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Opioid withdrawal symptoms, frequency, and pain characteristics as correlates of health risk among people who inject drugs

https://doi.org/10.1016/j.drugalcdep.2020.107932Get rights and content

Highlights

  • 85 % of opioid-using people who inject drugs (PWID) reported opioid withdrawal.

  • The majority of PWID reported very/extremely painful opioid withdrawal symptoms. were common among opioid-using PWID.

  • Opioid withdrawal was associated with risk for non-fatal overdose among PWID.

  • Opioid withdrawal was associated with receptive syringe sharing among PWID.

Abstract

Objective

Opioid withdrawal symptoms are widely understood to contribute to health risk but have rarely been measured in community samples of opioid using people who inject drugs (PWID).

Methods

Using targeted sampling methods, 814 PWID who reported regular opioid use (at least 12 uses in the last 30 days) were recruited and interviewed about demographics, drug use, health risk, and withdrawal symptoms, frequency, and pain. Multivariable regression models were developed to examine factors associated with any opioid withdrawal, withdrawal frequency, pain severity, and two important health risks (receptive syringe sharing and non-fatal overdose).

Results

Opioid withdrawal symptoms were reported by 85 % of participants in the last 6 months, with 29 % reporting at least monthly withdrawal symptoms and 35 % reporting at least weekly withdrawal symptoms. Very or extremely painful symptoms were reported by 57 %. In separate models, we found any opioid withdrawal (adjusted odds ratio [AOR] = 2.75, 95 % confidence interval [CI] = 1.52, 5.00) and weekly or more opioid withdrawal frequency (AOR = 1.94; 95 % CI = 1.26, 3.00) (as compared to less than monthly) to be independently associated with receptive syringe sharing while controlling for confounders. Any opioid withdrawal (AOR = 1.71; 95 % CI = 1.04, 2.81) was independently associated with nonfatal overdose while controlling for confounders. In a separate model, weekly or more withdrawal frequency (AOR = 1.69; 95 % CI = 1.12, 2.55) and extreme or very painful withdrawal symptoms (AOR = 1.53; 95 % CI = 1.08, 2.16) were associated with nonfatal overdose as well.

Conclusions

Withdrawal symptoms among PWID increase health risk. Treatment of withdrawal symptoms is urgently needed and should include buprenorphine dispensing.

Introduction

Opioid use, including prescription opioids, heroin, and licitly and illicitly manufactured fentanyl, is a national crisis in the United States. In 2017, an estimated 11.4 million people misused opioids in the past year, including 11.1 million people who misused pain relievers and 886,000 people who used heroin (Substance Abuse and Mental Health Services Administration, 2018). More than 130 people die each day in the United States from opioid-related overdose (Substance Abuse and Mental Health Services Administration, 2018), with overdose now the leading cause of accidental death in the United States (Kochanek et al., 2019).

Along with increased overdose deaths, there is evidence of increased injection use of opioids. Epidemiological studies have documented HIV outbreaks, regional and national increases in HCV infection, injection-related infective endocarditis, and skin and soft tissue infections since 2000 (Campbell et al., 2017; Centers for Disease Control and Prevention, 2014; Hedegaard et al., 2015; Keeshin and Feinberg, 2016; Longo et al., 2004; Mack et al., 2017; Unick and Ciccarone, 2017; Unick et al., 2013; Wurcel et al., 2016). Another common consequence of opioid use is opioid withdrawal.

Opioid withdrawal may occur if someone is physically dependent on opioids and then abruptly stops or substantially reduces their opioid dose, with the time of onset, peak symptoms, and duration of opioid withdrawal varying depending on the specific opioid being used. For example, symptoms of heroin withdrawal can begin as soon as 4–6 hours after last use, peak within approximately 24–48 hours, and may last for 7–14 days (O’Connor and Fiellin, 2000). The experience of opioid withdrawal is characterized by physical symptoms that may include muscle aches and bone pain, abdominal cramps, agitation and anxiety, nausea and vomiting, diarrhea, gastrointestinal upset, tachycardia, rhinorrhea, and chills (Donroe et al., 2016; Wesson and Ling, 2003).

As a person’s opioid use increases and they become more involved in the moral economy of drug use exchanges and relationships (Wakeman, 2016), they may become more focused on obtaining opioids as an effective way to avoid withdrawal symptoms (i.e., “getting sick” and “staying well”), resulting in increased unsafe drug use contexts (Sherman and Latkin, 2002), socioeconomic marginalization, and related consequences such as incarceration and unemployment that may further increase risk (Richardson et al., 2019). Along these lines, withdrawal has been found to be a common barrier to reducing the risk of unsafe drug contexts (Phillips, 2016) among people who inject drugs (PWID). This presents a cycle of increasing drug use to avoid withdrawal: a person develops an urgent need to avoid or alleviate withdrawal, they become anxious about withdrawal and/or getting well and will often seek injection as a route of administration to quickly alleviate being sick, which may lead to engaging in unsafe drug use behaviors (e.g., shared needles, using alone) with increased risk for infectious disease transmission and overdose, both nonfatal (Coffin et al., 2007; Pouget et al., 2017) and fatal (Fairbairn et al., 2017; Mars et al., 2018a, 2018b). To break this cycle and related health risks, evidence points to interventions to reduce exposure to withdrawal episodes and risky injecting networks (Barnes et al., 2018; Mateu-Gelabert et al., 2014; O’Connor and Fiellin, 2000; Weiss et al., 2014).

Chronic opioid use can lead to withdrawal symptoms, yet withdrawal symptoms have rarely been measured in community samples of PWID. In the following, we describe the prevalence, demographic, and drug use factors associated with opioid withdrawal symptoms, frequency, and pain severity in a sample of street-recruited PWID and examine if opioid withdrawal symptoms are associated with receptive syringe sharing and non-fatal overdose.

Section snippets

Study sample

Data for these analyses come from the “Change the Cycle” efficacy trial study in Los Angeles and San Francisco, California (Strike et al., 2014) (NIDA grant #R01DA038965). For these analyses, we use data from the baseline interview. Participants were recruited using targeted sampling methods (Bluthenthal and Watters, 1995; Kral et al., 2010; Watters and Biernacki, 1989). Study inclusion criteria were self-reported injection drug use in the last 30 days (confirmed by visual inspection of

Sample characteristics

The sample was mostly male (75 %) with an average age of 42 years (SD = 12.34; median = 42; Interquartile Range [IQR] = 31, 52)(Table 1). The plurality of subjects was White (41 %), with meaningful proportions reporting being Latinx (25 %), African American (21 %), Native American (7%), and Mixed Race/Other Race (6%). Average number of years of drug injection was 20.36 (SD = 14.20; median = 19.00; IQR = 7, 32). Current homelessness was reported by 84 % of our sample. Overall, the mean frequency

Discussion

To our knowledge, this is the first study to characterize opioid withdrawal symptoms among community recruited PWID on the West Coast. Opioid withdrawal symptoms were reported by the vast majority of opioid-using PWID (85 %) making opioid withdrawal symptoms among the most common chronic health problem experienced by this population (by way of comparison, HCV infection was reported by 61 % and HIV by 4% of this sample; other samples have found any mental health diagnosis as high as 82 % in

Role of funding source

Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number RO1 DA038965, Project Official, Richard Jenkins, Ph.D. and R01DA046049, Project Official, Heather Kimmel, Ph.D.

Contributors

Ricky N. Bluthenthal designed the study (along with Alex H. Kral), conducted the statistical analysis and prepared drafts of the manuscript (along with Kelsey Simpson, Rachel Carmen Ceasar, and Johnathan Zhao). Lynn Wenger managed the study protocol. All authors contributed to and have approved the final manuscript.

Data statement

Data will be made available to other investigators 1 year following the completion of this study (July 2021).

Declaration of Competing Interest

The authors have no conflict of interest to declare.

Acknowledgement

We would like to thank study participants for their time and effort in this project. We would also that the following individuals who meaningfully contributed to the study: Amin Afsahrezvani, Debra Allen, Letizia Alvarez, Julia Balboni, Joseph Becerra, Kacie Blackman, Guiseppe Cavaleri, Janae Chatmon, Fitsum Dejene, Karina Dominguez Gonzalez, Mohammed El-Farro, Brian Erwin, Sernah Essien, Allison Few, Hrant Gevorgian, Allessandra Gianino, Johnathan Hakakha, Jennifer Hernandez, Monika Howe,

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