1. Prescription Drug Abuse and the Emergence of Hepatitis C in Rural Appalachia
Jennifer R. Havens, PhD, MPH
Associate Professor
Department of Behavioral Science
Center on Drug and Alcohol Research
University of Kentucky College of Medicine

2. Percent of Respondents Using Pain Relievers Nonmedically: 2001 – 2011
Source: National Survey on Drug Use and Health 2001 – 2011

3. Past Year Illicit Drug Abuse/Dependence in Millions
Source: National Survey on Drug Use and Health 2002, 2011

4. Source: MMWR, May 6, 2011; 60(17):

5. 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).

6. 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)

7. Rural Substance Abuse – Mid-2000’s
Clear need for research
Little known about trends in drug use in rural Appalachia in particular
Even fewer empirical reports around injection drug use and other medical consequences of drug use
Specifically, HIV, HCV and other STI’s

8. Study Rationale Gaps in the literature in rural populations:
Injection drug use
Infectious disease prevalence and incidence
Social network and geospatial factors in disease transmission

9. Social Networks among Appalachian People (SNAP) study
Purpose: determine prevalence and incidence of HCV, HIV and HSV-2 and other risk behaviors in relation to social network characteristics among rural prescription drug users
Follow-up at 6-, 12-,18-, 24-, 30- and 36-months

10. Participants
500 rural out-of-treatment injection and non-injection drug users recruited and followed at 6-, 12-, 18-, 24-, 30-, and 36-months post-baseline
Recruitment began in November 2008 and was completed in August 2010
Storefront location in rural town
Participants recruited via Respondent Driven Sampling (RDS)

11. Hazard, KY

12. Participant Characteristics N=503%
Male
286
56.7
Age, median (IQR)
31 (26 ,38)
Caucasian
474
94.2
Employed Full-Time
173
34.4
Lifetime Injection Drug Use
394
78.3

13. Effect of Change in OxyContin Formulation on Abuse
New Formulation Released – August 2010

14. Emerging Trends in Prescription Drug Abuse
Neurontin (gabapentin)
165% increase in abuse between 2013 and 2014
2950% increase in abuse between 2008 and 2014
Participants reporting a mean of 25 days of use in past 30
More likely (p<0.05) to also be abusing IR oxycodone, buprenorphine and benzodiazepines
Smith, Lofwall and Havens, Am J Psychiatry, 2015

15. Proportion of Participants Accessing Substance Abuse Treatment

16. OST Uptake

17. Proportion of Participants Injecting Drugs

18. Baseline Data – Drug Type for Injecting (n=394 Lifetime IDUs)%
Rx Opiates
348
88.3
Rx Stimulants 27
6.8
Rx Benzodiazepines 23
5.8
Methamphetamine 39
9.9
Cocaine
271
68.8
Heroin 95
24.1
Speedball (cocaine/OxyContin) 60
15.2

19. Initiation to Injection by Age

20. Baseline Prevalence – HIV, HCV, HSV-2

21. HCV Prevalence by Age

22. Hepatitis C Seroconversion

23. HCV Incidence for PWID

24. Drug Network

25. Probability of Heroin Initiation

26. Heroin Availability and Potential for Abuse
One in ten participants noted an increase in the availability of heroin since 2013
However, when asked if they would abuse it if regularly available, less than 4% indicated they would

27. Conclusions HCV highly prevalent
Additional incident cases at each visit
Young PWID particularly at risk for seroconversion
Heroin use not prevalent

28. Future Directions Interventions HCV treatment engagement
Network based?
HCV treatment engagement
Harm reduction
Syringe exchange
Substance abuse treatment
HIV prevention

29. Acknowledgements NIH/NIDA (R01-DA024598 and R01-DA033862)
Drs. Carl Leukefeld, Carrie Oser, Rick Crosby, Michelle Lofwall, Sharon Walsh (Co-Investigators)
Study Staff – Hazard and Lexington
Study Participants