As the consequences of opioid misuse and abuse continue to be a concern throughout the United States—from a rise in overdose deaths to emergency department visits—the priority to hone effective prevention, harm reduction and addiction treatment strategies increases. One relatively easy potential pathway for interventions is simply to understand the motivations and circumstances that lead to the initiation of opioid misuse and yet very little current research actually examines these often-messy stories.

In an effort to help fill this gap, a recent mixed-methods study conducted by Khary K. Rigg et al. utilized survey and open-ended interviewing to draw out storylines related to opioid users’ early exposure to and experimentation with these drugs. Consistent with national data, the survey showed opioid misuse to be most common among teens and young adults, and that initiation most frequently occurred between the ages of 18 and 25. Via qualitative interviews, the authors sought to provide insights beyond the typical epidemiological points-in-time, revealing the context surrounding the initiation of opioid use.

Consistent with past research but contrary to popular assumption, most of the study’s interviewees were not looking for physical pain relief nor were they accessing those first opioids for misuse from a physician. In fact, only about a quarter of interviewees started taking the drugs with a doctor’s prescription before finding that they enjoyed the euphoria or began experiencing withdrawal symptoms. Interestingly, however, this changed once a habit was established, as Rigg et al.’s results showed that, of the 77 individuals who reported misusing prescription opioids in the past year, 46.8 percent got their drugs “from one or more physicians.” This discrepancy may be relevant to the development of interventions that target doctors, who may not be the key point of entry for most individuals to begin misusing opioids, but who are still viewed as a potential source of prescription drugs once a habit has been established.

Furthermore, a majority of the study’s interviewees reported that they began misusing opioids as a psychological coping mechanism or because they were looking for a “novel psychoactive experience.” Many participants reported multiple motivations. These findings are consistent with a large body of literature that supports the idea of self-medication as a major—but not always exclusive—motivating factor that underpins drug misuse and addiction.

However, by going back further in their timelines, Rigg et al. were able to showcase the fact that patterns of drug initiation and misuse are often shaped by many factors—rather than just one. For example, many interviewees reported that they were exposed to drug use among friends and family members during childhood. And, with that early exposure, they claimed they began to see the drugs as a solution to problems as well as a recreational outlet. Moreover, most interviewees began using other drugs—alcohol, marijuana, and sometimes stimulants—prior to trying opioids, and the vast majority (95 percent) of survey participants reported continuing use of substances other than opioids.

Taken as an entire narrative, it becomes clear that people’s motivations and behaviors with respect to drug use are frequently intertwined with the complexities and patterns of life. The authors suggest that early exposure sparked interviewees’ curiosity in drugs and caused them to normalize misuse and abuse, thus establishing a pattern that helps to explain their eventual misuse of opioids (and other drugs) later in life.

In their efforts to highlight implications for intervention, Rigg et al. draw on their findings to argue for the usefulness of peer-led intervention and the potential role motivational interviewing—a therapeutic technique that aims to help patients identify personal motivations for behavioral change—could play in improving treatment outcomes. However, research on the efficacy of the latter remains inconclusive.

For all the study shows us about the importance of considering motivations and behaviors, unfortunately, its greatest weakness is that it is not ambitious enough. While the authors do a good job of using initiation narratives to showcase the complicated nature of people’s introduction to opioid misuse, they do not extend the conversation far enough. For example, previous studies have highlighted the role of social learning in non-medical use of prescription opioids and have done so with more theoretical foundation. And ethnographers have shown that people’s physical and emotional survival—often facilitated by friends and family—can be tied to both the initiation and continuation of drug misuse, as well as perceived resistance to harm reduction. Thus, while Rigg et al. succeed in describing opioid use initiation narratives, they fail to identify one of the most applicable lessons for individuals looking to craft interventions: the need to consider influential interpersonal relationships beyond their role in drug use.

Stacey McKenna, PhD is a medical anthropologist-turned-freelance writer. She has covered health and drug use for Pacific Standard OnlineAeon and others. Read more of her work here.

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