By Rich Lord, Pittsburgh Post-Gazette
The often-told story of the prescription for an opioid that launches the patient down the road to ruin is not the typical tale of heroin addiction, according to a new report by researchers from Penn State and other universities.
More common, according to the study this week in the Journal of Addictive Diseases, is the “friends and family” introduction to opioids, in which the first pill comes not directly from a pharmacy, but from a trusted person. The finding could have implications for the way in which addiction prevention and treatment are accomplished, as a crackdown on prescribing continues even as overdoses remain historically high.
“I think our findings contrast with the popular media narrative that’s out there right now and the public perception,” said Khary Rigg, an assistant professor at the University of South Florida who worked with data derived by Penn State researchers in southwestern Pennsylvania. “When you talk to the average person on the street, they think it’s all about big pharma and that doctors are overprescribing. … Our findings show that the two top common sources for getting opioids are friends or family.”
Mr. Rigg worked with Katherine McLean, an assistant professor of administration of justice at Penn State Greater Allegheny in McKeesport, and other researchers at Penn State and at Syracuse University. Ms. McLean led an effort to survey 125 opioid users and conduct in-depth interviews with 30 of them, which has also yielded findings on the varied responses to the encroachment of fentanyl into the drug supply. The users were from Allegheny, Fayette, Greene and Washington counties.
The study — called Opioid Misuse Onset: Implications for Intervention — found that four in five users started with prescription opioids before progressing to full-blown addiction, usually to heroin and fentanyl.
Around one-third got their first taste of opioids from a prescription written for them, often following a tooth extraction or surgery. A small sliver bought their first pills from a dealer.
But for a big majority, said Ms. McLean, the first pill was “something that was on offer,” usually for free, from a friend or family member. It's tough, she said, to “refuse what seems like an innocuous drug from a person you trust.” A few stole their first pills from family or friends, or paid something, but for most it started with a gift.
That's consistent with findings by Raminta Daniulaityte of Wright State University who has been studying opioid users since 2002.
As the market became saturated with pain medication in the early years of this century, she said, many habits started with a simple act of sharing. “They maybe share with their peers if somebody has a headache or a bad day,” she said.
A shared pill or two can have especially long-term consequences when the recipient is young, said Stephen Lankenau, a professor and associate dean for research at Drexel University, who has done studies focused on users who started in their teens.
“What it does is, it kind of sensitizes a person to this substance. They may try it once or twice and then not try it again for a while,” he said. “When there are other opportunities later to try it again, or in larger amounts, you may be primed for use.”
There are increasingly prevalent efforts to get narcotics out of medicine cabinets, including twice-annual National Drug Take Back Days, permanent medicine drop-off boxes, and various pouches that turn opioids into harmless goo that can be tossed in the trash.
Prescribers should tell patients about these measures, said Mr. Rigg. “I’ve been prescribed opioids in the past for a variety of things,” he said. “And they don’t tell me anything [like], ‘Hey, don’t take more of this,’ or, ‘Hey, when you’re done with these pills, you should throw them away.’”
Schools have a role to play, too, said Ms. McLean. “We really have to start arming individuals with up-to-date, accurate information about the risks posed by different substances,” she said. “School-based curricula are still extraordinarily important, perhaps at that critical middle-school-to-high-school transition.”
A Pittsburgh Post-Gazette look at school district drug prevention efforts found last year that relatively few use proven, evidence-based curriculum.
The Penn State data showed another very common ingredient in addiction histories: Of the 30 interviewed, 23 first saw substance abuse affect a childhood peer or caregiver, and many cited that as “a turning point” in their attitude toward drugs, making it seem “benign, commonplace or even fun,” according to the study.
“Witnessing your parents or siblings or uncle using drugs has an effect of normalizing the behavior,” Mr. Rigg explained. “It has an effect of saying, [that drug use] is a legitimate way of having fun or coping with problems.”
The implications? If society can reduce childhood exposure to drug abuse, it can bend the curve of addiction, according to the study. Identifying young people who are vulnerable to addiction and addressing the needs of their families could help to break the cycle, researchers said.
With the epidemic as widespread as it is, there's a dark downside to the finding that people in addiction often had youthful models. “[I]f the children of current opioid misusers are at increased risk of misuse as they age into adolescence and young adulthood, we may see [opioid misuse] and mortality continue to rise in the coming decade,” the authors wrote.
While fatal overdoses in the nine-county southwestern Pennsylvania region are down from their peak of 1,413 in 2017, drugs still took more than 800 lives here last year. Researchers are seeing new drug trajectories taking root, including people who never used prescription opioids starting on heroin; cocaine users shifting — sometimes inadvertently — to heroin and fentanyl; and opioid users moving to methamphetamine.
“The epidemic has changed a lot over the years,” said Mr. Rigg. “It’s a living, breathing thing.”