Jennifer R. Havens

Understanding the Rural–Urban Differences in Nonmedical Prescription Opioid Use and Abuse in the United States

Nonmedical prescription opioid misuse remains a growing public problem in need of action and is concentrated in areas of US states with large rural populations such as Kentucky, West Virginia, Alaska, and Oklahoma. We developed hypotheses regarding the influence of 4 factors: (1) greater opioid prescription in rural areas, creating availability from which illegal markets can arise; (2) an out-migration of young adults; (3) greater rural social and kinship network connections, which may facilitate drug diversion and distribution; and (4) economic stressors that may create vulnerability to drug use more generally. A systematic consideration of the contexts that create differences in availability, access, and preferences is critical to understanding how drug use context varies across geography.

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.

Screening for depressive symptoms among HCV-infected injection drug users: Examination of the utility of the CES-D and the Beck Depression Inventory

The prevalence of depression is high among injection drug users (IDUs) and among those infected with the hepatitis C virus (HCV). Moreover, one of the drugs used in the standard treatment for HCV infection (interferon) has been known to exacerbate, underlying psychiatric disorders such as depression and has been associated with the development of major, depressive disorder among HCV-infected patients. For these reasons, the most recent National Institutes of Health consensus statement on the management of HCV infection recommends the identification and treatment of depression prior to the start of HCV treatment. This study aimed to examine the extent of current moderate/severe depressive symptoms in a cohort of HCV-infected IDUs as measured by two screening tools, the Center for Epidemiologic Studies Depression Scale (CES-D) and the Beck Depression Inventory (BDI). Subjects were participants in a multisite behavioral intervention trial among HCV-seropositive, human immunodeficiency virus-negative IDUs aged 18–35 years; the trial was designed to prevent secondary transmission of HCV and to enhance uptake of HCV treatment. Baseline data on demographics, risk behaviors, depression, alcohol use, and health care utilization were measured via audio computer-assisted self-interview. A factor analysis was conducted on each scale to examine the clustering of items used in each to measure depressive symptoms. Baseline depressive symptoms, as measured via the CES-D and the BDI, were also compared using Pearson’s correlation coefficient. Of 193 HCV-infected individuals enrolled to date, 75,6% were male, and 65.3% were white. Median age was 25.8 years. Factor analyses revealed that these scales measured depression differently; a distinct somatic component was present in the BDI, but not the CES-D. Using cutoff scores of 23 for the CES-D and 19 for the BDI, 44.0% and 41.5% of the participants were identified as having moderate/severe depressive symptoms, respectively. Over half (56.0%) were identified as having depressive symptoms

Factors associated with substance use during pregnancy: results from a national sample.

OBJECTIVE To examine the prevalence and correlates of substance use during pregnancy among women in the United States. METHODS We analyzed data from pregnant (n=1800) and non-pregnant women (n=37,527) aged 15-44 years who participated in the 2002 or 2003 National Survey on Drug Use and Health, a nationally representative epidemiologic survey. Study variables included demographics, any substance use in the prior 30 days, and possible current psychopathology. Data were analyzed using weighted chi-square and multiple logistic regressions that accounted for the complex survey design. RESULTS The overall prevalence of any past month substance use during pregnancy was 25.8%; the prevalence rates of past month illicit drug, cigarette and alcohol use were 4.7%, 18.9% and 10%, respectively. Compared to the prevalence of substance use among women in their first trimester, use was significantly lower among women in their second or third trimesters. Women who reported using substances during pregnancy were significantly more likely to meet the criteria for possible current psychopathology and be White. Additionally, women who were employed, married, and in their second or third trimester compared to the first were significantly less likely to have used any substance during pregnancy, adjusting for age, ethnicity and income. CONCLUSIONS Although the prevalence of substance use among pregnant women was significantly lower than non-pregnant women, some groups of women remain vulnerable to continued use, including those who are unemployed, unmarried, and experiencing possible current psychopathology. Prevention and intervention programs aimed at high-risk populations are warranted to reduce the deleterious effects of substance use on pregnancy outcomes.

Individual and Network Factors Associated With Prevalent Hepatitis C Infection Among Rural Appalachian Injection Drug Users

OBJECTIVES We determined the factors associated with hepatitis C (HCV) infection among rural Appalachian drug users. METHODS This study included 394 injection drug users (IDUs) participating in a study of social networks and infectious disease risk in Appalachian Kentucky. Trained staff conducted HCV, HIV, and herpes simplex-2 virus (HSV-2) testing, and an interviewer-administered questionnaire measured self-reported risk behaviors and sociometric network characteristics. RESULTS The prevalence of HCV infection was 54.6% among rural IDUs. Lifetime factors independently associated with HCV infection included HSV-2, injecting for 5 or more years, posttraumatic stress disorder, injection of cocaine, and injection of prescription opioids. Recent (past-6-month) correlates of HCV infection included sharing of syringes (adjusted odds ratio = 2.24; 95% confidence interval = 1.32, 3.82) and greater levels of eigenvector centrality in the drug network. CONCLUSIONS One factor emerged that was potentially unique to rural IDUs: the association between injection of prescription opioids and HCV infection. Therefore, preventing transition to injection, especially among prescription opioid users, may curb transmission, as will increased access to opioid maintenance treatment, novel treatments for cocaine dependence, and syringe exchange.

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.

Differences in Prevalence of Prescription Opiate Misuse Among Rural and Urban Probationers

We compared the prevalence of prescription opiate misuse among 2 cohorts of felony probationers (N = 1525). Multiple logistic regression was utilized to determine the independent correlates of prescription opiate misuse among rural (n = 782) and urban (n = 743) probationers participating in an HIV-intervention study. After adjustment for differences in demographic and drug use characteristics, rural participants were almost five times more likely than their urban counterparts to have misused prescription opiates. The prevalence of prescription opiate misuse was significantly higher among the rural probationers; however, given the paucity of illicit opiates and relatively recent emergence of prescription opiates in rural areas, rural substance abuse treatment may be ill-prepared to treat prescription opiate misuse.

Individual and network factors associated with non-fatal overdose among rural Appalachian drug users

BACKGROUND Fatal overdoses involving prescription opioids have increased significantly in recent years in the United States--especially in rural areas. However, there are scant data about non-fatal overdose among rural drug users. The purpose of this study is to examine the prevalence and correlates of non-fatal overdose and witnessed overdose among rural Appalachian drug users. METHODS Rural drug users were participants in a longitudinal study of social networks and HIV transmission. An interviewer-administered questionnaire elicited information in the following domains: sociodemographic characteristics, drug use (including lifetime overdose and witnessed overdose), psychiatric disorders, HIV risk behaviors and social networks (support, drug and sex networks). Negative binomial regression was used to model the number of lifetime overdoses and witnessed overdoses. RESULTS Of the 400 participants, 28% had ever experienced a non-fatal overdose, while 58.2% had ever witnessed an overdose (fatal or non-fatal). Factors independently associated with a greater number of overdoses included having ever been in drug treatment, past 30-day injection of prescription opioids, meeting the criteria for post-traumatic stress disorder and/or antisocial personality disorder and having more members in ones support network. CONCLUSIONS Rural drug users with history of overdose were more likely to have injected with prescription opioids--which is different from urban heroin users. However, the remaining correlates of non-fatal overdose among this cohort of rural drug users were similar to those of urban heroin users, which suggests current overdose prevention strategies employed in urban settings may be effective in preventing fatal overdose in this population.

Intergenerational Transmission of Violence: the Influence of Self-Appraisals, Mental Disorders and Substance Abuse

Although research has demonstrated connections between experiencing abuse as a child and being in a violent relationship as an adult, the specific mechanisms through which this transmission occurs are unclear. The purpose of this study was to identify the relationship between certain personal factors (self-appraisals and mental/substance use disorders) and experiencing violence as an adult. Data from the National Comorbidity Survey (NCS) 1990–1992 were utilized. Respondents who reported experiencing childhood abuse or victimization and were in a current intimate partnership (N = 590) were selected for analysis. Multivariate logistic regression indicated that low self-esteem, past year PTSD, and past year alcohol dependence were significantly associated with intimate partner violence after controlling for other self-appraisals and mental disorders.