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Keywords:

  • pharmaceutical opioid;
  • oxycodone;
  • heroin;
  • transition;
  • injecting

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

Introduction and Aims

The non-medical use of pharmaceutical opioids is associated with a range of negative health consequences, including the development of dependence, emergency room presentations and overdose deaths.

Design and Methods

Drawing on life history data from a broader qualitative study of the non-medical use of painkillers, this brief report presents two cases of transitions from recreational or non-medical pharmaceutical opioid use to intravenous heroin use by young adults in Australia.

Results

Although our study was not designed to assess whether recreational oxycodone use is causally linked to transitions to intravenous use, polyopioid use places individuals at high risk for progression to heroin and injecting. Our first case, Jake, used a range of analgesics before he transitioned to intravenous use, and the first drug he injected was methadone. Our second case, Emma, engaged in a broad spectrum of polydrug use, involving a range of opioid preparations, as well as benzodiazepines, cannabis and alcohol. Both cases transitioned from oral to intravenous pharmaceutical opioids use and subsequent intravenous heroin use.

Discussion and Conclusions

These cases represent the first documented reports of transitions from the non-medical or recreational use of oxycodone to intravenous heroin use in Australia. As such, they represent an important starting point for the examination of pharmaceutical opioids as a pathway to injecting drug use among young Australians and highlight the need for further research designed to identify pharmaceutical opioids users at risk of transitions to injecting and to develop interventions designed to prevent or delay these transitions. [Dertadian G, Maher L. From oxycodone to heroin: Two cases of transitioning opioid use in young Australians. Drug Alcohol Rev 2014;33:102–104]


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

The non-medical use of pharmaceutical opioids (PO) is associated with a range of negative health consequences, including the development of dependence, emergency room presentations and overdose deaths [1–3]. In the USA, non-medical PO use has increased by 40% in the last decade, with the largest increases seen among adolescents and young adults [4]. Since 1999, intentional overdose deaths related to PO have quadrupled and now account for more overdose deaths than heroin and cocaine combined [5].

Young non-medical users of POs are often unaware of the risks associated with their use [6], tending to view prescribed drugs as safer, less stigmatised and less subject to legal penalties than illicit street drugs [7,8]. Although most non-medical PO use begins with oral ingestion, recent research indicates that a significant minority may transition to the use of heroin and/or administration of opioids by injection, typically within 2–3 years of initiating use [9]. These data suggest that the non-medical use of PO may represent a new pathway [10] to intravenous heroin use, with a 2007 study posing the question, ‘Is OxyContin® a “Gateway Drug” ’? [11]. This brief report addresses this question by presenting the first reported cases of transitions from recreational or non-medical use of PO to intravenous heroin use by young adults in Australia. The cases draw on life history data from a broader qualitative study of the non-medical use of painkillers conducted by the first author as part of his PhD.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

From November 2011 to October 2012, 27 qualitative life-history interviews were conducted with 25 people who were identified as non-medical users of painkillers in Sydney, Australia (two participants were interviewed twice). Eligibility for the study was not restricted to PO use and also included use of over-the-counter codeine products. Participants were recruited from an errand outsourcing website (https://www.airtasker.com) (n = 10), via Facebook (http://www.facebook.com.au) (n = 5), classifieds website (http://www.gumtree.com.au) (n = 2), and through fliers placed at university campuses (n = 2) and the Sydney Medically Supervised Injecting Centre (n = 2), as well as direct approaches (n = 4). Ethical approval for the study was received from the University of Western Sydney Human Research Ethics Committee, and participants were remunerated $AUD25. Interviews were audio-recorded and transcribed verbatim. Although not the primary focus of the study, the data presented here are based on the transcripts of two participants who reported transitions from oral PO use to intravenous heroin use.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

At recruitment to the study in 2012, Jake was a 29-year-old heroin injector with a history of detoxification attempts and opioid substitution treatment since 2007. Reflecting on his oxycodone use, Jake remarked, ‘I've never been prescribed [OxyContin®] or anything but I feel that I need it sometimes’ (Jake—Interview, 8 October 2012). Although as a teenager Jake used alcohol heavily and cannabis occasionally, he did not use oxycodone until he was 21, recalling that: ‘I had a girlfriend that got murdered and I started using them [oxycodone® pills] to block that out.’ His use of oxycodone gradually became habitual: ‘I started out using maybe one pill a fortnight and I went to a pill a week and it got worse and started being nearly every day and eventually, probably after about twelve months or so … [I] couldn't basically start the day without one.’

Jake's escalating use of oxycodone over a period of 20 months culminated in the injection of methadone. A friend who had been supplying him with oxycodone recommended that he try injecting methadone to ‘get a good night's sleep’. Encouraged by the ‘relaxing effect’, Jake's initial intravenous use of methadone was followed rapidly by regular intravenous heroin use, which he described as ‘easier to get’. Jake moved to the city in 2008 where he was homeless for a period of six months. After being stabilised on methadone for a period of approximately two years, Jake reported first injecting his (prescribed) methadone two months prior to interview. This was followed a week later by a return to intravenous heroin use. Jake came across a flyer for the study on one of his regular visits to the Sydney Medically Supervised Injecting Centre.

At recruitment to the study, Emma was 21 years old and had not used an opiate for approximately 20 months. Emma grew up on Sydney's lower north shore where she said oxycodone use was ‘a common problem’ (Emma—Interview, 13 March 2012). Her drug use commenced with smoking cannabis at 14, which she used regularly for ‘calming down [and] chilling out’ and to ‘kill anxiety’. At 15, Emma was taking diazepam and alprazolam from her parent's bathroom cabinet to cut and snort with friends ‘just as like jokes or whatever on the weekend’. Reflecting on this period, Emma recalled: ‘I remember when we just thought it … was safe ‘cause it was a prescription thing. But um, yeah it kinda didn't turn out like that.’

By the age of 16, Emma was regularly mixing alcohol and oral analgesics (paracetamol and codeine phosphate). Six months into a newly formed relationship, Emma's partner, James, sustained a debilitating back injury and was prescribed oxycodone. The pair began crushing and snorting his prescriptions. Emma also started selling cannabis to support their oxycodone use and purchasing oxycodone from an inner-city dealer. After 10 months, both Emma's and James' growing tolerance culminated in a transition to intravenous oxycodone use, Emma recalling that ‘by the end of it we would never swallow the pills, we would always crush them, taking the binders out, and shooting [injecting] them’. Emma described herself as a ‘highly functioning addict’, reporting that she would still ‘wake up in the morning and go to school and I'd go to TAFE and I'd work’. In 2008, one of the several dealers Emma relied on was not able to supply oxycodone and suggested she use heroin instead. As their heroin use escalated and their relationship deteriorated, Emma's and James' use of oxycodone became less frequent and largely confined to when they were unable to access heroin. Emma reported ‘[I]t sounds weird but, I was half doing it because um I wanted to get high and half just because I wanted a fucking break from James’. Emma came across a flier for this study as part of a university course she was taking.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

Increases in the non-medical use of PO have coincided with a rapid growth in the medical use of new, high-dose, extended-release oral formulations for treating chronic, non-malignant pain [12]. Many of these extended-release oral formulations are easily converted into forms that can be administered intranasally or intravenously. More recently, pharmaceutical companies have reformulated some drugs to deter abuse by making the pills harder to crush or turning them into a gummy substance that is more difficult to snort or inject. However, some evidence suggests that in the US, non-medical PO users have adapted to these changes by shifting to alternative POs, such formulations of oxymorphone that are more readily converted for intranasal and intravenous use.

In a qualitative study of PO use among street-based young people who inject drugs (aged 16–25 years) in Los Angeles and New York City, Lankenau et al. found that 82% of respondents initiated non-medical use of PO orally prior to injecting, and more than 80% reported non-medical PO use prior to their first use of heroin [9]. A recent study of people who inject drugs in Montreal found that the proportion of participants reporting injecting PO increased from 21% to 75% (P < 0.001) between 2005 and 2009, whereas the prevalence of heroin and crack use remained stable [13].

Australian research on opioid users has tended to focus on the diversion and injection of opioid substitution treatment medications [14,15], but to date, there has been less focus on non-medical or recreational PO use. National data on non-medical PO use are collected annually as part of the Illicit Drug Reporting System and Drug Use Monitoring in Australia projects; however, these studies do not report on transitions from oral to intravenous opioid use. Although data are sparse in the Australian context, in 2009, the Royal Australasian College of Physicians produced guidelines for the prescription of opioids which specifically outline strategies for avoiding problematic misuse [16].

Although our study was not designed to assess whether recreational oxycodone use is causally linked to a transition to intravenous use, polyopioid use places individuals at high risk for progression to heroin and injecting [11]. Jake used a range of analgesics before he transitioned to intravenous use, and the first drug he injected was methadone. Emma engaged in a broad spectrum of polydrug use, involving a range of opioid preparations, as well as benzodiazepines, cannabis and alcohol. Both Jake and Emma transitioned from oral to intravenous PO use and subsequent intravenous heroin use.

The cases presented here are the first documented reports of transitions from the non-medical or recreational use of oxycodone to intravenous heroin use in Australia. As such, they represent an important starting point for the examination of PO as a pathway to injecting drug use among young Australians and highlight the need for further research designed to identify PO users at risk of transitions to injecting and to develop interventions designed to prevent or delay these transitions.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
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