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An exploratory study of OxyContin use among individuals with substance use disorders.

Abstract--This study surveyed 422 individuals being treated in a substance abuse treatment program that offers various levels of care in order to learn about OxyContin[R] use among this population. Focus areas included exposure and use of OxyContin, how this medication was obtained, reasons for initial use, and whether users of OxyContin were drug naive or experienced users of opiate or non-opiate drugs. Whether OxyContin users who previously had never used opiates would report migrating to heroin was also explored. Findings revealed that 48% of the population had used OxyContin and of this population, only 1% had no history of prior substance use. Seventy percent of this sample obtained them from friends and 14% obtained them directly from physicians. Many reported that their friends obtained their OxyContin from physicians, bringing the percentage of people who directly or indirectly obtained OxyContin through a physician to 37%. While most users of OxyContin had a history of past opiate use, a small percentage had not, and of this later group, 73% migrated to using heroin. The majority of individuals who obtained OxyContin from a physician had a history of recreational or problematic opiate or non-opiate drug use. Finally, over time, 90% had stopped using this drug, although other drug use continued.

Keywords--diversion, oxycodone, OxyContin, prescription drug use

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Recent reports have noted an increase in the illicit use of OxyContin[R] (oxycodone HCL controlled-release), a long-acting opioid analgesic most often prescribed for the treatment of chronic pain. From 2002-2004, an increase in prescription analgesic drug abuse has been found, with OxyContin leading the list (Cicero, Inciardi & Munoz 2005). The 2005 Monitoring the Future Report found that annual use of OxyContin was 1.8% among eighth graders, 3.2% among tenth graders, and 5.5% among twelfth graders. While there has not been an increase in OxyContin use in the two lower grades from 2002 to 2005, a 40% increase in OxyContin use was found among twelfth graders. Of additional concern is the increase noted in the use of OxyContin by college students and young adults from 2002 to 2004 (Johnston et al. 2005). In fact, increases in the nonmedical use of opioid-type drugs in general has been noted among college students during the past decade (Zacny et al. 2003) and among high school seniors and college students over the past two decades (Johnston, O'Malley & Bachman 2003).

Other disturbing trends in the use of OxyContin are reported by the National Institute on Drug Abuse's Community Epidemiology Work Group (CEWG). In most CEWG areas, indicators of narcotic analgesic abuse are causing concern, and increases in admissions for narcotic analgesic abuse were noted in half of the 14 CEWG areas that collect this information. Increases in helpline and poison control center calls as well as hospital discharges involving OxyContin have been observed as well, in addition to increases in diversion of these drugs to the illegal market. Deaths related to OxyContin have also been seen, and some CEWG members have observed a link between the use OxyContin and heroin. It has been suggested that the use of OxyContin may be a pathway to the use of heroin, or conversely, when the purity of heroin declines, users may switch to OxyContin, which is a more reliable "high." And in one CEWG area, 57% of heroin users reported using illicit narcotic analgesics. Finally, increases in OxyContin-related emergency department visits have also been observed in over half of the CEWGs (CEWG 2005).

In light of these trends and an observed increase in OxyContin use among the clients served by our agency, an exploratory survey was developed by the author that explored many aspects of OxyContin use. Our goal was not just to learn about its prevalence among our client population and their exposure to this drug, but also to achieve a better understanding of why it is used, how it is used, and how it is obtained. Furthermore, this survey was designed to explore whether clients who used OxyContin were drug-naive individuals or experienced users of either licit or illicit opiates, and/or other non-opiates. The relationship between OxyContin and heroin use was also explored, as well as whether OxyContin was a drug that clients use over the long haul after being exposed to it, or if instead individuals stop using it over time.

METHOD

A survey was developed and given to 422 current clients over the course of two weeks in the early part of 2006 within a large public substance abuse treatment continuum that offers many different levels of care for the treatment of substance abuse. Surveys were given to clients within detoxification, short and long-term residential, methadone maintenance, intensive outpatient, and outpatient programs. Program locations included both urban and suburban areas, located in Boston and on the North Shore of Massachusetts. All programs are state-wide and take individuals living throughout Massachusetts. However, most clients served within these programs reside in greater metropolitan Boston and in urban and suburban communities north of Boston.

Clients were told that the purpose of the survey was to learn more about their use of OxyContin and that all surveys were confidential and anonymous. Surveys were self-administered in group settings with clients in residential treatment programs, and for outpatient clients, clients completed surveys while waiting for an appointment. Clients who reported never having used OxyContin did not complete the survey. There were no reports of clients refusing to complete the survey.

Surveys gathered some basic demographic information, in addition to specific information about their use of OxyContin and other drugs. Specific questions were asked to determine clients' drug use history prior to using OxyContin, age of first exposure to OxyContin, whether clients reported getting addicted to OxyContin, and whether OxyContin use had continued to the present time. For clients who had never used a narcotic analgesic or opiate-type drug prior to using OxyContin, the survey asked whether they had switched to using heroin. All surveys were entered into an Access database and then analyzed.

RESULTS

Before reviewing the results, it should be noted that a breakdown by gender was done to determine if there were any differences between males and females in the use of OxyContin. However, after doing this, it became apparent that in every category the similarities across gender were overwhelming as opposed to there being any notable differences. Consequently, the results aggregate males and females together.

Demographics

Of 422 surveys, 204 individuals reported that they had used OxyContin, or 48% of the entire sample. Of this sample, 66% were male, and 34% were female, which mirrors the overall percentage of men and women treated in the agency. Ninety-two percent were Caucasian, 3% were Latina/Latino, 4% were African American, and 1% was Asian. The average age of the population was 28, and on average, individuals first used OxyContin at age 23, or five years prior. The primary drug problems of this sample were the following: 57% currently used heroin, including some who stated they had used it along with cocaine, OxyContin, and crack; 12% used cocaine/crack; 12% used OxyContin; 5% used alcohol; 3% used other opiates; 2% used marijuana; 1% used benzodiazepines; and 8% reported no current drug use, most of whom who were currently in treatment within various residential treatment programs, and some of whom were on long-term methadone maintenance, with a length of stay varying from several weeks to one year. Thus, length of time abstinent varied greatly from very short-term to long-term.

Previous Use of Opiates and Other Drugs

Of the clients who had used OxyContin, 40.7% (N = 83) acknowledged a previous problem with other opiates prior to using this drug, and 46.1% (N = 94) acknowledged past recreational use of opiates. Whether past opiate use was problematic or recreational was completely based on client's self-perception. Past other opiate use included heroin (34%), Percocet or Vicodin (53%), and 13% reported having used other types of narcotic analgesics. Only 13.2% (N = 27) had never before used an opiate.

Of the 83 people who reported previous problems with opiates, eight (9.6%) reported no other drug use, 28 (33.7%) reported past recreational non-opiate drug use, and 47 (56.6%) reported previous problems with other non-opiate drugs. Again, whether past non-opiate drug use was problematic or recreational was based on client's self-perception.

Of the 94 people who reported recreational opiate use, six (6.4%) had never used any other drugs, 68 (72.3%) had used other non-opiate drugs recreationally, and 20 (21.2%) reported previous problems with other non-opiate drugs.

Of the 27 individuals who had never before used an opiate, three (11.1%) had never used any drugs, 15 (55.6%) had used other non-opiate drugs recreationally, and nine (33.3%) reported problematic non-opiate drug use. See Table 1 for a breakdown of this population regarding comorbidity between opiate and non-opiate drug use.

The most commonly used non-opiate drugs were marijuana (32%), cocaine (32%), benzodiazepines (15%), LSD (9%), and alcohol (8%). Many reported having used a variety of other drugs and in fact, 9% reported having used all drugs listed.

How the Drug was Used

Oral use was reported by 24% of the sample, 37% reported using the drug intranasally, 22% reported using it both orally and intranasally, and 2% used it intravenously. The remaining 15% reported a combination of oral, nasal, and intravenous use. Even among individuals who had never before used an opiate, only 22% used it orally, and the rest used it intra-nasally, or a combination of intra-nasally and orally.

How the Drug was Obtained

The survey indicated that 70% had obtained OxyContin from a friend, 14% from a physician, 4% from a relative, 4% took it from someone, 3% from both doctors and friends and 5% reported "other." For those who stated that they obtained the drug from a friend, a subsequent question asked if they knew how their friend obtained the drug. Responses were the following: 27% stated their friend obtained it illegally; 27% stated it was from a dealer; 24% stated from a prescription; 7% stated their friend bought the drug from someone who had a prescription; 4% stated their friend stole the drug; and 11% didn't know.

Why the Drug was Used

Fifty-nine percent of clients stated they used OxyContin to get high; 15% for pain relief; 7% to get high and for pain relief; 7% to get high and to alleviate withdrawal; 7% to relax; and 5% to alleviate withdrawal.

Continued Use of OxyContin

Ninety percent of the population who had used OxyContin reported no longer using this drug, although 80% of the sample reported that it was fairly easy or very easy to obtain. Of those who still used OxyContin, 15% used it orally, 35% intranasally, and the rest either used it intravenously or through a combination of ways. The reasons reported for no longer using OxyContin were the following: heroin was used instead (35%); being "clean" (22%); being sick of using them for a variety of reasons or no longer liking them (17%); being on a methadone program (11%); OxyContin was too expensive (8%); being in a treatment program (5%); and being unable to get them (2%).

Transition from OxyContin to Heroin

One question asked whether individuals who had never previously used an opiate prior to using OxyContin (N = 27) switched to using heroin. Of this group, 22 individuals answered this question.

Sixteen of the 22 people or 73% reported having switched to heroin, which took an average of 17.5 months, with a range of several weeks to over four years. Reasons for switching to heroin were that OxyContin was too expensive (61%), heroin was a better high (28%), and 11% stated that they could no longer get OxyContin. While the numbers are small, it was found that those who switched to heroin generally began using OxyContin through nasal inhalation (94%) as opposed to oral use (6%). Among people who did not switch to heroin (N = 6), 50% used it orally and 50% used it through nasal inhalation.

Access Through Physician Prescription

The decision was made to look at individuals who obtained OxyContin directly from a physician. There were a total of 29 people or about 14% of the entire sample, who obtained OxyContin from a physician. Of these, 17 people or 59% stated it was for pain control, nine individuals or 31% reported using it to get high, and three or 10% stated they used it to alleviate withdrawal. Forty-one percent reported using it orally and the remainder either used it intranasally or through a combination of ways.

Seventeen people or 59% of this group reported past problematic use of opiates, nine people or 31% of the group reported past recreational use of opiates, and three people or 10% of this group had never before used an opiate. Prior use of opiates included heroin (24%) and other narcotic analgesics (76%). Non-opiate drug use was also prevalent: 11 (38%) reported past problematic drug use, 16 (55%) reported past recreational drug use, and two (7%) reported no prior non-opiate drug use (and in this group, one reported problematic opiate use and the other reported recreational opiate use). Thus, no one in this group of 29 was completely drug naive. See Table 2 for a breakdown of this population regarding the comorbidity between opiate and non-opiate drug use.

Even among the 17 people who reported getting a prescription for legitimate reasons (pain control), 10 or 59% reported previous problems with opiates and five or 29% reported past recreational opiate use. Other drug use was also common within this group: five or 29% reported past problems with other drugs and 10 or 59% reported past recreational non-opiate drug use. See Table 3 for a breakdown of the comorbidity between opiate and non-opiate drug use for people who obtained OxyContin from a physician for pain control.

Finally, of the three people who had never before used an opiate, all switched to using heroin and all began using OxyContin by nasal inhalation or through a combination of nasal inhalation and oral use.

DISCUSSION

This exploratory study of OxyContin use among a group of clients involved in substance abuse treatment revealed a number of findings. First, there is a significant amount of exposure to and use of OxyContin. Forty-eight percent of the clients reported having used OxyContin.

Second it is also clear that most users of OxyContin had a previous history of either recreational or problematic use of opiates, along with recreational or problematic use of non-opiate drugs. Only 13% of OxyContin users had no history of prior opiate use and 8% had no history of other drug use. Furthermore, only 1% had no history of drug use of any kind. Consistent with this finding, the majority reported using it to get high or using it to get high along with other reasons. Furthermore, only 24% of users used it orally; the remainder either reported intranasal use or a combination of ways of using this drug. Thus, it appears that the majority of OxyContin users in this sample were already involved in the use of drugs and used OxyContin to get high and in ways to maximize its psychogenic effects. This was even true of those who had not previously used opiates, among which only 22% reported using this drug orally. These findings are consistent with a previous study that found that 50% of patients admitted for OxyContin dependence experienced past problems with opiates and 77% reported past problems with non-opiate drugs (Sharpe Potter et al. 2004). Other studies have shown high rates of other drug use among nonmedical users of prescription analgesics (McCabe et al. 2005; McCabe, Boyd & Teter 2005). It has also been reported that many OxyContin users snort the drug to maximize its effect (National Drug Intelligence Center 2002).

Third, it is also clear that over time, many users of OxyContin stop using this drug for a variety of reasons, although they do not stop using other drugs. In fact, 90% of the sample reported no longer using OxyContin. It was also found that among previously opiate-naive users, 73% of users of OxyContin switched to using heroin, which took an average of 17.5 months, though the time span ranged from weeks to years. The primary reason reported for switching was because OxyContin was too expensive, although 28% reported that heroin was a better high and 11% reported being unable to get OxyContin. Thus, it appears that over time, many "at one time" exclusive users of OxyContin do switch to using heroin. They may be no different in many ways from users of heroin and may simply be earlier in their history of opiate use.

It is also interesting to note that individuals who reported no opiate use prior to using OxyContin who switched to heroin generally began using OxyContin intranasally (94% of the sample), whereas those that did not were evenly divided between oral and intranasal use. It may be that intranasal use has an increased risk of addiction, which in turn, leads to eventual heroin use. On the other hand, it is possible that individuals who used the drug intranasally to get a greater high are those that might tend to use a drug such as heroin even if OxyContin was never used. Whatever the cause, it is clear that users of OxyContin with no prior history of opiate use do switch to heroin.

Fourth, consistent with previous studies (McCabe, Teter & Boyd 2005; Hays 2004), the majority of users do not get this drug directly from physicians, but obtain it through their friends. Seventy percent of the sample reported getting the drug from friends and only 14% stated that they obtained the drug from a physician. However, among the people who reported obtaining OxyContin from friends, 24% stated that their friends obtained the drug through a prescription and 7% stated that their friend bought the drug from someone who had a prescription. So, both directly and indirectly, 37% of the sample obtained OxyContin through a physician prescription.

While OxyContin prescribed by physicians is only one source of diversion, it is important that physicians who prescribe OxyContin are careful in their prescribing practices. Physicians need to conduct careful assessments of individuals who are given OxyContin prescriptions, both initially and in an ongoing way, and they should remain mindful of signs of diversion. They must also be on guard for "doctor shoppers" or those people who see a number of doctors to obtain prescription drugs, as this is one of most common forms of diversion (National Drug Intelligence Center 2001). State prescription drug monitoring programs have also shown to be effective and can inform physicians of any patients who are seeing multiple providers for the same class of drugs (US GAO 2004). Other clients may fake pain to obtain these drugs, and physicians should also be mindful of this and monitor whether clients are adhering to other suggested therapies for the treatment of chronic pain, such as physical therapy, acupuncture, or massage therapy.

Fifth, it was found that many who obtained a prescription from a physician already experienced problematic opiate (59%) or non-opiate drug use (38%), and recreational opiate and non-opiate drug use was also high (31% and 55% respectively). Even if seeing a physician was for legitimate reasons (pain control) many already experienced problems with opiates (59%) and other drugs (29%), in addition to recreational opiate (29%) and non-opiate (59%) drug use. This is in contrast to a study that showed that of 15 OxyContin-dependent patients who first obtained OxyContin from a physician for pain control, not one reported past problems with opiates, although many did report problems with other drugs (Sharpe Potter et al. 2004). Why the current finding is so different is not known, but the client population in this study was being treated in a public sector drug treatment program, with a high percentage of heroin and other opiate dependence, whereas the contrasting finding studied patients being treated in a private hospital with perhaps a different patient population. Whatever the difference, it is clear that there are individuals who see physicians for pain control who already have opiate or other drug problems. Thus, careful screening for substance abuse problems is strongly encouraged. Even though clients may fail to report current substance use difficulties, a thorough assessment of this should be undertaken.

These results must be interpreted cautiously as they were based on individuals currently involved in various drug treatment programs within an urban and suburban public sector substance abuse treatment program in Boston and the North Shore of Massachusetts. In fact, with a different client population or geographic location, the results could be quite different. This data was also based on self-report and was cross-sectional in nature. Thus, caution should be exercised regarding the reported temporal relationship between OxyContin and heroin.

Despite these limitations, this study showed that among a population of individuals in treatment for substance use disorders, OxyContin use is quite prevalent and it is widely available. The majority of those who use them are not drug-naive and most use them for the purpose of getting high. Most obtain them through their friends rather than from physicians, but a significant percentage of their friends did obtain their OxyContin from a physician. Even among those who did obtain them from physicians, even for legitimate reasons, a majority had a history of substance use, and screening for this should take place. There are also individuals who have never used an opiate prior to using OxyContin, and eventually begin using heroin. Finally, these results demonstrated that over the course of several years, the majority of OxyContin users stop using this drug, although this should not be interpreted to mean that such individuals are no longer using other drugs to get high.

REFERENCES

Cicero, T.J.; Inciardi, J.A. & Munoz, A. 2005. Trends in abuse of OxyContin and other opioid analgesics. Journal of Pain 10: 662-72.

Community Epidemiology Work Group (CEWG). 2005. Epidemiologic Trends in Drug Abuse. Advance Report. Bethesda, MD: National Institute on Drug Abuse.

Hays, L.R. 2004. A profile of OxyContin addiction. Journal of Addictive Disease 23: 1-9.

Johnston, L.D.; O'Malley, P.M. & Bachman, J.G. 2003. Monitoring the Future: National Survey Results on Drug Use, 1975-2002: Vol. 2. College Students and Adults Ages 19-40. NIH Publication 03-5376. Bethesda, MD: National Institute on Drug Abuse.

Johnston, L.D.; O'Malley, P.M.; Bachman, J.G. & Schulenberg, J.E. 2005. Monitoring the Future: National Survey Results on Drug Use, 1975-2004: Volume 1. Secondary School Students. NIH Publication 05-5725. Bethesda, MD: National Institute on Drug Abuse.

McCabe, S.E.; Boyd, C.J. & Teter, C.J. 2005. Illicit use of opioid analgesics by high school seniors. Journal of Substance Abuse Treatment 28: 225-30.

McCabe, S.E.; Teter, C.J. & Boyd, C.J. 2005. Illicit use of prescription pain medication among college students. Drug and Alcohol Dependence 77: 37-47.

McCabe, S.E.; Teter, C.J.; Boyd, C.J.; Kight, J.R. & Wechsler, H. 2005. Nonmedical use of prescription opioids among U.S. college students: Prevalence and correlates from a national survey. Addictive Behaviors 30: 789-805.

National Drug Intelligence Center (NDIC). January, 2001. Information Bulletin: OxyContin diversion and abuse. Available at www.nsdoj. gov/ndic/pubs/651/index.htm

National Drug Intelligence Center (NDIC). 2002. OxyContin diversion and abuse. January, 2001. Available at http://usdoj.gov/ndic/pubs/651/ abuse.htm.

Sharpe Potter, J.; Hennessy, G.; Borrow, J.A.; Greenfield, S.F. & Weiss, R., 2004. Substance use histories in patients seeking treatment for controlled-release oxycodone dependence. Drug and Alcohol Dependence 76: 213-15.

US General Accounting Office (GAO). 2004. Prescription Drugs. State Monitoring Programs May Help to Reduce Illegal Diversion. Washington, DC: US GAO.

Zacny, J.; Bigelow, G.; Compton, P.; Foley, K.; Iguchi, M. & Sannerud, C. 2003. College on Problems of Drug Dependence taskforce on prescription opioid non-medical use and abuse: Position statement. Drug and Alcohol Dependence 69: 215-32.

Michael S. Levy, Ph.D.*

* Director of Clinical Treatment Services, CAB Health & Recovery Services, Peabody, MA.

Please address correspondence and reprint requests to Michael S. Levy, Ph.D., 7 Island Way, Andover, MA 01810; email mlevy@cabhealth.org
TABLE 1
Population Breakdown Regarding Opiate and Non-Opiate Drug Use Among
Oxycontin Users (N = 204)

 No Past Non-Opiate Past Recreational
 Drug Use Non-Opiate Drug Use

No past opiate use N = 3 (1.4%) N = 15 (7.4%)
Past recreational opiate use N = 6 (2.9%) N = 68 (33.3%)
Past problematic opiate use N = 8 (3.9%) N = 28 (13.7%)

 Past Problematic
 Non-Opiate Drug Use

No past opiate use N = 9 (4.4%)
Past recreational opiate use N = 20 (9.8%)
Past problematic opiate use N = 47 (23%)

TABLE 2
Population Breakdown Regarding Opiate and Non-Opiate Drug Use Among
Individuals Who Obtained Oxycontin from a Physician (N = 29)

 No Past Non-Opiate
 Drug Use

No past opiate use N = 0 (0%)
Past recreational opiate use N = 1 (3.4%)
Past problematic opiate use N = 1 (3.4%)

 Past Recreational Past Problematic
 Non-Opiate Drug Use Non-Opiate Drug
 Use

No past opiate use N = 2 (6.9%) N = 1 (3.4%)
Past recreational opiate use N = 5 (17.2%) N = 3 (10.3%)
Past problematic opiate use N = 9 (31%) N = 7 (24.1%)

TABLE 3
Population Breakdown Regarding Opiate and Non-Opiate Drug Use
Among Individuals Who Obtained Oxycontin from a Physician for Pain
Control (N = 17)

 No Past Non-Opiate
 Drug Use

No past opiate use N = 0 (0%)
Past recreational opiate use N = 2 (11.8%)
Past problematic opiate use N = 0 (0%)

 Past Recreational Past Problematic
 Non-Opiate Drug Use Non-Opiate Drug
 Use

No past opiate use N = 1 (5.9%) N = 1 (5.9%)
Past recreational opiate use N = 2 (11.8%) N = 1 (5.9%)
Past problematic opiate use N = 7 (41.2%) N = 3 (17.6%)
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Author:Levy, Michael S.
Publication:Journal of Psychoactive Drugs
Geographic Code:1USA
Date:Sep 1, 2007
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