1. 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

2. Annual numbers (in millions) of new nonmedical users of pain relievers aged 12 and older Source: National Household Survey on Drug Abuse 1970-2000

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

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

6. 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

7. 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).

8. 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)

9. 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

10. 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

11. 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

12. 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

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

14. 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

15. Baseline Data - Participant Characteristics N=503 n% Male28656.7 Age, median (IQR)31 (26,38) Caucasian47494.2 Employed Full-Time17334.4 Lifetime Injection Drug Use39478.3 Prevalent HIV00 Prevalent HCV22043.7 Prevalent HSV-25811.5 Incident HCV3612.7 Incident HSV-25011.2

16. Baseline Data – Drug Use LifetimePast 30 Days Alcohol49999.227654.9 Methadone (illicit)47694.630660.8 Heroin17635.0224.4 OxyContin47794.835169.8 Oxycodone48295.836472.4 Hydrocodone48897.040881.3 Benzodiazepines48095.542985.3 Methamphetamine21943.5173.4 Cocaine47293.811322.5 Marijuana49197.630861.2

17. 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

18. Drugs Initiated Injection With (n=394 Lifetime IDUs) n% OxyContin19048.2 Other Rx opiates5313.4 TOTAL ALL Rx opiates24361.7 Methamphetamine41.0 Cocaine11729.7 Heroin194.8

19. Baseline Data – IDU Drugs (n=394 Lifetime IDUs) n% Rx Opiates34888.3 Rx Stimulants276.8 Rx Benzodiazepines235.8 Methamphetamine399.9 Cocaine27168.8 Heroin9524.1 Speedball (cocaine/OxyContin)6015.2

20. Baseline Data -Sex Risk n% Male Sex Partners, median (IQR)9 (5, 17.5) Female Sex Partners, median (IQR)20 (10, 45) Sexual Orientation Heterosexual45991.2 Homosexual91.8 Bisexual346.8 Sex Encounters w/o Condom (30 days)14 (4, 30)

21. Baseline Data – Drug Risk n% Sharing Syringes (past 6 mo) N=2889231.9 Sharing Cottons, Cookers, Water (6 mo) N=288 13747.6 Daily Injection N=28810235.4 Sharing Straws (6 mo) N=50340788.9 Overdose (Lifetime) N=50314629.0

22. 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)

23. Drug Network

24. by Drug Network by HCV Status

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

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

27. Initiation to Injection Young and Havens, Addiction, 2012

28. Initiation to Injection Young and Havens, Addiction, 2012

29. 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

30. 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

31. 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

32. 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