Killing the Pain: Prescription Drug Abuse and Other Risky Behaviors in Rural Appalachia Jennifer R. Havens, PhD, MPH Department of Behavioral Science Center on Drug and Alcohol Research University of Kentucky College of Medicine

Annual numbers (in millions) of new nonmedical users of pain relievers aged 12 and older Source: National Household Survey on Drug Abuse

Past Year Illicit Drug Dependence or Abuse Source: National Survey on Drug Use and Health 2002

Percent increase in number of treatment admissions for narcotic painkillers: 1997 – 2002 Source: Treatment Episode Data Set

Background Rural Substance Abuse Differing trends – rates of prescription drug opiate use and methamphetamine higher than urban areas (Havens et al., Am J Drug Alc Abuse, 2007; Havens et al., Am J Drug Alc Abuse, 2009) Differing drugs of abuse may be due to lack of availability of drugs such as heroin in rural areas

Injection Drug Use among Rural Drug Users Previous research: IDU rare among rural drug users in Appalachian Kentucky (Leukefeld et al., Substance Use and Misuse, 1997) Recent research suggested a much higher prevalence of IDU among Appalachian drug users (>40%) (Havens et al., Drug and Alcohol Dependence, 2007).

IDU among Appalachian Drug Users Majority of rural IDUs reported injecting OxyContin® and other prescription drugs NOT designed for injection Fewer than 10% had ever injected heroin and/or cocaine Self-reported hepatitis C infection significantly higher among the IDUs versus non-IDUs (p<0.001) (Havens et al., Drug and Alcohol Dependence, 2007)

Social Networks and HIV Risk among Rural Drug Users Overall goal of the study is to determine the prevalence and incidence of HIV, hepatitis C and herpes simplex-2 virus as well as to examine both individual and social network-related risk factors for HIV and other infectious diseases among rural drug users

Specific Aims To determine prevalence and incidence of HIV, hepatitis C (HCV) and herpes simplex-2 virus (HSV-2) among rural IDUs and non-IDUs Characterize risk for HIV and other infectious diseases among rural injection and non-injection drug users in the context of both individual-level and network-level risk

Participants 500 rural out-of-treatment injection and non-injection drug users recruited and followed at 6-, 12-, and 18-months post- baseline Storefront location in rural town Participants recruited via Respondent Driven Sampling (RDS) 24- and 30-month follow-up ongoing

Eligibility Criteria Age 18+ English-speaking IDU (initial seeds) Use of at least 1 of the following drugs in prior 6 mo: Rx Opiates (illicit use) Cocaine Heroin Methamphetamine

Outcomes HIV, HCV, HSV-2 prevalence and incidence (i.e., seroconversion) HIV risk behaviors unprotected sex sharing syringes and other injection-related paraphernalia

Data Collection Procedures Interviewer-administered questionnaire Computer-assisted personal interview (CAPI) via tablet PC Serologic testing (with pre- and post-test counseling) HIV (with confirmatory testing) HCV HSV-2

Baseline Data - Participant Characteristics N=503 n% Male Age, median (IQR)31 (26,38) Caucasian Employed Full-Time Lifetime Injection Drug Use Prevalent HIV00 Prevalent HCV Prevalent HSV Incident HCV Incident HSV

Baseline Data – Drug Use LifetimePast 30 Days Alcohol Methadone (illicit) Heroin OxyContin Oxycodone Hydrocodone Benzodiazepines Methamphetamine Cocaine Marijuana

Baseline Data – Age of Onset Alcohol Marijuana Age 14 Benzodiazepines Hydrocodone Age 18 Cocaine Oxycodone Age 20 Crack Age 21 OxyContin Heroin Methadone Age 23 IDU Age 22 Methamphet amine Age 24

Drugs Initiated Injection With (n=394 Lifetime IDUs) n% OxyContin Other Rx opiates TOTAL ALL Rx opiates Methamphetamine41.0 Cocaine Heroin194.8

Baseline Data – IDU Drugs (n=394 Lifetime IDUs) n% Rx Opiates Rx Stimulants276.8 Rx Benzodiazepines235.8 Methamphetamine399.9 Cocaine Heroin Speedball (cocaine/OxyContin)6015.2

Baseline Data -Sex Risk n% Male Sex Partners, median (IQR)9 (5, 17.5) Female Sex Partners, median (IQR)20 (10, 45) Sexual Orientation Heterosexual Homosexual91.8 Bisexual346.8 Sex Encounters w/o Condom (30 days)14 (4, 30)

Baseline Data – Drug Risk n% Sharing Syringes (past 6 mo) N= Sharing Cottons, Cookers, Water (6 mo) N= Daily Injection N= Sharing Straws (6 mo) N= Overdose (Lifetime) N=

Baseline Data – Social Networks Support Network Members, median (IQR) 2 (1, 3) Drug Network Members, median (IQR) 4 (2, 9) Sex Network Members, median (IQR) 2 (1, 5)

Drug Network

by Drug Network by HCV Status

Results from Ongoing or Published Studies from SNAP Transition to Injection HCV Prevalence Methadone Use Overdose

Initiation to Injection 48.2% of participants initiated injection with OxyContin® Young and Havens, Addiction, 2012

Initiation to Injection Young and Havens, Addiction, 2012

Initiation to Injection Young and Havens, Addiction, 2012

Hepatitis C Overall prevalence is 44.1% (54.5% among IDUs) Incidence is about 10 cases/100 PY Independent associations with HCV: Syringe sharing (aOR: 2.04, 95% CI: 1.20, 3.45) Years IDU (aOR: 1.04, 95% CI: 1.01, 1.07) Injecting Rx opiates (aOR: 2.37, 95% CI: 1.21, 4.63) Injecting Cocaine (aOR: 2.24, 95% CI: 1.41, 3.54) Havens et al., American Journal of Public Health, 2013

Methadone Use 94.6% of cohort report lifetime illicit methadone use Methadone NOT diverted from treatment programs Factors associated with high frequency methadone use : older age, less exposure to drug tx, not having Rx for physical problem, not using OxyContin concurrently, fewer lifetime arrests and experiencing recent drug problems Hall, Leukefeld and Havens, under review, 2013

Overdose 28% experienced 1 or more ODs 58% witnessed 1 or more ODs Individual factors associated with OD: ever in drug tx, injection of Rx opiates, PTSD, ASPD Network factors associated with OD: having additional support network members Havens et al., Drug and Alcohol Dependence, 2011

Acknowledgements NIH/NIDA (R01-DA024598) Dr. Carl Leukefeld (BSC), Dr. Carrie Oser (Sociology) and Dr. Rick Crosby (Health Behavior) Center on Drug and Alcohol Research Department of Behavioral Science