1. Patterns, predictors, and consequences of non-medical use prescription opioids in the Veterans Aging Cohort Study
Brandon DL Marshall, PhD
Manning Assistant Professor of Epidemiology Brown University School of Public Health

2. NMUPO & Heroin Use in the US
Adapted from Compton et al., N Eng J Med, 2016
Data are from the Center for Behavioral Health Statistics and Quality

3. Opioid Overdose in the US
Adapted from Compton et al., N Eng J Med, 2016
Data are from the Centers for Disease Control and Prevention

4. Measuring NMUPO in VACS

5. Measuring NMUPO, FU 3-5 Variable first added at follow-up 3 (2006)
Completed by 4,122 participants
Consistent with NSDUH
Excluded participants reporting only Fioricet or Fiorinal, as well as “Other” response options that weren’t opioids

6. Reported by 525 (12.7%) participants
Patterns of NMUPO
Reported by 525 (12.7%) participants

7. Select factors associated with NMUPO
Hispanic ethnicity
40 to 44 (vs. 55+)
AUDIT >20 (vs. AUDIT <8)
Opioid use disorder
Hepatitis C
Past-year opioid prescription
Pain interference (per unit)
1.8 (1.2 – 2.6)
1.6 (1.1 – 2.3)
2.0 (1.3 – 3.1)
2.7 (1.9 – 3.9)
1.5 (1.2 – 1.9)
1.9 (1.3 – 2.8)
1.1 (1.0 – 1.2)
Remember to highlight alcohol findings to please Kendal
From Barry et al., Pain, 2011

8. Predictors of new onset NMUPO
3,272 did not report past-year NMUPO at follow-up 3
Of these, 434 (13.2%) reported new onset NMUPO at follow-up 4 or 5
Incidence rate = 4.6 per 100 person-years (95%CI: 4.2 – 5.0)

9. Predictors of new onset NMUPO
Age (per year older)
Hispanic
Black (vs. white)
Female (vs. male)
HIV-infected
Hepatitis C
Past-year opioid prescription
1.0 (0.9 – 1.1)
1.4 (1.0 – 2.1)
1.2 (0.9 – 1.6)
0.7 (0.4 – 1.2)
0.9 (0.7 – 1.1)
1.6 (1.3 – 2.0)
1.6 (1.3 – 1.9)

10. Consequences of NMUPO: Heroin Initiation

11. Study sample
From Banerjee et al., Addiction, 2016

12. NMUPO & Heroin Initiation

13. NMUPO & Heroin Initiation
Rate of heroin initiation: 2.6 per 100 person-years
1.0 per 100 person-years among those without prior or concurrent NMUPO
4.8 per 100 person-years among those with prior and/or concurrent NMUPO
77% of participants initiating heroin had prior or concurrent NMUPO
Adjusted HR = 5.43 (95%CI: 4.0 – 7.4, p < 0.001)

14. Heroin Initiation Rate by Site

15. Future Research
Does price and purity of heroin in the regional drug market modify the relationship between NMUPO and heroin initiation?
Formally test whether NMUPO mediates relationship between receipt of opioid prescription and heroin initiation
Determine factors associated with new onset NMUPO among persons receiving opioid prescriptions

16. Acknowledgements Veterans who participate in the VACS
Jen Edelman, Declan Barry, William Becker, David Fiellin, Amy Justice and many other opioid workgroup members!
Geetanjoli Banerjee
Melissa Skanderson
Funding from NIAAA (U24-AA022000, U10-AA013566, U01- AA020795, U01-AA020790, U24-AA020794, U10-AA013566, U24-AA022002, P01-AA019072, & K05-AA16928), NIAID (P30- AI042853), NIDA (F31-DA & K12-DA033312), and the U.S. Department of Veterans Affairs
Henry Wriston Fellowship from Brown University

17. VACS Opioids Workgroup
William C. Becker, MD
Co-Director
E. Jennifer Edelman, MD, MHS
Co-Director
Members: Kathleen Akgun, Declan Barry, Geetanjoli Banerjee, Stephen Crystal, Julie Gaither, Adam Gordon, Kirsha Gordon, Joseph Goulet, Robert Kerns, Kevin Kraemer, Brandon Marshall, Jessica Merlin, Brent Moore, Melissa Skanderson, Janet Tate, Amy Justice, and David Fiellin

18. Recent VACS Opioids Workgroup Highlights (2015-2016)
Peer Reviewed Publications
Becker WC et al. Trends in any and high-dose opioid analgesic receipt among aging patients with and without HIV. AIDS Behavior 2016 Mar; 20(3):
Gaither JR et al. The Effect of Substance Use Disorders on the Association Between Guideline-concordant Long-term Opioid Therapy and All-cause Mortality. J Addict Med Nov/Dec;10(6):
Banerjee G et al. Non-medical use of prescription opioids is associated with heroin initiation among US veterans: a prospective cohort study. Addiction Nov;111(11):
Edelman EJ et al. The impact of prescribed opioids on CD4 cell count recovery among HIV-infected patients newly initiating antiretroviral therapy. HIV Med Nov;17(10):
Gaither JR et al. The Association Between Receipt of Guideline-Concordant Long-Term Opioid Therapy and All-Cause Mortality. J Gen Intern Med May;31(5):
Weisberg DF et al. Long-term Prescription of Opioids and/or Benzodiazepines and Mortality Among HIV- Infected and Uninfected Patients. J Acquir Immune Defic Syndr Jun 1;69(2):
Dissertation-Related Work
Julie Gaither, PhD, MPH, RN - Yale University School of Public Health, 2015 graduate
Geetanjoli Banerjee, Brown University
New Grants
NIDA RO1 “Non-medical use of prescription opioids among HIV-infected individuals: trajectories and impact on healthy outcomes” (DA A1)