Killing the Pain: Prescription Drug Abuse and Other Risky Behaviorsin Rural Appalachia

Jennifer R. Havens, PhD, MPHDepartment of Behavioral ScienceCenter on Drug and Alcohol ResearchUniversity of Kentucky College of Medicine

Annual numbers (in millions) of new nonmedical users of pain relievers aged 12 and older

Source: National Household Survey on Drug Abuse 1970-2000

Past Year Illicit Drug Dependence or Abuse

Source: National Survey on Drug Use and Health 2002

Percent increase in number of treatment admissions for narcotic painkillers: 1997 – 2002

Source: Treatment Episode Data Set 1997 - 2002

BackgroundRural Substance Abuse

Differing trends – rates of prescription drug opiate use and methamphetamine higher than urban areas

(Havens et al., Am J Drug Alc Abuse, 2007; Havens et al., Am J Drug Alc Abuse, 2009)

Differing drugs of abuse may be due to lack of availability of drugs such as heroin in rural areas

Injection Drug Use among Rural Drug Users

Previous research: IDU rare among rural drug users in Appalachian Kentucky (Leukefeld et al., Substance Use and Misuse, 1997)

Recent research suggested a much higher prevalence of IDU among Appalachian drug users (>40%)

(Havens et al., Drug and Alcohol Dependence, 2007).

IDU among Appalachian Drug Users

Majority of rural IDUs reported injecting OxyContin® and other prescription drugs NOT designed for injection

Fewer than 10% had ever injected heroin and/or cocaine

Self-reported hepatitis C infection significantly higher among the IDUs versus non-IDUs (p<0.001)

(Havens et al., Drug and Alcohol Dependence, 2007)

Social Networks and HIV Risk among Rural Drug Users

Overall goal of the study is to determine the prevalence and incidence of HIV, hepatitis C and herpes simplex-2 virus as well as to examine both individual and social network-related risk factors for HIV and other infectious diseases among rural drug users

Specific Aims

To determine prevalence and incidence of HIV, hepatitis C (HCV) and herpes simplex-2 virus (HSV-2) among rural IDUs and non-IDUs

Characterize risk for HIV and other infectious diseases among rural injection and non-injection drug users in the context of both individual-level and network-level risk

Participants

500 rural out-of-treatment injection and non-injection drug users recruited and followed at 6-, 12-, and 18-months post-baseline

Storefront location in rural townParticipants recruited via Respondent

Driven Sampling (RDS)24- and 30-month follow-up ongoing

Eligibility Criteria

Age 18+ English-speaking IDU (initial seeds) Use of at least 1 of the following drugs in prior

6 mo:Rx Opiates (illicit use)CocaineHeroinMethamphetamine

Outcomes

HIV, HCV, HSV-2 prevalence and incidence (i.e., seroconversion)

HIV risk behaviorsunprotected sexsharing syringes and other injection-related

paraphernalia

Data Collection Procedures

Interviewer-administered questionnaireComputer-assisted personal interview

(CAPI) via tablet PCSerologic testing (with pre- and post-test

counseling)HIV (with confirmatory testing)HCVHSV-2

Baseline Data -Participant Characteristics N=503

n %

Male 286 56.7

Age, median (IQR) 31 (26 ,38)

Caucasian 474 94.2

Employed Full-Time 173 34.4

Lifetime Injection Drug Use 394 78.3

Prevalent HIV 0 0

Prevalent HCV 220 43.7

Prevalent HSV-2 58 11.5

Incident HCV 36 12.7

Incident HSV-2 50 11.2

Baseline Data – Drug Use

Lifetime Past 30 DaysAlcohol 499 99.2 276 54.9

Methadone (illicit) 476 94.6 306 60.8

Heroin 176 35.0 22 4.4

OxyContin 477 94.8 351 69.8

Oxycodone 482 95.8 364 72.4

Hydrocodone 488 97.0 408 81.3

Benzodiazepines 480 95.5 429 85.3

Methamphetamine 219 43.5 17 3.4

Cocaine 472 93.8 113 22.5

Marijuana 491 97.6 308 61.2

Baseline Data – Age of Onset

AlcoholMarijuana

Age 14

BenzodiazepinesHydrocodone

Age 18

CocaineOxycodone

Age 20CrackAge 21

OxyContinHeroin

MethadoneAge 23

IDUAge 22

MethamphetamineAge 24

Drugs Initiated Injection With (n=394 Lifetime IDUs)

n %

OxyContin 190 48.2

Other Rx opiates 53 13.4

TOTAL ALL Rx opiates 243 61.7

Methamphetamine 4 1.0

Cocaine 117 29.7

Heroin 19 4.8

Baseline Data – IDU Drugs (n=394 Lifetime IDUs)

n %

Rx Opiates 348 88.3

Rx Stimulants 27 6.8

Rx Benzodiazepines 23 5.8

Methamphetamine 39 9.9

Cocaine 271 68.8

Heroin 95 24.1

Speedball (cocaine/OxyContin) 60 15.2

Baseline Data -Sex Riskn %

Male Sex Partners, median (IQR) 9 (5, 17.5)

Female Sex Partners, median (IQR) 20 (10, 45)

Sexual Orientation

Heterosexual 459 91.2

Homosexual 9 1.8

Bisexual 34 6.8

Sex Encounters w/o Condom (30 days) 14 (4, 30)

Baseline Data – Drug Risk

n %

Sharing Syringes (past 6 mo) N=288 92 31.9

Sharing Cottons, Cookers, Water (6 mo) N=288

137 47.6

Daily Injection N=288 102 35.4

Sharing Straws (6 mo) N=503 407 88.9

Overdose (Lifetime) N=503 146 29.0

Baseline Data – Social Networks

Support Network Members, median (IQR)2 (1, 3)

Drug Network Members, median (IQR)4 (2, 9)

Sex Network Members, median (IQR)2 (1, 5)

Drug Network

by

Drug Network by HCV Status

Results from Ongoing or Published Studies from SNAP

Transition to InjectionHCV PrevalenceMethadone UseOverdose

Initiation to Injection

48.2% of participants initiated injection with OxyContin®

Young and Havens, Addiction, 2012

Initiation to Injection

Young and Havens, Addiction, 2012

Initiation to Injection

Young and Havens, Addiction, 2012

Hepatitis C

Overall prevalence is 44.1% (54.5% among IDUs)

Incidence is about 10 cases/100 PYIndependent associations with HCV:

Syringe sharing (aOR: 2.04, 95% CI: 1.20, 3.45)

Years IDU (aOR: 1.04, 95% CI: 1.01, 1.07)

Injecting Rx opiates (aOR: 2.37, 95% CI: 1.21, 4.63)

Injecting Cocaine (aOR: 2.24, 95% CI: 1.41, 3.54)

Havens et al., American Journal of Public Health, 2013

Methadone Use

94.6% of cohort report lifetime illicit methadone use

Methadone NOT diverted from treatment programs

Factors associated with high frequency methadone use: older age, less exposure to drug tx, not having Rx for physical problem, not using OxyContin concurrently, fewer lifetime arrests and experiencing recent drug problems

Hall, Leukefeld and Havens, under review, 2013

Overdose

28% experienced 1 or more ODs58% witnessed 1 or more ODsIndividual factors associated with OD:

ever in drug tx, injection of Rx opiates, PTSD, ASPD

Network factors associated with OD: having additional support network members

Havens et al., Drug and Alcohol Dependence, 2011

Acknowledgements

NIH/NIDA (R01-DA024598)Dr. Carl Leukefeld (BSC), Dr. Carrie

Oser (Sociology) and Dr. Rick Crosby (Health Behavior)

Center on Drug and Alcohol ResearchDepartment of Behavioral Science