We analyzed data available from 7 ROI sites, which included IL (n = 22), KY (n = 57), NC (n = 65), NE (n = 22), OH (n = 26), OR (n = 52), and WI (n = 60) (Table 2). The mean age of participants (n = 304) was 36 years (SD: 9.8, median 34, IQR: 28–42); 56% of participants were male. Approximately two-thirds reported illicit use of opioids in the 30 days prior to the interview, and 92% reported injecting drugs in the past 30 days (Table 2). The mean age of first illicit use of any drug was 14 years, first opioid use (whether illicit or prescribed) was 20 years, and first IDU was 24 years (Table 3). Figure 1 demonstrates drug use trajectories from most common first drugs and first opioids used, to first IDU.
Table 2 Demographic and substance use characteristics
Results are presented here in the following order: first illicit drug use; first opioid use, with a sub-section highlighting the transition specifically from prescribed initial opioid use to subsequent illicit use; and first injection drug use. Each of these three transition points are framed in terms of levels of the SEM starting with environmental factors, followed by interpersonal and person-level factors, where applicable. We note that organizational and systemic levels of the SEM are not included here, as participants did not discuss factors at these levels.
First drug use
Marijuana was the most common first drug used (60%, mean age: 13 years, see Table 3), and opioid pills were the second most common (16%, mean age: 19 years).
Table 3 a First illicit use of drug, ever (n=304, mean age 14), b First opioid use, (n=304, mean age 20), c First injection drug use (n=304, mean age 24)
Environmental level
Participants’ first exposure to drugs was often during childhood within their own household environment. Early availability within the household and general curiosity catalyzed experimentation:
I started smoking pot when I was young, probably 11 or 12, because my parents smoked through my whole growing up. I just wanted to know, more or less, what it was about. So I snuck some weed from them, and went out in the yard and smoked with a couple of my friends and got high for the first time. Woman, 26, Oregon.
Participants described ubiquitous drug use and availability in environments outside of their home. Drugs were commonly available from the households of friends:
I was with my best friend at her mom’s house [age 10], and her mom was someone who bought [opioid pills] on a regular…she really didn’t care. “Go for it, try it. I’ll leave you guys some on the plate.” Woman, 28, New England.
Interpersonal-level
At the interpersonal level, first drug experiences were typically brought forth by older siblings, relatives, or neighbors:
I was 14. My stepbrother was visiting and he had some hash, and so he asked me if I wanted to get high. I never had been…he had to show me how to smoke it. Man, 35, Oregon.
Often these were people they admired or looked up to:
When I first smoked pot, I was about eight or nine years old…I remember smoking out of a bubbler pipe with my mom’s boyfriend’s kids. Older guy, he was about 16 or something. I looked up to him…I spent a lot of time together with them, their family, because my mom was going out with their dad. Man, 55, Oregon.
Witnessing the pleasurable effects experienced by others catalyzed first drug use:
The older kids in the neighborhood would smoke pot, and they looked like they were having fun. I mean they were happy all the time, laughing, giggling, so we thought we’d try it. Woman, 30, Kentucky.
I seen my aunts and my uncles use pain pills. And I was around them more and more growing up and then I started. I said, “Well, they’ve tried it. Why don’t I try it?” …I think I seen them getting enjoyment out of it and I said, “Well, they’re getting enjoyment out of it, so can I.” Man, 26, Kentucky.
In several cases, parents supplied the drug directly, and used with them, as a means of bonding:
My dad thought it was cool that he was getting stoned with his kid. Woman, 36, Wisconsin.
Co-use with parents was a particularly common theme in adolescence. One participant describes a common theme of parental resignation:
My mom and me were doing [opioid pills] together when I was about 15, because my mom was my best friend. After I got in trouble at 15 years old on my birthday, my mom was like, “All right, dude. You’re going to do what you want anyways.” Man, 55, Oregon.
In adolescence, several initiated drug use to facilitate social inclusion:
I was with some friends wanting…acceptance, to be cool, one of the crowd, and my friend says, “I know where to get some marijuana.” Man, 55, Wisconsin.
I hit high school and…I found a group of people, one person in particular who accepted me. And “hey, come with me and we’ll go to this house,” and we smoked weed. And then we smoked opium and hash…I finally felt like I had a friend. Woman, 30, New England.
Person-level
For most, happenstance and curiosity were primary circumstances around drug use initiation. However, many participants began drug use to mitigate stress:
I was 9 years old and every morning I would wake up having complete anxiety break downs…a lot of times I would be humiliated by other classmates because I’ve always been bigger [in size]. When I was introduced to marijuana it totally helped… just to calm me down. Woman, 36, Wisconsin.
Participants also noted the use of drugs to cope with household marital stress:
My mom and dad, they fought a lot growing up. And it was miserable listening to it every day. That’s why I ran off and got on drugs, pretty much. Man, 26, Kentucky.
In childhood and adolescence participants described an intersection of factors at multiple levels of the SEM which facilitated first drug use. One participant echoes others in describing the combination of household drug availability, normalization of family drug use, desire for social inclusion, and parental encouragement to use drugs as a means of coping:
[Opioid medication] appealed to mom—it always seemed like it was around somehow, some way, and I kind of wanted to do it, I guess to be older, to fit in…she said it would make me feel good…I had a miserable childhood, so I…just wanted to escape from it, I guess and to feel good for once. Woman, 27, Kentucky.
Encouragement by family or loved ones to use opioids to cope with hardship was common for first use occurring in adulthood as well:
I was 18 and I got my first pain pill from my mother…me and my husband at the time was splitting up, and I just started taking them. You know, she said, here it’ll make you feel better. So, I just started taking ‘em and taking ‘em. Woman, 32, Ohio.
First opioid use
The majority of participants were first introduced to opioids (whether illicit or prescribed) in pill form (74%, mean age: 19 years), while 13% reported some form of heroin as their first opioid (mean age: 22 years) (Table 3). For participants, whose first opioids were in pill form, 44% first accessed the pills through friends or family, and another 44% were prescribed opioid pills to address a health issue before transitioning to illicit use.
Environmental-level
Participants described ease of accessibility of opioid pills, whether prescribed or not, in the larger community. Among persons for whom opioids were initially prescribed to them, it was common to receive large amounts of opioid pills, or continuous access:
I was [prescribed] Vicodin. I hurt my neck and had a herniated disk, and I went to the hospital for a workman’s comp…I didn’t know what Vicodin [was]- I had 120 of these pills, I wasn’t even gonna go fill [the prescription]…I hate pills. My buddy said, “you’re going to fill this.” I said, “why would I?” “Pain meds.” That was it, was on poppin’ after that. I mean, I was on Vicodin for about 6 months. Man, 45, Wisconsin.
Continuous, unrestricted access was a common occurrence reported by some:
I had a quack doctor and he just handing over opioids like it was candy, ya know? He was giving me Valium, Percocet, every single one. Woman, 50, Ohio.
At the household environment level, as with first drug use, opioid use was often normalized, and availed to participants by family members:
My dad would get fentanyl patches and Vicodin, and would give them to me, and that’s how it started for me, [my use] just gradually increased. Woman, 29, Wisconsin.
Interpersonal-level
As described with first drug use, at the interpersonal level, some parents used opioids to facilitate or improve relationships with their teenaged children, and was particularly salient in the context of divorce:
My parents got a divorce when I was 14 years old…I see now, my dad was [snorting Percocets] with us as a way bribing us to stay there. Man, 25, Ohio.
Person-level
While many were prescribed their first opioid for a medical reason, those who initially accessed opioids through non-medical sources typically started in order to cope with hardship or trauma. Some started their use of opioids to numb psychological pain:
I was 22 and my girlfriend had just broken up with me, and my friend basically gave me a hydrocodone 5 or 10 and was like, this will make you feel better. And that’s how it all started…and from there, it was pretty regular. Man, 29, North Carolina.
Several initiated opioid use to help cope with loss and grief:
My mom had just passed away, and she had a prescription of pain medication left over…it was a shock, and I couldn’t deal with it. I used her script to get through the funeral…when she died I didn’t know what to do. I didn’t know how to live. Woman, 39, Kentucky.
As these participants’ words demonstrate, unaddressed mental health needs were a common factor in motivating first opioid use. Uncertainty regarding a way forward from despair combined with broader factors such as widespread environmental and household availability of opioids and normalization of use. Mental health needs surrounding economic uncertainty were also common, as described by one man:
[I started opioid use because of] depression. To get away. We were losing our house. That’s when the coal mine started going down – the economy and all that. I just graduated high school and didn’t know what I was going to do in the future, as in career-wise. Man 26, Kentucky.
Participants commonly described personal economic incentives to use opioids. Several began opioid use to fulfill work related tasks, with the goal of having energy while minimizing pain:
I’ve hurt my back at work. It was just a pulled muscle, something simple. But a lady had gave me a couple of Lortabs [hydrocodone/acetomenophin]. Back then, I didn’t know nothing about addiction or anything. So they made me feel good, gave me a lot of energy. So I started buying them where if I wanted to work a double or something, them pills would give me extra energy. Man, 43, Illinois.
In a context of limited job opportunity inherent to rural settings, there was a desire to perform well within existing employment. The desire to meet multiple competing demands, such as parenting and work-related tasks, facilitated the appeal of trying opioids, was common, as expressed by one woman:
I was fixing to go to work and I was wore out because I work night shift and I had a baby all day. So I never got to sleep. And I talked about going and getting yellow jackets, them energy pills at the gas stations. And [my cousin] said, well, you don’t need to get one of them. I have a Lortab. We’ll just crush it up and snort it. [I said] I’ve never done that before. She said it’s just going to give you energy and just make you feel better. She said you’ll get in that work and you’ll make production so great, they’re going to make you manager. So I tried it. Woman, 29, Kentucky.
Transition from prescribed opioid use to increased illicit use
Environmental level
Many participants reported increased illicit use of opioids following a medical issue for which they had been legally prescribed opioids. As opioid prescribing practices became increasingly regulated, participants reported turning to illicit markets in their community to obtain them. Other options were readily available:
I tried getting a script for my pain. I was a waitress and my bones were hurting. Well, they wouldn’t give them to you. You had to fight and fight and fight to get something…so, we used to buy them off the streets. Woman, 56, Ohio.
Eventually, illicit opioid pills became less available. The high cost and increased scarcity of opioid pills on the illicit drug market led people to find ways to get more out of them, such as by pulverizing and snorting the pills:
…I think I only got one prescription of like 30 [Vicodin]. And after like five or six, I started breaking ‘em up and sniffin’ ‘em. Man, 24, New England.
Many described transitioning to heroin, which was cheaper and easier to access, as availability of opioid pills waned, as described by one participant:
I lost my doctor because I moved, and I couldn’t find another one. Buying [pills] on the streets was expensive and my husband was the only one working, so I found that the heroin was a lot cheaper…I had easier access to it. And, that is how it started. It grabbed a hold of me quick. Woman, 50, Ohio.
Fluctuations in opioid drug supply, whether prescribed or not, left many with unaddressed opioid withdrawal symptoms:
I woke up from surgery. I was hooked up to liquid morphine, and so I had my own button to where I could push it every 10 min, which I would. I’d push it every 10 min until I’d fall asleep, basically. Then they sent me home with a bottle of Percocet 10s, and as soon as those ran out, they cut me off of my prescription. They didn’t really tell me about withdrawals and stuff like that, so when I got cut off from those, I would go other places and I’d find oxy [oxycodone] and morphine… Man, 28, Oregon.
Person-and interpersonal-levels
While the most widely cited reason for continuous and increasing use was untreated physical pain, for many, the prospect of increased workplace competitiveness and productivity led to transitioning to illicit opioid use. Adults in the workforce were typically in positions involving physical labor, and first opioid use was often due to a work-related injury. Several found that opioids gave them energy and allowed them to be more productive or competitive in their position:
Well, when I had my prescription…everybody I worked with was guys, it was a very physical job. The very first time I took my medicine—I figured out I could run circles around them, like, “This is easy!” So I just started doing it more. Man, 38, Oregon.
As described among those initiating opioids, there was a commonly-described need to address multiple competing demands. One participant summarizes this in describing a confluence of reasons for continued, increased opioid use, in this case, coping with the stress of parenting, marital issues, and work productivity demands while attempting to maintain a semblance of quality of life:
I was working a lot when I really started. Before that I’d take like a Lortab here or whatever but it wasn’t on the regular. I had just had my daughter and my son and I was going through a divorce, and, good lord, I felt like I could never catch up. All I had to do was just eat two Lortabs or eat two Percocets and I felt good. I could work, cook for hours, get the shift out, go home, cook dinner, get the kids in bed, take a shower, go to bed. But then I woke up in the morning after a while I didn’t wanna wake up unless I had two Percocet, and that’s where injecting comes from…as that’s just not good enough anymore, you progress. My co-workers would get a prescription and I would buy some of them and then eventually I bought more and more, and then eventually I was buying the whole script. Man, 32, North Carolina.
Here, again, we note the implied broad availability of prescription opioids in workplace environments and the dissemination of opioids at the peer-level.
First injection drug use
The most common first drugs injected were methamphetamine (26%, mean age 25), opioid pills (22%, mean age 23) and heroin (22%, mean age 24) (Table 3). First time injection was commonly assisted by someone close to them such as an intimate partner or friend.
Environmental-level
As was the case with transitioning from prescribed use of opioids to illicit use, at the community environment level, the high cost and relative lack of availability of opioid pills in community environments catalyzed transition to injecting opioids. One man describes this trajectory:
At 18 years old, I was introduced to pain pills and that soon took over my life…I ended up getting introduced to a cheaper form…heroin, and more potent. I snorted it for a while and then I smoked it, and finally got introduced to injecting it. It was a financial decision at that point. Cheaper high and lasted longer. Man, 26, Ohio.
Interpersonal-level
At the interpersonal level, a common motivation to inject was to feel closer to an intimate partner, most commonly, for women to feel closer to male partners. In the words of one participant:
My husband started [injecting] pain pills. I got jealous that he was spending all his time with his friends or in the bathroom getting high. Finally, I just said I’m just going to get high, too. I’m lonely, whatever. That’s when I started injecting. Woman, 49, North Carolina.
As in other drug use transition points such as first opioid use, witnessing the highs achieved by others was a key driver to initiate injection use, for many. In the words of one participant:
[My boyfriend] does heroin, and I’m snorting it, and he’s shooting it. And [he’s] getting higher than I am…I’m getting jealous…so I explained to my boyfriend that I wanted to do it one time. Woman, 28, North Carolina.
As drug use progressed to IDU, we note more common participant use of words such as “jealousy” regarding the highs achieved by others, supplanting mere curiosity described at other transition points. The emotional motivators to initiate IDU became more potent.
Person-level
At the person-level, participants reported transitioning to IDU for either recreational or coping purposes. Approximately two-thirds began IDU in pursuit of a better-quality or more easily-attained high; often due to their increased tolerance to opioid pills:
I just couldn’t get high anymore [due to tolerance]. I only knew one person that shot up. So, I asked him to do it for me. I could eat a dump truck load of pills, and I can get high, but I’d still feel like I was lacking something, like I wouldn’t be satisfied until I did a shot. Man, 38, North Carolina.
A desire to control opioid withdrawals was a common initial reason for IDU:
I didn’t have any pain pills at the time, and I was sick [with opioid withdrawal symptoms]. My son said, “Well, I’ll make you well, Mom.” I said, “You will?” and he said, “Yeah, I’ve got something.” I said, “Well, hit me up [with injected opioids]. Let’s do it. I don’t care.” Woman, 55, Oregon.
Similarly to other transition points, such as first opioid use, participants initiated IDU to cope with an emotionally difficult life circumstance. Among our participants, approximately one-third initiated for this reason:
My dad passed away. And I just couldn’t get high enough. … and I knew the only way you’re gonna get high is by [injecting]. Man, 38, North Carolina.
My husband was having an affair on me and it was just really bad. That was the first time I [injected]…from the needle on, it was all over with the heroin. Woman, 32, Oregon.
While opioid pills were the first drug injected for many, it was common to move on to injecting other opioids as well as other more potent drug types such as fentanyl:
The first time [injecting] was fentanyl patches and roxie 15s [oxycodone hydrochloride pill, 15 mg]…we were shooting 100 micrograms of fentanyl a piece every day. And then opium had started coming around, and we were shooting opium just every day and all day. Man, 38, North Carolina.
Notably, methamphetamine was often the first drug injected. Goals for methamphetamine IDU were similar to that of opioids: to achieve a better quality high or to cope with a mental health issue. As with first use of opioids, some initiated IDU of methamphetamine to have more energy and/or be more productive in work environments:
Your tolerance [to methamphetamine] builds a little bit…I needed an energy boost, I’m super low energy all the time, since I was a kid. It just gets worse with age, I’m too young to be old. So, I [started injecting methamphetamine] to have a little pep in my step and get more work done. Woman, 27, North Carolina.
