April M. Young

Nonmedical Use of Prescription Medications Among Adolescents in the United States: A Systematic Review

PURPOSE The purpose of this review was to systematically summarize research on nonmedical use of prescription medications (NMUPM) among U.S. adolescents, with specific focus on scheduled medications falling into one of the following drug classes: pain relievers, stimulants, sedatives, or tranquilizers. METHODS Databases were searched for peer-reviewed primary quantitative research published between January 2000 and June 2011 on NMUPM among out-of-treatment U.S. adolescents aged 12-17 years (or age 18 if enrolled in high school). RESULTS Thirty publications met inclusion criteria. A total of 25 studies were represented; 15 involved nationally representative samples. The prevalence and correlates of NMUPM varied across studies and by drug class. Nonmedical use of pain relievers was more prevalent than for stimulants, sedatives, and tranquilizers. Female gender was generally associated with pain reliever use and, to a lesser degree, with tranquilizer use. White adolescents also appeared to have a higher prevalence of NMUPM, although there was some evidence to the contrary. Older age, illicit drug use, and delinquency were consistently associated with NMUPM across studies. CONCLUSIONS This review identified several areas for further research, including that of racially/ethnically diverse samples of adolescents, more focus on sedative and tranquilizer use, and longitudinal research to examine temporal patterns in NMUPM and other illicit drug use, delinquency, and substance abuse and dependence.

Nonmedical Prescription Drug Use in a Nationally Representative Sample of Adolescents Evidence of Greater Use Among Rural Adolescents

OBJECTIVES To compare the prevalence of nonmedical prescription drug use among adolescents residing in urban, suburban, and rural areas of the United States and to determine factors independently associated with rural nonmedical prescription drug use among adolescents aged 12 to 17 years. DESIGN Cross-sectional, population-based survey. SETTING Noninstitutionalized residents in the United States. PARTICIPANTS Participants included adolescents aged 12 to 17 years (N = 17 872), most of whom were residing in urban areas (53.2%), male (51%), and white (59%). MAIN EXPOSURE Living in rural compared with urban area. MAIN OUTCOME MEASURES Nonmedical use of prescription drugs (pain relievers, tranquilizers, sedatives, and stimulants). Data were from the 2008 National Survey on Drug Use and Health. RESULTS Rural adolescents were 26% more likely than urban adolescents to have used prescription drugs nonmedically (adjusted odds ratio, 1.26; 95% confidence interval, 1.01-1.57) even after adjustment for race, health, and other drug and alcohol use. When examining the rural adolescents in particular, factors positively associated with nonmedical use of prescription drugs included decreased health status, major depressive episode(s), and other drug (marijuana, cocaine, hallucinogens, and inhalants) and alcohol use. Protective factors for nonmedical prescription drug use among rural adolescents included school enrollment and living in a 2-parent household. CONCLUSIONS Rural adolescents were significantly more likely than urban adolescents to report nonmedical prescription drug use. However, these results suggest there are multiple potential points of intervention to prevent initiation or progression of use among rural adolescents including preventing school dropout, increased parental involvement, and increased access to health, mental health, and substance abuse treatment.

Route of administration for illicit prescription opioids: a comparison of rural and urban drug users

BackgroundNonmedical prescription opioid use has emerged as a major public health concern in recent years, particularly in rural Appalachia. Little is known about the routes of administration (ROA) involved in nonmedical prescription opioid use among rural and urban drug users. The purpose of this study was to describe rural-urban differences in ROA for nonmedical prescription opioid use.MethodsA purposive sample of 212 prescription drug users was recruited from a rural Appalachian county (n = 101) and a major metropolitan area (n = 111) in Kentucky. Consenting participants were given an interviewer-administered questionnaire examining sociodemographics, psychiatric disorders, and self-reported nonmedical use and ROA (swallowing, snorting, injecting) for the following prescription drugs: buprenorphine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, OxyContin® and other oxycodone.ResultsAmong urban participants, swallowing was the most common ROA, contrasting sharply with substance-specific variation in ROA among rural participants. Among rural participants, snorting was the most frequent ROA for hydrocodone, methadone, OxyContin®, and oxycodone, while injection was most common for hydromorphone and morphine. In age-, gender-, and race-adjusted analyses, rural participants had significantly higher odds of snorting hydrocodone, OxyContin®, and oxycodone than urban participants. Urban participants had significantly higher odds of swallowing hydrocodone and oxycodone than did rural participants. Notably, among rural participants, 67% of hydromorphone users and 63% of morphine users had injected the drugs.ConclusionsAlternative ROA are common among rural drug users. This finding has implications for rural substance abuse treatment and harm reduction, in which interventions should incorporate methods to prevent and reduce route-specific health complications of drug use.

A Comparison of Rural and Urban Nonmedical Prescription Opioid Users’ Lifetime and Recent Drug Use

Background: Nonmedical prescription opioid use has emerged as a major public health concern. The growing burden of nonmedical prescription opioid use in America may have unique manifestations and consequences in rural areas, which to a large extent have yet to be explored. Objectives: To describe rural–urban differences among drug users in recent and lifetime use and age of onset of use for alcohol, heroin, OxyContin®, oxycodone, hydrocodone, barbiturates, benzodiazepines, cocaine, crack, methamphetamine, amphetamine, marijuana, hallucinogens, and inhalants. Methods: A purposive sample of 212 prescription drug users was recruited from a rural Appalachian county (n = 101) and a major metropolitan area (n = 111) in Kentucky. Consenting participants were given an interviewer-administered questionnaire examining sociodemographics, psychiatric characteristics, and self-reported drug use. Results: Rural drug users had significantly earlier ages of onset for use of oxycodone, hydrocodone, benzodiazepines, cocaine, and crack. In age-, gender-, and race-adjusted logistic regression analyses, rural drug users had significantly higher odds of lifetime and recent use of methadone, OxyContin®, and oxycodone. Rural drug users also had significantly higher odds of lifetime cocaine and crack use. However, urban participants as expected had significantly higher odds of recent crack use. Conclusions: The findings demonstrate that, in this sample, nonmedical prescription opioid use is dissimilar among rural and urban drug users. Additional research is needed to better understand the individual, social, and structural level factors contributing to the burden of nonmedical opioid use, particularly in rural populations, with the aim of developing tailored substance abuse treatment and prevention.

Network structure and the risk for HIV transmission among rural drug users.

Research suggests that structural properties of drug users’ social networks can have substantial effects on HIV risk. The purpose of this study was to investigate if the structural properties of Appalachian drug users’ risk networks could lend insight into the potential for HIV transmission in this population. Data from 503 drug users recruited through respondent-driven sampling were used to construct a sociometric risk network. Network ties represented relationships in which partners had engaged in unprotected sex and/or shared injection equipment. Compared to 1,000 randomly generated networks, the observed network was found to have a larger main component and exhibit more cohesiveness and centralization than would be expected at random. Thus, the risk network structure in this sample has many structural characteristics shown to be facilitative of HIV transmission. This underscores the importance of primary prevention in this population and prompts further investigation into the epidemiology of HIV in the region.

Predictors of Consistent Condom Use Among Young African American Women

The purpose of this study was to determine the predictive value of selected factors to the consistent use of condoms among high-risk young African American women. A clinic-based, prospective, study of 242 young, African-American women (ages 15–21) was conducted. In multivariate analysis, consistent condom use was predicted by having greater perceptions of condom negotiation self-efficacy, lower fear of negotiating condom use, and having communicated with sex partners (during the recall period) about condom use. Relational variables were predictive of consistent condom use among young African American women. STD/HIV preventive interventions should target these factors, perhaps in dyad-level interventions.

Spatial, temporal and relational patterns in respondent-driven sampling: evidence from a social network study of rural drug users

Background Respondent-driven sampling (RDS) has become a common tool for recruiting high-risk populations for HIV research. However, few studies have explored the influence of geospatial proximity and relationship-level characteristics on RDS recruitment, particularly among high-risk individuals residing in rural areas of the US. Methods In a social network study of 503 drug users in rural Central Appalachia, interviewer-administered questionnaires were used to collect relationship-level data (eg, duration of relationship, frequency of communication, kinship, social/financial support, trust, drug use and sex) and residential location. Demographic and drug-use similarity were also evaluated. Residential data were geocoded and road distance (km) between participants and (1) their network members and (2) the study site were computed. Seasonal patterns were assessed using node-level analysis, and dyadic analyses were conducted using generalised linear mixed models. Adjusted ORs (AORs) and 95% CIs are reported. Results Differences in distance to the study office by season and order of study entry were not observed (F=1.49, p=0.209 and β=0.074, p=0.050, respectively). Participants with transportation lived significantly further from the interview site than their counterparts (p<0.001). Dyadic analyses revealed no association between RDS recruitment likelihood and geographic proximity. However, kinship (AOR 1.62; CI 1.02 to 2.58) and frequency of communication (AOR 1.63; CI 1.25 to 2.13) were significantly associated with RDS recruitment. Conclusions In this sample, recruitment from ones network was likely non-random, contradicting a core RDS assumption. These data underscore the importance of formative research to elucidate potential recruitment preferences and of quantifying recruitment preferences for use in analysis.

Hepatitis C viremia and genotype distribution among a sample of nonmedical prescription drug users exposed to HCV in rural Appalachia

Research has demonstrated that hepatitis C (HCV) genotype distribution varies geographically and demographically. This exploratory study examines HCV viremia, viral concentration, and genotype distribution among anti‐HCV positive, rural Appalachian nonmedical prescription drug users. The study population was randomly selected from a pool of 200 anti‐HCV positive participants in a longitudinal study. Those randomly chosen were representative of the overall pool in terms of demographics, drug use, and other risk behaviors. Participants were tested serologically for HCV RNA, viral concentration, and genotype, and interview‐administered questionnaires examined behavioral and demographic characteristics. Of the 81 participants, 69% tested RNA positive, 59% of which had viral loads exceeding 800,000 IU/ml. Approximately 66% of the RNA positive sample had genotype 1a; types 2b (16%) and 3a (13%) were less common. RNA positive participants were not significantly different than RNA negative participants demographically or behaviorally. Likewise, with the exception of education, genotype 1 participants were not significantly different than those with genotype 2 or 3. The prevalence of active HCV infection highlights a need for prevention and treatment in this population. However, the predominance of genotype 1 may present challenges due to its association with decreased responsiveness to drug treatment, although the novel class of direct‐acting antivirals such as telaprevir and boceprevir offer new hope in this regard. The prevalence of genotype 1 may also foreshadow heightened burden of hepatocellular carcinoma and elevated healthcare expenditures. More research is needed to characterize HCV infection and genotype in this population. J. Med. Virol. 84:1376–1387, 2012.

Gender differences in circumstances surrounding first injection experience of rural injection drug users in the United States

BACKGROUND Research has demonstrated that there can be substantial gender differences in circumstances surrounding initiation of injection drug use; however, little is known about the gendered dynamics of first injection in rural areas where syringe exchange is inaccessible or among those who predominantly inject prescription medications. The present study examines gender differences in first injection experience among rural residents who predominantly inject prescription opioids. METHODS Interview-administered questionnaires collected data from a sample of injection drug users (n=394) recruited from Appalachian Kentucky using respondent-driven sampling. RESULTS Women were more likely to have initiated injection due to social-pressure (p=0.001), received the drugs as a gift (p=0.011), initiated in their partners home (p=0.004) and in their partners presence (p<0.001), been injected by their partner (p<0.001), used an unclean syringe (p=0.026), and received the syringe from their partner (p<0.001). Women were also more likely to report having engaged in sexual intercourse before or after initiation (p<0.001). Men were more likely to have personally purchased the drugs (p=0.002), to have acquired the syringe from a pharmacy/clinic (p=0.004), and to have injected with a friend (p=0.001) or family member (p=0.020). Men were also more likely to have a friend administer the first injection (p=0.007). CONCLUSIONS In this population of rural drug users, notable gender differences in injection initiation were observed. Social pressure played a more substantial role in womens first injection experience, and male partners had an integral role in womens initiation.

Condom migration resulting from circumcision, microbicides and vaccines: brief review and methodological considerations.

OBJECTIVE To provide an updated review of condom migration as a means of highlighting methodological issues for future studies of this behavioural issue. METHODS Electronic searches of PubMed, MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were carried out in October 2010 and updated in January 2011 for English-language articles published from 1994 onward. RESULTS Evidence addressing condom migration from microbicides and vaccines is vastly underdeveloped, simply because these products are still experimental. In contrast, the more advanced evidence regarding male circumcision is hopeful because it suggests that migration may not be an overwhelming issue. Nonetheless, the entire body of empirical evidence on this question could be substantially expanded and improved. CONCLUSION Until stronger evidence suggests that condom migration is unlikely, it is important to be mindful of the potential for condom migration to occur in response to biomedical interventions (circumcision, microbicides and vaccines).