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Are painkillers the new “gateway” drug? New research says yes…

, by Emily Land

BETA is reporting from the 2017 Conference on Retroviruses and Opportunistic Infections (CROI) this week in Seattle—bringing you the latest news, updates, and research on HIV treatment and prevention.

About half of people who started injecting drugs in the years since 2005 were likely to say they were “hooked on painkillers” before they started injecting drugs, new research presented at CROI shows. This is a percentage that’s been on the rise since before 1995—when only 12% of people who started injecting drugs reported first being hooked on painkillers.

Dita Broz

Dita Broz,PhD, MPH

“Prescription opioids really started to increase in the U.S. in the mid- to late-1990s, but really started to take off in the 2000s,” researcher Dita Broz, PhD, MPH from the Centers for Disease Control, told BETA. “Misuse of prescription opioids has increased dramatically in the U.S. since the year 2000. We found that prescription opioid use prior to first injection was substantially higher among participants who began injecting during the opioid epidemic.”

Broz and colleagues analyzed data from the National HIV Behavioral Surveillance (NHBS), which surveyed people in 20 cities across the U.S. More than 7,400 people who reported injecting drugs were included in the study. This large sample size allowed the research team to compare drug use behaviors between people who started injecting during different years. They wanted to see, for instance, if there were differences in behaviors or risk factors between people who started injecting in the early 1990s compared to today.

“This is unique,” said Broz, “because others have looked at prescription opioid use before injecting, but they had smaller sample sizes and couldn’t break their samples down by year of injection initiation.”

Participants who reported painkiller use reported where they obtained their first prescription opioid (that wasn’t used for a medical reason). 31% obtained it from a doctor with a prescription; 20% obtained it from a friend, family member or other person; 20% bought it from someone; 23% reported “other/multiple sources”; and 7% reported either buying it off the internet or stealing it.

“These are commonly prescribed narcotics,” said Broz. “People have to have some way, through a prescription, to get them.” She added that it “makes sense” that many people likely obtained them for medical reasons first, then started misusing them later.

Although this study doesn’t provide information on whether the rate of injection drug use is increasing overall, Broz said that this study provides evidence that prescription opioids are “part of the trajectory to injection.”

If there’s a way to target people misusing opioids, with an intervention that prevents people from progressing to injection drug use, this could help prevent infections associated with injection drugs use like HIV and hepatitis C, she said.

“As far as I know, there’s no large-scale, coordinated effort to prevent injection in this country. There have been some peer-based behavioral interventions that have been tested in the early 1990s—but it’s been a long time. We found that the time between first opioid misuse and first drug injection was about four to five years—so there’s an opportunity here to reach people with injection prevention efforts.”

Substance use among men who have sex with men in the U.S.

A separate study, presented by Brooke Hoots, PhD, MSPH from the CDC, also used data from the National HIV Behavioral Surveillance, conducted in 20 cities across the U.S., to look at patterns of drug use over time.

They survey asked participants about meth use, cocaine use and prescription opioid use in the previous year.

Brooke Hoots

Brooke Hoots, PhD, MSPH

Rates of opioid use and meth use were similar, with about 8% of the survey sample reporting use the previous year. There were no significant changes seen over time—between the years of 2008, 2011 and 2014.

There were differences by race and ethnicity seen in opioid use, with a significant increase in opioid use occurring over time among Black participants. (Black MSM did have lower opioid use rates overall compared to white and Hispanic/Latino MSM.)

Cocaine use also did not change over time, but reported rates were high—more than double the rate seen for opioid or meth use. In 2008 19% of participants reported using cocaine, in 2011 17% reported cocaine use and in 2014 19% reported cocaine use.

“Use of methamphetamine, cocaine, prescription opioids and other drugs can lead to risky sexual behaviors among men who have sex with men and can lead to transition to injection drug use,” said Hoots. “Both of these are factors that can lead to infection with HIV. HIV prevention interventions need to consider assessing use of prescription opioids and not just traditional club drugs. Among MSM of all races, prevention interventions should also offer early treatment for drug use.”

Read more about substance use on BETA, including information about the fentanyl crisis and harm reduction advice for people who inject drugs. 

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