The Stories behind the Struggle: A Closer Look at First Experiences with Opioid Misuse

Khary K. Rigg, Shannon M. Monnat, Katherine McLean, Ashton Verdery, and Glenn Sterner

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KEY FINDINGS

  • Opioid misuse most often begins before age 25, peaking between ages 18-25.
  • Opioid misuse most often begins with prescription painkillers rather than heroin, but…
  • Most people obtain the opioids they misuse from friends and family, rather than a health care provider.
  • Experimenting and coping with life stressors are the most common motivations for starting opioid misuse.

Opioid use disorders and overdoses from prescription opioids, heroin, and fentanyl have become a national public health crisis. Since 2005, the national rate of opioid-related hospitalizations has risen sharply, with inpatient stays increasing by 64%, and emergency department visits almost doubling.1 Opioid deaths are at an all-time high, with over 49,000 deaths in 2017 alone. The cost of the opioid crisis is estimated to be a staggering $504 billion.2 Even with billions of dollars being spent to curb the opioid crisis, the problem continues to worsen, as over a million Americans are projected to begin misusing opioids over the next few years.3

Improving our knowledge about how people first come to misuse opioids can help to inform prevention and treatment interventions. When individuals are asked why they started using a particular drug, they typically do not point to a lone factor, but rather tell a story explaining the circumstances surrounding their initiation. Listening to the stories of people who misuse opioids allows for a fuller understanding of the factors that contribute to addiction. Below we summarize people’s stories about their first opioid misuse based on research we conducted in southwestern Pennsylvania in 2017 and 2018.4

When do most people begin misusing opioids?

Among our respondents, opioid misuse typically began prior to age 25, peaking between ages 18-25 (see Figure 1). Nearly 75% of respondents reported that their first prescription opioid misuse occurred before age 25, and 63% reported that they first tried heroin before age 25.

Respondents’ first opioid misuse typically occurred with prescription painkillers (81%), rather than heroin. However, our respondents reported misusing a variety of other substances (e.g., alcohol, marijuana, and other drugs), often for years, before ever trying opioids. Opioids were almost never the first drug our respondents tried.

Why do people begin misusing opioids?

We asked respondents about the situations or conditions that characterized the period in their lives when they first started misusing prescription opioids or using heroin. A major reason given for initiating opioid use was to cope with adverse childhood experiences and relationship problems. For example, Mary, a 51-year-old white female, described some of the stressors in her life that led her to begin misusing opioids:

“My life has always been very stressful…Last October, I broke up with a guy I was seeing…and my daughter went to prison all in the same month. And I do have bi-polar and depression…”

Another reason for initiating was experimentation or the desire for a novel psychoactive experience. This “experimental” initiation pattern occurred as a consequence of having access to the drug, boredom, and the absence of friends or family to deter such use.  For example, Caleb, a 29-year-old white male, decided to start using opioids on a “slow” night when curiosity overtook him:

“Yeah, it wasn’t like I was hanging out with my friends or anything. I was literally alone in my bedroom and I just figured, let me try this.”

Very few of our respondents said that they started misusing opioids for pain relief. For these participants, doctors prescribed opioid analgesics to relieve pain, but during treatment, participants felt an accompanying state of well-being and euphoria that they found appealing. Kathy described feeling her first opioid high while being prescribed Lorcet for pain:

“With the pain pills, it made me feel like I wasn’t locked in my body anymore…It unlocked me, gave me an energy boost, and made my concerns go away immediately. It made me not shy and truly fixed everything that was ever wrong with me and made me normal.”

How do people acquire the opioids they misuse?

Our findings also shed light on how opioids are initially acquired. Friends, acquaintances, or romantic partners were the most common sources of opioids the first time an opioid was misused (see Figures 2 and 3). Respondents rarely reported paying for the opioids they first misused. Friends or family typically shared opioids without charging. Nearly 40% of respondents got the prescription opioids they first misused given to them by a friend or family member, and over 60% got the heroin they first used from a friend or family member. However, some respondents reported stealing prescription opioids or heroin from a family member or friend without their knowledge. Less than 40% of respondents reported gaining access to the prescription opioids they first misused through a health care provider.

Implications for Intervention

Given that most opioid misuse begins prior to age 25, but after individuals have already tried several other substances, high schools and colleges may be an important venue for delivering prevention programs. Prevention interventions should especially target young people who are already misusing alcohol and other substances, as they are at highest risk of transitioning to opioids. It is also worth noting that although heroin and fentanyl now account for the largest share of opioid deaths, opioid misuse still tends to start with prescription opioids that are shared, traded, or stolen from friends or family. Opioid misuse does not typically begin from prescriptions legally obtained from a health care provider.

Client-centered approaches to counseling are also warranted. Such approaches aim to engage the client’s intrinsic motivations for behavior change by exploring and resolving ambivalence within the client. Because the overall goal is to help the client understand and resolve their competing drug use motivations (the motivation to continue using vs. the motivation to cease/reduce drug use), understanding the motivational forces that compel individuals to start misusing opioids in the first place is important.

Data

Data are from 125 surveys and 30 in-depth interviews conducted from July 2017 to July 2018 with residents of southwest Pennsylvania who reported recent opioid (prescription opioids and/or heroin) misuse. Prescription opioid misuse is defined as using pills that were not prescribed to you or taken them in a way that was not prescribed by a doctor. This includes things like taking them more frequently than prescribed, taking them to get high, and crushing them to get the dose faster. For more methodological details, or to read the full study, visit: https://doi.org./10.1080/10550887.2019.1609336.

Acknowledgments

This study was funded by the Social Science Research Institute and by the Justice Center for Research at Penn State University (PI: Ashton Verdery).

References

1. Weiss, A. J., Elixhauser, A., Barrett, M. L., Steiner, C. A., Bailey, M. K., & O’Malley, L.
(2017). Opioid-related inpatient stays and emergency department visits by state,
2009–2014. HCUP Statistical Brief #219Rockville, MD: Agency for Healthcare
Research and Quality via https://www.hcup-us.ahrq.gov/reports/statbriefs/sb219-
Opioid-Hospital-Stays-ED-Visits-by-State.jsp.
2. White House Council of Economic Advisers (2017). The underestimated cost of the opioid crisis. Washington, DC. via https://www.whitehouse.gov/sites/whitehouse.gov/
files/images/The%20Underestimated%20Cost%20of%20the%20Opioid%20Crisis.pdf.
3. Dart, R. C., Surratt, H. L., Cicero, T. J., Parrino, M. W., Severtson, S. G., Bucher-Bartelson, B., & Green, J. L. (2015). Trends in opioid analgesic abuse and mortality in the United States. New England Journal of Medicine, 372(3), 241-248.
4. Rigg, K. K., McLean, K., Monnat, S., Sterner, G., & Verdery, A. (2019). Opioid misuse onset: Implications for intervention. Journal of Addictive Diseases. Published online. https://doi.org/10.1080/10550887.2019.1609336

About the Authors

Khary Rigg is an Assistant Professor in the Department of Mental Health Law & Policy at the University of South Florida and a faculty affiliate with the Louis de la Parte Florida Mental Health Institute (rigg@usf.edu). Shannon Monnat is Lerner Chair for Public Health Promotion and Associate Professor of Sociology at Syracuse University (smmonnat@maxwell.syr.edu). Katherine McLean is Assistant Professor in Administration of Justice at Penn State Greater Allegheny (kjm47@psu.edu). Ashton Verdery is Assistant Professor of Sociology at Penn State University (amv5430@psu.edu). Glenn Sterner is Assistant Professor of Criminal Justice at Penn State Abington (ges5098@psu.edu).

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