In the August/September issue of the Addiction Treatment Forum newsletter we discussed a review article, “Long-Term Course of Opioid Addiction,” published in the Harvard Review of Psychiatry. The article highlighted recent research suggesting that the profiles of opioid users (e.g., sociodemographics, other drug use, and services used) vary, according to the type of opioid used—heroin only, prescription opioids only, or both. The authors urged using new approaches to tailoring clinical interventions when treating opioid addiction.
This issue’s research article, “Comparing Characteristics of Prescription Painkiller Misusers and Heroin Users in the United States,” does just that; it delves into the profiles of the three user groups. The study became available online in July, and will be published as a short communication in the December issue of Addictive Behaviors.
This new article takes things a step farther than the previous one: It notes that successful interventions must account for unique needs of the different user groups. Those needs are tied to characteristics of the specific opioid user group, such as age, linkage to social institutions, criminal justice involvement, and mental and physical health. Ultimately, “a one-size-fits-all approach to prevention and treatment . . . is likely to fail.”
Clearly, something must be done to tailor treatment so that it becomes comprehensive and individualized, benefiting as many patients as possible.
The new article compares characteristics of adults in three study groups comprising 10,201 adults. The data, drawn from the 2010-2013 National Survey on Drug Use and Health, are based on past-year illicit opioid use. The authors clarify users’ profiles by examining differences between the groups in key socioeconomic, demographic, medical, and psychosocial characteristics.
Selection criteria resulted in groups of dissimilar sizes:
Prescription painkiller only (P): 9,516
Heroin + prescription painkiller (HP): 506
Heroin only (H): 179
Studies have found that most people who illicitly use opioids strongly prefer prescription painkillers, believing them to be of known purity and potency, and safer and less stigmatized than heroin.
The table below lists characteristics more likely to occur in the prescription painkiller group than in those who use heroin only.
aAll differences are statistically significant.
For years the image of the heroin user (H) has been a disadvantaged, minority-group, low-income young man from the city streets. Closing in on him today is a better-educated user with a broader demographic profile and higher income—a man or woman driven to heroin in part because the local prescription painkiller supply has been cut off, or has become too expensive.
The changing picture, drawn by demographic data, underscores the fact that substance-abuse counselors need to assess each patient’s unique profile, and must then tailor counseling accordingly.
Those Who Use Heroin Only vs. Those Who Use Heroin + Prescription Painkillers
The study found fewer differences between these two heroin groups than between the two groups of single-substance users.
More likely to be in the HP group than in the H group:
—Men; those with yearly incomes of $30,000-$39,999; and those with children, a higher education level, previous emergency-department treatment, psychological distress; those who reported misuse of prescription medications (in addition to painkillers); those who reported prescription painkiller misuse or heroin use, starting in adolescence.
More likely to be in the H group than in the HP group:
—Hispanics (compared to whites); those employed in manual labor (compared to professional or white collar work).
The Three User Groups
When the authors looked at the odds that a patient would be in a specific user group, they found the characteristics below to be important. They confirmed their findings with those from other studies.
Heroin and Prescription Painkillers (HP)
- Young white males misusing other Rx medications since adolescence
- Poor mental and physical health
- Most likely to be IV drug users
- Likely to be heavy polysubstance users
- Socioeconomically disadvantaged
- Older age
- Involved with the criminal justice system
- Disconnected from social institutions
- Able to access heroin easily
Prescription Painkillers (P)
- The most economically stable
- The most connected to social institutions
- The least able to access heroin
- The least likely to have criminal justice involvement
Assessing the Groups in Terms of Treatment Challenges
HP group—People who use both types of opioids may pose the greatest treatment challenge. They generally carry a heavy burden of mental and physical disorders, visit the emergency department the most often, and tend to have a history of criminal involvement. They’re likely to have worse outcomes than patients who use heroin or prescription opioids alone. Providing them with the most effective help requires more-intensive treatment and monitoring.
The authors caution clinicians that asking patients about one type of opioid use alone isn’t enough; monitoring concurrent heroin and prescription painkiller medication is clinically warranted. “Concurrent use . . . may signal a more serious substance abuse problem with potentially worse health outcomes . . . including a greater risk of having a co-occurring mental disorder, an overdose, and/or HIV due to administering opiates intravenously.”
H group—People who use heroin only may pose a slightly lesser treatment challenge than the HP group. They tend to be the most disconnected from social institutions, the most economically disadvantaged, and most likely to live near heroin sources. They are also the least healthy, and least likely to be white. They lack the bonds to social institutions that are linked to a lower risk of substance use, and to a better clinical outcome. The authors suggest that clinicians assess whether their patients use heroin only, as this may point to “a greater degree of social isolation and disconnectedness.”
P group—People who misuse prescription painkillers only have the best prognosis. They have the strongest ties to religion, marriage, and employment, and the best mental and physical health. They are also the least likely to take part in polysubstance use. (The authors raise an interesting question for future research: does prescription painkiller misuse draw healthier patients than heroin abuse, or does painkiller misuse have less-adverse outcomes?)
A cloud hovers on the horizon, however: as restrictions on prescription painkillers have increased, many who misused these drugs have been forced to move on to heroin—a situation that could escalate.
Using Profiling Information in Intervention
The authors of the current study emphasize that “ultimately, a one-size-fits-all approach to opiate prevention and treatment is likely to fail. Interventions must account for the unique needs of different user groups.”
It’s important to remember that the authors’ analysis compares groups of people. Results for individual patients will differ in some cases from the group results. The analysis provides only guidelines and suggestions for understanding individual patients and their specific treatment needs.
Limitations of the Study
The authors cite several methodological limitations of their study. First, the cross-sectional data do not allow inferences about why some people become involved in a particular type of substance abuse. Second, self-reports may entail recall bias, under-reporting, or both. Third, given the current dynamics, the HP group may consist of painkiller users “transitioning” to heroin use. The authors recommend future longitudinal studies that gather data on individuals’ heroin and prescription painkiller use, over time.
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Rigg KK, Monnat SM. Comparing characteristics of prescription painkiller misusers and heroin users in the United States [Epub ahead of print July 26, 2015]. Addict Behav. 2015; Dec. 51:106-112. doi: 10.1016/j.addbeh.2015.07.013. PMID:26253938. PMCID: PMC4558364 (available 12-01-2015).
Hser Y, Evans E, Grella C, Ling W, Anglin D. Long-term course of opioid addiction. Harv Rev Psychiatry. 2015;Mar-Apr;23(2):76-89. doi:1097/HRP.0000000000000052. PMID:25747921.
Jones CM, Logan J, Gladden RM, Bohm MK. Vital Signs: Demographic and substance use trends among heroin users—United States, 2002-2013. MMWR Weekly. 2015; July 10. 64(26);719-725.
Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-49, HHS Publication No. (SMA) 14-4887. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. http://www.samhsa.gov/data/sites/default/files/NSDUHresults2012/NSDUHresults2012.pdf. Accessed November 28, 2015