Trends in non-medical prescription opioid and heroin co-use and medication assisted treatment utilization Open Access

Mital, Sasha (Spring 2018)

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Introduction: The rate of opioid-related overdoses more than quadrupled in the United States from 1999 to 2016. In response to the opioid epidemic, interventions emphasized reducing opioid availability rather than expanding access to medication-assisted treatment (MAT), the most effective treatment for problem opioid use. Evidence demonstrates that non-medical prescription opioid (NMPO)-only users transitioned to heroin and subsequent co-use of both opioids, which is associated with increased risk of morbidity and overdose. To better understand and inform a response to this phenomenon, this dissertation aims to 1) quantify and describe trends in co-use, 2) explore multilevel factors related to transition, and 3) examine corresponding trends in MAT enrollment and factors related to MAT completion.


Methods: We used data from the 2003-2014 National Surveys on Drug Use and Health and the 2004-2015 Treatment Episodes Datasets. Informed by trend theory, we examined trends in opioid use overall and in co-use by demographics, substance use behaviors, and mental health characteristics. We also explored the multilevel relationships between transition and access to healthcare, NMPO source, perceived opioid availability, and perceived risk of use according to the socioecological model. Guided by Andersen’s Behavioral Model of Health Services, we assessed trends in MAT admissions and correlates of treatment completion by opioid use type including access to health care and demographics.


Results: While the prevalence of all opioid use decreased, co-use increased substantially. The highest prevalence of co-use was among those who lacked health insurance, were unemployed, had psychological distress, and used illicit non-opioids in the past year. These characteristics were also associated with increased risk of transition, along with earlier age of NMPO initiation, an illicit NMPO source relative to a familial source, and a lower perceived risk of trying heroin. The frequency of MAT admissions increased over time but the proportion of those enrolled for co-use remained stable. Treatment completion was less likely among co-users relative to heroin-only users. Referral source was the strongest predictor of treatment completion for co-use, while the relationship between immediate admission and treatment completion was strongest for heroin-only use, indicating differences by opioid use type.


Conclusions: Findings highlight the importance of subgroup-specific efforts to investigate and address recent shifts in opioid use and lack of treatment. Taken together, they underscore the need for targeted prevention and response interventions reaching those at risk of transition, co-users, and subgroups with disproportionately low MAT admission and completion rates.


Table of Contents


Table of Contents


Chapter 1: Introduction 1


1.            The link between non-medical prescription opioid and heroin use              1


2.            Highly dynamic patterns of opioid use    3


3.            Research gaps and current research        10


4.            References         17


Chapter 2: Trends in non-medical prescription opioids and heroin co-use among adults, 2003-2014             33


1.            Background        34


2.            Methods             37


3.            Results 39


4.            Discussion           42


5.            Tables and Figures           46


Table 1. Current demographic, substance use and mental health characteristics of adult opioid users, by opioid use type—NSDUH 2013-2014              46


Figure 1. Prevalence trends of opioid use, overall and by opioid use type among all opioid users, adjusted for sex, age, race, rurality and employment status—NSDUH 2003-2014             47


Table 2. Stratified trends in prevalence of co-use—NSDUH, 2003-2014     48


Figure 2. Change in prevalence of co-use from 2003-2004 to 2013-2014, stratified trends compared to overall trend                49


6.            References         52


Chapter 3: Factors related to transition from non-medical prescription opioid use to heroin initiation and co-use of both opioids among adults, 2012-2014    58


1.            Background        59


2.            Methods             63


3.            Results 67


4.            Discussion           68


5.            Tables   75


Table 1. Descriptive statistics of current (past year) NMPO users—NSDUH 2012-2014, N=7,045     76


Table 2. Factors associated with transition in multivariable regression—NSDUH 2012-2014, N=7,045          77


6.            References         78


Chapter 4: Use of outpatient medication-assisted treatment by opioid use type: trends in admissions (2004-2015) and factors related to treatment completion 86


1.            Background        88


2. Methods        92


3.            Results 97


4.            Discussion           100


5.            Tables and Figures           107


Figure 1. MAT admissions overall and by problem opioid use type─2004-2015, TEDS-A     107


Table 1. Problem opioid use type, demographic, and access to healthcare characteristics among MAT admissions—2004-2015, TEDS-A          108


Table 2. Demographic and access to health care characteristics among MAT admissions, and differences by opiate use type—TEDS-A, 2015, N=44,086   109


Table 3. Association of opioid use type and demographics with successful MAT completion—2013 TEDS-D, N=13,883                110


Table 4. Association between access to healthcare and successful MAT completion, stratified by opioid use type—2013 TEDS-D, N=13,883 111


6.            References         112


Chapter 5: Summary and conclusions      124


1.            Rationale for research    124


2.            Summary of aims and main findings         125


3.            Practical implications      127


4.            Strengths, limitations and implications for future research            130


5.            Overall contributions of the research      132


6.            References         133




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