Opioid misuse and use disorder prevention strategies and programs must focus on multiple associated risk factors in the context of the person and their environment to ameliorate the ongoing epidemic. As epidemics do not occur in a vacuum, we accounted for the biopsychosocial characteristics associated with opioid misuse and/or use disorder. Sociodemographic, socioecological, and health factors, as well as other substance dependence or abuse were found to be independently significant for opioid misuse and/or use disorder. However, we found in our comprehensive model that socioecological indicators like criminality, health status factors including serious psychological distress and suicidality, and private health insurance were significant risk characteristics, as well as nicotine, alcohol, marijuana, cocaine, methamphetamine, tranquilizer, and stimulant dependence or abuse.
In our comprehensive biopsychosocial model we observed that sociodemographic factors functioned as controls rather than predictors for opioid misuse and/or use disorder. While other studies have focused on sociodemographic factors for describing risk in opioid misuse and overdose death [8, 9, 37, 45, 46], our model further revealed the significance of accounting for socioecological and health related risk factors in context of opioid misuse and/or use disorder. Our findings were similar to a study by Mojtabai, Amin‐Esmaeili, Nejat, and Olfson [47] that found prescribed-opioid misuse was associated with criminality, mental health distress, and other substance abuse or dependence. Similarly, a study by Grigsby and Howard [34] discovered that prescription opioid and polysubstance users had the greatest probability of past-year criminality and mental health distress.
The relationship of opioid misuse and/or use disorder, mental health distress, and socioecological factors like criminality are complex, and may be co-occurring. To understand this risk process we can look to a study by Prince [22], which found that individuals with opioid misuse disorder who had a severe mental illness were at an increased risk of criminality and suicidality. The risk increased for those using only heroin, both heroin and prescription opioids, and all other substances, in that order.[22] Moreover, we found that common mental health disorders such as major depression, dysthymia, generalized anxiety disorder, or panic disorder in the general population predicted a 96% increase in prescribed opioid use.[48] While the relationship between criminality, mental health, and substance use is notable for developing tailored interventions, an overemphasis on this link may also perpetuate harmful stigma and mask important underlying factors. For example, adverse childhood experiences may contribute to all three: criminality, mental health disorders, and opioid misuse and use disorder.[49-51]
Of note from our findings was that race/ethnicity in the presence of other socioecological and health factors related to polysubstance use may not be strongly associated with polysubstance dependence/abuse and opioid misuse and/or use disorder.[52] For instance, we found non-Hispanic Whites, American Indian/Alaska Natives, and non-Hispanic multiracial individuals were a significant group until polysubstance dependence/abuse was accounted for in the comprehensive model, but it may be explainable by other contextual factors.[53, 54] Whites, for example, are often prescribed more opioids compared to their Non-Hispanic Black counterparts, regardless of genuine clinical need.[53] Furthermore, other possibilities to consider between and within racial/ethnic groups are access to illicit drugs for purchase and use of drugs by friends and family members, as well as adverse childhood experiences or trauma.[51, 55-57]
Other substance dependence or abuse has been associated with opioid misuse based on various risk factors.[11, 25, 30, 45, 58] In our study, we found that nicotine [25, 26], alcohol [25, 27], cocaine [58], methamphetamine [29], tranquilizers [31, 32, 59], other illicit stimulants [15], and marijuana [25] have a positive relationship with opioid misuse and use disorder. The stimulant effect from nicotine, cocaine, methamphetamine, and other illicit stimulants may mitigate the depressive effects of opioids and may increase the “high” effect.[29] Substances such as tranquilizers have been reported to be used to heighten, maintain, and extend the effect of the “high” [31-33], which may explain the elevated odds ratio of 16.7 when compared to all other substance dependence or abuse. Further research would be necessary to capture this context. Tranquilizer dependence and abuse is also of particular note, as most opioid overdose reported in the US involved some type of tranquilizer—for example, benzodiazepines.[60, 61]
Our study also revealed an increased association of opioid misuse and/or use disorder with marijuana compared to non-marijuana users. This relationship, however, has been found to have mixed associations in previous studies. In the cases of marijuana dependence or abuse there is a positive relationship with opioid misuse.[34] A more recent review found that medical marijuana use may decrease the probability of opioid use.[36] Campbell et al. [36] further revealed that medical cannabis laws may slow the increase of opioid overdose deaths in states with medical cannabis laws compared to states with none. Alcohol has been another substance with mixed associations for opioid misuse and use disorder. For instance, Fernandez et al. [27] reported that alcohol dependence or abuse was not associated with opioid misuse. We found, however, in our comprehensive adjusted model that alcohol dependence or abuse was associated with a higher probability for opioid misuse, in line with the findings of Witkiewitz et al. [62] Overall, prevention strategies and prevention programs must focus on both the combined use of legal and illicit substances.
Our study used a comprehensive approach to understand how multiple biopsychosocial characteristics relate, in context, to opioid misuse and/or use disorder. Since the current opioid crisis is not unlike prior substance use disorder crises of the past, our goal was to provide data that can be used to inform primary, secondary, and tertiary prevention efforts along the continuum from opioid misuse to use disorder—with attention to particular groups and contextual factors. By identifying risk factors within our model, we were able to contextually examine biopsychosocial characteristics to inform future research and prevention strategies to intervene upon opioid use disorder and related distal outcomes for noninstitutionalized US adults. Tailored interventions could be effective for individuals reentering society from incarceration, experiencing unemployment, suffering from psychological distress, and/or using public health insurance.[63] Examples include reentry programs, jobs placement programs, and integrated mental health and substance abuse treatment.[64-67] Nonetheless, opioid use and misuse disorder may occur alongside use of other substances, and both the determinants and effects of concurrent use must be addressed by interventions.[5] Our hope is that our results do not perpetuate stigma but rather encourage the development of effective interventions for specific populations.
Lastly, our study using a biopsychosocial model elucidated that the opioid epidemic is not an epidemic as much a syndemic. The opioid syndemic involves multiple interacting social, health, and psychological factors with comorbid substance co-use that synergizes the negative effects of opioid misuse and/or use disorder.[68, 69] Future interventions will need to acknowledge the opioid syndemic as multiple dynamic and complex factors and health outcomes that come as a result not only from misuse and/or use disorder, but policies and environmental contexts. As such, future studies will have to use complex models to move beyond one-dimensional outcomes to understand the contextual issues of opioid misuse and/or use disorder and improve not only overdose outcomes but person-level quality of life.
Limitations
To our knowledge, this is the first US population-level study to comprehensively address risk profiles of opioid misuse using the latest national survey data available. Like most surveys of this kind, there are limitations to the NSDUH. The most prominent limitation is the use of self-reported data. These data are subject to the individual participant’s bias, truthfulness, recollection, and knowledge. Second, although the data are nationally representative, the survey is cross-sectional, and it excludes some subsets of the population. The NSDUH only targets noninstitutionalized US citizens, so active-duty military members and institutionalized groups (e.g., prisoners, hospital patients, treatment center patients, and nursing home members) are excluded. Thus, if substance use differs between US noninstitutionalized and institutionalized groups by more than 3%, data may be problematic for the total US population.[44] A particularly notable limitation of the NSDUH is that it does not include information regarding chronic pain. This omission necessarily narrowed our analysis and inhibited our ability to create a truly comprehensive model. Another issue that may have introduced bias is participant knowledge or lack thereof concerning opioids and other substances.[70] Moreover, heroin is a less commonly used opioid and there are issues in accounting for the true prevalence of this substance use.[70, 71] Finally, the opioid misuse data do not fully account for synthetic opioids like fentanyl.