Opioid initiation and injection transition in rural northern New England: A mixed-methods approach

Abstract

Background: In rural northern New England, located in the northeastern United States, the overdose epidemic has accelerated with the introduction of fentanyl. Opioid initiation and transition to opioid injection have been studied in urban settings. Little is known about opioid initiation and transition to injection drug use in rural northern New England. Methods: This mixed-methods study characterized opioid use and drug injection in 11 rural counties in Massachusetts, Vermont, and New Hampshire between 2018 and 2019. People who use drugs completed audio computer-assisted self-interview surveys on substance use and risk behaviors (n = 589) and shared personal narratives through in-depth interviews (n = 22). The objective of the current study is to describe initiation of opioid use and drug injection in rural northern New England. Results: Median age of first injection was 22 years (interquartile range 18–28 years). Key themes from in-depth interviews that led to initiating drug injection included normalization of drug use in families and communities, experiencing trauma, and abrupt discontinuation of an opioid prescription. Other factors that led to a transition to injecting included lower cost, increased effect/ rush, greater availability of heroin/ fentanyl, and faster relief of withdrawal symptoms with injection. Conclusions: Trauma, normalization of drug use, over-prescribing of opioids, and abrupt discontinuation challenge people who use drugs in rural northern New England communities. Inadequate opioid tapering may increase transition to non-prescribed drug use. The extent and severity of traumatic experiences described highlights the importance of enhancing trauma-informed care in rural areas.

Prescription opioid treatment for non-cancer pain and initiation of injection drug use: large retrospective cohort study

“…Our findings could have implications for strategies to prevent the initiation of injection drug use (eg, more judicious opioid prescribing), but should not be used as a reason to support involuntary tapering or discontinuation of prescription opioid treatment. Abrupt discontinuation could lead to some individuals to access the increasingly dangerous illicit drug market,23272843 and could explain some of the initiations of injection drug use in our analysis. Inadequately managed pain and denial of pain drug treatments have been identified as risk factors for illicit drug use, particularly among people with history of substance use 294344.…”

“…17 18 19 20 Further, qualitative studies suggest that prescription opioids can facilitate initiation of heroin or injection drug use, and these transitions can be motivated by increasing tolerance, relief of pain or withdrawal, desire for a better high, or sudden reduced access to opioid drug treatments. 21 22 23 24 25 Recent initiatives to promote appropriate prescription opioid use have raised concerns related to involuntary tapering or discontinuation and subsequent transitions to the illicit drug market to manage pain or withdrawal. 26 These concerns are supported by longitudinal studies identifying a heightened risk of harms after discontinuation of opioid treatment.…”

“…Individuals on long term opioid treatment tend to have a higher prevalence of potential risk factors for illicit or injection drug use, including chronic pain, lower socioeconomic status, mental health issues, and substance use 17181920. Further, qualitative studies suggest that prescription opioids can facilitate initiation of heroin or injection drug use, and these transitions can be motivated by increasing tolerance, relief of pain or withdrawal, desire for a better high, or sudden reduced access to opioid drug treatments 2122232425. Recent initiatives to promote appropriate prescription opioid use have raised concerns related to involuntary tapering or discontinuation and subsequent transitions to the illicit drug market to manage pain or withdrawal 26.…”

Kratom Use in the US: Both a Regional Phenomenon and a White Middle-Class Phenomenon? Evidence From NSDUH 2019 and an Online Convenience Sample

“…Given the high prevalence of prescription opioid misuse, poor psychiatric (Snell-Rood and Carpenter-Song, 2018) and physical health (including high rates of chronic pain) (Meit et al, 2017), and the difficulty in obtaining MOUD in rural areas (Sexton et al, 2008;Prunuske et al, 2014;Woolf et al, 2019;Monnat, 2020), it is possible that kratom use might be more prevalent in rural counties than in urban-metro counties. Although heroin use is increasing in many rural communities that had elevated rates of opioid prescribing (Nolte et al, 2020;Schnell et al, 2020;Hedegaard and Spencer, 2021;Strickland et al, 2021), kratom might be more accessible or more attractive than heroin to people whose sole prior opioid use had involved prescribable pills. To date, kratom use has not been well characterized in terms of rural/suburban/urban differences.…”

Association Between Prescription Opioid Therapy for Noncancer Pain and Hepatitis C Virus Seroconversion

“… 10 Although these associations may not be causal, qualitative studies suggest that some people attribute their initiation of heroin/injection drug use to prior medical or nonmedical prescription opioid use. 15 , 16 , 17 , 18 , 19 In particular, sudden discontinuation of prescription opioid therapy, potentially owing to more stringent policies and guidelines, may lead some individuals to initiate heroin/injection drug use and inadvertently increase the risk of harm. 18 , 20 There is also concern that the introduction of tamper-resistant formulations may have had a similar effect.…”