohort Study (VACS) participants, 2002–012.
Figure S1 Proportion who initiated heroin use among participants reported current or prior non-medical use of prescription opioids (NMUPO), stratified by follow-up wave, Veterans Aging Cohort Study (VACS) (2002–12).
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Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
References
- 1Volkow ND. What science tells us about opioid abuse and addiction. Testimony before House Committee on Energy and Commerce, Subcommittee on Oversight and Investigations. Bethedsa, MD: National Institute on Drug Abuse; 2015.
- 2Hedegaard H., Chen L.-H., Warner M. Drug-poisoning Deaths Involving Heroin: United States, 2000–2013. Hyattsville, MD: National Center for Health Statistics; 2015.
- 3Unick G. J., Rosenblum D., Mars S., Ciccarone D. Intertwined epidemics: national demographic trends in hospitalizations for heroin- and opioid-related overdoses, 1993–2009. PLOS ONE 2013; 8: e54496.
- 4Manchikanti L., Fellow B., Ailinani H., Pampati V. Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain Physician 2010; 13: 401–35.
- 5Fischer B., Keates A., Buhringer G., Reimer J., Rehm J. Non-medical use of prescription opioids and prescription opioid-related harms: why so markedly higher in North America compared to the rest of the world? Addiction 2014; 109: 177–81.
- 6 Substance Abuse and Mental Health Services (SAMHSA) Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD: SAMHSA; 2014.
- 7Joranson D., Ryan K., Gilson A., Dahl J. Trends in medical use and abuse of opioid analgesics. JAMA 2000; 283: 1710–14.
- 8Gilson A. M., Ryan K. M., Joranson D. E., Dahl J. L. A reassessment of trends in the medical use and abuse of opioid analgesics and implications for diversion control: 1997–2002. J Pain Symptom Manage 2004; 28: 176–1–8.
- 9Paulozzi L, Franklin G, Kerlikowske R, Jones C, Ghiya N, Popovic T. Prescription Drug Overdoses—a US Epidemic. Bethesda, MD: Centers for Disease Control and Prevention; 2012.
- 10Voon P., Callon C., Nguyen P., Dobrer S., Montaner J. S., Wood E. et al. Denial of prescription analgesia among people who inject drugs in a Canadian setting. Drug Alcohol Rev 2015; 34: 221––2218.
- 11van Amsterdam J., Phillips L., Henderson G., Bell J., Bowden-Jones O., Hammersley R. et al. Ranking the harm of non-medically used prescription opioids in the UK. Regul Toxicol Pharmacol 2015; 73: 999–1004.
- 12Peavy K. M., Banta-Green C. J., Kingston S., Hanrahan M., Merrill J. O., Coffin P. O. ‘Hooked on’ prescription-type opiates prior to using heroin: results from a survey of syringe exchange clients. J Psychoact Drugs 2012; 44: 259–65.
- 13Cicero T. J., Ellis M. S., Surratt H. L., Kurtz S. P. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry 2014; 71: 821–6.
- 14Jones C. M. 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; 132: 95–100.
- 15Muhuri P. K., Gfroerer J. C., Davies M. C. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. Rockville, MD: National Institute on Drug Abuse; 2013.
- 16Irish C., Maxwell R., Dancox M., Brown P., Trotter C., Verne J. et al. Skin and soft tissue infections and vascular disease among drug users, England. Emerg Infect Dis 2007; 13: 1510–1.
- 17Dart R. C., Surratt H. L., Cicero T. J., Parrino M. W., Severtson S. G., Bucher-Bartelson B. et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med 2015; 372: 241–8.
- 18Robins L. N., Helzer J. E., Hesselbrock M., Wish E. Vietnam veterans three years after Vietnam: how our study changed our view of heroin. Am J Addict 2010; 19: 203–11.
- 19Bray R. M., Hourani L. L. Substance use trends among active duty military personnel: findings from the United States Department of Defense Health Related Behavior Surveys, 1980–2005. Addiction 2007; 102: 1092–101.
- 20McFall M. E., Mackay P. W., Donovan D. M. Combat-related posttraumatic stress disorder and severity of substance abuse in Vietnam veterans. J Stud Alcohol 1992; 53: 357––63.
- 21Lew H. L., Otis J. D., Tun C., Kerns R. D., Clark M. E., Cifu D. X. Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: polytrauma clinical triad. J Rehabil Res Dev 2009; 46: 697.
- 22Golub A., Bennett A. S. Prescription opioid initiation, correlates, and consequences among a sample of OEF/OIF military personnel. Subst Use Misuse 2013; 48: 811–20.
- 23Seal K. H., Shi Y., Cohen G., Cohen B. E., Maguen S., Krebs E. E. et al. Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA 2012; 307: 940–7.
- 24Robins L. N. Vietnam veterans’ rapid recovery from heroin addiction: a fluke or normal expectation? Addiction 1993; 88: 1041–54.
- 25Barry D. T., Goulet J. L., Kerns R. K., Becker W. C., Gordon A. J., Justice A. C. et al. Nonmedical use of prescription opioids and pain in veterans with and without HIV. Pain 2011; 152: 1133–8.
- 26Green T. C., Kershaw T., Lin H., Heimer R., Goulet J. L., Kraemer K. L. et al. Patterns of drug use and abuse among aging adults with and without HIV: A latent class analysis of a US Veteran cohort. Drug Alcohol Depend 2010; 110: 208–20.
- 27Gaither J. R., Goulet J. L., Becker W. C., Crystal S., Edelman E. J., Gordon K. et al. Guideline-concordant management of opioid therapy among human immunodeficiency virus (HIV)-infected and uninfected veterans. J Pain 2014; 15: 1130–40.
- 28Edelman E. J., Gordon K., Becker W. C., Goulet J. L., Skanderson M., Gaither J. R. et al. Receipt of opioid analgesics by HIV-infected and uninfected patients. J Gen Intern Med 2013; 28: 82–90.
- 29Weisberg D. F., Gordon K. S., Barry D. T., Becker W. C., Crystal S., Edelman E. J. et al. Long-term prescription of opioids and/or benzodiazepines and mortality among HIV-infected and uninfected patients. J Acquir Immune Defic Syndr 2015; 69: 223––3.
- 30Justice A. C., Dombrowski E., Conigliaro J., Fultz S. L., Gibson D., Madenwald T. et al. Veterans Aging Cohort Study (VACS): overview and description. Med Care 2006; 44: S13––S124.
- 31Justice A. C., Lasky E., McGinnis K. A., Skanderson M., Conigliaro J., Fultz S. L. et al. Medical disease and alcohol use among veterans with human immunodeficiency infection: a comparison of disease measurement strategies. Med Care 2006; 44: S52–S60.
- 32Swartz J. A., Lurigio A. J. Screening for serious mental illness in populations with co-occurring substance use disorders: performance of the K6 scale. J Subst Abuse Treat 2006; 31: 287–96.
- 33Boscarino J. A., Rukstalis M., Hoffman S. N., Han J. J., Erlich P. M., Gerhard G. S. et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction 2010; 105: 1776––82.
- 34Dobscha S. K., Morasco B. J., Duckart J. P., Macey T., Deyo R. A. Correlates of prescription opioid initiation and long-term opioid use in veterans with persistent pain. Clin J Pain 2013; 29: 102–8.
- 35Khosla N., Juon H. S., Kirk G. D., Astemborski J., Mehta S. H. Correlates of non-medical prescription drug use among a cohort of injection drug users in Baltimore City. Addict Behav 2011; 36: 1282–7.
- 36Kolodny A., Courtwright D. T., Hwang C. S., Kreiner P., Eadie J. L., Clark T. W. et al. The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Annu Rev Public Health 2015; 36: 559–74.
- 37Salyers M. P., Bosworth H. B., Swanson J. W., Lamb-Pagone J., Osher F. C. Reliability and validity of the SF-12 health survey among people with severe mental illness. Med Care 2000; 38: 1141–50.
- 38Bradley K. A., Bush K. R., Epler A. J., Dobie D. J., Davis T. M., Sporleder J. L. et al. Two brief alcohol-screening tests from the alcohol use disorders identification test (AUDIT). Arch Intern Med 2003; 163: 821–9.
- 39Becker W. C., Gordon K., Jennifer Edelman E., Kerns R. D., Crystal S., Dziura J. D. et al. Trends in any and high-dose opioid analgesic receipt among aging patients with and without HIV. AIDS Behav 2016; 20: 679–86.
- 40Christensen E. Multivariate survival analysis using Cox's regression model. Hepatology 1987; 7: 1346–58.
- 41Robins J. M., Finkelstein D. M. Correcting for noncompliance and dependent censoring in an AIDS clinical trial with inverse probability of censoring weighted (IPCW) log-rank tests. Biometrics 2000; 56: 779–88.
- 42Cain L. E., Cole S. R. Inverse probability-of-censoring weights for the correction of time-varying noncompliance in the effect of randomized highly active antiretroviral therapy on incident AIDS or death. Stat Med 2009; 28: 1725–38.
- 43Graubard B. I., Korn E. L. Regression analysis with clustered data. Stat Med 1994; 13: 509–22.
- 44Lipari RN, Hughes A. The NSDUH report: trends in heroin use in the United States: 2002 to 2013. Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA); 2015.
- 45Mars S. G., Bourgois P., Karandinos G., Montero F., Ciccarone D. ‘Every “never” I ever said came true’: transitions from opioid pills to heroin injecting. Int J Drug Policy 2014; 25: 257–66.
- 46Guarino H., Marsch L. A., Deren S., Straussner S. L., Teper A. Opioid use trajectories, injection drug use, and hepatitis C virus risk among young adult immigrants from the former Soviet Union living in New York City. J Addict Dis 2015; 34: 162–77.
- 47Ringwalt C., Roberts A. W., Gugelmann H., Skinner A. C. Racial disparities across provider specialties in opioid prescriptions dispensed to medicaide beneficiaries with chronic noncancer pain. Pain Med 2015; 16: 633–40.
- 48Krebs E. E., Ramsey D. C., Miloshoff J. M., Blair M. J. Primary care monitoring of long-term opioid therapy among veterans with chronic pain. Pain Med 2011; 12: 740–6.
- 49 Healthcare Inspection. VA Patterns of Dispensing Take-Home Opioids and Monitoring Patients on Opioid Therapy 2014. Available at: http://www.va.gov/oig/pubs/VAOIG-14-00895-163.pdf (7 June 2016).
- 50Cicero T. J., Surratt H., Inciardi J. A., Munoz A. Relationship between therapeutic use and abuse of opioid analgesics in rural, suburban, and urban locations in the United States. Pharmacoepidemiol Drug Saf 2007; 16: 827–40.
- 51Dowell D., Haegerich T. M., Chou R. CDC guideline for prescribing opioids for chronic pain—United States. Morb Mortal Wkly Rep 2016; 65: 1–49.
- 52Voon P., Kerr T. Nonmedical’ prescription opioid use in North America: a call for priority action. Subst Abuse Treat Prev Policy 2013; 8:39.
- 53Weisberg D. F., Becker W. C., Fiellin D. A., Stannard C. Prescription opioid misuse in the United States and the United Kingdom: cautionary lessons. Int J Drug Policy 2014; 25: 1124–30.
- 54McCabe S. E., Cranford J. A., Boyd C. J., Teter C. J. Motives, diversion and routes of administration associated with nonmedical use of prescription opioids. Addict Behav 2007; 32: 562–75.
- 55Sung H. E., Richter L., Vaughan R., Johnson P. B., Thom B. Nonmedical use of prescription opioids among teenagers in the United States: trends and correlates. J Adolesc Health 2005; 37: 44–51.
- 56McCabe S. E., West B. T., Teter C. J., Boyd C. J. Medical and nonmedical use of prescription opioids among high school seniors in the United States. Arch Pediatr Adolesc Med 2012; 166: 797–802.
- 57Boyd C. J., Young A., Grey M., McCabe S. E. Adolescents’ nonmedical use of prescription medications and other problem behaviors. J Adolesc Health 2009; 45: 543–50.
