Sources of pharmaceutical opioids for non-medical use among young adults.

The study uses qualitative and quantitative data to describe sources of pain pills for illicit use among young adult (18- to 23-year-old) users. Respondent-driven sampling was used to recruit 383 individuals in the Columbus, Ohio, area. The sample was almost 50% Caucasian and about 55% male. Qualitative interview participants (n = 45) were selected from the larger sample. Qualitative data suggest that pharmaceutical opioid availability was so pervasive that most individuals did not have to venture outside of their immediate social networks to find people who sold or shared pills. Participants emphasized differences between those who are actively involved in obtaining pills and those who play a more passive role. Active involvement was described as going out searching for pills and paying money to obtain them. In contrast, passive role included obtaining pills when somebody offered or shared them free of charge. Multiple logistic regression analysis indicates that a more active role in obtaining pharmaceutical opioids was related to being White, more frequent use of pharmaceutical opioids, extended-release oxycodone use, and using pharmaceutical opioids to get high, as opposed to self-treating a health problem. The study results can help inform drug use epidemiology, interventions, and policy.

Latent class analysis of non-opioid dependent illegal pharmaceutical opioid users in Ohio.

BACKGROUND: Increases in non-medical use of pharmaceutical opioids in the U.S. have resulted in increases in opioid dependence and unintentional overdose deaths. We characterize heterogeneity in opioid use patterns among a community-based sample of 18-23 year-olds who use non-medical pharmaceutical opioids, yet are not opioid dependent. METHODS: Respondent-driven sampling recruited 390 participants. Latent class analysis stratified by racial/ethnic group identified subgroups of non-medical opioid users based on: six-month frequency of use; number of opioid disorder criteria; oral vs. non-oral administration; number of types of opioids used; use of CNS depressants while under using opioids; and reason for opioid use. Multinomial logistic regression estimated the significance of covariates in predicting class membership. RESULTS: Within whites and non-white groups, three classes emerged that were, generally, hierarchically ordered with respect to negative characteristics associated with non-medical opioid use. Within each group, the class with the least negative characteristics also had the highest proportion of individuals who use opioids only to self-medicate a health problem. Within each group's three classes, a larger proportion who had ≥ 2 opioid abuse and dependence disorder criteria always coincided with a larger proportion who use opioids ≥ 3 days per week, a larger proportion who used CNS depressants while under the influence of opioids, and a smaller proportion who used opioids only to self-medicate. CONCLUSION: Differences in patterns of opioid use within each racial/ethnic group of young people who are not opioid dependent suggest the need for tailored interventions designed to reduce the risk of transition to opioid dependence.

Risky sex in rural America: longitudinal changes in a community-based cohort of methamphetamine and cocaine users.

BACKGROUND AND OBJECTIVES: This study examined the longitudinal associations between stimulant use and sexual behaviors. METHODS: Data are from a 3-year community-based study of 710 rural stimulant users. Past 30-day crack cocaine, powder cocaine, and methamphetamine use and sexual behaviors (any sex, inconsistent condom use, and multiple sexual partners) were assessed through in-person interviews every 6 months. RESULTS: GEE analyses revealed that the odds of having sex remained steady over time, with crack cocaine and methamphetamine use positively associated with having sex. The odds of multiple sexual partners declined, but the odds of inconsistent condom use remained steady over time. Crack cocaine use was positively associated with multiple sexual partners, whereas powder cocaine use was negatively associated with inconsistent condom use. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Many rural stimulant users could potentially benefit from safe sex educational programs. Such efforts could reduce the incidence of HIV and other STIs in rural America.

PREDOSE: a semantic web platform for drug abuse epidemiology using social media.

OBJECTIVES: The role of social media in biomedical knowledge mining, including clinical, medical and healthcare informatics, prescription drug abuse epidemiology and drug pharmacology, has become increasingly significant in recent years. Social media offers opportunities for people to share opinions and experiences freely in online communities, which may contribute information beyond the knowledge of domain professionals. This paper describes the development of a novel semantic web platform called PREDOSE (PREscription Drug abuse Online Surveillance and Epidemiology), which is designed to facilitate the epidemiologic study of prescription (and related) drug abuse practices using social media. PREDOSE uses web forum posts and domain knowledge, modeled in a manually created Drug Abuse Ontology (DAO--pronounced dow), to facilitate the extraction of semantic information from User Generated Content (UGC), through combination of lexical, pattern-based and semantics-based techniques. In a previous study, PREDOSE was used to obtain the datasets from which new knowledge in drug abuse research was derived. Here, we report on various platform enhancements, including an updated DAO, new components for relationship and triple extraction, and tools for content analysis, trend detection and emerging patterns exploration, which enhance the capabilities of the PREDOSE platform. Given these enhancements, PREDOSE is now more equipped to impact drug abuse research by alleviating traditional labor-intensive content analysis tasks. METHODS: Using custom web crawlers that scrape UGC from publicly available web forums, PREDOSE first automates the collection of web-based social media content for subsequent semantic annotation. The annotation scheme is modeled in the DAO, and includes domain specific knowledge such as prescription (and related) drugs, methods of preparation, side effects, and routes of administration. The DAO is also used to help recognize three types of data, namely: (1) entities, (2) relationships and (3) triples. PREDOSE then uses a combination of lexical and semantic-based techniques to extract entities and relationships from the scraped content, and a top-down approach for triple extraction that uses patterns expressed in the DAO. In addition, PREDOSE uses publicly available lexicons to identify initial sentiment expressions in text, and then a probabilistic optimization algorithm (from related research) to extract the final sentiment expressions. Together, these techniques enable the capture of fine-grained semantic information, which facilitate search, trend analysis and overall content analysis using social media on prescription drug abuse. Moreover, extracted data are also made available to domain experts for the creation of training and test sets for use in evaluation and refinements in information extraction techniques. RESULTS: A recent evaluation of the information extraction techniques applied in the PREDOSE platform indicates 85% precision and 72% recall in entity identification, on a manually created gold standard dataset. In another study, PREDOSE achieved 36% precision in relationship identification and 33% precision in triple extraction, through manual evaluation by domain experts. Given the complexity of the relationship and triple extraction tasks and the abstruse nature of social media texts, we interpret these as favorable initial results. Extracted semantic information is currently in use in an online discovery support system, by prescription drug abuse researchers at the Center for Interventions, Treatment and Addictions Research (CITAR) at Wright State University. CONCLUSION: A comprehensive platform for entity, relationship, triple and sentiment extraction from such abstruse texts has never been developed for drug abuse research. PREDOSE has already demonstrated the importance of mining social media by providing data from which new findings in drug abuse research were uncovered. Given the recent platform enhancements, including the refined DAO, components for relationship and triple extraction, and tools for content, trend and emerging pattern analysis, it is expected that PREDOSE will play a significant role in advancing drug abuse epidemiology in future.

"I just wanted to tell you that loperamide WILL WORK": a web-based study of extra-medical use of loperamide.

AIMS: Many websites provide a means for individuals to share their experiences and knowledge about different drugs. Such User-Generated Content (UGC) can be a rich data source to study emerging drug use practices and trends. This study examined UGC on extra-medical use of loperamide among illicit opioid users. METHODS: A website that allows for the free discussion of illicit drugs and is accessible for public viewing was selected for analysis. Web-forum posts were retrieved using web crawlers and retained in a local text database. The database was queried to extract posts with a mention of loperamide and relevant brand/slang terms. Over 1290 posts were identified. A random sample of 258 posts was coded using NVivo to identify intent, dosage, and side-effects of loperamide use. RESULTS: There has been an increase in discussions related to loperamide's use by non-medical opioid users, especially in 2010-2011 Loperamide was primarily discussed as a remedy to alleviate a broad range of opioid withdrawal symptoms, and was sometimes referred to as "poor man's" methadone. Typical doses ranged 70-100mg per day, much higher than an indicated daily dose of 16mg. CONCLUSIONS: This study suggests that loperamide is being used extra-medically to self-treat opioid withdrawal symptoms. There is a growing demand among people who are opioid dependent for drugs to control withdrawal symptoms, and loperamide appears to fit that role. The study also highlights the potential of the Web as a "leading edge" data source in identifying emerging drug use practices.

Surveying teens in school to assess the prevalence of problematic drug use.

BACKGROUND: Illicit drug use by school-aged teens can adversely affect their health and academic achievement. This study used a survey administered in schools to assess the prevalence of problematic drug use among teenagers in a Midwestern community. METHODS: Self-report data were collected from 11th- and 12th-grade students (N = 3974) in 16 school districts in the Dayton, Ohio, area. Students responded to a drug use survey that also included CRAFFT, a brief substance abuse screening instrument. Binomial and zero-inflated Poisson regressions were used to examine the association between CRAFFT scores and drug use practices, including abstinence. RESULTS: More than one third of students had CRAFFT scores suggestive of problematic use. Of these, 14.1% had scores suggesting drug dependence. Although alcohol, marijuana, and tobacco were the drugs most commonly used, an array of other drugs including opioids, benzodiazepines, stimulants, hallucinogens, and dextromethorphan were also commonly used. Higher CRAFFT scores were associated with a greater number of drugs used (p < .0001). Proportionately more 12th graders than 11th graders had CRAFFT scores indicating problems (p < .0001). Among 12th graders, boys were more likely than girls to have CRAFFT scores indicating dependence (p = .01). CONCLUSIONS: The results suggest that problematic drug use among high school students is more prevalent than has been recognized previously. CRAFFT can be used easily to assess the prevalence of problematic drug use among teenagers in school settings. CRAFFT results can also inform prevention and intervention activities, particularly if the CRAFFT instrument is paired with a drug use survey.

Physical victimization of rural methamphetamine and cocaine users.

Substance use and physical violence often coincide, but little has been published on the correlates associated with receipt of partner versus nonpartner physical violence for rural users of methamphetamine and/or cocaine. In this study, participants' substance use, depression and past-year physical victimization were assessed. In separate logistic regression models, received partner violence in females was associated with age; alcohol, cocaine, and methamphetamine abuse/dependence; and number of drugs used in the past 6 months. In males, received nonpartner violence was associated with age, cocaine abuse/dependence, and being Caucasian. Findings suggest a relationship between stimulant use and received violence among rural substance users and a need for victimization screenings in settings where such individuals seek health care.

"I'm not afraid of those ones just 'cause they've been prescribed": perceptions of risk among illicit users of pharmaceutical opioids.

BACKGROUND: There has been a rise in the illicit use of pharmaceutical opioids ("pain pills") in the United States. Conducted with young adult non-medical users of pharmaceutical opioids, this study uses qualitative methods and cultural consensus analysis to describe risk perceptions associated with pharmaceutical opioids and to determine patterns of cultural sharing and intra-cultural variation of these views. METHODS: The qualitative sub-sample (n=47) was selected from a larger sample of 396 young adults (18-23 years old), who were participating in a natural history study of illicit pharmaceutical opioid use. Qualitative life history interviews, drug ranking task, and cultural consensus analysis were used to elicit participant views about risks and harms associated with pain pills and other drugs, as well as alcohol and tobacco. RESULTS: Cultural consensus analysis revealed that the participants shared a single cultural model of drug risks, but the level of agreement decreased with the increasing range of drugs ever used. Further, those with more extensive drug use histories differed from less "experienced" users in their views about OxyContin and some other drugs. Overall, pain pills were viewed as addicting and potentially deadly substances, but these properties were linked to the patterns and methods of use, as well as characteristics of an individual user. Further, risks associated with pharmaceutical opioids were further curtailed because they "came from the doctor," and thus had a legitimate aspect to their use. CONCLUSIONS: This study highlights potential problems with universal approaches to substance use prevention and intervention among young people since such approaches ignore the fact that substance use education messages may be experienced differently depending on an individual's drug use history and his/her perceptions of drug risks. Findings reported here may be useful in the development of prevention and intervention programs aimed at reducing the harm associated with illicit use of pain pills.

Respondent-driven sampling to recruit young adult non-medical users of pharmaceutical opioids: problems and solutions.

Respondent-driven sampling (RDS) has been promoted as a superior method in recruiting hard-to-reach and hidden populations. Although its application has expanded enormously, there remains a need for empirical data evaluating the performance of RDS in different settings. This study describes the application of RDS to recruit a community sample (N=396) of young adults (18-23 years old) into a natural history study of non-medical pharmaceutical opioid use. Since recruitment targeted non-dependent pharmaceutical opioid users, and applied other eligibility restrictions, several modifications had to be made to make RDS work with this narrowly defined target population. RDS recruitment was less efficient than expected, and produced greater numbers of African American recruits than anticipated. Although the sampling quota was met, sample analysis revealed a lack of equilibrium in terms of ethnic composition and very strong in-group recruitment tendencies among White and African American respondents. This study contributes potentially helpful insights into the strengths and limitations of using RDS which may benefit future studies.

Illicit use of buprenorphine in a community sample of young adult non-medical users of pharmaceutical opioids.

BACKGROUND: There is growing evidence about illicit use of buprenorphine in the U.S. The study aims to: (1) identify prevalence and predictors of illicit buprenorphine use in a community sample of 396 young adult (18-23 years old) non-medical users of pharmaceutical opioids and (2) describe knowledge, attitudes and behaviors linked to illicit buprenorphine use as reported by a qualitative sub-sample (n=51). METHODS: Participants were recruited using respondent-driven sampling. Qualitative interview participants were selected from the larger sample. The sample (n=396) was 54% male and 50% white; 7.8% reported lifetime illicit use of buprenorphine. RESULTS: Logistic regression analysis results indicate that white ethnicity, intranasal inhalation of pharmaceutical opioids, symptoms of opioid dependence, and a greater number of pharmaceutical opioids used in lifetime were statistically significant predictors of illicit buprenorphine use. Qualitative interviews revealed that buprenorphine was more commonly used by more experienced users who were introduced to it by their "junkie friends." Those who used buprenorphine to self-medicate withdrawal referred to it as a "miracle pill." When used to get high, reported experiences ranged from "the best high ever" to "puking for days." Participants reported using buprenorphine/naloxone orally or by intranasal inhalation. Injection of buprenorphine without naloxone was also reported. CONCLUSION: Our findings suggest that illicit buprenorphine use is gaining ground primarily among whites and those who are more advanced in their drug use careers. Continued monitoring is needed to better understand evolving patterns and trends of illicit buprenorphine use.

Characteristics of rural crack and powder cocaine use: gender and other correlates.

BACKGROUND: Little is known about the relationship of gender with cocaine use in rural areas. This study describes these relationships among stimulant users residing in rural areas of Arkansas, Kentucky, and Ohio. OBJECTIVES: Understanding the characteristics of crack and powder cocaine users in rural areas may help inform prevention, education, and treatment efforts to address rural stimulant use. METHODS: Participants were 690 stimulant users, including 274 (38.6%) females, residing in nine rural counties. Cocaine use was measured by self-report of cocaine use, frequency of use, age of first use, and cocaine abuse/dependence. Powder cocaine use was reported by 49% of this sample of stimulant users and 59% reported using crack cocaine. FINDINGS: Differing use patterns emerged for female and male cocaine users in this rural sample; females began using alcohol, marijuana, and cocaine at later ages than males but there were no gender differences in current powder cocaine use. Females reported more frequent use of crack cocaine and more cocaine abuse/dependence than males, and in regression analyses, female crack cocaine users had 1.8 times greater odds of reporting frequent crack use than male crack users. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: These findings suggest differing profiles and patterns of cocaine use for male and female users in rural areas, supporting previous findings in urban areas of gender-based vulnerability to negative consequences of cocaine use. Further research on cocaine use in rural areas can provide insights into gender differences that can inform development and refinement of effective interventions in rural communities.

Criminality Among Rural Stimulant Users in the United States.

Despite the increase in media attention on "meth cooking" in rural areas of the United States, little is known about rural stimulant use, particularly the criminality associated with stimulant use. Data were collected from community stimulant users in rural Ohio, Arkansas, and Kentucky (N=709). Findings from three logistic regression models indicate that younger stimulant users (x =32.55, SD = 10.35), those with more convictions, and those who used crack frequently were significantly more likely to have been arrested for committing a substance-related crime, a property crime, or another crime in the 6-months before entering the study. Implications include the need for longitudinal studies to further understand rural stimulant use as well as increasing community and corrections-based drug abuse prevention and treatment interventions for stimulant users who live in rural areas.

Rural drug users: factors associated with substance abuse treatment utilization.

The purpose of this study is to use a modified version of Andersen's Behavioral Model of Health Services Use to identify the correlates of the number of substance abuse treatment episodes received by rural drug users. Data were collected from face-to-face interviews with 711 drug users in rural areas of Ohio, Arkansas, and Kentucky. Descriptive analyses examine rural drug users' substance use histories and retrospective substance abuse treatment service utilization patterns. A negative binomial regression model indicated that selected predisposing, historical health, and enabling factors were significantly associated with the utilization of substance abuse treatment among rural drug users. Despite high levels of recent and lifetime self-reported substance use among these rural drug users, treatment services were underutilized. Future studies are needed to examine the impact of the health care system and characteristics of the external environment associated with rural substance abuse treatment in order to increase utilization among drug users.

Predictors of substance abuse treatment entry among rural illicit stimulant users in Ohio, Arkansas, and Kentucky.

Illicit drug use in the rural United States is increasingly common, yet little is known about drug users' treatment-seeking behaviors. This study identifies predictors of substance abuse treatment entry over 24 months among 710 illicit stimulant users in rural areas of Ohio, Arkansas, and Kentucky. Active users of powdered cocaine, crack cocaine, and/or methamphetamine (MA) were recruited using respondent-driven sampling. Participants completed structured interviews at baseline and follow-up questionnaires every 6 months for 24 months. Data were analyzed using the Cox proportional hazards model. The paper is informed by the Anderson-Newman Model. Overall, 18.7% of the sample entered treatment. Ohio or Kentucky residence, perceived need for substance abuse treatment, higher Addiction Severity Index (ASI) legal problem composite scores, prior substance abuse treatment, and tranquilizer use were positively associated with treatment entry. Nondaily crack cocaine users and marijuana users were less likely to enter treatment. The findings can help inform rural substance abuse treatment program development and outreach.

Longitudinal relationship between psychological distress and multiple substance use: results from a three-year multisite natural-history study of rural stimulant users.

OBJECTIVE: Substance use is associated with poor mental health, but little is known regarding how use of multiple substances is associated with mental health, particularly longitudinally, in community studies. This article examines this issue in a large (N = 710), natural-history study of rural stimulant (cocaine and/or methamphetamine) users in three states. METHOD: Respondent-driven sampling recruited recent (past-30-day) stimulant users in three counties each in Arkansas, Kentucky, and Ohio. Participants were interviewed every 6 months for 3 years. Mental health was measured by the Brief Symptom Inventory, and prior 6 months' substance use was measured for 17 possible substances. Data analysis used generalized estimating equations for longitudinal data with the Global Severity Index of the Brief Symptom Inventory as the dependent variable at each interview and substance use as predictor variables measured by number of substances used in the past 6 months and, separately, the 17 individual substances, adjusting for use of substance-use treatment, demographics, and recruitment site. RESULTS: On average, both Global Severity Index score and use of many substances declined over the course of study. Global Severity Index score was significantly associated with (a) greater number of substances used in the past 6 months (p < .0001) and (b) use of crack cocaine, methamphetamine, and nonprescription use of prescription painkillers and tranquilizers. CONCLUSIONS: Multiple and specific substances appear to incrementally increase psychological distress. Users of cocaine and methamphetamine are present in rural areas; these associations with poor psychological health raise concerns regarding availability of local treatment services for individuals with mental-health problems, as well as substance abuse.

Examining factorial structure and measurement invariance of the Brief Symptom Inventory (BSI)-18 among drug users.

The purpose of this study is to examine the factorial structure of the Brief Symptom Inventory 18 (BSI-18) and test its measurement invariance among different drug using populations. A total sample of 710 drug users was recruited using respondent-drive sampling (RDS) from three states: Ohio (n=248), Arkansas (n=237), and Kentucky (n=225). The results of confirmatory factor analysis (CFA) show: 1) the BSI-18 has a three-factor structure (somatization, depression, and anxiety) with an underlying second-order factor (global severity index of distress); and 2) its factorial structure and metric (factor loadings) are invariant across populations under study. However, the scalars (intercepts) of the BSI-18 items are not invariant, and the means of the latent factors also varied across populations. Our findings provide evidence of a valid factorial structure of the BSI-18 that can be readily applied to studying drug using populations.

Predictors of depressive symptomatology among rural stimulant users.

This study examined sociodemographic and drug-related predictors of depressive symptoms among a rural, multistate sample of not-in-treatment stimulant drug users (n=710). Participants were recruited using respondent-driven sampling in Ohio, Arkansas, and Kentucky. The Patient Health Questionnaire (PHQ-9) was used to measure symptoms of depression. Moderate to severe depressive symptomatology was reported by 43.0% of the sample. Cumulative logistic regression analysis showed that daily and nondaily crack use as well as the daily use of cocaine HCl increased the odds of depressive symptoms. Methamphetamine use had no significant association with depression. The daily use of marijuana, the illicit use of tranquilizers, light/moderate cigarette smoking, and injection drug use also increased the risk of depressive symptoms. Living in Kentucky or Ohio (compared to Arkansas), having unstable living arrangements, and being White, female, and older were related to higher odds of depressive symptoms. These results suggest that a host of drug and nondrug factors need to be considered when addressing depressive symptoms in stimulant users.

Longitudinal changes in drug use severity and physical health-related quality of life among untreated stimulant users.

The primary objective of this study was to investigate whether drug use severity is associated with physical health-related quality of life (HRQL) over time. Data are from a longitudinal, multi-state, natural history community study of users of cocaine and/or methamphetamine who were interviewed at 6-month intervals over 2 years with a 79% follow-up participation rate. Physical HRQL was assessed with the physical component summary (PCS) of the SF-8 Health Survey and drug, alcohol, and psychiatric severity were all assessed with the Addiction Severity Index (ASI). Random coefficient regression analyses were conducted to test for longitudinal associations between the independent variables and SF-8 PCS scores. Reductions in drug use severity over time were accompanied by only minor improvements in SF-8 PCS scores, underscoring the potential long-term harm of illicit drug use on physical health. Greater psychiatric severity was strongly associated with lower SF-8 PCS scores, suggesting that clinical attention to mental health issues could potentially lead to improvements in perceived physical health as well as among stimulant users.

Prescription opiate misuse among rural stimulant users in a multistate community-based study.

OBJECTIVES: The purpose of the current analysis was to examine the factors associated with prescription opiate misuse among stimulant users from rural counties in Arkansas, Kentucky, and Ohio (N = 714). METHODS: Multiple logistic regression was utilized to determine the independent correlates of recent (prior 6 months) prescription opiate misuse. RESULTS: More than half of participants (53.2%) reported prescription opiate misuse in the previous 6 months. Other drug use (heroin, cocaine, methamphetamine, and marijuana) and anxiety (Adjusted Odds Ratio: 2.04, 95% Confidence Interval: 1.60, 2.59) were independently associated with prescription opiate misuse. Chronic pain and other health indicators were not associated with prescription opiate misuse after adjustment for covariates. CONCLUSIONS: Results indicate that illicit drug involvement and psychiatric symptoms may be driving the high rates of prescription opiate misuse among rural stimulant users. These findings have implications for the provision of treatment in resource-deprived rural areas.

Among long-term crack smokers, who avoids and who succumbs to cocaine addiction?

Crack cocaine is a highly addictive drug. To learn more about crack addiction, long-term crack smokers who had never met the DSM-IV criteria for lifetime cocaine dependence were compared with those who had. The study sample consisted of crack users (n=172) from the Dayton, Ohio, area who were interviewed periodically over 8 years. Data were collected on a range of variables including age of crack initiation, frequency of recent use, and lifetime cocaine dependence. Cocaine dependence was common with 62.8% of the sample having experienced it. There were no statistically significant differences between dependent and non-dependent users for age of crack initiation or frequency of crack use. In terms of sociodemographics, only race/ethnicity was significant, with proportionally fewer African-Americans than whites meeting the criteria for cocaine dependence. Controlling for sociodemographics, partial correlation analysis showed positive, statistically significant relationships between lifetime cocaine dependence and anti-social personality disorder, attention deficit/hyperactivity disorder, and lifetime dependence on alcohol, cannabis, amphetamine, sedative-hypnotics, and opioids. These results highlight the importance addressing race/ethnicity and comorbid disorders when developing, implementing, and evaluating interventions targeting people who use crack cocaine. Additional research is needed to better understand the role of race/ethnicity in the development of cocaine dependence resulting from crack use.