By Brenda L. Mooney
PROVIDENCE, RI—Veterans who misuse opioid painkillers have a very high risk of also beginning to use heroin, according to a new study.
The report published in the journal Addiction was based on a decade long study by researchers at Brown and Yale Universities who followed nearly 3,400 veterans who were participating in the Veterans Aging Cohort Study (VACS).1
The authors strongly urged healthcare providers who serve veterans to closely monitor them for signs of nonmedical use of opioid painkillers. They also point out that chronic pain was not found to be a significant risk factor for heroin use.
“This study quantifies the issue of starting painkiller misuse and heroin use in a specific, high-risk population—veterans around the U.S.,” explained corresponding author Brandon Marshall, PhD, Manning Assistant Professor in the Brown University School of Public Health. “Of the 500 participants who initiated heroin, 77% reported prior or concurrent nonmedical prescription painkiller use.”
Veterans who misused painkillers were 5.4 times more likely to begin using heroin than those who did not, even taking into account other risk such as race, income, use of other drugs and post-traumatic stress disorder (PTSD) or depression, according to the report.
The study focused on 3,396 VACS participants who, at the study’s beginning in 2002, said they had never used heroin or opioids for nonmedical reasons. The veterans were being treated at infectious disease and primary care clinics in Atlanta, Baltimore, New York, Houston, Los Angeles, Pittsburgh and Washington.
“Our findings demonstrate a pattern of transitioning from nonmedical use of prescription opioids to heroin use that has only been demonstrated in select populations,” explained co-author David Fiellin, MD, a Yale public health and medical professor and director of the VACS study intervention group. “Our findings are unique in that our sample of individuals consisted of patients who were receiving routine medical care for common medical conditions.”
While none of the veterans in the new analysis had previously reported misusing opioids, 1,416 of them had begun nonmedical use of opioid painkillers by 2012. Results also indicate that, of the 500 veterans in the study who began using heroin, 386 had also begun using prescription painkillers nonmedically.
That was the best predictor in the data of who ended up using heroin, according to study authors, who also pointed to other sociodemographic risk factors, such as being male (2.6-fold risk) or being black (2-fold risk). Abusing stimulant drugs, as opposed to not doing so, was associated with a 2.1-fold risk of using heroin, they added.
Interestingly, according to the study, receiving a short-term prescription for an opioid painkiller was associated with a less-than-1.7-fold risk of starting heroin, while a longer-term prescription was not significant at all as a risk factor..
“This paper shows that, as a general clinical practice, particularly for this population, which does experience a lot of chronic pain and other risks for substance use, including PTSD, screening for nonmedical painkiller use, whether you are prescribing an opioid or not, may be effective to prevent even more harmful transitions to heroin or other drugs,” Marshall said.
Meanwhile, the VA has responded to the risks created by rising opioid dependence among veterans. The agency’s facilities began implementing opioid overdose education and naloxone distribution (OEND) in 2013 and a national program began in 2014 – making it the first national healthcare system to implement such a program.
A recent study published in the journal Substance Abuse sought to determine patient perceptions of OEND training and naloxone kits.2
Results of focus groups indicated that OEND training was generally well received among study participants, including those with no indication for a naloxone kit. Patients described a need for OEND and believed it could save lives.
“Patient feedback on OEND training benefits, concerns, opinions, and suggestions provides important insights to inform future OEND training programs both within VA and in other healthcare settings,” conclude study authors from the VA Palo Alto, CA, Healthcare System. “Training is critical to maximizing the potential for OEND to save lives, and this study includes specific suggestions for improving the effectiveness and acceptability of training.
- Banerjee G, Edelman EJ, Barry DT, Becker WC, Cerdá M, Crystal S, Gaither JR,
Gordon AJ, Gordon KS, Kerns RD, Martins SS, Fiellin DA, Marshall BD. Non-medical
use of prescription opioids is associated with heroin initiation among US
veterans: a prospective cohort study. Addiction. 2016 Aug 23. doi:
10.1111/add.13491. [Epub ahead of print] PubMed PMID: 27552496.
- Oliva EM, Nevedal A, Lewis ET, McCaa MD, Cochran MF, Konicki PE, Davis CS,
Wilder C. Patient perspectives on an opioid overdose education and naloxone
distribution program in the U.S. Department of Veterans Affairs. Subst Abus.
2016;37(1):118-26. doi: 10.1080/08897077.2015.1129528. PubMed PMID: 26675643.